Percutaneous Coronary Intervention for Left Main and Multivessel Coronary Artery Disease – A Review of Strategies

Patients with complex and multivessel disease present challenging clinical problems in defining treatment strategies. The Synergy between PCI with taxus and cardiac surgery (SYNTAX) trial, which included both a randomised as well as a registry experience has clarified many issues. These include the extent and severity of the disease, the clinical presentation, and the metrics used for comparison. The development, validation and application of the SYNTAX score has been of fundamental importance. In those patients with the least complex coronary anatomy, using hard endpoints such as death and myocardial infarction, the outcomes of treatment with either percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) are similar although repeat revascularisation rates remain higher with PCI. In those patients with more extensive and complex disease, coronary artery bypass remains the standard of care. It must be remembered that the drug-eluting stent tested in SYNTAX was a first generation device and that newer generations are safer and more effective. Perhaps the most important guidance in the field of treatment of complex multivessel coronary disease is the attention paid to the Heart Team concept wherein both interventional cardiologists and cardiovascular surgeons are strongly encouraged to work together in these patients to identify the optimal approach consistent with the patients needs and objectives.