Courtesy of Dr. Carlos Fava.

Severe left main coronary artery (LMCA) lesions have a bad prognosis in coronary disease. In that scenario, current guidelines recommend surgery as the treatment of choice. However, due to the current development of second-generation drug-eluting stents (DES) and greater operator expertise, left main coronary artery angioplasty appears as a valid alternative in various modern randomized studies.

In this case, 6 studies (EXCEL, NOBLE, LE MANS, PRE COMBAT, Boudriot, and SYNTAX) including 4700 total patients were analyzed.

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There were no significant differences in all-cause mortality at 30 days (0.61; 95% confidence interval [CI]: 0.27 to 1.36), 1 year (0.66; 95% CI: 0.42 to 1.04), and 3 years (1.04; 95% CI: 0.81 to 1.33). However, there was a trend towards lower mortality during the first year.

The risk of major adverse cardiac events (MACE) at 30 days and 1 year was similar for both strategies; however, in the long term, it was higher for patients who underwent angioplasty, due to higher revascularization rates between the first and third year.

Patients who underwent angioplasty experienced less events of stroke at 30 days and 1 year. No difference was observed beyond that period. Conversely, the risk of acute myocardial infarction (MI) was similar at 30 days, 1 year, 3 years, and 10 years.

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The composite outcome of death, stroke and MI was lower with angioplasty at 30 days (0.67; 95% CI: 0.49 to 0.92), but similar at 1 and 3 years.

Conclusion

No significant differences in all-cause mortality were observed between angioplasty and myocardial revascularization surgery (MRS) in the short and the long term. Angioplasty was associated with a reduction in the risk of major cardiovascular events in the short term in patients with left main coronary artery (LMCA) stenosis, as well as with increased rates of MACE in the long term.

Editorial Comment

This meta-analysis of modern randomized studies shows that LMCA angioplasty is safe and offers outcomes similar to those obtained with MRS, beyond its short-term benefits.

While, after a year, patients who underwent angioplasty experienced more MACE events, this is mainly due to a higher need for reintervention and is in no way related to hard events such as death or stroke.

These results will surely improve with new stents, more technology involvement in the assessment of stent implantation, and greater cumulative operator expertise.

Courtesy of Dr. Carlos Fava.

Original title: All-Cause Mortality and Major Cardiovascular Outcomes Comparing Percutaneous Coronary Angioplasty Versus Coronary Bypass Grafting in the Treatment of Unprotected Left Main Stenosis: A Meta-Analysis of Short-Term and Long-Term Randomized Trials.

Reference: Jari A. Laukkanen, et al. Open Heart BMJ 2017;4e000638.

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