Revascularization Strategy for Proximal LAD Disease

SEE PAGE 2717 S ignificant proximal left anterior descending artery (LAD) disease may jeopardize up to 50% of the left ventricular myocardium (1) and predicts worse outcomes (2), with a significantly worse 5-year patient survival rate (90% vs. 98%) than downstream LAD lesions (3). In the 1990s, randomized controlled trials (RCTs) showed that all treatment modalities, namely, medical therapy, percutaneous transluminal coronary angioplasty (PTCA), and surgery provided symptomatic relief, but a significantly smaller proportion of patients who received only medical therapy were totally asymptomatic. Left internal mammary artery (LIMA) bypass was associated with a greater event-free probability than either PTCA or medical treatment (4). Novel surgical techniques, such as off-pump coronary artery bypass graft (CABG) surgery and minimally invasive direct coronary artery bypass (MIDCAB) surgery, involving a LIMA to LAD bypass, gained widespread acceptance, keeping pace with the introduction of bare-metal stents (BMS) and drug-eluting stents (DES), which revolutionized percutaneous coronary intervention (PCI) by reducing restenosis rates (5). This necessitated the performance of RCTs to compare PCI with BMSs and/or DES and MIDCAB (2 by our group [6–9]), which consistently associated PCI with significantly higher target vessel revascularization (TVR) rates and correspondingly more major adverse cardiac and cerebrovascular events (MACCE)