Mortality after drug-eluting stents vs. coronary artery bypass grafting for left main coronary artery disease: a meta-analysis of randomized controlled trials

Selected in the European Heart Journal by S. Brugaletta

This metanalysis demonstrates similar long-term mortality after PCI with DES compared with CABG in patients with LMCAD. Nor were there significant differences in cardiac death, stroke, or MI between PCI and CABG. Unplanned revascularization procedures were less common after CABG compared with PCI.

Reviewer

Salvatore Brugaletta

@sbrugaletta

Interventional cardiologist / Cardiologist

Barcelona, Spain

Latest contributions

Optical coherence tomography- vs angiography-guided coronary stent implantation in calcified lesions: the ILUMIEN IV trial Percutaneous coronary treatment with Bioadaptor implant vs drug-eluting stent : 2-year outcomes from BIOADAPTOR RCT Coronary revascularisation deferral based on quantitative flow ratio or fractional flow reserve: a post-hoc analysis of the FAVOR III Europe trial

View full profile

My Comment

Why this study? – the rationale/objective

The optimal method of revascularization for patients with left main coronary artery disease (LMCAD) is controversial. Coronary artery bypass graft surgery (CABG) has traditionally been considered the gold standard therapy, and recent randomized trials comparing CABG with percutaneous coronary intervention (PCI) with drug-eluting stents (DES) have reported conflicting outcomes.

How was it executed? – the methodology

This is a systematic review and updated meta-analysis comparing CABG to PCI with DES for the treatment of LMCAD.

All randomized trials comparing PCI with DES vs. CABG in patients with LMCAD were identified. The primary efficacy endpoint was all-cause mortality. Secondary endpoints included cardiac death, myocardial infarction (MI), stroke, and unplanned revascularization. All analyses were by intention-to-treat. There were five eligible trials in which 4612 patients were randomized. The weighted mean follow-up duration was 67.1months.

What is the main result?

There were no significant differences between PCI and CABG for the risk of all-cause mortality [relative risk (RR) 1.03, 95% confidence interval (CI) 0.81–1.32; P = 0.779] or cardiac death (RR 1.03, 95% CI 0.79–1.34; P = 0.817). There were also no significant differences in the risk of stroke (RR 0.74, 95% CI 0.35–1.50; P = 0.400) or MI (RR 1.22, 95% CI 0.96–1.56; P=0.110). Percutaneous coronary intervention was associated with an increased risk of un-planned revascularization (RR 1.73, 95% CI 1.49–2.02; P < 0.001).

Critical reading and the relevance for clinical practice

The present metanalysis demonstrates similar long-term mortality after PCI with DES compared with CABG in patients with LMCAD. Nor were there significant differences in cardiac death, stroke, or MI between PCI and CABG. Unplanned revascularization procedures were less common after CABG compared with PCI.

The goodness of this metanalysis is to have all-cause mortality as primary endpoint, without any dependency from event adjudication or from event definition. This endpoint was underpowered in all the trials herein included and it is at least better powered in such metanalysis. As definition of MI differs between studies considered, no definite conclusions can be drawn on this endpoint. Eventually difference in terms of revascularization is important and it is probably the most important factor to be taken into account in the heart team discussion to decide which revascularization strategy for a specific patient.

Although CABG ensures equal mortality and less revascularization than PCI, my personal opinion is that it cannot satisfy all patients, having in mind two specific scenarios: isolated LM disease and those patients who prefer a quicker recovery coming back to work early, counterbalanced by a revascularization by CABG 5 years later. A patient-centred approach may help to have surgeon and interventional worlds closer.

How does the heart team work in your institution?

Isolated left main stenosis in a young patient with low syntax score