Major cardiovascular events at 5 years in surgical versus percutaneous revascularization for left main stem disease: an updated meta-analysis

The aim of the present study was to analyse the incidence of major adverse cardiovascular events in patients undergoing either coronary artery bypass grafting (CABG) or percutaneous coronary intervention with drug-eluting stents for left main stem disease. Five manuscripts publishing 5-year results of 4 trials (SYNTAX, PRECOMBAT, NOBLE and EXCEL) were included. Overall meta-analysis with inclusion of the 5-year results from the EXCEL trial using the protocol definition for myocardial infarction showed that CABG is associated with a significant reduction in the risk of major adverse cardiovascular events (MACE) (risk ratio = 0.74; 95% confidence interval = 0.68-0.80). When the universal definition was used to define myocardial infarction in the EXCEL trial, the analysis demonstrated a larger benefit of coronary surgery in terms of reduction in the risk of MACE (risk ratio = 0.70; 95% confidence interval = 0.63-0.76). Non-significant differences were detected in terms of risk of overall mortality, cardiac mortality or stroke. In conclusion, this meta-analysis shows that CABG significantly reduces the risk of MACE in patients with left main stem disease. The inclusion of the 5-year results of the EXCEL trial using third universal definition amplifies the benefit of CABG over percutaneous coronary intervention.