Revascularization in Patients With Left Main Coronary Disease
Revascularization in Patients With Left Main Coronary Disease
The multiple trials comparing CABG with PCI for LMD have suggested that both strategies have similar rates of MI, stroke, and death and that PCI might be an acceptable or even superior alternative for certain LM subsets. However, SYNTAX was underpowered to specifically address the LM subset. Therefore, the results of trials such as SYNTAX should be considered as hypothesis-generating. In addition, since SYNTAX, advances have been made in DES technology, adjunctive techniques (IVUS/FFR), and pharmacotherapy. The EXCEL trial is expected to address those limitations and determine the optimal revascularization strategy for patients with LMD. EXCEL has been designed to randomize 2634 patients with significant LMD and SYNTAX scores ≤32 to undergo either PCI with EES or CABG. The hard endpoints of MI/stroke/death will be assessed up to 3 years. Awaiting the results of the EXCEL trial, we suggest the following approach for management of LMD:
Future Studies/Conclusions
The multiple trials comparing CABG with PCI for LMD have suggested that both strategies have similar rates of MI, stroke, and death and that PCI might be an acceptable or even superior alternative for certain LM subsets. However, SYNTAX was underpowered to specifically address the LM subset. Therefore, the results of trials such as SYNTAX should be considered as hypothesis-generating. In addition, since SYNTAX, advances have been made in DES technology, adjunctive techniques (IVUS/FFR), and pharmacotherapy. The EXCEL trial is expected to address those limitations and determine the optimal revascularization strategy for patients with LMD. EXCEL has been designed to randomize 2634 patients with significant LMD and SYNTAX scores ≤32 to undergo either PCI with EES or CABG. The hard endpoints of MI/stroke/death will be assessed up to 3 years. Awaiting the results of the EXCEL trial, we suggest the following approach for management of LMD:
There should be a consensus approach to patients with LMD consisting of an interventional cardiologist and a cardiothoracic surgeon. Risks and benefits should be completely reviewed and ad hoc procedures should be avoided.
A SYNTAX score should be calculated for every patient. Patients with a SYNTAX score ≥33 should be referred for CABG.
The use of IVUS and FFR is encouraged to assess the need for intervention in ambiguous LM lesions and intermediate lesions in other vessels.
Lesion preparation is critical. Direct stenting, especially of calcified lesions, should not be undertaken. Heavily calcified lesions should be treated with rotational atherectomy in preparation for optimal stent delivery and expansion.
In bifurcation lesions of the LM, we prefer to use one stent, if possible. Familiarity and experience with bifurcation techniques and rotational atherectomy are critical when planning to undertake intervention in this challenging group of patients.
The majority of PCI cases do not require hemodynamic support. Both the IABP and Impella can provide significant benefit for high-risk patients. In the EXCEL trial, the use of these devices will be at the discretion of the operator.
Pharmacology: the use of the following medications is recommended in patients undergoing PCI:
Acetylsalicyclic acid: preloading (325 mg) at least 2 hours before PCI.
Adenosine diphosphate antagonists: preloading with either clopidogrel 600 mg (>6 hours before PCI) or 300 mg (>12 hours before PCI) OR prasugrel 60 mg OR ticagrelor 180 mg with reduced dose aspirin.
Statins: administer the first dose 12 hours before PCI. Atorvastatin 80 mg daily is preferred.
Anticoagulation during the procedure: the use of bivalirudin is recommended.
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