Almoghairi Abdulrahman, Al-Asiri Nayef, Aljohani Khalid, AlSaleh Ayman, Alqahtani Nasser G, Alasmary Mohammed, Alali Rudaynah, Tamam Khaled, Alasnag Mirvat
Adult Cardiology Department, Prince Sultan Cardiac Center Riyadh, Saudi Arabia.
Cardiac Center, Mouwasat Hospital Jubail Industrial City, Saudi Arabia.
US Cardiol. 2023 Jul 20;17:e09. doi: 10.15420/usc.2022.24. eCollection 2023.
Left main (LM) coronary artery disease accounts for approximately 4-6% of all percutaneous coronary interventions (PCIs). There has been mounting evidence indicating the non-inferiority of LM PCI as a revascularization option, particularly for those with a low SYNTAX score. The EXCEL and NOBEL trials have shaped current guidelines. The European Society of Cardiology assigned a class 2a (level of evidence B) for isolated LM disease involving the shaft and ostium and a class IIb (level of evidence B) for isolated LM disease involving the bifurcation or additional two- or three-vessel disease and a SYNTAX score <32. However, data on the use of a single stent or an upfront two-stent strategy for distal LM disease are conflicting, wherein the EBC Main trial reported similar outcomes with a stepwise provisional approach and the DKCRUSH-V trial reported better outcomes with an upfront two-stent strategy using the 'double-kissing' crush technique. Although several studies have noted better immediate results with image-guided PCI, there are few data on outcomes in LM disease specifically. In fact, the uptake of imaging in the aforementioned landmark trials was only 40%. More importantly, the role of mechanical circulatory support (MCS) has been less well studied in LM PCI. Indiscriminate use of MCS for LM PCI has been noted in clinical practice. Trials evaluating the benefit of MCS in high-risk PCI demonstrated no benefit. This review highlights contemporary trials as they apply to current practice in LM PCI.
左主干（LM）冠状动脉疾病约占所有经皮冠状动脉介入治疗（PCI）的4%-6%。越来越多的证据表明，LM PCI作为一种血运重建选择并不逊色，特别是对于那些SYNTAX评分较低的患者。EXCEL和NOBEL试验塑造了当前的指南。欧洲心脏病学会对累及主干和开口的孤立性LM疾病指定为2a类（证据水平B），对累及分叉或额外的双支或三支血管疾病且SYNTAX评分<32的孤立性LM疾病指定为IIb类（证据水平B）。然而，关于远端LM疾病使用单支架或先行双支架策略的数据相互矛盾，其中EBC Main试验报告逐步临时方法的结果相似，而DKCRUSH-V试验报告使用“双吻”挤压技术的先行双支架策略有更好的结果。尽管多项研究指出影像引导PCI有更好的即刻结果，但关于LM疾病具体结局的数据很少。事实上，在上述具有里程碑意义的试验中影像检查的使用率仅为40%。更重要的是，机械循环支持（MCS）在LM PCI中的作用研究较少。临床实践中已注意到在LM PCI中不加区分地使用MCS。评估MCS在高危PCI中获益的试验未显示出益处。本综述重点介绍适用于当前LM PCI实践的当代试验。
