Left main coronary stenosis: surgery still reigns
Marc Ruel1, Hidetake Kawajiri, David Glineur
1aDivision of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, CanadabDepartment of Cardiothoracic Surgery, Weill-Cornell Medical Center, New York City, New York, USAcDepartment of Surgery, Division of Cardiac Surgery, St. Michael's Hospital, Toronto, Ontario, Canada.
Insights
Percutaneous coronary intervention (PCI) for unprotected left main coronary artery (ULMCA) stenosis shows conflicting results. Further data are needed to confirm PCI
Area of Science:
- Cardiology
- Interventional Cardiology
Background:
- Coronary artery bypass grafting (CABG) is the standard treatment for unprotected left main coronary artery (ULMCA) stenosis.
- Recent trials, including the EXCEL trial, have questioned the superiority of CABG over percutaneous coronary intervention (PCI) for ULMCA stenosis.
Purpose of the Study:
- To critically appraise recent randomized control trials (RCTs) evaluating PCI versus CABG for ULMCA stenosis.
- To address the discrepancy in findings between major RCTs on ULMCA revascularization.
Main Methods:
- Review and critical appraisal of published randomized control trials.
- Comparative analysis of study designs and endpoints in key ULMCA revascularization trials.
Main Results:
- The EXCEL trial suggested PCI non-inferiority to CABG for ULMCA stenosis.
- The Nordic-Baltic-British Left Main Revascularization trial indicated PCI inferiority to CABG for ULMCA stenosis.
- Discrepancies may stem from differing study designs, myocardial infarction definitions, and endpoint selections.
Conclusions:
- Long-term efficacy of PCI for ULMCA stenosis remains unproven.
- Further research and long-term follow-up are necessary before expanding PCI indications for ULMCA stenosis.
Purpose Of Review:
Coronary artery bypass grafting (CABG) has been regarded as the mainstream treatment for unprotected left main coronary artery (ULMCA) stenosis. However, the results of the Evaluation of XIENCE versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization (EXCEL) trial, in which percutaneous coronary intervention (PCI) was deemed noninferior to CABG, have raised a question whether the guidelines should be changed. This article provides a critical appraisal of recent randomized control trials (RCTs) on ULMCA stenosis.
Recent Findings:
In contrast to EXCEL trial, another large RCT named the Nordic-Baltic-British Left Main Revascularization trial showed that PCI is inferior to CABG in patients treated for ULMCA stenosis. The reason for the discrepancy between these two RCTs may be due to differences in study design. In EXCEL trial, the adoption of new periprocedural myocardial infarction definition, the noninclusion of target vessel revascularization as a primary endpoint component, and the timeline of the study may have helped claim that PCI is noninferior to CABG.
Summary:
The long-term efficacy of PCI for ULMCA stenosis has not yet been demonstrated. Further studies and follow-up data are needed before the indications for PCI are expanded in this scenario.
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