5-year survival of patients with Unprotected left main (ULM) stenosis according to the choice of revascularization (percutaneous vs. surgical) remains to be defined.
Randomized Controlled Trials (RTCs) comparing Percutaneous Coronary Intervention (PCI) vs. Coronary Artery Bypass Graft (CABG) with a follow-up of at least 5 years were included. All-cause death was the primary endpoint. MACCE (a composite endpoint of all-cause mortality, myocardial infarction [MI], stroke and repeat revascularization) along with its single components and cardiovascular (CV) death were the secondary ones. Analyses were stratified according to use of first vs. last generation coronary stents. Subgroup comparisons were performed according to Syntax Score (below or above 33) and to age (using cutoffs of each trial’s subgroup analysis). 4 RCTs with 4394 patients were identified: 2197 were treated with CABG, 657 with first generation and 1540 with last generation stents. At 5 years rates of all-cause death did not differ (OR 0.93:0.71-1.21), as those of CV death and stroke. CABG reduced rates of MACCE (OR 0.69:0.60-0.79), mainly driven by MI (OR 0.48:0.36-0.65) and revascularization (OR 0.53:0.45-0.64). Benefit of CABG for MACCE was consistent, although with different extent, across values of Syntax Score (OR 0.76:0.59-0.97 for values<32 and OR 0.63:0.47-0.84 for values≥33) while was not evident for "younger" patients (OR 0.83:0.65-1.07 vs. OR 0.65:0.51-0.84 for "older" patients, all CI 95%).
For patients with ULM disease followed up for five years, no significant difference was observed in all-cause and cardiovascular death between PCI and CABG. CABG reduced risk of MI, revascularization and MACCE especially in older patients and in those with complex coronary disease and a high syntax score.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions please email: journals.permissions@oup.com.