Revascularization of left main coronary artery disease

Coronary artery disease with left main stenosis is associated with the highest mortality of any coronary lesion. Studies in the 1970s and 1980s comparing coronary artery bypass grafting (CABG) and medical therapy showed a significant survival benefit with revascularization. In the angioplasty era, initial experience with percutaneous intervention was associated with poor clinical outcomes. As a result, percutaneous coronary intervention (PCI) was restricted to patients who were considered inoperable, or those with prior CABG with a functional graft to the left anterior descending or circumflex artery ("protected left main disease"). With the introduction of drug-eluting stents, there are new studies demonstrating comparable survival in patients who were revascularized using PCI and CABG, although percutaneous revascularization is associated with a higher rate of repeat revascularization. In the SYNTAX (Synergy between PCI with Taxus and Cardiac Surgery) trial, the combined incidence of death, myocardial infarction, and stroke was similar between the CABG and PCI groups; however, the stroke rate was higher in the CABG group. The degree and extent of disease as defined by the SYNTAX scoring system has allowed for stratification of risk and improved assignment of patients with left main stenosis to either PCI or CABG.