The primary goal of revascularization in left main coronary artery disease (LMCA) is to improve survival. However, debate continues regarding whether, in anatomically suitable patients, the choice between percutaneous coronary intervention (PCI) with drug-eluting stents or coronary artery bypass grafting (CABG) translates into differences in mortality when follow-up extends beyond the early years.
This analysis pooled individual patient data from the four randomized trials comparing PCI with drug-eluting stents (DES) versus CABG in LMCA disease: SYNTAX, PRECOMBAT, NOBLE, and EXCEL.
A total of 4,394 patients considered suitable for both PCI and CABG were included. The primary endpoint was all-cause mortality at 10 years, using all available follow-up data: 10-year follow-up for SYNTAX, PRECOMBAT, and NOBLE, and 5-year follow-up for EXCEL.
The study population had a mean age of 66 years; 77% were male, 25% had diabetes, and 12% had a left ventricular ejection fraction below 50%. The mean SYNTAX score was 25.0.
Regarding coronary disease extent, isolated LMCA disease was present in 16% of patients, LMCA plus one-vessel disease in 31%, LMCA plus two-vessel disease in 32%, and LMCA plus three-vessel disease in 21%.
In the PCI arm, an average of two stents were implanted, and IVUS guidance was used in 71% of cases. In the surgical arm, patients received an average of two bypass grafts, with left internal mammary artery (LIMA) use in 96% of procedures and exclusively arterial revascularization in 23%.
At 10 years, all-cause mortality was similar between both strategies: 23.5% with PCI and 23.1% with CABG (HR 1.04; 95% CI 0.90–1.19; p=0.62).
Time-period analysis also showed no temporal divergence. Between 0 and 5 years, mortality was 11.2% with PCI versus 10.3% with CABG (HR 1.09; 95% CI 0.91–1.31), while between 5 and 10 years it was 13.8% versus 14.3%, respectively (HR 0.96; 95% CI 0.77–1.20).
Bayesian analysis demonstrated a 61.9% probability that mortality was higher with PCI than with CABG. However, it also showed a 31.6% probability that the absolute difference between strategies was ≤1% at 10 years, and only a 5.0% probability that the difference would reach or exceed 2.5%.
Results were consistent across anatomical complexity strata. In patients with a SYNTAX score ≤22, mortality was 19.7% with PCI and 20.2% with CABG. In the SYNTAX 23–32 group, mortality was 24.3% versus 23.8%, while among patients with SYNTAX ≥33 it was 30.2% versus 29.2% (HR 1.13; 95% CI 0.86–1.49).
Conclusions: PCI and CABG Showed Similar Long-Term Survival in Left Main Coronary Artery Disease
In patients with LMCA disease considered appropriate candidates for both PCI and CABG, particularly those with low-to-moderate anatomical complexity, no significant differences in long-term all-cause mortality were observed. These findings support an individualized treatment decision-making process involving both the Heart Team and the patient whenever both strategies are technically feasible.
Presented by Brian A. Bergmark during the Major Late-Breaking Trials session at EuroPCR 2026, held from May 19–22, 2026, in Paris.
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