Abstract
BackgroundThe optimal revascularization technique in patients with left main coronary artery disease (CAD) remains controversial. We aimed to compare the long-term performance of percutaneous coronary intervention (PCI) versus coronary artery bypass graft (CABG) surgery in treatment of left main CAD.MethodsPubMed, EMBASE, and the Cochrane Library were searched until November 16, 2016.ResultsSix randomized controlled trials and 22 matched observational studies including 22,487 patients and 90,167 patient-years of follow-up were included. PCI was associated with an overall higher risk for the major adverse cardiac and cerebrovascular events (hazard ratio (HR), 1.42; 95% confidence interval (CI), 1.14–1.77), mainly driven by higher rates of myocardial infarction (HR, 1.69; 95% CI, 1.22–2.34) and revascularization (HR, 2.80; 95% CI, 1.86–4.22). The overall risks for all-cause death (HR, 1.05; 95% CI, 0.93–1.20), cardiac death (HR, 1.05; 95% CI, 0.69–1.59), stroke (HR, 0.64; 95% CI, 0.33–1.24), and the composite safety endpoint of death, myocardial infarction, or stroke (HR, 1.06; 95% CI, 0.97–1.16) were similar between PCI and CABG. Stratified analysis based on stent types showed that the increased risk for myocardial infarction associated with PCI was only evident in patients with bare-metal stents or early-generation drug-eluting stents (DES), but not newer-generation DES. Stratified analyses based on study designs showed largely similar findings with the overall analyses, except for a significantly higher incidence of myocardial infarction in adjusted studies (HR, 2.01; 95% CI, 1.64–2.45) but a trend toward higher incidence in randomized trials (HR, 1.39; 95% CI, 0.85–2.27) associated with PCI.ConclusionsCompared with CABG, PCI with newer-generation DES might be a safe alternative revascularization strategy for treatment of left main CAD, but is associated with more repeat revascularization.
Highlights
The optimal revascularization technique in patients with left main coronary artery disease (CAD) remains controversial
We identified 2597 citations though database searches; 28 studies reported in 26 articles met inclusion criteria
On the basis of pooled data from 28 studies that included nearly 22,500 patients with left main CAD receiving percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) treatment, we found that PCI was associated with a higher risk for major adverse cardiac and cerebrovascular events (MACCE), which was evident both in studies with newer-generation drug-eluting stents (DES) and those with bare-metal stents (BMS) or early-generation DES, mainly driven by higher rates of myocardial infarction and revascularization associated with PCI
Summary
The optimal revascularization technique in patients with left main coronary artery disease (CAD) remains controversial. We aimed to compare the long-term performance of percutaneous coronary intervention (PCI) versus coronary artery bypass graft (CABG) surgery in treatment of left main CAD. The most recent European and US guidelines made a recommendation with a Class II to I indication for PCI in left main CAD patients with low to intermediate anatomic complexity [4, 5] These guidelines were mainly based on midterm findings of the SYNTAX trial [6], the PRECOMBAT trial [7], and two other small trials [8, 9], all of which were underpowered to determine the comparative safety and efficacy of PCI versus CABG, for individual hard endpoints. We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) and matched observational studies to compare the long-term performance of PCI versus CABG in patients with left main CAD, and to determine whether the development of stents would affect these findings
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