Percutaneous Coronary Intervention vs. Coronary Artery Bypass Graft Surgery for Unprotected Left Main Coronary Artery Disease in the Drug-Eluting Stents Era

Abstract

Patients with unprotected left main coronary artery (LMCA) disease are increasingly treated with percutaneous coronary intervention (PCI) using drug-eluting stents (DES), but its benefits compared with coronary artery bypass grafting (CABG) remain controversial. We hypothesized that PCI with DES for unprotected LMCA disease is safe and effective compared with CABG. We performed aggregate data meta-analyses of clinical outcomes [death; non-fatal myocardial infarction (MI); stroke; repeat revascularization; and major adverse cardiac and cerebrovascular events (MACCE)] in studies comparing PCI with DES vs. CABG in patients with LMCA disease. A comprehensive literature search (01/01/2003 to 12/01/2011) identified 27 studies comparing PCI and CABG (11,148 patients). Summary odds ratios (OR) were calculated using a random-effects model. At 30 days, PCI for unprotected LMCA disease was associated with lower MACCE [odds ratio (OR) 0.57, 95% confidence interval (CI) 0.36-0.89) and stroke rates (OR 0.22, 95% CI 0.11-0.44) compared with CABG. At 12 months, the PCI group experienced higher rates of repeat revascularization (OR 3.72, 95% CI 2.75-5.03), but lower rates of stroke (OR 0.25, 95% CI 0.14-0.44) and all-cause death (OR 0.69, 95% CI 0.49-0.97). At the longest follow-up of 60 months, PCI was associated with equivalent mortality, lower rates of stroke (OR 0.42, 95% CI 0.28-0.62) and higher rates of MACCE (OR 1.30, 95% CI 1.10-1.55) and repeat revascularization (OR 3.54, 95% CI 2.75-4.54). In the DES era, PCI for unprotected LMCA disease is associated with equivalent mortality and MI, lower stroke rates and higher rates of repeat revascularization compared with CABG.