Abstract Background The management of left main (LM) coronary artery disease continues to pose a clinical challenge, particularly regarding the optimal revascularization strategy. The long-standing debate between percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) remains unresolved, although current evidence generally supports CABG in patients with a SYNTAX score ≥22, reflecting the complexity of coronary anatomy in this subgroup. Methods We conducted a single-center retrospective study including 114 patients who underwent PCI for bifurcation LM disease between 2010 and 2024. The aim was to evaluate long-term cardiovascular outcomes and compare them with those reported in the literature. The primary endpoint was a composite of cardiovascular death, myocardial infarction, stroke, or target lesion revascularization. Observed outcomes were compared with expected cumulative rates of major adverse cardiac and cerebrovascular events (MACCE) for PCI and CABG derived from the SYNTAX trial logistic regression model. Results A total of 113 patients were analyzed, with a median follow-up of 38 months (10 patients were lost to follow-up). The mean age was 70.8 ± 11.1 years, and 77.2% were male. Clinical presentation included chronic coronary syndrome (CCS) in 42.1% and STEMI in 30.7% of patients. The mean SYNTAX score was 27.0 ± 11.8. As expected, patients with more complex coronary anatomy had higher MACCE rates: 18.9% for SYNTAX 22, 19.5% for SYNTAX 22–33, and 42.9% for SYNTAX ≥ 33. These outcomes were lower than predicted for PCI and comparable to CABG in patients with SYNTAX 22 and SYNTAX 22–33. In the SYNTAX ≥ 33 group, MACCE rates exceeded those anticipated for both PCI and CABG. Subgroup analysis revealed that patients with SYNTAX ≥ 33 presenting with CCS had a MACCE rate of 25%. Conclusions Despite being an older risk stratification tool, the SYNTAX score remains clinically relevant, providing meaningful insight into coronary disease complexity. In our experience, PCI achieved outcomes comparable to CABG in patients with SYNTAX 33, even among those with acute coronary syndromes. For SYNTAX 33, CABG remains slightly superior in CCS (25% vs 21.9%), reflecting a greater disease burden. Nevertheless, PCI continues to represent a viable and pragmatic option, particularly in acute settings and where surgical waiting times are prolonged.
Louro et al. (2026) studied this question.