Long-term outcomes after percutaneous coronary intervention with drug-eluting stents versus coronary artery bypass grafting for left main coronary artery disease: a prospective analysis of the multicentre IRIS-MAIN registry

Wee SB 1 , Kang DY 1 , Ahn JM 1 , Kim JH 1 , Kim MJ 2 , Rha SW 3 Show all authors , Her SH 4 , Kim HS 5 , Park H 6 , Nam CW 7 , Kaul U 8 , Shin WY 9 , Rhew JY 10 , Kim JH 11 , Kim JY 12 , Santoso T 13 , Chung WY 14 , Ahn Y 15 , Lee BK 16 , Chae JK 17 , Lee JB 18 , Hong SJ 19 , Jeong JO 20 , Han KR 21 , Fong A 22 , Sapra R 23 , Kim DB 24 , Kim HJ 25 , Kim K 25 , Kim JB 25 , Yoo JS 25 , Chung CH 25 , Park SJ 1 , Park DW 26 , IRIS-MAIN Investigators

Affiliations 

  • 1 Department of Cardiology, Asan Medical Centre, University of Ulsan College of Medicine, Seoul, South Korea
  • 2 Division of Biostatistics, Asan Medical Centre, University of Ulsan College of Medicine, Seoul, South Korea
  • 3 Cardiovascular Centre, Korea University Guro Hospital, Korea University College of Medicine, Seoul, South Korea
  • 4 Department of Cardiology, St Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, South Korea
  • 5 Cardiovascular Centre, Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
  • 6 Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, South Korea
  • 7 Division of Cardiology, Keimyung University Dongsan Hospital, Daegu, South Korea
  • 8 Department of Cardiology, Batra Hospital and Medical Research Centre, New Delhi, India
  • 9 Department of Cardiology, Soon Chun Hyang University Cheonan Hospital, Cheonan, South Korea
  • 10 Division of Cardiology, Department of Internal Medicine, Presbyterian Medical Centre, Jeonju, South Korea
  • 11 Division of Cardiology, Department of Internal Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, South Korea
  • 12 Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, South Korea
  • 13 Department of Cardiology, Medistra Hospital, University of Indonesia Medical School, Jakarta, Indonesia
  • 14 Department of Internal Medicine and Cardiovascular Centre, Seoul National University Boramae Medical Centre, Seoul National University College of Medicine, Seoul, South Korea
  • 15 Department of Cardiology, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, South Korea
  • 16 Division of Cardiology, Department of Internal Medicine, Kangwon National University Hospital, Kangwon National University School of Medicine, Chuncheon, South Korea
  • 17 Division of Cardiology, Department of Internal Medicine, Jeonbuk National University Hospital, Jeonju, South Korea
  • 18 Division of Cardiology, Department of Internal Medicine, Daegu Catholic University Medical Centre, Daegu, South Korea
  • 19 Cardiovascular Centre, Korea University Anam Hospital, Korea University College of Medicine, Seoul, South Korea
  • 20 Division of Cardiology, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon, South Korea
  • 21 Division of Cardiology, Department of Internal Medicine, Hallym University Kangdong Sacred Heart Hospital, Seoul, South Korea
  • 22 Department of Cardiology, Sarawak Heart Centre, Kota Samarahan, Malaysia
  • 23 Department of Cardiology, Marengo Asia Hospitals, Faridabad, India
  • 24 Division of Cardiology, Department of Internal Medicine, Bucheon St Mary's Hospital, College of Medicine, The Catholic University of Korea, Bucheon, South Korea
  • 25 Department of Thoracic and Cardiovascular Surgery, Asan Medical Centre, University of Ulsan College of Medicine, Seoul, South Korea
  • 26 Department of Cardiology, Asan Medical Centre, University of Ulsan College of Medicine, Seoul, South Korea. Electronic address: dwpark@amc.seoul.kr
Lancet, 2026 Nov 03.
PMID: 42976899 DOI: 10.1016/S0140-6736(26)02104-5

Abstract

BACKGROUND: Percutaneous coronary intervention (PCI) with drug-eluting stents has been widely used to treat patients with left main coronary artery disease; however, long-term comparative outcomes versus coronary artery bypass grafting (CABG) in real-world populations remain poorly characterised. We aimed to compare long-term all-cause mortality after PCI or CABG in Asian patients with unprotected left main coronary artery disease.

METHODS: We analysed prospectively collected data from the multicentre IRIS-MAIN registry, conducted at 46 hospitals in South Korea, India, Japan, Indonesia, and Malaysia. The registry enrolled adults aged 18 years or older with unprotected left main coronary artery disease (defined as a stenosis diameter of ≥50% as visually estimated on angiography), who had been treated with PCI, CABG, or medical therapy alone. The primary outcome was all-cause mortality. We used a target trial emulation framework to compare the long-term risk of all-cause mortality between PCI with drug-eluting stents and isolated CABG. We used propensity-score overlap weighting to adjust for measured baseline covariates. The IRIS-MAIN Registry study is registered with ClinicalTrials.gov (NCT01341327).

FINDINGS: Between Jan 1, 2003, and Dec 31, 2024, 6900 patients were enrolled in the IRIS-MAIN registry, of whom 5379 (78·0%) underwent coronary revascularisation through either PCI with drug-eluting stents (3836 [71·3%]) or CABG (1543 [28·7%]) and were included in the analysis. The median duration of follow-up for all patients was 10·0 years (IQR 5·0-16·7). In the overlap-weighted population, no statistically detectable difference in 10-year weighted Kaplan-Meier rates of all-cause mortality was observed between PCI and CABG (24·0% vs 22·9%; overlap-weighted hazard ratio 1·00 [95% CI 0·87-1·14]; p=0·99). The confidence interval does not exclude a mortality benefit or harm with either strategy.

INTERPRETATION: In this non-randomised registry analysis of patients with left main coronary artery disease, there was no statistically detectable difference in all-cause mortality between PCI and CABG. For patients considered suitable for either strategy, multidisciplinary Heart Team discussion might help patients and clinicians weigh potential trade-offs in the choice between PCI and CABG. These findings are observational and cannot establish causal treatment effects or equivalence in survival.

FUNDING: The CardioVascular Research Foundation (South Korea).

* Title and MeSH Headings from MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.

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