PURPOSE OF REVIEW: The aim of this article is to review the current 
revascularization strategies in patients presenting with unprotected left main 
coronary artery disease (LMCAD).
RECENT FINDINGS: Coronary artery bypass grafting (CABG) is the current standard 
of treatment for patients with LMCAD. The development and refinement of 
techniques increased the number of percutaneous coronary interventions (PCI) in 
LMCAD patients.
SUMMARY: Although several observational studies show comparable results of CABG 
and/or PCI in patients with LMCAD, there is currently no convincing randomized 
evidence that either one of the two is associated with better long-term 
survival. Recent meta-analyses of four small randomized trials revealed a 
similar rate of 1-year major adverse cardiovascular and cerebrovascular events, 
higher rates of target vessel revascularization and lower stroke rates for PCI. 
Pooling randomized patients studies stratified by lesion complexity strengthened 
the hypothesis that CABG is better in more complex LMCAD patients. However, the 
randomized comparisons are affected by methodological limitations and lack power 
to be conclusive. The ongoing Evaluation of XIENCE V Everolimus Eluting Stent 
System Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main 
Revascularization (EXCEL) trial is expected to provide a better answer on the 
optimal treatment strategy for LMCAD patients. In the meantime, risk models need 
to be improved and the most appropriate revascularization strategy for the 
individual LMCAD patient should be chosen using a multidisciplinary heart team 
that considers not only risk models but also other clinical and economic facets.