Percutaneous coronary intervention of unprotected left main coronary artery disease

Procedural strategies and technical considerations

Authors

  • Michael S. Lee MD, FACC,

    1. University of California Los Angeles Medical Center, Los Angeles, California
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    • Michael S. Lee: Honoraria from BMS, BSCI, Novartis, Merck, St. Jude Medical

  • Gregg W. Stone MD, FACC,

    1. Columbia University Medical Center, New York-Presbyterian Hospital and the Cardiovascular Research Foundation, New York, New York
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    • Gregg Stone: Scientific advisory boards for Boston Scientific and Abbott Vascular; consultant to Medtronic, The Medicines Company, BMS-Sanofi, Eli Lilly, AstraZeneca, and Merck.

  • Seung-Jung Park MD, FACC,

    1. Asan Medical Center, Seoul, South Korea
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    • Seung-Jung Park: consulting fees from Cordis, lecture fees from Cordis, Medtronic, Boston Scientific, research grant from Cordis and Medtronic

  • Paul Teirstein MD, FACC,

    1. Scripps Clinic, La Jolla, California
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    • Paul Teirstein: consultant for Cordis, Boston Scientific, Abbott, Medtronic, and Conor; receives royalties (not on drug-eluting stents) from Boston Scientific; and owns equity in MediVas

  • Jeffrey Moses MD, FACC,

    1. Columbia University Medical Center, New York-Presbyterian Hospital and the Cardiovascular Research Foundation, New York, New York
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    • Jeffrey Moses: Supported by Cordis, Advisory board for MIV Therapeutics, Caliber Therapeutics

  • Antonio Colombo MD, FACC,

    1. San Raffaele Hospital, Milan, Italy
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    • Antonio Colombo: None

  • David E. Kandzari MD, FACC

    Corresponding author
    1. Piedmont Heart Institute, Atlanta, Georgia
    • Piedmont Heart Institute, Suite 2045, 95 Collier Road, Atlanta, Georgia 30309
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    • 7

      David Kandzari: Medtronic, Research/grant support; Cordis, consulting


Abstract

Data have emerged demonstrating the safety and efficacy of percutaneous coronary intervention (PCI) of the unprotected left main (ULM) artery. The 2009 American College of Cardiology/American Heart Association/Society for Cardiovascular Angiography and Interventions focused guidelines for PCI no longer state that ULM PCI is contraindicated in patients with anatomic conditions that are associated with a low risk of procedural complications and clinical conditions that predict an increased risk of adverse surgical outcomes. ULM PCI should be performed by operators with experience in the management of the anatomic complexities of left main and multivessel disease, specifically in issues relating to bifurcation disease, calcification, and hemodynamic support. Patients with ostial or shaft disease have lower risk of restenosis compared with distal bifurcation disease. Drug-eluting stents (DES) should be used whenever possible as they reduce clinical restenosis. Intravascular ultrasound is an integral component of the procedure as it provides accurate assessment of lesion severity and can confirm optimal stent expansion and apposition. Compliance with dual antiplatelet therapy for at least 12 months is essential if DES are used. A collaborative, multidisciplinary approach with a “Heart Team” represented by a cardiac surgeon, interventional cardiologist, and non-invasive cardiologist may optimize patient education and objective decision making when obtaining informed consent. Application of clinical and angiographic variables into risk models facilitates appropriate patient selection. Randomized clinical trials will address unanswered issues and help build consensus between cardiology and surgical societies to inform clinical decision making and optimize the outcomes for patients with ULM coronary artery disease. © 2011 Wiley Periodicals, Inc.

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