Physiologically Significant Obstructions in the Left Main Coronary Artery: Revascularizing vs. Deferring

Most randomized studies on revascularization in stable coronary artery disease exclude left main coronary artery disease (LMCAD). One example of this was the ISCHEMIA study. However, the benefits of functional lesion assessment, as demonstrated in the FAME studies, highlight the importance of this tool in guiding decisions regarding revascularization. Nevertheless, the clinical outcomes of patients with stable coronary artery disease and LMCAD with demonstrated ischemia remain poorly understood.

La ATC es una alternativa válida en el TCI

The objective of this multicenter registry was to evaluate the long-term clinical outcomes of physiologically significant LMCAD lesions (iFR ≤0.89) according to the therapeutic strategy: revascularization versus medical treatment.

The primary endpoint (PEP) was the rate of major adverse cardiovascular events (MACE), which included a combination of death, non-fatal myocardial infarction (MI), and ischemia-driven treated-LMCA lesion revascularization. The secondary endpoint (SEP) was cardiac death, MI related to LMCAD, and ischemia-driven treated-LMCA lesion revascularization.

The analysis included a total of 225 patients, of which 151 patients were assigned to the revascularization group and 74 patients to the deferred group. The mean age was 68 years, and most patients were men. The mean SYNTAX Score was 22, and the mean iFR value was 0.83. According to quantitative angiography, the mean percentage of stenosis was approximately 45%. Propensity score matching was used to homogenize the samples. The most frequent LMCA lesion was found in its distal third in around 80% of patients. The mean follow-up was 2.8 years.

Read also: Transcatheter Myotomy for the Treatment of the Dynamic Obstruction of the Left Ventricular Outflow Tract.

Regarding the PEP, the MACE rate was 28.4% for the deferred group and 14.9% for the revascularization group (hazard ratio [HR]: 0.42 [95% confidence interval (CI), 0.20–0.89]; P=0.023). Regarding the SEP, the incidence of cardiac death and LMCAD-related MI was significantly lower in the revascularization group (0.0% versus 8.1%; P=0.004). The rate ischemia-driven treated-LMCA lesion revascularization was significantly lower in the revascularization group (5.4% vs 17.6%; HR: 0.20 [95% CI, 0.056–0.70]; P=0.012).


In patients with LMCAD and physiologically significant lesions, revascularization, compared with a conservative strategy, was associated with a significant reduction in long-term MACE (including cardiac death, LMCAD-related MI, and treated-lesion revascularization).

Dr. Andrés Rodríguez.
Member of the Editorial Board of

Original Title: Deferred Versus Performed Revascularization for Left Main Coronary Disease With Hemodynamic Significance.

Reference: Takayuki Warisawa MD et al Circ Cardiovasc Interv. 2023;16:e012700.

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