Mortality after multivessel revascularisation involving the proximal left anterior descending artery

Abstract

Objective: We sought to investigate whether long-term clinical outcomes differ following percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) in patients with three-vessel disease (3VD) and lesions in the proximal left anterior descending artery (P-LAD).

Methods: This post-hoc analysis of the Synergy between PCI with Taxus and Cardiac Surgery (SYNTAX) Extended Survival study included patients with 3VD who were classified according to the presence or absence of lesions located in the P-LAD. Ten-year all-cause death and 5-year major adverse cardiac or cerebrovascular events (MACCE) were assessed.

Results: Among 1088 patients with 3VD, 559 (51.4%) had involvement of P-LAD and their 10-year mortality was numerically higher following PCI versus CABG (28.9% vs 21.9%; HR: 1.39, 95% CI 0.99 to 1.95). Although patients without P-LAD lesions had significantly higher 10-year mortality following PCI compared with CABG, there was no evidence of a treatment-by-subgroup interaction (28.8% vs 20.2%; HR: 1.47, 95% CI 1.03 to 2.09, pinteraction=0.837). The incidence of MACCE at 5 years was significantly higher with PCI than CABG, irrespective of involvement of P-LAD (with P-LAD: HR: 1.86, 95% CI 1.36 to 2.55; without P-LAD: HR: 1.54, 95% CI 1.11 to 2.12; pinteraction=0.408). Individualised assessment using the SYNTAX Score II 2020 established that a quarter of patients with P-LAD lesions had significantly higher mortality with PCI than CABG, whereas in the remaining three-quarters CABG had similar mortality.

Conclusions: Among patients with 3VD, the presence or absence of a P-LAD lesion was not associated with any treatment effect on long-term outcomes following PCI or CABG.

Trial registration number: SYNTAXES: NCT03417050; SYNTAX: NCT00114972.

Keywords: Coronary Artery Bypass; Coronary Artery Disease; Percutaneous Coronary Intervention.

Conflict of interest statement

Competing interests: PWS reports personal fees from Biosensors, Micel Technologies, Sino Medical Sciences Technology, Philips/Volcano, Xeltis and HeartFlow, outside the submitted work. HH reports a grant for studying overseas from the Japanese Circulation Society and a grant from Fukuda Foundation for Medical Technology, outside the submitted work. JJP reports personal fees and non-financial support from Philips/Volcano, outside the submitted work. M-CM is CEO and shareholder of CERC, a CRO not involved in this trial, and is a minor shareholder of Electroducer. SH reports to work as employee of Medtronic, outside the submitted work. APK reports to work as employee of Medtronic, outside the submitted work. All other authors have no conflict of interest to declare.

© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Figures

Figure 1

Flow chart of the present study. 3VD, three-vessel disease; CABG, coronary artery bypass graft; CAD, coronary artery disease; LAD, left anterior descending artery; PCI, percutaneous coronary intervention; SYNTAX, Synergy between PCI with Taxus and Cardiac Surgery; SYNTAXES, SYNTAX Extended Survival.

Figure 2

Cumulative incidence of (A) MACCE up to 5 years and (B) all-cause death up to 10 years after PCI or CABG in patients with or without P-LAD stenosis. (A) The incidence of MACCE at 5 years was significantly higher in PCI than in CABG irrespective of the involvement of a P-LAD lesion. (B) In the P-LAD group, all-cause death at 10 years did not differ significantly between PCI and CABG, whereas in the non-P-LAD group PCI was associated with a significantly higher risk of all-cause death at 10 years compared with CABG, although there was no significant treatment-by-subgroup interaction. CABG, coronary artery bypass grafting; MACCE, major adverse cardiac or cerebrovascular events; PCI, percutaneous coronary intervention; P-LAD, proximal left anterior descending artery.