CABG Surgery Remains the best Option for Patients with Left Main Coronary Disease in Comparison with PCI-DES: Meta-Analysis of Randomized Controlled Trials

Abstract Objective: To compare the safety and efficacy of coronary artery bypass grafting (CABG) with percutaneous coronary intervention (PCI) using drug-eluting stents (DES) in patients with unprotected left main coronary artery (ULMCA) disease. Methods: MEDLINE, EMBASE, CENTRAL/CCTR, SciELO, LILACS, Google Scholar and reference lists of relevant articles were searched for clinical studies that reported outcomes at 1-year follow-up after PCI with DES and CABG for the treatment of ULMCA stenosis. Five studies fulfilled our eligibility criteria and they included a total of 4.595 patients (2.298 for CABG and 2.297 for PCI with DES). Results: At 1-year follow-up, there was no significant difference between CABG and DES groups concerning the risk for death (risk ratio [RR] 0.973, P=0.830), myocardial infarction (RR 0.694, P=0.148), stroke (RR 1.224, P=0.598), and major adverse cerebrovascular and cardiovascular events (RR 0.948, P=0.680). The risk for target vessel revascularization (TVR) was significantly lower in the CABG group compared to the DES group (RR 0.583, P<0.001). It was observed no publication bias regarding the outcomes, but only the outcome TVR was free from substantial statistical heterogeneity of the effects. In the meta-regression, there was evidence that the factor "female gender" modulated the effect regarding myocardial infarction rates, favoring the CABG strategy. Conclusion: CABG surgery remains the best option of treatment for patients with ULMCA disease, with lower TVR rates.

摘要：研究目的：比较冠状动脉旁路移植术（coronary artery bypass grafting, CABG）与药物洗脱支架（drug-eluting stents, DES）辅助经皮冠状动脉介入治疗（percutaneous coronary intervention, PCI）在无保护左主干冠状动脉（unprotected left main coronary artery, ULMCA）疾病患者中的安全性与有效性。研究方法：检索MEDLINE、EMBASE、CENTRAL/CCTR、SciELO、LILACS、Google Scholar及相关文献的参考文献列表，筛选报道药物洗脱支架经皮冠状动脉介入治疗与冠状动脉旁路移植术治疗无保护左主干冠状动脉狭窄后1年随访结局的临床研究。最终纳入5项符合入组标准的研究，共纳入4595例患者（冠状动脉旁路移植术组2298例，药物洗脱支架经皮冠状动脉介入治疗组2297例）。研究结果：1年随访结果显示，冠状动脉旁路移植术组与药物洗脱支架组在全因死亡（风险比[RR]=0.973，P=0.830）、心肌梗死（RR=0.694，P=0.148）、卒中（RR=1.224，P=0.598）及主要不良心脑血管事件（RR=0.948，P=0.680）的发生风险上无显著统计学差异。与药物洗脱支架组相比，冠状动脉旁路移植术组的靶血管血运重建（target vessel revascularization, TVR）风险显著更低（RR=0.583，P<0.001）。本研究未观察到各结局指标存在发表偏倚，但仅靶血管血运重建这一结局指标的效应量无显著统计学异质性。Meta回归分析显示，“女性性别”这一因素可调控心肌梗死发生率的效应，更倾向于支持冠状动脉旁路移植术治疗策略。研究结论：冠状动脉旁路移植术仍是无保护左主干冠状动脉疾病患者的最优治疗选择，其靶血管血运重建率更低。