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.

Keywords: Coronary artery bypass; Left main disease; Meta-analysis; Percutaneous coronary intervention.

Figure 1

Flow diagram for study selection. ULMCA, Unprotected left main coronary artery disease.

Figure 2

Forest plot comparing major adverse cardiac and cerebrovascular events (a composite of all-cause mortality, stroke, myocardial infarction, or repeat revascularization) between percutaneous coronary intervention and coronary artery bypass grafting. The blue diamond is the point estimate with the line representing the 95% confidence interval. The red dotted line represents the random effects generated overall estimate. Data are presented with risk ratios and 95% confidence intervals. CABG, Coronary artery bypass grafting; CI, Confidence intervals; MACCE, Major adverse cardiac and cerebrovascular events; PCI, Percutaneous coronary intervention; RR, Risk ratio.

Figure 3

Forest plots comparing for all-cause mortality (Panel A), myocardial infarction (Panel B), stroke (Panel C), and all revascularization (Panel D) between percutaneous coronary intervention and coronary artery bypass grafting. The blue diamond is the point estimate with the line representing the 95% confidence interval. The red dotted line represents the random effects generated overall estimate. Data are presented with risk ratios and 95% confidence intervals. CABG, Coronary artery bypass grafting; CI, Confidence intervals; PCI, Percutaneous coronary intervention; RR, Risk ratio.

Figure 4

Panel A: Forest plot comparing outcomes stratified by time between percutaneous coronary intervention and coronary artery bypass grafting. Data are presented with risk ratios and 95% confidence intervals. Risk ratio at 30 days: MAACE was derived from EXCEL, PRECOMBAT, and LE MANS trials; all revascularization and myocardial infarction were derived from NOBLE, EXCEL, LEIPZIG, and LE MANS trials; stroke and all-cause mortality were derived from NOBLE, EXCEL, and LE MANS trials. Risk ratio for 1 year outcomes were derived from SYNTAX, NOBLE, PRECOMBAT, LEIPZIG, and LE MANS trials. Risk ratio for at long-term outcomes were derived from SYNTAX, NOBLE, EXCEL, PRECOMBAT, LEIPZIG, and LE MANS trials. Panel B: Forest plot comparing outcomes stratified by SYNTAX score categories between percutaneous coronary intervention and coronary artery bypass grafting. Data are presented with risk ratios and 95% confidence intervals. Risk ratio for major adverse cardiac and cerebrovascular event was derived from SYNTAX, NOBLE, and PRECOMBAT trials and risk ratio for other outcomes was derived from SYNTAX and PRECOMBAT trials. CABG, Coronary artery bypass grafting; CI, Confidence intervals; MACCE, Major adverse cardiac and cerebrovascular events; PCI, Percutaneous coronary intervention; RR, Risk ratio.

Figure 5

Schematic representation of major adverse cardiac and cerebrovascular event outcome comparison (percutaneous coronary intervention vs. coronary artery bypass grafting) for left main disease revascularization. CABG, Coronary artery bypass grafting; MACCE, Major adverse cardiac and cerebrovascular events; PCI, Percutaneous coronary intervention.

Figure 6

Forest plots assessing cumulative (Panel A) and one study removed (Panel B) sensitivity meta-analysis to assess the effect of individual studies on major adverse cardiac and cerebrovascular event. Data are presented with risk ratios and 95% confidence intervals. CABG, Coronary artery bypass grafting; CI, Confidence intervals; PCI, Percutaneous coronary intervention; RR, Risk ratio.

Figure 7

Depiction of publication bias for major adverse cardiac and cerebrovascular events (MACCE) between percutaneous coronary intervention versus coronary artery bypass grafting. Hollow blue circles represent available studies. Hollow red circles represent imputed studies. The solid blue diamond is the log risk ratio for MACCE prior to publication bias adjustment. The solid red diamond is the log risk ratio for MACCE after publication bias adjustment.