1. Debate: What Does the Future Hold for the Treatment of Unprotected Left Main Disease? More PCI
No More Routine Surgery
Ron Waksman, MD, FACC
Washington DC

2. Disclosures Ron Waksman serves on the advisory board of :
Medtronic vascular
Boston Scientific
Abbott Vascular

3. What’s missing from the PCI vs. CABG trial data discussion?
Why does the debate seem to always focus on mortality and repeat revascularization?
Shouldn’t we include morbidity endpoints?
What about return to work?
What about pain?

4. BACKGROUND Percutaneous revascularization of left main
coronary artery disease is potentially attractive
because:
Large diameter vessel
Proximal location
And potentially unattractive because:
Up to 80% of LM disease involves the bifurcation
(high risk of restenosis)
Up to 80% of patients have multivessel CAD:
with potential survival benefit with CABG
Serruys, PW; presented at TCT 2010

5. Main Compare

6. SYNTAX Eligible Patients Serruys PW et al. NEJM 2009;360:961-72
De novo disease (n=1800)
Limited Exclusion Criteria
Previous interventions
Acute MI with CPK>2x
Concomitant cardiac surgery
Left Main Disease
(isolated, +1, +2 or +3 vessels)
N=705
3 Vessel Disease
(revasc all 3 vascular territories)
N=1095
Serruys PW et al. NEJM 2009;360:961-72 6

7. Syntax LM

11. ACC/AHA/SCAI guidelines in 2009
In the 2009 focused update of the guidelines on
PCI Class IIb, LoE B recommendation
“the best case for PCI as an alternative to
CABG for LM CAD is in ostial and mid-body
lesions without additional multivessel disease”
The writing group also decided that routine
angiographic follow-up after LM PCI
should be omitted from the guidelines
Kushner et al.; JACC; 2009

14. Wijns et al.; European Heart Journal; 2010

15. PCI to LM Get Simpler & Better You Ain’t Seen Nothing Yet
Techniques and pharmacology have evolved in the past 5 years
More stage procedure
More vessel preparation
No need for Hemodynamic Support
IVUS guidance mandatory
Post dilatation and kissing technique
Improved stents second generation
Better antiplatelet therapy

16. IVUS Guidance Reduce Restenosis

17. IVUS Guidance for LM Treatment (145 propensity matched pairs – DES)
Park SJ et al, Circulation Cardiovascular Intervent 2009

18. FFR guidance for LMCA
Hamilos et al, Circulation 2009

19. Unprotected LMCA CABG vs PCI
Meta-analysis of 3,773 patients in 10 studies
• CABG:
2,114 patients,
Study range of patients
• PCI:
1,659 patients
Study range of patients
Naik H et al: J Am Coll Cardiol Intv 2:739-47, 2009

21. Unprotected LMCA CABG vs PCI Conclusions
Naik H et al: J Am Coll Cardiol Intv 2:739-47, 2009

22. 4134 pts with left main disease Consensus agreement by heart team
EXCEL: Study Design
Draft design
4134 pts with left main disease
SYNTAX score ≤32
Consensus agreement by heart team
Yes
(N=2634) No
(N=1500)
PCI and CABG
registries
(limited in-hosp data) R
PCI (Xience Prime)
(N=1317)
CABG
(N=1317)
Clinical follow-up: 30 days, 6 months, yearly through 5 years

23. If this study meets its endpoint???
We will see more PCI for unprotected LM

24. How are the surgeons are doing???

25. DES IN NON-BIFURCATED LM PCI

26. DES IN NON-BIFURCATED LM PCI

27. Is it time to debate the other side of the equation?
“Isolated Non-bifurcation Left Main Stenosis amenable to PCI is
Class III indication for
CABG”

28. Conclusions
With Team Approach and evidence based medicine there is a change in paradigm
No more routine surgery for LM
Definitely more PCI now
If EXCEL meets the endpoint more PCI in the future