Left main coronary artery disease: pathophysiology, diagnosis, and treatment
Carlos Collet1, Davide Capodanno2,3, Yoshinobu Onuma4
1Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands.
Insights
Unprotected left main coronary artery disease poses significant risks. While surgery is often preferred, new trials show catheter-based revascularization benefits selected patients, aiding treatment decisions.
Area of Science:
- Cardiology
- Interventional Cardiology
- Vascular Medicine
Background:
- Unprotected left main coronary artery disease (ULMCAD) carries a high risk of mortality due to the large myocardial territory supplied.
- Coronary angiography, while standard, has limitations in accurately assessing ULMCAD, potentially leading to misclassification.
Purpose of the Study:
- To review the pathophysiology and diagnostic approaches for ULMCAD.
- To discuss risk stratification models and revascularization strategies for ULMCAD.
- To evaluate the role of new imaging techniques and recent clinical trial data.
Main Methods:
- Review of existing literature on ULMCAD, including historical context and recent clinical trials.
- Discussion of diagnostic modalities: coronary angiography, fractional flow reserve, and emerging imaging techniques.
- Analysis of risk stratification tools and treatment outcomes for surgical vs. catheter-based revascularization.
Main Results:
- Coronary angiography has interpretative challenges and limitations in ULMCAD assessment.
- Surgical revascularization has historically improved survival in significant ULMCAD.
- Recent trials indicate efficacy of percutaneous coronary intervention in select ULMCAD patients.
Conclusions:
- Accurate diagnosis and risk stratification are crucial for managing ULMCAD.
- Treatment decisions for ULMCAD require a Heart Team approach, considering both surgical and catheter-based options.
- Advancements in imaging and interventional techniques are expanding treatment possibilities for ULMCAD.
Abstract:
The advent of coronary angiography in the 1960s allowed for the risk stratification of patients with stable angina. Patients with unprotected left main coronary artery disease have an increased risk of death related to the large amount of myocardium supplied by this vessel. Although coronary angiography remains the preferred imaging modality for the evaluation of left main coronary artery stenosis, this technique has important limitations. Angiograms of the left main coronary artery segment can be difficult to interpret, and almost one-third of patients can be misclassified when fractional flow reserve is used as the reference. In patients with clinically significant unprotected left main coronary artery disease, surgical revascularization was shown to improve survival compared with medical therapy and has been regarded as the treatment of choice for unprotected left main coronary artery disease. Two large-scale clinical trials published in 2016 support the usefulness of catheter-based revascularization in selected patients with unprotected left main coronary artery disease. In this Review, we describe the pathophysiology of unprotected left main coronary artery disease, discuss diagnostic approaches in light of new noninvasive and invasive imaging techniques, and detail risk stratification models to aid the Heart Team in the decision-making process for determining the best revascularization strategy for these patients.
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