Distal Left Main Lesions Research Articles

Pivotal Decision for Acute Coronary Syndrome Patient with Left Main Coronary Artery Disease, When to Choose PCI over CABG

Background: Surgery is acceptable as a standard treatment of Left Main Coronary Artery (LMCA) Disease in a stable angina condition. But, in Acute Coronary Syndrome (ACS) setting, LMCA intervention is a still clinical challenge in many cardiac centers. Percutaneous coronary intervention (PCI) has emerged as a suitable alternative to coronary artery bypass grafting (CABG) for high-risk complex coronary artery disease (CAD) scenario. This study aimed to outline the management of NSTEMI patient include LMCA disease. Case presentation: A 72-year-old male presented with persistent chest pain, with a confirmed NSTEMI. A coronary angiography was done and revealed Three Vessel Disease (TVD) and Left Main (LM) CAD with highly calcified stenosis in the distal LM and Left Anterior Descending (LAD). An early invasive procedure was successfully performed for severely calcified LAD artery and distal LM lesions, using proper selection of several bail-out pre-dilatation difficult attempts such as scoring ballon and rotational atherectomy (RA). We observed the aftercare period, which showed no subsequent ACS events. Conclusion: Managing ACS patients requires careful consideration and risk assessment before deciding on revascularization procedures, especially in high-risk case such as LMCA disease. PCI can be an effective treatment strategy for this population but require good consideration of patient’s anatomical factors, comorbidities, the availability of appropriate skill and equipment. Keyword: Acute Coronary Syndrome, Coronary Artery Bypass Graft Surgery, Left Main Coronary Artery, Percutaneous Coronary Intervention.

Cost-effectiveness of stepwise provisional versus systematic dual stenting strategies in patients with distal bifurcation left main stem lesions: economic analysis of the EBC MAIN trial

BackgroundIn patients with distal bifurcation left main stem lesions requiring intervention, the European Bifurcation Club Left Main Coronary Stent Study trial found a non-significant difference in major adverse cardiac events...

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.

One-stent Versus Two-stent Techniques for Unprotected Distal Left Main Bifurcational Lesions: Early and Late Outcomes

Background and aim: Left main disease account for 3% to 5% of the coronary lesions. PCI on coronary bifurcation lesions is considered a challenge for any cardiologist. These lesions include a wide spectrum of anatomic complexity varying from simple lesions, which can be managed with a single stent, to complex lesions necessitating more complex procedures. The goal of the present study was to compare the clinical outcomes of PCI with single-stent vs. double-stent implantation for the management of ULMCA distal bifurcation lesions. Patients and methods: a total of 60 cases with ULMCA distal bifurcation lesions eligible for PCI were included in the current study. Cases were divided into 2 main groups: one-stent group (20 cases) and two-stents group (40 cases). All patients underwent follow up during hospitalization and post-discharge at 1 and 6 months. Results: Comparison between the study groups as regards the lesional and angiographic characteristics demonstrated that cases in the one-stent group had significantly lower SYNTAX score (21.70 ± 5.58 versus 24.88 ± 4.93, p=0.028) and lower frequency of true bifurcation lesion (65.0 % versus 100.0 %, p0.001) and higher frequency of 1,1.0 Median class (55.0 % versus 7.5 %, p0.001). Besides, both groups had similar early post-interventional outcomes including hematoma and used target vessel revascularization techniques. Also, no significant differences were reported between both groups as regards the 6-month outcome parameters including cardiac death, TV MI, TVR and TL failure. Conclusions: Both single-stent and two-stents techniques are technically feasible and safe techniques for management of ULMCA with comparable outcomes.

Unrecoverable stent deformation in the left main: Crush it or remove it?

Serial ostial and distal left main lesions continue to be one of the most difficult tasks for the interventional cardiologist, with many potential complications occurring. We present such a high-risk percutaneous coronary intervention where immediate stent explantation was deemed necessary because the metal deformation and high radial strength of the particular stent platform would prevent an acceptable procedural result if it had been crushed to the vessel wall. The aim of this paper was to discuss left main stent deformation, debate the risks and benefits of stent explantation and finally test in-vitro our theory on "insufficient" crush with stents with high radial strength and compare it with conventional stents. Bench-testing supports our ad-hoc explantation decision showing stent underexpansion, recoil, and malapposition, obtaining an inadequate minimal stent area.

Comparison of Clinical and Angiographic Profiles of Patients with or without Left Main Coronary Artery Disease

Background: Left main coronary artery disease constitutes highest risk lesion subset of CAD population. Flow dynamics and pathophysiology in the left main coronary artery are different from that of the other coronary arteries. So traditional risk factors might interact differently with left main artery resulting in different clinical and angiographic characteristics compared to others. Anatomic pattern evaluation in left main coronary artery disease is important in deciding best management options. However, their pattern and profiles were variably shown in different studies with discrepant Results suggesting geographic variation and lead to evaluation of characteristics in our own population. Better understanding this specific problem might lead to further improvement in its management. Methods: It was an observational cross-sectional study. Ninety-one adult coronary artery disease patients over the period of one year who underwent invasive coronary angiogram were studied. Study subjects were divided into two groups after coronary angiogram: Left main (Group 1) and Non-left main (Group 2) CAD. Demographic data, risk factor profiles and angiographic patterns of both groups were compared to see if any statistically significant difference present or not. Results: The mean age and standard deviation in group 1 is 55.2±9.4 and in group 2 is 55.5±12.9; the comparative analysis showed no statistically significant difference. Most of the patients were male 69 (76%) and the comparative study showed statistically significant differences (p=0.046) which showed left main disease tended to be higher in male. Majority (64%) had BMI in normal range with no significant difference. Among the risk factors comparison, diabetes and family history of CAD showed significant association with the left main cohort (p<0.05). Non-ST elevated ACS was the most common presentation and significantly associated with the left main group (p<0.05). On coronary angiogram, there were 80 patients (87.92%) who had no left main artery involvement while 11 patients (12.08%) had left main disease. The comparative study of coronary artery involvement among the two groups reveals no statistically significant differences (p>0.05) but triple vessel disease was found more commonly than single and double vessel disease. Distal lesions (64%) were found more frequently than other types of left main stenosis followed by ostio-proximal lesion (36%). Conclusion: In the patients with left main coronary artery disease, male gender, diabetes mellitus, positive family history and presentation with non-ST elevation ACS were found to be significantly associated. Distal left main lesion and triple vessel disease were commonly found. University Heart Journal 2022; 18(1): 3-9

A new sequential two-stent strategy for treating true distal left main trifurcation lesion.

A new sequential two-stent strategy for treating true distal left main trifurcation lesion.

Angiographic Results After Percutaneous Coronary Interventions in Ostial Versus Distal Left Main Lesions

PurposeWe sought to evaluate angiographic outcomes in ostial and distal LM lesions. Methods176 patients with LM disease undergoing PCI were retrospectively included in this study. 9 months of angiographic and 12 months of clinical follow-up was obtained. Quantitative coronary analysis (QCA) was performed for all lesions, using an 11-segment model. Clinical endpoint measure was a composite endpoint of cardiac death, myocardial infarction and target lesion revascularization (TLR). ResultsDuring 12 months follow up after successful PCI, the composite endpoint occurred more frequently in distal LM bifurcation lesions mainly driven by elevated TLR rates (14.1% in distal LM disease vs. 5.6% in ostial/midshaft LM disease, P = 0.20). Concordantly angiographic binary restenosis (8.2% compared to 0.0%) and late lumen loss (LLL, 0.42 ± 0.97 vs. 0.28 ± 0.34 mm) were increased in distal LM bifurcation lesions compared to ostial LM lesions. In distal lesions highest values for LLL were observed in segments adjacent to the bifurcation (0.37 ± 1.13 mm and 0.37 ± 0.73 mm). On cox proportional regression analysis the angiographic parameter LLL in a bifurcation segment (P = 0.03, HR 1.68 [1.1–2.7]) as well as presence of diabetes mellitus as a clinical parameter (P = 0.046, HR 2.77 [1.0–7.5]) were independent correlates for occurrence of MACE in distal LM bifurcations lesions. ConclusionPCI of ostial LM in accomplished with low LLL (0.28 ± 0.34 mm) and binary restenosis rates. In distal left main lesions highest rates for LLL and binary restenosis were observed in segments nearest to the bifurcation and rather focused on the main vessel (0.42 ± 0.97 mm).

Influence of final kissing balloon inflation on long-term outcomes after PCI of distal left main bifurcation lesions in the EXCEL trial.

The impact of final kissing balloon inflation (FKBI) after percutaneous coronary intervention (PCI) of bifurcation lesions on long-term clinical outcomes remains controversial. We sought to determine the impact of FKBI on four-year outcomes after PCI of distal left main (LM) bifurcation lesions. The EXCEL trial compared PCI with everolimus-eluting stents and coronary artery bypass graft surgery (CABG) in patients with left main (LM) disease. We examined four-year clinical outcomes after PCI of distal LM bifurcation lesions according to use of FKBI. The primary endpoint was the composite rate of death, myocardial infarction (MI), or stroke. The major secondary endpoint was the composite rate of death, MI, stroke, or ischaemia-driven revascularisation (IDR). Among 948 patients randomised to PCI, 759 had distal LM lesions treated, 430 of which were treated with one stent and 329 of which were treated with two or more stents. The four-year rates of the primary and major secondary endpoints were similar with versus without FKBI in both the one-stent and ≥2-stent groups in both unadjusted and adjusted analyses. In the EXCEL trial, the performance of FKBI after PCI of distal LM bifurcation lesions was not associated with improved four-year clinical outcomes regardless of whether one stent or ≥2 stents were implanted.

Angioplasty of the unprotected left main trunk: short and medium term outcomes

RésuméIntroductionNotre but était de déterminer le devenir des patients traités par angioplastie du tronc commun non protégé de l'artère coronaire gauche.MéthodesUne étude rétrospective a porté sur tous les patients traités par angioplastie du tronc commun non protégé de la coronaire gauche entre janvier 2004 et juin 2009. Les données cliniques et angiographiques ont été recueillies sur les dossiers médicaux, complétées par un entretien téléphonique avec le patient ou ses médecins.RésultatsQuarante-huit patients d'âge moyen de 68,50±14,06 ans ont été inclus. Les syndromes coronariens aigus étaient le principal motif d'admission (75%). Les lésions du tronc étaient distales (77,1%) et pluritronculaires (64,6%). Un stent nu a été implanté chez 73% des patients. Après un suivi moyen de 22 mois, le taux d'événements cardiovasculaires majeurs a été de 31,3% dont 20,8% de resténose et 14,6% de revascularisation. Le taux de décès hospitalier a été de 4,2%. Les facteurs prédictifs d'événements cardiovasculaires majeurs ont été un EuroSCORE ≥ 10 et les antécédents cardiovasculaires.ConclusionL'angioplastie du tronc commun est une alternative dans les situations d'urgence ou en cas de contre-indication de la chirurgie. Le risque évolutif des patients est lié à leur risque global avant angioplastie.

Unprotected Left Main Coronary Artery Disease: Management in the Post NOBLE and EXCEL Era.

The optimal management of unprotected left main coronary artery (ULMCA) disease is currently a debated topic. Percutaneous coronary intervention (PCI) has seen an increased adoption for the management of ULMCA disease after numerous small-scale randomised trials and cohort studies showed equipoise with coronary artery bypass grafting (CABG) for low complexity lesions. The recently published NOBLE and EXCEL trials are two of the largest international randomised clinical trials comparing PCI and CABG in patients with ULMCA disease. In lieu of all the available evidence, PCI appears to be equivalent to CABG in regard to mortality in patients with ULMCA disease. In non-diabetic patients with low complexity coronary disease (SYNTAX score ≤32), PCI appears to be a reasonable alternative to CABG, especially for ostial and midshaft left main coronary lesions. CABG is preferable in the presence of diabetes, multivessel coronary disease in addition to ULMCA or complex coronary lesions (SYNTAX score >33) including distal left main lesions.

The European Bifurcation Club Left Main Study (EBC MAIN): rationale and design of an international, multicentre, randomised comparison of two stent strategies for the treatment of left main coronary bifurcation disease

Our aim is to investigate clinical outcomes following single versus dual stenting strategies for the treatment of true bifurcation distal left main coronary artery lesions. The EBC MAIN study is a prospective, multinational, randomised clinical study of left main stem true bifurcation lesions (type 1,1,1 or 0,1,1: both left anterior descending and circumflex artery >2.75 mm diameter). The study hypothesis is that left main coronary bifurcation lesions are best treated with a planned single-stent strategy rather than a planned dual-stent strategy, with respect to death, target lesion revascularisation and myocardial infarction at one year. A total of 450 patients will be enrolled and treated either with a planned single or a planned dual zotarolimus-eluting stent strategy according to randomisation. The primary study endpoint is a composite of death, myocardial infarction and target lesion revascularisation at 12 months. Secondary endpoints are: death, myocardial infarctions, and target lesion revascularisation, each at 12 months; angina status, stent thrombosis, death, myocardial infarction, target lesion revascularisation at three- and five-year clinical follow-up. EBC MAIN will be the first randomised clinical trial to compare single versus dual stenting strategies for the treatment of true bifurcation distal left main coronary artery lesions.

Angioplasty of unprotected left main coronary stenosis: Real world experience of a single-operator group from eastern India

BackgroundCoronary artery bypass graft surgery is the standard treatment of unprotected left main coronary stenosis (ULMCA). However, in the real world scenario, many of these patients are unfit for CABG or prefer angioplasty as an alternative when offered the choice. MethodsA total of 86 clinically stable patients with ULMCA stenosis who were unfit or unwilling for CABG underwent PCI with DES at two tertiary care centers in Kolkata. Patients were followed up prospectively for a median of 34.6 months for major adverse cardiovascular events. Angiographic follow-up was done after 1 year of index procedure or earlier, if indicated. ResultsFifty-five patients (64%) had distal left main stenosis. Two-stent technique was used in 19 patients (22%) and single-stent technique in 36 patients (42%) with distal left main lesion. Thirteen patients (15.1%) had left ventricular ejection fraction (LVEF) of ≤45%. There was no in-hospital death, MI, or stent thrombosis. During follow-up, major adverse cardiac event (MACE) occurred in 9 patients (10.5%). Our study revealed significantly greater MACE in patients with distal left main lesion with LVEF ≤45% (50% vs 6.38%, p=0.0002), high SYNTAX score (36.36% vs 6.82%, p=0.008), and diabetes (17.95% vs 0.00%, p=0.07). Overall, also patients with Diabetes, LVEF ≤ 45%, and SYNTAX score >32 had significantly higher MACE. Use of IC Stent, IVUS, or procedural strategy in distal lesion did not affect MACE. ConclusionIn selective patients with low-intermediate SYNTAX score and without diabetes and LV dysfunction, ULMCA PCI with DES is feasible.

Complex percutaneous coronary intervention for unprotected distal left main bifurcation lesion in a patient with cardiac allograft vasculopathy

Introduction: Cardiac allograft vasculopathy (CAV) is a progressive form of coronary disease that defines the long term prognosis in heart transplant patients. The mortality of surgical revascularization in post-transplant patients is very high. Percutaneous coronary intervention (PCI) has a relatively low periprocedural mortality and high acute angiographic success, but still high restenosis rate and poor long-term results. Bypass surgery (CABG) is considered the gold-standard for unprotected left main coronary artery (LMCA) disease in non-transplant patients, especially with the distal bifurcation lesion. Optimal PCI techniques are needed to improve the results and complex double kissing crush technique seems to be promising. Case Report: We present a case of a 27-year-old patient who received heart transplant at the age of 24. During the second post-transplant year, he developed acute inferior ST-elevation myocardial infarction and primary PCI of RCA was performed. An eccentric LMCA stenosis with an involvement of large ramus intermedius (RI) and almost occluded, minor left circumflex (LCx) were detected on control angio. We decided to perform PCI on this complex lesion with double kissing crush technique. Two wires were positioned distally to the lesions in both the LAD and ramus intermedius (RI). A stent was positioned in the RI with few proximal millimeters protruding into the LMCA, a balloon with a length long enough to cover the protruding stent segment was concurrently positioned in the LAD. The RI stent was deployed. The SB stent-balloon and wire were removed. The balloon in LAD was then inflated at a high pressure to crush the protruding RI stent. The RI ostium was rewired and dilated with a balloon. The bifurcation was then kissed with two balloons. Afterwards, a stent was deployed in the LMCA toward LAD at a high pressure. The RI ostium was rewired for the second time through the LMCA stent strut and dilated with a balloon at a high pressure. The final kissing balloon inflation in the bifurcation was performed at a high pressure and finished with proximal optimization of LMCA. The control angio performed 6 months later showed no signs of restenosis. Summary: The treatment of CAV is very challenging and while CABG remains a poor revascularization option, PCI of complex lesions such as those of LMCA require optimal technique to reduce the incidence of adverse cardiac events and prevent further graft deterioration.

The impact of main branch restenosis on long term mortality following drug‐eluting stent implantation in patients with de novo unprotected distal left main bifurcation coronary lesions: The Milan and New‐Tokyo (MITO) registry

In-stent restenosis (ISR) remains one of the main limitations for percutaneous coronary intervention of unprotected distal left main (UDLM). This study aims to demonstrate the impact of main-branch ISR (MB-ISR) on mortality and to clarify the optimal strategy. Between 2002 and 2008, 482 consecutive UDLM patients treated with drug eluting stent (sirolimus and paclitaxel) were evaluated. During follow-up period (median 52.6 months), MB-ISR occurred in 29, SB-ISR in 65, and MB/SB-ISR in 24. Multivariable analysis demonstrated that the independent predictors of MB-ISR were calcification (HR 2.284, p = 0.016), true-bifurcation (HR 2.331, p = 0.024), insulin-dependent diabetes mellitus (insulin-DM) (HR 2.259, p = 0.048). Furthermore, final proximal postdilatation (FPPD) (HR 0.548, p = 0.077), full LM cover approach (FCA) (HR 0.605, p = 0.093) and greater MLD (HR 0.611, p = 0.062) had a tendency to reduce MB-ISR. Furthermore, the occurrence of MB-ISR within 1-year was associated with cardiac-death (HR 2.734, p = 0.017). The patients with MB-ISR had more comorbidities and complex lesions, resulting in higher risk of cardiac mortality as compared to the patients without MB-ISR. Presence of calcification, true-bifurcation and insulin-DM were associated with MB-ISR following UDLM intervention, while FCA, FPPD, and greater MLD seemed to be associated with the low occurrence of MB-ISR.

Abstract 19241: Evolving Techniques and Outcomes in Left Main Pci With Des

Objective: To evaluate the impact of technical evolutions on clinical outcomes for patients undergoing percutaneous coronary intervention (PCI) with drug eluting stent (DES) for left main (LM) disease. Background: PCI techniques and materials are improving. Those evolutions could have a positive clinical impact for patients undergoing PCI for LM disease. Methods: We compared baseline characteristics, procedural and clinical outcomes in 601 consecutive patients undergoing PCI for LM stenosis with DES from 2004 to 2009. Patients were analyzed in 3 separate groups according to the PCI timing: 2004/2005 (group 1); 2006/2007 (group 2); 2008/2009 (group 3). The primary outcome was death at 1-year. Results: Comparing to 2004/2005, patients undergoing PCI in 2008/2009 were at higher risk (Logistic Euroscore 8.4±0.7% in group 3 vs. 7.4±0.6% in group 1; p=0.045). The radial approach was increasingly used (28.2% in 2004/2005; 34.2% in 2006/2007 and 61.4% in 2008/2009; p<0.0001), a predilation was more frequently performed (32.1% in 2004/2005; 42.7% in 2006/2007 and 45.8% in 2008/2009; p=0.046) and a second generation DES was more frequently used (38.2% in group 3 vs. 0% in group 1; p<0.0001). The stent diameter significantly increased with time (3.5±0.02mm in group 1; 3.6±0.02mm in group 2; 3.7±0.02mm in group 3; p<0.0001) and a post dilation was more often performed (32.1% in group 1; 37.9% in group 2; 46.4% in group 3; p=0.021). One-year mortality is significantly decreasing with time (9.9% in 2004/2005; 8.9% in 2006/2007; 4.1% in 2008/2009; p=0.028), and this difference is driven by fewer deaths in patients treated for distal LM (13.2% in 2004/2005; 8.6% in 2006/2007; 4.2% in 2008/2009; p=0.033). Conclusion: In this observational study, clinical outcome are improving for patients undergoing LM PCI with DES, because of fewer death at one year for patients with a distal LM lesion.

A new surrogate to assess distal left main bifurcating lesions?

Catheterization and Cardiovascular InterventionsVolume 82, Issue 5 p. 746-747 Coronary Artery Disease A new surrogate to assess distal left main bifurcating lesions? Juan C. Leoni MD, Juan C. Leoni MD Division of Cardiovascular Diseases, Mayo Clinic, Jacksonville, FloridaSearch for more papers by this authorMichael S. Levy MD, MPH, Corresponding Author Michael S. Levy MD, MPH Division of Cardiovascular Diseases, Mayo Clinic, Jacksonville, FloridaCorrespondence to: Michael S. Levy, md, mph; Division of Cardiovascular Diseases, Mayo Clinic, Jacksonville, FL 32224. E-mail: levy.michael1@mayo.eduSearch for more papers by this author Juan C. Leoni MD, Juan C. Leoni MD Division of Cardiovascular Diseases, Mayo Clinic, Jacksonville, FloridaSearch for more papers by this authorMichael S. Levy MD, MPH, Corresponding Author Michael S. Levy MD, MPH Division of Cardiovascular Diseases, Mayo Clinic, Jacksonville, FloridaCorrespondence to: Michael S. Levy, md, mph; Division of Cardiovascular Diseases, Mayo Clinic, Jacksonville, FL 32224. E-mail: levy.michael1@mayo.eduSearch for more papers by this author First published: 26 October 2013 https://doi.org/10.1002/ccd.25191 Conflict of interest: Nothing to report. Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article. Volume82, Issue51 November 2013Pages 746-747 SCAI Member Sign in RelatedInformation

Safety in a Very Long Term Follow-up (> 5 Years) of a Cut-off Value of 6 mm2 for the Minimal Lumen Area of Intermediate Left Main Coronary Artery Lesions

Clinical Impact of IVUS-guided Left Main PCI: Insights from the Multicenter Study ESTROFA-LM. Fernando Alfonso, Jose Maria De La Torre Hernandez, Angel Sanchez Recalde, Manuel F. Jimenez Navarro, Armando Perez De Prado, Felipe Hernandez, Omar Abdul-Jawad Altisent, Gerard Roura, Tamara Garcia Camarero, Jaime Elizaga, Fernando Rivero, Federico Gimeno, Ramon Calvio, Jose Moreu, Francisco Bosa, Jose Ramon Rumoroso, Juan A. Bullones, Arsenio Gallardo, Jose A. Fernandez Diaz, Jose R. Ruiz Arroyo, Victor Aragon, Monica Masotti. Hospital Universitario Marques de Valdecilla, Santander, Spain; Hospital Clinico San Carlos, Madrid, Spain; Hospital La Paz, Madrid, Spain; Hospital Virgen de la Victoria, Malaga, Spain; Hospital de Leon, Leon, Spain; Hospital 12 de Octubre, Madrid, Spain; Hospital Vall d’Hebron, Barcelona, Spain; Hospital Bellvitge, Barcelona, Spain; Hospital Gregorio Maranon, Madrid, Spain; Hospital La Princesa, Madrid, Spain; Hospital de Valladolid, Valladolid, Spain; Hospital de la Corua. CHUAC, La Corua, Spain; Hospital Virgen de la Salud, Toledo, Spain; Hospital Clinico de Tenerife, Santa Cruz de Tenerife, Spain; Hospital de Galdakano, Bilbao, Spain; Hospital Carlos Haya, Malaga, Spain; Hospital de Albacete, Albacete, Spain; Hospital Puerta de Hierro, Madrid, Spain; Hospital Clinico Lozano Blesa, Zaragoza, Spain; Hospital de Jaen, Jaen, Spain; Hospital Clinic, Barcelona, Spain. Background: Percutaneous revascularization of left main coronary artery (LMCA) lesions with drug eluting stent (DES) is an alternative to surgery in high risk patients and in those cases with non severe coronary disease. Whether the use of intravascular ultrasound (IVUS) during the procedure adds a clinical benefit remains unclear. There is only one single study (MAIN COMPARE) that supports this statement. Therefore we sought to investigate the clinical impact of the use of IVUS in this setting. Methods: From a retrospective multicenter study that compared different DES in the setting of left main we have analyzed the clinical impact of the use of IVUS. Consecutive patients from 21 different hospitals with leftmain lesions treatedwithDESwere included. A systematic follow upwas performed. A propensity scorematchingmethodwas used to obtain matched pairs of patients with and without IVUS guidance during DES implantation in LMCA. Results: A total of 770 pts were included in the registry. IVUS was used in 233 cases (30.2%) and not used in 537 pts. After a three years follow up period the use of two stents, age, diabetes and acute coronary syndrome were found independent predictors of events in the global group after a Cox analysis. In the subgroup of 409 (53.1%) patients with distal left main lesions the independent predictors were the use of two stents, age, diabetes and the use of IVUS, being the latest a protective predictor (HR 0.5, IC 95% 0.23-0.99; p1⁄40.04). After propensity score matching 200 matched pairs of patients treated with DES in LMCA with and without IVUS were included in the analysis. Among these, 80 and 85 pts in each group respectively were treated in distal LM lesions. The data for survival free of events at 3 years are shown in table: No IVUS N1⁄4200 IVUS N1⁄4200 p Cardiac death, MI and TLR 86.7% 90.2% 0.9 Cardiac death and MI 89.2% 94.7% 0.6 TLR 97.3% 94% 0.4 Distal lesions No IVUS n[85 IVUS n[80 Cardiac death, MI and TLR 82% 94.4% 0.08 Cardiac death and MI 84% 95.7% 0.09 TLR 97.5% 95.7% 0.9 The American Journal of Cardiology APRIL 23e26, 2013 AN Conclusion: The results of this multicenter registry suggest a potential clinical benefit derived from IVUS-guided PCI with DES in distal left main lesions.

225: Impact of platelet function monitoring and optimization of dual antiplatelet therapy in patients with unprotected left main disease treated by percutaneous coronary intervention: The ALMA Registry

Cardiac surgery is the recommended treatment for patients with left main (LM) disease, although percutaneous coronary intervention (PCI) is emerging as an alternative technique. Stent thrombosis (ST) even if rare is a serious complication after PCI with high rate of mortality. Aggregation tests can identify patients with high platelet reactivity under clopidogrel and aspirin. The objective of this registry was to evaluate the 2-years rate of ST and outcomes in patients with PCI for unprotected LM disease and adapted dual antiplatelet therapy (DAPT) according to aggregation tests. Fifty one patients with LM disease were prospectively included in a single center registry. Acute myocardial infarction (MI) and cardiogenic shock were exclusion criteria. DAPT response was evaluated by VASP index and light transmission aggregometry (LTA) with acid arachidonic acid (AA 0.5 mg/ml) and with adenosine diphosphate (ADP 20 µmol/L). Patients were 67±12 years old, 52% were diabetic, 33% admitted for acute coronary syndrome and 61% had multivessel disease. For distal LM lesions (73%), the provisional T-stenting approach was used in all cases with 84% of final kissing balloon inflation and 20% of T stenting. 27% patients were aspirin non responders (LTA-AA 0.5 mg/ml≥20%) and 47% clopidogrel non responders according to VASP index (≥50%). After optimization of DAPT, aspirin was given twice a day in 27% of patients, prasugrel in 45%, clopidogrel high dose (≥150 mg) in 35% and clopidogrel standard dose (75 mg) in only 20%. At 2 years, no ST occurred. Outcomes were 24% with 3 non Q-wave MI (6%), 2 cerebrovascular accidents (4%), and 7 repeat revascularizations (14%) with 4 target lesion revascularization (8%). Mortality rate was 4% (n=2) with one cardiovascular death (2%). Unprotected LM stenting and systematic platelet function assessment with DAPT optimization provides excellent clinical outcomes without any stent thrombosis at 2 years.

Unprotected left main stenting in the real world: five-year outcomes of the French Left Main Taxus registry

Limited long-term data are available to support drug-eluting stent (DES) unprotected left main (LM) intervention. We sought to evaluate long-term outcomes of LM intervention with paclitaxel-eluting stents. In this prospective multicentre registry, 291 patients with unprotected LM stenosis underwent percutaneous revascularisation with the TAXUS® Express® stent, using a consistent technical approach for both ostial/shaft and bifurcation lesions (provisional side branch stenting). At five years (n=263), the cumulative incidence of major adverse cardiac events (MACE) and cardiac death were 23.6% and 12.5%, respectively. Myocardial infarction (MI) occurred in 16 patients (6.1%), definite stent thrombosis in 0.4%, and target lesion revascularisation (TLR) was required in 10.3%. Patients with distal LM lesions requiring two-stent procedures had increased MACE compared with those with single-stent interventions (34.1% vs. 17.8%, p=0.009). This was primarily driven by an increased incidence of cardiac death (18.2% vs. 8.5%, p=0.05). Diabetes was associated with increased TLR and was an independent predictor of MACE at five years (odds ratio [OR] 2.10, 95% confidence interval [CI] 1.10-3.99, p=0.02). This study confirms the long-term safety and efficacy of the TAXUS® DES in unprotected LM stenting. Diabetes and the need for a second stent in distal LM interventions were associated with an increased risk of adverse outcomes.