An individual patient data meta-analysis of long-term data from four major trials comparing percutaneous coronary intervention (PCI) to coronary artery bypass graft (CABG) surgery among patients with left main coronary artery disease has shown no significant differences in mortality over 10 years with the two revascularisation approaches.
Led by researchers from the Thrombolysis in Myocardial Infarction (TIMI) Study Group at Brigham & Women’s Hospital in Boston, USA, the analysis included data from four randomised trials involving 4,394 patients, comprising 10-year data from the SYNTAX, PRECOMBAT and NOBLE trials, as well as five-year data from the EXCEL trial.
Presenting the findings at EuroPCR 2026 (19–22 May, Paris, France), investigator Brian Bergmark (Brigham and Women’s Hospital, Boston, USA) commented that the study’s findings suggest either PCI or CABG may be considered for left main revascularisation in patients deemed appropriate for both approaches by a multidisciplinary team.
Breaking down the results, Bergmark reported that rates of all-cause mortality did not differ between patients randomised to PCI with a drug-eluting stent (DES, 23.5%) or undergoing CABG (23.1%). Furthermore, there were no apparent differences between the treatment approaches amongst various subgroups, which included baseline SYNTAX score (≤22, 23–32, and ≥33).
The choice of revascularisation strategy in patients with left main coronary artery disease has previously been a topic of contention amongst interventional cardiologists and cardiac surgeons, with differences in trial composite endpoints and findings having led to uncertainty over the optimal approach.
The TIMI Study Group set about to address this controversy, performing an initial meta-analysis of the four trials with data out to five-years, with the results presented at the American Heart Association’s (AHA) 2021 Scientific Sessions and published simultaneously published in The Lancet. This showed that overall, there was no statistically significant difference in mortality between the two treatment strategies despite an early diversion of the curves—in favour of PCI—that then crossed. The five-year rates of mortality stood at 11.2% for PCI, compared to 10.2% for CABG.
Despite these findings, Bergmark commented at EuroPCR 2026 that the question still remained as to whether a significant difference between the two strategies would emerge over time, prompting the latest analysis using now available long-term follow-up from the trials. The latest analysis showed that in the five-to-10-year time period, the rate of mortality for PCI stood at 13.8%, compared to 14.9% for CABG.
Bergmark noted that the analysis had some limitations, notably that, as patients were required to be suitable for either approach, they typically had low Syntax scores, as well as commenting that the primary endpoint, mortality, “does not capture the entirety of the patient experience”.
“Other typical cardiovascular endpoints such as myocardial infarction and stroke are important but are not available in the long-term follow-up. Additionally, patient-reported outcomes may be relevant,” he noted, adding: “Procedural and surgical techniques, medical therapy and clinical decision-making evolve over time, with inherent tension between long-term follow-up versus state-art-practice.”
Bergmark concluded that among patients with left main coronary artery disease considered suitable for PCI or CABG, there was no significant difference in mortality between these two strategies over 10 years of follow-up. The similar rates of mortality over 10 years were consistent across key clinical subgroups, and in the 0-to-five-year and five-to-10-year periods.
“As such either PCI or CABG may be considered for left main revascularisation in patients deemed appropriate for both approaches by a multidisciplinary team,” he said.
