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The great debate - Left main in 2011: CABG or PCI?

The Great Debate has been a fundamental part of the EuroPCR program for the last few years. Six renowned panelists (3 interventional cardiologists and 3 cardiac surgeons) have discussed this year's topic: "Left main in 2011: CABG or PCI?"

Chronic Ischaemic Heart Disease (IHD)

The Debate started with an explanation of why surgeons consider that surgery is still the gold standard in left main stenosis. On the other hand cardiologists maintain that PCI of left main stenosis is evolving with respectable results. Based on this the SYNTAX-study has been discussed extensively and it was stated that it was, statistically, adequately powered to compare CABG and PCI in left main stenosis. SYNTAX reported that there have been more reinterventions with PCI and more strokes with CABG, but that the combined safety endpoint (death, MI, stroke) did not show a significant difference. A subgroup analysis, which is statistically not legitimate though, showed better results for PCI in patients with less complex lesions while in patients with a SYTAX Score above 32 CABG provided better outcomes. There was quite some debate on the ‘magic’ number of SYNTAX Score 32 concluding that the final decision has to be based on the individual circumstances. Since SYNTAX results do not provide enough information to make a final decision, two further trials (the EXCEL and the NOBLE trial) are on their way.

It was stated that in PCI of the left main, there is a volume/outcome relationship but the necessity of an in-house cardiac surgery unit as a back up for hospitals performing left main PCI was controversial. There has been considerable controversy regarding the patient’s perspective. While cardiologists believed that patients would always vote for PCI, surgeons argued that if the patients are properly informed, many would accept the potential long-term benefits of surgery. There was heated debate on the value of the 2010 ESC/EACTS-Guidelines for revascularisation of left main stenosis. Surgeons insist that the guidelines should be followed in appropriate patients in contrast to the interventional cardiologists who believe that they are not applicable to every patient. Furthermore, they believe that the technology used is already outdated. There was however strong agreement on the importance of the role of multidisciplinary teams and that these should underpin cooperation between departments for cardiology and cardiac surgery. Not every case requires discussion if they are following the ESC/EACTS guidelines but rather those where the intended treatment shall not follow the guidelines.

The lively debate at this session was a great success, highlighting the necessity of a collaborative approach between interventional cardiologists and cardiac surgeons. All agreed that an unbiased view is in the best interest of our patients.

Chairperson: G. Wimmer-Greinecker
Panelists: A. Ērglis, V. Falk, D. Hildick-Smith, M.-C. Morice, D. Taggart, L. Torracca




The great debate - Left main in 2011: CABG or PCI?

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.