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Review
. 2022 Mar 15;2(2):119-138.
doi: 10.1016/j.jacasi.2021.12.011. eCollection 2022 Apr.

Percutaneous Coronary Intervention for Left Main Coronary Artery Disease: Present Status and Future Perspectives

Sangwoo Park  1 , Seung-Jung Park  2 , Duk-Woo Park  2
Affiliations
Review

Percutaneous Coronary Intervention for Left Main Coronary Artery Disease: Present Status and Future Perspectives

Sangwoo Park et al. JACC Asia. .

Abstract

For several decades, coronary artery bypass grafting has been regarded as the standard choice of revascularization for significant left main coronary artery (LMCA) disease. However, in conjunction with remarkable advancement of device technology and adjunctive pharmacology, percutaneous coronary intervention (PCI) offers a more expeditious approach with rapid recovery and is a safe and effective alternative in appropriately selected patients with LMCA disease. Several landmark randomized clinical trials showed that PCI with drug-eluting stents for LMCA disease is a safe option with similar long-term survival rates to coronary artery bypass grafting surgery, especially in those with low and intermediate anatomic risk. Although it is expected that the updated evidence from recent randomized clinical trials will determine the next guidelines for the foreseeable future, there are still unresolved and unmet issues of LMCA revascularization and PCI strategy. This paper provides a comprehensive review on the evolution and an update on the management of LMCA disease.

Keywords: BMS, bare-metal stent(s); CABG, coronary artery bypass grafting; CAD, coronary artery disease; DAPT, dual antiplatelet therapy; DES, drug-eluting stent(s); DK, double-kissing; FFR, fractional flow reserve; IVUS, intravascular ultrasound; LAD, left anterior descending artery; LCX, left circumflex artery; LMCA, left main coronary artery; LVEF, left ventricular ejection fraction; MACCE, major adverse cardiac or cerebrovascular events; MI, myocardial infarction; MLA, minimal lumen area; PCI, percutaneous coronary intervention; RCT, randomized clinical trial; coronary artery bypass grafting; iFR, instantaneous wave-free ratio; left main coronary artery disease; percutaneous coronary intervention.

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Conflict of interest statement

The authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Figures

None
Graphical abstract
Figure 1
Figure 1
Heart Team Approach to LMCA Revascularization CABG = coronary artery bypass grafting; DAPT = dual antiplatelet therapy; LMCA = left main coronary artery; LVEF = left ventricular ejection fraction; PCI = percutaneous coronary intervention.
Figure 2
Figure 2
Treatment Effects of PCI and CABG According to Diabetic Status BEST = Randomized Comparison of Coronary Artery Bypass Surgery and Everolimus Eluting Stent Implantation in the Treatment of Patients With Multivessel Coronary Artery Disease; CABG = coronary artery bypass grafting; CAD = coronary artery disease; DM = diabetes mellitus; EXCEL = Evaluation of Xience Everolimus Eluting Stent vs Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization; FREEDOM = Future Revascularization Evaluation in Patients With Diabetes Mellitus: Optimal Management of Multivessel Disease; IPD = individual patient-level data; LM = left main; MVD = multivessel disease; NOBLE = Nordic-Baltic-British Left Main Revascularization; PCI = percutaneous coronary intervention; PRECOMBAT = Premier of Randomized Comparison of Bypass Surgery versus Angioplasty Using Sirolimus-Eluting Stent in Patients with Left Main Coronary Artery Disease; RCT = randomized clinical trial; SYNTAX = Synergy Between Percutaneous Coronary Intervention With TAXUS and Cardiac Surgery. Reproduced with permission from Park et al with permission. Copyright © 2019, Elsevier.
Figure 3
Figure 3
IVUS and FFR Roles in Left Main PCI FFR = fractional flow reserve; IVUS = intravascular ultrasound; LMCA = left main coronary artery; PCI = percutaneous coronary intervention;
Figure 4
Figure 4
Contemporary Complex Bifurcation Stenting Techniques for Left Main Bifurcation Lesions Each figure depicts the schematic representation of the key steps of complex 2-stent techniques. DK = double-kissing.
Central Illustration
Central Illustration
Key Summary of Issues for Left Main Revascularization Key points are summarized for what is known and what is unknown for left main revascularization. CABG = coronary artery bypass grafting; CR = complete revascularization; IR = incomplete revascularization; PCI = percutaneous coronary intervention; LAD = left anterior descending artery; LCX = left circumflex artery; LMCA = left main coronary artery; MI = myocardial infarction.
See this image and copyright information in PMC

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