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Left main bifurcation lesions: Medina reclassification revisited—as easy as ABC

To the Editor: Revascularization of left main (LM) coronary artery disease by percutaneous coronary intervention is complex, with involvement of the bifurcation in up to 80% of cases. Differences in the distribution and severity of atheroma in the bifurcation leads to wide variability in LM anatomy making revascularization decisions challenging, with disease of the distal LM bifurcation increasing PCI procedural complexity and associated with worse clinical outcomes compared to disease limited to the LM ostium and shaft. The LM (mean 4.5 mm) branches into left anterior descending (LAD; mean 3.6 mm) and left circumflex (Cx; mean 3.4 mm) arteries with a wide range of diameters dependent on age, sex, ethnicity, and circulatory dominance. The most commonly used classification of distribution of disease in the LM is the Medina classification, that assesses plaque burden based on the presence (“1”) or absence (“0”) of stenosis in the proximal main vessel, distal vessel, and side branch. While the Medina classification provides information around the distribution of disease, it provides no information around sizing and therefore whether the LAD or Cx is the dominant branch which would be relevant particularly if a provisional stenting approach is utilized. Furthermore, in the EXCEL trial up to 10% of lesions were distal trifurcation lesions in which the Medina classification cannot be used.