Is CABG the best approach for multivessel, left main CAD?

Mario F.L. Gaudino, MD says PCI and CABG are complementary - not antagonistic – strategies for patients with MVD, LMCAD

A leading cardiac surgeon stressed that percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) are complementary, not antagonistic, interventions for patients with coronary artery disease (CAD).

As a writing committee member of the recently updated American guidelines, Mario F.L. Gaudino, MD(Weill Cornell Medical College, Cornell University, New York, USA) presented his perspective on optimal revascularization for CAD patients at TCTAP 2022.

“We are essentially comparing two different interventions,” he said at the virtual conference on Apr 27 while comparing revascularization strategies for multivessel disease (MVD) and left main disease (LMD).

The subject incited heavy antagonism between interventional cardiologists and cardiac surgeons who have stood at odds regarding the benefits of CABG and PCI in patients with stable ischemic heart disease (SIHD).

The recent 2021 American College of Cardiology, American Heart Association, Society for Cardiovascular Angiography and Interventions (ACC/AHA/SCAI) guidelines on coronary artery revascularization stoked the conflict with the controversial downgraded CABG recommendation in MVD (Class I → Class IIb) and Class IIa recommendation for PCI in LMD as a reasonable alternative to CABG.

Despite the ongoing feud, Gaudino emphasized that studies show both PCI and CABG are acceptable and complementary strategies in MVD and LMD, and subgroups benefit differently from each approach.

Results from the 5-year and 10-year follow-up of the SYNTAX trial showed similar mortality rates between CABG and PCI, but CABG had better long-term clinical outcomes and lower rates of myocardial infarction (MI) and repeat revascularization, particularly in complex disease.

An individual pooled analysis also showed patients with diabetes benefitted more from CABG.

For risk stratification with the SYNTAX score, a meta-analysis by Gaudino and investigators found no significant association between the score and the comparative effectiveness of PCI and CABG: “While we believe the complexity of coronary lesion matters – and more for PCI than CABG – the SYNTAX score should not be used to guide clinical decision-making, per se.”

As for CABG drawbacks, findings from SYNTAX and other quality-of-life (QoL) studies showed that CABG was associated with more periprocedural complications and discomfort during recovery.

These findings applied to patients with LMD. The NOBLE study found no difference in survival or stroke between PCI and CABG for patients with LMCAD but significant reductions with CABG for MI and major adverse cardiovascular events (MACE), including repeat revascularization.

QoL analysis of the EXCEL trial showed that patients faced a higher upfront risk with CABG but obtained a longer period of benefit, indicating that patients “fit enough for the risk” could benefit more from surgery.

“But it’s not just about survival; it’s also about QoL,” Gaudino said. “The two revascularization strategies are highly effective in relieving angina-related QoL, but CABG has a high upfront cost regarding physical limitations after surgery.”

The recent meta-analysis by Sabatine and investigators published in the Lancet last November also showed no difference between PCI and CABG for survival, indicating that PCI had comparable outcomes to surgery for the first two years while being less invasive.

Drawbacks of PCI included higher rates of MI and repeat revascularization compared to CABG, although MI outcomes varied according to the definition used, Gaudino said.

“Surgery has consistently shown similar mortality and reduced risk of MI and repeat revascularization for patients with MVD and LMD, amenable by either CABG or PCI. A difference favoring surgery is evident for patients with diabetes and complex disease.

“Although surgery shows better long-term clinical outcomes, it is associated with higher periprocedural risk and longer recovery rates. PCI demonstrated comparable results to surgery for the first two years as a less invasive strategy.

“Exempting the relative risk (RR), the absolute difference between the two is small, which becomes evident in the long-term follow-up. Ultimately, PCI and CABG are two different interventions performed for different patients with different aims.”

CHECK THE SESSION

Lawton, Jennifer S., et al. “2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization.” Journal of the American College of Cardiology, vol. 79, no. 2, 2022
Gaudino reported no financial interest, arrangement, or affiliation as potential conflicts of interest for the presentation.
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