News | COMPLEX PCI 2023
Celebration of LM PCI: Joy in Growth, Journeying Towards 25 Years
This year marks the 25th anniversary of publishing a paper on Left Main PCI in JACC
In an illuminating presentation at COMPLEX-PCI 2023, Dr. Duk-Woo Park provided a comprehensive overview of the growth of Left Main Percutaneous Coronary Intervention (PCI) over the last 25 years, delving into future perspectives while addressing the remaining challenges in this critical field.
Duk-Woo Park
Asan Medical Center, Republic of Korea
Dr. Park presented a historical timeline of Left Main PCI, comparing two major procedures: the standard of care, Coronary Artery Bypass Graft (CABG) surgery, and the less invasive PCI treatment. Pivotal trials such as Syntax, PRECOMBAT, EXCEL, and NOBLE were highlighted, illustrating the comparative effectiveness of these interventions for Left Main and multivessel diseases.
With Korea being a global leader in Left Main PCI, Dr. Duk-Woo Park traced back almost 25 years of history, mentioning early pioneers like Dr. Gudino and showcasing the first consecutive report of Left Main PCI at Asan Medical Center in 1998. The center's long-standing expertise and innovative techniques were instrumental in shaping the landscape of Left Main interventions.
Addressing recent advancements, Dr. Park highlighted a Lancet-published review by cardiac surgeon Mario Gudino, emphasizing the continuous revolution in both CABG and PCI procedures. This evolution includes advancements in drug-eluting stents,
adjunctive drugs, and imaging- and FFR-guided PCI, leading to improved patient outcomes.
Dr. Park delved into long-term outcomes, discussing key trials like SYNTAX, PRECOMBAT, EXCEL, and NOBLE. He emphasized a recent combined individual patient data (IPD) meta-analysis, revealing that over 15 years, PCI and CABG showed no significant difference in mortality, with PCI demonstrating lower procedural complications and CABG having lower spontaneous myocardial infarctions.
Providing insights into guideline updates, Dr. Park discussed recommendations from both the American and European societies, underlining ongoing debates and controversies. He particularly addressed the ESC guideline's withdrawal of cardiac surgeon recommendations after the EXCEL trial.
Future Directions: FATE-MAIN Trial and DEFINE-DM Trial
Highlighting real-world practices, particularly in the Asian-Pacific region, Dr. Park shed light on the preference for bypass surgery in cases with extensive non-LM coronary artery disease and diffuse three-vessel diseases. Conversely, PCI was favored for cases involving multivessel comorbidity.
Dr. Park introduced two upcoming trials shaping the future of Left Main PCI. The FATE-MAIN trial (Figure 1), involving over 40 Asian Pacific centers, will evaluate physiology-guided PCI versus conventional angiography-guided PCI. The DEFINE-DM trial (Figure 2) will focus on ischemic cardiomyopathy and diabetic patients, aiming to provide crucial insights into the remaining unmet issues.
The presentation concluded by addressing persisting challenges in LM PCI, particularly in cases of ischemic cardiomyopathy with an ejection fraction below 40%. Dr. Park highlighted two ongoing trials, STICH3C and DEFINE-DM, poised to provide insights into optimal revascularization strategies for these patient populations.
Figure 1. FATE-MAIN Trial Study Design
In the FATE-MAIN trial, we assume that the improved outcomes with FFR-guided PCI are likely a result of more judicious PCI whereby ischemia-inducing LMCA lesions are revascularized and non-ischemia-inducing LMCA lesions are treated with OMT alone.
Figure 2. DEFINE-DM Trial Study Design
In the contemporary clinical practice, the goal of PCI is to achieve complete functional revascularization of ischemic territories. Thus, the theoretical and practical concept of physiology-guided PCI will also work even in Left Main PCI setting.
Dr. Park's lecture highlighted the rich history and advancements in Left Main PCI and outlined the current controversies and future directions, setting the stage for continued innovation in this crucial field of interventional cardiology.
Edited by
Junghoon Lee, MD
Catholic university of Korea, Eunpyeong St. Mary's hospital, Korea (Republic of)
KyungAe Kim, RN
CardioVascular Research Foundation (CVRF), Korea (Republic of)
In an illuminating presentation at COMPLEX-PCI 2023, Dr. Duk-Woo Park provided a comprehensive overview of the growth of Left Main Percutaneous Coronary Intervention (PCI) over the last 25 years, delving into future perspectives while addressing the remaining challenges in this critical field.
Duk-Woo Park
Asan Medical Center, Republic of Korea
Dr. Park presented a historical timeline of Left Main PCI, comparing two major procedures: the standard of care, Coronary Artery Bypass Graft (CABG) surgery, and the less invasive PCI treatment. Pivotal trials such as Syntax, PRECOMBAT, EXCEL, and NOBLE were highlighted, illustrating the comparative effectiveness of these interventions for Left Main and multivessel diseases.
With Korea being a global leader in Left Main PCI, Dr. Duk-Woo Park traced back almost 25 years of history, mentioning early pioneers like Dr. Gudino and showcasing the first consecutive report of Left Main PCI at Asan Medical Center in 1998. The center's long-standing expertise and innovative techniques were instrumental in shaping the landscape of Left Main interventions.
Addressing recent advancements, Dr. Park highlighted a Lancet-published review by cardiac surgeon Mario Gudino, emphasizing the continuous revolution in both CABG and PCI procedures. This evolution includes advancements in drug-eluting stents,
adjunctive drugs, and imaging- and FFR-guided PCI, leading to improved patient outcomes.
Dr. Park delved into long-term outcomes, discussing key trials like SYNTAX, PRECOMBAT, EXCEL, and NOBLE. He emphasized a recent combined individual patient data (IPD) meta-analysis, revealing that over 15 years, PCI and CABG showed no significant difference in mortality, with PCI demonstrating lower procedural complications and CABG having lower spontaneous myocardial infarctions.
Providing insights into guideline updates, Dr. Park discussed recommendations from both the American and European societies, underlining ongoing debates and controversies. He particularly addressed the ESC guideline's withdrawal of cardiac surgeon recommendations after the EXCEL trial.
Future Directions: FATE-MAIN Trial and DEFINE-DM Trial
Highlighting real-world practices, particularly in the Asian-Pacific region, Dr. Park shed light on the preference for bypass surgery in cases with extensive non-LM coronary artery disease and diffuse three-vessel diseases. Conversely, PCI was favored for cases involving multivessel comorbidity.
Dr. Park introduced two upcoming trials shaping the future of Left Main PCI. The FATE-MAIN trial (Figure 1), involving over 40 Asian Pacific centers, will evaluate physiology-guided PCI versus conventional angiography-guided PCI. The DEFINE-DM trial (Figure 2) will focus on ischemic cardiomyopathy and diabetic patients, aiming to provide crucial insights into the remaining unmet issues.
The presentation concluded by addressing persisting challenges in LM PCI, particularly in cases of ischemic cardiomyopathy with an ejection fraction below 40%. Dr. Park highlighted two ongoing trials, STICH3C and DEFINE-DM, poised to provide insights into optimal revascularization strategies for these patient populations.
In the FATE-MAIN trial, we assume that the improved outcomes with FFR-guided PCI are likely a result of more judicious PCI whereby ischemia-inducing LMCA lesions are revascularized and non-ischemia-inducing LMCA lesions are treated with OMT alone.
In the contemporary clinical practice, the goal of PCI is to achieve complete functional revascularization of ischemic territories. Thus, the theoretical and practical concept of physiology-guided PCI will also work even in Left Main PCI setting.
Dr. Park's lecture highlighted the rich history and advancements in Left Main PCI and outlined the current controversies and future directions, setting the stage for continued innovation in this crucial field of interventional cardiology.
Edited by
Junghoon Lee, MD
Catholic university of Korea, Eunpyeong St. Mary's hospital, Korea (Republic of)
KyungAe Kim, RN
CardioVascular Research Foundation (CVRF), Korea (Republic of)
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