Distal Left Main Coronary Artery Research Articles

Intravascular lithotripsy compared to rotational atherectomy for the treatment of calcified distal left main coronary artery disease: A single center experience.

The safety and efficacy of intravascular lithotripsy (IVL) for the treatment of calcified distal left main (LM) disease remains unclear, especially compared to rotational atherectomy (RA). We retrospectively analyzed the baseline clinical, angiographic, intravascular ultrasound (IVUS) characteristics and procedural outcomes of 107 patients who underwent distal LM percutaneous coronary intervention (PCI) with IVL (with or without adjunct atherectomy) versus RA alone for plaque modification before stenting at a single center between 2020 and 2022. A total of 50 patients underwent calcium modification with IVL with or without adjunct atherectomy and 57 with RA only. The mean age was 73 years and with a high prevalence of diabetes (58.9%), chronic kidney disease (42.1%), prior revascularization (coronary artery bypass graft surgery [36.4%] or prior PCI [32.7%]). Acute coronary syndrome was the primary indication for PCI in over 50% of the patients in both groups. Medina 1-1-1 LM bifurcation disease was identified in 64% and 60% of the IVL and RA groups (p = 0.64) respectively. Final minimum stent area in distal LM (>8.2 mm2 ), ostial LAD (>6.3 mm2 ) and ostial LCX (>5.0 mm2 ) were achieved in 96%, 85% and 89% of cases treated with IVL respectively and 93%, 93% and 100% of cases treated with RA respectively (LM p = 1.00; LAD p = 0.62; LCX; p = 1.00 for difference between the two groups). Procedural success (technical success without in-hospital major adverse events) was achieved in 98% of the IVL group and 86% of the RA-only group (p = 0.04). There were eight procedural complications (flow-limiting dissection, perforation, or slow/no-reflow) in the RA group compared to four in the IVL group (NS), and one patient in the RA required salvaged mechanical support compared to none in the IVL group. Plaque modification with coronary IVL appears to be efficacious and safe for the treatment of severely calcified distal LM lesions compared to RA only. Larger randomized studies are needed to confirm these findings.

Hybrid Treatment for a Distal Left Main Coronary Artery Aneurysm ― Coronary Artery Bypass Grafting and Surgical Ligation Followed by Intraoperative Covered Stent Implantation ―

Hybrid Treatment for a Distal Left Main Coronary Artery Aneurysm ― Coronary Artery Bypass Grafting and Surgical Ligation Followed by Intraoperative Covered Stent Implantation ―

Unprotected Left Main Bifurcation Stenting in Acute Coronary Syndromes: Two-Stent Technique versus One-Stent Technique.

There is little evidence guiding the choice between a one-stent and a two-stent approach in unprotected distal left main coronary artery disease (UDLMCAD) presenting as acute coronary syndrome (ACS). We aim to compare these two techniques in an unselected ACS group. We conducted a single center retrospective observational study, that included all patients with UDLMCAD and ACS undergoing PCI between 2014 and 2018. Group A underwent PCI with a one-stent technique (n = 41, 58.6%), Group B with a two-stent technique (n = 29, 41.4%). A total of 70 patients were included, with a median age of 63 years, including n = 12 (17.1%) with cardiogenic shock. There were no differences between Group A and B in terms of patient characteristics, including SYNTAX score (median 23). The 30-day mortality was 15.7% overall, and was lower in Group B (3.5% vs. 24.4%, p = 0.02). Mortality rate at 4 years was significantly lower in Group B (21.4% vs. 44%), also when adjusted in a multivariable regression model (HR 0.26, p = 0.01). In our study, patients with UDLMCAD and ACS undergoing PCI using a two-stent technique had lower early and midterm mortality compared to one-stent approach, even after adjusting for patient-related or angiographic factors.

Gender differences in clinical characteristics, angiographic profile, and outcomes of left main coronary artery disease

Context: Left main coronary artery (LMCA) disease is associated with high morbidity and mortality in spite of advances in management. There is a paucity of data on the gender differences in LMCA disease. Aims: We aimed to study the clinical characteristics, angiographic profile, and outcome of coronary artery disease patients with significant LMCA disease. Settings and Design: This is a prospective observational study among patients with significant LMCA disease undergoing coronary angiography in a tertiary care center. Subjects and Methods: We compared clinical, angiographic characteristics among male and female patients with significant LMCA disease and followed up for 4 months. Statistical Analysis Used: Differences between the groups were compared with Student's t-test for parametric continuous variables. Chi-square test was applied for estimating the occurrence of categorical variables. Pearson's correlation coefficient was used to test the relationship between parameters. Results: Among 100 consecutive patients with LMCA disease, 70 were males and 30 were females. Chronic stable angina was the most common presentation. Distal LMCA was the most common site. Isolated LMCA disease was less compared to LMCA + multivessel disease. Coronary artery bypass grafting was the predominant management strategy. Mortality rates at 6 months were higher in females compared to males (20% vs. 3.3%). Conclusions: LMCA disease has mostly similar angiographic and clinical characteristics among males and females. LMCA disease is associated with high mortality in females compared to males.

180 LONG TERM FOLLOW UP OF A NON-PROGRESSIVE LEFT MAIN CORONARY ARTERY FISTULA TO RIGHT ATRIUM

Abstract A 63 years old man, with multiple cardiovascular risk factor, presented at the emergency department with a transient ischemic attack during an hypertensive crisis. Electrocardiogram revealed a sinus rhythm and no sign of ischemia. No critical stenosis were detected at ultrasonography of the supra-aortic trunks. Brain CT showed an arachnoid cyst in right posterior cerebellar site. Transthoracic echocardiographic showed normal wall motion with a left ventricular ejection fraction of 66%. The transesophageal echocardiography, performed for searching possible emboligenic heart disease, revealed a fistulous aneurysmal formation arising from the left main coronary artery. Angio-CT confirmed a CAF between distal left main coronary artery and right atrium, with a retro-aortic serpiginous course and an ectasic vascular structure (above 8.35 mm), this pathological vessel also had an aneurismatic formation of maximum diameter of 1 cm. CT scan detected also a 50% soft eccentric plaque in mid circumflex coronary artery and a less than 50% soft eccentric plaque in the right coronary artery. An elective hospitalization was performed in order to better assess the CAF. Coronary angiography revealed no significant coronary atherosclerotic disease and confirmed the CAF with its convoluted course. No left to right shunt was found either in cardiac magnetic resonance (Qp/Qs close to 1) or in right heart catheterization. Maximal stress test with cycloergometer was negative for clinical and electrocardiographic inducible ischemia (120W). CAF is a rare vascular abnormality, occurring in only 0.002% of the general population. The majority of CAFs have a congenital origin, but occasionally they may be acquired after cardiac surgery or repeated myocardial biopsies in cardiac transplantation. The CAFs may increase in size over time, although this does not occur invariably, and complications include: myocardial ischemia (due to myocardial ‘steal’), thrombosis and embolism, heart failure, atrial fibrillation, rupture, endocarditis/endarteritis, arrhythmias and also spontaneous rupture of the CAF causing hemopericardium. Current treatment options for CAF include surgery or transcatheter closure. Considered the age of the patient, the absence of clinical symptoms and the absence of left to right shunt, a conservative strategy was chosen. The patient had strict follow up, with clinical and echocardiographic assessment every 6 months, and with annually CT scan and stress test. During these 9 years of follow up the CAF remained stable, and the patients clinically asymptomatic.

Left Main Coronary Artery Bifurcation Lesions: Two Stents vs One Stent Strategy-Comparison of Major Adverse Cardiac Events (MACE) at 2 years

Objective: To evaluate the long-term clinical results for a one-stent (1S) strategy compared to a two-stent (2S) strategy in distal unprotected left main coronary artery (ULMCA) bifurcation disease.
 Study Design: Comparative Cross-sectional study.
 Place and Duration of Study: Armed Forces Institute of Cardiology, Rawalpindi Pakistan, from Jan 2019 to Apr 2020.
 Methodology: 1-S approach was defined as stenting of the main vessel only and 2-S approach as stenting side branch and main vessel. Individual undergoing LMCA intervention were included via consecutive sampling in the study. Stent Crossover approach was used in 1-S technique; whereas, DK crush, culotte, and T-stenting approaches were employed in individuals who were treated with a 2-S approach. A composite of major adverse cardiovascular event (MACE) i.e., myocardial infarction, stroke or death and target lesion revascularization (TLR) were considered as primary end-point.
 Results: A sum of 110 individuals were inducted, 74 of them had stenting of left main bifurcation using a 1-S approach; and 36 patients underwent a 2-S PCI. Average age of the patients included in the study was 63.9±10.8 years. In 1 stent subset, the success rate of procedure was 99% whereas 100% success rate was seen in 2-S group. During the 2-year duration of follow up,frequency of MACE in single stent subset was (5.4%) whereas it was (13.8%, p=0.253) in the 2-S subset.
 Conclusion: When compared to 2-S approach of distal left main stenting, a 1-S strategy appears to demonstrate optimal clinical results and 2-year survival free of MACE. Choosing appropriate interventional strategy has proven prognostically significant; so, it demands mindful approach selection.

Debate: Percutaneous revascularization strategies for distal left main coronary artery disease. Approach from the DKCRUSH-V trial

Debate: Percutaneous revascularization strategies for distal left main coronary artery disease. Approach from the DKCRUSH-V trial

Debate: Percutaneous revascularization strategies for distal left main coronary artery disease. The EBC MAIN approach

Debate: Percutaneous revascularization strategies for distal left main coronary artery disease. The EBC MAIN approach

Behavior of restenosis after distal unprotected bifurcation left main coronary artery stenting

Behavior of restenosis after distal unprotected bifurcation left main coronary artery stenting

Left main coronary artery dimension and variation in Thai population

Abstract Funding Acknowledgements Type of funding sources: None. Objectives The aim of our study was to determine the length, proximal and distal dimension of the left main coronary artery (LMCA) in Thai population with normal LMCA, from coronary computed tomography angiography (CCTA). Background The dimensions and length of the coronary artery are important to treatment planning and outcome prediction after revascularization. The previous studies showed that coronary artery dimensions are influenced by age, sex and BSA which may be effected by race. Recently, very limited data about coronary artery dimensions in general Thai population are available. Methods 560 patients who have undergone CCTA at a Thai hospital with normal coronary angiogram of LMCA and no history of previous percutaneous coronary interventions and coronary artery bypass graft surgery were included in the study. The LMCA cross-sectional dimensions were obtained at two points of each vessel: ostium and distal. The length of LMCA was studied. The baseline characteristics data of participants such as age, body weight, height body surface area (BMI) and body surface area (BSA) and the other findings of CCTA on the LMCA dimensions and length were evaluated. Results This study showed that the mean cross-sectional dimensions of the proximal and distal of LMCA were 3.89 ± 0.76 mm. and 3.4 ± 0.67 mm. respectively. The mean length of LMCA was 8.66 ± 3.69 mm. The dimension of vessels in males were significantly larger in size than females. The proximal and distal LMCA dimensions in males were 3.98 ± 0.81 mm. and 3.8 ± 0.69 mm. respectively. And the proximal and distal LMCA dimensions in females were 3.51 ± 0.72 mm. and 3.27 ± 0.59 mm. respectively. The factors of significant correlations were found with sex, height, weight, BMI, BSA, left dominant vessel and coronary artery calcium scores (CACs) on the proximal and distal dimensions of LMCA. In multivariate analysis, BSA and dominant system were showed significant correlation to the proximal dimension of LMCA, and BSA was showed significant correlation to the distal dimension of LMCA. The influences on length of LMCA were height, weight, BMI, BSA, right dominant vessel and CACs but no factors were significant correlation by multivariate analysis. Conclusions The length, proximal and distal dimensions of LMCA in general Thai population were differences from the previous studies which were studied in other nations. The influences on the dimensions of LMCA were sex, height, weight, BMI, BSA, left dominant vessel, and CACs. And the influences on the length of LMCA were height, weight, BMI, BSA, right dominant vessel and CACs.

Presence of ramus intermedius increases the risk of atherosclerotic plaque formation at the left main bifurcation's region: A retrospective study from CT coronary angiography in UMMC

<h2>Background</h2> Ramus intermedius (RI) is a variant vessel arising from the left main bifurcation angle (LMBA). Haemodynamically, its presence increases coronary turbulence flow and reduces the endothelial shear stress. In theory, this haemodynamic effect promotes atherosclerotic plaque formation, especially around the bifurcation region. <h3>Objectives</h3> This study aims to identify RI as a risk factor for atherosclerosis at the left main coronary artery (LMCA), proximal left anterior descending (LAD) and proximal left circumflex (LCx) using coronary computed tomography angiography (CCTA). <h3>Methodology</h3> A retrospective review was carried out on 374 CCTA cases in University Malaya Medical Centre (UMMC) between January 2017 and December 2018. The atherosclerotic plaque at the LMCA, proximal LAD and proximal LCx arteries were analysed in the presence or absence of RI. Statistical analysis was done using the chi-square test and binary logistic regression. <h3>Results</h3> RI was identified in 32.4% (<i>n</i> = 121) of patients. Age > 65 years old, male gender, diabetes, hypertension and RI were identified as significant risk factors for atherosclerosis. The presence of RI increases plaque formation by 8.5-fold for proximal and distal LMCA compared to those without RI (aOR: 8.5, 95% CI: 1.7, 43.0, <i>p</i> > 0.001). Meanwhile, at the proximal LAD, RI increases the risk for plaque formation by 3.7 folds (aOR: 3.7, 95% CI: 1.5, 9.4 <i>p</i> = 0.006) at the lateral wall and by 4.9 folds (aOR: 4.9, 95% CI: 1.7, 14.2, <i>p</i> = 0.003) for both lateral and medial wall. RI also independently increases the risk for atherosclerosis by 3 folds at the lateral and medial wall of proximal LCx (aOR: 3.7, 95% CI: 1.2, 11.4, <i>p</i> = 0.020). Lastly, RI increases the risk of obstructive stenosis in the LMCA, LAD and LCx by 3.9 folds (aOR: 3.9, 95% CI: 1.4, 10.5, <i>p</i> < 0.001). <h3>Conclusion</h3> Our findings suggest that the presence of RI independently increases the risk for atherosclerotic plaque formation in the left main stem and its proximity. RI in situ is believed to exert altered haemodynamic effect promoting atherosclerotic plaque formation.

Abstract 10428: Bad Fall, Good Catch: Diagnosing a Rare Condition Presenting as Acute Coronary Syndrome

A 72 year-old mountain bicyclist suffered a biking accident. The following week, he presented to the emergency room with abdominal pain, where he was treated for superior mesenteric artery thrombosis and new-onset atrial fibrillation. Two months later, he presented with intermittent left scapular pain that radiated to the chest. Pharmacologic stress testing revealed a large reversible perfusion defect in the anterior wall with an ejection fraction of 41%. Left heart catheterization showed narrowing of the distal left main coronary artery and the proximal left anterior descending (LAD) and circumflex arteries, by what appeared to be external compression. Follow-up CT angiogram demonstrated two sinus of Valsalva aneurysms (SOVA) originating from the left and right coronary cusps. A transesophageal echocardiogram confirmed these findings and showed tremendous thrombus within the larger aneurysm. The patient was admitted to cardiothoracic surgery. Troponin was elevated to 0.16 μg/L, with EKG showing 1 mm ST-segment depressions in V4-6, prompting treatment for a non-ST segment myocardial infarction. He underwent complex surgery involving thrombus extraction and closure of the SOVA with pericardial patch repair, and coronary artery bypass grafting of the LAD and obtuse marginal arteries. After a prolonged ICU course in which the patient was managed for cardiogenic shock, he was discharged to a hospital equipped with a rehabilitation facility. Unfortunately, he developed profound lactic acidosis from ischemic bowel and passed away. SOVA are rare lesions that arise from congenital or acquired etiologies, such as this patient’s biking accident. Multi-modality imaging is important for quantifying size and anatomy. Unruptured SOVA can present as embolic phenomenon from thrombus, valvular regurgitation, or chest pain from compression of the coronary arteries. Rupture is a highly morbid condition, and so urgent referral to cardiothoracic surgery is recommended.

Procedural characteristics and clinical outcomes in patients undergoing percutaneous coronary intervention for left main trifurcation disease: the EXCEL trial.

Limited data exist regarding procedural and clinical outcomes of percutaneous coronary intervention (PCI) in patients with trifurcation disease of the distal left main (LM) coronary artery. We therefore aimed to examine the procedural methods and early and late outcomes among patients undergoing distal LM trifurcation versus bifurcation PCI in the EXCEL trial. Patients with distal LM bifurcation disease randomised to PCI with everolimus-eluting stents in the EXCEL trial were categorised into those with and without trifurcation involvement. Angiographic and procedural characteristics in addition to clinical events up to five-year follow-up after PCI were compared. Among 605 patients with site-reported distal LM disease, 61 patients (10.1%) were identified with trifurcation anatomy. The five-year primary composite endpoint of death, myocardial infarction, or stroke occurred in 16.6% of patients with trifurcation disease compared with 22.5% of patients with distal bifurcation disease only (p=0.32). Ischaemia-driven target lesion revascularisation rates were also similar (11.9% vs 12.0%, p=0.94). No significant differences in definite or probable stent thrombosis were observed between treatment groups (1.7% vs 2.3%, p=0.76). Despite the greater inherent complexity, procedural and long-term clinical outcomes following PCI of distal LM trifurcations with everolimus-eluting stents in a modest-sized cohort from the EXCEL trial were similar compared with treatment of distal LM bifurcation disease without trifurcations. These findings support PCI as a treatment strategy for selected patients with distal LM trifurcation disease. ClinicalTrials.gov Identifier: NCT01205776.

Long-Term Outcomes After PCI or CABG for Left Main Coronary Artery Disease According to Lesion Location.

The aim of this study was to investigate the impact of lesion site (ostial or shaft vs. distal bifurcation) on long-term outcomes after percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) for left main coronary artery (LMCA) disease. Long-term comparative data after PCI and CABG for LMCA disease according to lesion site are limited. Patients from the MAIN-COMPARE (Revascularization for Unprotected Left Main Coronary Artery Stenosis: Comparison of Percutaneous Coronary Angioplasty Versus Surgical Revascularization) registry were analyzed, comparing adverse outcomes (all-cause mortality [a composite outcome of death, Q-wave myocardial infarction, or stroke] and target vessel revascularization) between PCI and CABG according to LMCA lesion location during a median follow-up period of 12.0 years. In overall population, the adjusted risks for death and serious composite outcome were higher after PCI than after CABG for distal bifurcation disease, which was mainly separated beyond 5 years. These outcomes were not different for ostial or shaft disease. When comparing drug-eluting stents (DES) and CABG, the adjusted risks for death and serious composite outcome progressively diverged beyond 5 years after DES compared with CABG for distal bifurcation disease (death: hazard ratio: 1.78; 95% confidence interval: 1.22 to 2.59; composite outcome: hazard ratio: 1.94; 95% confidence interval: 1.35 to 2.79). This difference was driven mainly by PCI with a 2-stent technique for distal bifurcation. In contrast, the adjusted risks for these outcomes were similar between DES and CABG for ostial or shaft disease. Among patients with distal LMCA bifurcation disease, CABG showed lower mortality and serious composite outcome rates compared with DES beyond 5 years. However, there were no between-group differences in these outcomes among patients with ostial or shaft LMCA disease.

Percutaneous Coronary Intervention for Left Main Coronary Artery Bifurcation Lesions: Two-stent versus one-stent Strategy for Comparison of 6-month MACE.

To assess the short term clinical outcomes for a single-stent (SS) strategy versus a double-stent (DS) strategy in percutaneous coronary intervention (PCI) of distal unprotected left main coronary artery (ULMCA) lesions. Descriptive comparative study. Armed Forces Institute of Cardiology, Rawalpindi, Pakistan from January 2017 to April 2018. SS treatment was defined as stenting of the main branch alone and DS treatment as stenting of both the main and side branches. Patients who underwent LMCA PCI were recruited in the study using consecutive sampling. Crossover technique, with or without kissing balloon (KB) dilatation, was employed in those getting PCI with a SS strategy; whereas, DK crush, mini-crush , culotte and T-stenting techniques were used in patients undergoing PCI with a DS strategy. The primary endpoints were a composite of major adverse cardiovascular event (MACE) i.e. myocardial infarction, stroke or death and target lesion revascularisation (TLR). A total of 103 patients were recruited in the study; out of which, 73 underwent LMCA PCI employing a SS technique; whereas, 30 of them were treated with a DS strategy. Mean age of the study participants was 63.2 ±10.6 years. The procedural success rate was 100% in both groups. There was a lower frequency of MACE with single-stent strategy (4.1%) versus the double-stent strategy (16.7%, p=0.031) during the 6-month follow-up period. In comparison to the two-stent strategy of ULMCA bifurcation intervention, a single-stent approach seems to show favourable clinical outcomes and 6-month MACE-free survival. The choice of optimal revascularisation technique proves to be important for the prognosis; therefore, it requires pragmatic decision-making. Key Words: PCI (percutaneous coronary intervention), ULMCA (unprotected left main coronary artery), SS (single-stent), DS (double-stent), MACE (major adverse cardiovascular events), CABG (cardiopulmonary bypass grafting), TLR (target lesion revascularisation).

Technical Feasibility and Safety of Percutaneous Coronary Intervention for True Ostial Left Anterior Descending Artery–Chronic Total Occlusion

BackgroundPercutaneous coronary intervention (PCI) for true ostial left anterior descending artery (LAD)–chronic total occlusion (CTO) lesions poses technical challenges owing to its inherent anatomic features. MethodsIn total, 270 consecutive patients who underwent PCI for ostial LAD-CTO at 13 major cardiac centers in South Korea were included. Ostial LAD-CTO was strictly defined as a LAD-CTO lesion whose proximal cap was within 1 mm from the carina of the distal left main coronary artery (LMCA) bifurcation. ResultsOstial LAD-CTOs were frequently accompanied by stumpless lesion entry (43.4%), whereas significant bending within the occluded segment was less frequent (14.4%). The overall technical success rate was 85.9%, and serious in-hospital adverse events occurred in 5.6%. The retrograde approach tended to contribute more frequently to success in patients with concomitant LMCA disease, stumpless CTO, interventional collaterals, and higher Japanese-CTO scores. Apparent dissection or hematoma requiring rescue procedure at the LMCA or left circumflex artery occurred in 14 patients (5.2%), with a higher tendency in patients who had LMCA disease (12.1% vs 4.2%) and stumpless entry (9.4% vs 2.0%) than in those without. Among patients who were successfully treated, with an average of 1.7 stents, target-vessel failure occurred in 23 patients (9.9%) during a median 3.3 years of follow-up. ConclusionsIn this first large-scale analysis of true ostial LAD-CTO, PCI was feasible with a high technical success rate and favourable mid-term outcomes. Clinically relevant inflow vessel injury can occur during PCI and should be an important technical consideration regarding safety.

A lateral lead variant of the de Winter pattern due to left main stenosis and left anterior descending artery occlusion

Early recognition of ST-segment elevation myocardial infarction equivalent electrocardiogram patterns is of paramount importance. Successful identification of these ischemic patterns helps ensure proper triage of patients needing urgent restoration of coronary perfusion. The so-called de Winter sign has become increasingly recognized as a ST-segment elevation myocardial infarction equivalent pattern due to proximal left anterior descending artery occlusion. Yet, despite the de Winter pattern's well-defined electrocardiographic-angiographic relationship, the electrophysiologic explanation for its characteristic electrocardiographic manifestations remains unclear. Herein, we report a case in which an ischemic lateral lead variant of the de Winter pattern emerged from a patient inflicted by an abrupt thrombotic occlusion of the ostial left anterior descending artery, which developed in series with a high-grade stenosis of the distal left main coronary artery. We examine the patient's presenting electrocardiographic findings and clinical course to (i) establish causal inferences that align with the distribution of myocardial ischemia supported by coronary angiography and (ii) provide an accompanying analysis of the relevant scientific literature.

885 Spontaneous Coronary Artery Dissection

Spontaneous coronary artery dissection (SCAD) is an uncommon cause of Acute Coronary Syndrome (ACS). Predisposing factors include fibromuscular dysplasia, connective tissue disease and systemic inflammatory conditions. There is predilection to female sex. Pregnancy associated (p-SCAD) has the worst clinical outcome- the cause of which is not entirely understood. We describe the case of a 34-year-old woman, at 14 weeks of pregnancy, who presented to Emergency Department with sudden onset of central chest pain and shortness of breath. No preceding triggers or cardiovascular risk factors were identified. ECG showed anterolateral ST segment elevation and she was haemodynamically unstable. She underwent emergency Coronary Angiogram that revealed SCAD of left main coronary artery (LMCA) / proximal left anterior descending artery (LAD) with TIMI flow 0. Percutaneous coronary intervention restored TIMI 3 flow. At 38+3 weeks she had an elective Caesarean section and underwent permanent contraception with bilateral salpingectomy. Our case is interesting as due to clinical instability, compromised haemodynamics and involvement of distal LMCA/ proximal LAD, intervention was preferred over conservative approach. Appropriate interventional strategies helped overcome technical difficulties and avoid complications. We addressed the use of pharmacy during pregnancy and lactation. Fortunately, she had no complications due to interruption of dual anti-platelet therapy at time of Caesarean section and pro-thrombotic post-partum period. She has minimal risk for p-SCAD recurrence due to permanent contraception. Our case highlights SCAD as an important differential in young women presenting with chest pain; early recognition is imperative as treatment differs from ACS.

P2697Percutaneous coronary intervention with 2nd generation drug eluting stent versus coronary artery bypass grafting in patients with unprotected left main disease: clinical outcome from a referral center

Abstract Background Percutaneous coronary intervention (PCI) of unprotected left main coronary artery disease is currently recommended as an alternative to coronary artery bypass grafting (CABG) in patients with low and intermediate SYNTAX score. Purpose We sought to compare clinical outcomes of unprotected left main coronary artery disease by PCI or CABG in a “real world” population referred to high volume center. Methods All consecutive patients with unprotected left main coronary artery disease treated by PCI with second-generation drug-eluting stent were compared to those treated by CABG. The primary endpoint was the composite of death, non-fatal myocardial infarction (MI) or stroke at 2 years follow-up. Results A total of 558 patients were included. The mean age was 71±9 years, diabetes was present in 29%, and 56% of the patients presented with acute coronary syndrome. The distal left main coronary artery was involved in 84.6% of the lesions, the rate of Syntax score &gt;32 was 50%. At 2 years, the primary end-point occurred in 10% of the patients in the PCI group and in 9.6% in the CABG group (p=0.862). The rates of death, non-fatal MI or stroke at 2 years were comparable; conversely the rate of ischemia driven revascularization at 2 years was higher in PCI group than CABG (5.5% and 1.5% p=0.010, respectively in PCI and CABG group). Kaplan-Meier curves of MACCE Conclusions In a “real world” population with unprotected left main coronary artery disease, PCI with second generation stent, as compared to CABG, showed similar rates of the composite end point of death, non-fatal MI or stroke at 2 years, irrespective of coronary anatomy complexity.

Complex percutaneous coronary intervention of highly calcified distal left main coronary artery supported by percutaneous left ventricular assist device in an octogenarian with severely reduced left ventricular ejection fraction

Complex percutaneous coronary intervention of highly calcified distal left main coronary artery supported by percutaneous left ventricular assist device in an octogenarian with severely reduced left ventricular ejection fraction