For which patients with left main stem disease is percutaneous intervention rather than coronary artery bypass grafting the better option?

A best evidence topic in cardiac surgery was written according to a structured protocol. The topic addressed was to identify the patients with left main stem disease for which percutaneous intervention would be a better option than coronary artery bypass grafting. Altogether 665 papers were found using the reported search, of which 15 presented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers were tabulated. We conclude that if a bare metal stent is used for left main stenting the mortality at one year may be from 3% to over 28% in reported series. The restenosis rate of the bare metal stent in the left main position is around 20% at one year. There are some early series and randomized studies of drug eluting stents for left main stem lesions and the restenosis rate is reported to be around 10%. The European Society of Cardiology in their 2005 percutaneous intervention guidelines state that coronary bypass grafting is the procedure of choice for left main stem disease and only patients with a prohibitively high surgical risk should be considered. We consider that with such high restenosis rates, and with short-term follow-up in such low numbers and short periods compared to coronary artery bypass grafting, left main stenting should only be used as a last resort in patients turned down for coronary artery bypass grafting after full assessment by a cardiac surgeon due to prohibitive co-morbidities.