Benefits of coronary artery bypass grafting over percutaneous coronary intervention in left main disease: the strength of the evidence

This commentary refers to ‘PCI or CABG for left main coronary artery disease: the SWEDEHEART registry’, by J. Persson et al., https://doi.org/10.1093/eurheartj/ehad369. Randomized control trials (RCTs) tell us how good an intervention is while registries tell us its benefit in the population. Clinical registry offers a wider analysis of therapeutics strategies based on real word settings and can overcome the limits, in terms of external validation, for which all RCTs, inevitably, suffer. Major benefit for patients comes when conclusions from both agree. The solid large observational study by Persson et al.1 who analysed a sample population of 11 137 patients with left main disease, provides, one more time, a clear prove that coronary artery bypass grafting (CABG) is the best therapeutic option in this setting. These data have come to support what RCT has already shown. Coronary artery bypass grafting has, in fact, been shown to achieve better results than percutaneous coronary intervention (PCI) in the treatment of coronary disease independently from the SYNTAX score and the presence of left main or multivessel disease.2 Randomized control trials comparing CABG vs. PCI with drug eluting stents were the substratum of the individual patient data meta-analysis by Sabatine et al.3 The Kaplan–Meier estimate of 5-year events showed a significant benefit of CABG in terms of spontaneous myocardial infarction (hazard ratio [HR] 2.35; 95% confidence interval [CI] 1.71–3.23) and revascularization (HR 1.78; 95% CI 1.51–2.10), but not in in terms of mortality (HR 1.10; 95% CI 0.91–1.32). Still, according to the Bayesian analyses, there was an 85.7% probability that death at 5 years was greater with PCI than with CABG. In conclusion, we deeply appreciate the work of the investigators of clinical registries, such as the Swederegistry.1 In contrast to what has been proposed by Alfonso et al.,4 CABG has been associated with lower major adverse events at 5 years which explain the current conclusion of the 2022 Joint ESC/EACTS review of the 2018 guideline recommendations on LM revascularization5: class I for CABG and IIa for PCI, level of evidence A.