Left Main Coronary Artery Disease Research Articles

Assessment of Risk Factors and Angiographic Profile in Left Main Coronary Artery Disease

Background: Diagnostic and management challenges with unpredictable angiographic presentations are encountered in left main coronary artery disease (LMCAD) patients. Therefore, this study was designed to evaluate the prevalence, risk factors, angiographic profile, and outcomes associated with LMCAD at 6-month follow-up. Materials and Methods: This was a prospective observational study where a total of 1474 patients undergoing coronary angiography were enrolled between March 2018 and August 2019. Demographic details, physical examination, and routine biochemical investigations were reported. Obstructive LMCAD patients were managed either with percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) according to syntax score, and outcomes were recorded at 6-month follow-up. Results: The mean age of the overall study population (1474 patients) was 59 ± 8.1 years with male 959 (65%) preponderance. Obstructive LMCAD was observed in 103 (6%) patients. Smoking was the prime risk factor associated with obstructive LMCAD observed among 58 (56%) patients followed by hypertension in 45 (43%), dyslipidemia in 42 (40%), obesity in 26 (25%), and diabetes mellitus in 23 (22%) patients. Among 41 (40%) obstructive LMCAD patients, non-ST-elevation myocardial infarction/unstable angina was the major presentation. The majorly affected target vessels were left anterior descending artery (100%) and left circumflex artery (80%) among 103 and 83 patients, respectively. Triple-vessel disease was predominantly observed among 63 (62%) obstructive LMCAD patients. PCI and CABG were performed in 19 (18.4%) and 27 (26.2%) patients with a mean syntax score of 20 and 31, respectively. Conclusion: Smoking, advanced age, diabetes, and dyslipidemia were significantly associated risk factors of LMCAD.

Percutaneous coronary intervention vs. coronary artery bypass grafting in emergency and non-emergency unprotected left-main revascularization

BackgroundThe optimal revascularization strategy in patients with left main coronary artery (LMCA) disease in the emergency setting is still controversial. Thus, we aimed to compare the outcomes of percutaneous coronary interventions (PCI) vs. coronary artery bypass grafting (CABG) in patients with and without emergent LMCA disease.MethodsThis retrospective cohort study included 2138 patients recruited from 14 centers between 2015 and 2019. We compared patients with emergent LMCA revascularization who underwent PCI (n = 264) to patients who underwent CABG (n = 196) and patients with non-emergent LMCA revascularization with PCI (n = 958) to those who underwent CABG (n = 720). The study outcomes were in-hospital and follow-up all-cause mortality and major adverse cardiovascular and cerebrovascular events (MACCE).ResultsEmergency PCI patients were older and had a significantly higher prevalence of chronic kidney disease, lower ejection fraction, and higher EuroSCORE than CABG patients. CABG patients had significantly higher SYNTAX scores, multivessel disease, and ostial lesions. In patients presenting with arrest, PCI had significantly lower MACCE (P = 0.017) and in-hospital mortality (P = 0.016) than CABG. In non-emergent revascularization, PCI was associated with lower MACCE in patients with low (P = 0.015) and intermediate (P < 0.001) EuroSCORE. PCI was associated with lower MACCE in patients with low (P = 0.002) and intermediate (P = 0.008) SYNTAX scores. In non-emergent revascularization, PCI was associated with reduced hospital mortality in patients with intermediate (P = 0.001) and high (P = 0.002) EuroSCORE compared to CABG. PCI was associated with lower hospital mortality in patients with low (P = 0.031) and intermediate (P = 0.001) SYNTAX scores. At a median follow-up time of 20 months (IQR: 10–37), emergency PCI had lower MACCE compared to CABG [HR: 0.30 (95% CI 0.14–0.66), P < 0.003], with no significant difference in all-cause mortality between emergency PCI and CABG [HR: 1.18 (95% CI 0.23–6.08), P = 0.845].ConclusionsPCI could be advantageous over CABG in revascularizing LMCA disease in emergencies. PCI could be preferred for revascularization of non-emergent LMCA in patients with intermediate EuroSCORE and low and intermediate SYNTAX scores.

Percutaneous Coronary Intervention versus Coronary Artery Bypass Grafting in Complex Coronary Artery Disease: Long-term Clinical Outcomes from a High-volume Center.

Clinical equipoise between a percutaneous coronary intervention (PCI) and coronary artery bypass grafting surgery (CABG) in the treatment of complex coronary artery disease (CAD), including unprotected left main coronary artery (LMCA) and/or three-vessel disease (3VD), remains debatable. A retrospective analysis of an unselected cohort undergoing contemporary PCI versus CABG at a large center in 2015. Patients who received nonemergent treatment of unprotected LMCA and/or 3VD were included. The primary study endpoint was all-cause mortality at 5 years. Secondary endpoints included a composite of all-cause mortality, spontaneous myocardial infarction (MI), or ischemia-driven repeat revascularization at 30 days and 1 year. Four hundred and thirty patients met the inclusion criteria, 225 had PCI, and 205 had CABG. PCI patients were older with frequent LMCA involvement and higher EuroSCORE yet they had a fourfold shorter in-hospital stay compared to CABG patients. At 5 years, there was no significant difference in the primary endpoint between CABG and PCI (adjusted Hazard ratios 0.68, 95% confidence interval: 0.38-1.22, P = 0.19). Likewise, there was no significant difference in the incidence of the secondary composite endpoint or its components at 30 days or 1 year. A propensity score-matched analysis in 220 patients revealed similar outcomes. In real-world long-term contemporary data, survival after PCI was comparable to CABG at 5 years in patients with unprotected LMCA and/or 3VD. At 1 year, the incidence of spontaneous MI and ischemia-driven repeat revascularization did not differ between the two cohorts. The mode of revascularization in these complex patients should be guided by the heart team.

Treatment recommendation based on SYNTAX score 2020 derived from coronary computed tomography angiography and invasive coronary angiography

The diagnostic performance of the SYNTAX score 2020 (SS-2020) when calculated using CCTA remains unknown. This study aimed to compare treatment recommendations based on the SS-2020 derived from coronary computed tomography angiography (CCTA) versus invasive coronary angiography (ICA). This interim analysis included 57 of the planned 114 patients with de-novo three-vessel disease, with or without left main coronary artery disease, enrolled in the ongoing FASTTRACK CABG trial. The anatomical SYNTAX scores derived from ICA or CCTA were evaluated by two separate teams of blinded core-lab analysts. Treatment recommendations were based on a maximal individual absolute risk difference in all-cause mortality between percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) of 4.5% ([predicted PCI mortality] – [predicted CABG mortality]). The level of agreement was evaluated with Bland–Altman plots and Cohen’s Kappa. The mean age was 66.2 ± 9.2 years and 89.5% of patients were male. Mean anatomical SYNTAX scores derived from ICA and CCTA were 35.1 ± 11.5 and 35.6 ± 11.4 (p = 0.751), respectively. The Bland–Altman analysis showed mean differences of − 0.26 and − 0.93, with standard deviation of 3.69 and 5.23, for 5- and 10-year all-cause mortality, respectively. The concordance in recommended treatment for 5- and 10-year mortalities were 84.2% (48/57 patients) and 80.7% (46/57 patients), with Cohen’s κ coefficients of 0.672 and 0.551. There was moderate to substantial agreement between treatment recommendations based on the SS-2020 derived using CCTA and ICA, suggesting that CCTA could be used as an alternative to ICA when making decisions regarding the modality of revascularization.

Impact of on-pump and off-pump coronary artery bypass grafting on 10-year mortality versus percutaneous coronary intervention.

The very long-term mortality of off-pump and on-pump coronary artery bypass grafting (CABG) versus percutaneous coronary intervention (PCI) in a randomized complex coronary artery disease population is unknown. This study aims to investigate the impact of on-pump and off-pump CABG versus PCI on 10-year all-cause mortality. The SYNTAX trial randomized 1800 patients with three-vessel and/or left main coronary artery disease to PCI or CABG and assessed their survival at 10 years. In this sub-study, the hazard of mortality over 10 years was compared according to the technique of revascularization: on-pump CABG (n = 725), off-pump CABG (n = 128) and PCI (n = 903). There was substantial inter-site variation in the use of off-pump CABG despite baseline characteristics being largely homogeneous among the 3 groups. The crude rate of mortality was significantly lower following on-pump CABG versus PCI [25.6% vs 28.4%, hazard ratio (HR) 0.79, 95% confidence interval (CI) 0.65-0.96], while it was comparable between off-pump CABG and PCI (28.5% vs 28.4%, HR 0.98, 95% CI 0.69-1.40). After adjusting for the 9 variables included in the SYNTAX score II 2020, 10-year mortality remained significantly lower with on-pump CABG than PCI (HR 0.75 against PCI, P = 0.009). In the SYNTAXES trial, 10-year mortality adjusted for major confounders was significantly lower following on-pump CABG compared to PCI. There was no evidence for unadjusted difference between off-pump CABG and PCI, although the unadjusted estimated HR had a wide CI. Site heterogeneity in the technique used in bypass surgery has had measurable effects on treatment performance.

Validation of coronary CTA based-British cardiovascular intervention society Jeopardy score (CT-BCIS-JS) against invasive BCIS-JS - a feasibility and reproducibility study

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): Promedica Stiftung and the Iten-Kohaut Foundation in collaboration with the USZ Foundation Background/Introduction The invasive British Cardiovascular Intervention Society Jeopardy Score (iBCIS-JS) is a simple angiographic scoring system, enabling quantification of the extent of jeopardized myocardium related to clinically significant coronary artery disease (CAD). Ranging from 0 (no significant CAD) to 12 (CAD jeopardizing the whole LV- myocardium), the score is used for the entire spectrum of CAD including left main coronary artery and coronary artery bypass graft disease. A score of ≥6 identifies patients with anatomically high-risk CAD. Non-invasive CAD assessment with coronary CTA is hampered by modest specificity, leading potentially to increased utilization of downstream diagnostic tests. Purpose To validate coronary CTA-based assessment of the BCIS-JS (CT-BCIS-JS) against the iBCIS-JS and to assess its feasibility and reproducibility. Methods A total of 137 patients who underwent clinically indicated coronary CTA and subsequent invasive coronary angiography within 90 days were included in the analysis. Eleven patients were excluded due to suboptimal CTA image quality. CT-BCIS-JS and iBCIS-JS were calculated. Correlations were assessed with the Spearman’s rank correlation coefficient and agreement between scores with Bland-Altman (BA) analysis and with weighted kappa statistics. Inter-observer variability was investigated in a subset of 51 randomly selected patients. Results Median and interquartile range (IQR) of CT-BCIS-JS was 4 (IQR=8) and of iBCIS-JS 4 (IQR=8) (Figure 1). A CT-BCIS-JS of ≥6 and was observed in 56 (44%) patients and an iBCIS-JS of ≥6 in 54 patients (43%). An excellent correlation between the iBCIS-JS and the CT-BCIS-JS was observed (rho=0.97, p&amp;lt;0.0001; Figure 2A) with high agreement (BA bias 0.1 and limits of agreement −2.0 to 2.2; Figure 2B). Kappa analysis demonstrated excellent aagreement for identification of a iBCIS-JS of ≥6 (Kappa Weighted= 0.94, 95% CI 0.87–0.99). Inter-observer analysis revealed excellent correlation (rho=0.98, p&amp;lt;0.0001) and agreement (BA bias 0.12 and limits of agreement −1.33 to 1.57). Conclusions The CT-BCIS-JC represents a feasible and highly reproducible tool for accurate, non-invasive identification of patients with anatomically high-risk CAD. Hence, the CT-BCIS-JC may serve as reliable gatekeeper for invasive testing in the management of patients with CAD.

Clinical characteristics and in - hospital outcome of acute coronary syndrome in patients with three - vessel and/ or left main coronary artery disease after percutaneous coronary intervention

ABSTRACT Background: Many studies in Vietnam have shown that there is an increasing number of patients hospitalized due to acute coronary syndrome (ACS) with multivessel stenosis and/or with left main stenosis. The SYNTAX score based on the results of percutaneous coronary angiography is valuable for risk stratification of patients requiring coronary revascularization, especially for those with multivessel coronary artery disease, then optimizing the clinicians’ decision on percutaneous coronary intervention or bypass surgery for these patients. This study aims to: (1) investigate some clinical characteristics of ACS patients with multivessel and/or left main coronary artery disease (LMCAD); (2) characterize coronary artery lesions according to SYNTAX score by the results of percutaneous coronary angiography; and (3) evaluate intervention outcomes and in - hospital outcomes of these patients treated by percutaneous coronary intervention. Methods: 121 patients with three - vessel and/or LMCAD treated at 115 People’s Hospital in Ho Chi Minh city, from July 2019 to July 2020. Research design: retrospective; collecting clinical characteristics, and coronary intervention results during the in - hospital stay. Results: Mean age 66.03 ± 11.84, male/female ratio 3/1; average total coronary lesions 3.1 ± 1.2 lesions in left anterior descending (LAD) and right coronary artery (RCA), mean SYNTAX score 27.7 ± 6.21; Short - term intervention outcomes: anatomical success 99.2%, procedural success 98.34%, major in - hospital main cardiovascular events including fatal death and other - causes mortality during hospitalization was 2.4%, the cumulative intra - and post - procedure complications was 8.2%.

Off-pump CABG surgery in left main coronary artery disease: a single-center prospective registry.

The treatment of left main (LM) coronary artery disease (CAD) requires complex decision-making. Patients with left main multi-vessel coronary artery disease (LM CAD) have concerns regarding incomplete revascularization and reduced survival with off-pump (OPCAB) when compared with on-pump (ONCAB) coronary bypass surgery. To evaluate outcomes among high-risk LM CAD patients undergoing OPCAB, we performed a registry-based prospective study. We performed 4868 coronary artery bypass graft (CABG) surgeries from Jan 2013 to Jun 2019 with 4662 (95.8%) OPCAB. In OPCAB cohort, we had 1323 patients (28.4%) with significant LM (> 50%) triple vessel CAD. Data regarding clinical features, extent of CAD, operative details, in-hospital outcomes, and 3-year follow-up were obtained. Descriptive statistics are reported. The study cohort (n = 1323) was aged 63 ± 9years with men 88.4%. Tobacco use was in 328 (24.8%), diabetes 598 (45.2%), previous myocardial infarction 463 (35.0%), previous coronary intervention 40 (3.0%), and congestive heart failure in 54 (4.1%). All patients had LM (100.0%) with triple vessel disease in 99.4% (LAD, left anterior descending 100.0%; LCX, left circumflex 99.4%; RCA, right coronary artery 78.7%). Vessels bypassed/patient were 2.7 ± 0.4 with 3.2 ± 0.7 total grafts and 2.1 ± 0.8 venous grafts. In total, 1278 (96.5%) patients received left internal mammary artery (LIMA), 63(4.7%) bilateral internal mammary artery (BIMA), and 74 (5.6%) radial artery grafts. There was no patient with conversion from OPCAB to ONCAB. In-hospital major adverse cardiovascular events (MACE: all-cause deaths, myocardial infarction, and stroke) were in 21 (1.6%). At 3-year follow-up (n = 1041), MACE rates were in 84 (8.1%) and cardiovascular deaths in 28 (2.7%). This study shows that off-pump CABG surgery is safe in patients with LM CAD. There is low in-hospital mortality and MACE and 3-year outcomes are similar to the published data of LM CAD patients who undergo on-pump CABG. The online version contains supplementary material available at 10.1007/s12055-023-01526-3.

How to treat left main coronary artery disease: the complementary lessons from trials and registries.

Graphical AbstractOpen in new tabDownload slideThe many factors, the knowns and unknowns, surrounding left main revascularization therapy. DAPT, dual antiplatelet therapy; RCT, randomized controlled trial; LVEF, left ventricular ejection fraction; HBR, high bleeding risk; PCI, percutaneous coronary intervention; CABG, coronary artery bypass graft.

PCI or CABG for left main coronary artery disease: the SWEDEHEART registry.

An observational nationwide all-comers prospective register study to analyse outcomes after coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) in unprotected left main coronary artery (LMCA) disease. All patients undergoing coronary angiography in Sweden are registered in the Swedish Web-system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies registry. Between 01/01/2005 and 12/31/2015, 11 137 patients with LMCA disease underwent CABG (n = 9364) or PCI (n = 1773). Patients with previous CABG, ST-elevation myocardial infarction (MI) or cardiac shock were excluded. Death, MI, stroke, and new revascularization during follow-up until 12/31/2015 were identified using national registries. Cox regression with inverse probability weighting (IPW) and an instrumental variable (IV), administrative region, were used. Patients undergoing PCI were older, had higher prevalence of comorbidity but lower prevalence of three-vessel disease. PCI patients had higher mortality than CABG patients after adjustments for known cofounders with IPW analysis (hazard ratio [HR] 2.0 [95% confidence interval (CI) 1.5-2.7]) and known/unknown confounders with IV analysis (HR 1.5 [95% CI 1.1-2.0]). PCI was associated with higher incidence of major adverse cardiovascular and cerebrovascular events (MACCE; death, MI, stroke, or new revascularization) than CABG, with IV analysis (HR 2.8 [95% CI 1.8-4.5]). There was a quantitative interaction for diabetic status regarding mortality (P = 0.014) translating into 3.6 years (95% CI 3.3-4.0) longer median survival time favouring CABG in patients with diabetes. In this non-randomized study, CABG in patients with LMCA disease was associated with lower mortality and fewer MACCE compared to PCI after multivariable adjustment for known and unknown confounders.

Revascularization strategy for left main coronary artery disease.

Revascularization strategy for left main coronary artery disease.

Percutaneous Coronary Intervention vs Coronary Artery Bypass Graft Surgery for Left Main Disease in Patients With and Without Acute Coronary Syndromes

Patients with left main coronary artery disease presenting with an acute coronary syndrome (ACS) represent a high-risk and understudied subgroup of patients with atherosclerosis. To assess clinical outcomes after PCI vs CABG in patients with left main disease with vs without ACS. Data were pooled from 4 trials comparing PCI with drug-eluting stents vs CABG in patients with left main disease who were considered equally suitable candidates for either strategy (SYNTAX, PRECOMBAT, NOBLE, and EXCEL). Patients were categorized as presenting with or without ACS. Kaplan-Meier event rates through 5 years and Cox model hazard ratios were generated, and interactions were tested. Patients were enrolled in the individual trials from 2004 through 2015. Individual patient data from the trials were pooled and reconciled from 2020 to 2021, and the analyses pertaining to the ACS subgroup were performed from March 2022 through February 2023. The primary outcome was death through 5 years. Secondary outcomes included cardiovascular death, spontaneous myocardial infarction (MI), procedural MI, stroke, and repeat revascularization. Among 4394 patients (median [IQR] age, 66 [59-73] years; 3371 [76.7%] male and 1022 [23.3%] female) randomized to receive PCI or CABG, 1466 (33%) had ACS. Patients with ACS were more likely to have diabetes, prior MI, left ventricular ejection fraction less than 50%, and higher SYNTAX scores. At 30 days, patients with ACS had higher all-cause death (hazard ratio [HR], 3.40; 95% CI, 1.81-6.37; P < .001) and cardiovascular death (HR, 3.21; 95% CI, 1.69-6.08; P < .001) compared with those without ACS. Patients with ACS also had higher rates of spontaneous MI (HR, 1.70; 95% CI, 1.25-2.31; P < .001) through 5 years. The rates of all-cause mortality through 5 years with PCI vs CABG were 10.9% vs 11.5% (HR, 0.93; 95% CI, 0.68-1.27) in patients with ACS and 11.3% vs 9.6% (HR, 1.19; 95% CI, 0.95-1.50) in patients without ACS (P = .22 for interaction). The risk of early stroke was lower with PCI vs CABG (ACS: HR, 0.39; 95% CI, 0.12-1.25; no ACS: HR, 0.35; 95% CI, 0.16-0.75), whereas the 5-year risks of spontaneous MI and repeat revascularization were higher with PCI vs CABG (spontaneous MI: ACS: HR, 1.74; 95% CI, 1.09-2.77; no ACS: HR, 3.03; 95% CI, 1.94-4.72; repeat revascularization: ACS: HR, 1.57; 95% CI, 1.19-2.09; no ACS: HR, 1.90; 95% CI, 1.54-2.33), regardless of ACS status. Among largely stable patients undergoing left main revascularization and with predominantly low to intermediate coronary anatomical complexity, those with ACS had higher rates of early death. Nonetheless, rates of all-cause mortality through 5 years were similar with PCI vs CABG in this high-risk subgroup. The relative advantages and disadvantages of PCI vs CABG in terms of early stroke and long-term spontaneous MI and repeat revascularization were consistent regardless of ACS status. ClinicalTrials.gov Identifiers: NCT00114972, NCT00422968, NCT01496651, NCT01205776.

Assessment of the Graft Quality and Patency during and after Coronary Artery Bypass Grafting.

Coronary artery bypass grafting (CABG) is the gold standard procedure for multi vessels and left main coronary artery disease. The prognosis and survival outcomes of CABG surgery are highly dependent on the patency of the bypass graft. Early graft failure which can occur during or soon after CABG remains a significant issue, with reported incidences of 3-10%. Graft failure can lead to refractory angina, myocardial ischemia, arrhythmias, low cardiac output, and fatal cardiac failure, emphasizing the importance of ensuring graft patency during and after surgery to prevent such complications. Technical errors during anastomosis are among the leading causes of early graft failure. To address this issue, various modalities and techniques have been developed to evaluate graft patency during and after CABG surgery. These modalities aim to assess the quality and integrity of the graft, thus enabling surgeons to identify and address any issues before they lead to significant complications. In this review article, we aim to discuss the strengths and limitations of all available techniques and modalities, with the goal to identify the best modality for evaluating graft patency during and after CABG surgery.

Contemporary Left Main Percutaneous Coronary Intervention: A State-of-the-art Review.

The majority of the left ventricular myocardium is supplied by the left main coronary artery. Atherosclerotic obstruction of the left main coronary artery therefore leads to significant myocardial jeopardy. Coronary artery bypass surgery (CABG) has been the gold standard for left main coronary artery disease in the past. However, advancements in technology have established percutaneous coronary intervention (PCI) as a standard, safe and reasonable alternative to CABG, with comparable outcomes. Contemporary PCI of left main coronary artery disease comprises careful patient selection, accurate technique guided by either intravascular ultrasound or optical coherence tomography and - if necessary - physiological assessment using fractional flow reserve. This review focuses on current evidence from registries and randomised trials comparing PCI with CABG, procedural tips and tricks, adjuvant technologies and the triumph of PCI.

Off-Pump Versus On-Pump Coronary Artery Bypass Grafting In Patients With Left Main Coronary Artery Disease: A Randomized Controlled Trial.

To compare the outcome of off-pump and on-pump coronary artery bypass graftsurgery in patients with left main coronary artery disease. The randomised, controlled, prospective, multicentric study was conducted in 2020 during the period from January 2020 to December 2020 at Kafrelsheikh University Hospital, International Cardiac Centre and Alexandria New Medical Centre, Egypt, and comprised patients with left main coronary artery disease who underwent coronary artery bypass graftsurgery. The patients were randomised to on-pump surgery group I (Control Group) and off-pump surgery group II(Interventional Group). All patients were assessed pre-operatively for the presence of comorbid conditions and post-operatively for myocardial infarction, acute kidney injury, pneumonia, sternal dehiscence and 3-month mortality. Data was analysed using SPSS 20. Of the 60 patients, 44(73.3%) were men and 16(26.6%) were women. The overall mean age was 66.4±9.2 years. There were 30(50%) patients in each of the two groups. There were 2(6.7%) cases of myocardial infarction in group I and 1(3.3%) in group II. There was 1(3.3%) case of acute kidney injury in group I and none in group II. There were 3(10%) cases of pneumonia in group 1 compared to 1(3.3%) in group II. There was 1(3.3%) case of sternal dehiscence in group I and none in group II. Mortality at 3 months was 2(6.7%) in group I and 1(3.3%) in group II. There was no significant difference with respect to outcome between the groups (p>0.05). Off-pump coronary artery bypass graft surgery was found to be efficient and non-inferior to on-pump procedure in patients with left main coronary artery disease. The RCT was registered retrospectively at the Pan African Clinical Trials Registry (PACTR) (Trial #: PACTR202301506140749 Date of Approval: 06/01/2023). Link: https://pactr.samrc.ac.za/Search.aspx.

Outcome of percutaneous coronary intervention compared to coronary artery bypass grafting in left main coronary artery stenosis: a systematic review

Background: Coronary artery bypass graft (CABG) surgery has been recommended as the standard treatment for patients with left main coronary artery (LMCA) disease. However, with advances in interventional cardiology, percutaneous coronary intervention (PCI) has been increasingly used for LMCA disease although long-term outcomes comparing PCI with CABG remain limited. Objectives: This systematic review was performed using PubMed/MEDLINE, ScienceDirect, and Google Scholar databases to analyze PCI and CABG’s effects on patients with coronary artery disease. Methods: This systematic review used all studies on the differences in PCI and CABG intervention outcomes in left main coronary artery stenosis. This search yielded 1,427 studies, of which 18 studies were included for the final analysis. In the studies, 62,632 patients were treated with PCI and CABG. A total of 17 studies stated that CABG provides better outcomes than PCI. However, one study stated otherwise. Conclusion: Other factors that also affect PCI or CABG outcomes include patient risk factors before revascularization, SYNTAX score, and gender. Among LMCA stenosis patients, CABG is associated with lower incidence of mortality, repeat revascularization, myocardial infarction, and MACE than PCI. Meanwhile, PCI results in lower stroke incidence.

Left Main Total Chronic Occlusion in a Patient with Colorectal Cancer: A Case Report of a Rare and Severe Localization of Coronary Artery Disease

The aim of this case report is to draw attention at the potential severity of presentation of these associated pathologies. Prevention through early screening of colorectal cancer in patients with coronary artery disease and vice versa is the guarantee of a better management of the two pathologies. Cardiovascular disease and cancer are the two leading causes of death worldwide. Emerging evidence suggests associations between cardiovascular disease and several cancers, including colorectal cancer. Many cases have reported severe coronary artery disease (CAD) in association with colorectal cancer including triple vessel disease. To the best of our knowledge this is the first case reporting a total occlusion of the left main coronary artery in such patients.&#x0D; We report the case of a 52 years old woman presented to our cath lab for severe angina (Class III of the Canadian classification) and impairment of left ventricle function. Six months before the patient was diagnosed with a metastatic colorectal cancer. Coronary angiography showed absence of anterograde opacification of the left coronary system. Selective right coronary artery angiography showed a retrograde filling of the left coronary system by collaterals issued from proximal and distal dominant right coronary artery.&#x0D; Several studies have reported the association between colorectal neoplasm and CAD but Isolated left main coronary artery disease is extremely uncommon. Patients with left main coronary artery disease have always a grim prognosis and without prompt revascularization 60% will die after 5 years while survivors live with severe angina; heart failure or both.

Revascularization in Left Main Coronary Artery Disease

Revascularization in Left Main Coronary Artery Disease

Impact of repeat revascularization within 5 years on 10-year mortality after percutaneous or surgical revascularization

BackgroundThe SYNTAX trial demonstrated negative impact of repeat revascularization (RR) on 5-year outcomes following PCI/CABG in patients with three-vessel(3VD) and/or left main coronary artery disease(LMCAD). We aimed to investigate the impact of RR within 5 years, on 10-year mortality in patients with 3VD and/or LMCAD after PCI/CABG.MethodsThe SYNTAXES study evaluated the vital status out to 10 years of patients with 3VD and/or LMCAD. Patients were stratified by RR within 5 years and randomized treatment. The association between RR within 5 years and 10-year mortality was assessed.ResultsA total of 330 out of 1800 patients (18.3%) underwent RR within 5 years. RR occurred more frequently after initial PCI than after initial CABG (25.9% vs. 13.7%, p < 0.001). Overall, 10-year mortality was comparable between patients undergoing RR and those not (28.2% vs. 26.1%, adjusted HR: 1.17, 95%CI 0.93–1.48, p = 0.187). In the PCI arm, RR was associated with a trend toward higher 10-year mortality (adjusted HR: 1.29, 95%CI 0.97–1.72, p = 0.075), while in the CABG arm, the trend was opposite (adjusted HR: 0.74, 95%CI 0.46–1.20, p = 0.219). Among patients requiring RR, those who underwent PCI as initial revascularization had a higher risk of 10-year mortality compared to initial CABG (33.5% vs. 17.6%, adjusted HR: 2.09, 95%CI 1.21–3.61, p = 0.008).ConclusionIn the SYNTAXES study, RR within 5 years had no impact on 10-year all-cause death in the population overall. Among patients requiring any repeat procedures, 10-year mortality was higher after initial treatment with PCI than after CABG. These exploratory findings should be investigated with larger populations in future studies.Trial registrationURL: https://www.clinicaltrials.gov; SYNTAXES Unique identifier: NCT03417050. URL: https://www.clinicaltrials.gov; SYNTAX Unique identifier: NCT00114972.Graphical abstract

A primer for the student joining the adult cardiac surgery service tomorrow: Primer 1 of 7

A primer for the student joining the adult cardiac surgery service tomorrow: Primer 1 of 7