Division of Cardiology, Cardiovascular and Thoracic Department, AOU Città della Salute e della Scienza di Torino and University of Turin, Turin, Italy.
Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY.
J Thorac Cardiovasc Surg. 2023 Jul;166(1):120-132.e11. doi: 10.1016/j.jtcvs.2021.08.040. Epub 2021 Aug 21.
Comparative data after percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) for unprotected left main coronary artery (ULMCA) disease according to lesion site (ostial/shaft vs distal) are scant. The aim of this meta-analysis was to investigate outcomes after PCI or CABG for ULMCA disease according to lesion site.
Randomized controlled trials (RCTs) and adjusted observational studies that compared PCI versus CABG in patients with ULMCA disease and reported outcomes according to lesion site were systematically identified. Major adverse cardiovascular events (MACE; a composite of all-cause death, myocardial infarction, stroke, and repeat revascularization) and all-cause death were the co-primary end points. Individual components of MACE were secondary end points. Sensitivity analysis including RCTs only were performed for each outcome.
Nine studies (3 RCTs, 6 adjusted observational), encompassing 6296 patients (2274 and 4022 treated for ostial/shaft or distal ULMCA, respectively) were included. At the 5-year follow-up, there were no significant differences between CABG and PCI for MACE, death, or any other secondary outcome for ostial/shaft ULMCA lesions (MACE: hazard ratio [HR], 1.0 [95% confidence interval (CI), 0.79-1.27]; death: HR, 1.10 [95% CI, 0.84-1.46]). For distal ULMCA, PCI was associated with an increased risk of MACE (HR, 1.32; 95% CI, 1.10-1.58), death (HR, 1.56; 95% CI, 1.19-2.04), and revascularization (HR, 2.07; 95% CI, 1.5-2.84). The benefit of CABG for MACE and revascularization was confirmed in the analysis limited to RCTs, whereas the benefit for mortality was not.
Among patients with distal ULMCA disease, CABG is associated with lower incidence of MACE and revascularization compared with PCI, whereas no differences in outcomes were observed for ostial/shaft ULMCA disease.
经皮冠状动脉介入治疗（PCI）或冠状动脉旁路移植术（CABG）治疗无保护左主干冠状动脉（ULMCA）疾病的对比数据，根据病变部位（开口/主干 vs 远端）很少。本荟萃分析的目的是研究根据病变部位，PCI 或 CABG 治疗 ULMCA 疾病的结局。
系统地检索了比较 ULMCA 疾病患者中 PCI 与 CABG 的随机对照试验（RCT）和调整后的观察性研究，并根据病变部位报告结果。主要不良心血管事件（MACE；全因死亡、心肌梗死、卒中和再次血运重建的复合终点）和全因死亡是共同的主要终点。MACE 的各个组成部分是次要终点。对每种结局进行了仅包括 RCT 的敏感性分析。
纳入了 9 项研究（3 项 RCT，6 项调整后的观察性研究），共纳入 6296 例患者（2274 例和 4022 例分别接受开口/主干或远端 ULMCA 治疗）。在 5 年随访时，CABG 和 PCI 治疗开口/主干 ULMCA 病变的 MACE、死亡或任何其他次要结局均无显著差异（MACE：风险比[HR]，1.0[95%置信区间（CI），0.79-1.27]；死亡：HR，1.10[95%CI，0.84-1.46]）。对于远端 ULMCA，PCI 与 MACE（HR，1.32；95%CI，1.10-1.58）、死亡（HR，1.56；95%CI，1.19-2.04）和血运重建（HR，2.07；95%CI，1.5-2.84）的风险增加相关。在仅限于 RCT 的分析中，CABG 治疗 MACE 和血运重建的获益得到了证实，而死亡率的获益则没有。
在远端 ULMCA 疾病患者中，与 PCI 相比，CABG 与较低的 MACE 和血运重建发生率相关，而开口/主干 ULMCA 疾病的结局无差异。
