Left main intervention

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Discuss Left main intervention further in the WikiDoc Cardiology Network
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Associate Editors-In-Chief: Neil M. Gheewala, M.D.; Anthony Smeglin, M.D.

Background

Approximately 5% of all patient undergoing coronary angiography have significant (> 50%) left main coronary artery (LMCA) stenosis. The ACC/AHA recommends coronary artery bypass grafting (CABG) in patient with significant LMCA disease who have angina and ACS. However, not all patients are operative candidates. In selected patients, LM PCI can safely and effectively treat patients in whom coronary artery bypass grafting (CABG) is suboptimal, or have prior CABG with a ‘protected’ LMCA. ‘Protected’ left main in patients with prior CABG is defined as at least one patent graft to left anterior descending or circumflex artery.

Goals of Treatment

The main goal of treatment is to provide a treatment option in patients who would otherwise be poor surgical candidates, declined by surgery, or refuse CABG. It is essential to properly select patients based on their anatomy who would be better candidates for DES vs BMS vs bifurcation stents.

Treatment Choices

Medical Therapy

Treating a patient with non-surgical methods include smoking cessation and risk factor modification. If a stent is placed, the patient is placed on prolonged dual antiplatelet therapy.

Appropriate Candidate Selection

CABG has generally been accepted as the standard of care for patients with LMCA disease. Left main intervention is considered a high risk subset of PCI, but it may be necessary for certain patients.

Candidates for LMCA PCI include:

  • Poor operative candidates
  • Low-risk patients who refuse CABG
  • Patients with 'protected' left main disease (see above)
  • Syntax score less than or equal to 22 is considered reasonable based on the Syntax trial (remains subject to debate)

High-risk features in patients with left main disease PCI include:

Hemodynamic Monitoring and Support

Hemodynamic support is not mandatory, but should be considered for high-risk patients who have refractory angina or are awaiting CABG with persistent angina on maximal medical therapy. Options include Intra-aortic balloon pump (IABP), Impella, and Tandom Heart. Also, [pulmonary artery (PA) line monitoring may be helpful.

Pre-interventional Preparation: Clearly Define Relevant Anatomy

Characterizing the patient's anatomy may reduce complications and the duration of the intervention. This can be done in several different methods:

  • Intravascular ultrasound (IVUS): IVUS allows you to characterize the extent of the plaque, and identify any calcification.
  • Multiple angiographic views: A layout of the anatomy can help characterize any disease in the LMCA ostium, the distal/bifurcation lesion, and the extent of the lesion.
  • Guiding catheter selection: Larger guiding catheters (i.e.: 7 or 8 French) can be used in the event that distal bifurcation intervention becomes necessary, as they provide good support and do not occlude the ostium. If necessary, you can use side hole guiding catheters.

In addition to characterizing the patient's anatomy, it's essential to have all stents and balloons on the table, prepped, and ready to be deployed so that no time is wasted.


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