Comparison of Five-Year Outcomes of Coronary Artery Bypass Grafting Versus Percutaneous Coronary Intervention in Patients With Left Ventricular Ejection Fractions ≤50% Versus >50% (from the CREDO-Kyoto PCI/CABG Registry Cohort-2)

Coronary heart disease is a major risk factor for left ventricular (LV) systolic dysfunction. However, limited data are available regarding long-term benefits of percutaneous coronary intervention (PCI) in the era of drug-eluting stent or coronary artery bypass grafting (CABG) in patients with LV systolic dysfunction with severe coronary artery disease. We identified 3,584 patients with 3-vessel and/or left main disease of 15,939 patients undergoing first myocardial revascularization enrolled in the CREDO-Kyoto PCI/CABG Registry Cohort-2. Of them, 2,676 patients had preserved LV systolic function, defined as an LV ejection fraction (LVEF) of >50% and 908 had impaired LV systolic function (LVEF ≤50%). In patients with preserved LV function, 5-year outcomes were not different between PCI and CABG regarding propensity score–adjusted risk of all-cause and cardiac deaths. In contrast, in patients with impaired LV systolic function, the risks of all-cause and cardiac deaths after PCI were significantly greater than those after CABG (hazard ratio 1.49, 95% confidence interval 1.04 to 2.14, p = 0.03 and hazard ratio 2.39, 95% confidence interval 1.43 to 3.98, p <0.01). In both patients with moderate (35% < LVEF ≤ 50%) and severe (LVEF ≤35%) LV systolic dysfunction, the risk of cardiac death after PCI was significantly greater than that after CABG (hazard ratio 2.25, 95% confidence interval 1.15 to 4.40, p = 0.02 and hazard ratio 4.42, 95% confidence interval 1.48 to 13.24, p = 0.01). Similarly, the risk of all-cause death tended to be greater after PCI than after CABG in both patients with moderate and severe LV systolic dysfunction without significant interaction (hazard ratio 1.57, 95% confidence interval 0.96 to 2.56, p = 0.07 and hazard ratio 1.42, 95% confidence interval 0.71 to 2.82, p = 0.32; interaction p = 0.91). CABG was associated with better 5-year survival outcomes than PCI in patients with impaired LV systolic function (LVEF ≤50%) with complex coronary disease in the era of drug-eluting stents. In both patients with moderate (35% < LVEF ≤ 50%) and severe (LVEF ≤35%) LV systolic dysfunction, CABG tended to have better survival outcomes than PCI.