Percutaneous coronary intervention vs. coronary artery bypass grafting for left main revascularization: an updated meta-analysis

Abstract

Aims The optimal revascularization strategy for left main coronary artery disease (LMD) remains controversial, especially with two recent randomized controlled trials showing conflicting results. We sought to address this controversy with our analysis. Methods and results Comprehensive literature search was performed. We compared percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) for LMD revascularization using standard meta-analytic techniques. A 21% higher risk of long-term major adverse cardiac and cerebrovascular event [MACCE; composite of death, myocardial infarction (MI), stroke, and repeat revascularization] was observed in patients undergoing PCI in comparison with CABG [risk ratio (RR) 1.21, 95% confidence interval (CI) 1.05–1.40]. This risk was driven by higher rate of repeat revascularization in those undergoing PCI (RR 1.61, 95% CI 1.34–1.95). On the contrary, MACCE rates at 30 days were lower in PCI when compared with CABG (RR 0.55, 95% CI 0.39–0.76), which was driven by lower rates of stroke in the PCI arm (RR 0.41, 95% CI 0.17–0.98). At 1 year, lower stroke rates (RR 0.21, 95% CI 0.08–0.59) in the PCI arm were balanced by higher repeat revascularization rates in those undergoing PCI (RR 1.78, 95% CI 1.33–2.37), resulting in a clinical equipoise in MACCE rates between the two revascularization strategies. There was no difference in death or MI between PCI when compared with CABG at any time point. Conclusion Outcomes of CABG vs. PCI for LMD revascularization vary over time. Therefore, individualized decisions need to be made for LMD revascularization using the heart team approach.

Safety and efficacy of percutaneous coronary intervention versus coronary artery bypass graft in patients with STEMI and unprotected left main stem disease: A systematic review & meta-analysis

“…A possible explanation for this could be that bypassing diseased coronary arteries through graft helps protect the heart against MI, thereby improving survival [98] . The above results are concordant with a previous meta -analysis [92] .The advantage of CABG over PCI in preventing myocardial infarction was lost at our short and long-term follow-ups, which could be elucidated by losing patients to follow-up. Therefore, further research is warranted to determine whether PCI is a safe and effective alternative to CABG in terms of reducing post-operative MI rates.…”

“…Our study rendered that there is no difference in the composite outcome of all-cause mortality between the two groups on follow-up. These findings are supported by previous meta -analysis including randomized trials [92] , [93] . Nevertheless, PCI treatment was associated with improved survival during hospital stay.This can be explained by recent advances in PCI including drug eluting stents and biodegradable stents.This finding is also corroborated by a previous meta -analysis that considered 10 randomised trials and concluded that statistics of in-hospital mortality were much higher in patients undergoing CABG with cardiogenic shock compared to PCI [94] .However, future trials should update the existing evidence.…”

Long-Term Clinical Outcomes of Unprotected Left Main Percutaneous Coronary Intervention: A Large Single-Centre Experience

“…The techniques used in this series were similar to European Bifurcation Club recommendations [ 32 ]. In this observational study, DM status was not seen to be significantly associated with worse long-term adverse events, and this finding was inconsistent with previous reports [ 35 – 38 ].…”

Coronary Artery Bypass Graft Surgery Brings Better Benefits to Heart Failure Hospitalization for Patients with Severe Coronary Artery Disease and Reduced Ejection Fraction

“…Although heart failure with reduced EF accounts for approximately 50% of cases [ 7 , 8 ], there is no consensus about the preference to receive PCI or CABG for patients with severe CAD and reduced EF in current medical guidelines. In some studies, patients who received CABG had better overall survival compared to those who underwent PCI [ 9 , 10 ], though the others conclude that there is no significant difference in both groups [ 11 , 12 ]. In such a population, the evaluation of the ischemic area and involved vessels and the healthy collateral vessel are very important and the methods of PCI or CABG also have an impact on the outcomes [ 13 , 14 , 15 , 16 ].…”