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European Heart Journal Advance Access originally published online on November 4, 2005
European Heart Journal 2006 27(4):413-418; doi:10.1093/eurheartj/ehi646
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© The European Society of Cardiology 2005. All rights reserved. For Permissions, please e-mail: journals.permissions@oxfordjournals.org

Predictors of revascularization method and long-term outcome of percutaneous coronary intervention or repeat coronary bypass surgery in patients with multivessel coronary disease and previous coronary bypass surgery

Sorin J. Brener1,*, Bruce W. Lytle2, Ivan P. Casserly3, Stephen G. Ellis1, Eric J. Topol1 and Michael S. Lauer1

1Department of Cardiovascular Medicine, Cleveland Clinic Foundation, 9500 Euclid Avenue, Desk F-25, Cleveland, OH 44195 USA
2Department of Cardiothoracic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
3The Veterans' Administration Medical Center, Denver, CO, USA

Received 6 July 2005; revised 12 October 2005; accepted 20 October 2005; online publish-ahead-of-print 4 November 2005.

* Corresponding author. Tel: +1 216 444 0732; fax: +1 216 444 8050. E-mail address: breners{at}ccf.org

See page 375 for the editorial comment on this article (doi:10.1093/eurheartj/ehi669)

Aims The optimal revascularization strategy in patients with symptomatic multivessel coronary artery disease (CAD) and previous coronary artery bypass grafting (CABG) remains unknown.

Methods and results We evaluated all patients with previous CABG undergoing isolated, non-emergency multivessel revascularization between 1 January 1995 and 31 December 2000. The analysis concentrated on the independent predictors of the revascularization method, as well as on long-term mortality and its predictors, after calculating a propensity score for the method of revascularization. There were 2191 patients (1487 with reoperation and 704 with percutaneous coronary intervention, PCI) in the study. The most important factors in choosing reoperation were presence of more diseased or occluded grafts, previous infarction, lower ejection fraction (EF), longer interval from first CABG, and more total occlusions of native arteries, as well as absence of a patent mammary graft. The distribution of the propensity score was skewed towards the two extremes. At 5 years, the unadjusted cumulative survival was 79.5% for CABG and 75.3% for PCI, P=0.008. After adjustment for the propensity score for PCI vs. CABG, PCI was associated with a hazard ratio of 1.47 (0.94–2.28), P=0.09. The most powerful predictors of mortality were higher age and lower EF.

Conclusion The choice of the revascularization method in patients with previous CABG is dictated mostly by anatomical considerations and less by clinical characteristics. In contrast, clinical characteristics predominantly affect long-term outcome, whereas the method of revascularization has a limited effect. A randomized clinical trial addressing this important segment of the population with ischaemic heart disease is warranted.

Key Words: PCI • CABG • CAD • Long-term outcome


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