[Left main intervention: options and limitations in interventional cardiology]

Revascularisation is indicated in patients with left main stenosis (LMS) because of its known positive effect on long-term survival. Coronary artery bypass graft (CABG) surgery has been the traditional procedure of choice for LMS patients, with percutaneous coronary intervention (PCI) being reserved for high-risk surgical patients or for those who have one or more functioning distal bypass grafts (i.e. "protected" left main PCI). Recent studies have re-examined the role of PCI in LMS, however, leading to a recent Class II recommendation for its use in selected patients. The SYNTAX Trial demonstrated that PCI can be performed with good results in the following patient subgroups: patients with isolated LMS, particularly if confined to the ostium; patients with concomitant LMS and isolated single vessel disease; patients with a SYNTAX score of <33; and patients who are at high risk for conventional CABG surgery. Patients with complex coronary anatomy (SYNTAX score >33) or those with concomitant double- or triple-vessel disease are more suited to CABG surgery. Patients who undergo PCI for LMS should be treated in specialized centers with surgical back-up, preferably with patient management decisions being made by a "heart team" consisting of at least one cardiologist and one cardiac surgeon. Ongoing studies are being performed using the hard clinical endpoints of death, myocardial infarction, and stroke in order to further compare the results of PCI vs CABG in LMS patients.