Left main coronary stenosis: surgery still reigns.

Abstract

Coronary artery bypass grafting (CABG) has been regarded as the mainstream treatment for unprotected left main coronary artery (ULMCA) stenosis. However, the results of the Evaluation of XIENCE versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization (EXCEL) trial, in which percutaneous coronary intervention (PCI) was deemed noninferior to CABG, have raised a question whether the guidelines should be changed. This article provides a critical appraisal of recent randomized control trials (RCTs) on ULMCA stenosis. In contrast to EXCEL trial, another large RCT named the Nordic-Baltic-British Left Main Revascularization trial showed that PCI is inferior to CABG in patients treated for ULMCA stenosis. The reason for the discrepancy between these two RCTs may be due to differences in study design. In EXCEL trial, the adoption of new periprocedural myocardial infarction definition, the noninclusion of target vessel revascularization as a primary endpoint component, and the timeline of the study may have helped claim that PCI is noninferior to CABG. The long-term efficacy of PCI for ULMCA stenosis has not yet been demonstrated. Further studies and follow-up data are needed before the indications for PCI are expanded in this scenario.