Outcomes After Percutaneous Coronary Intervention or Bypass Surgery in Patients With Unprotected Left Main Disease

• Published in: Journal of the American College of Cardiology Vol. 68; no. 10; pp. 999 - 1009
• Main Authors: Cavalcante, Rafael, Sotomi, Yohei, Lee, Cheol W., Ahn, Jung-Min, Farooq, Vasim, Tateishi, Hiroki, Tenekecioglu, Erhan, Zeng, Yaping, Suwannasom, Pannipa, Collet, Carlos, Albuquerque, Felipe N., Onuma, Yoshinobu, Park, Seung-Jung, Serruys, Patrick W.
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 06.09.2016; Elsevier Limited
• Subjects: Cardiology; Cardiovascular; Cardiovascular disease; Chronic obstructive pulmonary disease; Clinical trials; Confidence intervals; Coronary Artery Bypass - adverse effects; coronary artery bypass graft surgery; Coronary Artery Disease - pathology; Coronary Artery Disease - surgery; Coronary vessels; Female; Heart attacks; Heart surgery; Humans; Ischemia; left main coronary artery disease; long-term outcomes; Male; Middle Aged; Mortality; Patients; percutaneous coronary intervention; Percutaneous Coronary Intervention - adverse effects; Population; Postoperative Complications - epidemiology; Postoperative Complications - etiology; randomized controlled trials; Stents; Stroke; Taxus; Treatment Outcome; LM; left main coronary artery disease; CI; CAD; HR; randomized controlled trials; coronary artery bypass graft surgery; percutaneous coronary intervention; MACE; PCI; UPLMD; long-term outcomes; CABG; MI; coronary artery disease; myocardial infarction; coronary artery bypass graft; left main; major adverse cardiac event(s); unprotected left main disease; hazard ratio; confidence interval
• ISSN: 0735-1097; 1558-3597; 1558-3597
• DOI: 10.1016/j.jacc.2016.06.024

Currently available randomized data on the comparison between percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) for the treatment of unprotected left main coronary disease (LMD) lacks statistical power due to low numbers of patients enrolled. This study assessed long-term outcomes of PCI and CABG for the treatment of LMD in specific subgroups according to disease anatomic complexity. We conducted a pooled analysis of individual patient-level data of the LMD patients included in the PRECOMBAT (Bypass Surgery Versus Angioplasty Using Sirolimus-Eluting Stent in Patients With Left Main Coronary Artery Disease) and SYNTAX (Synergy Between PCI With TAXUS and Cardiac Surgery) trials. Incidences of major adverse cardiac events were assessed at 5 years follow-up. Study population comprised 1,305 patients. The incidence of major adverse cardiac and cerebrovascular events at 5 years was 28.3% in the PCI group and 23.0% in the CABG group (hazard ratio [HR]: 1.23; 95% confidence interval [CI]: 1.01 to 1.55; p = 0.045). This difference is mainly driven by a higher rate of repeat revascularization associated with PCI (HR: 1.85; 95% CI: 1.38 to 2.47; p < 0.001). The 2 strategies showed similar rates of the safety composite endpoint of death, myocardial infarction, or stroke (p = 0.45). In patients with isolated LM or LM + 1-vessel disease, PCI was associated with a 60% reduction in all-cause mortality (HR: 0.40; 95% CI: 0.20 to 0.83; p = 0.029) and 67% reduction in cardiac mortality (HR: 0.33; 95% CI: 0.12 to 0.88; p = 0.025) when compared with CABG. In patients with unprotected LMD, CABG, and PCI result in similar rates of the safety composite endpoint of death, myocardial infarction, or stroke. In patients with isolated LM or LM + 1-vessel disease, PCI is associated with lower all-cause and cardiac mortality when compared to CABG.