Stent Versus Off-Pump Coronary Bypass Grafting in the Second-Generation Drug-Eluting Stent Era

Background. Second-generation drug-eluting stents (DESs) are known to have better safety and clinical outcomes compared with the first-generation DESs. We compared the clinical results of off-pump coronary artery bypass grafting (OPCAB) with percutaneous coronary intervention (PCI) using second-generation DESs. Methods. The study enrolled 1,821 patients with triple-vessel or left main coronary disease, or both, who underwent OPCAB or PCI with second-generation DESs from 2008 to 2011. Major adverse cardiac and cerebrovascular events (MACCEs), including death, myocardial infarction, stroke, and target vessel revascularization, were retrospectively compared between the two groups in a real-world and in a matched population (n = 1,294). Followup duration was 23.0 +/- 13.0 months (range, 0 to 56 months). Results. The postprocedural mortality rate was comparable between the two groups (p = 0.384). The overall rate of MAACEs was 7.3% in the PCI group and 3.8% in the OPCAB group (p = 0.001). The 3-year rate of freedom from MACCEs was 88.4% +/- 1.5% in the PCI group and 94.9% +/- 1.0% in the OPCAB group (p < 0.001). In a matched population comparison, the 3-year rate of freedom from a MACCE was 87.5% +/- 2.0% in the PCI group and 95.3% +/- 1.2% in the OPCAB group (p = 0.001). The determining factors were nonfatal myocardial infarction and target vessel revascularization. The OPCAB group showed a superior rate of freedom from MACCEs in the triple-vessel (p = 0.008) and left main subset analysis (p = 0.001). Conclusions. The OPCAB showed superior outcomes in triple-vessel or left main disease, or both, compared with PCI in the second-generation DES era after 23 months of follow-up. Nonfatal myocardial infarction and target vessel revascularization were the determining factors. Longer follow-up with randomization will clarify our results. (C) 2013 by The Society of Thoracic Surgeons