Long-Term Outcomes of Patients with Unprotected Left Main Coronary Artery Disease Treated with Percutaneous Angioplasty versus Bypass Grafting: A Meta-Analysis of Randomized Controlled Trials

doi:10.3390/jcm9072231

Review

. 2020 Jul 14;9(7):2231.

doi: 10.3390/jcm9072231.

Long-Term Outcomes of Patients with Unprotected Left Main Coronary Artery Disease Treated with Percutaneous Angioplasty versus Bypass Grafting: A Meta-Analysis of Randomized Controlled Trials

Gani Bajraktari^{1

2

3}, Fjolla Zhubi-Bakija², Gjin Ndrepepa⁴, Fernando Alfonso⁵, Shpend Elezi³, Zarife Rexhaj², Ibadete Bytyçi^{1

2}, Artan Bajraktari¹, Afrim Poniku^{2

3}, Michael Y Henein¹

Affiliations

¹ Department of Public Health and Clinical Medicine, Umeå University, 90737 Umeå, Sweden.
² Clinic of Cardiology, University Clinical Centre of Kosova, 10000 Prishtina, Kosovo.
³ Medical Faculty, University of Prishtina "Hasan Prishtina", 10000 Prishtina, Kosovo.
⁴ Deutsches Herzzentrum München, Technische Universität, 80636 Munich, Germany.
⁵ Cardiac Department, La Princesa University Hospital, Institute of Health Research, IIS-IP, CIBER-CV University Autónoma of Madrid, 28029 Madrid, Spain.

PMID: 32674522
PMCID: PMC7408984
DOI: 10.3390/jcm9072231

Review

Long-Term Outcomes of Patients with Unprotected Left Main Coronary Artery Disease Treated with Percutaneous Angioplasty versus Bypass Grafting: A Meta-Analysis of Randomized Controlled Trials

Gani Bajraktari et al. J Clin Med. 2020.

. 2020 Jul 14;9(7):2231.

doi: 10.3390/jcm9072231.

Authors

Affiliations

¹ Department of Public Health and Clinical Medicine, Umeå University, 90737 Umeå, Sweden.
² Clinic of Cardiology, University Clinical Centre of Kosova, 10000 Prishtina, Kosovo.
³ Medical Faculty, University of Prishtina "Hasan Prishtina", 10000 Prishtina, Kosovo.
⁴ Deutsches Herzzentrum München, Technische Universität, 80636 Munich, Germany.
⁵ Cardiac Department, La Princesa University Hospital, Institute of Health Research, IIS-IP, CIBER-CV University Autónoma of Madrid, 28029 Madrid, Spain.

PMID: 32674522
PMCID: PMC7408984
DOI: 10.3390/jcm9072231

Abstract

Background and aim: Treatment of patients with left main coronary artery disease (LMCA) with percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) remains controversial. The aim of this meta-analysis was to compare the long-term clinical outcomes of patients with unprotected LMCA treated randomly by PCI or CABG.

Methods: PubMed, MEDLINE, Embase, Scopus, Google Scholar, CENTRAL and ClinicalTrials.gov database searches identified five randomized trials (RCTs) including 4499 patients with unprotected LMCA comparing PCI (n = 2249) vs. CABG (n = 2250), with a minimum clinical follow-up of five years. Random effect risk ratios were used for efficacy and safety outcomes. The study was registered in PROSPERO. The primary outcome was major adverse cardiac events (MACE), defined as a composite of death from any cause, myocardial infarction or stroke.

Results: Compared to CABG, patients assigned to PCI had a similar rate of MACE (risk ratio (RR): 1.13; 95% CI: 0.94 to 1.36; p = 0.19), myocardial infarction (RR: 1.48; 95% CI: 0.97 to 2.25; p = 0.07) and stroke (RR: 0.87; 95% CI: 0.62 to 1.23; p = 0.42). Additionally, all-cause mortality (RR: 1.07; 95% CI: 0.89 to 1.28; p = 0.48) and cardiovascular (CV) mortality (RR: 1.13; 95% CI: 0.89 to 1.43; p = 0.31) were not different. However, the risk of any repeat revascularization (RR: 1.70; 95% CI: 1.34 to 2.15; p < 0.00001) was higher in patients assigned to PCI.

Conclusions: The findings of this meta-analysis suggest that the long-term survival and MACE of patients who underwent PCI for unprotected LMCA stenosis were comparable to those receiving CABG, despite a higher rate of repeat revascularization.

Keywords: coronary artery bypass graft; coronary artery disease; percutaneous coronary intervention; unprotected left main.

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Conflict of interest statement

The authors declare no conflict of interest.

Figures

**Figure 1**
Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) study selection flow chart. PCI: percutaneous coronary intervention and CABG: coronary artery bypass grafting.

**Figure 2**
Risk of major adverse cardiac events (MACE) at the latest follow-up: PCI vs. CABG.

**Figure 3**
Risk of all-cause mortality at the latest follow-up: PCI vs. CABG.

**Figure 4**
Risk of cardiovascular mortality at latest follow-up: PCI vs. CABG.

**Figure 5**
Risk of stroke at the latest follow-up: PCI vs. CABG.

**Figure 6**
Risk of myocardial infarction at the latest follow-up: PCI vs. CABG.

**Figure 7**
Risk of repeat revascularization at the latest follow-up: PCI vs. CABG.

See this image and copyright information in PMC

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References

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1. Stone G.W., Kappetein A.P., Sabik J.F., Pocock S.J., Morice M.C., Puskas J., Kandzari D.E., Karmpaliotis D., Brown W.M., II, EXCEL Trial Investigators et al. Five-Year Outcomes after PCI or CABG for Left Main Coronary Disease. N. Engl. J. Med. 2019;381:1820–1830. doi: 10.1056/NEJMoa1909406. - DOI - PubMed

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[1] Neumann F.J., Sousa-Uva M., Ahlsson A., Alfonso F., Banning A.P., Benedetto U., Byrne R.A., Collet J.-P., Falk V., ESC Scientific Document Group et al. 2018 ESC/EACTS Guidelines on myocardial revascularization. Eur. Heart J. 2019;40:87–165. doi: 10.1093/eurheartj/ehy394. - DOI - PubMed

[2] Neumann F.J., Sousa-Uva M., Ahlsson A., Alfonso F., Banning A.P., Benedetto U., Byrne R.A., Collet J.-P., Falk V., ESC Scientific Document Group et al. 2018 ESC/EACTS Guidelines on myocardial revascularization. Eur. Heart J. 2019;40:87–165. doi: 10.1093/eurheartj/ehy394. - DOI - PubMed

[3] Patel M.R., Dehmer G.J., Hirshfeld J.W., Smith P.K., Spertus J.A. ACCF/SCAI/STS/AATS/AHA/ASNC/HFSA/SCCT 2012 appropriate use criteria for coronary revascularization focused update: A report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, American Association for Thoracic Surgery, American Heart Association, American Society of Nuclear Cardiology, and the Society of Cardiovascular Computed Tomography. J. Am. Coll. Cardiol. 2012;59:857–881. doi: 10.1016/j.jacc.2011.12.001. - DOI - PubMed

[4] Patel M.R., Dehmer G.J., Hirshfeld J.W., Smith P.K., Spertus J.A. ACCF/SCAI/STS/AATS/AHA/ASNC/HFSA/SCCT 2012 appropriate use criteria for coronary revascularization focused update: A report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, American Association for Thoracic Surgery, American Heart Association, American Society of Nuclear Cardiology, and the Society of Cardiovascular Computed Tomography. J. Am. Coll. Cardiol. 2012;59:857–881. doi: 10.1016/j.jacc.2011.12.001. - DOI - PubMed

[5] Holm N.R., Mäkikallio T., Lindsay M.M., Spence M.S., Erglis A., Menown I.B.A., Trovik T., Eskola M., Romppanen H., SYNTAX Extended Survival Investigators et al. Percutaneous coronary angioplasty versus coronary artery bypass grafting in the treatment of unprotected left main stenosis: Updated 5-year outcomes from the randomised, non-inferiority NOBLE trial. Lancet. 2020;395:191–199. doi: 10.1016/S0140-6736(19)32972-1. - DOI - PubMed

[6] Holm N.R., Mäkikallio T., Lindsay M.M., Spence M.S., Erglis A., Menown I.B.A., Trovik T., Eskola M., Romppanen H., SYNTAX Extended Survival Investigators et al. Percutaneous coronary angioplasty versus coronary artery bypass grafting in the treatment of unprotected left main stenosis: Updated 5-year outcomes from the randomised, non-inferiority NOBLE trial. Lancet. 2020;395:191–199. doi: 10.1016/S0140-6736(19)32972-1. - DOI - PubMed

[7] Thuijs D.J.F.M., Kappetein A.P., Serruys P.W., Mohr F.-W., Morice M.-C., Mack M.J., Holmes D.R., Jr., Curzen N., Davierwala P., SYNTAX Extended Survival Investigators et al. Percutaneous coronary intervention versus coronary artery bypass grafting in patients with three-vessel or left main coronary artery disease: 10-year follow-up of the multicentre randomised controlled SYNTAX trial. Lancet. 2019;394:1325–1334. doi: 10.1016/S0140-6736(19)31997-X. - DOI - PubMed

[8] Thuijs D.J.F.M., Kappetein A.P., Serruys P.W., Mohr F.-W., Morice M.-C., Mack M.J., Holmes D.R., Jr., Curzen N., Davierwala P., SYNTAX Extended Survival Investigators et al. Percutaneous coronary intervention versus coronary artery bypass grafting in patients with three-vessel or left main coronary artery disease: 10-year follow-up of the multicentre randomised controlled SYNTAX trial. Lancet. 2019;394:1325–1334. doi: 10.1016/S0140-6736(19)31997-X. - DOI - PubMed

[9] Stone G.W., Kappetein A.P., Sabik J.F., Pocock S.J., Morice M.C., Puskas J., Kandzari D.E., Karmpaliotis D., Brown W.M., II, EXCEL Trial Investigators et al. Five-Year Outcomes after PCI or CABG for Left Main Coronary Disease. N. Engl. J. Med. 2019;381:1820–1830. doi: 10.1056/NEJMoa1909406. - DOI - PubMed

[10] Stone G.W., Kappetein A.P., Sabik J.F., Pocock S.J., Morice M.C., Puskas J., Kandzari D.E., Karmpaliotis D., Brown W.M., II, EXCEL Trial Investigators et al. Five-Year Outcomes after PCI or CABG for Left Main Coronary Disease. N. Engl. J. Med. 2019;381:1820–1830. doi: 10.1056/NEJMoa1909406. - DOI - PubMed

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Long-Term Outcomes of Patients with Unprotected Left Main Coronary Artery Disease Treated with Percutaneous Angioplasty versus Bypass Grafting: A Meta-Analysis of Randomized Controlled Trials

Affiliations

Long-Term Outcomes of Patients with Unprotected Left Main Coronary Artery Disease Treated with Percutaneous Angioplasty versus Bypass Grafting: A Meta-Analysis of Randomized Controlled Trials

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Conflict of interest statement

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Abstract

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