ORIGINAL ARTICLE Coronary bypass surgery versus stenting in multivessel disease involving the proximal left anterior descending coronary artery Rafael Cavalcante, 1,2 Yohei Sotomi, 3 Yaping Zeng, 1 Cheol Whan Lee, 4 Jung-Min Ahn, 4 Carlos Collet, 3 Erhan Tenekecioglu, 1 Pannipa Suwannasom, 1,3 Yoshinobu Onuma, 1 Seung-Jung Park, 4 Patrick W Serruys 5 1 Erasmus University Medical Center, Rotterdam, The Netherlands 2 Heart Institute (InCor), University of Sao Paulo Medical School, Sao Paulo, Brazil 3 Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands 4 Heart Institute, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea 5 International Center for Circulatory Health, Imperial College London, London, UK Correspondence to Professor Patrick W Serruys, Department of Cardiology in the Cardiovascular Science Division of the NHLI within Imperial College of Science, Technology and Medicine, London, UK; Emeritus Professor of Medicine Erasmus University, Rotterdam, 3015 CE, The Netherlands; patrick.w.j.c.serruys@gmail. com RC and YS contributed equally to this study. An abstract of this study has been presented at the American College of Cardiology Meeting in Chicago on 2 April 2016. Received 30 March 2016 Revised 9 August 2016 Accepted 22 August 2016 To cite: Cavalcante R, Sotomi Y, Zeng Y, et al. Heart Published Online First: [ please include Day Month Year] doi:10.1136/heartjnl- 2016-309720 ABSTRACT Objective In patients with multivessel disease and proximal left anterior descending artery (LAD) involvement, the best revascularisation strategy is still unclear. We assess outcomes after coronary artery bypass graft surgery (CABG) and percutaneous coronary intervention (PCI) with drug-eluting stents in a pooled analysis of individual patient-level data of the SYNTAX and BEST randomised trials. Design Proximal LAD involvement was defined by any lesion ≥ 50% diameter stenosis in the arterial segment starting from the left-main bifurcation up to (and including) the origin of the first major septal branch. The primary endpoint was the composite of all-cause death, myocardial infarction (MI) or stroke at 5 years of follow-up. Results The present study population comprises 1166 patients of which 577 were randomised to PCI and 589 to CABG. Baseline characteristics were well balanced across study arms. The primary endpoint occurred in 94 (16.3%) patients in the PCI arm and in 68 (11.5%) patients in the CABG arm (HR 1.43; 95%CI 1.05 to 1.95; p=0.026). CABG was also associated with a significantly lower rate of cardiac death (p=0.007), MI (p<0.001), all- cause revascularisation (p<0.001) and major adverse cardiovascular and cerebrovascular events (all-cause death, MI, stroke, revascularisation) (p<0.001). The rates of all- cause mortality (p=0.06) and stroke (p=0.09) were not statistically different between the two groups. The overall study results for the primary outcome were consistent across several subgroups. Conclusions In patients with multivessel disease with proximal LAD involvement, CABG is associated with lower rates of the safety composite endpoint of death, MI or stroke as compared with PCI with drug-eluting stents at 5 years of follow-up (number needed to treat=21). Trial registration number PRECOMBAT clinicaltrials. gov NCT00997828; SYNTAX: clinicaltrials.gov identifier: NCT00114972 NCT00114972. INTRODUCTION The proximal segment of the left anterior descend- ing artery (LAD) is an important part of coronary tree responsible for a major portion of the blood supply to the left ventricle myocardium. Coronary artery disease involving the proximal part of the LAD is associated with poor outcomes if left untreated. 12 For that reason, such patients receive a class IA recommendation for revascularisation to improve prognosis in latest guidelines. 3 Currently available data show equivalence in safety outcomes (death, myocardial infarction (MI) and stroke) for coronary artery bypass graft surgery (CABG) and percutaneous intervention (PCI) in patients with single-vessel disease involving the proximal LAD. 45 In the case of patients with mul- tivessel disease (MVD) with proximal LAD involve- ment, the literature harbours conflicting data. In registry-based studies, CABG was associated with better outcomes than PCI. 67 Alternatively, the Arterial Revascularisation Therapies Study Part II (ARTS II) trial ruled out very large differences in safety in terms of death, MI and stroke between the two revascularisation modalities. 8 9 Nevertheless, the ARTS II was underpowered to detect differ- ences in these outcomes. The use of bare metal or exclusively first- generation drug-eluting stents (DESs) along with the observational nature of these studies prevents a definite conclusion about the best revascularisation strategy for this subset of patients. Therefore, the present study had the objective of comparing CABG and PCI outcomes in patients with MVD with proximal LAD involvement in a pooled data- base of two large randomised trials, including the use of new-generation DESs. METHODS The BEST (Randomised Comparison of Coronary Artery Bypass Surgery and Everolimus-Eluting Stent Implantation in the Treatment of Patients with Multivessel Coronary Artery Disease) multicentre, randomised controlled trial compared PCI with the use of everolimus-eluting stents and CABG for treatment of patients with multivessel coronary artery disease (CAD). 10 The SYNTAX (Synergy Between PCI With TAXUS and Cardiac Surgery) multicentre, randomised con- trolled trial compared PCI with the use of paclitaxel-eluting stents and CABG in patients with multivessel CAD. 11 12 In the present study, we per- formed a merging of the individual patient-level data of both trials. The institutional review board at each site approved the protocol, and all patients pro- vided written informed consent. The protocol and consent forms were consistent with the Declaration Cavalcante R, et al. Heart 2016;0:1–6. doi:10.1136/heartjnl-2016-309720 1 Coronary artery disease Heart Online First, published on September 20, 2016 as 10.1136/heartjnl-2016-309720 Copyright Article author (or their employer) 2016. Produced by BMJ Publishing Group Ltd (& BCS) under licence.