Original title: Five-year outcomes in patients with left main disease treated with either percutaneous coronary intervention or coronary artery bypass grafting in the synergy between percutaneous coronary intervention with taxus and cardiac surgery trial. Reference: Morice MC et al. Circulation. 2014 Jun 10;129(23):2388-94.

Current guidelines recommend CABG as the strategy of choice for treating lesions of the left main coronary artery (LMCA), however after the results of the SYNTAX trial, angioplasty has become a class IIA indication in selected patients. This study analyzes the final 5 years of CABG versus angioplasty in the patient cohort of SYNTAX study with left main coronary injury.

The SYNTAX study randomized 1800 patients with LM lesion or 3 vessels to receive angioplasty (TAXUS paclitaxel-eluting stent) or CABG. 

The LM lesion cohort (n = 705) was predefined by protocol to achieve sufficient statistical power. The primary end point was a composite of major cardiovascular and cerebrovascular events (death, myocardial infarction, revascularization and stroke) that at 5 years showed no significant differences between the two strategies with 36.9% for angioplasty and 31% for surgery (HR 1.23, CI 95% 0.95 1.59; p=0.12). Mortality was 12.8% and 14.6% for angioplasty and surgery respectively (HR 0.88, CI 95% de 0.58 a 1.32; p=0.53).

A difference was observed in favor of angioplasty with respect to the rate of stroke (1.5% versus 4.3%, P = 0.03) and favoring surgery with respect to the rate of repeat revascularization (26.7% versus 15.5%, P <0.01). In patients with low or intermediate SYNTAX score or combined cardiovascular and cerebrovascular events both strategies in contrast to that observed in patients with high SYNTAX score where surgery was superior.

Conclusion

In five years, no significant difference in the combined cardiovascular and cerebrovascular events between surgery and angioplasty to treat patients with left main coronary artery and low or intermediate SYNTAX score was observed.

Editorial comment

These results suggest that long-term strategies are both valid to treat left main coronary artery, with the extent of disease elsewhere in the coronary tree, which tips the balance in favor of one or the other.

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