Aims

Recent randomized controlled trials have sparked debate about the optimal treatment of patients suffering from left main coronary artery disease. The present study analyzes the decision making and outcomes of left main stenting versus coronary bypass grafting (CABG) in a nationwide registry in patients with chronic coronary syndrome (CCS).

Methods and results

All cases without acute coronary syndrome and without concomitant heart valve surgery, suffering from left main coronary artery disease treated either with CABG or stent, were identified within the database of the German bureau of statistics by ICD and procedural codes. Since patients were not randomized to the two treatment options, logistic or linear regression models were used with 20 baseline patient characteristics as potential confounders.  In the most recent available year 2018 1,318 cases with left main stenosis were treated with CABG and 8,920 with stent. Patients assigned for stenting were older (72.58±9.87 vs. 68.63±9.40, p<0.001) and at higher operative risk, as assessed by logistic EuroSCORE (8.77±8.45 vs. 4.85±4.65, p<0.001). After risk adjustment, no marked differences in outcomes were found for in-hospital mortality and stroke (risk adjusted odds ratio (aOR) for stent instead of CABG: aOR mortality: 1.08 [95%CI 0.66;1.78], p=0.748; aOR stroke: 0.59 [0.27;1.32], p=0.199). Stent implantation was associated with a reduced risk of relevant bleeding (aOR 0.38 [0.24;0.61], p<0.001), reduced prolonged ventilation time (aOR 0.54 [0.37;0.79], p=0.002), and postoperative delirium (aOR 0.16 [0.11;0.22], p<0.001). Furthermore, stent implantation was associated with shorter hospital stay (-6.78 days [-5.86;-7.71], p<0.001) and lower costs (-€10,035 [-€11,500;-€8,570], p<0.001).

Conclusion

Concerning in-hospital outcomes, left main stenting is a safe and effective treatment option for CCS-patients suffering from left main coronary artery disease at reasonable economic cost.