A Simple, Effective, and Durable Treatment Choice for Left Main Coronary Artery Disease: Stents or Surgery?

SEE PAGE 1102 L eft main coronary artery disease (CAD) (stenosis $50%) is found in 5% to 7% of patients undergoing coronary angiography and is associated with poor prognosis because occlusion of the left main coronary artery compromises blood flow to about 75% of the left ventricle (1). Coronary artery bypass graft (CABG) surgery has been the standard of care because of its significant survival advantage over medical therapy (2). However, its prognosis remains highly unpredictable, and the benefits of CABG surgery for moderate left main CAD are currently not definitive. In a recent study (3), the long-term outcomes of patients with intermediate left main CAD in whom surgery was deferred on the basis of fractional flow reserve values >0.80 were favorable and similar to those of patients in whom CABG surgery was performed by fractional flow reserve values <0.80. Furthermore, medical therapy has greatly evolved, with improved outcomes for medically treated patients, which suggests a more benign prognosis for left main CAD than previously reported. Traditionally, percutaneous coronary intervention (PCI) has been limited to patients with left main CAD, who are at high risk for CABG surgery, or with protected left main CAD. However, over the past decades, PCI has rapidly advanced, and a