Optimal revascularization strategies in patients with left main coronary artery disease

The EuroPCR Course Directors have selected 3 major late-breaking trials that will be presented for the first time during EuroPCR 2026 and are set to impact practice worldwide. Among them is a meta-analysis of long-term data from 4 randomized trials investigating revascularization strategies in patients with left main coronary artery disease.

Background 

Randomized trials have investigated the optimal revascularization strategy for patients with left main coronary artery disease, comparing percutaneous coronary intervention (PCI) using drug-eluting stents (DES) with coronary artery bypass grafting (CABG). In 2021, a meta-analysis of 4 trials − SYNTAX, PRECOMBAT, NOBLE and EXCEL – found no statistically significant difference in 5-year all-cause mortality between DES PCI and CABG. Long-term follow-up of these trials is now complete, providing the opportunity to evaluate the effects of DES PCI and CABG on mortality over an extended period.

An individual participant data meta-analysis of these trials was presented by Brian Bergmark. The meta-analysis included 10-year data for SYNTAX, PRECOMBAT and NOBLE, and 5-year data for EXCEL.

Results 

• The meta-analysis included data from 4,394 patients. 
• Rates of all-cause mortality did not differ between patients randomized to DES PCI (23.5%) or CABG (23.1%). 
• There were no apparent differences between the treatments amongst various subgroups studied, including baseline SYNTAX score (≤22, 23–32 and ≥33). 
• Similar mortality results for DES PCI (22.3%) and CABG (23.3%) were obtained when analysis was restricted to trials with 10-year follow up data. 
• In landmark analyses of all 4 trials, results were similar for DES PCI and CABG in the 0–5-year and 5–10-year follow up time periods.

Key learnings 

• There is no significant difference in mortality over 10 years of follow-up in patients with left main coronary artery disease considered suitable for revascularization with DES PCI or CABG. 
• These similar mortality rates were consistent across key clinical subgroups, and in both the 0–5-year and 5–10-year follow up time periods.

Conclusions and PCR recommendations

This meta-analysis of long-term data indicates that either DES PCI or CABG may be considered for left main revascularization in patients who are deemed to be suitable for both approaches by a multidisciplinary team. These findings strengthen the role of DES PCI in contemporary practice and endorse the role of the multidisciplinary team in clinical decision-making processes.