Korean Circ J.  2018 Jun;48(6):447-462. 10.4070/kcj.2018.0078.

Revascularization for Left Main and Multivessel Coronary Artery Disease: Current Status and Future Prospects after the EXCEL and NOBLE Trials

• Al-Hijji M
• El Sabbagh A
• Holmes DR

• KMID: 2412538
• DOI: http://doi.org/10.4070/kcj.2018.0078

Abstract

Revascularization of severe left main and multivessel coronary artery disease has been shown to improve survival in both stable ischemic heart disease and acute coronary syndrome. While revascularization with coronary artery bypass surgery for these disease entities carries class I recommendation in most current guidelines, recent trials has shown potential comparable survival and cardiovascular outcomes between percutaneous and surgical interventions in patients with less complex coronary anatomy. Despite the conflicting results observed in the most recent left main revascularization trials, Everolimus-Eluting Stents or Bypass Surgery for Left Main Coronary Artery Disease (EXCEL) and Nordic-Baltic-British left main revascularization (NOBLE), both treatment strategies remain important for the management of left main disease (LMD) and multivessel disease (MVD) reflecting on the importance of heart team discussion. This review is focused on revascularization of LMD and MVD in patients who are not presenting with ST-segment elevation myocardial infarction, encompassing the evidence from historic and contemporary trials which shaped up current practices. This review discusses the heart team approach to guide decision making, including special populations that are not represented in clinical trials.

Keyword

Coronary artery disease; Percutaneous coronary intervention; Coronary artery bypass; Coronary disease

MeSH Terms

Acute Coronary Syndrome
Coronary Artery Bypass
Coronary Artery Disease*
Coronary Disease
Coronary Vessels*
Decision Making
Heart
Humans
Myocardial Infarction
Myocardial Ischemia
Percutaneous Coronary Intervention
Stents

Figure

• 

  Figure 1 Comparison of ACC/AHA and ESC guidelines recommendations on LMD and MVD revascularizations. Class I: revascularization strategy is recommended or should be performed. Class IIa: revascularization strategy is reasonable and can be useful. Class IIb: revascularization strategy might be reasonable or considered. Class III: revascularization strategy is not recommended.ACC/AHA = American College of Cardiology/American Heart Association; CABG = coronary artery bypass graft; ESC = European Society of Cardiology; LM = left main; LMD = left main disease; MVD = multivessel disease; PCI = percutaneous coronary intervention; SYNTAX = Synergy between PCI with TAXUS and Cardiac Surgery; 2VD = two vessel disease; 3VD = three vessel disease.

• 

  Figure 2 Algorithm integrating heart team approach and evidence from literature to determine best revascularization strategies.CABG = coronary artery bypass graft; CAD = coronary artery disease; DM = diabetes mellitus; EF = ejection fraction; ESC = European Society of Cardiology; LM = left main; MI = myocardial infarction; PCI = percutaneous coronary intervention; SYNTAX = Synergy between PCI with TAXUS and Cardiac Surgery.

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