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Original Investigation
September 13, 2017

Percutaneous Coronary Intervention vs Coronary Artery Bypass Grafting in Patients With Left Main Coronary Artery StenosisA Systematic Review and Meta-analysis

Author Affiliations
  • 1Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
  • 2German Centre for Cardiovascular Research, Partner Site Munich Heart Alliance, Munich, Germany
JAMA Cardiol. Published online September 13, 2017. doi:10.1001/jamacardio.2017.2895
Key Points

Question  Does percutaneous coronary intervention with drug-eluting stenting and coronary artery bypass grafting provide similar long-term safety and efficacy in patients presenting with significant coronary artery disease involving the left main coronary artery?

Findings  In this systematic review and meta-analysis including 4394 patients, the 2 revascularization techniques provided similar long-term outcomes in terms of death, myocardial infarction, and stroke. Coronary artery bypass grafting was associated with a significant reduction in the risk of repeat revascularization.

Meaning  Although patients undergoing coronary artery bypass grafting benefit from a lower risk of repeat revascularization, if a patient wishes to avoid the morbidity associated with surgical revascularization, percutaneous coronary intervention is a safe and effective alternative.

Abstract

Importance  In patients with left main coronary artery (LMCA) stenosis, coronary artery bypass grafting (CABG) has been the standard therapy for several decades. However, some studies suggest that percutaneous coronary intervention (PCI) with drug-eluting stents may be an acceptable alternative.

Objective  To compare the long-term safety of PCI with drug-eluting stent vs CABG in patients with LMCA stenosis.

Data Sources  PubMed, Scopus, EMBASE, Web of Knowledge, and ScienceDirect databases were searched from December 18, 2001, to February 1, 2017. Inclusion criteria were randomized clinical trial, patients with LMCA stenosis, PCI vs CABG, exclusive use of drug-eluting stents, and clinical follow-up of 3 or more years.

Data Extraction and Synthesis  Trial-level hazard ratios (HRs) and 95% CIs were pooled by fixed-effect and random-effects models with inverse variance weighting. Time-to-event individual patient data for the primary end point were reconstructed. Sensitivity analyses according to drug-eluting stent generation and coronary artery disease complexity were performed.

Main Outcomes and Measures  The primary end point was a composite of all-cause death, myocardial infarction, or stroke at long-term follow-up. Secondary end points included repeat revascularization and a composite of all-cause death, myocardial infarction, stroke, or repeat revascularization at long-term follow-up.

Results  A total of 4 randomized clinical trials were pooled; 4394 patients were included in the analysis. Of these, 3371 (76.7%) were men; pooled mean age was 65.4 years. According to Grading of Recommendations, Assessment, Development and Evaluation, evidence quality with respect to the primary composite end point was high. Percutaneous coronary intervention and CABG were associated with a comparable risk of all-cause death, myocardial infarction, or stroke both by fixed-effect (HR, 1.06; 95% CI, 0.90-1.24; P = .48) and random-effects (HR, 1.06; 95% CI, 0.85-1.32; P = .60) analysis. Sensitivity analyses according to low to intermediate Synergy Between PCI With Taxus and Cardiac Surgery (SYNTAX) score (random-effects: HR, 1.02; 95% CI, 0.74-1.41; P = .89) and drug-eluting stent generation (first generation: HR, 0.90; 95% CI, 0.68-1.20; P = .49; second generation: HR, 1.19; 95% CI, 0.82-1.73; P = .36) were consistent. Kaplan-Meier curve reconstruction did not show significant variations over time between the techniques, with a 5-year incidence of all-cause death, myocardial infarction, or stroke of 18.3% (319 events) in patients treated with PCI and 16.9% (292 events) in patients treated with CABG. However, repeat revascularization after PCI was increased (HR, 1.70; 95% CI, 1.42-2.05; P < .001). Other individual secondary end points did not differ significantly between groups. Finally, pooled estimates of trials with LMCA stenosis tended overall to differ significantly from those of trials with multivessel coronary artery disease without left main LMCA stenosis.

Conclusions and Relevance  Percutaneous coronary intervention and CABG show comparable safety in patients with LMCA stenosis and low to intermediate–complexity coronary artery disease. However, repeat revascularization is more common after PCI.

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