Abstract
Background: Percutaneous coronary intervention (PCI) has been increasingly employed to treat unprotected left main (ULM) stenosis, with hard endpoints similar to by-pass surgery, in patients selected by a Heart Team. Methods: From January 2008 to December 2011, 317 unselected and consecutive patients with de novo ULM stenosis underwent PCI with both bare metal (BMS) and drug-eluting (DES) stents. Major adverse cardiovascular events, target lesion (TLR) and vessel (TVR) revascularization were evaluated over a mean period of 590 ± 371 days. Results: Our population was characterized by a mean age 72 ± 10 years, high rate of acute coronary syndrome (ACS) (either with ST or non-ST elevation myocardial infarction, 15.5% and 35% respectively), severe comorbidity 16%, mean Euroscore 7 ± 3, mean Syntax Score 25 ± 9. In-hospital mortality was 6%. During the follow-up period, all-cause mortality was 16.7%, falling to 7% at the end of the follow-up, excluding patients presenting with ACS. TLR was observed and treated in 15% of patients. BMS utilization, age >75 years, ACS indication, Syntax Score >32 and associated peripheral artery disease were independent predictors of mortality at multivariate analysis. Conclusions: Stenting of ULM stenosis appears to be associated with a favorable mid-term outcome, even in an unselected population.
Highlights
IntroductionUnprotected left main (ULM) percutaneous coronary intervention (PCI) has recently become a valid alternative to coronary artery bypass graft (CABG) showing similar mid-term results for hard endpoints (death and myocardial infarction) even if still penalized by a higher rate of repeated revascularization in the drug-eluting stent (DES) era.Four randomized studies [1,2,3,4], 1 metanalysis [5], and several mono and multicentre registries [6,7,8,9,10,11,12,13,14,15] support these conclusions and 2010 ESC/EACT guidelines on myocardial revascularization have recognized a class IIa or IIb level of indication for unprotected left main (ULM) Percutaneous coronary intervention (PCI) [16] and probably they will be updated to a level of evidence A
Most of the patients were admitted with an acute coronary syndrome (ACS), who had frequent comorbidities and a complex anatomic situation frequently associated with multivessel disease (Tables 1 and 2)
The peculiarity of our left main (LM) Percutaneous coronary intervention (PCI) experience lies in the absence of a proper “heart team” and in the presence of experienced operators leading to the preferred choice of the percutaneous revascularization option if possible without employing more than 4 - 5 stents, and in the absence of absolute contraindications to drug-eluting stent (DES)
Summary
Unprotected left main (ULM) percutaneous coronary intervention (PCI) has recently become a valid alternative to coronary artery bypass graft (CABG) showing similar mid-term results for hard endpoints (death and myocardial infarction) even if still penalized by a higher rate of repeated revascularization in the drug-eluting stent (DES) era.Four randomized studies [1,2,3,4], 1 metanalysis [5], and several mono and multicentre registries [6,7,8,9,10,11,12,13,14,15] support these conclusions and 2010 ESC/EACT guidelines on myocardial revascularization have recognized a class IIa or IIb level of indication for ULM PCI [16] and probably they will be updated to a level of evidence A. Unprotected left main (ULM) percutaneous coronary intervention (PCI) has recently become a valid alternative to coronary artery bypass graft (CABG) showing similar mid-term results for hard endpoints (death and myocardial infarction) even if still penalized by a higher rate of repeated revascularization in the drug-eluting stent (DES) era. In the metanalysis of Capodanno [5], where 1611 patients from 4 randomized clinical trials were evaluated, there were no significant differences between PCI and CABG in 1year death (PCI 3.0% vs CABG 4.1%, p = 0.29) or myocardial infarction (2.8% vs 2.9%, p = 0.95), with increased target vessel revascularization (11.4% vs 5.4%, p < 0.001) and less frequent stroke (0.1% vs 1.7%, p = 0.013) in PCI group. Conclusions: Stenting of ULM stenosis appears to be associated with a favorable mid-term outcome, even in an unselected population
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