Updates in Left Main PCI

A recent article provides a comprehensive overview of percutaneous coronary intervention (PCI) for left main (LM) disease. The article, published in US Cardiology Review,  evaluates key landmark randomized trials comparing PCI with coronary artery bypass grafting (CABG) and while highlighting the evidence supporting the use of PCI for LM revascularization, particularly in patients with low to intermediate SYNTAX scores.

Furthermore, the article details different stenting techniques for both aorto-ostial and distal LM disease, emphasizing the importance of precise stent positioning and intracoronary imaging (IVUS or OCT) for optimal outcomes. Additionally, it explores the role of mechanical circulatory support devices in high-risk LM PCI . The article concludes by underlining the significance of a heart team approach and individualized decision-making based on patient and lesion characteristics.

Among the key takeaways highlighted in this article:

• Percutaneous coronary intervention (PCI) of left main (LM) disease has become a common procedure in modern catheterization laboratories due to advances in drug-eluting stent platforms and bifurcation techniques.
• Several landmark randomized controlled trials (RCTs) have compared PCI with coronary artery bypass grafting (CABG) for LM revascularization, showing that both approaches have benefits and risks depending on patient characteristics and lesion complexity.
• The SYNTAX trial demonstrated that PCI is a reasonable alternative to CABG for LM disease with low to intermediate SYNTAX scores, while high SYNTAX score patients had better outcomes with CABG.
• For ostial lesions, precise stent positioning is crucial, and various techniques like aortic free-floating wire, tail-wire (Szabo technique), and intravascular imaging guidance can be used to avoid geographical miss and ensure accurate stent deployment with full stent coverage of the aorto-ostial landing zone (AOLZ).
• For distal LM disease, selecting the appropriate bifurcation strategy between provisional stenting and a two-stent strategy remains debatable, requiring a careful heart team approach and consideration of lesion complexity.
• A stepwise provisional stenting approach is generally safe and commonly adopted for LM PCI, while two-stent strategies may be considered for more complex lesions based on clinical and anatomical factors.
• Intracoronary imaging, such as intravascular ultrasound (IVUS) or optical coherence tomography (OCT), provides valuable information for stent optimization and lesion assessment in LM PCI, leading to better outcomes.
• Current guidelines recommend PCI for LM disease with low to intermediate SYNTAX scores and suggest considering IVUS use for stent optimization, but further studies are needed to fully incorporate intracoronary imaging into guidelines.
• Mechanical circulatory support devices such as Impella, TandemHeart, venoarterial extracorporeal membrane oxygenation (VA-ECMO), and intra-aortic balloon pump (IABP) can be considered to support high-risk LM PCI, but careful patient selection and operator expertise are essential to avoid over-utilization and device-related complications.
• Geographic and genetic differences in LM PCI outcomes should be explored in larger randomized studies to better guide clinical practice.

“Although evidence suggests better outcomes with image-guided PCI, the guidelines are yet to acknowledge its utility. The totality of evidence suggests a stepwise provisional strategy is safe. The review alludes to the geographic differences in studies, and larger randomized studies exploring genetic and geographic differences would be useful in guiding practice,” the authors concluded.

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