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Canadian Journal of Cardiology

Modality Selection for the Revascularization of Left Main Disease

Published:December 14, 2018DOI:https://doi.org/10.1016/j.cjca.2018.12.017

      Abstract

      The management of severe left main (LM) disease remains controversial and continues to evolve as new evidence emerges. Patient selection for coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) relies on both predicting mortality with CABG from clinical characteristics using the Society of Thoracic Surgeons (STS) risk score and anatomical complexity, using the Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery (SYNTAX) score. LM stenting techniques continue to evolve; for bifurcation lesions, the use of the double-kiss crush technique may reduce the incidence of late target vessel revascularization. In patients with acute coronary syndrome (ACS) complicated by cardiogenic shock, PCI is likely the first-line option in those with anatomically amenable disease, whereas all other stable non–ST-elevated ACS should be treated similar to stable ischemic heart disease. Outcomes comparing CABG and PCI have been recently examined in 2 large randomized clinical trials. In general, early outcomes of periprocedural myocardial infarction and stroke favoured PCI or were not different from outcomes with CABG. However, the conclusions of both trials are at present discordant with respect to late major adverse cardiac and cerebral events; additional follow-up of the trial patients is important for informed patient decision making. The appropriate mode of revascularization should be selected according to patient clinical characteristics and the complexity of the coronary lesions according to European and American guidelines. In those with low or intermediate SYNTAX scores, particularly with high surgical risk, PCI may be preferred to CABG in most other scenarios. A multidisciplinary heart team is recommended to help individualize revascularization decisions.

      Résumé

      La prise en charge de la sténose du tronc commun de l’artère coronaire gauche (ACG) demeure une controverse, mais continue d’évoluer en fonction des nouvelles données probantes. La sélection des patients pour le pontage aortocoronarien (PAC) ou pour l’intervention coronarienne percutanée (ICP) repose sur la prédiction de la mortalité après le PAC à partir des caractéristiques cliniques établies par le score de risque de la Society of Thoracic Surgeons (STS) et de la complexité anatomique établie par le score SYNTAX (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery). Les techniques d’implantation d’endoprothèses dans l’ACG continuent d’évoluer. Pour les lésions de bifurcation, l’utilisation de la technique du double-kiss crush peut réduire la fréquence de la revascularisation tardive du vaisseau cible. Chez les patients atteints d’un syndrome coronarien aigu (SCA) compliqué d’un choc cardiogénique, l’ICP est probablement l’option de première intention chez les patients qui ont une maladie favorable à son exécution sur le plan anatomique, tandis que tous les autres patients atteints d’un SCA stable sans sus-décalage du segment ST devraient être traités de la même façon que les patients atteints d’une cardiopathie ischémique stable. Les résultats cliniques sur la comparaison du PAC et de l’ICP ont récemment fait l’objet de 2 grandes études cliniques à répartition aléatoire. En général, les premiers résultats cliniques de l’infarctus du myocarde et de l’accident vasculaire cérébral en phase péri-opératoire favorisaient l’ICP ou n’étaient pas différents des résultats cliniques en lien avec le PAC. Toutefois, les conclusions des deux études montrent à l’heure actuelle une incohérence par rapport aux événements indésirables cardiaques et cérébraux majeurs tardifs. Il est important d’offrir un autre suivi aux patients de l’étude pour leur faire prendre une décision éclairée. Le mode de revascularisation appropriée devrait être choisi selon les caractéristiques cliniques et la complexité des lésions coronaires des patients en se basant sur les lignes directrices européennes et américaines. Chez les patients qui ont des scores SYNTAX faibles ou intermédiaires, et un risque chirurgical particulièrement élevé, on peut privilégier plutôt l’ICP que le PAC dans la plupart des autres scénarios. Une équipe multidisciplinaire en cardiologie est recommandée pour faciliter les décisions individualisées en ce qui a trait à la revascularisation.
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