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Percutaneous coronary intervention in left main disease: SYNTAX, PRECOMBAT, EXCEL and NOBLE-combined cardiology and
Duk-Woo Park1, Jung-Min Ahn1, Seung-Jung Park1
1Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
Insights
Percutaneous coronary intervention (PCI) using drug-eluting stents (DES) is expanding for left main coronary artery (LMCA) disease. However, conflicting results from large trials comparing PCI with coronary-artery bypass grafting (CABG) create uncertainty regarding optimal revascularization strategies.
Area of Science:
- Cardiology
- Interventional Cardiology
- Cardiovascular Surgery
Background:
- Coronary-artery bypass grafting (CABG) is the established treatment for significant left main coronary artery (LMCA) disease.
- Percutaneous coronary intervention (PCI) with drug-eluting stents (DES) has emerged as a viable alternative for selected LMCA patients.
- Early trials suggested PCI efficacy, but larger, contemporary trials were needed.
Discussion:
- Two major trials, EXCEL and NOBLE, compared contemporary DES-based PCI with CABG for LMCA disease.
- These trials yielded conflicting results regarding the comparative effectiveness of PCI versus CABG.
- This discrepancy has led to ongoing debate and uncertainty in clinical practice.
Key Insights:
- Contemporary DES have expanded PCI's role in LMCA disease treatment.
- Conflicting outcomes from EXCEL and NOBLE trials highlight the complexity of treatment decisions.
- Patient selection and procedural expertise are critical factors influencing outcomes.
Outlook:
- Further research is needed to clarify the optimal revascularization strategy for LMCA disease.
- Personalized treatment approaches considering individual patient factors and risk profiles are essential.
- Continued evaluation of long-term outcomes for both PCI and CABG in LMCA disease is warranted.
Abstract:
Although coronary-artery bypass grafting (CABG) is the standard choice of revascularization for significant left main coronary artery (LMCA) disease, percutaneous coronary intervention (PCI) for LMCA disease has been widely expanded with adoption of drug-eluting stents (DES). Several small- and moderate-sized trials of CABG and first-generation DES showed that PCI might be a good alternative for selected patients with LMCA disease. However, these early trials were relatively underpowered and comparative results of contemporary DES and CABG were clearly required. Subsequently, two large-sized trials comparing CABG and contemporary DES (EXCEL and NOBLE) were conducted, but these trials showed conflicting results with regards to the effects of PCI and CABG on clinical outcomes, which raises further uncertainty on the optimal revascularization for LMCA disease. This article serves to summarize the key findings of landmark clinical trials, to share our knowledge and experience and to express personal opinions on current controversies in the treatment of LMCA disease.
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