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Left Main Coronary Revascularization

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This book comprehensively reviews LM revascularization, one of the

most technically challenging and prognostically relevant topics for

cardiologists. LM carries blood to 70-80% of the normal heart, and

diseases affecting this coronary segment are a common cardiac condition.

Beginning in the sixties, management was exclusively within the

domain of cardiac surgeons, and recent dramatic changes in percutaneous

techniques have led to huge improvements but have also

brought significant surgical challenges. In the book, top cardiac surgeons

describe current and future operative techniques, while leading

interventional cardiologists discuss new bifurcation techniques. This book

also investigates the recently released European Society of Cardiology

Guidelines in detail.

Featuring the latest scientific studies with long-term follow up, and

detailed descriptions of the techniques used, this book provides comprehensive

guidance for any clinician, and is a valuable resource for

cardiologists, interventional cardiologists, cardiac surgeons and

internists.


This is an open access book.

Author(s): Bernardo Cortese
Publisher: Springer
Year: 2022

Language: English
Pages: 179
City: Cham

Foreword
Preface
References
Contents
1: History of Left Main Revascularization
1.1 Introduction
1.2 The History of Left Main Stenosis
1.3 Overview of Early Trials in the Medical Management Era of LMCA Stenosis
1.4 Overview of Early Trials of Supporting CABG Superiority in LMCA Stenosis
1.5 Historical Background and Early Experience of LMCA PCI
1.6 Overview of Randomized Trials of LMCA PCI Using First Degeneration DES with/without BMS
References
2: Historical Background of Left Main Stem Revascularization: A Step Further
2.1 Introduction of the Percutaneous Revascularization
2.2 The First-Generation DES Versus CABG for Unprotected LMCAD: Were Interventional Cardiologists Overconfident?
2.3 Tackling the Left Main Stem with the Second-Generation DES
References
3: Anatomical and Pathophysiological Considerations on the Left Main Coronary Artery
3.1 Anatomy of the Left Main Coronary Artery
3.1.1 Normal Anatomy of the Left Main Coronary Artery
3.1.2 Anatomical Variations of the Left Main Coronary Artery
3.1.3 Histological Characteristics of the Left Main Coronary Artery
3.1.4 Normal Dimensions of the Left Main Coronary Artery
3.1.5 Anatomy of Distal Left Main Coronary Artery Bifurcation
3.2 Pathophysiology of the Left Main Coronary Artery
3.2.1 Prevalence of Left Main Coronary Artery Disease
3.2.2 Role of Endothelial Shear Stress in LM Bifurcation
3.2.3 Left Main Plaque Distribution
3.2.4 The Medina Classification for Left Main Bifurcation Disease
3.2.5 Uncommon Causes of Left Main Coronary Artery Disease
References
4: CABG Vs. PCI for Left Main Revascularization
4.1 Introduction
4.2 Current Evidence Comparing PCI to CABG for LMCAD
4.2.1 Real-World Evidence
4.2.2 Randomized Clinical Trials
4.3 Guideline Recommendations on LMCAD Revascularization
4.4 Individualized Patient Approach
4.4.1 Predicted Surgical Risk
4.4.2 Anatomy of CAD
4.4.3 Completeness of Revascularization
4.4.4 Procedural Urgency
4.4.5 Clinical Characteristics
4.4.5.1 Diabetes Mellitus
4.4.5.2 Heart Failure with Reduced Ejection Fraction
4.4.5.3 Chronic Kidney Disease
4.4.5.4 Bleeding Risk
4.4.5.5 General Status of the Patient
4.5 Conclusions
References
5: CABG Should Be the First Option for Left Main Disease: A Cardiac Surgeon’s Perspective
5.1 Introduction
5.2 When PCI Is the Better Choice?
5.3 When Surgery Is the Better Choice?
5.4 Conclusions
References
6: PCI Should Be the First Option for All Left Main Disease? An Interventional Cardiologist’s Perspective
6.1 Introduction
6.2 Not all LMS Disease is the Same
6.3 The Evidence
6.4 Longer Term Outcomes PCI vs CABG
6.5 Limitations of Trials to Date
6.6 PCI Technique and Strategy
6.7 PCI in the Emergency Setting
6.8 Unanswered Questions
6.9 Conclusion
References
7: Which Interventional Device for Left Main PCI? A Description of Available Stents
7.1 Introduction
7.1.1 Xience (Abbott Vascular, Santa Clara, CA, USA)
7.1.2 Xience Vs Synergy
7.1.3 Biomatrix ™ Stent
7.1.4 Resolute Onyx
7.1.5 Orsiro Sirolimus-Eluting Stent
7.1.6 Ultimaster™ Tansei™ Stent (Terumo Corporation, Tokyo, Japan)
7.1.7 Xposition S Sirolimus-Eluting Stent (Stentys, Paris, France)
7.1.8 Dedicated Bifurcation Stent
7.2 Conclusion
References
8: Which Interventional Technique for Left Main PCI?
8.1 Introduction
8.2 What Is Special About the Left Main Stem?
8.3 Provisional Side Branch Stenting
8.4 Systematic Two-Stent Approach
8.5 Difficult Wire Access
8.6 Role of Intracoronary Imaging
8.7 Role of Stent Enhancement
8.8 Role of Mentorship
8.9 Tips and Tricks
8.10 Conclusion
References
9: Which Surgical Technique for Left Main Coronary Artery Bypass? A Mini-Invasive Approach
9.1 Introduction and History
9.2 Indications
9.3 Contraindications
9.4 Surgical Procedure
9.5 Outcomes and Comparison to Other Revascularization Strategies
9.6 Hybrid Coronary Revascularization
9.6.1 Timing of the HCR
9.6.2 HCR Outcomes
9.7 Conclusions
References
10: Preoperative IVUS Assessment of the Left Main
10.1 Introduction
10.2 Intravascular Ultrasound (IVUS) Technology
10.3 The Role of IVUS in Pre-operative LMCA Assessment
10.3.1 Plaque Morphology at IVUS
10.3.2 IVUS-Based Indication for Treatment and Relationship with Functional Evaluation
10.3.3 IVUS-Guided LMCA Assessment: Impact on Therapeutic Strategies
10.4 IVUS-Guided LMCA PCI: Clinical Evidences
10.5 Conclusions
References
11: Preoperative Functional Assessment of the Left Main and Postoperative Side Branch Evaluation
11.1 Left Main Anatomy and Atherosclerotic Process
11.2 Limitations of the Angiography for LMS Evaluation
11.3 FFR and iFR: Principles
11.4 Tips and Tricks for LM Functional Assessment
11.5 Assessment of the Distal LM Bifurcation Post PCI
11.6 Conclusions
References
12: Is There a Role for OCT for Left Main Assessment Before and After PCI?
12.1 Introduction
12.2 Left Main Stem Anatomy and Atherosclerotic Disease Distribution
12.3 Practical Tips and Tricks for Correct Assessment of Left Main by OCT
12.4 Use of OCT for the Definition of LM Disease and for the Assessment of Plaque Morphology
12.5 Use of OCT for the Guidance and Optimization of Left Main Bifurcation PCI
12.6 Conclusions
References
13: A Clinical Appraisal of Optical Coherence Tomography for Left Main Stem Intervention
13.1 Introduction
13.2 Role of Intravascular Imaging to Improve Clinical Outcomes in Left Main Intervention
13.3 Assessment of Intermediate Lesions in the Left Main Stem
13.4 Clinical Data Supporting the Use of OCT Over IVUS
13.5 Ongoing Clinical Studies for LM PCI with OCT Guidance
13.6 Optimizing the Use of OCT in the LM with a Non-stent-Based Approach
13.7 Future Perspective
References
14: The Role of Intravascular Imaging for Post-procedural and Long-Term Evaluation of the Revascularized Left Main
References
15: Follow-up of Left Main Patients Treated with PCI or CABG
15.1 Background
15.2 Incidence and Time Course of Adverse Events After LMCA Revascularization
15.3 Dual Antiplatelet Therapy Duration
15.4 Role of Non-invasive and Invasive Ischemia Testing After LMCA PCI
15.4.1 Myocardial Perfusion Imaging
15.4.2 Exercise Stress Testing
15.4.3 Stress Echocardiography
15.4.4 Coronary Computed Tomography Angiography
15.4.5 Invasive Coronary Angiogram
15.5 Conclusion
References