Coronary artery bypass graft surgery versus percutaneous coronary intervention in unprotected left main coronary
Liviu Macovei1,2, Robert Magopet1, Ana Tanasa1,2
1Institute of Cardiovascular Diseases "Prof. dr. George I.M. Georgescu", Iasi 700503, Romania.
Insights
Coronary artery bypass grafting and percutaneous coronary intervention show similar survival for unprotected left main disease. Coronary artery bypass grafting may reduce ischemic events but increases stroke risk in multivessel disease.
Area of Science:
- Cardiology
- Interventional Cardiology
- Cardiovascular Surgery
Background:
- Unprotected left main coronary disease (ULMD) poses a significant mortality risk.
- Coronary artery bypass grafting (CABG) has been the traditional treatment for decades.
- Percutaneous coronary intervention (PCI) with drug-eluting stents (DES) is an emerging alternative.
Purpose of the Study:
- To review randomized clinical trials and meta-analyses comparing PCI with DES versus CABG for ULMD.
- To analyze current European and American revascularization guidelines.
- To clarify the optimal revascularization strategy for ULMD.
Main Methods:
- Systematic review of major randomized clinical trials and meta-analyses.
- Analysis of comparative effectiveness data for PCI with DES versus CABG.
- Evaluation of guideline recommendations for ULMD treatment.
Main Results:
- No significant difference in survival rates between PCI and CABG for isolated ULMD.
- CABG demonstrated fewer major ischemic events than PCI in multivessel disease.
- PCI was associated with a higher incidence of stroke compared to CABG.
Conclusions:
- PCI with DES is a viable option for ULMD, particularly in low SYNTAX score patients.
- CABG remains preferred for reducing ischemic events in multivessel disease, despite higher stroke risk.
- Further research is needed on new-generation DES and acute coronary syndromes involving ULMD.
Abstract:
Critical lesion of the unprotected left main coronary disease carries a tremendous mortality burden, often associated with a diabetes status or multivessel disease, with coronary artery bypass grafting being the standard treatment for over 40 years. Percutaneous coronary intervention with drug eluting stents should be taken into consideration and could be a better option for patients with low SYNTAX score as validated by the recently published studies. This review summarizes the major randomized clinical trials and meta-analyses concerning the debate regarding percutaneous coronary intervention with drug eluting stents versus coronary artery bypass grafting for unprotected left main coronary disease, along with the latest European and American revascularization guidelines and tries to shed light on this matter. The most results advocate that there is no convincing difference in survival rate for both therapies, especially in patients with isolated left main disease but with fewer major ischemic events for coronary artery bypass grafting when compared with percutaneous coronary intervention in multivessel coronary artery disease, at the rate of a higher stroke incidence. The gaps in evidence are also highlighted, especially the lack of randomized clinical trials with new generation drug eluting stents versus coronary artery bypass grafting or those regarding the best revascularization strategy for an acute coronary syndrome when unprotected left main coronary disease is involved.
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