Review
Modality Selection for the Revascularization of Left Main Disease

https://doi.org/10.1016/j.cjca.2018.12.017Get rights and content

Abstract

The management of severe left main (LM) disease remains controversial and continues to evolve as new evidence emerges. Patient selection for coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) relies on both predicting mortality with CABG from clinical characteristics using the Society of Thoracic Surgeons (STS) risk score and anatomical complexity, using the Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery (SYNTAX) score. LM stenting techniques continue to evolve; for bifurcation lesions, the use of the double-kiss crush technique may reduce the incidence of late target vessel revascularization. In patients with acute coronary syndrome (ACS) complicated by cardiogenic shock, PCI is likely the first-line option in those with anatomically amenable disease, whereas all other stable non–ST-elevated ACS should be treated similar to stable ischemic heart disease. Outcomes comparing CABG and PCI have been recently examined in 2 large randomized clinical trials. In general, early outcomes of periprocedural myocardial infarction and stroke favoured PCI or were not different from outcomes with CABG. However, the conclusions of both trials are at present discordant with respect to late major adverse cardiac and cerebral events; additional follow-up of the trial patients is important for informed patient decision making. The appropriate mode of revascularization should be selected according to patient clinical characteristics and the complexity of the coronary lesions according to European and American guidelines. In those with low or intermediate SYNTAX scores, particularly with high surgical risk, PCI may be preferred to CABG in most other scenarios. A multidisciplinary heart team is recommended to help individualize revascularization decisions.

Résumé

La prise en charge de la sténose du tronc commun de l’artère coronaire gauche (ACG) demeure une controverse, mais continue d’évoluer en fonction des nouvelles données probantes. La sélection des patients pour le pontage aortocoronarien (PAC) ou pour l’intervention coronarienne percutanée (ICP) repose sur la prédiction de la mortalité après le PAC à partir des caractéristiques cliniques établies par le score de risque de la Society of Thoracic Surgeons (STS) et de la complexité anatomique établie par le score SYNTAX (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery). Les techniques d’implantation d’endoprothèses dans l’ACG continuent d’évoluer. Pour les lésions de bifurcation, l’utilisation de la technique du double-kiss crush peut réduire la fréquence de la revascularisation tardive du vaisseau cible. Chez les patients atteints d’un syndrome coronarien aigu (SCA) compliqué d’un choc cardiogénique, l’ICP est probablement l’option de première intention chez les patients qui ont une maladie favorable à son exécution sur le plan anatomique, tandis que tous les autres patients atteints d’un SCA stable sans sus-décalage du segment ST devraient être traités de la même façon que les patients atteints d’une cardiopathie ischémique stable. Les résultats cliniques sur la comparaison du PAC et de l’ICP ont récemment fait l’objet de 2 grandes études cliniques à répartition aléatoire. En général, les premiers résultats cliniques de l’infarctus du myocarde et de l’accident vasculaire cérébral en phase péri-opératoire favorisaient l’ICP ou n’étaient pas différents des résultats cliniques en lien avec le PAC. Toutefois, les conclusions des deux études montrent à l’heure actuelle une incohérence par rapport aux événements indésirables cardiaques et cérébraux majeurs tardifs. Il est important d’offrir un autre suivi aux patients de l’étude pour leur faire prendre une décision éclairée. Le mode de revascularisation appropriée devrait être choisi selon les caractéristiques cliniques et la complexité des lésions coronaires des patients en se basant sur les lignes directrices européennes et américaines. Chez les patients qui ont des scores SYNTAX faibles ou intermédiaires, et un risque chirurgical particulièrement élevé, on peut privilégier plutôt l’ICP que le PAC dans la plupart des autres scénarios. Une équipe multidisciplinaire en cardiologie est recommandée pour faciliter les décisions individualisées en ce qui a trait à la revascularisation.

Section snippets

Patient Selection for CABG and the Role of Surgical Risk Scores

LM disease is present in almost a third of patients undergoing CABG in the Society of Thoracic Surgeons (STS) National Database of more than 1.4 million isolated cases of CABG.2 Physiological and anatomic considerations are in play when it comes to decision making for selecting a revascularization strategy for LM disease. Two clinically based risk models are the mainstay for assessing the predicted perioperative surgical mortality: the European System for Cardiac Operative Risk Evaluation

Overview of LM Stenting Techniques

PCI has been increasingly adopted in clinical practice, particularly in favourable anatomical settings. Data from the Interventional Research Incorporation Society-Left MAIN Revascularization (IRIS-MAIN) registry showed a progressive adoption of PCI in patients with LM disease that increased from 25% in the time period between 1995 and 2002, to 61% in the period between 2007 and 2013.28 From an anatomic standpoint, LM disease represents a heterogeneous anatomical cohort of patients with an

LM Disease in Acute Coronary Syndrome/Cardiogenic Shock

The discussion regarding revascularization in patients with LM disease revolves primarily around the treatment of patients with stable ischemic heart disease. However, LM disease is found in 5% to 7% of patients admitted with an acute coronary syndrome (ACS)/acute MI (AMI).48 A culprit LM thrombosis for ACS/AMI, however, is a much rarer event (0.6% to 0.9%),49 is more often detected in patients with ST-segment elevation MI (STEMI) and frequently results in severe LV dysfunction, with

Comparative Outcomes Among Medical Therapy, PCI, and CABG for LM

Medical therapy as a sole therapeutic approach is not recommended for patients with angiographically defined LM coronary artery stenosis graded at a severity of more than 50%. This realization came after the publication of a meta-analysis by Yusuf et al.,1 in which CABG was found to be associated with a 3-fold reduction in death due to LM coronary artery stenosis (OR 0.32, 95% CI, 0.15-0.70; P = 0.004), despite more than 65% of patients initially treated with medical therapy having crossed over

Guidelines

In the most recent version of the 2018 European Society of Cardiology (ESC)/ European Association for Cardiothoracic Surgery (EACTS) revascularization guidelines,64 LM disease can be managed via CABG or PCI, depending on the complexity of the disease (Fig. 1). However, it is important to note that recommendations are for patients with suitable anatomy for both PCI and CABG and low predicted surgical mortality. Calculation of the SYNTAX score in LM disease received a Class I, Level of Evidence

Conclusion

CABG remains the cornerstone in the management of significant LM disease, particularly for patients with stable ischemic heart disease who are otherwise good surgical candidates. Societies have recommended a heart team approach for the selection of the most appropriate method of revascularization for any individual patient. The importance of risk stratification for both the coronary anatomy and clinical characteristics is key to the selection of appropriate treatment (Fig. 2). In those with low

Funding Sources

D.Y.T. is supported by a CIHR Fellowship (Canada). S.E.F. is supported in part by the Bernard S. Goldman Chair in Cardiovascular Surgery (Toronto, ON).

Disclosures

The authors have no conflicts of interest to disclose.

References (67)

  • J. Chikwe et al.

    Long-term outcomes after off-pump versus on-pump coronary artery bypass grafting by experienced surgeons

    J Am Coll Cardiol

    (2018)
  • U. Benedetto et al.

    Comparison of outcomes for off-pump versus on-pump coronary artery bypass grafting in low-volume and high-volume centers and by low-volume and high-volume surgeons

    Am J Cardiol

    (2018)
  • J.D. Puskas et al.

    Off-pump coronary artery bypass disproportionately benefits high-risk patients

    Ann Thorac Surg

    (2009)
  • D.-F. Zhao et al.

    Coronary artery bypass grafting with and without manipulation of the ascending aorta: a network meta-analysis

    J Am Coll Cardiol

    (2017)
  • P.H. Lee et al.

    Left main coronary artery disease: secular trends in patient characteristics, treatments, and outcomes

    J Am Coll Cardiol

    (2016)
  • P.E. Buszman et al.

    Early and long-term results of unprotected left main coronary artery stenting: the LE MANS (Left Main Coronary Artery Stenting) registry

    J Am Coll Cardiol

    (2009)
  • E. Boudriot et al.

    Randomized comparison of percutaneous coronary intervention with sirolimus-eluting stents versus coronary artery bypass grafting in unprotected left main stem stenosis

    J Am Coll Cardiol

    (2011)
  • S.-L. Chen et al.

    A randomized clinical study comparing double kissing crush with provisional stenting for treatment of coronary bifurcation lesions: results from the DKCRUSH-II (Double Kissing Crush versus Provisional Stenting Technique for Treatment of Coronary Bifurcation Lesions) trial

    J Am Coll Cardiol

    (2011)
  • S.-L. Chen et al.

    Comparison of double kissing crush versus culotte stenting for unprotected distal left main bifurcation lesions: results from a multicenter, randomized, prospective DKCRUSH-III study

    J Am Coll Cardiol

    (2013)
  • S.-L. Chen et al.

    Clinical outcome after DK crush versus Culotte stenting of distal left main bifurcation lesions: the 3-year follow-up results of the DKCRUSH-III study

    JACC Cardiovasc Interv

    (2015)
  • S.-L. Chen et al.

    Double kissing crush versus provisional stenting for left main distal bifurcation lesions: DKCRUSH-V Randomized Trial

    J Am Coll Cardiol

    (2017)
  • R. Bing et al.

    Percutaneous transcatheter assessment of the left main coronary artery: current status and future directions

    JACC Cardiovasc Interv

    (2015)
  • M. Ragosta

    The complexity involved in assessment of left main coronary artery disease

    JACC Cardiovasc Interv

    (2012)
  • D.V. Daniels et al.

    The impact of downstream coronary stenoses on fractional flow reserve assessment of intermediate left main disease

    JACC Cardiovasc Interv

    (2012)
  • N. Patel et al.

    Outcomes after emergency percutaneous coronary intervention in patients with unprotected left main stem occlusion: the BCIS national audit of percutaneous coronary intervention 6-year experience

    JACC Cardiovasc Interv

    (2014)
  • S.M. Gharacholou et al.

    Characteristics and long term outcomes of patients with acute coronary syndromes due to culprit left main coronary artery disease treated with percutaneous coronary intervention

    Am Heart J

    (2018)
  • S.S. Almudarra et al.

    Comparative outcomes after unprotected left main stem percutaneous coronary intervention: a national linked cohort study of 5,065 acute and elective cases from the BCIS Registry (British Cardiovascular Intervention Society)

    JACC Cardiovasc Interv

    (2014)
  • T. Rab et al.

    Cardiac shock care centers: JACC review topic of the week

    J Am Coll Cardiol

    (2018)
  • D. Acharya et al.

    Clinical characteristics and outcomes of patients with myocardial infarction and cardiogenic shock undergoing coronary artery bypass surgery: data from the Society of Thoracic Surgeons National Database

    Ann Thorac Surg

    (2016)
  • M. Gaudino et al.

    Long-term survival and quality of life of patients undergoing emergency coronary artery bypass grafting for postinfarction cardiogenic shock

    Ann Thorac Surg

    (2016)
  • P.E. Buszman et al.

    Left main stenting in comparison with surgical revascularization: 10-year outcomes of the (left main coronary artery stenting) LE MANS trial

    JACC Cardiovasc Interv

    (2016)
  • S.J. Head et al.

    Stroke rates following surgical versus percutaneous coronary revascularization

    J Am Coll Cardiol

    (2018)
  • M.R. Patel et al.

    ACC/AATS/AHA/ASE/ASNC/SCAI/SCCT/STS 2017 Appropriate use criteria for coronary revascularization in patients with stable ischemic heart disease: a report of the American College of Cardiology Appropriate Use Criteria Task Force, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and Society of Thoracic Surgeons

    J Am Coll Cardiol

    (2017)
  • Cited by (20)

    • Effects of Protective Controlled Coronary Reperfusion on Left Ventricular Remodeling in Dogs With Acute Myocardial Infarction: A Pilot Study

      2020, Cardiovascular Revascularization Medicine
      Citation Excerpt :

      These phenomena are due to infarct expansion (distention and thinning of the infarct-related ventricular wall), infarct extension (progressive enlargement of the infarcted area) and development of compensatory “pathologic” hypertrophy of the non-infarcted LV wall. Clinically, the end result is the onset of the clinical syndrome of CHF, with its associated considerable morbidity and mortality [16,17]. Prompt restoration of blood flow to an acutely occluded coronary artery remains the best and most reliable strategy to salvage an ischemic myocardium [18].

    • Reply: Going from stable to unstable

      2020, Journal of Thoracic and Cardiovascular Surgery
    • Long-Term Survival After Surgical or Percutaneous Revascularization in Patients With Diabetes and Multivessel Coronary Disease

      2020, Journal of the American College of Cardiology
      Citation Excerpt :

      Our study was the largest to-date, to the best of our knowledge, to examine the real-world clinical practice of revascularization in patients with diabetes and supported the generalizability of the FREEDOM trial results. However, we note that both PCI and CABG techniques continue to improve and evolve, and that the use of intravascular ultrasound, optical coherence tomography, and fractional flow reserve may improve outcomes, as shown in the SYNTAX II study that examined state-of-the-art PCI (29). This study must be interpreted in the context of some significant limitations.

    View all citing articles on Scopus

    See page 990 for disclosure information.

    View full text