PCI or CABG for Unprotected Left Main Disease

Study Questions:

What is the outcome of contemporary percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG) for treatment of unprotected left main coronary artery disease (LMD)?

Methods:

The authors conducted a pooled analysis of individual patient-level data of the patients with unprotected LMD in the PRECOMBAT (Bypass Surgery Versus Angioplasty Using Sirolimus-Eluting Stent in Patients With Left Main Coronary Artery Disease) and SYNTAX (Synergy Between PCI With TAXUS and Cardiac Surgery) trials. The primary endpoint was the incidence of major adverse cardiac and cerebrovascular events (MACCE) at 5 years.

Results:

The study population was comprised of 1,305 patients (705 SYNTAX and 600 PRECOMBAT). The incidence of MACCE at 5 years was slightly higher in patients undergoing PCI compared to those treated with CABG (28.3% vs. 23%, hazard ratio [HR], 1.23; 95% confidence interval [CI], 1.01-1.55; p = 0.045). This difference was predominantly driven by a higher rate of repeat revascularization associated with PCI (19.5% vs. 10.8%, HR, 1.85; 95% CI, 1.38-2.47; p < 0.001). There was no difference in the safety composite endpoint of death, myocardial infarction (MI), or stroke (14.3% vs. 16.8%, p = 0.45) or of all-cause death (9.4% vs. 11.1%). In patients with isolated LM or LM + one-vessel disease, compared with CABG, PCI was associated with a lower all-cause mortality (HR, 0.40; 95% CI, 0.20-0.83; p = 0.029) and cardiac mortality (HR, 0.33; 95% CI, 0.12-0.88; p = 0.025).

Conclusions:

In patients with unprotected LMD, CABG and PCI result in similar risk of death, MI, or stroke, while revascularization was more common with PCI. In patients with isolated LM or LM + one-vessel disease, PCI was associated with better survival compared with CABG.

Perspective:

Unprotected left main artery stenosis is considered a surgical problem in the United States, and PCI is usually offered only to those patients who are turned down for surgery. This study adds to the growing body of data demonstrating better long-term survival with PCI in patients with a low or intermediate SYNTAX score. The results of this study make a strong case for use of PCI as the preferred treatment in patients with isolated LMD or those with a low SYNTAX score.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Vascular Medicine, Aortic Surgery, Interventions and Coronary Artery Disease, Interventions and Vascular Medicine

Keywords: Cardiac Surgical Procedures, Constriction, Pathologic, Coronary Artery Bypass, Coronary Artery Disease, Cerebrovascular Disorders, Drug-Eluting Stents, Myocardial Infarction, Myocardial Revascularization, Percutaneous Coronary Intervention, Stroke, Treatment Outcome


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