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STATE-OF-THE-ART PAPER AND COMMENTARY

Revascularization for Unprotected Left Main Stem Coronary Artery Stenosis

Stenting or Surgery

David P. Taggart, MD (Hons), PhD, FRCS^_*,_*, Sanjay Kaul, MD, FACC, William E. Boden, MD, FACC, T. Bruce Ferguson, Jr, MD, FACC, Robert A. Guyton, MD, FACC^¶, Michael J. Mack, MD^#, Paul T. Sergeant, MD, PhD, Richard J. Shemin, MD, FACC^_**, Peter K. Smith, MD, FACC^|| and Salim Yusuf, DPhil, FRCPC, FRSC, FACC

^_* Department of Cardiac Surgery, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom
Division of Cardiology, Cedars-Sinai Heart Institute, Los Angeles, California
Department of Cardiovascular Services, Kaleida Health, Buffalo General and Millard Fillmore Hospitals, University at Buffalo School of Medicine and Biomedical Sciences, Buffalo, New York
Division of Cardiothoracic and Vascular Surgery, Brody School of Medicine, Eastern Carolina University, Greenville, North Carolina
^¶ Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia
^# Cardiopulmonary Research Science Technology Institute, Medical City Hospital, Dallas, Texas
Cardiac Surgery Department, University Hospital Gasthuisberg, Leuven, Belgium
^_** Division of Cardiothoracic Surgery, Department of Surgery, David Geffen School of Medicine at UCLA, Cardiovascular Center, Los Angeles, California
^|| Division of Cardiothoracic Surgery, Duke University Medical Center, Durham, North Carolina
Population Health Research Institute, McMaster University, Hamilton Health Sciences, Heart and Stroke Foundation, Hamilton, Ontario, Canada.

Manuscript received July 3, 2007; revised manuscript received August 9, 2007, accepted September 7, 2007.

^_* Reprint requests and correspondence: Prof. David P. Taggart, Cardiovascular Surgery, University of Oxford, Department of Cardiac Surgery, John Radcliffe Hospital, Oxford OX3 9DU, United Kingdom. (Email: david.taggart{at}orh.nhs.uk).

For coronary artery disease with unprotected left main stem (LMS) stenosis, coronary artery bypass grafting (CABG) is traditionally regarded as the "standard of care" because of its well-documented and durable survival advantage. There is now an increasing trend to use drug-eluting stents for LMS stenosis rather than CABG despite very little high-quality data to inform clinical practice. We herein: 1) evaluate the current evidence in support of the use of percutaneous revascularization for unprotected LMS; 2) assess the underlying justification for randomized controlled trials of stenting versus surgery for unprotected LMS; and 3) examine the optimum approach to informed consent. We conclude that CABG should indeed remain the preferred revascularization treatment in good surgical candidates with unprotected LMS stenosis.

Abbreviations and Acronyms   ACC/AHA = American College of Cardiology/American Heart Association   BMS = bare-metal stent(s)   CABG = coronary artery bypass grafting   CAD = coronary artery disease   DES = drug-eluting stent(s)   IMA = internal mammary artery   LMS = left main stem   MACE = major adverse coronary events   PCI = percutaneous coronary intervention   RCT = randomized controlled trial

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