Revascularization for Left Main and Multivessel Coronary Artery Disease: Current Status and Future Prospects after
Mohammed Al-Hijji1, Abdallah El Sabbagh1, David R Holmes2
1Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA.
Insights
Revascularization improves survival for left main and multivessel coronary artery disease. Both surgical and percutaneous interventions are options, with heart team discussion crucial for optimal patient management.
Area of Science:
- Cardiovascular Medicine
- Interventional Cardiology
Background:
- Revascularization of left main and multivessel coronary artery disease improves survival in stable ischemic heart disease and acute coronary syndrome.
- Coronary artery bypass surgery has a class I recommendation for these conditions.
- Recent trials suggest comparable outcomes for percutaneous coronary intervention and surgery in less complex cases.
Purpose of the Study:
- To review evidence on revascularization strategies for left main and multivessel coronary artery disease.
- To discuss the role of the heart team in decision-making.
- To cover special populations not typically included in clinical trials.
Main Methods:
- Review of historic and contemporary clinical trials.
- Analysis of data comparing surgical and percutaneous revascularization.
- Discussion of guidelines and expert consensus.
Main Results:
- Revascularization, whether surgical or percutaneous, improves survival for severe coronary artery disease.
- Conflicting results from EXCEL and NOBLE trials highlight the need for individualized treatment.
- Heart team discussion is essential for managing left main and multivessel disease.
Conclusions:
- Both coronary artery bypass surgery and percutaneous coronary intervention are viable options for left main and multivessel disease.
- The optimal strategy depends on patient-specific factors and heart team consensus.
- Further research is needed for special populations and complex coronary anatomy.
Abstract:
Revascularization of severe left main and multivessel coronary artery disease has been shown to improve survival in both stable ischemic heart disease and acute coronary syndrome. While revascularization with coronary artery bypass surgery for these disease entities carries class I recommendation in most current guidelines, recent trials has shown potential comparable survival and cardiovascular outcomes between percutaneous and surgical interventions in patients with less complex coronary anatomy. Despite the conflicting results observed in the most recent left main revascularization trials, Everolimus-Eluting Stents or Bypass Surgery for Left Main Coronary Artery Disease (EXCEL) and Nordic-Baltic-British left main revascularization (NOBLE), both treatment strategies remain important for the management of left main disease (LMD) and multivessel disease (MVD) reflecting on the importance of heart team discussion. This review is focused on revascularization of LMD and MVD in patients who are not presenting with ST-segment elevation myocardial infarction, encompassing the evidence from historic and contemporary trials which shaped up current practices. This review discusses the heart team approach to guide decision making, including special populations that are not represented in clinical trials.
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