Navigating Optimal Revascularization for Unprotected Left Main Disease in Changing Interventional Seas.

U nprotected left main coronary artery (ULMCA) disease is observed in 4% of coronary angiograms and is often associated with disease in other coronary arteries. Without the foresight of an oracle, the selection of the most appropriate coronary revascularization strategy for a patient with ULMCA disease associated with complex multivessel coronary disease (MVD) can be difficult. It is guided, in part, by accurately predicting a patient’s clinical outcome using risk prediction tools and determining the impact on this outcome of competing revascularization strategies: percutaneous coronary intervention (PCI) or cardiac surgery. Although surgical revascularization has traditionally been the cornerstone of therapy for ULMCA disease with MVD, there is an increasing role for PCI, especially in patients who present with increased surgical risk. The SYNTAX (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery) study (1) defined patients withMVD by anatomy alone: the SYNTAX score (SS). The investigators confirmed that SS tertiles of #22, 23 to 32, and $33 predicted the interventional but not surgical outcomes of revascularized patients (2) and that surgical revascularization was superior to PCI in the whole cohort, out to 5 years, except in those with the lowest SS (3). The majority of the early difference was driven by myocardial infarction and the need for repeat revascularization in the PCI group. However, in those with ULMCA disease and