Left main intervention: Difference between revisions
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Treating a patient with non-surgical methods include smoking cessation and risk factor modification. If a stent is placed, the patient is placed on prolonged dual antiplatelet therapy. | Treating a patient with non-surgical methods include smoking cessation and risk factor modification. If a stent is placed, the patient is placed on prolonged dual antiplatelet therapy. | ||
==Appropriate Candidate Selection== | ===Appropriate Candidate Selection=== | ||
[[CABG]] has generally been accepted as the [[standard of care]] for patients with LMCA disease. [[Left main intervention]] is considered a high risk subset of [[PCI]], but it may be necessary for certain patients. | [[CABG]] has generally been accepted as the [[standard of care]] for patients with LMCA disease. [[Left main intervention]] is considered a high risk subset of [[PCI]], but it may be necessary for certain patients. | ||
Revision as of 15:11, 5 August 2010
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Associate Editors-In-Chief: Neil M. Gheewala, M.D.; Anthony Smeglin, M.D.
Background
Approximately 5% of all patient undergoing coronary angiography have significant (> 50%) left main coronary artery (LMCA) stenosis. The ACC/AHA recommends coronary artery bypass grafting (CABG) in patient with significant LMCA disease who have angina and ACS. However, not all patients are operative candidates. In selected patients, LM PCI can safely and effectively treat patients in whom coronary artery bypass grafting (CABG) is suboptimal, or have prior CABG with a ‘protected’ LMCA. ‘Protected’ left main in patients with prior CABG is defined as at least one patent graft to left anterior descending or circumflex artery.
Goals of Treatment
The main goal of treatment is to provide a treatment option in patients who would otherwise be poor surgical candidates, declined by surgery, or refuse CABG. It is essential to properly select patients based on their anatomy who would be better candidates for DES vs BMS vs bifurcation stents.
Treatment Choices
Medical Therapy
Treating a patient with non-surgical methods include smoking cessation and risk factor modification. If a stent is placed, the patient is placed on prolonged dual antiplatelet therapy.
Appropriate Candidate Selection
CABG has generally been accepted as the standard of care for patients with LMCA disease. Left main intervention is considered a high risk subset of PCI, but it may be necessary for certain patients.
Candidates for LMCA PCI include:
- Poor operative candidates
- Low-risk patients who refuse CABG
- Patients with 'protected' left main disease (see above)
- Syntax score less than or equal to 22 is considered reasonable based on the Syntax trial (remains subject to debate)
High-risk features in patients with left main disease PCI include:
- Absence of internal mammary artery, radial artery, or saphenous vein grafts distally leading to an ‘unprotected’ left main.
- Concomitant right coronary artery (RCA) disease and/or lack of collaterals from RCA
- Left ventricular dysfunction