Management of Left Main and Multivessel Coronary Artery Disease with Preserved Ejection Fraction
This patient requires coronary artery bypass grafting (CABG) as the definitive treatment, given the combination of significant left main stenosis (71%), severe multivessel disease (81% LAD, 91% RCA), and preserved ejection fraction (66%). 1
Primary Recommendation: CABG Over Medical Therapy and PCI
CABG is recommended over medical therapy alone to improve long-term survival in patients with left main disease (Class I, Level B). 1 This recommendation is particularly strong given:
- Left main stenosis >50% is a Class I indication for CABG to improve survival 1
- The presence of three-vessel disease with preserved LV function (EF 66%) further strengthens the survival benefit of CABG 1
- Left main equivalent disease (significant proximal LAD and multivessel involvement) carries Class I recommendation for CABG 1
Why CABG is Preferred Over PCI in This Case
While PCI may be considered for left main disease in selected patients, CABG is recommended as the overall preferred revascularization mode over PCI for left main stenosis, given the lower risk of spontaneous myocardial infarction and repeat revascularization 1.
The patient's anatomy makes CABG particularly favorable:
- With multivessel disease involving left main, LAD, and RCA, the anatomical complexity likely results in a high SYNTAX score (>22), making CABG strongly preferred over PCI 1
- PCI should not be performed in stable patients with significant left main CAD who have unfavorable anatomy for PCI and who are good candidates for CABG (Class III: Harm) 1
- At 5-year follow-up, PCI for left main disease is associated with higher rates of myocardial infarction and repeat revascularization compared to CABG 2
Specific Surgical Approach
The left internal mammary artery (LIMA) should be given primary consideration for revascularization of the LAD artery, as this provides superior long-term patency and survival benefit 1. Given the 81% LAD stenosis and 91% RCA stenosis, complete revascularization of all three vessels is indicated 1.
Risk Assessment Before Surgery
Before proceeding to CABG, the following assessments are mandated:
- Calculate the STS (Society of Thoracic Surgeons) score to estimate in-hospital morbidity and 30-day mortality after CABG (Class I, Level B) 1
- Calculate the SYNTAX score to assess the anatomical complexity of multivessel disease (Class I, Level B) 1
- Assess procedural risks and post-procedural outcomes through shared clinical decision-making (Class I, Level C) 1
When PCI Might Be Considered (Not Applicable Here)
PCI would only be reasonable as an alternative to CABG in left main disease if both of the following criteria were met:
- Low anatomical complexity (SYNTAX score ≤22) where PCI can provide equivalent completeness of revascularization to CABG 1
- High surgical risk (STS-predicted operative mortality >2%, severe COPD, previous cardiac surgery, or disability from stroke) 1
This patient does not meet these criteria given the extensive three-vessel disease with left main involvement, which suggests high anatomical complexity.
Symptom Management Indication
Beyond survival benefit, revascularization is recommended for patients with persistent angina despite guideline-directed medical treatment (Class I, Level A) 1. CABG provides superior symptom relief compared to medical therapy alone in this anatomical pattern 1.
Common Pitfalls to Avoid
- Do not delay CABG for a prolonged trial of medical therapy in left main disease, as this is a survival indication, not just symptom management 1
- Do not choose PCI based solely on patient preference for "less invasive" approach when anatomy clearly favors CABG for survival 1
- Ensure complete revascularization is planned for all three vessels (left main/LAD, circumflex territory, and RCA), not just the most severe lesion 1