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OBJECTIVES There are a number of minimally invasive approaches to revascularization of coronary artery disease that involve the left main or proximal left anterior descending artery; however, studies to date provide mixed results. METHODS A Bayesian network meta-analysis was performed to compare early and late postoperative outcomes between percutaneous coronary intervention with first- and second-generation drug-eluting stents (DESs), off-pump coronary artery bypass and minimally invasive direct coronary artery bypass (MIDCAB) in patients with involvement of left main or left anterior descending disease. RESULTS A total of 37 studies with 31 728 patients were included in the analysis. There were no significant differences in early mortality rates, strokes or myocardial infarctions (MIs). The long-term all-cause mortality rate was equivalent between the groups. Patients who had off-pump coronary artery bypass had fewer late MI compared with those who had first-generation DES (DES1) [odds ratio (OR) 0.38, 95% confidence interval (CI) 0.20–0.72] and MIDCAB (OR 0.41, 95% CI 0.17–0.97) and reduced late target vessel revascularization compared with DES1 (OR 0.17, 95% CI 0.09–0.32) and second-generation DES (DES2) (OR 0.32, 95% CI 0.14–0.72). The rate of late major adverse cardiac events was lower with off-pump coronary artery bypass compared with that with DES1 (OR 0.33, 95% CI 0.26–0.43) and DES2 (OR 0.62, 95% CI 0.45–0.90). The rate of late major adverse cardiac events with MIDCAB was lower than that with DES1 (OR 0.43, 95% CI 0.31–0.62) as was that with DES2 compared with DES1 (OR 0.53, 95% CI 0.39–0.70). CONCLUSIONS Surgical approaches to left main or proximal left anterior descending disease remain superior to first- or second-generation DES in terms of long-term freedom from MI and target vessel revascularization as well as improved overall long-term survival. Conflicting rates of late MI and target vessel revascularization in patients who underwent MIDCAB suggest disease in alternate vessels that may best be approached via hybrid techniques.

european journal of cardio-thoracic surgery

Minimally invasive surgical approaches to left main and left anterior descending coronary artery revascularization are superior compared to first- and second-generation drug-eluting stents: a network meta-analysis