Revascularization strategies for stable multivessel and unprotected left main coronary artery disease: from BARI to
George Hahalis1, George Dangas, Periklis Davlouros
1Department of Cardiology, Patras University Medical School, Rio, Patras, Greece. ghahalis@otenet.gr
Insights
Coronary artery bypass surgery (CABG) benefits high-risk patients with complex coronary artery disease. Percutaneous coronary interventions (PCI) are increasingly used, but CABG may be superior for those with high atheroma burden and left ventricular dysfunction.
Area of Science:
- Cardiology
- Cardiac Surgery
- Interventional Cardiology
Background:
- Percutaneous coronary interventions (PCI) are increasingly used for complex coronary anatomy, including stem disease.
- Coronary artery bypass surgery (CABG) shows mortality benefits over optimal medical therapy in high-risk patients with left main or multivessel coronary artery disease and left ventricular systolic dysfunction.
- The optimal initial strategy for stable patients with multivessel or left main (LM) disease remains debated.
Purpose of the Study:
- To review the current evidence comparing PCI and CABG for complex coronary artery disease.
- To identify patient subgroups who may benefit most from CABG.
- To discuss the evolving role of PCI in left main disease management.
Main Methods:
- Review of current guidelines and emerging evidence.
- Analysis of factors influencing treatment decisions, such as age, diabetes, extent of multivessel disease (MVD), and left ventricular (LV) dysfunction.
- Consideration of interdisciplinary team-based decision-making.
Main Results:
- Patients with higher atheroma burden (older age, diabetes, extensive MVD, LV dysfunction) may gain the most benefit from CABG.
- PCI for unprotected LM disease with limited additional disease has a Class II recommendation.
- Interdisciplinary collaboration is recommended for intermediate-to-high disease severity.
Conclusions:
- Treatment decisions for complex coronary artery disease require careful consideration of individual patient factors.
- An integrated approach involving cardiac surgeons and cardiologists can optimize patient outcomes.
- Ongoing clinical trials are expected to provide further evidence to guide clinical practice.
Abstract:
Percutaneous coronary interventions are increasingly applied in patients with complex coronary anatomy, including those with stem disease. Coronary artery bypass surgery confers a mortality reduction over optimal medical therapy in high-risk patients with both left main or multivessel coronary artery disease and left ventricular systolic dysfunction. Whether PCI might be preferred as an initial strategy in stable patients with multivessel disease and/or LM disease remains debatable. Emerging evidence suggests that patients with higher atheroma burden, as indicated by older age, presence of diabetes mellitus and extensive MVD in combination with LV dysfunction may derive the greatest benefit from CABG. PCI for unprotected LM with limited additional disease has been revised to a class II recommendation in the recent U.S. and European guidelines. An interdisciplinary team of both cardiac surgeons and cardiologists may optimize treatment in patients with intermediate-to-high disease severity characteristics. Ongoing trials will further strengthen evidence-base clinical decision making.
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