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TYPE
Original Research
PAGE NO.
58-64
10.37547/tajmspr/Volume07Issue01-08
OPEN ACCESS
SUBMITED
18 October 2024
ACCEPTED
20 December 2024
PUBLISHED
23 January 2025
VOLUME
Vol.07 Issue01 2025
CITATION
Makhmudova M.M., & Vinokurova E.S. (2025). Ischemic heart disease with
damage of the left main coronary artery. The American Journal of Medical
Sciences and Pharmaceutical Research, 7(01), 58
–
64.
https://doi.org/10.37547/tajmspr/Volume07Issue01-08
COPYRIGHT
© 2025 Original content from this work may be used under the terms
of the creative commons attributes 4.0 License.
Ischemic heart disease
with damage of the left
main coronary artery
Makhmudova M.M.
Central Military Clinical Hospital of the Ministry of Defense of the Republic
of Uzbekistan. Tashkent, Uzbekistan
Vinokurova E.S.
Central Military Clinical Hospital of the Ministry of Defense of the Republic
of Uzbekistan. Tashkent, Uzbekistan
Abstract:
It is known and proven that the degree of
damage to the left main coronary artery (LMCA), along
with the indicators of the
left ventricle (LV) myocardium’s
contractile function, are the main factors determining the
survival of patients with coronary artery disease (CAD).
Therefore, the effectiveness of the chosen management
strategy for such patients determines not only the quality
of life, i.e relief from angina symptoms, but also long-term
prognosis [1,2].
Keywords:
Contractile function, survival of patients.
Introduction:
It is known and proven that the degree of
damage to the left main coronary artery (LMCA), along
with the indicators of the left ventricle (LV)
myocardium’s contractile function, are the main factors
determining the survival of patients with coronary
artery disease (CAD). Therefore, the effectiveness of the
chosen management strategy for such patients
determines not only the quality of life, i.e relief from
angina symptoms, but also long-term prognosis [1,2].
More than 100 years have passed since the first
description by American physician J. Negis of the case of
a death of a 55-year-old patient with large anterior
myocardial infarction (MI), complicated by cardiogenic
shock, the cause of which, according to the occlusion of
the left main coronary artery (LMCA) [2,3]. It was only
50 years ago that the issue of treating such patients
became the subject of intense research attention [4].
However, this issue still remains a topic of discussion
and debate. One of the most debated questions is the
choice of treatment strategy for patients with
hemodynamically significant left main coronary artery
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The American Journal of Medical Sciences and Pharmaceutical Research
(LMCA) disease.
The left main coronary artery (LMCA) is the proximal
segment of the left coronary artery, starting from the
left sinus Valsalva and extending to the bifurcation into
the left anterior descending (LAD) and circumflex (Cx)
coronary arteries [5]. This type of bifurcation is found
in two-thirds of cases, while in about one-third of
patients, the trunk ends in trifurcation, with the third
branch referred to as the intermediate branch. Cases
of more than three branches are extremely rare. There
are also reports of complete absence of the LMCA
trunk, where the LAD and Cx arise from separate
orifices. This variant occurs in less than 1% of patients
[6,7].
In the right coronary circulation type, approximately
75% of the blood supplying the myocardium passes
through the LMCA, while in the left type, nearly 100%
does. Due to this, patients with hemodynamically
significant LMCA disease have a high risk of mortality
[2,5].
Anatomically, the left main coronary artery (LMCA) is
divided into the ostium, the middle portion, and the
distal segment. The average diameter of a healthy
LMCA, as measured by angiography, is 4,5 ± 0,5 mm in
men and 3,9 ± 0,4 mm in women [8]. However, there
have been reports of autopsy findings where the
diameter of the LMCA in individuals with healthy
hearts reached 10 mm. The length of the LMCA trunk
is highly variable. In one study analyzing 106 hearts
based on autopsy data, the length of the LMCA ranged
from 2 to 44 mm. A short LMCA is notably associated
with the presence of a bicuspid aortic valve [9,10].
However, most studies indicate a weak correlation
between the size of the LMCA and the patient’s
anthropometric data [11]. The LMCA, compared to
other coronary arteries, contains a large number of
elastic smooth muscle fibers, which contributes to
rapid re-narrowing of the vessel (recall - effect) and
makes isolated balloon angioplasty without stenting
ineffective, due to the development of the “elastic
recoil” phenomen [12].
European and American experts are unanimous in their
opinion that a hemodynamically significant stenosis is
a narrowing of the LMCA greater than 50% [1]. It is well
known that atherosclerotic plaques tend to form in
specific areas of the coronary network, characterized
by low levels of vascular wall shear stress [13]. In the
most cases, the plaque in the trunk is located in the
distal segment, with further involvement of the middle
portion and the ostium. In the bifurcation area,
atherosclerotic lesions typically begin on the lateral
walls, where the shear stress of the vascular wall is
lower than at the point where the blood flow splits into
the LAD and Cx. The arterial wall at the blood flow
division point is usually unaffected. This patterns of
lesion distribution is found in 80% of patients with
stenosis of the trunk [2,11].
Lesions of the LMCA, as assessed by coronary
angiography (CAG), occur in 4-8% of patients with
coronary artery disease (CAD) [14
–
16]. In one of the first
large registries, the CASS (Coronary Artery Surgery
Study), which included 24,958 patients with
angiographic evaluations conducted at 14 centers in the
United States and Canada between 1974 and 1979, due
to the presence of or suspicion of CAD, LMCA lesions
with stenosis of 50% or more were found in 1,484 (5,9%)
patients [17]. Isolated LMCA lesions are more the
exception than the rule. Most patients with LMCA
disease have multi-vessel involvement. According to
various registries and studies, the incidence of isolated
LMCA lesions ranges from 1,5% to 13% [18
–
20]. The
results of the CASS registry show that isolated LMCA
lesions were identified in 7% of patients, combined with
one additional artery lesion in 13%, two in 27%, and
three in 52%. Total occlusion of the LMCA, as assessed
by CAG, is rare, occurring in 0,01-0,7% of cases [21, 22].
When assessing the severity of coronary artery disease
using the SYNTAX score, LMCA lesions are considered
the most prognostically dangerous, increasing the score
by 5 to 6 points, depending on the type of myocardial
perfusion [23].
The portrait of patient with LMCA stenosis was first
described by R. Favaloro: severe disease symptoms,
including low exercise tolerance, high functional class
(FC) of angina and heart failure, and the development of
life
–
threatening arrhythmias [24]. On the
electrocardiogram (ECG), recorded during a stress-
induced angina episode, deep depression of the ST
segment is senn in the leads corresponding to the
anterior wall of the left ventricle, as well as a prolonged
recovery period after the termination of physical load
[25].
A LMCA stenosis of more than 50% places patients in a
high-risk category for sudden death. Sudden death
occurs 3-4 times more frequently in patients with LMCA
stenosis compared to those with coronary artery lesions
in other locations [25].
M.S. Gotsman referred to the LMCA
as the “artery of
sudden death” [26]. Consequently, several authors
equate patients with LMCA stenosis to those with acute
coronary syndrome, regardless of the severity of their
clinical condition [27].
In later studies, a detailed description of the clinical and
functional characteristics of patients with LMCA
stenosis was provided. Monitoring of 6,436 patients
with coronary artery disease (CAD) allowed D.B. Pryor
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The American Journal of Medical Sciences and Pharmaceutical Research
and colleagues [28] to identify 11 key predictors of “”
three vessel coronary artery disease or LMCA stenosis.
These characteristics included the typicality of clinical
manifestations of myocardial ischemia (angina),
patient age and gender, disease duration, and the
presence of cardiovascular risk factors such as
hypertension, diabetes, dislipidemia, and smoking.
Another distinctive feature for this group of patients is
the presence of multifocal atherosclerosis (MFA). In
patients without carotid stenosis, LMCA stenosis is
detected in 5% of cases, while in patients with MFA
(those with carotid artery involvement), it occurs in
40% of cases [29]. The presence of high functional class
(FC) angina and signs of impaired myocardial
contractility determines the need for invasive coronary
angiography (CAG) as a first diagnostic step.
Subsequently the strategy for intervention should be
determined and the correct method must be chosen.
For patients with LMCA stenosis, the decision-making
algorithm, according to the latest European guidelines
for the management of stable angina, requires
discussion by a team of cardiologists and cardiac
surgeons
–
“Heart Team” –
to determine the most
effective and safe revascularization strategy.
The role of the cardiologist in this discussion cannot be
overestimated! The choice of revascularization
method is based on the degree of coronary artery
involvement, the assessment of disease severity and
the presence of comorbidities, which are crucial
factors when dealing with patients with left main
coronary artery (LMCA) disease [30,31].
Coronary artery bypass grafting (CABG) is considered
the “gold standard” in the tr
eatment of unprotected
LMCA disease. The technique of CABG has been well-
established and proven in the treatment of coronary
artery disease (CAD) since the 1970s. In a review by D.
Taggart et al., published in 2008 y., the in-hospital
mortality rate after CABG for LMCA disease was
reported to be 2-3%, with a 5
–
year mortality rate of 5-
6% [32].
According to the quidelines of the American Heart
Association (AHA) and the American Colege of
Cardiology (ACC), coronary artery bypass grafting
(CABG) is recommended for left main coronary artery
(LMCA) stenosis more than 50% in patients with stabile
angina or silent myocardial ischemia. In a study W.
Rogers, the 4-year survival rate for patients with
hemodynamically significant LMCA disease on medical
therapy was 63%, while for those who underwent CABG,
was 88% [33].
According to A. Dacosta, the 30- month survival rate for
patients with hemodynamically significant LMCA
Lesion of the LMCA with significant stenosis
± 1 vessel lesion
± 2 or 3 vessels lesions
Ostium/middle
third
Distal
bifurcation
SYNTAX
Score ≤ 32
SYNTAX Score
≥ 32
High surgical risk
Heart Team discussion
Low surgical risk
PCI
(Percutaneous Coronary
Intervention)
CABG
(Coronary Artery Bypass
Grafting)
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The American Journal of Medical Sciences and Pharmaceutical Research
disease on medical therapy was 64%, compared to 80%
for those who underwent CABG [34].
E. Caracciolo et al. reported data on 1484 patients
whith hemodynamically significant LMCA stenosis.
One group of patients received only medical therapy,
while the other group underwent CABG. The average
survival in the first group was 6,6 years, while in the
second group it was 13,3 years [35].
The assessment of the complexity of atherosclerotic
coronary artery disease (CAD) has long been one of the
primary concerns of non-interventional cardiologists,
not only for predicting potential peri-procedural
complications
during
percutaneous
coronary
interventions (PCI), but also for determining the risk-
benefit of various myocardial ratio of various
myocardial
revascularization
methods.
Several
randomized clinical trials (RCTs) and registries have
shown that in patients with left main coronary artery
(LCA) stenosis and/or multi-vessel coronary artery
disease (CAD), myocardial revascularization with
coronary artery bypass grafting (CABG) is preferable
and more effective [36
–
39]. One of the largest RCTs
comparing
two
myocardial
revascularization
strategies, CABG and PCI, in patients with multi-vessel
atherosclerotic CAD with a SYNTAX Score of 33 or
higher, is the SYNTAX trial [40,41].
The SYNTAX score holds a central position in the
ESC/EACTS 2014 guidelines, with a class I level of
evidence, and serves as a long-term predictor of
serious adverse cardiovascular and cerebrovascular
events in patients following PCI.
The SYNTAX Score is divided into three tiers: low-risk
PCI
–
0
–
22, intermediate-risk
–
23
–
32, and high-risk
greater than 33). Higher scores indicate greater
complexity in performing PCI and represent the
greatest risk for patients undergoing PCI, with a worse
prognosis for revascularization compared to CABG.
Intermediate SYNTAX scores allow for a choice
between PCI and CABG, while lower scores favor PCI.
The 5-rear follow-up results of this RCT demonstrated
that, in patients with high SYNTAX score (33 or higher),
CABG was associated with lower mortality compared
to PCI (14,1% vs. 20,9%, p=0,11) and reduced need for
repeat revascularization (11,6% vs. 34,1%, p=0,001),
however, an increased frequency of stroke was noted
in the CABG group (4,9% vs. 1,6, p=0,13). The findings
of this RCT became the cornerstone of the European
myocardial revascularization guidelines of 2014 [42],
which emphasize the priority of CABG for patients with
left main coronary artery stenosis and/or multi-vessel
CAD with a SYNTAX score of 33 or higher.
Researchers such as W.E. Boden and G.B. Mancini have
shown that despite the findings of the SYNTAX trial,
many cardiologists and therapists continue to
recommend PCI for patients with severe multi-vessel
coronary artery disease (CAD) [43]. Aggregate data on
myocardial revascularization in the USA indicate thet
more than half of patients who are candidates for CABG
undergo endovascular interventions [44
–
46].
It is also important to mention a large meta-analysis
published in 2016, which summarized the results of
several RCTs comparing two revascularization strategies
for unprotected left main coronary artery (LMCA)
disease in 4594 patients (CABG vs. PCI using drug eluting
stents) [47]. The analysis included the following RCTs:
PRECOMBAT (Premier of Randomized Comparison of
Bypass Surgery versus Angioplasty Using Sirolimus-
Eluting Stent in Patients with Left Main Coronary Artery
Disease) (with 60 months of follow-up) [48], SYNTAX
(with 60 months of follow-up) [49], NOBLE (Coronary
Artery Bypass Grafting Vs Drug Eluting Stent
Percutaneous Coronary Angioplasty in the Treatment of
Unprotected Left Main Stenosis) (with 60 months of
follow-up) [50], EXCEL (with 36 months of follow-up)
[51] and one study with 12 months of clinical follow-up
[52].
The results of the meta-analysis indicate that there were
no difference between PCI and CABG in terms of the
overall mortality rate (OR 1,03; 95% CI 0,78
–
1,35;
p=0,61), myocardial infarction (OR 1,46; 95% CI 0,88
–
2,45; p=0,08) and stroke (OR 0,88; 95% CI 0,39
–
1,97;
p=0,53). However, PCI was associated with a higher
frequency of repeat revascularization (OR 1,85; 95% CI
1,53
–2,23; р<0,001). It is important to note that only the
SYNTAX trial, among other RCTs, included patients with
severe coronary artery disease (CAD) defined by a
SYNTAX Score of 33 or higher. In all other RCTs
comparing the two revascularization strategies, either
patients with a SYNTAX Score below 32 were included,
or the group with a SYNTAX Score of 33 or more was
small. This fact is more likely to have contributed to the
absence of differences in cardiac mortality and the
development of myocardial infarction between the
study groups in the meta-analysis mentioned above.
The study by Y. Cho and collegues in 2016 published 10-
year follow-up data on patients after CABG with varying
severity og CAD based on the SYNTAX Score [53].
This study demonstrated that the increased incidence of
“major” adverse cardiovascular and cerebrovascular
events correlates with higher SYNTAX Score (log-rank
p=0,0012) and is associated with a significant increase in
the frequency of repeat revascularization in patients
with a high SYNTAX Score (log-rank p=0,0032).The
cumulative rate of repeat revascularization over 10
years in patients with low, moderate, and high SYNTAX
Score was 4,6, 15,7 and 16,8% respectively (log-rank
p=0,0032); The composite endpoint (all-cause mortality,
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The American Journal of Medical Sciences and Pharmaceutical Research
stroke, myocardial infarction) over 10 years showed no
statistically significant differences between the three
groups
–
22,3, 25,0 and 38,4% respectively (log-rank
p=0,063).
Currently, according to the latest recommendations
om myocardial revascularization, PCI is not indicated
for patients with stable CAD and left main coronary
artery (LMCA) stenosis and/or multivessel coronary
artery disease (SYNTAX Score of 33 or higher).
However, in patients with high surgical risk, some
researchers consider endovascular interventions to be
justified.
In 2016, I. Sanchez-Perez et al. published 10-year
follow-up data on patients with left main coronary
artery (LMCA) stenosis and high SYNTAX Score, who
enderwent myocardial revascularization with PCI [54].
The incidence of “major” adverse cardiac events over
the 10-year follow-up period was 16,1% (10,3% cardiac
death, 0,9% nonfatal myocardial infarction, 4,9%
repeat revascularization and 0% stent thrombosis). The
authors of this study conclude that revascularization of
the left main coronary artery with a high SYNTAX Score
using PCI is an effective and safe procedure. The
success of endovascular treatment for patients with
CAD and complex coronary lesions can be attributed to
the evolution of stents and the emergence of a new
class of antithrombotic drugs, which have played a
revolutionary role in reducing stent thrombosis and
restenosis.
Currently, the number of endovascular interventions
in patients with CAD significantky exceeds the number
of open-heart surgeries. Undoubtedly, PCI is a
minimally invasive method for treating CAD, but when
choosing between CABG or PCI, a careful approach
must be taken for each individual patients, based on
European and American quidelines for myocardial
revascularization, which are derived from the results of
large randomized trials and the assessment of long-
term quality of life and the development of adverse
cardiac ana non-cardiac events. The decision of CABG,
PCI or to continue with optimal medical therapy should
be made by a multidisciplinary team, including
cardiologists, interventional cardiologists and cardiac
surgeons. This decision must be based on risk
stratification, discussed collaboratively with the
patient, and take into account the experience of the
interventional cardiologists and cardiac surgeon
involved.
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