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JACC WHITE PAPER

Revascularization for Unprotected Left Main Disease

Evolution of the Evidence Basis to Redefine Treatment Standards

David E. Kandzari, MD^_*, Antonio Colombo, MD, Seung-Jung Park, MD, PhD, Carl L. Tommaso, MD^||, Stephen G. Ellis, MD^¶, Luis A. Guzman, MD, Paul S. Teirstein, MD^_*, Corrado Tamburino, MD, John Ormiston, MD^#, Gregg W. Stone, MD^_**, George D. Dangas, MD^_**, Jeffrey J. Popma, MD, Theodore A. Bass, MD^,_* on behalf of the American College of Cardiology Interventional Scientific Council

^_* Scripps Clinic, Division of Cardiovascular Diseases, La Jolla, California
EMO Centro Cuore Columbus, San Raffaele Scientific Institute, Milan, Italy
Division of Cardiology, University of Catania, Catania, Italy
Division of Cardiology, Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
^|| North Shore University Health System, Skokie, Illinois
^¶ Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
^# Auckland City Hospital, Auckland, New Zealand
^_** Columbia University Medical Center and Cardiovascular Research Foundation, New York, New York
Beth Israel Deaconess Medical Center, Boston, Massachusetts
Division of Cardiology, University of Florida College of Medicine-Shands Jacksonville, Jacksonville, Florida

Manuscript received June 12, 2009; revised manuscript received July 13, 2009, accepted July 21, 2009.

^_* Reprint requests and correspondence: Dr. Theodore A. Bass, Shands Cardiovascular Center, ACC 5th Floor, 655 West 8th Street, Jacksonville, Florida 32209 (Email: ted.bass{at}jax.ufl.edu).

Determining the most appropriate revascularization strategy for patients presenting with unprotected left main coronary (UPLM) disease has been a topic of great recent interest. During this current decade, there have been multiple clinical trials and registries addressing this subject. Previously, UPLM disease has almost exclusively resulted in utilizing a surgical revascularization treatment strategy. However, recent improvements in percutaneous coronary intervention (PCI) techniques in parallel with the benefits of drug-eluting stents (DES) to reduce clinical restenosis have enabled further investigation in catheterization-based treatment strategies as possible alternative therapeutic options. These advances as well as an increased understanding of both the procedural and anatomical challenges involved with complex coronary interventions have allowed further advancements in the field. Better adjunctive antithrombotic pharmacological therapy in the PCI setting has favored such progress. American College of Cardiology/American Heart Association/Society for Coronary Angiography and Interventions guidelines do not currently endorse the performance of PCI as an appropriate alternative to surgical revascularization for patients with UPLM disease. This paper is a review of the current evidence on UPLM PCI and proposes future directions in this evolving field.

Key Words: left main coronary • percutaneous coronary intervention • revascularization

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