Courtesy of Dr. Carlos Fava.
Left main coronary artery disease (LMD), has historically been treated with myocardial revascularization surgery (CABG), but for some years now, and with the development of new drug eluting stents (DES), percutaneous coronary intervention (PCI) has been gathering support in this challenging territory.
The study analyzed the SYNTAX and PRECOMBAT populations presenting severe left main disease.
It included 1,305 patients (657 treated with PCI and 648 with CABG) and MACE were analyzed at 5 years.
Mean population age was 64, most of patients were men and 28% were diabetic. Baseline characteristics were well balanced between populations.
At 5 years, MACE was 28.3% for the PCI group and 23% for the CABG group (HR: 1.23; CI 95% 1.01 to 1.55; p=0.045). This difference was mainly driven by the higher rate of repeat revascularization associated to PCI (19.5% vs. 10.8%; HR: 1.85; CI 95% 1.38 to 2.47; p<0.001). Both strategies showed similar death and infarction rates, but there was higher stroke rate in favor of PCI.
In patients presenting only LMD or LM + one vessel disease, PCI was associated to a 60% reduction in all-cause mortality. (HR: 0.40; CI 95% 0.20 to 0.83; p=0.029) and a 67% reduction in cardiac mortality (HR: 0.33; CI 95% 0.12 to 0.88; p=0.025) compared to CABG.
Conclusion
In patients with left main disease, myocardial revascularization surgery and PCI present similar rates of death, MI and stroke. In the LMD group or LM + 1 vessel disease, PCI was associated to lower all-cause and cardiac death.
Editorial Comment
This analyzis of two large randomized studies with the first two DES, shows promising results, especially in patients with low or intermediate anatomical risk, with lower cardiac and non-cardiac mortality, but with higher reintervention rate.
Courtesy of Dr. Carlos Fava. Favaloro Foundation, Buenos Aires, Argentina.
Original Title: Outcomes After Percutaneous Coronary Intervention or Bypass Surgery in Patients with Unprotected Left Main Disease
Reference: Rafael Cavalcante et al. J Am Cardiol 2016;68:999-1009.
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