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Percutaneous or surgical revascularization for left main stem disease: NOBLE ideas, but do they EXCEL?

George Kassimis1,2, Tushar Raina1, Nestoras Kontogiannis1

  • 1a Department of Cardiology , Cheltenham General Hospital, Gloucestershire Hospitals NHS Foundation Trust , Cheltenham , UK.

Expert Review of Cardiovascular Therapy
|May 16, 2019
PubMed

Insights

Percutaneous coronary intervention (PCI) with drug-eluting stents (DES) and coronary artery bypass grafting (CABG) are both viable treatments for left main stem (LMS) disease. A Heart Team approach is crucial for selecting the best revascularization strategy for individual patients.

Area of Science:

  • Cardiology
  • Interventional Cardiology
  • Cardiac Surgery

Background:

  • Coronary artery bypass grafting (CABG) was the traditional standard for left main stem (LMS) disease.
  • Percutaneous coronary intervention (PCI) with drug-eluting stents (DES) is now an accepted alternative for LMS disease treatment.

Purpose of the Study:

  • To summarize landmark clinical trials on LMS revascularization.
  • To review recent ESC/EACTS guidelines for myocardial revascularization in LMS disease.

Main Methods:

  • Review of landmark clinical trials.
  • Analysis of recent European Society of Cardiology/European Association of Cardio-Thoracic Surgery guidelines.

Main Results:

  • Both PCI and CABG are reasonable revascularization options for selected LMS disease patients.
  • A 'Heart Team' approach is vital for guiding management when clinical equipoise exists.
  • Extrapolation of trial results to real-world, co-morbid patients is challenging.

Conclusions:

  • No further large randomized trials on LMS revascularization are anticipated.
  • Patient selection and a multidisciplinary Heart Team approach are essential for optimal LMS disease management.

Keywords:
EXCELLeft main stem diseaseMAIN COMPARENOBLESYNTAXSYNTAXEScoronary artery bypass graftingpercutaneous coronary interventionrevascularization guidelines

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