Decade-Long Study of PCI and CABG in Left Main Coronary Artery Disease Shows Comparable All-Cause mortality in NOBLE Trial: TCT 2025

The NOBLE trial is a large, multicenter, randomized comparison of PCI versus CABG in patients with significant unprotected LMCA stenosis. Conducted across 36 Nordic, Baltic, and British centers, the study enrolled 1,201 patients between 2008 and 2015, with a median follow-up of 10 years—the longest to date among contemporary left main revascularization trials.

Eligible patients had stable or stabilized acute coronary syndromes (ACS) with >50% LMCA stenosis or fractional flow reserve ≤0.80, and were deemed suitable for either revascularization strategy by a Heart Team. Participants were randomized 1:1 to PCI (n=598) or CABG (n=603) and analyzed by intention to treat. The median SYNTAX score was 22.5, reflecting intermediate anatomical complexity, and 82% presented with chronic coronary syndromes.

At 10 years, all-cause mortality was 23% for PCI versus 25% for CABG (HR 0.93; 95% CI 0.74–1.18; p=0.56), showing no significant difference between the two strategies. Landmark analyses revealed no mortality difference during the 0–5-year or 5–10-year periods. In subgroup analyses, outcomes were consistent across SYNTAX score categories (<23, 23–32, >32), and there was no interaction between anatomical complexity and treatment effect.

Interestingly, among patients with acute coronary syndrome (ACS), PCI was associated with lower long-term mortality compared to CABG (HR 0.57; 95% CI 0.32–0.99; p=0.047), while outcomes in chronic coronary syndrome were similar (HR 1.04; p=0.78). Mortality outcomes were also unaffected by the use of intravascular ultrasound (IVUS) guidance during PCI.

Procedural characteristics reflected contemporary standards of care: 94% of PCI cases achieved complete revascularization, and 96% of CABG patients received a left internal mammary artery graft to the LAD. IVUS was used post-procedure in 74% of PCI cases.

Investigators emphasized that the NOBLE trial’s 10-year results together with prior data from EXCEL, SYNTAX, and PRECOMBAT, suggest long-term equipoise between PCI and CABG for left main disease, provided anatomical suitability and procedural optimization. 

The NOBLE trial thus provides the most extended randomized follow-up in left main revascularization, confirming comparable survival between PCI and CABG at 10 years, with a potential advantage for PCI in acute coronary syndrome patients.

Reference: Dr. Evald Høj Christiansen, Percutaneous Coronary Angioplasty Versus Coronary Artery Bypass Grafting in the Treatment of Unprotected Left Main Stenosis 10-year Mortality Outcomes from the Randomized NOBLE Trial, TCT Conference 2025, San Francisco.

https://www.tctconference.com/

About the Study Presenter: Dr Evald Høj Christiansen is an Associate Professor in the Cardiology Department of Aarhus University Hospital. He is an interventional cardiologist with 15 years' of experience in the field. His main interest is chronic total occlusions, bifurcations, coronary imaging, physiologic evaluations of coronary artery disease, and TAVR. He has performed a series of studies in this area and has conducted many clinical trials.