LAUSR

Left main (LM) bifurcation lesion was no-touch zone for the interventionalists in the past and was considered a surgical domain. Significant unprotected LM disease constitutes approximately 5–7% of patients undergoing coronary angiography and more than 80% involve bifurcation. Randomized clinical trials (RCTs) have demonstrated a higher rate of repeat revascularization after percutaneous coronary intervention (PCI) compared with coronary artery bypass grafting (CABG), but a lower incidence of cerebrovascular events; no differences were reported in overall major adverse cardiovascular events (MACEs). The 5-year outcome data reported that patients of LM disease with a SYNTAX (Synergy Between Percutaneous Coronary Intervention With TAXUS and Cardiac Surgery) score >33 had lower mortality and a lower rate of repeat revascularization with CABG compared with PCI, thus establishing CABG as the preferred revascularization method. The introduction of newer generation drug-eluting stent (DES) with proven improvements in both safety and efficacy has prompted the design of two new dedicated randomized trials comparing CABG and PCI: the NOBLE (Coronary Artery Bypass Grafting Vs Drug Eluting Stent Percutaneous Coronary Angioplasty in the Treatment of Unprotected Left Main Stenosis) 11 and EXCEL (Evaluation of XIENCE Everolimus Eluting Stent Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization). In the EXCEL trial, the composite primary end point of allcause death, stroke, or myocardial infarction (MI) at 3 years occurred in 15.4% of patients treated with PCI and in 14.7% of patients undergoing CABG. The difference was significant for noninferiority. In contrast, in the NOBLE trial, treatment with PCI using predominantly a biolimus-eluting stent (Biomatrix Flex, Biosensors) was associated with a significantly higher rate of MACCE at 5 years when compared with CABG. Both studies had a median follow-up duration of 3.1 years, which is relatively short; hence longer term follow-up is needed before any concrete conclusion is drawn. In the EXCEL trial, by the time one gets out over 3 years, death begins to split in favor of CABG. It is going to become statistically significant once the median follow-up is extended up to 5 years. Both PCI and CABG fare quite well when performed by experienced operators at experienced centers. This, in fact, is a testimony to the value of Heart Team approach. Patient discussion should center on risks and benefits of both the procedures and include the important use of long term dual antiplatelet. The LM represents the largest coronary bifurcation, and stenting techniques are driven by potential complications to the