10.2 Left Main PCI: New Life Following a NOBLE Effort?

Problem Presenter: Hadley Wilson for Ayman Magd

These proceedings summarize the educational activity of the 18th Biennial Meeting of the International Andreas Gruentzig Society held January 27 to 30, 2026, in Puerto Ayora, Santa Cruz, Ecuador.

Faculty Disclosures     Sponsors

2026 IAGS Summary Document

Statement of problem or issue

Current guidelines from both European and United States cardiovascular societies recommend revascularization with CABG over PCI for patients with left main disease (Figure 1).[1,2]

These recommendations were based on two large clinical trials of revascularization in patients with left main disease, EXCEL and NOBLE, which compared CABG with PCI.[3,4] At 5-years after their index procedures, patients in both trials showed no difference in mortality, but significant differences in other endpoints like myocardial infarction and ischemia-driven repeat revascularization, all in favor of CABG.

Gaps in current knowledge

Recent investigation has revealed a large knowledge gap in our understanding of PCI in left main disease, especially as derived from these two large trials, EXCEL and NOBLE. The 10-year results from the NOBLE trial revealed that all-cause mortality was lower in patients with acute coronary syndromes treated with PCI compared to CABG, whereas mortality was equivalent in patients with chronic, stable coronary syndromes (Figure 2).[5]

Additionally, further analysis of these two trials revealed the important role that intravascular ultrasound (IVUS) imaging may have played. In the NOBLE trial, the 10-year outcomes data revealed that the lowest mortality was observed in patients with IVUS-guided PCI (Figure 3).[5] In the EXCEL trial, it was noted that larger minimal stent area (MSA) in the left main, as determined by IVUS at the conclusion of the PCI procedure, was associated with significantly better long term clinical outcomes.[6]

Possible solutions or future directions

At the times that these two large trials, EXCEL and NOBLE, were undertaken, there was greater emphasis placed on stent deployment techniques and less on lesion preparation, procedure optimization, and use of imaging guidance. The task for the future will be to explore all of this new information. The role of IVUS-guided lesion preparation prior to stent implantation, adjunctive therapies like intravascular lithotripsy (IVL), atherectomy, and others, require thorough investigation.

References

1. Neumann FJ, et al; ESC Scientific Document Group. 2018 ESC/EACTS Guidelines on myocardial revascularization. Eur Heart J. 2019;40(2):87-165. doi: 10.1093/eurheartj/ehy394. Erratum in: Eur Heart J. 2019 Oct 1;40(37):3096. doi: 10.1093/eurheartj/ehz507. PMID: 30165437.
2. Lawton JS, et al. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022;145(3):e18-e114. doi: 10.1161/CIR.0000000000001038. Epub 2021 Dec 9. Erratum in: Circulation. 2022 Mar 15;145(11):e772. doi: 10.1161/CIR.0000000000001060. PMID: 34882435.
3. Stone GW, et al; EXCEL Trial Investigators. Five-Year Outcomes after PCI or CABG for Left Main Coronary Disease. N Engl J Med. 2019;381(19):1820-1830. doi: 10.1056/NEJMoa1909406. Epub 2019 Sep 28. Erratum in: N Engl J Med. 2020;382(11):1078. doi: 10.1056/NEJMx200004. PMID: 31562798.
4. Holm NR, et al; NOBLE investigators. Percutaneous coronary angioplasty versus coronary artery bypass grafting in the treatment of unprotected left main stenosis: updated 5-year outcomes from the randomised, non-inferiority NOBLE trial. Lancet. 2020;395(10219):191-199. doi: 10.1016/S0140-6736(19)32972-1. Epub 2019 Dec 23. PMID: 31879028.
5. Holck EN, et al. Percutaneous coronary intervention versus coronary artery bypass grafting for unprotected left main stenosis: 10-year final results from the randomised, open-label, non-inferiority NOBLE trial. Lancet. 2026;407(10536):1374-1382. doi: 10.1016/S0140-6736(26)00205-9. PMID: 41936368.
6. Maehara A, et al. Impact of final minimum stent area by IVUS on the 3-year outcome after PCI of left main coronary disease: the EXCEL trial. J Am Coll Cardiol. 2017;69:963.