Practical Approach to Left Main Coronary Artery Disease: Key Points

Davidson LJ, Cleveland JC, Welt FG, et al.
A Practical Approach to Left Main Coronary Artery Disease: JACC State-of-the-Art Review. J Am Coll Cardiol 2022;80:2119-2134.

The following are key points to remember from this state-of-the-art review on a practical approach to left main (LM) coronary artery disease (CAD):

  1. LM disease is the CAD subset with the strongest evidence that revascularization provides survival benefit over medical treatment alone in stable patients. However, the optimal treatment of LM CAD requires complex decision making.
  2. Recent clinical practice guidelines provide clinicians with guidance; however, decisions regarding treatment for individual patients can still be difficult.
  3. The American College of Cardiology’s Cardiac Surgery Team and Interventional Council joined together to develop a practical approach to the treatment of LM CAD, taking into account randomized clinical trials, meta-analyses, and clinical practice guidelines.
  4. Recognizing the complexity of LM CAD, which rarely presents isolated and is often in combination with multivessel disease, a treatment algorithm with medical therapy alone or in conjunction with percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) is proposed. LM CAD can be categorized as ostial/shaft and distal lesions, and may be complicated by multivessel disease.
  5. Clinical, procedural, and institutional factors should be considered along with clinical practice guidelines in selecting the mode of revascularization for patients with LM CAD. In patients with stable disease and symptoms, ad hoc intervention is strongly discouraged.
  6. A heart team approach is recommended that accounts for clinical, procedural, operator, and institutional factors, and features shared decision making that meets the needs and preferences of each patient and their specific clinical situation.
  7. Factors that may favor CABG for LM CAD include diabetes mellitus, complex multivessel disease, significant left ventricular systolic dysfunction, concomitant ascending aortic or valvular pathology, recurrent prior stent failure, anatomy unlikely to achieve complete revascularization with PCI, and contraindications to dual antiplatelet therapy.
  8. Factors that may favor PCI for LM CAD include significant obstructive or restrictive lung disease, advanced age, clinical frailty, severe chest deformation, porcelain aorta, sequelae of prior chest radiation, poor surgical conduits or bypass targets, barriers to postoperative rehabilitation, ST-segment elevation myocardial infarction, or cardiogenic shock.
  9. Factors that may favor medical therapy for LM CAD include high burden of severe comorbidities, severe frailty, limited life expectancy, and informed patient preference.
  10. Of note, the optimal revascularization strategy for a given patient can vary, based on the expertise, experience, and outcomes of the specific surgical and interventional teams at a given institution.

Clinical Topics: Cardiac Surgery, Cardiovascular Care Team, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Prevention, Atherosclerotic Disease (CAD/PAD), Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Acute Heart Failure, Interventions and Coronary Artery Disease

Keywords: Cardiac Surgical Procedures, Coronary Artery Bypass, Coronary Artery Disease, Diabetes Mellitus, Frailty, Geriatrics, Lung Diseases, Myocardial Infarction, Myocardial Ischemia, Myocardial Revascularization, Percutaneous Coronary Intervention, Platelet Aggregation Inhibitors, Secondary Prevention, Shock, Cardiogenic, Stents

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