Outcome after surgery and percutaneous intervention for cardiogenic shock and left main disease.
BACKGROUND
The ideal revascularization strategy (bypass surgery versus percutaneous coronary intervention [PCI]) for patients with cardiogenic shock in the setting of left main coronary artery disease is unknown.


METHODS
The Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock Trial and Registry included 164 patients with left main disease who underwent revascularization. Although the standard of care at the time and the trial protocol recommended coronary artery bypass graft surgery for patients with left main disease, the revascularization strategy (79 coronary artery bypass graft surgery and 85 PCI) was individualized for each patient by site investigators.


RESULTS
The median time from myocardial infarction to revascularization was 24.3 hours (interquartile range, 8.7 to 82.5 hours) in the surgical group and 7.4 hours (interquartile range, 3.7 to 19.5 hours) in the PCI group (p < 0.05). Overall 30-day survival with surgery in this setting was 54% (95% confidence interval, 0.43 to 0.69) and was significantly superior to the 14% (95% confidence interval, 0.09 to 0.35) in the PCI group (p <or= 0.001). When the left main was the infarct-related artery, the 30-day survival rate was 40% in the surgical group (n = 6) and 16% in the PCI group (n = 15; p = 0.03). Coronary artery bypass graft surgery (hazard ratio, 0.41; 95% confidence interval, 0.22 to 0.77; p = 0.006) and age (per 10 years, hazard ratio, 1.04; 95% confidence interval, 1.01 to 1.08; p = 0.02) were independently associated with 30-day survival.


CONCLUSIONS
Coronary artery bypass graft surgery appeared to provide a survival advantage over PCI at 30-day follow-up in patients with left main coronary artery disease. The impact of current PCI strategies on this subgroup is undetermined.
Lee
Michael S
MS
Division of Cardiology, University of California, Los Angeles Medical Center, Los Angeles, CA 90095-171715, USA. mslee@mednet.ucla.edu
Tseng
Chi-Hong
CH
Barker
Colin M
CM
Menon
Venu
V
Steckman
David
D
Shemin
Richard
R
Hochman
Judith S
JS
D000367:Age Factors; D000368:Aged; D015906:Angioplasty, Balloon, Coronary / Q000379:methods* / Q000401:mortality; D015331:Cohort Studies; D016001:Confidence Intervals; D017023:Coronary Angiography; D001026:Coronary Artery Bypass / Q000379:methods* / Q000401:mortality; D004638:Emergency Treatment; D005260:Female; D005500:Follow-Up Studies; D006084:Graft Rejection; D006085:Graft Survival; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000000981:diagnostic imaging / Q000401:mortality* / Q000628:therapy; D011336:Probability; D016016:Proportional Hazards Models; D012042:Registries; D018570:Risk Assessment; D012720:Severity of Illness Index; D012737:Sex Factors; D012770:Shock, Cardiogenic / Q000000981:diagnostic imaging / Q000401:mortality* / Q000628:therapy*; D016019:Survival Analysis; D016896:Treatment Outcome