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Left main equivalent: results of medical and surgical therapy
Insights
Left main equivalent (LME) disease, a severe coronary artery condition, shows better outcomes with surgery. Early surgical intervention for LME disease is recommended over medical management for improved survival and reduced heart attack risk.
Area of Science:
- Cardiology
- Cardiovascular Surgery
- Interventional Cardiology
Background:
- Left main equivalent (LME) disease involves significant stenosis in the left anterior descending and circumflex coronary arteries.
- LME disease is sometimes distinguished from left main coronary artery (LMCA) stenosis.
Purpose of the Study:
- To compare the outcomes of surgical versus nonoperative management in patients with LME disease.
- To compare LME disease outcomes with those of LMCA stenosis and multivessel coronary artery disease.
Main Methods:
- Retrospective analysis of 189 LME patients (surgical vs. nonoperative) and comparison with LMCA stenosis and three-vessel disease patients undergoing coronary artery bypass grafting (CABG).
- Follow-up was 99.2% complete at an average of 48 months.
Main Results:
- LME surgical patients had significantly lower operative mortality (0.8%) than LMCA surgical patients (4.0%).
- Five-year survival was significantly better for LME surgical patients (98.2%) compared to LME medical patients (75.9%) and LMCA surgical patients (92.8%).
- Operative groups experienced lower rates of myocardial infarction and better angina relief than LME medical patients.
Conclusions:
- LME disease is best considered a variant of multivessel coronary artery disease.
- Patients with LME disease should be strongly considered for early operative therapy due to superior outcomes compared to medical management.
Abstract:
Stenosis of at least 50% of both the left anterior descending and circumflex coronary arteries proximal to their major branches has sometimes been called left main equivalent (LME) disease. During a 4-year interval, 189 LME patients were identified as surgical candidates by angiographic criteria. Coronary artery bypass grafting (CABG) was performed in 119 patients; 70 patients were managed nonoperatively. Treatment assignment was nonrandom. During the same interval, 203 patients with significant left main coronary artery (LMCA) stenosis and 742 patients with three-vessel disease without LMCA or LME stenosis underwent CABG. Follow-up is 99.2% complete at an average of 48 months (range 24--73 months). Operative mortality was significantly higher among LMCA patients (4.0%) than among LME surgical patients (0.8%) (p less than 0.05). Cumulative 5-year survival was better among LME surgical patients (98.2 +/- 1.3%) than among LME medical patients (75.9 +/- 5.7%) (p less than 0.0001) or LMCA surgical patients (92.8 +/- 2.1%) (p less than 0.03). All operative patient groups had a significantly lower incidence of myocardial infarction (10.3--13.4%) than the LME medical patients (25.7%) (p less than 0.05). Relief of angina was also significantly better in the operative groups (61--67.6%) than in LME medical patients (36%) (p less than 0.005). Major differences exist between LME and LMCA patients; LME is more properly considered a variant of multivessel coronary artery disease. Results of medical and surgical therapy suggest that patients with LME disease should be strongly considered for early operative therapy.