Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting in Patients With Left Ventricular Dysfunction

Decades have passed since studies comparing coronary artery bypass grafting (CABG) with medical therapy for multivessel coronary disease indicated a survival advantage of surgery in the subset of patients with significant left ventricular impairment.(1-3) These investigations changed the prevailing clinical impression such that severe LV dysfunction might be an indication for revascularization as opposed to a relative contraindication. While the studies might currently be deemed obsolete by many measures, they continue to inform societal guidelines with regards to CABG and LV dysfunction.(4-5) Recently the long-term outcomes after the STICH trial have reinforced the potential benefits of surgical revascularization in patients with CHF and an EF of <35%.(6) Over the intervening period, numerous trials have compared percutaneous coronary intervention (PCI) with CABG in patients with stable angina and multivessel disease. Aside from diabetes, the trials have by and large have demonstrated equivalence in endpoints of death and myocardial infarction. So can one extrapolate equivalence for PCI with CABG in patients with left ventricular dysfunction? The short answer is no: There is scant direct evidence from randomized trials comparing the two methods of revascularization because patients with congestive heart failure or severe LV dysfunction have typically been under-represented or excluded.(7-9).