Management of left main disease: an update

Abstract

A severe narrowing of the left main coronary artery (LMCA), usually due to atherosclerosis, jeopardizes a large area of myocardium and increases the risk of major adverse cardiac events. Management strategies for LMCA disease include coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI). In general, PCI offers more rapid recovery and a lower early adverse event rate, whereas CABG offers a more durable procedure. The largest of six LMCA trials comparing PCI with CABG recently reported that in patients with site-reported low or intermediate anatomical complexity PCI was non-inferior to CABG with respect to the composite of death, stroke, or myocardial infarction at 3 years. This result was obtained on a background of contemporary PCI standards, including safer and more effective stents, intravascular imaging and physiology assessment. This review updates on the current management of LMCA disease, with an emphasis on clinical data and procedural knowledge supporting the use of PCI in a growing proportion of patients.

Left Main PCI—Current Evidence, Techniques, and Triumph

“…Several randomized and large observational studies are ongoing to further clarify the safety and efficacy of LMCA intervention. 26…”

Controversies in the Indications of Percutaneous Angioplasty Or Coronary Artery Bypass Grafting In The Treatment Of Left Main Disease

“…Two larger studies that specifically evaluated revascularization strategies for LMCA disease were the EXCEL 16 and the NOBLE trials 28 (Table 2). Even the most recent revascularization guidelines, published by the ESC in 2018, 22 , were made without the availability of the long-term results of these studies, 29,30 but it gave a class recommendation for PCI in patients with low complexity LMCA disease, and maintained class IIA indication for moderate complexity anatomies.…”

Long‐term clinical outcomes in transradial versus transfemoral access for left main percutaneous coronary intervention

“…Furthermore, left main (LM) PCI is considered a high-risk procedure because this artery supplies blood to a large area of the myocardium. 2 Therefore, given the technical complexity of LM PCI, which may require use of an intravascular ultrasound (IVUS) catheter or a twostent strategy, operators often select transfemoral assess (TFA) for its broader support options.…”