Gregg W. Stone
Mount Sinai, USA
At TCTAP 2025, during the "Left Main & Multi-Vessel: Updated Practice and New Concept" session, Dr. Gregg W. Stone (Mount Sinai, USA) presented the 2025 updated guidelines on coronary revascularization, focusing on left main and multivessel disease. Reflecting recommendations from major U.S. cardiovascular societies, the new guidance emphasizes both clinical evidence and patient-centered decision-making.
For symptomatic patients, revascularization (PCI or CABG) is a Class I recommendation to relieve angina when medical therapy fails. PCI becomes a reasonable option (Class IIa) in patients unsuitable for surgery.
In left main disease, CABG is recommended for high-complexity cases due to survival benefits. When PCI can achieve equivalent revascularization, it may be reasonable in low-to-moderate complexity settings. Contrary to expectations, diabetes did not significantly alter outcomes in left main disease, though complexity (measured by SYNTAX score) did show impact, with CABG favored in high-risk cases.
For multivessel disease, pooled trial data reveal a modest mortality benefit for CABG over PCI—especially in diabetics, where the difference reaches 5.5%. Non-diabetic patients show no significant mortality difference. A consistent more stroke risk (~1%) with CABG remains a consideration.
Dr. Stone referenced trials like SYNTAX, EXCEL, and FAME 3. While early benefits of CABG were noted, long-term outcomes—such as death, stroke, and MI—tended to converge. The FAME 3 trial showed PCI and CABG have similar long-term results in triple-vessel disease.
In patients with left ventricular dysfunction, CABG showed a survival benefit in the STICH trial. However, this was not replicated in the smaller REVIVED-BCIS2 trial, highlighting variability in results depending on study size, duration, and patient characteristics.
Dr. Stone closed by stressing the importance of shared decision-making. “For many patients, outcomes between PCI and CABG are very similar,” he noted. “Preferences, comorbidities, and anatomy should all guide the final treatment plan.”
Left Main & Multi-Vessel: Updated Practice and New Concept
Friday, April 25, 8:30 AM-9:40 AM
Coronary Theater, Level 1
Edited by
Yong-Hoon Yoon, MD
Ulsan City Hospital, Korea (Republic of)