**2.6 Guidelines**

The evidence is clear regarding patients with low scores, where treatment with both PCI and CABG is appropriate, where there is a class I recommendation. In patients with high scores, because the evidence is much lower because many of these patients have been excluded from RCTs, the recommendation for PCI is class III, since the benefit is clearly greater with CABG. In patients with intermediate scores, due to the lack of evidence in the long-term follow-up, the recommendation remains IIa [20, 43]. When one makes a global evaluation of the LMCA and addresses the guidelines, one must also take into consideration the different portions of the LMCA such as the ostium, the middle third, and the distal third, since they have different implications, both in the technique and in the evolution of these patients, so they would probably have to be analyzed separately. Also the degree of angiographic stenosis has been changing and should not be left with the 50% obstruction that has been used universally, and perhaps it should be passed at least 70%. Although this analysis can have many deficiencies, the use of images such as IVUS or OCT or even functional studies with iwFR or FFR can be closer to a true significant obstruction. It is believed that a minimum luminal diameter of 2.8 mm or an area of < 6 mm<sup>2</sup> would suggest a physiologically significant obstruction [21].

#### **2.7 Ongoing trials**

Xience versus Synergy in LMCA PCI (ideal-LM), PCI of the LMCA a comparison of the newest generation of DES in combination with a short duration of

**15**

the potential risks.

*Current Status, Perspectives, and Future Directions of Multivessel Disease and Left Main…*

DAPT. The additional use of OCT image can be considered a standard procedure with a very low risk of major complications 0.4% [44]. VeRy thin Stents for Patients with Left mAIN or bifurcation in real life: the RAIN Multicenter Study, for coronary stents, reducing the thickness of the struts has become one of the most important innovations, since it is related to easier crushability and reduced risk of thrombosis and low rate of TVR. They performed a multicenter registry of patients treated with Biomatrix flex, Xience Alpine, Ultimaster, Resolute Onyx and Synergy. MACCE (death, MI, TLR and stent thrombosis) will be the primary

In the treatment of severe LMCA in patients with low to intermediate ERACI score, the percutaneous treatment is of choice. In those with a higher score or who have total occlusions and are DM, surgical treatment is better. It is very important to evaluate each case in particular as well as work with a heart team to discuss cases that may generate controversy. The interventional cardiology must be trained in the different bifurcation techniques as well as have images such as IVUS or OCT for procedures. The implementation of the final kissing balloon and the POT in all patients is important. DKC seems to be the technique of choice in

About half of the patients who enter with acute myocardial infarction with ST segment elevation (STEMI) have MVD [46]. Although it seems logical that patients with MVD have a worse prognosis, due to the extent of coronary lesions manifested by higher scores, this remains controversial. There are elements that determine that lesions at multiple sites of the coronary arteries can be complicated, and there are studies in which the multivessel PCI shows a better evolution compared to patients in whom they only receive treatment of the culprit vessel, although there are other studies they don't confirm it and consider them innocent [47], and therefore these arteries warrant treatment in much the same way one would approach any unstable lesion. An update on primary PCI for patients with STEMI (class IIb) [20, 48] by the guidelines recommends intervention of the non-culprit at the time of primary PCI if the patient is hemodynamically stable before the discharge. Subsequently, two randomized trials showed that treatment of non-culprit lesions in the acute phase reduced the risk of future adverse events. The PRAMI trial [49], CvlPRIT trial [50], and recently DANAMI-3-PRIMULTI trial [51] studied the clinical outcomes by comparing the FFR guided by CR with culprit-only PCI in STEMI and found that the composite rate of all-cause mortality, nonfatal reinfarction, and repeat revascularization was significantly lower in the CR group, which was mainly driven by a reduction in repeat revascularization. More recently, another randomized trial (COMPARE ACUTE) [52] revealed that FFR-guided complete revascularization of non-culprit arteries in an acute setting was associated with a lower risk of the composite cardiovascular outcome. We emphasized the importance of individualizing care for each patient, balancing the anticipated benefits from multivessel PCI against

*DOI: http://dx.doi.org/10.5772/intechopen.89419*

LMCA diseases with true bifurcations.

**3. Patients with STEMI and MVD**

end point [45].

**2.8 Conclusions**

**3.1 Introduction**

*Current Status, Perspectives, and Future Directions of Multivessel Disease and Left Main… DOI: http://dx.doi.org/10.5772/intechopen.89419*

DAPT. The additional use of OCT image can be considered a standard procedure with a very low risk of major complications 0.4% [44]. VeRy thin Stents for Patients with Left mAIN or bifurcation in real life: the RAIN Multicenter Study, for coronary stents, reducing the thickness of the struts has become one of the most important innovations, since it is related to easier crushability and reduced risk of thrombosis and low rate of TVR. They performed a multicenter registry of patients treated with Biomatrix flex, Xience Alpine, Ultimaster, Resolute Onyx and Synergy. MACCE (death, MI, TLR and stent thrombosis) will be the primary end point [45].

## **2.8 Conclusions**

*The Current Perspectives on Coronary Artery Bypass Grafting*

to translate into improved clinical results [42].

**2.6 Guidelines**

or an area of < 6 mm<sup>2</sup>

**2.7 Ongoing trials**

with Medina 1,1,1 or 0,1,1 [33, 38]. In both studies, a reduction in ischemic events was observed. The decision to use a bifurcation technique with one or two stents is basically in the exact evaluation of the compromise of the origin of the left coronary circumflex or the left coronary ramus in a trifurcation. The best way to assess these vessels is with the images of the IVUS or the optimal coherence tomography (OCT) [39]. When the provisional stent technique is used and a residual obstruction of around 50% is observed, the measurement with functional study with iwFR or FFR could be considered as a complement in the decision-making of its definitive treatment. The use of kissing balloon and POT has been invoked as optimizers for this complex carrefour. Also, the post-stent images or stents of both the IVUS and the OCT are important when making decisions, since these elements clearly inform two elements that are key such as uncovered dissections or stent not well positioned [40]. The technique used in the treatment of LMCA is extremely important, just as training in true bifurcation is also difficult. Patients with true bifurcation are those who have Medina 1,1,1 or 0,1,1 and should be treated with two stents and we believe that the technique of choice is DKC. Another important element is to only include patients with low and intermediate ERACI score [17] and leave patients with high scores for very selected centers and true contraindication or patients who really refuses surgery. The use of images in diagnosis, implantation, and postimplantation has become a mandatory strategy, including the use of IVUS and optimal coherence tomography [41]. An element that has been incorporated into the technical arsenal is the technique of proximal optimization. The proximal optimization technique is a key part of treating large bifurcation lesions and will optimize results of both single- and two-stent strategies. An appropriately sized balloon should be positioned and inflated just up to the carina. When performed well, the enhanced lesion scaffolding, reduced strut mal-apposition, and improved flow dynamics are likely

The evidence is clear regarding patients with low scores, where treatment with both PCI and CABG is appropriate, where there is a class I recommendation. In patients with high scores, because the evidence is much lower because many of these patients have been excluded from RCTs, the recommendation for PCI is class III, since the benefit is clearly greater with CABG. In patients with intermediate scores, due to the lack of evidence in the long-term follow-up, the recommendation remains IIa [20, 43]. When one makes a global evaluation of the LMCA and addresses the guidelines, one must also take into consideration the different portions of the LMCA such as the ostium, the middle third, and the distal third, since they have different implications, both in the technique and in the evolution of these patients, so they would probably have to be analyzed separately. Also the degree of angiographic stenosis has been changing and should not be left with the 50% obstruction that has been used universally, and perhaps it should be passed at least 70%. Although this analysis can have many deficiencies, the use of images such as IVUS or OCT or even functional studies with iwFR or FFR can be closer to a true significant obstruction. It is believed that a minimum luminal diameter of 2.8 mm

would suggest a physiologically significant obstruction [21].

Xience versus Synergy in LMCA PCI (ideal-LM), PCI of the LMCA a comparison of the newest generation of DES in combination with a short duration of

**14**

In the treatment of severe LMCA in patients with low to intermediate ERACI score, the percutaneous treatment is of choice. In those with a higher score or who have total occlusions and are DM, surgical treatment is better. It is very important to evaluate each case in particular as well as work with a heart team to discuss cases that may generate controversy. The interventional cardiology must be trained in the different bifurcation techniques as well as have images such as IVUS or OCT for procedures. The implementation of the final kissing balloon and the POT in all patients is important. DKC seems to be the technique of choice in LMCA diseases with true bifurcations.
