Left main coronary artery disease

Summary

The management of significant (≥ 50% diameter stenosis) left main coronary artery disease (LMCAD) has progressed significantly since the first description of a fatal left main coronary artery (LM) thrombosis over 100 years ago. The prognostic implications of significant LMCAD have been recognised for the past 50 years, and the results of historical trials comparing coronary artery bypass grafting (CABG) and guideline directed medical therapy (GDMT) have resulted in universal recommendations supporting the revascularization of significant LMCAD.

Subsequently, there has been significant interest in determining the optimal revascularization strategy for LMCAD, with numerous trials comparing CABG and percutaneous coronary intervention (PCI) in this context. While these trials and meta-analyses (MA) have generated some controversy, the most recent guidelines favour a Heart Team-based approach, with both CABG and PCI considered reasonable treatment options in stable patients with an indication for LMCA revascularization, anatomy suitable for both procedures and low predicted surgical mortality. When PCI is the chosen revascularization modality, intracoronary imaging (ICI) is an essential tool to understand the LMCA morphology, adequately prepare the lesion and ensure optimal stent implantation. Antithrombotic therapy (ATT) in this setting can generally follow the same principles as after other complex PCI procedures.

Scope of...