Midterm outcome of off-pump bypass procedures versus drug-eluting stent for unprotected left main coronary artery disease

Background: Although surgical revascularization is recommended for the treatment of left main coronary artery (LMCA) disease, percutaneous coronary intervention (PCI) attempts have increased, especially after the introduction of the drug-eluting stent. The goal of this study was to compare the midterm outcomes between drug-eluting stenting and off-pump coronary artery bypass (OPCAB) grafting in LMCA disease. Methods: Five hundred twelve consecutive patients with unprotected LMCA disease who underwent OPCAB (N = 269) or drug-eluting stenting (N = 243) were enrolled. We compared major cardiac and cerebrovascular events (MACCEs) in a real-world cohort and in a matching patient cohort (N = 256). The duration of mean follow-up was 38 ± 20 months, and the follow-up rate was 97.7%. Results: In a real-world comparison, the OPCAB group showed better 5-year freedom from MACCEs compared with the stenting group (71.5% ± 4.4% versus 67.6% ± 4.0%; p = 0.031), despite worse patient characteristics. After patient matching, the OPCAB group showed more distinct benefit in 5-year freedom from MACCEs (75.3% ± 6.6% versus 62.8% ± 5.4; p < 0.001), including a significantly lower target vessel revascularization (TVR) rate (p < 0.001). In a subgroup analysis, the benefit of OPCAB regarding 5-year freedom from MACCEs was more clearly defined for lesions of the distal LCMA and in LMCA lesions with multivessel disease (p = 0.015, p = 0.004, respectively). Conclusions: Patients with LMCA disease who were treated with OPCAB showed better 5-year freedom from MACCEs in a real-world practice and in a patient matching cohort compared with the drug-eluting stenting group. TVR was the main factor that made the difference. The benefit of OPCAB was more prominent in distal LMCA lesions and in LMCA lesions with multivessel involvement.