Predictors of revascularization method and long-term outcome of percutaneous coronary intervention or repeat coronary bypass surgery in patients with multivessel coronary disease and previous coronary bypass surgery.
OBJECTIVE
The optimal revascularization strategy in patients with symptomatic multivessel coronary artery disease (CAD) and previous coronary artery bypass grafting (CABG) remains unknown.


RESULTS
We evaluated all patients with previous CABG undergoing isolated, non-emergency multivessel revascularization between 1 January 1995 and 31 December 2000. The analysis concentrated on the independent predictors of the revascularization method, as well as on long-term mortality and its predictors, after calculating a propensity score for the method of revascularization. There were 2191 patients (1487 with reoperation and 704 with percutaneous coronary intervention, PCI) in the study. The most important factors in choosing reoperation were presence of more diseased or occluded grafts, previous infarction, lower ejection fraction (EF), longer interval from first CABG, and more total occlusions of native arteries, as well as absence of a patent mammary graft. The distribution of the propensity score was skewed towards the two extremes. At 5 years, the unadjusted cumulative survival was 79.5% for CABG and 75.3% for PCI, P=0.008. After adjustment for the propensity score for PCI vs. CABG, PCI was associated with a hazard ratio of 1.47 (0.94-2.28), P=0.09. The most powerful predictors of mortality were higher age and lower EF.


CONCLUSIONS
The choice of the revascularization method in patients with previous CABG is dictated mostly by anatomical considerations and less by clinical characteristics. In contrast, clinical characteristics predominantly affect long-term outcome, whereas the method of revascularization has a limited effect. A randomized clinical trial addressing this important segment of the population with ischaemic heart disease is warranted.
Brener
Sorin J
SJ
Department of Cardiovascular Medicine, Cleveland Clinic Foundation, 9500 Euclid Avenue, Desk F-25, Cleveland, OH 44195 USA. breners@ccf.org
Lytle
Bruce W
BW
Casserly
Ivan P
IP
Ellis
Stephen G
SG
Topol
Eric J
EJ
Lauer
Michael S
MS
D017677:Age Distribution; D000368:Aged; D015906:Angioplasty, Balloon, Coronary / Q000379:methods / Q000401:mortality; D001026:Coronary Artery Bypass / Q000379:methods / Q000401:mortality; D003327:Coronary Disease / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D017052:Hospital Mortality; D006801:Humans; D008875:Middle Aged; D009203:Myocardial Infarction / Q000209:etiology / Q000401:mortality* / Q000503:physiopathology; D009204:Myocardial Revascularization / Q000379:methods* / Q000401:mortality; D011237:Predictive Value of Tests; D012086:Reoperation; D013318:Stroke Volume; D016019:Survival Analysis; D013997:Time Factors; D016896:Treatment Outcome