Coronary artery bypass graft surgery versus percutaneous coronary intervention in unprotected left main coronary artery disease: A systematic review

Reviews in Cardiovascular Medicine  2020, Vol. 21 Issue (1): 65-73     DOI: 10.31083/j.rcm.2020.01.590 Coronary artery bypass graft surgery versus percutaneous coronary intervention in unprotected left main coronary artery disease: A systematic review Liviu Macovei1, 2, Robert Magopet1, *(), Ana Tanasa1, 2, Cezara Raileanu1, Cristina Prisacariu1, 2, Mihai Razvan Presura3, Mircea Ovanez Balasanian1, 2 1 Institute of Cardiovascular Diseases "Prof. dr. George I.M. Georgescu", Iasi 700503, Romania
2 University of Medicine and Pharmacy "Grigore T. Popa", Iasi 700115, Romania
3 Cardiology Clinic of Piatra Neamt General Hospital, Neamt 610136, Romania Abstract:

Critical lesion of the unprotected left main coronary disease carries a tremendous mortality burden, often associated with a diabetes status or multivessel disease, with coronary artery bypass grafting being the standard treatment for over 40 years. Percutaneous coronary intervention with drug eluting stents should be taken into consideration and could be a better option for patients with low SYNTAX score as validated by the recently published studies. This review summarizes the major randomized clinical trials and meta-analyses concerning the debate regarding percutaneous coronary intervention with drug eluting stents versus coronary artery bypass grafting for unprotected left main coronary disease, along with the latest European and American revascularization guidelines and tries to shed light on this matter. The most results advocate that there is no convincing difference in survival rate for both therapies, especially in patients with isolated left main disease but with fewer major ischemic events for coronary artery bypass grafting when compared with percutaneous coronary intervention in multivessel coronary artery disease, at the rate of a higher stroke incidence. The gaps in evidence are also highlighted, especially the lack of randomized clinical trials with new generation drug eluting stents versus coronary artery bypass grafting or those regarding the best revascularization strategy for an acute coronary syndrome when unprotected left main coronary disease is involved.

Submitted:  07 November 2019      Accepted:  29 December 2019      Published:  30 March 2020      *Corresponding Author(s):  Magopet Robert     E-mail:  robert.magopet@gmail.com Service E-mail this article Add to citation manager E-mail Alert RSS Articles by authors Liviu Macovei    Robert Magopet    Ana Tanasa    Cezara Raileanu    Cristina Prisacariu    Mihai Razvan Presura    Mircea Ovanez Balasanian   

Table 1.  Summary of randomized clinical trials on PCI vs. CABG for ULMCAD up to 2016

TrialSYNTAX score (mean)Primary endpointSecondary endpoint
Outcomes
PCI
CABG
P
Outcomes
PCI
CABG
PLEMANSunknownChange at 1 year in left ventricular ejection fraction3.3 ± 6.7%0.5 ± 0.8%0.047Repeat revascularization26.1%31.3%0.39Results at 1 and 10 yearsDeath (10 years)8.7%30.2%0.41MI (10 years)8.7%10.4%0.68Stroke (10 years)4.3%6.3%0.58Composite52.2%62.5%0.42Boudriot et al. (2011)23Death, repeat revascularization or MI,
at 1 year.19%13.9%Non-inf. = 0.19MI3%3%Non-inf. = 0.002Results at 1 yearDeath2%5%Non-inf. < 0.001Repeat revascularization14%5.9%Non-inf. = 0.019SYNTAX-LM30Death, MI, stroke or repeat revascularization (1 year)15.8%13.6%Non-inf. = 0.19Stroke (5 years)1.5%4.3%0.03Results at 1 and 5 yearsDeath (5 years)12.8%14.6%0.53MI (5 years)8.2%4.8%0.10Repeat revascularization (5 years)26.7%15.5%< 0.001Death, stroke, MI or repeat
revascularization (5 y)36.9%31%
0.12PRECOMBAT25Death, stroke, MI or
ischemia-driven
target lesion
revascularization
(only at 1 year)8.7%6.7%Non-inf. = 0.01Stroke (5 years)0.7%0.7%0.99Results at 1 and 5 yearsRepeat revascularization (5 years)13%7.3%0.02MI (5 years)2%1.7%0.76Death (5 years)5.7%7.9%0.32Death, stroke or MI (5 y)8.4%9.6%0.66Death, stroke, MI, or
ischemia-driven
target lesion
revascularization (5 y)17.5%14.3%0.26

Table 2.  Summary of endpoints concerning EXCEL and NOBLE trials

TrialSYNTAX score (mean)Primary endpointSecondary endpointOutcomesPCICABGPOutcomesPCICABGPEXCEL21Composite: stroke, MI, death15.4%14.7%Non-inf. = 0.02Ischemia-driven revascularization12.6%7.5%0.001Results at 3 yearsSuper. = 0.98Death8.2%5.9%0.11MI8%8.3%0.64Stroke2.3%2.9%0.37Composite23.1%19.1%Non-inf. 0.01EXCEL21Composite: stroke, MI, death22%19.2%0.13Ischemia-driven revascularization16.9%10%Results at 5 yearsDeath13%9.9%MI10.6%9.1%Stroke2.9%3.7%Composite31.1%24.9%0.002NOBLE22Composite-repeat revascularization, death, MI (non-procedural) and stroke29%19%0.007MI (non-procedural)7%2%0.004Results at 5 yearsDeath12%9%0.77Repeat revascularization16%10%0.032Stroke5%2%0.073

Table 3.  Summary of trials which included patients with ACS

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