Minimally Invasive Direct Coronary Artery Bypass versus Percutaneous Coronary Intervention in Patients with Chronic Total Occlusion of the Left Anterior Descending Artery

Background: Chronic total occlusion (CTO) of the left anterior descending (LAD) artery is common, with almost 30% of all CTOs affecting the LAD. Minimally invasive direct coronary artery bypass (MIDCAB) is a minimally invasive surgical alternative to PCI for patients with LAD-CTO, but no direct comparison of both therapeutic modalities exists so far.

Methods: We analyzed retrospectively our institutional database for patients who underwent MIDCAB or PCI for CTO of the LAD. Propensity matching was performed, forming 44 matched pairs. Data are presented as a median (interquartile range, IQR = 25–75th percentile) or frequencies (%). The primary outcome was long-term survival. The secondary outcomes were myocardial infarction (MI) re-intervention, revascularization success, cancelled intervention, and 30-day mortality.

Results: One hundred patients underwent MIDCAB and 122 patients PCI for LAD-CTO. Most patients were male (81.0% vs. 80.3%). Follow-up was complete in 100%. The follow-up time was 51.2 (IQR = 21.4–97.5) months for MIDCAB and 40.8 (IQR = 26.0–48.5) months for PCI. PCI patients were older (62.5 vs. 70.1 years), with lower left ventricular ejection fraction (55.6 vs. 50.3) and worse kidney function (creatinine = 90.8 vs. 116.7 µmol/L). After adjustment, there were no differences in the baseline characteristics. There was no difference in the long-term survival at 10 years before (p = 0.338) and after adjustment (p = 0.135) as well as similar rates of MI (p = 0.120 and p = 0.692). Other secondary outcomes are displayed in [Table 1].

Table 1 Secondary outcomes

	MIDCAB	PCI	p value
Re-intervention—Before matchingRe-intervention—After matching	4/68 (5.9%)0/27 (0%)	26/83 (31.3%)13/32 (40.6%)	<0.001<0.001
Revasc. success—Before matchingRevasc. success—After matching	99/100 (99%)44/44 (100%)	105/121 (86.8%)38/43 (88.4%)	<0.0010.026
Cancelled intervention—Before matchingCancelled intervention—After matching	0/100 (0%)0/44 (0%)	18/121 (14.9%)7/44 (15.9%)	<0.0010.012
30-day mortality—Before matching30-day mortality—After matching	1/100 (1%)1/44 (2.3%)	12/118 (10.2%)2/42 (4.8%)	0.0040.612

Conclusion: When compared with PCI for LAD-CTO, MIDCAB is associated with less re-interventions, higher success rates, less cancelled interventions, without difference in MI rates, short- or long-term mortality.