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Revascularization of Left Anterior Descending Coronary Artery in Patients With Single and Multivessel Disease^*

Comparison Between Off-Pump Internal Thoracic Artery and Drug-Eluting Stent

^* From the Department of Cardiology (Dr. Moshkovitz), Assuta Medical Center, Petach Tikva, Israel; and the Departments of Thoracic and Cardiovascular Surgery (Drs. Mohr, Braunstein, Uretzky, and Ben-Gal, and Mr. Zivi) and Cardiology (Dr. Herz), The Tel Aviv Sourasky Medical Center Tel Aviv, Israel.

Correspondence to: Yaron Moshkovitz, MD, Departments of Cardiology and Cardiac Surgery, Floor 6, Assuta Medical Center, 3 Spigel St, Petach Tikva 49261, Israel; e-mail: mosko{at}assuta.com

Study objectives: The left anterior descending artery (LADA), particularly when the proximal segment of the vessel is involved, is a challenging area for percutaneous coronary interventions (PCIs); therefore, coronary artery bypass grafting is often considered and sometimes performed even in patients with single-vessel disease involving the LADA. This study compares mid-term results of LADA revascularization with a drug-eluting stent (DES), with off-pump coronary artery bypass grafting (OPCAB) in patients with single-vessel or multivessel coronary artery disease (CAD).

Design: Matched-groups, retrospective cohort comparison between the DES and OPCAB.

Patients: From June 2002 to December 2003, 354 patients underwent myocardial revascularization of the LADA by OPCAB, and 168 by DES. After matching for age, sex, and extent of CAD, two groups (116 patients each) were used to compare the two revascularization modalities. The groups were similar; however, an ejection fraction of <30%, old myocardial infarction, and use of an intraaortic balloon pump were more prevalent in the OPCAB group.

Results: The average number of coronary vessels treated per patient in the two groups was similar (OPCAB, 1.97; DES, 1.6; p = 0.581). The 30-day mortality rate was 0.9% in the OPCAB group and 0% in the DES group (p = 0.329). The mean duration of follow-up was 12 months. There was one late death in each group. Angina returned in 31% of patients in the DES group and in 11.2% of the patients in the OPCAB group (p = 0.001). There were 12 reinterventions in the DES group compared to three reinterventions in the surgical group (p = 0.020). The only independent predictor (Cox proportional hazards regression model) of the return of angina (risk ratio [RR], 3.36; 95% confidence interval [CI], 1.57 to 7.14) and reintervention (RR, 3.9; 95% CI, 1.34 to 11.24) was assignment to the DES group.

Conclusions: The mid-term clinical outcome of OPCAB in patients with CAD, including multivessel disease, was better than that for PCIs with only one DES used in patients with similar extents of CAD.

Key Words: aortocoronary bypass • percutaneous administration • stents