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Original Articles: Adult Cardiac

Outcome After Surgery and Percutaneous Intervention for Cardiogenic Shock and Left Main Disease

^a Division of Cardiology, University of California, Los Angeles Medical Center, Los Angeles, California
^b Department of Medicine, University of California, Los Angeles Medical Center, Los Angeles, California
^c Department of Cardiac Surgery, University of California, Los Angeles Medical Center, Los Angeles, California
^d Division of Cardiology, New York University Medical Center, New York, New York
^e Division of Cardiology, Cleveland Clinic, Cleveland, Ohio

Accepted for publication March 7, 2008.

^_* Address correspondence to Dr Lee, UCLA Medical Center, Adult Cardiac Catheterization Laboratory, 10833 Le Conte Ave, Room BL-394 CHS, Los Angeles, CA 90095-171715 (Email: mslee{at}mednet.ucla.edu).

Background: The ideal revascularization strategy (bypass surgery versus percutaneous coronary intervention [PCI]) for patients with cardiogenic shock in the setting of left main coronary artery disease is unknown.

Methods: The Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock Trial and Registry included 164 patients with left main disease who underwent revascularization. Although the standard of care at the time and the trial protocol recommended coronary artery bypass graft surgery for patients with left main disease, the revascularization strategy (79 coronary artery bypass graft surgery and 85 PCI) was individualized for each patient by site investigators.

Results: The median time from myocardial infarction to revascularization was 24.3 hours (interquartile range, 8.7 to 82.5 hours) in the surgical group and 7.4 hours (interquartile range, 3.7 to 19.5 hours) in the PCI group (p < 0.05). Overall 30-day survival with surgery in this setting was 54% (95% confidence interval, 0.43 to 0.69) and was significantly superior to the 14% (95% confidence interval, 0.09 to 0.35) in the PCI group (p 0.001). When the left main was the infarct-related artery, the 30-day survival rate was 40% in the surgical group (n = 6) and 16% in the PCI group (n = 15; p = 0.03). Coronary artery bypass graft surgery (hazard ratio, 0.41; 95% confidence interval, 0.22 to 0.77; p = 0.006) and age (per 10 years, hazard ratio, 1.04; 95% confidence interval, 1.01 to 1.08; p = 0.02) were independently associated with 30-day survival.

Conclusions: Coronary artery bypass graft surgery appeared to provide a survival advantage over PCI at 30-day follow-up in patients with left main coronary artery disease. The impact of current PCI strategies on this subgroup is undetermined.