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Current Use and Trends in Unprotected Left Main Coronary Artery Percutaneous Intervention

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Abstract

Purpose of Review

To review the clinical evidence on the use of percutaneous coronary intervention (PCI) revascularization options in left main (LM) disease in comparison with coronary artery bypass graft (CABG). Coronary artery disease (CAD) involving the LM is associated with high morbidity and mortality. Though CABG remains the gold standard for complex CAD involving the LM artery, recent trials have shown a trend towards non-inferiority of the LM PCI when compared with CABG in certain subset of patients.

Recent Findings

Two recent major randomized trials compared the outcomes of PCI versus CABG in the LM and multi-vessel disease with LM involvement. The NOBLE trial included patients with all range of Synergy Between Percutaneous Coronary Intervention With TAXUS and Cardiac Surgery (SYNTAX) scores and utilized biolimus drug-eluting stent (DES). The trial concluded that MACCE (major adverse cardiac and cerebrovascular event) was significantly higher with PCI (28%) when compared with CABG (18%) but overall stroke and motility were not different. EXCEL trial evaluated the same treatment option in low to intermediate SYNTAX score population with third-generation everolimus DES platform as PCI option. Results showed no significant differences in the composite primary endpoints of death, stroke, and myocardial infarction (MI) at the end of 30 days (22% versus 19.2%, p = 0.13), although repeat revascularization was higher in PCI group (16.9% versus 10%).

Summary

Recent evidence suggests that PCI is an acceptable alternative to treat symptomatic LM stenosis in select group of patients. In low to medium SYNTAX score, particularly in patients without diabetes mellitus, PCI remains a viable option. Future trials focusing on evaluating subset of patients who would benefit from one particular revascularization option in comparison with other is warranted.

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Fig. 1

Abbreviations

CAD:

Coronary artery disease

PCI:

Percutaneous coronary intervention

CABG:

Coronary artery bypass grafting

LM:

Left main

ACS:

Acute coronary syndrome

ST:

Stent thrombosis

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Correspondence to Harsha S. Nagarajarao.

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Harsha S. Nagarajarao, Chandra P. Ojha, Venkatachalam Mulukutla, Ahmed Ibrahim, Adriana C. Mares, and Timir K. Paul declare that they have no conflict of interest.

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Nagarajarao, H.S., Ojha, C.P., Mulukutla, V. et al. Current Use and Trends in Unprotected Left Main Coronary Artery Percutaneous Intervention. Curr Cardiol Rep 22, 16 (2020). https://doi.org/10.1007/s11886-020-1268-8

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Keywords

  • Left main coronary artery disease
  • Non-invasive imaging
  • Percutaneous coronary intervention
  • Anti-platelet therapy
  • Mechanical circulatory support
  • Evidence-based medicine