Letter to the Editor

Five-year outcomes of percutaneous coronary intervention versus coronary artery bypass graft surgery in patients with left main coronary artery disease: An updated meta-analysis of randomized trials and adjusted observational studies

Revascularisation of left main coronary artery (LMCA) disease can be potentially managed with percutaneous coronary intervention (PCI) or coronary artery bypass graft surgery (CABG). Recent randomised controlled trial (RCT) data have added to the literature on this subject and this meta-analysis aims to assess the state of the data to assist in guiding patient treatment decisions.

A systematic literature search of Cochrane Library, EMBASE, OVID, and PubMed Medline was performed. Randomised controlled trials of patients with LMCA disease undergoing PCI with drug eluting stents or CABG were included. Clinical outcomes and adverse events were assessed and analysed.

Four suitable RCTs of adequate quality and follow-up were identified. The incidence of major adverse cardiac and cerebrovascular events (MACCE) at 3 to 5 years of follow-up was significantly increased with PCI compared to CABG (23.3% vs 18.2%, OR 1.37; 95% CI: 1.18–1.58; p = < 0.0001; I² = 0%) and was largely driven by more repeat revascularisation procedures among patients treated with PCI. There was no statistically significant difference in rates of mortality, myocardial infarction or stroke (either individually or when these outcomes were combined as a composite endpoint).

Coronary artery bypass grafting and PCI both represent reasonable treatment modalities for LMCA disease in appropriately selected patients. However, where CABG is feasible it offers superior long-term freedom from repeat revascularisation. Longer-term follow-up is required to further clarify the durability of mortality outcomes, especially in patients treated with PCI.

The relative efficacy and safety of percutaneous coronary intervention (PCI) with drug-eluting stents (DES), in comparison to coronary artery bypass grafting (CABG) for left main coronary artery disease (LMCAD) remains controversial.

We performed a meta-analysis of randomised studies comparing patients with LMCAD treated with PCI with DES versus those treated with CABG, with respect to clinical outcomes at 1, 3 and 5 years. A secondary meta-analysis was performed according to low (< 32), or high (≥ 33) SYNTAX score.

Five studies comprising 4595 patients were included. There was no significant difference in all-cause death at all time points or when stratified with respect to SYNTAX score. The need for repeat revascularization was significantly higher with PCI at all time-points, and regardless of SYNTAX score. There was significant association between need for repeat revascularization with PCI and diabetics (p = 0.04). At 5 years, non-fatal MI was higher with PCI owing to increased non-procedural events (OR 3.00; CI 1.45–6.21; p = 0.003). CABG showed higher rate of stroke at 1 year (OR 0.21; CI 0.07–0.63; p = 0.005). There was no difference in non-fatal MI or stroke at other time points, nor according to SYNTAX score.

PCI with DES or CABG are equivalent strategies for LMCAD up to 5 years with respect to death, regardless of SYNTAX score. PCI increases the rate of non-procedural MI at 5 years. CABG avoids the need for repeat revascularization, especially in diabetics, but this benefit is offset by higher rate of stroke in the first year of follow up.

La enfermedad del tronco principal izquierdo ha venido en aumento en los últimos años y con ello, la utilidad del manejo percutáneo en algunos grupos seleccionados. Existen publicaciones que comparan resultados similares de la angioplastia percutánea frente a la cirugía de revascularización miocárdica. El advenimiento de nuevas técnicas de imagen o medición fisiológica de las lesiones mejora la apreciación diagnóstica de esta enfermedad. Por otro lado, la evolución vertiginosa de las diferentes plataformas de stents, ofrece más opciones al momento de intervenir a los pacientes. Cualquiera que sea el contexto del paciente con enfermedad del tronco principal, es indispensable contar con un grupo multidisciplinario para poder ofrecer la mejor alternativa de manejo, al paciente indicado.

Left main trunk disease has been increasing over the last few years, and, with it, the usefulness of percutaneous management in some select groups. There are publications showing similar results from percutaneous angioplasty and myocardial revascularization surgery. The advent of new lesion imaging or physiological measurement techniques improves the diagnostic assessment of this disease. Furthermore, the phenomenal evolution of the various stent platforms offers more options for patient interventions. Whatever the context of patients with main trunk disease, it is essential to have a multidisciplinary group in place, in order to offer the best treatment alternative to the appropriate patient.

Despite several clinical studies, efficacy of coronary artery bypass grafting (CABG) surgery versus percutaneous coronary intervention (PCI) in patients with left main (LM) disease remains controversial. The objective of this meta-analysis of randomized trials was to evaluate the clinical outcome of CABG versus PCI with drug-eluting stents in LM coronary disease.

We systematically searched online databases up to March 2017 for randomized trials comparing CABG to PCI with drug-eluting stents. We calculated odds ratios (ORs) and 95% confidence intervals (CIs).

We included data from 5 randomized trials and 4595 patients. At 30 days, CABG was associated with higher stroke (OR 2.54 [95% CI, 1.02–6.31]) and periprocedural myocardial infarction (OR 1.45 [95% CI, 1.00–2.10]), with no other significant differences compared to PCI. At 1 year, CABG reduced repeat revascularization (OR 0.56 [95% CI, 0.40–0.77]), but increased stroke (OR 5.11 [95% CI, 1.62–16.12]). At 3–5 years, CABG reduced repeat revascularization (OR 0.55 [95% CI, 0.45–0.67]) and non-periprocedural myocardial infarction (OR 0.45 [95% CI, 0.29–0.70]), without significant differences on other outcomes.

From the present updated meta-analysis of available studies on LM coronary disease treatment, there were no differences in mortality, myocardial infarction, and stroke rate at 3–5 years follow-up after CABG or PCI, but CABG decreased the rate of repeat revascularization and non-periprocedural infarction. However, at short-term follow-up, CABG showed higher rate of stroke and periprocedural myocardial infarction, but these effects attenuated over time. These findings merit further investigation at longer follow-up.

The study sought to investigate the impact of different computing methods for composite endpoints other than time-to-event (TTE) statistics in a large, multicenter registry of unprotected left main coronary artery (ULMCA) disease.

TTE statistics for composite outcome measures used in ULMCA studies consider only the first event, and all the contributory outcomes are handled as if of equal importance.

The TTE, Andersen-Gill, win ratio (WR), competing risk, and weighted composite endpoint (WCE) computing methods were applied to ULMCA patients revascularized by percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) at 14 international centers.

At a median follow-up of 1,295 days (interquartile range: 928 to 1,713 days), all analyses showed no difference in combinations of death, myocardial infarction, and cerebrovascular accident between PCI and CABG. When target vessel revascularization was incorporated in the composite endpoint, the TTE (p = 0.03), Andersen-Gill (p = 0.04), WR (p = 0.025), and competing risk (p < 0.001) computing methods showed CABG to be significantly superior to PCI in the analysis of 1,204 propensity-matched patients, whereas incorporating the clinical relevance of the component endpoints using WCE resulted in marked attenuation of the treatment effect of CABG, with loss of significance for the difference between revascularization strategies (p = 0.10).

In a large study of ULMCA revascularization, incorporating the clinical relevance of the individual outcomes resulted in sensibly different findings as compared with the conventional TTE approach. In particular, using the WCE computing method, PCI and CABG were no longer significantly different with respect to the composite of death, myocardial infarction, cerebrovascular accident, or target vessel revascularization at a median of 3 years.