Table 3. Secular change of myocardial revascularization guidelines for left main coronary artery disease.
| Guideline | Class of recommendation | Level of evidence | |
|---|---|---|---|
| 2005 ACC/AHA/SCAI66) | III—PCI is not recommended in patients with unprotected LMCA disease and eligibility for CABG | C | |
| 2005 ESC/EACTS67) | IIb—Stenting for unprotected LMCA disease should only be considered in the absence of other revascularization options | C | |
| 2009 ACC/AHA/SCAI68) | IIb—PCI of the LMCA with stents as an alternative to CABG may be considered in patients with anatomic conditions that are associated with a low risk of PCI procedural complications and clinical conditions that predict an increased risk of adverse surgical outcomes | B | |
| 2010 ESC/EACTS69) | IIa—LMCA isolated or þ 1VD, ostium/shaft | B | |
| IIb—LMCA isolated or þ 1VD, distal bifurcation | |||
| IIb—LMCA þ 2VD or 3VD, SYNTAX score ≤32 | |||
| III—LMCA þ 2VD or 3VD, SYNTAX score ≥33 | |||
| 2011 ACCF/AHA/SCAI21) | IIa—For SIHD patients when both of the following are present: | B | |
| • Anatomic conditions associated with a low risk of PCI procedural complications and a high likelihood of good long-term outcomes (e.g., a low SYNTAX score [#22], ostial or trunk left main stenosis) | |||
| • Clinical characteristics that predict a significantly increased risk of adverse surgical outcomes (e.g., STS-predicted risk of operative mortality >5%) | |||
| IIb—For SIHD patients when both of the following are present: | B | ||
| • Anatomic conditions associated with a low-to-intermediate risk of PCI procedural complications and an intermediate-to-high likelihood of good long-term outcomes (e.g., low-intermediate SYNTAX score of <33, bifurcation left main stenosis) | |||
| • Clinical characteristics that predict an increased risk of adverse surgical outcomes (e.g., moderate-severe chronic obstructive pulmonary disease, disability from previous stroke, or previous cardiac surgery; STS-predicted risk of operative mortality >2%) | |||
| III: HARM—For SIHD patients (vs. performing CABG) with unfavorable anatomy for PCI who are good candidates for CABG | B | ||
| 2014 ESC/EACTS70) | I—LMCA with a SYNTAX score ≤22 | B | |
| IIa—LMCA with a SYNTAX score 23–32 | |||
| III—LMCA with a SYNTAX score ≥33 | |||
| 2014 ACC/AHA/AATS/PCNA/SCAI/STS71) | IIa—For SIHD patients when both of the following are present: | B | |
| • Anatomic conditions associated with a low risk of PCI procedural complications and a high likelihood of good long-term outcomes (e.g., a low SYNTAX score [≤22], ostial or trunk left main stenosis) | |||
| • Clinical characteristics that predict a significantly increased risk of adverse surgical outcomes (e.g., STS-predicted risk of operative mortality >5%) | |||
| IIb—For SIHD patients when both of the following are present: | B | ||
| • Anatomic conditions associated with a low-to-intermediate risk of PCI procedural complications and an intermediate-to-high likelihood of good long-term outcome (e.g., low-intermediate SYNTAX score of <33, bifurcation left main stenosis) | |||
| • Clinical characteristics that predict an increased risk of adverse surgical outcomes (e.g., moderate-severe chronic obstructive pulmonary disease, disability from previous stroke, or previous cardiac surgery; STS-predicted risk of operative mortality >2%) | |||
| III: HARM—For SIHD patients (vs. performing CABG) with unfavorable anatomy for PCI and who are good candidates for CABG | B | ||
| 2018 ESC/EACTS62) | I—LMCA with a SYNTAX score ≤22 | A | |
| IIa—LMCA with a SYNTAX score 23–32 | |||
| III—LMCA with a SYNTAX score ≥33 | |||
AATS = American Association for Thoracic Surgery; ACC = American College of Cardiology; ACCF = American College of Cardiology Foundation; AHA = American Heart Association; CABG = coronary artery bypass grafting; EACTS = European Association for Cardio-Thoracic Surgery; ESC = European Society of Cardiology; LMCA = left main coronary artery; PCI = percutaneous coronary intervention; PCNA = Preventive Cardiovascular Nurses Association; SCAI = Society for Cardiovascular Angiography and Interventions; SIHD = stable ischemic heart disease; STS = Society of Thoracic Surgeons; VD = vessel disease.