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A Meta-Analysis of 3,773 Patients Treated With Percutaneous Coronary Intervention or Surgery for Unprotected Left Main Coronary Artery Stenosis

Hursh Naik, MD^_*, Anthony J. White, MBBS, PhD^_*, Tarun Chakravarty, MD^_*, James Forrester, MD^_*, Gregory Fontana, MD^_*, Saibal Kar, MD^_*, Prediman K. Shah, MD^_*, Robert E. Weiss, PhD, Raj Makkar, MD^_*,_*

^_* Cedars-Sinai Heart Institute, Cedars Sinai Medical Center, Los Angeles, California
Department of Biostatistics, University of California, Los Angeles School of Public Health, Los Angeles, California

^_* Reprint requests and correspondence: Dr. Raj Makkar, Cedars-Sinai Heart Institute, Cardiovascular Intervention Center, Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, California 90048 (Email: Raj.Makkar{at}cshs.org).

Objectives: This study sought to understand the total weight of evidence regarding outcomes in coronary artery bypass grafting (CABG) versus percutaneous coronary intervention (PCI) in unprotected left main coronary artery (ULMCA) stenosis.

Background: Following a diagnosis of significant ULMCA stenosis in an individual that is a candidate for surgery, CABG is recommended by the American College of Cardiology/American Heart Association guidelines, whereas PCI is not recommended (Class III).

Methods: Databases were searched for clinical studies that reported outcomes after PCI and CABG for the treatment of ULMCA stenosis. Ten studies were identified that included a total of 3,773 patients.

Results: Meta-analysis showed that death, myocardial infarction, and stroke (major adverse cardiovascular or cerebrovascular events) were similar in the PCI- and CABG-treated patients at 1 year (odds ratio [OR]: 0.84 [95% confidence interval: 0.57 to 1.22]), 2 years (OR: 1.25 [95% CI: 0.81 to 1.94]), and 3 years (OR: 1.16 [95% CI: 0.68 to 1.98]). Target vessel revascularization was significantly higher in the PCI group at 1 year (OR: 4.36 [95% CI: 2.60 to 7.32]), 2 years (OR: 4.20 [95% CI: 2.21 to 7.97]), and 3 years (OR: 3.30 [95% CI: 0.96 to 11.33]). There was no difference in mortality in PCI- versus CABG-treated patients at 1 year (OR: 1.00 [95% CI: 0.70 to 1.41]), 2 years (OR: 1.27 [95% CI: 0.83 to 1.94]), and 3 years (OR: 1.11 [95% CI: 0.66 to 1.86]).

Conclusions: Our analysis reveals no difference in mortality or major adverse cardiovascular or cerebrovascular events, for up to 3 years, between PCI and CABG for the treatment of ULMCA stenosis. However, PCI patients had a significantly higher risk of target vessel revascularization. In selected patients with ULMCA stenosis, PCI is emerging as an acceptable option.

Key Words: left main coronary artery • stent • coronary artery bypass surgery • coronary artery disease

Abbreviations and Acronyms   CABG = coronary artery bypass grafting   MACCE = major adverse cardiac and cerebrovascular events   MI = myocardial infarction   OR = odds ratio   PCI = percutaneous coronary intervention   TVR = target vessel revascularization   ULMCA = unprotected left main coronary artery