Left Main Coronary Artery Angioplasty vs. Surgery: A Large Meta-Analysis

Courtesy of Dr. Carlos Fava.

Around 5% of patients undergoing coronary angiography present severe left main coronary artery (LMCA) lesions. Myocardial revascularization surgery (MRS) is the preferred method for this group, although there is evidence from different randomized trials demonstrating the safety and efficacy of unprotected LMCA angioplasty, with results similar to those obtained through the traditional strategy.

This analysis included data from 5 randomized studies (PRECOMBAT, SYNTAX, NOBLE, EXCEL, and a study carried out by Boudriot et al.) and 4594 patients.

The primary safety endpoint was defined as a composite of all-cause death, infarction, or stroke, and the secondary endpoint was a composite of all-cause death, infarction, stroke, and repeat revascularization.

The characteristics of both patient groups were well-balanced. There was no difference in the primary safety endpoint between strategies (odds ratio [OR]: 0.97; 95% confidence interval [CI]: 0.79-1.17; p = 0.73). In patients with complex coronary anatomy (SYNTAX >22), MRS was safer (OR: 1.64; 95% CI: 1.22-2.20; p_interaction = 0.006).

The secondary endpoint favored MRS because of significantly higher rates of repeat revascularization for the angioplasty group (OR: 1.85; 95% CI: 1.53-2.23; p <0.001). No differences were observed upon consideration of each individual component of the primary endpoint.

Conclusion

Angioplasty using drug-eluting stents and myocardial revascularization surgery are equally safe methods of revascularization for patients with less complex coronary anatomy and significant unprotected left main coronary artery lesions. However, surgery is associated with lower rates of repeat revascularization.

Editorial

This meta-analysis including the most modern randomized studies showed that angioplasty is as effective as surgery in patients with non-complex anatomy as defined by a SYNTAX <22 score.

While second-generation DES have been developed and complementary methods are applied during angioplasty (intravascular ultrasound [IVUS] vs. optical coherence tomography [OCT]), a higher need for revascularization continues to be the Achilles’ heel of angioplasty.

Courtesy of Dr. Carlos Fava. Buenos Aires Favaloro Foundation, Argentina.

Original title: Percutaneous Coronary Intervention Using Drug-Eluting Stents Versus Coronary Artery Bypass Grafting for Unprotected Left Main Coronary Stenosis. A Meta-Analysis of Randomized Trials.

Reference: Nitesh Nerlekar et al. Circ Cardiovasc Interv 2016;9e004729.

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