Left Main Coronary Disease: Evolving Management Concepts

Armstrong PW, Bates ER, Gaudino M.
Left Main Coronary Disease: Evolving Management Concepts. Eur Heart J 2022;Sep 29:[Epub ahead of print].

The following are key points to remember from this state-of-the-art review of left main coronary disease:

  1. Although disease of the left main coronary artery (LMCA) represents a minority (<10%) of the overall coronary artery disease (CAD) population, they are disproportionally associated with higher morbidity and mortality.
  2. Diagnosis beyond angiography includes utility of tools such as fractional flow reserve, instantaneous wave-free ratio, and intravascular ultrasound (<6.0 mm minimum lumen diameter). Coronary computed tomography angiography may also be useful, especially if coupled with flow-reserved assessment.
  3. Individualized assessment of patient-related risk and patient preferences/expectations should be performed to identify optimal management.
  4. Medical therapy and risk factor optimization should be pursued for patients with stable ischemic heart disease and LM disease. It should be noted that current evidence does not support a survival benefit for revascularization versus optimal medical therapy (OMT) in patients with chronic multivessel CAD and preserved ventricular function, although revascularization is associated with better event-free survival.
  5. In most, but not all instances, revascularization of a LMCA stenosis of ≥70% will be the obvious choice based on its ability to delay or prevent cardiovascular events and extend life expectancy.
  6. Optimal revascularization strategy is dependent on several factors. These include LM disease anatomy (ostial, shaft, bifurcation), institutional experience with revascularization of the LM, patient-specific risk and comorbidities, and patient preferences and expectations.
  7. A Heart Team approach to determine the best revascularization strategy should be considered. Patients at high surgical risk, favorable anatomy for percutaneous coronary intervention (PCI), and elderly patients with serious comorbidities might be better suited for PCI. On the other hand, diabetics with complex anatomy and those with left ventricular (LV) dysfunction benefit from surgical revascularization over the long term.
  8. For patients without major ischemia and well-preserved LV function, who have a LMCA stenosis <70% and a good quality of life, optimizing their medical therapy may be a reasonable option.
  9. The therapeutic elements of OMT should permeate every LMCA management pathway, irrespective of treatment choice, given that all three strategies may intersect over the lifetime of an individual patient.
  10. Longer-term follow-up from randomized controlled trials is eagerly awaited.

Clinical Topics: Cardiac Surgery, Cardiovascular Care Team, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Atherosclerotic Disease (CAD/PAD), Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Interventions and Coronary Artery Disease, Interventions and Imaging, Angiography, Computed Tomography, Echocardiography/Ultrasound, Nuclear Imaging

Keywords: Angiography, Cardiac Surgical Procedures, Computed Tomography Angiography, Constriction, Pathologic, Coronary Artery Disease, Coronary Stenosis, Fractional Flow Reserve, Myocardial, Morbidity, Myocardial Ischemia, Myocardial Revascularization, Percutaneous Coronary Intervention, Quality of Life, Risk Factors, Secondary Prevention, Ultrasonography, Interventional, Ventricular Dysfunction, Left, Ventricular Function

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