SAN FRANCISCO—CABG is the preferred treatment strategy for patients with left main disease, according to Michael J. Mack, MD, president of the Society for Thoracic Surgeons (STS), who presented on the topic Nov. 7 at the Transcatheter Cardiovascular Therapeutics (TCT) conference. “While I personally refer some left main patients for PCI, it just shouldn’t become inappropriately utilized due to the increasingly popular message that PCI is equivalent to surgery in these patients,” Mack told Cardiovascular Business .
Results with CABG have significantly improved over the past 10 years, according to Mack, who pointed to the 27 percent decrease in operative mortality, based on records in the STS database from 2000 to 2010. “However, left main disease has always been associated with a higher mortality and complication rate with surgery than in patients with non-left main disease,” he said.
In fact, while left main disease constitutes 28 percent of all CABG procedures, the STS database reveals that the mortality rates are 43 percent higher and stroke rates 15 percent higher than CABG in non-left main disease.
“Can we do any better?” asked Mack.
There has been a “big push” for off-pump CABG and arterial grafting CABG to improve outcomes for patients with left main disease, he reported. “While there is very little data to prove this concept, a few single-center studies have showed these methods do improve outcomes.”
As a result, Mack said that surgery is a good approach for these patients, and is the current gold-standard treatment. Also, the longer the follow-up of these left main patients, the better the surgical outcomes become, such as the four-year results from SYNTAX. At four years, the difference between surgery and stenting patients with left main continue to diverge in favor of CABG, including for major adverse cardiac and cerebrovascular events (33.5 vs. 23.6 percent); all-cause death (11.7 vs. 8.8 percent); and cardiac death (7.6 vs. 4.3 percent).
He added, however, that the results of randomized controlled trials are not generalizable to all patients.
Also, in patients with a high SYNTAX score who have left main disease, “surgery clearly does better, and I hypothesize that we’ll see a mortality difference at five years,” Mack said. “The results consistently indicate that with higher, more complex three-vessel disease—which represents the majority of left main patients—CABG is a more favorable approach.”
Based on these data, he was critical of a few recent studies that did not state that most patients with left main disease should receive surgery, but instead alluded to the fact that PCI is appropriate for all patients with left main disease.
“PCI is an appropriate option for those patients with ostial or trunk left main disease,” Mack said in the interview. “In the U.S., PCI is currently not being inappropriately used to treat left main disease, as U.S. interventional cardiologists are pretty cautious about overutilization of stenting.” However, he still cautioned about the conclusions of certain trials that have suggested results are the same in all left main patients, PCI versus surgery.
“PCI can be considered as an option [as a Class IIB indication] in a minority of patients with left main disease,” Mack concluded, “as CABG remains the standard of care in the majority (about 60 percent) of left main patients.” He added that any further guideline change should await the results of the ASCERT and EXCEL trials.