Revascularisation strategy in ischemic heart failure: coronary artery bypass grafting versus percutaneous coronary intervention
A Ben Salem, R Oueslati, M Abbassi, B Besbes, M S Mourali, Z Daoued, R DenguirAbstract
Background
Revascularization strategies in the setting of heart failure are still debatable. while coronary artery bypass grafting (CABG) maintains a defined position in current guidelines, albeit with varying strength of recommendation, the role of percutaneous coronary intervention (PCI) is more contentious.
Purpose
The aim of our study was to evaluate short and mid-term clinical outcomes following PCI and CABG in heart failure with reduced ejection fraction (HFrEF) patients.
Methods
We conducted a retrospective study that included patients from January 2020 to September 2023 with left ventricle ejection fraction (LVEF)<=40% and multivessel coronary artery disease suitable for revascularization treated either by PCI or CABG. Patients requiring urgent revascularization for acute ST segment elevation myocardial infarction or cardiogenic shock, as well as those with prior cardiac surgery or needing concomitant valve surgery, were excluded. The primary endpoint was to compare 30-day and mid-term major adverse cardiac and cerebrovascular events between the two groups (MACCE).
Results
The study included 120 patients: 80 patients in the PCI arm and 40 patients in the CABG arm. There were no significant differences in baseline demographic, clinical, or historical characteristics between the two subgroups.Patients had lower LVEF in the PCI group (32,9 ± 5,6% vs. 35,4 ± 4,1%, p=0.014). Higher prevalence of 3 vessel disease (41,3% vs. 80%, p <0,001) and greater anatomic complexity defined by a SYNTAX I score ≥33 were more frequently observed in the CABG group (12,5% vs. 45%, p<0,001).CABG conferred a significantly greater probability of complete revascularization than PCI (90% vs. 46.3%, p<0.001). At 30 days, MACCE rates were significantly lower in the PCI group than in the CABG group (7.5% vs. 30%, p=0.001), a difference largely driven by higher all-cause mortality following CABG (6.3% vs. 27.5%, p=0.001). Median follow-up was 30 months.Overall MACCE occurred in 45% and 50% of patients in the PCI and CABG groups, respectively (p=0.605). MACCE components included all-cause mortality (13.8% vs. 35%, p=0.007), cardiovascular mortality (12.5% vs. 25%, p=0.083), myocardial infarction (MI)(15% vs. 2.5%, p=0.038), target vessel revascularization (TVR) (18.7% vs. 2.5%, p=0.014), stroke (6.3% vs. 7.5%, p=0.796), and heart failure hospitalization (12.5% vs. 15%, p=0.704).
Conclusion
In-hospital mortality following CABG in patients with HFrEF represented the main distinction of this study compared with previous trials, adversely impacting long-term outcomes and favoring PCI for the primary endpoint of all-cause mortality. Conversely, CABG demonstrated superiority over PCI regarding recurrent MI and TVR.Cumulated Survival Curve for deathFor image description, please refer to the figure legend and surrounding text.Cumulated Survival Curve free of MACCEFor image description, please refer to the figure legend and surrounding text.