Percutaneous or surgical revascularization for left main stem disease: NOBLE ideas, but do they EXCEL?

ABSTRACT

Introduction: Although coronary artery bypass grafting (CABG) has traditionally been the standard treatment for significant left main stem (LMS) disease, percutaneous coronary intervention (PCI) using drug-eluting stents (DES) is now considered an acceptable alternative.

Areas covered: This article aims to summarise the key findings of the landmark clinical trials on LMS revascularization and the recently published ESC/EACTS guidelines on myocardial revascularization related to LMS disease.

Expert opinion: It is unlikely that there will be a further large randomized trial aimed at addressing the issue of the optimum method of revascularization for LMS disease. Both PCI and CABG are reasonable revascularization options for appropriately selected patients with LMS disease. ‘Heart Team’ approach is vital to guide the management of patients with LMS disease, when there is obvious clinical equipoise and a mandate for complete revascularization. With an aging and increasing co-morbid patient population, clinical equipoise may not always be obvious, making extrapolation of clinical trial results to the ‘real world’ difficult.

KEYWORDS:

• Left main stem disease
• coronary artery bypass grafting
• percutaneous coronary intervention
• NOBLE
• EXCEL
• SYNTAX
• SYNTAXES
• MAIN COMPARE
• revascularization guidelines

Article highlights

• Coronary artery bypass grafting (CABG) has traditionally been the standard treatment for significant left main stem (LMS) disease; Percutaneous coronary intervention (PCI) using drug-eluting stents (DES) is now considered an acceptable alternative for appropriately selected patients.

• ‘Heart Team’ approach is vital to guide the management of patients with LMS disease, when there is obvious clinical equipoise and a mandate for complete revascularization.

• It is unlikely that there will be a further large randomized trial aimed at addressing the issue of the optimum method of revascularization for LMS disease, but further subgroup analyses from the recently published trials may be hypothesis-generating.

• With an aging and increasing co-morbid patient population, clinical equipoise may not always be obvious, making extrapolation of clinical trial results to the ‘real world’ difficult.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer Disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.