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overestimated 4-year all-cause mortality in the EXCEL trial.788 The updated version, SYNTAX score II 2020, using the SYNTAX Extended Survival (SYNTAXES) data and external validation in the population of the FREEDOM, BEST, and PRECOMBAT trials,789 showed modest discrimination for predicting 5-year MACE (c-index for PCI and CABG of 0.62 and 0.67, respectively) and acceptable discrimination for predicting 10-year mortality. Another validation study indicated that the score displayed acceptable discrimination for all-cause mortality at 5 years in a Japanese cohort with LMCAD and/or multivessel CAD,787 but external validation in a prospective setting is lacking.783 The British Cardiovascular Intervention Society myocardial jeopardy score (BCIS-JS) is an alternative to the SYNTAX score, enabling the assessment of the severity and extent of CAD. It has been proven effective in predicting mortality after PCI and assessing the completeness of revascularization,790 but it is not as commonly used as the SYNTAX score.

4.4.5 Choice of myocardial revascularization

modality Both myocardial revascularization modalities—PCI and CABG—can achieve excellent outcomes, although through different mechanisms, in appropriately selected patients when GDMT alone fails.

4.4.5.1 Patients with single- or two-vessel coronary artery disease

Randomized evidence and subgroup analyses of trials enrolling a broader spectrum of CAD patients showed similar performance of PCI and CABG in patients with one- or two-vessel CAD, with or without the involvement of the proximal LAD in terms of death, stroke, or MI.791–797 In patients with complex LAD lesions, the need for late repeat revascularization is higher after PCI than CABG,797 but CABG is a more invasive procedure with inherent risks, longer hospital stay and healing.758

4.4.5.2 Patients with unprotected left main coronary artery disease

Over the past two decades, several trials have compared PCI and CABG in patients with multivessel CAD, with or without unprotected LMCAD326,728,730,798–801 (Table 9). The patients who were included in these trials had to meet the eligibility criteria for both CABG or PCI at an acceptable risk level, and their coronary anatomy had to allow complete revascularization through both procedures. However, due to the strict inclusion criteria, only a small percentage of eligible patients (ranging from 6% to 40%) were enrolled in these trials.798,801 The strict inclusion criteria resulted in enrolling a relatively young population with a lower burden of comorbidities (mean age <66 years).728,730,798,801 Meta-analyses of RCTs have shown that the risk of death is similar for both CABG and PCI for LMCAD, even for patients with a high SYNTAX score, up to 5–10 years after the intervention. However, the risk of stroke is higher with CABG, while the risk of spontaneous MI is higher with PCI.728,730,800,802–804 In the individual-patient data meta-analysis of four randomized trials,730 mortality over 5 years was not statistically different between patients treated with PCI or with CABG [11.2% vs. 10.2%; HR 1.10 (95% CI, 0.91–1.32); P = .33; absolute risk difference of 0.9%]. A similar treatment effect was observed for 10-year mortality [22.4% vs. 20.4%; HR 1.10 (95% CI, 0.93–1.29); P = .25; absolute risk difference 2.0%]. Spontaneous MI was lower in the CABG arm [6.2% vs. 2.6%; HR 2.35 (95% CI, 1.71–3.23); P < .0001; absolute risk difference 3.5%], while the results of periprocedural MI differed according to whether the analysis used the protocol definition or the universal definition of MI (available for only two studies). Stroke was not statistically different overall [2.7% vs. 3.1%; HR 0.84 (95% CI, 0.59–1.21); P = .36; absolute risk difference of −0.4%]. However, in a pre-specified analysis of the first 12 months of follow-up, stroke was lower after PCI than after CABG [0.6% vs. 1.6%; HR 0.37 (95% CI, 0.19–0.69); P = .002; absolute risk difference of −1.0%].782 Subgroup analysis based on the SYNTAX score and the number of additionally involved coronary vessels revealed no difference in all-cause mortality between CABG and PCI for SYNTAX score ≤32 or LMCA stenosis with 0/1 vessel disease. However, a trend for higher all-cause mortality was noted with PCI for SYNTAX score >32 (HR 1.30; 95% CI, 0.92–1.84) and/or LMCA stenosis with 2/3 vessel disease (HR 1.25; 95% CI, 0.97–1.60).782 Of note, the LMCA stenosis involved distal bifurcation in 75% of the patients, and the absence of a bifurcation lesion had no impact on mortality.730 True bifurcation left main lesions (defined as Medina type 1,1,1 or 0,1,1 both main vessel and side vessel >50% narrowed with reference diameters ≥2.75 mm),805

which frequently require 2-stent techniques, have worse clinical outcomes than non-bifurcation lesions.806–808 Despite excellent results after LMCA bifurcation stenting on angiography, 13% of patients still experience residual ischaemia in turn associated with higher longterm cardiovascular mortality.809 Using intracoronary imaging guidance to optimize stent expansion and prevent side-branch jailing may improve outcomes after PCI of bifurcation LMCA lesions.810 Operator experience may significantly affect the outcomes after interventional procedures. A single-centre study from China found that operators with a higher volume of procedures performed (>15 per year) had better outcomes for unprotected LMCA PCI.811 An analysis of the outcome data from the British Cardiovascular Intervention Society’s national PCI database on 6724 patients who underwent PCI for unprotected LMCA between 2012 and 2014 revealed that the volume of procedures performed by the operator plays a significant role in determining the outcome after PCI of unprotected LMCA.812 Although high-volume operators undertook PCIs on patients with greater comorbid burden and CAD complexity compared with low-volume operators, 12-month survival was lower in high-volume operators [odds ratio (OR) 0.54; 95% CI, 0.39–0.73]. A close association between operator volume and superior 12-month survival was observed (P < .001). A 2022 Joint ESC/EACTS (European Association for Cardio- Thoracic Surgery) task force recently reviewed the 2018 guideline recommendations on the revascularization of LMCAD in low-risk surgical patients with suitable anatomy for PCI or CABG.782 The review was mainly based on the recent individual-patient data meta-analysis730 of the long-term outcomes after CABG or PCI for LMCAD from four randomized clinical trials that included 4394 patients between March 2005 and January 2015. The review confirmed that for stable CCS patients with left main stem disease requiring revascularization, both treatment options are clinically reasonable based on patient preference, expertise availability, and local operator volumes. It was proposed that revascularization with CABG be the recommended option, with suggested class I and LOE A, while PCI be overall recommended with a suggested class IIa and LOE A. The present guidelines confirm that, among patients suitable for both revascularization modalities, CABG is recommended as the overall preferred revascularization mode over PCI, given the lower risk of spontaneous MI and repeat revascularization.730,782 The present guidelines also acknowledge that in patients with significant LMCA stenosis of low complexity (SYNTAX score ≤22), in whom PCI can provide equivalent completeness of revascularization to that of CABG, PCI is recommended as an alternative to CABG, given its lower invasiveness and non-inferior survival.718,728,730,802,813 Downloaded from academic.oup.com/eurheartj/article/45/36/3415/7743115 by guest on 07 October 2026