Management of Left Main Disease: An Update

Authors:
Fajadet J, Capodanno D, Stone GW.
Citation:
Management of Left Main Disease: An Update. Eur Heart J 2018;Apr 30:[Epub ahead of print].

The following are key points to remember from this review article on the management of left main disease:

  1. A severe narrowing of the left main coronary artery (LMCA) jeopardizes a large area of myocardium and increases the risk of major adverse cardiac events.
  2. In general, management strategies for LMCA disease include coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI).
  3. PCI offers more rapid recovery and a lower early adverse event rate, whereas CABG offers a more durable procedure.
  4. 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 noninferior 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.
  5. It should be noted that the relative outcomes of PCI vs. CABG for LMCA disease are determined by a complex interplay of patient comorbidities, coronary anatomic complexity and ventricular function, and other less tangible factors such as operator expertise and likely medication compliance.
  6. The decision for an individual patient with LMCA disease for PCI vs. CABG is best made by the local multidisciplinary heart team consisting of a general cardiologist, interventional cardiologist, and cardiac surgeon, considering the clinical circumstances, the technical issues, and the likelihood of safely achieving complete revascularization with each procedure, and importantly, taking into account each patient’s preferences after full informed discussion.
  7. Based on current 2014 guidelines from the European Society of Cardiology, LMCA patients with stable angina or silent ischemia should undergo revascularization in case of a >90% stenosis or in case of a ≥50%-90% stenosis with documented ischemia or fractional flow reserve ≤0.80 (Class I, Level of Evidence A).
  8. CABG is recommended in all patients with stable coronary artery disease with suitable coronary anatomy and low predicted surgical mortality (Class I, Level of Evidence B).
  9. The recommendations from 2014 guidelines from the European Society of Cardiology for PCI vary depending on whether the SYNTAX score is low (Class I, Level of Evidence B), intermediate (Class IIa, Level of Evidence B), or high (Class III, Level of Evidence B).
  10. The recommendations for PCI for LMCA disease across SYNTAX score tertiles from the 2014 US focused update for the diagnosis and management of patients with stable ischemic heart disease are currently Class IIa if SYNTAX score is low, Class IIb if SYNTAX score is intermediate, and Class III if SYNTAX score is high. Both US and European guidelines emphasize the need for a Heart Team approach for deciding revascularization strategies for LMCA disease.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Prevention, Stable Ischemic Heart Disease, Atherosclerotic Disease (CAD/PAD), Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and SIHD, Interventions and Coronary Artery Disease, Chronic Angina

Keywords: Angina, Stable, Cardiac Surgical Procedures, Constriction, Pathologic, Coronary Artery Bypass, Coronary Artery Disease, Fractional Flow Reserve, Myocardial, Medication Adherence, Myocardial Infarction, Myocardial Ischemia, Myocardial Revascularization, Myocardium, Percutaneous Coronary Intervention, Secondary Prevention, Stents, Stroke, Ventricular Function


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