Revascularization in left main coronary artery disease: comparison of off-pump coronary artery bypass grafting vs percutaneous coronary intervention. 
There is no evidence for the increasing use of percutaneous coronary intervention (PCI) compared with surgery in patients with left main coronary artery (LMCA) disease.  We compared the clinical outcomes of patients with LMCA disease who had undergone PCI with those of patients who had off-pump coronary artery bypass (OPCAB) grafting.  From January 2001 to December 2009, 899 patients with LMCA disease were treated with OPCAB (n = 553) or PCI (n = 346).  Analyses using propensity-score matching were performed to minimize the selection bias.  We compared major adverse cardiac and cerebrovascular events (MACCE) including death, stroke, acute myocardial infarction and target-vessel revascularization.  The median follow-up was 55.9 months.  For the 159 propensity-matched pairs, the early mortality in the OPCAB group was lower than in the PCI group (0 vs 5%, the PCI group; P < 0.001).  Overall survival at 8 years was similar between groups (88.6 ± 3.5%, the OPCAB group vs 85.8 ± 5.3%, the PCI group; P = 0.394).  Freedom from MACCE at 8 years was significantly higher in the OPCAB than in the PCI group (83.9 ± 5.1 vs 60.2 ± 6.9%, P < 0.001).  Although there was no intergroup difference in the risk of death [hazard ratio (HR) for the PCI group, 1.435; 95% confidence interval (CI), 0.62-3.31; P = 0.396], a significant difference was found in the risk of MACCE (HR for the PCI group, 4.193; 95% CI, 2.165-8.121; P < 0.001).  This difference was primarily due to a higher risk of acute myocardial infarction (HR for the PCI group, 4.730; 95% CI, 0.99-22.63; P = 0.049) and higher rates of target-vessel revascularization (HR for the PCI group, 5.508; 95% CI, 1.87-16.22; P = 0.002).  Compared with PCI, OPCAB is associated with a lower incidence of MACCE in patients with LMCA disease, determined mainly by the lower incidences of acute myocardial infarction and target-vessel revascularization.  The incidence of stroke in the OPCAB group was similar to the PCI group.