Revascularization strategies for stable multivessel and unprotected left main coronary artery disease: From BARI to SYNTAX

Percutaneous coronary interventions are increasingly applied in patients with complex coronary anatomy, including those with stem disease. Coronary artery bypass surgery confers a mortality reduction over optimal medical therapy in high-risk patients with both left main or multivessel coronary artery disease and left ventricular systolic dysfunction. Whether PCI might be preferred as an initial strategy in stable patients with multivessel disease and/or LM disease remains debatable. Emerging evidence suggests that patients with higher atheroma burden, as indicated by older age, presence of diabetes mellitus and extensive MVD in combination with LV dysfunction may derive the greatest benefit from CABG. PCI for unprotected LM with limited additional disease has been revised to a class II recommendation in the recent U.S. and European guidelines. An interdisciplinary team of both cardiac surgeons and cardiologists may optimize treatment in patients with intermediate-to-high disease severity characteristics. Ongoing trials will further strengthen evidence-base clinical decision making.