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Percutaneous coronary intervention versus coronary bypass surgery for unprotected left main disease: a meta-analysis
Mohamed Rahouma1, Ahmed Abouarab1, Antonino Di Franco1
1Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA.
Insights
Coronary artery bypass grafting (CABG) is superior to percutaneous coronary intervention (PCI) for unprotected left main coronary disease, particularly in high-SYNTAX score patients. CABG reduces the risk of death, myocardial infarction, stroke, and repeat revascularization compared to PCI.
Area of Science:
- Cardiology
- Interventional Cardiology
- Cardiac Surgery
Background:
- Unprotected left main coronary disease (LMD) poses significant risks.
- Treatment options include coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI).
- Comparing the long-term efficacy and safety of CABG versus PCI for LMD is crucial.
Purpose of the Study:
- To compare the effectiveness of CABG and PCI in treating unprotected left main coronary disease (LMD).
- To evaluate the composite outcome of death, myocardial infarction, stroke, and repeat revascularization.
- To assess secondary outcomes including peri-procedural mortality and individual event rates.
Main Methods:
- Meta-analysis of six randomized controlled trials (RCTs) involving 4,700 patients.
- Included RCTs compared any PCI with stents versus CABG for LMD.
- Pooled data using random effects models; performed subgroup analyses by PCI type (BMS vs. DES) and SYNTAX score tertiles.
Main Results:
- PCI was associated with a significantly higher risk of the composite outcome (death/MI/stroke/repeat revascularization) and repeat revascularization.
- No significant differences were observed in peri-procedural mortality, follow-up mortality, myocardial infarction, or stroke between PCI and CABG.
- Higher SYNTAX scores correlated with increased risk for the primary outcome in the PCI group.
Conclusions:
- Coronary artery bypass grafting (CABG) remains the preferred treatment for unprotected left main coronary disease (LMD).
- This is particularly true for patients with high SYNTAX scores, where CABG demonstrates better outcomes.
- PCI outcomes worsen progressively with increasing SYNTAX scores.
Background:
This meta-analysis of randomized controlled trials (RCTs) was aimed at comparing coronary artery bypass grafting (CABG) with percutaneous coronary intervention (PCI) for the treatment of unprotected left main coronary disease.
Methods:
All RCTs randomizing patients to any type of PCI with stents vs. CABG for left main disease (LMD) were included. Primary outcome was a composite of follow-up death/myocardial infarction/stroke/repeat revascularization. Secondary outcomes were peri-procedural mortality and the individual components of the primary outcome. Incidence rate ratio (IRR) or odds ratio (OR) and 95% confidence intervals (CIs) were pooled using a generic inverse variance method with random effects model. Subgroup analyses were done based on: (I) type of PCI [bare metal stents (BMS) vs. drug-eluting stents (DES)] and; (II) mean SYNTAX score tertiles. Leave one-out analysis and meta-regression were performed.
Results:
Six trials were included (4,700 patients; 2,349 PCI and 2,351 CABG). Follow-up ranged from 2.33 to 5 years. PCI was associated with higher risk of follow-up death/myocardial infarction/stroke/repeat revascularization (IRR =1.328, 95% CI, 1.114-1.582, P=0.002) and of repeated revascularization (IRR =1.754, 95% CI, 1.470-2.093, P<0.001). The risk of peri-procedural mortality (OR =0.866, 95% CI, 0.460-1.628, P=0.654), follow-up mortality (IRR =0.947, 95% CI, 0.711-1.262, P=0.712), myocardial infarction (IRR =1.342, 95% CI, 0.827-2.179, P=0.234) and stroke (IRR =0.800, 95% CI, 0.374-1.710, P=0.565) were similar between groups. No differences were found between DES and BMS subgroups. The risk of follow-up death/myocardial infarction/stroke/repeat revascularization with PCI was higher in all SYNTAX tertiles, with a progressive increase from the 1st to the 3rd tertile. At meta-regression, higher mean SYNTAX score was associated with higher risk for the primary outcome in the PCI group (beta =0.02, P=0.05), whereas no association was found with female gender, mean age, or diabetes.
Conclusions:
CABG remains the therapy of choice for the treatment of unprotected LMD, especially for patients with a high SYNTAX score.
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