Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza, Corso Bramante 88, 10126, Turin, Italy.
Division of Cardiac Surgery, Department of Surgical Sciences, Città della Salute e della Scienza, Corso Bramante 88, 10126, Turin, Italy.
Eur Heart J Qual Care Clin Outcomes. 2021 Sep 16;7(5):476-485. doi: 10.1093/ehjqcco/qcaa041.
A 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 (RCTs) 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 the use of first- vs. last-generation coronary stents. Subgroup comparisons were performed according to SYNTAX score (below or above 33) and to age (using cut-offs of each trial's subgroup analysis). Four RCTs with 4394 patients were identified: 2197 were treated with CABG, 657 with first generation, and 1540 with last-generation stents. At 5-year rates of all-cause death did not differ [odds ratio (OR) 0.93, 95% confidence interval (CI) 0.71-1.21], as those of CV death and stroke. Coronary artery bypass graft reduced rates of MACCE (OR 0.69, 95% CI 0.60-0.79), mainly driven by MI (OR 0.48, 95% CI 0.36-0.65) and revascularization (OR 0.53, 95% CI 0.45-0.64). Benefit of CABG for MACCE was consistent, although with different extent, across values of SYNTAX score (OR 0.76, 95% CI 0.59-0.97 for values < 32 and OR 0.63, 95% CI 0.47-0.84 for values ≥ 33) while was not evident for 'younger' patients (OR 0.83, 95% CI 0.65-1.07 vs. OR 0.65, 95% CI 0.51-0.84 for 'older' patients).
For patients with ULM disease followed-up for 5 years, no significant difference was observed in all-cause and cardiovascular death between PCI and CABG. Coronary artery bypass graft reduced risk of MI, revascularization, and MACCE especially in older patients and in those with complex coronary disease and a high SYNTAX score.
接受经皮冠状动脉介入治疗（PCI）与冠状动脉旁路移植术（CABG）治疗的无保护左主干（ULM）狭窄患者的 5 年生存率，取决于血运重建方式的选择，目前尚未明确。
本研究纳入了比较 PCI 与 CABG 治疗并随访至少 5 年的随机对照试验（RCT）。全因死亡是主要终点，主要不良心脑血管事件（MACCE）[包括全因死亡、心肌梗死（MI）、卒中和再次血运重建]及其各组成部分，以及心血管（CV）死亡是次要终点。分析根据第一代和最新一代冠状动脉支架的使用情况进行分层。根据 SYNTAX 评分（<33 分和≥33 分）和年龄（各试验亚组分析的界值）进行亚组比较。共纳入 4 项 RCT，共 4394 例患者，其中 2197 例接受 CABG 治疗，657 例接受第一代支架治疗，1540 例接受最新一代支架治疗。5 年时全因死亡发生率无差异[比值比（OR）0.93，95%置信区间（CI）0.71-1.21]，CV 死亡和卒中等发生率也无差异。CABG 降低了 MACCE 发生率（OR 0.69，95% CI 0.60-0.79），主要是由 MI（OR 0.48，95% CI 0.36-0.65）和再次血运重建（OR 0.53，95% CI 0.45-0.64）所致。CABG 降低 MACCE 的获益是一致的，尽管在不同程度上取决于 SYNTAX 评分值（<32 分时 OR 0.76，95% CI 0.59-0.97；≥33 分时 OR 0.63，95% CI 0.47-0.84），但在“年轻”患者中不明显（<65 岁时 OR 0.83，95% CI 0.65-1.07；≥65 岁时 OR 0.65，95% CI 0.51-0.84）。
对于 ULM 病变患者随访 5 年，PCI 与 CABG 治疗的全因死亡和心血管死亡发生率无显著差异。CABG 可降低 MI、再次血运重建和 MACCE 的风险，尤其在老年患者和复杂冠状动脉疾病及高 SYNTAX 评分患者中获益更大。
