Percutaneous coronary intervention versus coronary artery bypass grafting for unprotected left main stenosis: 10-year final results from the randomised, open-label, non-inferiority NOBLE trial.

Summary

In 1,201 patients with unprotected left main disease, PCI and CABG showed no difference in 10-year all-cause mortality (23% vs 25%; HR 0.93, p=0.56). Findings support PCI as an equally safe option to CABG for eligible patients, aiding individualized heart-team decision-making.

Key Findings

• Randomized 1,201 patients with unprotected left main disease to PCI or CABG across 36 hospitals in 9 countries.
• 10-year all-cause mortality: 23% after PCI vs 25% after CABG (HR 0.93, 95% CI 0.74–1.18; p=0.56).
• No significant interaction of mortality with SYNTAX score; findings apply to patients eligible for both PCI and CABG without additional complex lesions.

Clinical Implications

For patients with unprotected left main disease deemed suitable for both strategies, PCI can be considered as safe as CABG regarding 10-year mortality. Heart teams should integrate lesion complexity and patient preferences when selecting revascularization strategy.

Limitations

• Open-label design may introduce performance bias for non-mortality outcomes.
• Generalizability limited to patients eligible for both PCI and CABG and without additional complex lesions.

Future Directions

Evaluate other clinical endpoints (e.g., stroke, myocardial infarction, repeat revascularization), patient-reported outcomes, and cost-effectiveness to refine patient selection.