Five-Year Outcomes in Patients With Left Main Disease Treated With Either Percutaneous Coronary Intervention or Coronary Artery Bypass Grafting in the Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery Trial
What is the relative efficacy of percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG) in patients with left main coronary artery disease?
The SYNTAX trial authors reported the 5-year outcomes of patients with de novo left main coronary artery disease who were randomized in the SYNTAX trial to undergo CABG or PCI with the Taxus stent.
The SYNTAX trial randomly assigned 705 patients with left main artery disease to receive either PCI (with TAXUS Express paclitaxel-eluting stents) or CABG. There was no difference in the major adverse cardiac and cerebrovascular event rates at 5 years (36.9% in PCI patients vs. 31.0% in CABG patients; hazard ratio [HR], 1.23; 95% confidence interval [CI], 0.95-1.59; p = 0.12). There was no difference in the 5-year mortality rate (12.8% with PCI vs. 14.6% with CABG; HR, 0.88; 95% CI, 0.58-1.32; p = 0.53). Stroke was significantly increased in the CABG group (PCI 1.5% vs. CABG 4.3%; HR, 0.33; 95% CI, 0.12-0.92; p = 0.03) and repeat revascularization in the PCI arm (26.7% vs. 15.5%; HR, 1.82; 95% CI, 1.28-2.57; p < 0.01). Major adverse cardiac and cerebrovascular events were similar between the two arms in patients with low/intermediate SYNTAX scores, but significantly increased in PCI patients with high scores (≥33).
At 5 years, there was no difference in overall major adverse cardiac and cerebrovascular events among patients with left main artery disease who were randomized to PCI versus CABG. PCI-treated patients had a lower stroke, but a higher revascularization rate versus CABG.
The overall results of the SYNTAX trial favored PCI, whereas the outcomes were similar among patients with left main disease. Among patients with left main disease, outcomes were broadly similar overall, and especially in patients with a low SYNTAX score. The stent used in this trial has been supplanted in practice by second-generation stents that have better safety and efficacy than the first-generation Taxus stent, and it is likely that the outcomes with contemporary PCI would be even better than seen in this trial. This suggests that both CABG and PCI should be considered viable options for left main disease, and the choice of revascularization should be influenced by a careful discussion of the unique risks and benefit of each approach and patient and physician preference. Outcomes with stenting for left main lesions that do not involve the bifurcation have been excellent in studies of drug-eluting stents, and it may be worth considering a PCI first approach for this group of patients.
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