Percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) yield similar long-term survival in patients with unprotected left main coronary artery disease, according to 10-year data from the NOBLE trial. Findings presented at the Transcatheter Cardiovascular Therapeutics (TCT) 2025 conference revealed after a decade of follow-up. There was no difference in all-cause mortality between the two approaches, with 23% mortality for PCI and 25% for CABG. “This is the first time we have such robust 10-year randomized data comparing percutaneous coronary intervention and coronary artery bypass grafting in left main disease,” said presenter Evald Høj Christiansen, MD, PhD, from Aarhus University Hospital in Aarhus, Denmark on Monday. ‘PCI not inferior to CABG’ “Our results show that PCI is not inferior to CABG when it comes to all-cause mortality, even in the long term,” Dr. Christiansen said. The trial randomized 1,201 patients between 2008 and 2015 at centers across Northern Europe, the Baltics, Germany, and the United Kingdom. Of those, 598 were assigned to PCI and 603 to CABG. Follow-up was remarkably complete, with 582 and 574 patients assessed at 10 years. Patients were eligible if they had significant left main stenosis and either chronic coronary syndrome or stabilized acute coronary syndrome, provided a Heart Team agreed that similar revascularization could be achieved. Those with chronic total occlusions, bifurcations requiring two stents, severe calcification, or ST-elevation infarction within 24 hours were excluded. Main findings The analysis found no difference in mortality across the first five years and the subsequent five years of follow-up. Subgroup results highlighted that in patients with acute coronary syndrome, PCI was associated with lower mortality compared with CABG (HR 0.57, 95% CI 0.32-0.99, p= 0.047). In patients with chronic coronary syndrome, outcomes were equivalent (hazard ratio [HR] 1.04, p=0.78). Stratification by SYNTAX score categories (<23, 23–32, and >32) showed no significant mortality differences, with hazard ratios of 1.13, 0.75, and 0.94, respectively. Previously, CABG was favored for left main disease due to durability and lower rates of spontaneous myocardial infarction and repeat revascularization. The NOBLE findings, however, strengthen the case for PCI as a valid alternative in carefully selected patients, especially those presenting with acute coronary syndrome. Risk vs benefit “It is not a one-size-fits-all situation,” said Dr. Christiansen. “Heart teams must carefully weigh the clinical profile, anatomy, and patient preferences when recommending PCI or CABG.” The study also confirmed that anatomical complexity, measured by the SYNTAX score, did not drive differences in survival, suggesting that patient presentation may be more relevant than lesion complexity when considering long-term mortality. The NOBLE trial was sponsored by Aarhus University and Aarhus University Hospital with unrestricted grants, including support for the Biolimus-eluting stent (Biomatrix). Image Caption: Evald Høj Christiansen, MD, PhD, presents during a press conference Monday, October 27, at the Transcatheter Cardiovascular Therapeutics (TCT) 2025 conference in San Francisco. Image Credit: Screenshot by Bailey G. Salimes, CRTonline.org.