Optimal Interventional Approach in Ischemic Cardiomyopathy for Patients With Multivessel Coronary Artery Disease

Abstract

Background: Ischemic cardiomyopathy (ICM), characterized by reduced left ventricular function due to coronary artery disease, necessitates revascularization to restore blood flow. Despite guidelines favoring revascularization, the choice between coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) remains complex due to evolving techniques and patient profiles. Ischemic mitral regurgitation is another factor related to poor prognosis for mortality and morbidity in patients with ICM. There are limited real-world data for long-term follow-up that compared CABG vs. concomitant mitral valve repair for moderate mitral regurgitation in multivessel ICM disease.

Specific Aims:

• Aim 1) Explore the trends in utilization and 30-day mortality of CABG vs. PCI in multivessel ICM patients

• Aim 2) Examine the long-term effectiveness of CABG vs. PCI in multivessel ICM patients

• Aim 3) Examine the long-term effectiveness of isolated CABG vs. concomitant mitral valve repair with moderate mitral valve regurgitation in multivessel ICM patients

Summary of Findings:

We have observed a significant change in revascularization strategies for patients with ischemic cardiomyopathy (ICM) and multivessel disease. Percutaneous coronary intervention (PCI) use has increased, and by the end of the study, 60% of patients underwent PCI, while 40% chose CABG.

The completeness of revascularization was found to be highly associated with mortality after either PCI or CABG. Unadjusted mortality rates were higher for PCI than CABG. However, after adjusting for completeness of revascularization, there was no significant difference in mortality between groups. Completeness of revascularization remained constant during the study at 20% for PCI and 93% for CABG.

CABG versus PCI is associated with lower rates of repeat revascularizations and the incidence of myocardial infarction, with similar survival rates achieved when completeness of revascularization is attained. However, because completeness of revascularization is lower with PCI, real-world long-term survival rates were higher after CABG than PCI.

In patients with moderate ischemic mitral regurgitation, concomitant mitral valve repair during CABG was associated with similar long-term survival and incidence of major adverse cardiac and cerebrovascular events as observed after the isolated CABG. This was found in community hospitals, however, the findings may be different in large reference centers specializing in mitral valve repair. In conclusion, the shift in revascularization strategies for ICM patients with multivessel disease has led to an increase in PCI use and a stabilization of CABG rates. The completeness of revascularization has been found to be crucial in determining mortality rates, with CABG associated with higher rates of completeness of revascularizations and better long-term outcomes in real-world settings. For patients with moderate ischemic mitral regurgitation, isolated CABG is comparable to concomitant mitral valve repair in ICM patients with multivessel disease.