Percutaneous Coronary Intervention vs. Coronary Artery Bypass Grafting in Left Main Coronary Artery Disease: An
Conor Hennessy1, John Henry2, Gokul Parameswaran3
1Medicine and Surgery, Nuffield Department of Surgical Sciences, John Radcliffe Hospital, Oxford, GBR.
Insights
Percutaneous coronary intervention (PCI) is a viable alternative to coronary artery bypass grafting (CABG) for uncomplicated left main coronary artery disease, showing similar long-term mortality. However, CABG may be preferred for complex cases.
Area of Science:
- Cardiovascular Medicine
- Interventional Cardiology
- Clinical Trials Analysis
Background:
- Current guidelines favor coronary artery bypass grafting (CABG) for left main coronary artery (LMCA) disease.
- Emerging evidence suggests percutaneous coronary intervention (PCI) may be a comparable alternative.
Purpose of the Study:
- To conduct a meta-analysis of randomized controlled trials (RCTs) comparing PCI and CABG for LMCA disease.
- To evaluate long-term efficacy and safety outcomes of PCI versus CABG.
Main Methods:
- Systematic search of Medline, Embase, Cochrane, and clinicaltrials.gov up to August 20, 2022.
- Inclusion of six RCTs analyzing all-cause mortality, MACCE, MI, stroke, and revascularization at 30 days, 1, 5, and 10 years.
- Random effects model used for data analysis.
Main Results:
- PCI demonstrated non-inferiority to CABG for all-cause mortality across all time points.
- Major adverse cerebrovascular and cardiovascular events (MACCE) favored PCI at 30 days and CABG at 5 years.
- Myocardial infarction rates varied based on definition, with higher rates for PCI under the third universal definition at 5 years; stroke favored PCI early on, while revascularization favored CABG at 1 and 5 years.
Conclusions:
- PCI is a feasible alternative to CABG for uncomplicated LMCA disease.
- CABG may offer advantages for patients with complex LMCA lesions.
- Further research may be needed to clarify MI definitions and long-term outcomes.
Abstract:
Recently, both US and European guidelines have predominantly recommended coronary artery bypass grafting (CABG) as the preferred revascularisation method. However, emerging data have raised the possibility of percutaneous coronary intervention (PCI) being a viable and effective alternative. This meta-analysis sought to evaluate the latest insights from major clinical trials to ascertain whether PCI could be as effective as CABG in treating left main coronary artery (LMCA) disease. To achieve this, a comprehensive systematic search was conducted across databases, including Medline (via PubMed), Embase, Cochrane, and clinicaltrials.gov. The search spanned from the inception of these databases to August 20, 2022, and exclusively focused on randomized controlled trials (RCTs). Employing the random effects model, selected studies underwent rigorous analysis. The study outcomes encompassed a spectrum of factors such as all-cause mortality, major adverse cerebrovascular and cardiovascular events (MACCE), myocardial infarction (MI), stroke, and revascularisation procedures. The observation periods of interest included the 30-day mark, 1 year, 5 years, and 10 years. The analysis integrated six RCTs, revealing noteworthy patterns. In terms of all-cause mortality, PCI demonstrated non-inferiority to CABG across all observed time frames: 30 days (OR 0.6), 1 year (OR 0.77), 5 years (OR 1.41), and 10 years (OR 1.08). Analysis of MACCE outcomes favored PCI at 30 days and CABG at 5 years. The utilisation of the original five-year EXCEL (Evaluation of XIENCE versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularisation) trial definition for MI highlighted higher MI rates for PCI compared to CABG (OR 1.66, P < 0.05). Intriguingly, when the subsequently released EXCEL data, aligned with the third universal MI definition, was incorporated, the five-year data consistently leaned towards CABG. Specifically, the PCI group exhibited 7.5% MI rates in contrast to the 3.6% in the CABG cohort (OR 2.19, P < 0.001). Concerning stroke, PCI proved advantageous at 30 days and 1 year while exhibiting no significant disparity at 5 and 10 years. Revascularisation procedures favoured CABG at one and five years, with comparability at the remaining time points. In summation, the outcomes of this comprehensive meta-analysis suggest that PCI could serve as a feasible alternative to CABG in the context of uncomplicated LMCA disease. It's worth noting that CABG might still hold an advantage for complex lesions.
