Percutaneous Coronary Intervention Versus Coronary Artery Bypass Graft Surgery in Left Main Coronary Artery Disease: A Meta-Analysis of Randomized Clinical Data

Study Questions:

What is the safety and efficacy of percutaneous coronary intervention (PCI) compared with coronary artery bypass grafting (CABG) in patients with left main coronary artery (LMCA) disease?

Methods:

The investigators identified 1,611 patients from four randomized clinical trials for the present meta-analysis. The primary endpoint was the 1-year incidence of major adverse cardiac and cerebrovascular events (MACCE), defined as death, myocardial infarction (MI), target vessel revascularization (TVR), or stroke. The results of all studies were combined using a random-effects model to minimize heterogeneity between groups and confirmed by a fixed-effects model to avoid overweighting of small studies.

Results:

PCI was associated with a nonsignificantly higher 1-year rate of MACCE compared with CABG (14.5% vs. 11.8%; odds ratio [OR], 1.28; 95% confidence interval [CI], 0.95-1.72; p = 0.11), driven by increased TVR (11.4% vs. 5.4%; OR, 2.25; 95% CI, 1.54-3.29; p < 0.001). Conversely, stroke occurred less frequently with PCI (0.1% vs. 1.7%; OR, 0.15; 95% CI, 0.03-0.67; p = 0.013). There were no significant differences in death (3.0% vs. 4.1%; OR, 0.74; 95% CI, 0.43-1.29; p = 0.29) or MI (2.8% vs. 2.9%; OR, 0.98; 95% CI, 0.54-1.78; p = 0.95).

Conclusions:

The authors concluded that in patients with LMCA disease, PCI was associated with nonsignificantly different 1-year rates of MACCE, death, and MI; a lower risk of stroke; and a higher risk of TVR compared with that for CABG.

Perspective:

This meta-analysis found no significant differences between PCI and CABG in patients with LMCA disease for the occurrence of 1-year MACCE and the component endpoints of death or MI. However, PCI was associated with higher rates of TVR, but with fewer CVAs compared with CABG. CABG is still regarded as the standard of care for significant LMCA disease in patients eligible for surgery, and it is crucial to assess whether the results reported in this analysis remain durable at longer-term follow-up (at least 5 years). Ideally, for patients with LMCA disease, all relevant data should be reviewed by a clinical/noninvasive cardiologist, a cardiac surgeon, and an interventional cardiologist (Heart Team Approach) to determine the optimal revascularization strategy with either PCI or CABG.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Aortic Surgery

Keywords: Incidence, Myocardial Infarction, Follow-Up Studies, Death, Cardiovascular Diseases, Coronary Artery Bypass, Angioplasty, Balloon, Coronary, Percutaneous Coronary Intervention


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