ReviewModality Selection for the Revascularization of Left Main Disease
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.
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Cited by (20)
Frequentist or Bayesian: Coronary artery bypass grafting offers advantages over percutaneous coronary intervention in left main coronary disease
2023, Journal of Thoracic and Cardiovascular SurgeryCommentary: Does the SYNTAX (Synergy between PCI with Taxus and Cardiac Surgery) score even matter?
2023, Journal of Thoracic and Cardiovascular SurgeryCommentary: Does a meta-analysis of controversial trials yield controversial results?
2022, Journal of Thoracic and Cardiovascular SurgeryEffects of Protective Controlled Coronary Reperfusion on Left Ventricular Remodeling in Dogs With Acute Myocardial Infarction: A Pilot Study
2020, Cardiovascular Revascularization MedicineCitation 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 SurgeryLong-Term Survival After Surgical or Percutaneous Revascularization in Patients With Diabetes and Multivessel Coronary Disease
2020, Journal of the American College of CardiologyCitation 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.
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