Left main coronary artery disease: is CABG still the gold standard?

Abstract

Severe stenosis of the left main coronary artery (LMCA) is a coronary artery-disease manifestation of critical prognostic importance. As a consequence of the survival advantage conferred by coronary artery bypass grafting (CABG) over medical therapy, lesions in the LMCA have been considered a standard indication for CABG for nearly 3 decades. Initial attempts to treat LMCA disease percutaneously by balloon angioplasty resulted in poor clinical outcomes, leading many to regard significant LMCA disease as a contraindication for percutaneous coronary intervention (PCI). However, the development and refinement of coronary stenting over the last 15 years, followed by the recent introduction of drug-eluting stents, has fueled renewed interest in percutaneous treatment of LMCA disease. Outcomes of recent studies using sirolimus- and/or paclitaxel-eluting stents for treatment of LMCA disease have yielded rates of in-hospital and 1-year mortality that compare favorably with those of surgery. This article will review the natural history of LMCA disease, the outcomes of CABG for LMCA disease, and the history and recent developments regarding PCI for LMCA disease.