Short- and Mid-term outcomes of Coronary Artery Bypass Grafting versus Percutaneous Coronary Intervention in patients with unprotected left main coronary artery disease and impaired left ventricular ejection fraction

Abstract

Background: Acute left main (LM) coronary occlusion jeopardizes over 80% of the myocardial blood supply, which commonly hinders the left ventricular ejection fraction (LVEF), making it a life-threatening condition that demands prompt reperfusion. However, the best method for revascularization in such a condition is not settled yet.

Objective: We aimed to determine the safest method of revascularization for patients with significant unprotected left main coronary artery (ULMCA) occlusion and low ejection fraction by comparing the short- and midterm outcomes of surgical versus percutaneous coronary interventions (PCIs).

Methods: In this study, we recruited 440 patients from university hospitals in Cairo, Sohag, and other locations who underwent urgent revascularization due to angiographically evident significant occlusion of the ULMCA and a low ventricular ejection fraction (LVEF < 40%) between January 2020 and June 2024, with follow-up extending to June 2025.

Patients were divided into 2 groups: Group A, the coronary artery bypass grafting (CABG) group, which included 220 patients, and Group B, the PCI group, which had the same number. Our primary endpoint was to compare the incidence of the major adverse cardiac and cerebrovascular events (MACCE: all-cause mortality, myocardial infarction, stroke, and repeat revascularization) throughout the early postoperative period up to 3-year follow-up duration between the 2 groups. Propensity score matching and multivariable Cox proportional hazards models were used to adjust for baseline differences.

Results: Analyzing the initial (at 30 days) outcomes, the PCI cohort was associated with significantly shorter hospital stays. Rates of all-cause mortality (4.5% vs. 7.7%) and cerebrovascular stroke (2.3% vs. 2.7%) were numerically lower in the CABG group, but these differences were not statistically significant (p-value > 0.05(. At the 36 months median follow-up, MACCE was observed in 18.9% of the CABG cohort while it was noted in 29.6% of PCI patients (HR 0.68, 95% CI 0.48–0.96, p = 0.01). This disparity was primarily due to the observation that patients undergoing CABG needed less re-revascularization (6.8% compared to 16.4%, p = 0.002). Furthermore, the PCI group experienced a significantly higher overall mortality rate through the median follow-up (21.8% vs. 14.1%, p = 0.04), while the CABG group showed a greater enhancement in LVEF compared to the PCI group (+6.8 ± 4.2% vs +3.1 ± 3.7%; p = 0.001).

Conclusion: In patients with reduced LVEF and ULMCA disease, CABG and PCI showed comparable short-term outcomes. Less need for re-revascularization, CABG group showed significantly lower MACCE rates and higher LVEF levels up to a three-year period. In order to determine the best revascularization techniques for this high-risk population, a heart-team approach is essential.