Long-term outcomes of coronary artery bypass grafting versus stent-PCI for unprotected left main disease: a meta-analysis

Salvatore De Rosa,Jolanda Sabatino,Ciro Indolfi,Alberto Polimeni

doi:10.1186/s12872-017-0664-5

Abstract

BackgroundCoronary artery bypass graft (CABG) surgery has traditionally represented the standard of care for left main coronary artery (LMCA) disease. However, percutaneous coronary intervention with stent implantation (PCI) has more recently emerged as a valuable alternative. The long-time awaited results of the largest randomized trials on the long-term impact of PCI versus CABG in LMCA disease, the newly published NOBLE and EXCEL studies, revealed contrasting results. Thus, aim of the present meta-analysis was to review the most robust evidence from randomized comparisons of CABG versus PCI for revascularization of LMCA.MethodsRandomized studies comparing long-term clinical outcomes of CABG or Stent-PCI for the treatment of LMCA disease were searched for in PubMed, the Chochrane Library and Scopus electronic databases. A total of 5 randomized studies were selected, including 4499 patients.ResultsNo significant difference between CABG and PCI was found in the primary analysis on the composite endpoint of death, stroke and myocardial infarction (OR = 1·06 95% CI 0·80–1·40; p = 0·70). Similarly, no differences were observed between CABG and PCI for all-cause death (OR = 1·03 95% CI 0·81–1·32; p = 0·81). Although not statistically significant, a lower rate of stroke was registered in the PCI arm (OR = 0·86; p = 0·67), while a lower rate of myocardial infarction was found in the CABG arm (OR = 1·43; p = 0·17). On the contrary, a significantly higher rate of repeat revascularization was registered in the PCI arm (OR = 1·76 95% CI 1·45–2·13; p < 0·001).ConclusionsThe present meta-analysis, the most comprehensive and updated to date, including 5 randomized studies and 4499 patients, demonstrates no difference between Stent-PCI and CABG for the treatment of LMCA disease in the composite endpoint of death, stroke and myocardial infarction. Hence, a large part of patients with unprotected left main coronary artery disease can be managed equally well by means of both these revascularization strategies.

Highlights

Coronary artery bypass graft (CABG) surgery has traditionally represented the standard of care for left main coronary artery (LMCA) disease
Search results Our search retrieved a total of 8902 entries, which were reduced to 155 studies after an initial pre-screening. 130 studies were excluded for one of the following reasons: a) they were not related to our research question b) they weren’t original articles
Analyzing results for single endpoints, we found no difference betwen CABG and percutaneous coronary intervention with stent implantation (PCI) in terms of all-cause death (OR = 1·04 95% CI 0·82–1·32; p = 0·81) (Fig. 5a) and cardiovascular death (OR = 1·01 95% CI 0·71–1·44; p = 0·95) (Fig. 5b)

Summary

Introduction

Coronary artery bypass graft (CABG) surgery has traditionally represented the standard of care for left main coronary artery (LMCA) disease. Percutaneous coronary intervention with stent implantation (PCI) has emerged as a valuable alternative, given the lower peri-procedural risk and the continuous improvement in device technology, associated with better procedural performance and long-term clinical prognosis. In this scenario, the most recent European guidelines for myocardial revascularization endorse PCI with a class I recommendation for LMCA disease with a SYNTAX score (SS) < and and with a class IIa recommendation patients with a SS between and 32 [2]. The aim of the present meta-analysis was to evaluate the long-term outcome of Stent-PCI and CABG for the treatment of LMCA stenoses, on the basis of the larger clinical evidence available to date

Methods

Results

Discussion

Conclusion