PCI or CABG? That is the question for left main!

The Great Debate

The hot debate around whether to carry out PCI or CABG for left main continues, and this year at EuroPCR, a number of sessions will be hosted that look to create lively discussions around this taxing question. Two sessions, chaired by Gerhard Wimmer-Greinecker, analyse and discuss this issue in the context of left main stenosis. First, the ‘Great Debate’ at 12.30 will specifically look at the treatment options of left main disease and whether PCI or CABG is more beneficial for the patient. This will be followed by live demonstration from Toulouse, co-chaired with Morton Kern at 14.00, which will cover a left main disease case.

Historically, left main stem stenosis in need of revascularisation has always been a case for surgery, as reflected by the ESC Guidelines. However for some time now interventionalists have felt that PCI may be feasible in left main patients. It was the SYNTAX trial that finally provided the evidence that demonstrated that in some cases, PCI is preferable to CABG. The SYNTAX Score, relating to the complexity of the coronary artery disease, provides further insight as to which patients might benefit from PCI. The results so far indicate that the groups with the least complex form of the disease may benefit from either PCI or CABG. PCI of the left main stem has only been targeted by a small number of interventionalists so far. Thus, at this point in time, left main disease is not an established domain for PCI and some uncertainty still remains as to when PCI is absolutely indicated. The EXCEL trial is now under way and may finally provide the evidence needed to determine which treatment is best for which patients.

The ‘Great Debate’ will examine current guidelines for treatment of left main disease, how to avoid bias when gaining patient consent for treatment and the role of the multi-disciplinary team. Current treatment strategies are based on evaluation of results from previously completed clinical trials. Further discussion today will examine study protocols of upcoming trials to discuss and perhaps predict the direction in which left main disease treatment may be moving.

One of the major challenges here is there is no real consensus between cardiac surgeons and interventionalists regarding guidelines. The guidelines are generally held in high regard by surgeons, whereas the interventionalists often point out the values of the rapidly evolving technologies. Clearly both opinions have to be considered. Guidelines are based on historic data and therefore reflect scientific findings. However, it can be difficult for a cardiologist to apply treatment guidelines that have been developed using older technologies and data when using today’s techniques and methodologies that are so innovative and cutting edge.

There is also a different perception on patient perspective among the two groups. An interventionalist will often state that no patient really wants surgery if given the choice, whereas surgeons believe that if patient consent has been achieved in a correct and ethical manner and there are no major risks involved, then surgery is often well accepted.

Despite the disparity in perception and understanding, it is clear is that both groups agree on the importance of a multidisciplinary approach and that patients should consent in an unbiased fashion. There is a clear need to ensure that such teams are available in cardiac centres and that the potential treatment strategy for each patient is discussed thoroughly. Differences in opinion do not come into assessing how a patient should be treated; instead it is the evidence-based approach and experience of the multidisciplinary team that informs the final treatment decision.

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