ABSTRACT

INTRODUCTION Percutaneous coronary intervention (PCI) on the left main coronary artery (LMCA) has been a challenge since the inception of coronary angioplasty. In fact, in 1979, Andreas Gruentzig wrote, “We have not been too successful in dilating stenotic main stems of left coronary arteries” (1). Indeed the poor immediate and short-term outcome of the first attempts of PCI with balloon angioplasty led Gruentzig to list LMCA as an exclusion criterion for elective PCI. However, PCI for the LMCA has come a long way from those days and is currently associated with shortand medium-term survival rates similar to coronary artery bypass surgery (CABG) (2-6). This dramatic change and improved results are consequences of the evolution and development of PCI techniques, especially in regards to bifurcations, improvements in hemodynamic support during PCI, and the introduction of drug-eluting stents (DES). LMCA PCI has also become the object of randomized trials such as the Synergy between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery (SYNTAX) Study, which showed similar major adverse cardiac and cerebrovascular events at 12 months in the LMCA subgroup between PCI with DES and CABG (4). As a result these new data, the update current guidelines no longer consider PCI for unprotected LMCA as a Class III recommendation (contraindication) if the patient is eligible for CABG (7,8). The ACC/AHA/SCAI 2009 updated guidelines (9) have modified the class of recommendation for PCI to unprotected LMCA to Class IIb (Level of Evidence: B), explaining the recommendation as follows: “PCI of the left main coronary artery with stents as an alternative to CABG may be considered in patients with anatomic conditions that are associated with a low risk of PCI procedural complications and clinical conditions that predict an increased risk of adverse surgical outcomes.”