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Updated: Mar 15, 2026
Author Spotlight: Enhancing Coronary Artery Revascularization
Published on: September 15, 2023
Outcomes After Percutaneous Coronary Intervention or Bypass Surgery in Patients With Unprotected Left Main Disease
Rafael Cavalcante1, Yohei Sotomi2, Cheol W Lee3
1Thoraxcenter, Department of Interventional Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands; Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil.
Insights
Percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) offer similar safety for unprotected left main coronary disease (LMD). However, PCI shows reduced mortality in patients with isolated LMD or LMD plus one-vessel disease.
Area of Science:
- Cardiovascular Medicine
- Interventional Cardiology
- Cardiac Surgery
Background:
- Randomized data comparing percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) for unprotected left main coronary disease (LMD) is limited by small patient numbers.
- Existing studies often lack the statistical power to definitively guide treatment decisions for complex LMD cases.
Purpose of the Study:
- To assess and compare the long-term outcomes of PCI versus CABG in patients with unprotected left main coronary disease (LMD).
- To evaluate treatment efficacy in specific subgroups based on the anatomical complexity of the LMD.
Main Methods:
- A pooled analysis of individual patient-level data from the PRECOMBAT and SYNTAX trials was conducted.
- The study included 1,305 patients with unprotected left main coronary disease (LMD).
- Major adverse cardiac and cerebrovascular events were assessed at a 5-year follow-up.
Main Results:
- At 5 years, the incidence of major adverse cardiac and cerebrovascular events was 28.3% for PCI and 23.0% for CABG (HR: 1.23; p=0.045).
- The difference was primarily driven by a higher rate of repeat revascularization with PCI (HR: 1.85; p<0.001).
- Both strategies showed similar rates for the composite safety endpoint of death, myocardial infarction, or stroke (p=0.45).
- In patients with isolated LMD or LMD plus one-vessel disease, PCI significantly reduced all-cause mortality (HR: 0.40; p=0.029) and cardiac mortality (HR: 0.33; p=0.025) compared to CABG.
Conclusions:
- For unprotected left main coronary disease (LMD), both coronary artery bypass graft (CABG) and percutaneous coronary intervention (PCI) yield similar rates of death, myocardial infarction, or stroke.
- PCI demonstrates a significant survival benefit in patients with isolated LMD or LMD plus one-vessel disease compared to CABG.
Background:
Currently available randomized data on the comparison between percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) for the treatment of unprotected left main coronary disease (LMD) lacks statistical power due to low numbers of patients enrolled.
Objectives:
This study assessed long-term outcomes of PCI and CABG for the treatment of LMD in specific subgroups according to disease anatomic complexity.
Methods:
We conducted a pooled analysis of individual patient-level data of the LMD patients included 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. Incidences of major adverse cardiac events were assessed at 5 years follow-up.
Results:
Study population comprised 1,305 patients. The incidence of major adverse cardiac and cerebrovascular events at 5 years was 28.3% in the PCI group and 23.0% in the CABG group (hazard ratio [HR]: 1.23; 95% confidence interval [CI]: 1.01 to 1.55; p = 0.045). This difference is mainly driven by a higher rate of repeat revascularization associated with PCI (HR: 1.85; 95% CI: 1.38 to 2.47; p < 0.001). The 2 strategies showed similar rates of the safety composite endpoint of death, myocardial infarction, or stroke (p = 0.45). In patients with isolated LM or LM + 1-vessel disease, PCI was associated with a 60% reduction in all-cause mortality (HR: 0.40; 95% CI: 0.20 to 0.83; p = 0.029) and 67% reduction in cardiac mortality (HR: 0.33; 95% CI: 0.12 to 0.88; p = 0.025) when compared with CABG.
Conclusions:
In patients with unprotected LMD, CABG, and PCI result in similar rates of the safety composite endpoint of death, myocardial infarction, or stroke. In patients with isolated LM or LM + 1-vessel disease, PCI is associated with lower all-cause and cardiac mortality when compared to CABG.
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