CABG and stenting ‘comparable’ in complex, unprotected left main disease
MedWire News: Coronary artery bypass graft (CABG) surgery and percutaneous coronary intervention (PCI) are associated with similar long-term outcomes in patients with unprotected left main coronary artery (ULMCA) disease regardless of the extent of additional vascular disease, suggest findings from the large MAIN-COMPARE registry.
There was no significant difference at 4 years in major adverse cardiac events (death, myocardial infarction [MI], or stroke) across subgroups stratified by number of diseased vessels, report Seung-Jung Park (University of Ulsan College of Medicine, Seoul, South Korea) and colleagues in the Journal of the American College of Cardiology.
The advantage of CABG over stenting lies principally in a reduction in target vessel revascularization (TVR), say the authors.
Nevertheless, they write: “In contrast to concerns regarding the long-term safety of drug-eluting stents in patients with complex coronary lesions our results indicate that stenting and CABG for ULMCA stenosis were of comparable safety, regardless of extra-ULMCA coronary artery disease.”
The researchers studied 2240 patients with ULMCA stenosis in the MAIN-COMPARE (Revascularization for Unprotected Left Main Coronary Artery Stenosis: Comparison of Percutaneous Angioplasty versus Surgical Revascularization) registry.
After adjusting for differences in EuroSCORE (European System for Cardiac Operative Risk Evaluation), diabetes, and bifurcation ULMCA stenosis, they found that risks for death, MACE, or major adverse cardiac or cerebrovascular events (MACCE; including death, MI, cerebrovascular accident, or TVR) were not associated with the number of extra-ULMCA diseased vessels in either stent or CABG groups.
Patients treated with stenting and CABG showed comparable risks for death and MACE across subgroups stratified by vascular disease overall as well as for an earlier wave of the registry in which bare-metal stents (BMS) were used among patients undergoing PCI (Wave 1), and a later wave in which patients receiving drug-eluting stents (DES) in the stenting group (Wave 2).
However, the risk for MACCE was significantly higher with stenting than with CABG for patients having two-vessel (hazard ratio [HR]=1.7, p=0.006) or three-vessel (HR=1.5, p=0.011) disease in the overall patient population.
Further analysis showed that the risk for MACCE was higher with PCI in patients with isolated ULMCA (HR=3.1) and three-vessel disease (HR=2.2) in Wave 1, and in those with two-vessel disease in Wave 2 (HR=2.4).
Although many questions remain, commented Barry Uretsky (University of Arkansas, Little Rock, USA) in a related editorial, the research provides “reassurance that long-term major adverse outcomes after LM stenting, both with BMS and DES, compare favorably with bypass surgery, thus providing increased confidence to the treating physician who must evaluate which therapy is preferred for the individual patient.”
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By Caroline Price