Percutaneous coronary intervention versus coronary artery bypass grafting in left main coronary artery disease: A review

The left main coronary artery is responsible for most of the irrigation of the left ventricle. Left main coronary artery disease (LMCAD) therefore leads to important morbidity and mortality. Coronary artery bypass grafting (CABG) is considered the standard treatment, however, percutaneous coronary intervention (PCI) has become a frequent alternative in the treatment of LMCAD. In the current review, four randomized clinical trials comparing PCI with CABG in patients with LMCAD, including new longer follow-up results, are reviewed. Major adverse cardiac and cerebrovascular event rates were similar between the two intervention groups in both the SYNTAX and PRECOMBAT trials, and favored the CABG group in the EXCEL and NOBLE trials. The composite of death, stroke and myocardial infarction was similar in all trials. Mortality rates were similar across all trials except for the EXCEL trial at five years, which favored CABG. Cardiac mortality was similar in all trials. Stroke rates were similar, apart from the SYNTAX trial, which favored PCI. CABG was more favorable concerning myocardial infarction in the NOBLE trial, but not in the other trials. Repeat revascularization was generally less frequent in the CABG group. Stent thrombosis and graft occlusion were less frequent with PCI in the EXCEL trial, with no differences in the other trials. Based on the overall similarity in the primary endpoint rates, as well as favorable short-term outcomes, it is plausible to state that PCI can be considered a good alternative to CABG, although the higher risk of repeat revascularization should be taken into consideration.