Physiological assessment of left main coronary artery disease

The left main coronary artery (LMCA) is responsible for supplying the majority of the left ventricular myocardium. Visual estimation of stenosis severity on angiography has major limitations and methods to assess functional significance, such as fractional flow reserve (FFR), have been shown to yield better outcomes; however, to date, major trials examining the use of such physiological indices have excluded LMCA disease. Furthermore, LMCA disease commonly co-exists with downstream disease, which complicates the interpretation of coronary physiological data. This review summarises existing evidence for physiology-guided management of LMCA disease. It will also explore the difficulties posed when functionally assessing LMCA lesions and outline potential solutions. Finally, we aim to provide insight into how novel physiological tools may improve the management of LMCA disease in the future