Choice of revascularization strategy for ischemic cardiomyopathy due to multi-vessel coronary disease

Background Limited comparative data guide the decision between coronary bypass surgery (CABG) versus percutaneous coronary intervention (PCI) for multivessel revascularization in ischemic cardiomyopathy. Objectives To compare long-term outcomes of CABG and PCI for ischemic cardiomyopathy. Methods Clinical registries from NJ Department of Health linked to administrative databases were used to compare all-cause mortality, repeat revascularization, heart failure (HF) readmissions, myocardial infarction (MI), and stroke using Cox proportional hazards and propensity matching with competing risk analysis in 5988 patients with ejection fraction ≤35% who underwent CABG (3673,61.3%) or PCI (2315,38.6%) for multivessel coronary disease between 2007-2018. Median follow-up time was 5.2 years (range: 0-13 years); last follow-up date was 12/31/2020. Results After controlling for completeness of revascularization, at 13 years, mortality was 57% (95% CI,51%-63%) after PCI and 60% (95% CI,53%-66%) after CABG (hazard ratio (HR)1.10;95% confidence interval (CI)0.93-1.31;P=0.28); risk of repeat revascularization was 18% for PCI versus 14% for CABG (HR=1.62;95% CI,1.17-2.25;P=0.003); risk of readmission for HF was 16% after PCI and CABG (HR=1.13,95% CI,0.84-1.51, weighted P=0.10); MI was 10% versus 6%, (HR=1.91;95% CI,1.18-3.09;P=0.007); and stroke risk was 3% versus 4%, respectively (HR=0.79;95% CI,0.41-1.53;P=0.52). Rate of complete revascularization was lower following PCI than CABG, associated with higher mortality after PCI (HR=1.35;95% CI 1.20-1.52;P<0.001). Conclusion Coronary bypass was associated with similar mortality, stroke and HF readmissions, and reduced repeat revascularization compared to PCI in patients with ischemic cardiomyopathy if similar rates of complete revascularization were achieved. These findings support consensus recommendations for CABG and medical therapy in patients with multivessel coronary disease and left ventricular dysfunction.