Percutaneous coronary intervention versus cardiac bypass surgery for left main coronary artery disease: A trial sequential analysis

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Several updated meta-analyses comparing percutaneous coronary intervention (PCI) with coronary artery bypass grafting (CABG) for left main coronary artery disease (LM CAD) have been published recently. However, the risk of false-positive results could be high in conventional updated meta-analyses due to repetitive testing of accumulating data. Therefore, we compared these treatment approaches via trial sequential analysis (TSA).


The MEDLINE, Embase, and Cochrane Central Register of Controlled Trials databases were searched for published randomized controlled trials (RCTs) or subgroups of RCTs comparing PCI and CABG in patients with LM CAD. The primary outcome was major cardiac and cerebrovascular adverse events (MACCE). TSA was used to confirm the conclusions derived from conventional meta-analysis.


Six RCTs with 4700 patients were included. PCI was associated with a greater risk of MACCE compared with CABG (pooled relative risk [RR] 1.21, 95% confidence interval [CI]: 1.05–1.40, P = .008). In addition, PCI resulted in a significantly higher risk of revascularization than CABG (pooled RR 1.61, 95% CI: 1.33–1.95, P < .0001). TSA provided firm evidence for the reduction of MACCE and revascularization with CABG compared with PCI (cumulative z-curve crossed the monitoring boundary). In the subgroup analysis, CABG was better than PCI in patients with SYNTAX score >32 (pooled RR 1.41, 95% CI: 1.12–1.76, P = .003), which was confirmed by the TSA. There was no difference in patients with a SYNTAX score from 0 to 32.


In patients with LM CAD, CABG may be better than PCI for reducing MACCE due to a reduced risk of revascularization. CABG remains the first choice for LM CAD patients with high anatomic complexity, while PCI could be an alternative for those with low-to-moderate anatomic complexity.

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