A 69-Year-Old Woman With Left Main Coronary Artery Disease

DR DELBANCO: Mrs D is a 69-year-old woman with angina pectoris and left main coronary artery disease, documented recently by cardiac catheterization. Retired from a career in business, she volunteers in charitable organizations. Mrs D is married and is close to her children and grandchildren. She lives in a suburb of Boston and has Medicare and supplemental health insurance.

Mrs D has a 35-year history of hypertension, treated successfully over the years with a variety of medications. She has a long-standing history of hyperlipidemia, and for the past several years has taken statins, with good response. About 25 years ago, she underwent total abdominal hysterectomy for a fibroid uterus and until very recently, she took conjugated steroid hormone therapy in varying doses. Her past surgical history also includes appendectomy as a teenager and 4 episodes of small-bowel obstruction, each requiring lysis of adhesions. In 1984, the surgery was complicated by a pulmonary embolus; the most recent surgery was 12 years ago. She has a strong family history for coronary artery disease on one side of her family, with her father dying before the age of 50 from an acute myocardial infarction (MI). She has a 36 pack-year smoking history, but stopped smoking 40 years ago. She does not drink alcohol, does not exercise actively, and feels it is unlikely she will begin exercising in the future.

About 13 years ago, Mrs D was hospitalized briefly for complaints of chest pain. Evaluation showed no evidence for cardiac disease. Seven years ago, an electrocardiogram taken when she was seeking life insurance showed diffuse T wave changes. Shortly thereafter, she developed transient chest pain, but an exercise tolerance test with cardiac imaging was normal. In 1998, an echocardiogram revealed mild mitral regurgitation, with normal left ventricular function. Thallium stress testing showed 0.5- to 1.0-mm ST depression, but no radiographic evidence for ischemia or infarction. A few months later, Mrs D developed symptoms of angina pectoris, and a stress echocardiogram revealed normal chamber sizes, moderate mitral regurgitation, and hypokinesis of the inferior apex postexercise. The ejection fraction was normal. She was prescribed atenolol, isosorbide, nitroglycerin, folic acid, and aspirin.

For the next few years, she was followed up closely, with occasional episodes of angina pectoris and stable electrocardiograms and stress tests. More recently, she has experienced intermittent angina pectoris, rapidly responsive to nitroglycerin sublingually, and clopidogrel was added to her medical regimen. In November 2003, a stress electrocardiogram documented sinus bradycardia and distal anterolateral ischemia. A week prior to Mrs D’s interview, cardiac catheterization revealed 60% to 70% stenosis of the left main coronary artery, with 80% stenosis of a diagonal artery coming from the left anterior descending (LAD) artery (Figure 1). There was 40% stenosis of the distal left circumflex artery, mild mitral regurgitation, and normal cardiac function.

On physical examination, Mrs D looks and feels well. She is 157 cm tall (62 in), weighing 62 kg (138 lb). Her cardiac rhythm is regular, with a rate of 42/min. Vital signs are otherwise normal, with a blood pressure of 134/80 mm Hg. Cardiopulmonary examination is unremarkable, with a soft, holosystolic murmur heard at the point of maximal impulse. Peripheral pulses are full and equal. The skin shows no bruising.

Laboratory evaluation revealed a total cholesterol level of 167 mg/dL and high-density lipoprotein cholesterol of 48 mg/dL. Her studies were otherwise unremarkable. Her current medications include atenolol, 25 mg/d; aspirin, 325 mg/d; atorvastatin, 40 mg/d; clopidogrel, 75 mg/d; folic acid, 2 mg/d; isosorbide, 30 mg/d; nitroglycerin, 0.3 mg, as needed; vitamins B₆, B₁₂, and E; risedronate, 35 mg/wk; calcium supplements; and clindamycin used prophylactically for dental and other procedures.

Given the risk of adverse cardiac events including sudden cardiac death associated with left main coronary artery disease, she was told that revascularization was indicated. After consultation with 2 experienced physicians, an interventional cardiologist who recommended a stenting procedure and a cardiac surgeon who felt she should have coronary artery bypass graft (CABG) surgery, Mrs D is trying to decide which to choose.

The pressure I get periodically makes me feel as though something is pushing inside my chest. The pressure builds up from the bottom of my chest, and I can feel it building up into my throat. I take a nitro, lie down, and try to stay as quiet as I can. I don’t wait 5 minutes like I’m supposed to—I wait probably 3 minutes and I take the second nitro because I know it’s going to help me.

The blockage in my left main artery has increased to a point where it could be dangerous, and at this point I must decide on 1 of 2 situations. Either I go in for bypass surgery or I have a stent put into that artery and open it up.

The stent sounds like the easiest thing to do. There’s no rehabilitation attached to it. Plus it’s quick, it’s easy, and it’s not the least bit invasive. I’ve gone through surgeries; I don’t like surgery. Consequently, the thought of it not being invasive to me is a big plus. However, on the negative side, who is to say that when they put in the stent it’s going to work? Is it going to work for a long time or be short-lived? From what I can gather from asking questions, there isn’t enough data on stents in the left main artery for me to arrive at a truly educated decision.

I also know that bypass surgery in and of itself is supposedly a run-of-the-mill cardiac operation. Is it a run-of-the-mill operation when it’s your left main artery? I don’t think so. I think it’s dangerous in any event. The plus to cardiac surgery is that once they take care of it, I don’t have to worry about that left main artery again. But, when you’re dealing with the left main artery, what exactly is involved in the bypass? What complications could result? What kind of recuperation is involved? What will I be able to do or not do afterwards? Why does the surgeon feel that a bypass would be more beneficial to me than a stent?

After speaking with the interventional doctor, I asked him point blank, why is a stent better than a bypass? And of course, he was quick to tell me why. But at this point, I know that there have been a lot more people who have recovered from bypass surgery than have recovered from a stent on the left main artery.

You don’t make a decision about this very easily. You wake up at 4:00 in the morning, and you ponder and you worry. You listen to people, and you wish sometimes that people wouldn’t talk to you because everybody has a different viewpoint. I think it’s the hardest decision I will probably ever have to make. It was easier to decide who I was going to marry than it will be to decide what type of an operation I want, and if and when I do want surgery at all.

Describe briefly the epidemiology and clinical significance of coronary artery disease involving the left main artery. What are the outcomes with respect to short- and long-term survival, and short- and long-term morbidity for surgical and interventional approaches? Describe the differences in experience with stents with and without an eluting drug. What would Mrs D experience during and shortly after surgery or medical intervention? When could Mrs D expect to leave the hospital, return to her regular activities, and feel “back to normal”? From the perspective of the patient, what are the trade-offs in terms of the need for additional monitoring and procedures (time and morbidity) after intervention or surgery? What does the future hold for management of this illness, and what would you recommend for Mrs D?

DRS CARROZZAAND SELLKE: “Left main” refers to that portion of the epicardial left coronary artery, from its origin in the sinus of Valsalva to its bifurcation into the LAD and circumflex coronary arteries. In many people, more than 75% of the coronary blood flow to the left ventricle passes through the left main coronary artery.¹ Since the left main perfuses the majority of left ventricular muscle mass, atherosclerosis of this vessel may place the patient at risk for life-threatening left ventricular dysfunction and dysrhythmia. Significant obstructive disease, ie, in excess of 50% diameter stenosis, is found in 4.3% of patients who undergo diagnostic coronary angiography for chest pain.² In more than half of all patients with significant stenosis of the left main coronary artery, the stenosis exceeds 75% of the diameter. In Mrs D’s case, the stenosis is almost 75%.

Mrs D has been considering 2 options: CABG or percutaneous coronary intervention (PCI) with a drug-eluting stent. Ideally, randomized trials comparing the most up-to-date techniques for intervention will define how left main disease should be treated in the future. Mrs D would love to have such evidence available right now. Unfortunately no studies comparing these therapies have been completed, but one trial, SynTax (Synergy between PCI with TAXUS and Cardiac Surgery) is planned. Short of definitive, comparative evidence, what is known about her disease and the options she has today?

Historically, the long-term prognosis for patients with significant stenosis of the left main coronary artery treated medically has been poor without intervention. Three-year survival for patients with more than 50% stenosis is only 50%, and only 41% when the stenosis exceeds 70%.^{2 - 3} CABG involves the surgical anastomosis of arteries and/or veins around the obstructions in the native coronary arteries. For left main coronary artery disease, CABG using the left internal mammary artery (LIMA) to LAD bypass has become the surgical treatment of choice, since it appears best suited for imparting long-term event-free survival.⁴ This is the surgical option we would offer Mrs D.

Most of the indications for CABG in patients with angina derive from the survival benefit observed in patients treated with CABG vs maximum medical therapy in the Coronary Artery Surgery Study (CASS),⁵ Veterans Administration (VA) Coronary Artery Bypass Surgery Cooperative Study,⁶ and European Coronary Surgery Study.⁷ Performed in the 1970s, these trials used saphenous vein grafts rather than the LIMA, enrolled a disproportionally low number of women, and did not use postoperative lipid-lowering therapy, aspirin, angiotensin-converting enzyme inhibitors, or β-blockers. Only the VA Coronary Artery Bypass Surgery Cooperative Study attempted to randomize patients with significant left main coronary artery disease to CABG or medical therapy. Nevertheless, a meta-analysis of 7 trials found a mortality benefit at 5 years for patients with left main coronary artery disease treated with bypass surgery.⁸

Following Gruntzig’s landmark description of balloon dilatation of a stenotic coronary artery, many envisioned that catheter-based therapeutics would replace surgical revascularization for many patients with severe coronary artery disease.⁹ However, the presence of significant “unprotected” (ie, without patent graft to either the LAD or circumflex vessels) left main coronary artery disease was considered a contraindication to PCI, unless CABG surgery was contraindicated.¹⁰ Interventional cardiologists encountered a high incidence of death associated with acute occlusion of the left main artery, and a high incidence of flow-limiting, restenosis of the stented left main segment. In a series of patients who underwent balloon angioplasty of the left main coronary artery, O’Keefe et al¹¹ reported procedural mortality of 9.1% for elective dilatation of unprotected left main lesions and 50% for dilatation during acute MI. By 3 years, 65% of patients in whom unprotected left main lesions were dilated had died, and the rate of repeat revascularization exceeded 40%. These sobering results affirmed surgical revascularization as the standard of care for treatment of left main coronary artery lesions.

Endovascular prostheses, or stents, have revolutionized the field of interventional cardiology. Multiple randomized trials and registries have demonstrated that stenting is associated with improved procedural safety, reduction in angiographic restenosis, and less need for repeat revascularization.^{12 - 16} The New York State Registry reported outcomes for 19 792 patients treated with either balloon angioplasty or stenting. Stenting was associated with a 40% reduction in emergency bypass surgery prior to discharge, and a 20% reduction in risk-adjusted mortality at 2 years.¹⁵ In a multicenter registry of left main artery PCI, 107 patients were treated with balloon angioplasty, atherectomy, or stenting.¹⁷ Stenting was associated with the lowest posttreatment residual stenoses (7% for stents, compared with 37% for balloon angioplasty, and 12% for directional atherectomy). Patients who received elective left main artery stenting had a 100% technical success rate, with 94% surviving to discharge. Stenting was correlated independently with survival to hospital discharge. Several other investigators have documented excellent procedural outcomes in patients treated with elective left main stenting, with in-hospital mortality ranging from 0% to 4%.^{18 - 21} Interestingly, for patients deemed appropriate candidates for CABG surgery, in-hospital mortality for left main coronary artery stenting was low (0%-2%), similar to historical data for bypass surgery.

However, despite these excellent acute results, 1-year mortality rates were disappointingly high, due to late cardiac deaths that may result from restenosis. Park et al¹⁹ analyzed 270 consecutive patients with unprotected left main stenosis and normal left ventricular function. After 3 years, the restenosis rate was 21.1%, and there were 20 deaths (7.4%), of which 8 deaths (3.0%) were believed to be cardiac in etiology.¹⁸ Target and nontarget lesion revascularizations were required in 45 (17%) and 31 (11.5%) patients, respectively. In a smaller study by Takagi et al,¹⁹ 64 patients underwent left main PCI, including stenting. Angiography at 5 months revealed a restenosis rate in excess of 30%, and overall and cardiovascular mortality of 16.4% and 11.9%, respectively.

In aggregate, these studies suggest that while elective stenting of left main artery lesions in CABG-eligible patients can be performed with a high rate of success and low incidence of complication, intermediate and long-term outcomes are poorer than expected for similar patients undergoing bypass surgery.^{22 - 28} The problem of late cardiac death observed for bare metal stents limits their use to patients with inordinately high surgical risk.

Using stents as a platform for in situ drug delivery offers the possibility of delivering drugs directly to the locus of arterial injury, while avoiding systemic toxicity. Although restenosis of lesions outside of the left main coronary artery is rarely associated with adverse clinical outcomes such as death or MI, restenosis is the putative mechanism leading to sudden cardiac death within the first year after stenting of the left main coronary artery. Recently, 3 randomized trials compared acute and intermediate outcomes of patients with coronary artery disease treated with a sirolimus-eluting stent vs a bare metal stent.^{29 - 31} The SIRIUS study,²⁹ the largest of these trials, documented a 75% relative reduction in angiographic restenosis and target lesion revascularization in patients treated with drug-eluting stents. Furthermore, the recently published E-SIRIUS trial demonstrated even lower rates of restenosis than did the SIRIUS trial (5.1% vs 8.9%).³¹

Recently, Suárez et al³² presented the first series of patients with unprotected left main coronary artery lesions treated with drug-eluting stents. Forty-seven patients underwent stenting with a sirolimus-eluting stent. Procedural success was 98%, and at a mean follow-up interval of 5 months 96% were symptom free, with only 1 patient requiring revascularization of the target lesion. However, given the small number of patients treated, and the relatively brief follow-up period, it would be presumptuous to assert that these results validate the concept of routine stenting of left main coronary artery lesions. Furthermore, drug-eluting stents are presently available in limited sizes, restricting their use to vessels at least 2.5 or less than 4.75 mm.

In 2003, the operative mortality of CABG (defined as any death occurring within 30 days of the procedure) across North American centers participating in the Society of Thoracic Surgeons database was 2% despite treatment of higher risk patients, a marked improvement since 1994, when the risk-adjusted mortality was 3.2%.³³ In 19 016 patients in the Northern New England Cardiovascular Disease Study Group who received a LIMA graft during CABG, the overall 30-day mortality was 2.4%.³⁴ A 30-day mortality of 1% or less can be predicted in patients undergoing elective CABG who are younger than 65 years, have preserved left ventricular dysfunction, and do not have congestive heart failure.³⁵ Nevertheless, in CASS, the presence of significant left main coronary artery stenosis was an independent predictor of long-term mortality.⁵

Morbidity from surgical coronary revascularization has been scrutinized increasingly in recent years, with attention to the incidence of procedural complications, as well as overall cost. The most common complications of CABG are MI, postoperative bleeding, low cardiac output syndrome, renal failure, neurocognitive dysfunction, stroke, atrial arrhythmias, and sternal wound infection.

The incidence of perioperative MI after CABG is difficult to quantify, since there is no universally accepted definition. In general, development of Q waves after CABG is a reliable indicator of perioperative MI. The incidence of perioperative Q wave MI is approximately 2%. In the absence of new Q waves, large elevations (greater than 5 times normal) of cardiac markers such as creatine kinase-MB fraction occur in 17% of patients and have been associated with worse prognosis.^{36 - 37} The “low cardiac output syndrome” is defined as the need for a postoperative intra-aortic balloon pump or significant new inotropic support to maintain systolic blood pressure greater than 90 mm Hg, and a cardiac index greater than 2.2 L/min per square meter. It occurs in 5% to 9% of patients and carries a 17% risk of mortality.³⁸

Neurologic impairment after CABG has been attributed to hypoxia, emboli, hemorrhage, and metabolic abnormalities and has been divided into 2 types: type 1 deficits, which represent major focal neurologic deficits, and type 2 deficits, characterized by deterioration of intellectual function or memory.³⁸ A large registry found the incidence of type 1 deficit after CABG to be 1.4%, with a mortality of 25%.³⁹ Between 20% and 50% of patients experience some neurocognitive dysfunction after CABG,¹³ although it has been difficult to separate the effects of aging and anesthesia from those causally linked to surgery.

Many controversies exist regarding the role of cardiopulmonary bypass in type 2 deficits after CABG. Following CABG, most patients show some degree of cognitive decline across 1 or more domains tested. However, in a small observational study, Taggart et al⁴⁰ noted a similar pattern of early decline and recovery of cognitive function at 3 months in patients undergoing CABG independent of cardiopulmonary bypass, suggesting that cardiopulmonary bypass per se may not be the major cause. In a randomized study, Ascione et al³⁹ found no significant difference between the incidence of type 1 deficit in CABG patients using cardiopulmonary bypass vs “off-pump” CABG patients. Off-pump CABG involves coronary revascularization on a stabilized, beating heart without extracorporeal support. While generalizations are difficult to make, off-pump CABG seems to be associated with less early neurocognitive decline, but little difference compared with standard CABG with regard to late neurocognitive function or overt neurologic injury or stroke.⁴¹ Another study found that patients who had undergone CABG did not differ in subjective ratings of memory, concentration, general health, social functioning, and emotional state from patients who had undergone PCI.⁴²

Postoperative renal dysfunction may occur after CABG, but dialysis is required in less than 1% of patients. Risk factors include: age older than 70 years, congestive heart failure, type 1 diabetes mellitus, baseline renal insufficiency, and cardiopulmonary bypass lasting 3 or more hours.^{38 ,40} With respect to graft attrition, long-term angiographic studies document factors associated with their premature closure and the patency rates of different types of grafts. Early occlusion (ie, within 1-2 months) is usually due to thrombosis, which results from hemodynamic factors related to poor graft outflow or technical errors.⁴³ Once this early postoperative period has passed, vein grafts develop intimal hyperplasia as early as 1 month after operation.¹⁶ Beyond 1 year, saphenous vein grafts occlude at a rate of 2% per year, and by 15 years more than 50% were occluded or had significant stenoses.⁴⁴ This high rate of attrition is attributed to aggressive atherosclerosis and secondary thrombosis.

The internal mammary graft appears relatively resistant to atherosclerosis, although narrowing at the distal anastomosis may result from a hyperplastic response to injury. Patency of LIMA to LAD grafts is 95% to 98.7% at 1 year, 94% at 7 years, and 90% at 10 years.^{44 - 45} With contemporary medical therapy and aggressive secondary prevention, patency rates may be higher. Thus, the LIMA to LAD bypass has become the surgical treatment of choice, since it appears to impart long-term survival and freedom from subsequent cardiovascular events. This is the surgical option we would offer Mrs D.

In addition to the morbidity and mortality as previously outlined, complications of PCI may derive particularly from the use of stents, especially the currently favored drug-eluting stents. Several months after the sirolimus-eluting Cypher stent was approved for marketing in the United States, reports of subacute stent thrombosis were reported to the US Food and Drug Administration. Unlike restenosis, which rarely leads to adverse cardiac events, subacute stent thrombosis is associated with an incidence of death or MI of 64%.⁴⁶ The randomized SIRIUS and RAVEL trials reported no higher incidence of subacute stent thrombosis between bare metal and drug-eluting stents.^{29 - 30} However, there was concern that use of these devices in the real world might result in higher rates of this devastating complication. Jeremias et al⁴⁷ reported a 1.1% overall incidence of subacute stent thrombosis, but only 0.4% in patients who complied with dual antiplatelet therapy, raising the possibility that delayed endothelialization from the antiproliferative effects of sirolimus might contribute to a higher risk of subacute stent thrombosis unless patients rigorously adhered to antiplatelet medications. More recently, anecdotal reports of adverse events resulting from failure of the stent delivery balloon to deflate have been reported in several patients treated with the paclitaxel-eluting TAXUS stent. The problem is presumed to reflect a correctable problem in manufacturing.

It is important to recognize that the 2 principal treatment options differ with regard to anticipated recovery time and follow-up requirements (Table). In the event that Mrs D chooses CABG surgery, she should anticipate being in the intensive care unit for 1 to 2 days, and then on a regular patient care unit for an additional 3 to 5 days. Her postsurgical pain would not be severe, but she would experience fatigue for 2 to 3 weeks. She should avoid heavy lifting (more than 4.5 kg) for 6 to 8 weeks and driving a car for 3 weeks. Generally, individuals can anticipate returning to work after 6 to 8 weeks. After 8 weeks, she should be virtually back to normal. And while she should continue to work at improving her cardiovascular risk factors, she would not need to undergo surveillance angioplasty.

Length of stay following stenting is significantly shorter (about 1 day) than with bypass, and prolonged absence from employment is very uncommon. Just as with CABG, patients should work to reduce cardiovascular risk factors to slow disease progression. However, surveillance angiography (with its associated cost and risk) is prudent following left main coronary artery stenting. Despite the cost of additional angiography, aggregate 1-year costs of stenting are less than bypass surgery, approximately $16 813³⁰ vs $19 805 although formal cost comparison studies have not been performed and a major difference in revascularization rates would reduce any savings.⁴⁸

As Mrs D suggests, one possibility is to first try the less invasive treatment, in this case stenting, and then to perform CABG if stenting does not provide positive or durable results. We do not advocate this approach, as the most likely failure following left main coronary artery stenting is restenosis, which may manifest as sudden cardiac death.

For patients not like Mrs D for whom other major comorbid conditions preclude an acceptable risk of surgery, and in whom the reference vessel diameter of the left main coronary artery is greater than 2.5 and less than 4.75 mm, drug-eluting stent placement may be a viable option (Figure 2). As a variety of drug-eluting stents arrive in the near future, we suspect that many patients may choose this less-invasive option, even in the absence of a large corpus of evidence supporting their decisions. We know that factors driving such choices are complex, idiosyncratic, and may be as important to the patient as evidence and expert recommendations.

In summary, given the paucity of long-term data available for drug-eluting stenting of left main coronary artery lesions, current evidence for the treatment of left main coronary artery disease favors CABG over PCI, especially if the lesion involves the distal bifurcation. Regardless of which treatment Mrs D chooses, all health care providers should emphasize to Mrs D the importance of control of all risk factors that promote atherosclerosis, including her hypertension, hyperlipidemia, and sedentary lifestyle. We cannot emphasize strongly enough that Mrs D’s major focus for postprocedural care should be a serious effort to begin exercising, maintain a healthy diet, and take cholesterol-lowering (statin) drugs, antiplatelet agents, and other appropriate medications. Neither bypass surgery nor stenting is a cure for the chronic disease of coronary atherosclerosis.

DR DELBANCO: What do each of you recommend to Mrs D?

DR SELLKE: Without a doubt, I would recommend bypass surgery because the risks are really very low, less than 1% mortality, and the risk for major complications is very low. The long-term efficacy is very high. As I mentioned, the patency for LIMA artery bypass to the LAD artery at 10 years is 90% to 98%. Dr Carrozza presented a slide showing a 10% occlusion rate at 1 year. I think that’s an aberration. I would recommend surgery.

DR CARROZZA: In this case, I concur with Dr Sellke. If I were her cardiologist, I would recommend surgery for the following reason: her left main was significantly larger than could be accommodated today with a drug-eluting stent. To treat her with a stent at this point in time, you would have to use a bare metal stent. Although her left main is a large vessel, and large arteries tend to restenose less than small vessels, I think bare metal stenting of the left main in CABG-eligible patients is not the equivalent of CABG. I would recommend bypass surgery. On the other hand, if she said to me, “I really don’t want surgery; would you be willing to treat this?” I would say yes.

DR DELBANCO: Mrs D did make a decision. She decided not to wait for the conference, and she had a bare metal stent placed a couple of weeks ago (Figure 1). She feels very well and is here today. Mrs D, would you like to comment on how you came to this decision and what you are feeling about it now?

MRS D: I did have the stent. Why? I had to go with what I felt in my heart. Not so much what was being told to me by my surgeon, the interventionalist, or my cardiologist. I had to do what I felt was the right thing for me. As this surgeon said, the decision was 100% mine. Am I sorry for what I did? No. You’re looking for proof. I cannot tell you what will be in 5 or 10 years, but can any physicians here, surgeon or otherwise, tell me exactly what will be in 5 or 10 years? I made myself happy. I made my husband happy. I made my family happy by doing what I did. Therefore, for me, that’s enough of a reason to feel good about having made the decision to go with the stent.

DR DELBANCO: Do you think we’ll ever get enough evidence-based data to go beyond subjective opinion in this rapidly evolving field?

DR SELLKE: Both of these procedures have advantages. The PCI has a short-term advantage in terms of recovery, but I think coronary bypass surgery has the long-term advantage. Each of us can emphasize whichever argument we prefer, but the decision is ultimately up to the patient, regardless of what we think is the best way to proceed. For example, some patients have an aversion to surgery. Given her multiple surgeries, I think Mrs D is one of those patients, and she may not make the “best” medical decision because of this aversion.

DR CARROZZA: I agree. Our job as physicians is to present to patients the best data we have. Nevertheless, patients will make decisions based on what is important in their lives, and they may actually go against what the evidence might suggest.

Mrs D did say 2 things that troubled me. One is that the stenting procedure is not invasive. That is wrong; it certainly is invasive. Moreover, it has complications associated with it, and people may die on the table during left main stenting. She also stated if she got through the bypass surgery, then she’d be fixed at that point—meaning that bypass surgery essentially is a cure for life. Again we must always remind patients that no form of revascularization cures coronary artery disease.

A PHYSICIAN: A few assumptions have been made, one of which is that this is a homogeneous population with isolated left main disease. Stenting only the left main may not do much for the other vessels. And when you talk about mortality, you haven’t separated out the fact that women don’t do as well with either stents or bypass surgery. They have much smaller vessels, and treating the other vessels poses a problem, because they tend to be much smaller.

DR SELLKE: Nobody knows exactly why the risks are higher with women.⁴³ They are slightly increased, but I think the same algorithms hold in a good risk patient, whether it’s a man or a woman. In this situation, I think patients should have surgery.

DR CARROZZA: Our discussion focused on left main disease. But you are right; most patients don’t have that alone, and that is the case with Mrs D. Remember, there are 2 reasons to subject patients to a procedure. One is to make them feel better. The other is to help them live longer. We spent a lot of time talking about mortality differences. But if 3 or 4 months from now she still has angina because of the diagonal lesion, that’s not acceptable. And that’s why I think Dr Sellke makes a good point about complete revascularization and angina-free survival in these patients.

Women do indeed have higher procedural complications during PCI than do men. However, the effect is not so profound when outcomes are adjusted for comorbidities, such as advanced age and diabetes mellitus. Long-term outcomes are similar in women and men, and there is no effect of sex on restenosis following stenting.^{44 ,49}

A PHYSICIAN: Left main disease really comes in 2 flavors. We’re talking about atherosclerotic disease of the vessel, but there’s also a type that is primary aortic root disease, with calcium impinging from the aortic root onto the left main. What would be your opinion on someone with a heavily calcified root that had severe calcium ledge impinging on the left main?

DR CARROZZA: That creates a technical problem in terms of stent expansion. If there’s significant calcification, you can’t expand the stent. The patient is then at increased risk for both thrombotic and restenotic complications. We have ways of getting around that in non–left main areas; there we can use rotational atherectomy. But in the left main, patients often don’t tolerate the ischemic burden that those kinds of procedures entail.

On the other hand, those are often patients who are turned down by surgeons because of advanced age, extensive aortic root calcification, and other comorbidities. With devices such as the intra-aortic balloon pump and, in some unusual cases even cardiopulmonary bypass in the catheterization lab, we can usually get most patients through the procedure.

DR DELBANCO: So what do you think will happen in the future? Do you think you’re going to be stenting these lesions regularly?

DR CARROZZA: I think that ostial left main lesions will be treated by drug-eluting stents, once the appropriate sizes are available. However, I’ll reserve judgment until more comparative data are available.

DR SELLKE: I think the quality of surgery will continue to improve. I also think that in 20 to 30 years, we’ll probably be doing very few bypass operations. With the advent of gene therapy, protein-based angiogenesis therapy, cell-based therapy, and improved drug-eluting stents, I think we’ll be treating these patients without bypass surgery.