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Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting in Treatment of Unprotected Left Main Stenosis

  • Ischemic Heart Disease (D Mukherjee, Section Editor)
  • Published:
Current Cardiology Reports Aims and scope Submit manuscript

Abstract

Purpose of Review

This article reviews the latest data on unprotected left main (ULM) percutaneous coronary intervention (PCI) versus coronary artery bypass graft (CABG) surgery, with a focus on the NOBLE and EXCEL trials.

Recent Findings

In EXCEL trial, the primary endpoint at 3 years was 15.4% in the PCI group and 14.7% in the CABG group (p = 0.02 for non-inferiority of PCI versus CABG). In NOBLE, the primary endpoint at 5 years was 28% and 18% for PCI and CABG, respectively (HR 1.51, CI 1.13–2.0, which did not meet the criteria for non-inferiority of PCI to CABG; p for superiority of CABG was 0.0044). Higher repeat revascularization and non-procedural myocardial infarction were noted in PCI group but there was no difference in all-cause or cardiac mortality between the two groups.

Summary

A heart team approach with appropriate patient selection, careful assessment of LM lesions, and meticulous procedural technique makes PCI a valid alternative to CABG for ULM stenosis.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Kalbfleisch H, Hort W. Quantitative study on the size of coronary artery supplying areas postmortem. Am Heart J. 1977;94:183–8.

    Article  CAS  Google Scholar 

  2. Ragosta M, Dee S, Sarembock IJ, Lipson LC, Gimple LW, Powers ER. Prevalence of unfavorable angiographic characteristics for percutaneous intervention in patients with unprotected left main coronary artery disease. Catheter Cardiovasc Interv. 2006;68:357–62.

    Article  Google Scholar 

  3. Yusuf S, Zucker D, Peduzzi P, Fisher LD, Takaro T, Kennedy JW, et al. Effect of coronary artery bypass graft surgery on survival: overview of 10-year results from randomised trials by the Coronary Artery Bypass Graft Surgery Trialists Collaboration. Lancet. 1994;344:563–70.

    Article  CAS  Google Scholar 

  4. Shah R, Morsy MS, Weiman DS, Vetrovec GW. Meta-analysis comparing coronary artery bypass grafting to drug-eluting stents and to medical therapy alone for left main coronary artery disease. Am J Cardiol. 2017;120:63–8.

    Article  Google Scholar 

  5. Al Ali J, Franck C, Filion KB, Eisenberg MJ. Coronary artery bypass graft surgery versus percutaneous coronary intervention with first-generation drug-eluting stents: a meta-analysis of randomized controlled trials. JACC Cardiovasc Interv. 2014;7:497–506.

    Article  Google Scholar 

  6. Joner M, Nakazawa G, Finn AV, Quee SC, Coleman L, Acampado E, et al. Endothelial cell recovery between comparator polymer-based drug-eluting stents. J Am Coll Cardiol. 2008;52:333–42.

    Article  CAS  Google Scholar 

  7. •• Mäkikallio T, Holm NR, Lindsay M, Spence MS, Erglis A, Menown IBA, et al. Percutaneous coronary angioplasty versus coronary artery bypass grafting in treatment of unprotected left main stenosis (NOBLE): a prospective, randomised, open-label, non-inferiority trial. Lancet. 2016;388:2743–52 This is a well-designed European multicenter randomized trial with a > 1200 sample size with 5 years follow-up data.

  8. •• Stone GW, Sabik JF, Serruys PW, Simonton CA, Généreux P, Puskas J, et al. Everolimus-Eluting Stents or Bypass Surgery for Left Main Coronary Artery Disease. N Engl J Med. 2016;375:2223–35. This prospective randomized trial addressing the question with 3 years follow-up has the largest sample size (N=1905). The results of this trial are likely more generalizable as it had 126 sites in 17 countries including USA.

  9. Buszman PE, Buszman PP, Banasiewicz-Szkróbka I, Milewski KP, Żurakowski A, Orlik B, et al. Left main stenting in comparison with surgical revascularization: 10-year outcomes of the (Left Main Coronary Artery Stenting) LE MANS Trial. JACC Cardiovasc Interv. 2016;9:318–27.

    Article  Google Scholar 

  10. Boudriot E, Thiele H, Walther T, Liebetrau C, Boeckstegers P, Pohl T, et al. Randomized comparison of percutaneous coronary intervention with sirolimus-eluting stents versus coronary artery bypass grafting in unprotected left main stem stenosis. J Am Coll Cardiol. 2011;57:538–45.

    Article  Google Scholar 

  11. • Ahn J-M, Roh J-H, Kim Y-H, Park D-W, Yun S-C, Lee PH, et al. Randomized Trial of stents versus bypass surgery for left main coronary artery disease: 5-year outcomes of the PRECOMBAT Study. J Am Coll Cardiol. 2015;65:2198–206 This landmark trial has a good sample size with 5-year follow-up outcome results. This in turn gives more applicable real life mid- to long-term follow-up perspectives.

  12. • Morice M-C, Serruys PW, Kappetein AP, Feldman TE, Ståhle E, Colombo A, et al. Outcomes in patients with de novo left main disease treated with either percutaneous coronary intervention using paclitaxel-eluting stents or coronary artery bypass graft treatment in the Synergy Between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery (SYNTAX) trial. Circulation. 2010;121:2645–53 The acronym SYNTAX is well known to cardiologists as the foundation of coronary artery disease and PCI complexity assessment. This is the trial that initiated SYNTAX score.

  13. Buszman PE, Kiesz SR, Bochenek A, Peszek-Przybyla E, Szkrobka I, Debinski M, et al. Acute and late outcomes of unprotected left main stenting in comparison with surgical revascularization. J Am Coll Cardiol. 2008;51:538–45.

    Article  Google Scholar 

  14. Park S-J, Kim Y-H, Park D-W, Yun S-C, Ahn J-M, Song HG, et al. Randomized trial of stents versus bypass surgery for left main coronary artery disease. N Engl J Med. 2011;364:1718–27.

    Article  CAS  Google Scholar 

  15. Morice M-C, Serruys PW, Kappetein AP, Feldman TE, Ståhle E, Colombo A, et al. Five-year outcomes in patients with left main disease treated with either percutaneous coronary intervention or coronary artery bypass grafting in the synergy between percutaneous coronary intervention with taxus and cardiac surgery trial. Circulation. 2014;129:2388–94.

    Article  Google Scholar 

  16. Fajadet J, Capodanno D, Stone GW. Management of left main disease: an update. Eur Heart J [Internet] 2018; Available from: https://doi.org/10.1093/eurheartj/ehy238

  17. Giacoppo D, Colleran R, Cassese S, Frangieh AH, Wiebe J, Joner M, et al. Percutaneous Coronary Intervention vs Coronary Artery Bypass Grafting in Patients With Left Main Coronary Artery Stenosis: A Systematic Review and Meta-analysis. JAMA Cardiol. 2017;2:1079–88.

    Article  Google Scholar 

  18. Palmerini T, Serruys P, Kappetein AP, Genereux P, Riva DD, Reggiani LB, et al. Clinical outcomes with percutaneous coronary revascularization vs coronary artery bypass grafting surgery in patients with unprotected left main coronary artery disease: A meta-analysis of 6 randomized trials and 4,686 patients. Am Heart J. 2017;190:54–63.

    Article  Google Scholar 

  19. Sardar P, Giri J, Elmariah S, Chatterjee S, Kolte D, Kundu A, et al. Meta-Analysis of Drug-Eluting Stents Versus Coronary Artery Bypass Grafting in Unprotected Left Main Coronary Narrowing. Am J Cardiol. 2017;119:1746–52.

    Article  Google Scholar 

  20. Head SJ, Milojevic M, Daemen J, Ahn J-M, Boersma E, Christiansen EH, et al. Mortality after coronary artery bypass grafting versus percutaneous coronary intervention with stenting for coronary artery disease: a pooled analysis of individual patient data. Lancet. 2018;391:939–48.

    Article  Google Scholar 

  21. Patel MR, Calhoon JH, Dehmer GJ, Grantham JA, Maddox TM, Maron DJ, et al. Correction to: ACC/AATS/AHA/ASE/ASNC/SCAI/SCCT/STS 2017 Appropriate Use Criteria for Coronary Revascularization in Patients With Stable Ischemic Heart Disease. J Nucl Cardiol [Internet] 2018; Available from: https://doi.org/10.1007/s12350-018-1292-x

  22. Neumann F-J, Sousa-Uva M, Ahlsson A, Alfonso F, Banning AP, Benedetto U, et al. 2018 ESC/EACTS Guidelines on myocardial revascularization. Eur Heart J [Internet] 2018; Available from: https://doi.org/10.1093/eurheartj/ehy394

  23. Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, et al. 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. Circulation. 2011;124:e574–651.

    PubMed  Google Scholar 

  24. Serruys PW, Morice M-C, Kappetein AP, Colombo A, Holmes DR, Mack MJ, et al. Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease. N Engl J Med. 2009;360:961–72.

    Article  CAS  Google Scholar 

  25. Sotomi Y, Cavalcante R, van Klaveren D, Ahn J-M, Lee CW, de Winter RJ, et al. Individual long-term mortality prediction following either coronary stenting or bypass surgery in patients with multivessel and/or unprotected left main disease: An external validation of the SYNTAX Score II Model in the 1,480 Patients of the BEST and PRECOMBAT Randomized Controlled Trials. JACC Cardiovasc Interv. 2016;9:1564–72.

    Article  Google Scholar 

  26. Capodanno D, Miano M, Cincotta G, Caggegi A, Ruperto C, Bucalo R, et al. EuroSCORE refines the predictive ability of SYNTAX score in patients undergoing left main percutaneous coronary intervention. Am Heart J. 2010;159:103–9.

    Article  Google Scholar 

  27. Capodanno D, Caggegi A, Miano M, Cincotta G, Dipasqua F, Giacchi G, et al. Global risk classification and clinical SYNTAX (synergy between percutaneous coronary intervention with TAXUS and cardiac surgery) score in patients undergoing percutaneous or surgical left main revascularization. JACC Cardiovasc Interv. 2011;4:287–97.

    Article  Google Scholar 

  28. Bhatt DL. CABG the clear choice for patients with diabetes and multivessel disease. Lancet. 2018;391:913–4.

    Article  Google Scholar 

  29. Jasti V, Ivan E, Yalamanchili V, Wongpraparut N, Leesar MA. Correlations between fractional flow reserve and intravascular ultrasound in patients with an ambiguous left main coronary artery stenosis. Circulation. 2004;110:2831–6.

    Article  Google Scholar 

  30. Park S-J, Ahn J-M, Kang S-J, Yoon S-H, Koo B-K, Lee J-Y, et al. Intravascular ultrasound-derived minimal lumen area criteria for functionally significant left main coronary artery stenosis. JACC Cardiovasc Interv. 2014;7:868–74.

    Article  Google Scholar 

  31. Daniels DV, van’t Veer M, Pijls NHJ, van der Horst A, Yong AS, De Bruyne B, et al. The impact of downstream coronary stenoses on fractional flow reserve assessment of intermediate left main disease. JACC Cardiovasc Interv. 2012;5:1021–5.

    Article  Google Scholar 

  32. Rab T, Sheiban I, Louvard Y, Sawaya FJ, Zhang JJ, Chen SL. Current interventions for the left main bifurcation. JACC Cardiovasc Interv. 2017;10:849–65.

    Article  Google Scholar 

  33. Chen S-L, Zhang J-J, Han Y, Kan J, Chen L, Qiu C, et al. Double kissing crush versus provisional stenting for left main distal bifurcation lesions: DKCRUSH-V randomized trial. J Am Coll Cardiol. 2017;70:2605–17.

    Article  Google Scholar 

  34. Lassen JF, Burzotta F, Banning AP, Lefèvre T, Darremont O, Hildick-Smith D, et al. Percutaneous coronary intervention for the left main stem and other bifurcation lesions: 12th consensus document from the European Bifurcation Club. EuroIntervention. 2018;13:1540–53.

    Article  Google Scholar 

  35. Chen S-L, Xu B, Han Y-L, Sheiban I, Zhang J-J, Ye F, et al. Comparison of double kissing crush versus Culotte stenting for unprotected distal left main bifurcation lesions: results from a multicenter, randomized, prospective DKCRUSH-III study. J Am Coll Cardiol. 2013;61:1482–8.

    Article  Google Scholar 

  36. Chieffo A, Hildick-Smith D. The European Bifurcation Club Left Main Study (EBC MAIN): rationale and design of an international, multicentre, randomised comparison of two stent strategies for the treatment of left main coronary bifurcation disease. EuroIntervention. 2016;12:47–52.

    Article  Google Scholar 

  37. Puri R, Kapadia SR, Nicholls SJ, Harvey JE, Kataoka Y, Tuzcu EM. Optimizing outcomes during left main percutaneous coronary intervention with intravascular ultrasound and fractional flow reserve: the current state of evidence. JACC Cardiovasc Interv. 2012;5:697–707.

    Article  Google Scholar 

  38. Park S-J, Kim Y-H, Park D-W, Lee S-W, Kim W-J, Suh J, et al. Impact of intravascular ultrasound guidance on long-term mortality in stenting for unprotected left main coronary artery stenosis. Circ Cardiovasc Interv. 2009;2:167–77.

    Article  Google Scholar 

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Author information

Authors and Affiliations

  1. Morehouse School of Medicine, Atlanta, GA, USA

    Yasir Taha & Rajesh Sachdeva

  2. Ochsner Medical Center, New Orleans, LA, USA

    Rajan A. G. Patel

  3. Vanderbilt University Medical Center, Nashville, TN, USA

    Jayant Bagai

  4. Emory University School of Medicine, Atlanta, GA, USA

    Gautam Kumar

  5. University of Texas at San Antonio, San Antonio, TX, USA

    Anand Prasad

  6. University of Chicago, Chicago, IL, USA

    Sandeep Nathan

  7. Division of Cardiology, Department of Internal Medicine, East Tennessee State University, 329 N State of Franklin Rd, Johnson City, TN, 37604, USA

    Timir K. Paul

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Correspondence to Timir K. Paul.

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Conflict of Interest

Yasir Taha, Rajan A.G. Patel, Jayant Bagai, Rajesh Sachdeva, Gautam Kumar, and Timir K. Paul declare that they have no conflict of interest.

Anand Prasad reports the following: Speaker: AstraZeneca, Abiomed, Gilead; Consultant: Osprey Medical, GE; Research: ACIST Medical, Medtronic.

Sandeep Nathan has served as a consultant for Medtronic, Inc.

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Taha, Y., Patel, R.A.G., Bagai, J. et al. Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting in Treatment of Unprotected Left Main Stenosis. Curr Cardiol Rep 21, 27 (2019). https://doi.org/10.1007/s11886-019-1113-0

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