Five-Year Outcomes in Patients with Left Main Disease Treated with Either Percutaneous Coronary Intervention or Coronary Artery Bypass Grafting in the SYNTAX Trial
Background—Current guidelines recommend coronary artery bypass graft surgery (CABG) when treating significant de novo LM stenosis; however, percutaneous coronary intervention (PCI) has a Class IIa indication for unprotected LM disease in selected patients. This analysis compares 5-year clinical outcomes in PCI- and CABG-treated LM patients in the SYNTAX trial, the largest trial in this group to date.
Methods and Results—SYNTAX randomized 1800 LM and/or 3-vessel disease patients to receive either PCI (with TAXUS Express paclitaxel-eluting stents) or CABG. The unprotected LM cohort (N=705) was predefined and powered. MACCE at 5 years was 36.9% in PCI patients and 31.0% in CABG patients (hazard ratio (HR) 1.23 [0.95, 1.59]; P=0.12). Mortality was 12.8% and 14.6% in PCI and CABG patients, respectively (HR 0.88 [0.58, 1.32], P=0.53). Stroke was significantly increased in the CABG group (PCI 1.5% vs CABG 4.3%, HR 0.33 [0.12, 0.92], P=0.03) and repeat revascularization in the PCI arm (26.7% vs 15.5%, HR 1.82 [1.28, 2.57], P<0.01). MACCE was similar between arms in patients with low/intermediate SYNTAX Scores but significantly increased in PCI patients with high scores (≥33).
Conclusions—At 5 years, no difference in overall MACCE was found between treatment groups. PCI-treated patients had a lower stroke but higher revascularization rate versus CABG. These results suggest that both treatments are valid options for LM patients. The extent of disease should accounted for when choosing between surgery and PCI as patients with high SYNTAX scores seem to benefit more from surgery compared to the lower terciles.
Clinical Trial Registration Information—clinicaltrials.gov. Identifier: NCT00114972.
- Received October 15, 2013.
- Revision received January 14, 2014.
- Accepted January 31, 2014.