Left main coronary artery disease

Summary

The following chapter is a contemporary overview of the management of patients with unprotected left main coronary artery disease. A background of the anatomy and pathophysiology of the left main stem is given, followed by the appropriate selection of patients electing to undergo either surgical or percutaneous revascularisation based on contemporary clinical evidence, established and new/emerging decision-making tools and international guidelines. Contemporary clinical issues in undertaking unprotected left main revascularisation are also discussed. Principles of adjunctive intravascular imaging and tools such as intravascular ultrasound, optical coherence tomography and physiological assessments of lesions – either invasively (pressure wire assessment) or non-invasively (HeartFlowTM technology applied to computed tomography angiography) – and how this influences distal left main bifurcation management. To conclude a dedicated practical based section involving ‘tips and tricks’ in undertaking left main percutaneous coronary intervention, is detailed.

Introduction

Significant unprotected left main coronary artery (ULMCA) disease occurs in 5-7% of patients undergoing coronary angiography 1, 21. Stone P, Goldschlager N. Left main coronary artery disease: review and appraisal. Cardiovasc Med. 1979;4:165 – 177. Link2. DeMots H, Rosch J, McAnulty J. Left main coronary artery disease. Cardiovasc Clin. 1977;8:201 – 211. Link. The left main stem...