Unprotected left main revascularization: Percutaneous coronary intervention versus coronary artery bypass. An updated systematic review and meta-analysis of randomised controlled trials.

Luca Testa,Antonio Colombo,Filippo Crea,Azeem Latib,Mario Bollati,Francesco Bedogni,Rocco Antonio Montone,Michael J Lipinski

doi:10.1371/journal.pone.0179060

Abstract

BackgroundThe optimal treatment of unprotected left main (UPLM) with either PCI or CABG remains uncertain.AimThe purpose of this study was to determine the comparative safety and efficacy of PCI versus CABG in patients with UPLM disease.MethodsSearch of BioMedCentral, CENTRAL, mRCT, PubMed, major cardiological congresses proceedings and references cross-check (updated November 2016). Outcomes were the rate of MACE [all cause death, MI, stroke], the rates of the individual components of MACE and the rate of target vessel revascularisation (TVR).ResultsWe identified 6 Randomised Controlled Trials totalling 4717 patients allocated to PCI or CABG. At 1 year follow up, PCI and CABG were substantially equivalent with respect to the rates of MACE [PCI 8.5% vs CABG 8.9%, OR 1.02,(0.76–1.36), p = 0.9], death [PCI 5.4% vs CABG 6.6%, OR 0.81,(0.63–1.03),p = 0.08] and MI [PCI 3.4% vs CABG 4.3%, OR 0.80(0.59–1.07), p = 0.14]. Notably, PCI was associated with a significantly lower rate of stroke [PCI 0.6% vs CABG 1.8%, OR 0.36,(0.17–0.79), p = 0.01] and with a significantly higher rate of TVR [PCI 8.7% vs CABG 4.5%, OR 2.00(1.46–2.75), p<0.01]. At a median follow up of 5years, the rates of MACE were similar between the two strategies: PCI 14.6% vs CABG 13.8%, OR 1.02(0.76–1.38), p = 0.89. Likewise, the rates of death [PCI 8% and CABG 7.7%, OR 1(0.77–1.31), P = 0.9], MI [PCI 6.1% vs CABG 5%, OR 1.41(0.85–2.34), P = 0.19, I2 59%], and stroke [PCI 2% vs CABG 2.2%, OR 0.85(0.42–1.81), p = 0.65,] were similar while PCI was associated with a significantly higher rate of TVR [14.5% vs CABG 8.9%, OR 1.73(1.41–2.13), p<0.01].ConclusionIn patients with UPLM disease, PCI and CABG are associated with similar rates of MACE and mortality at 1 year as well as after 5 years. Differences can be detected for individual end points at both short and long term FU.

Highlights

European and U.S guidelines currently recommend that the majority of patients with unprotected left main coronary artery disease (UPLM) undergo coronary-artery bypass grafting (CABG). [1,2]percutaneous coronary intervention (PCI) should be considered in patients with UPLM and coronary disease favorable to PCI [1,2] The guidelines are substantially based on the 705 patient subgroup with UPLM in the SYNTAX trial, [3] and on the findings of some randomized trials, LE MANS (100 patients), [4] PRECOMBAT (600 patients), [5] and Boudriot and colleagues (201 patients) [6]
We identified 6 Randomised Controlled Trials totalling 4717 patients allocated to PCI or CABG
At 1 year follow up, PCI and CABG were substantially equivalent with respect to the rates of MACE [PCI 8.5% vs CABG 8.9%, odds ratios (OR) 1.02,(0.76–1.36), p = 0.9], death [PCI 5.4% vs CABG 6.6%, OR 0.81,(0.63–1.03),p = 0.08] and MI [PCI 3.4% vs CABG 4.3%, OR 0.80 (0.59–1.07), p = 0.14]

Summary

Introduction

European and U.S guidelines currently recommend that the majority of patients with unprotected left main coronary artery disease (UPLM) undergo coronary-artery bypass grafting (CABG). PCI should be considered in patients with UPLM and coronary disease favorable to PCI (ie, in the absence of complex and diffuse lesions) [1,2] The guidelines are substantially based on the 705 patient subgroup with UPLM in the SYNTAX trial, [3] and on the findings of some randomized trials, LE MANS (100 patients), [4] PRECOMBAT (600 patients), [5] and Boudriot and colleagues (201 patients) [6]. The optimal treatment of unprotected left main (UPLM) with either PCI or CABG remains uncertain

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