Experts debate future of left main disease: More PCI or more surgery?

Posted by: admin on: June 21, 2011

Cardiac Vessel blocks are treated with stents or by CABG surgeries. To make a choice between the two has always been a debate able topic amongst cardiac specialists. The final decision is taken by the patient.


Now that the professional guidelines regard stenting as a reasonable option for some patients with left main coronary disease, interventionalists expect to treat an increasing number of these patients, while surgeons are trying to maintain their share of this difficult patient population.

During a formal debate on the future of left main revascularization, the Cardiovascular Research Technologies conference, conference chair Dr Ron Waksman (Washington Hospital Center, DC) argued that the portion of left main patients revascularized with PCI instead of bypass surgery will grow in the next few years. Surgeon Dr Michael Mack (Medical City Dallas Hospital, TX) argued that about 80% of these patients will continue to be treated with CABG surgery for the foreseeable future.

American Heart Association/American College of Cardiology state that PCI in the left main, previously not recommended, should be considered an alternative to surgery in patients at low risk for procedural complications. Surgery is the only option for patients with a score of 33 or higher, while patients with a score of 22 or lower are good candidates for PCI.
In light of SYNTAX and the development of transcatheter valves, the new guidelines also recommend the creation of teams of interventionalists and surgeons who discuss the best options for the patient.

The 2500-patient EXCEL study, sponsored by Abbott, will compare PCI with drug-eluting stents vs CABG in patients with unprotected left main coronary artery disease who are considered candidates for either PCI or CABG. The three-year study’s primary composite end point includes death, MI, and stroke. Target lesion revascularization will be a secondary end point. These results will determine which way to go about it.

In SYNTAX, repeat revascularizations were higher with PCI, while strokes were more common in the CABG patients. But both Waksman and Mack argued that the SYNTAX results do not reflect the outcomes that can be expected from PCI or surgery in the future as both procedures continue to improve.

Despite the confidence in PCI for more left main patients, the importance of interventionalists collaborating with surgeons to decide on the best course for every patient was reiterated. Patients should hear their options for most of these cases. Except for single-lesion, single-vessel circumflex disease, no case of revascularization is so straightforward and certainly no left main is so straightforward that we wouldn’t want to hear about the surgical alternative.


For: Allopaths.

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