Minimally-Invasive Coronary Bypass vs. PCI for Isolated Complex Stenosis of the LAD

Abstract Objective Debate continues as to the optimal minimally-invasive treatment modality for complex disease of the left anterior descending (LAD) coronary artery, with advocates for both robotic-assisted minimally-invasive direct coronary artery bypass (MIDCAB) and for percutaneous intervention (PCI) with a drug-eluting stent (DES). We analyzed mid-term outcomes for patients with isolated LAD disease, revascularized by either MIDCAB or DES-PCI, focusing on those with complex lesion anatomy. Methods A retrospective review was undertaken of all patients who underwent coronary revascularization between January 2008 and December 2016. From this population, 158 propensity-matched pairs of patients were generated from 158 individuals who underwent MIDCAB for isolated complex LAD disease and from 373 who had PCI utilizing second-generation DES. Mid-term survival and incidence of repeat LAD intervention were analyzed for both patient groups. Results Overall nine-year survival was not significantly different between patient groups, both before and after propensity-matching. Mid-term mortality in the matched MIDCAB group was low, irrespective of patient risk profile. By contrast, advanced age (HR 1.10, P = 0.012) and obesity (HR 1.09, P = 0.044) predicted increased late death after DES-PCI amongst matched patients. Patients who underwent MIDCAB were significantly less likely to require repeat LAD revascularization than those who had PCI, both before and after propensity-matching. Smaller stent diameter in DES-PCI was associated with increased LAD re-intervention (HR 3.53, P = 0.005). Conclusions In patients with complex disease of the LAD, both MIDCAB and PCI are associated with similar excellent intermediate-term survival, although re-intervention requirements are lower after surgery.