Practical recommendation and clinical situations favouring percutaneous coronary intervention or coronary artery bypass grafting in patients with left main disease
| . | . | Favours PCI . | Favours CABG . |
|---|---|---|---|
| Clinical characteristics | Advanced age/frailty/reduced life expectancy | ✓ | |
| Severe co-morbidity (not adequately reflected by scores) | ✓ | ||
| High surgical risk | ✓ | ||
| Reduced LVEF <35% | ✓ | ||
| Diabetes | ✓ | ||
| Contraindication for DAPT | ✓ | ||
| Recurrent diffuse in-stent restenosis | ✓ | ||
| Prior CABG with patent LIMA-LAD graft | ✓ | ||
| Anatomical and Technical aspects | Ostial or mid-shaft lesion | ✓ | |
| Distal or bifurcation lesion | ✓ | ||
| Presence of multivessel disease | ✓ | ||
| High anatomic complexity (e.g. SYNTAX score >32) | ✓ | ||
| Anatomy likely resulting in incomplete revascularization with PCI | ✓ | ||
| Occluded dominant graftable right coronary artery | ✓ | ||
| Severely calcified coronary artery lesions limiting lesion expansion | ✓ | ||
| Sequelae of chest radiation | ✓ | ||
| Severe chest deformity | ✓ | ||
| Porcelain aorta (if local expertise with OPCAB with anaortic grafting not available) | ✓ | ||
| Need for concomitant cardiac surgery or surgery of ascending aorta | ✓ |
| . | . | Favours PCI . | Favours CABG . |
|---|---|---|---|
| Clinical characteristics | Advanced age/frailty/reduced life expectancy | ✓ | |
| Severe co-morbidity (not adequately reflected by scores) | ✓ | ||
| High surgical risk | ✓ | ||
| Reduced LVEF <35% | ✓ | ||
| Diabetes | ✓ | ||
| Contraindication for DAPT | ✓ | ||
| Recurrent diffuse in-stent restenosis | ✓ | ||
| Prior CABG with patent LIMA-LAD graft | ✓ | ||
| Anatomical and Technical aspects | Ostial or mid-shaft lesion | ✓ | |
| Distal or bifurcation lesion | ✓ | ||
| Presence of multivessel disease | ✓ | ||
| High anatomic complexity (e.g. SYNTAX score >32) | ✓ | ||
| Anatomy likely resulting in incomplete revascularization with PCI | ✓ | ||
| Occluded dominant graftable right coronary artery | ✓ | ||
| Severely calcified coronary artery lesions limiting lesion expansion | ✓ | ||
| Sequelae of chest radiation | ✓ | ||
| Severe chest deformity | ✓ | ||
| Porcelain aorta (if local expertise with OPCAB with anaortic grafting not available) | ✓ | ||
| Need for concomitant cardiac surgery or surgery of ascending aorta | ✓ |
CABG, coronary artery bypass grafting; DAPT, dual antiplatelet therapy; LAD, left anterior descending artery; LIMA, left internal mammary artery; LVEF, left ventricular ejection fraction; OPCAB, off-pump coronary artery bypass; PCI, percutaneous coronary intervention; SYNTAX, Synergy Between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery. A visual representation of patient outcomes at 5 years after PCI or CABG based on the individual patient data meta-analysis of Sabatine et al. [6] is shown in Figure 2.
Practical recommendation and clinical situations favouring percutaneous coronary intervention or coronary artery bypass grafting in patients with left main disease
| . | . | Favours PCI . | Favours CABG . |
|---|---|---|---|
| Clinical characteristics | Advanced age/frailty/reduced life expectancy | ✓ | |
| Severe co-morbidity (not adequately reflected by scores) | ✓ | ||
| High surgical risk | ✓ | ||
| Reduced LVEF <35% | ✓ | ||
| Diabetes | ✓ | ||
| Contraindication for DAPT | ✓ | ||
| Recurrent diffuse in-stent restenosis | ✓ | ||
| Prior CABG with patent LIMA-LAD graft | ✓ | ||
| Anatomical and Technical aspects | Ostial or mid-shaft lesion | ✓ | |
| Distal or bifurcation lesion | ✓ | ||
| Presence of multivessel disease | ✓ | ||
| High anatomic complexity (e.g. SYNTAX score >32) | ✓ | ||
| Anatomy likely resulting in incomplete revascularization with PCI | ✓ | ||
| Occluded dominant graftable right coronary artery | ✓ | ||
| Severely calcified coronary artery lesions limiting lesion expansion | ✓ | ||
| Sequelae of chest radiation | ✓ | ||
| Severe chest deformity | ✓ | ||
| Porcelain aorta (if local expertise with OPCAB with anaortic grafting not available) | ✓ | ||
| Need for concomitant cardiac surgery or surgery of ascending aorta | ✓ |
| . | . | Favours PCI . | Favours CABG . |
|---|---|---|---|
| Clinical characteristics | Advanced age/frailty/reduced life expectancy | ✓ | |
| Severe co-morbidity (not adequately reflected by scores) | ✓ | ||
| High surgical risk | ✓ | ||
| Reduced LVEF <35% | ✓ | ||
| Diabetes | ✓ | ||
| Contraindication for DAPT | ✓ | ||
| Recurrent diffuse in-stent restenosis | ✓ | ||
| Prior CABG with patent LIMA-LAD graft | ✓ | ||
| Anatomical and Technical aspects | Ostial or mid-shaft lesion | ✓ | |
| Distal or bifurcation lesion | ✓ | ||
| Presence of multivessel disease | ✓ | ||
| High anatomic complexity (e.g. SYNTAX score >32) | ✓ | ||
| Anatomy likely resulting in incomplete revascularization with PCI | ✓ | ||
| Occluded dominant graftable right coronary artery | ✓ | ||
| Severely calcified coronary artery lesions limiting lesion expansion | ✓ | ||
| Sequelae of chest radiation | ✓ | ||
| Severe chest deformity | ✓ | ||
| Porcelain aorta (if local expertise with OPCAB with anaortic grafting not available) | ✓ | ||
| Need for concomitant cardiac surgery or surgery of ascending aorta | ✓ |
CABG, coronary artery bypass grafting; DAPT, dual antiplatelet therapy; LAD, left anterior descending artery; LIMA, left internal mammary artery; LVEF, left ventricular ejection fraction; OPCAB, off-pump coronary artery bypass; PCI, percutaneous coronary intervention; SYNTAX, Synergy Between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery. A visual representation of patient outcomes at 5 years after PCI or CABG based on the individual patient data meta-analysis of Sabatine et al. [6] is shown in Figure 2.
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