Percutaneous coronary intervention vs. coronary artery bypass grafting for left main revascularization: an updated
Navkaranbir S Bajaj1,2, Nirav Patel2, Rajat Kalra3
1Division of Cardiovascular Medicine, Department of Radiology, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115, USA.
Insights
Percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) for left main coronary artery disease (LMAD) show similar long-term outcomes. Individualized treatment decisions are crucial for optimal revascularization strategies.
Area of Science:
- Cardiology
- Interventional Cardiology
- Cardiac Surgery
Background:
- Left main coronary artery disease (LMAD) treatment strategies, percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG), have conflicting trial results.
- Optimal revascularization for LMAD remains a significant clinical controversy.
Purpose of the Study:
- To analyze and compare long-term outcomes of PCI versus CABG for LMAD revascularization.
- To address the ongoing controversy regarding the best revascularization strategy for LMAD.
Main Methods:
- A comprehensive literature search was conducted.
- Standard meta-analytic techniques were used to compare PCI and CABG for LMAD.
- Major adverse cardiac and cerebrovascular events (MACCE), including death, myocardial infarction (MI), stroke, and repeat revascularization, were analyzed.
Main Results:
- PCI showed a 21% higher long-term risk of MACCE compared to CABG, primarily due to increased repeat revascularization.
- At 30 days, PCI had lower MACCE rates, driven by reduced stroke.
- At 1 year, stroke rates were lower with PCI, but higher repeat revascularization balanced MACCE, showing clinical equipoise. No significant differences in death or MI were observed between PCI and CABG.
Conclusions:
- Revascularization outcomes for LMAD via CABG versus PCI differ over time.
- Individualized treatment decisions, utilizing a heart team approach, are essential for LMAD revascularization.
Aims:
The optimal revascularization strategy for left main coronary artery disease (LMD) remains controversial, especially with two recent randomized controlled trials showing conflicting results. We sought to address this controversy with our analysis.
Methods And Results:
Comprehensive literature search was performed. We compared percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) for LMD revascularization using standard meta-analytic techniques. A 21% higher risk of long-term major adverse cardiac and cerebrovascular event [MACCE; composite of death, myocardial infarction (MI), stroke, and repeat revascularization] was observed in patients undergoing PCI in comparison with CABG [risk ratio (RR) 1.21, 95% confidence interval (CI) 1.05-1.40]. This risk was driven by higher rate of repeat revascularization in those undergoing PCI (RR 1.61, 95% CI 1.34-1.95). On the contrary, MACCE rates at 30 days were lower in PCI when compared with CABG (RR 0.55, 95% CI 0.39-0.76), which was driven by lower rates of stroke in the PCI arm (RR 0.41, 95% CI 0.17-0.98). At 1 year, lower stroke rates (RR 0.21, 95% CI 0.08-0.59) in the PCI arm were balanced by higher repeat revascularization rates in those undergoing PCI (RR 1.78, 95% CI 1.33-2.37), resulting in a clinical equipoise in MACCE rates between the two revascularization strategies. There was no difference in death or MI between PCI when compared with CABG at any time point.
Conclusion:
Outcomes of CABG vs. PCI for LMD revascularization vary over time. Therefore, individualized decisions need to be made for LMD revascularization using the heart team approach.
Related Concept Videos
01:27Coronary Artery Disease V: Interprofessional Care
01:24Cardiac Catheterization III: Left Heart Catheterization