BackgroundThe optimal revascularization strategy in patients with left main coronary artery (LMCA) disease in the emergency setting is still controversial. Thus, we aimed to compare the outcomes of percutaneous coronary interventions (PCI) vs. coronary artery bypass grafting (CABG) in patients with and without emergent LMCA disease.MethodsThis retrospective cohort study included 2138 patients recruited from 14 centers between 2015 and 2019. We compared patients with emergent LMCA revascularization who underwent PCI (n= 264) to patients who underwent CABG (n= 196) and patients with non-emergent LMCA revascularization with PCI (n= 958) to those who underwent CABG (n= 720). The study outcomes were in-hospital and follow-up all-cause mortality and major adverse cardiovascular and cerebrovascular events (MACCE).ResultsEmergency PCI patients were older and had a significantly higher prevalence of chronic kidney disease, lower ejection fraction, and higher EuroSCORE than CABG patients. CABG patients had significantly higher SYNTAX scores, multivessel disease, and ostial lesions. In patients presenting with arrest, PCI had significantly lower MACCE (P= 0.017) and in-hospital mortality (P= 0.016) than CABG. In non-emergent revascularization, PCI was associated with lower MACCE in patients with low (P= 0.015) and intermediate (P< 0.001) EuroSCORE. PCI was associated with lower MACCE in patients with low (P= 0.002) and intermediate (P= 0.008) SYNTAX scores. In non-emergent revascularization, PCI was associated with reduced hospital mortality in patients with intermediate (P= 0.001) and high (P= 0.002) EuroSCORE compared to CABG. PCI was associated with lower hospital mortality in patients with low (P= 0.031) and intermediate (P= 0.001) SYNTAX scores. At a median follow-up time of 20 months (IQR: 10–37), emergency PCI had lower MACCE compared to CABG [HR: 0.30 (95% CI 0.14–0.66),P< 0.003], with no significant difference in all-cause mortality between emergency PCI and CABG [HR: 1.18 (95% CI 0.23–6.08),P= 0.845].ConclusionsPCI could be advantageous over CABG in revascularizing LMCA disease in emergencies. PCI could be preferred for revascularization of non-emergent LMCA in patients with intermediate EuroSCORE and low and intermediate SYNTAX scores.