UPDATE ON THE TREATMENT OF LEFT MAIN DISEASE


Barry F. Uretsky, M.D., University of Arkansas for Medical Sciences, Little Rock, AR, USA

Percutaneous coronary intervention (PCI) with drug eluting stents (DES) has emerged as a treatment alternative with left main (LM) disease. Three randomized clinical trials (RCT) compared DES to coronary artery bypass surgery (CABG). Certain conclusions are forthcoming: at 4 year follow-up, PCI and CABG are comparable for the combined outcome of death, MI, and stroke. Target vessel revascularization is required more frequently with PCI. There are several areas of uncertainty. With 4-year follow-up, the low/intermediate Syntax terciles showed similar outcomes. In the highest tercile, however, PCI showed a trend to worsened survival. Whether this trend relates to PCI itself or less complete revascularization with PCI is uncertain. There is agreement-though no RCT- that IVUS should be used for stent optimization. Fractional flow reserve, particularly in isolated LM disease, and probably IVUS may be helpful to differentiate patients who can be safely deferred from revascularization. LM bifurcation stenting has a higher restenosis risk (vs ostial/shaft lesions) without increased risk of death/MI. The preferred treatment method is one stent when possible. Whether it is safe to observe or proactively perform angiography for LM restenosis is unsettled but current data suggest that surveillance angiography may be unnecessary. Finally, current RCT are confined to stable CAD patients with relatively preserved ventricular function. LM ACS patients with cardiogenic shock have a high mortality whether treated with PCI or CABG. If the PCI pt survives the in-hospital period, long-term outcome is relatively good, with 50-70% alive at one year.