Left Main Coronary Disease Research Articles

Revascularization for unprotected left main coronary artery disease: an evolution in clinical decision making.

Coronary artery bypass grafting (CABG) has been considered the standard therapy for unprotected (nonrevascularized) left main coronary disease (ULM). However, increasing experience with ULM percutaneous coronary intervention (PCI) has resulted in high procedural success and favorable early and late clinical outcomes. In particular, reduction in clinical restenosis with drug-eluting stents, evolution of procedural technique, and demonstration of favorable outcomes from comparative trials with CABG have promoted consideration of PCI as an alternative revascularization strategy in selected patients with ULM disease. This review summarizes the results from comparative studies examining PCI versus CABG for ULM disease, discusses changing indications for ULM PCI and identifies outstanding issues that must be considered before further advancing treatment recommendations.

Comparison of coronary bypass surgery with drug-eluting stenting for the treatment of left main and/or three-vessel disease: 3-year follow-up of the SYNTAX trial

Long-term randomized comparisons of percutaneous coronary intervention (PCI) to coronary artery bypass grafting (CABG) in left main coronary (LM) disease and/or three-vessel disease (3VD) patients have been limited. This analysis compares 3-year outcomes in LM and/or 3VD patients treated with CABG or PCI with TAXUS Express stents. SYNTAX is an 85-centre randomized clinical trial (n= 1800). Prospectively screened, consecutive LM and/or 3VD patients were randomized if amenable to equivalent revascularization using either technique; if not, they were entered into a registry. Patients in the randomized cohort will continue to be followed for 5 years. At 3 years, major adverse cardiac and cerebrovascular events [MACCE: death, stroke, myocardial infarction (MI), and repeat revascularization; CABG 20.2% vs. PCI 28.0%, P< 0.001], repeat revascularization (10.7 vs. 19.7%, P< 0.001), and MI (3.6 vs. 7.1%, P= 0.002) were elevated in the PCI arm. Rates of the composite safety endpoint (death/stroke/MI 12.0 vs. 14.1%, P= 0.21) and stroke alone (3.4 vs. 2.0%, P= 0.07) were not significantly different between treatment groups. Major adverse cardiac and cerebrovascular event rates were not significantly different between arms in the LM subgroup (22.3 vs. 26.8%, P= 0.20) but were higher with PCI in the 3VD subgroup (18.8 vs. 28.8%, P< 0.001). At 3 years, MACCE was significantly higher in PCI- compared with CABG-treated patients. In patients with less complex disease (low SYNTAX scores for 3VD or low/intermediate terciles for LM patients), PCI is an acceptable revascularization, although longer follow-up is needed to evaluate these two revascularization strategies.

Prognostic Value of the SYNTAX Score in Patients With Acute Coronary Syndromes Undergoing Percutaneous Coronary Intervention: Analysis From the ACUITY (Acute Catheterization and Urgent Intervention Triage StrategY) Trial

We sought to investigate the predictive value of the SYNTAX (Synergy Between PCI With Taxus and Cardiac Surgery) score (SS) for risk assessment of 1-year clinical outcomes in patients with non-ST-segment elevation acute coronary syndromes undergoing percutaneous coronary intervention (PCI). In the SYNTAX trial, the SS was effective in risk-stratifying patients with left main and triple-vessel coronary disease, the majority of whom had stable ischemic heart disease. The SS was determined in 2,627 patients with non-ST-segment elevation acute coronary syndromes undergoing PCI in the angiographic substudy of the ACUITY (Acute Catheterization and Urgent Intervention Triage StrategY) trial. Patients were stratified according to tertiles of the SS: <7 (n = 854), ≥ 7 and <13 (n = 825), and ≥ 13 (n = 948). Among patients in the first, second, and third SS tertiles, the 1-year rates of mortality were 1.5%, 1.6%, and 4.0%, respectively (p = 0.0005); the cardiac mortality rates were 0.2%, 0.9%, and 2.7%, respectively (p < 0.0001); the myocardial infarction (MI) rates were 6.3%, 8.3%, and 12.9%, respectively (p < 0.0001); and the target vessel revascularization (TVR) rates were 7.4%, 7.0%, and 9.8%, respectively (p = 0.02). By multivariable analysis, the SS was an independent predictor of 1-year death (hazard ratio [HR]: 1.04, 95% confidence interval [CI]: 1.01 to 1.07; p = 0.005), cardiac death (HR: 1.06, 95% CI: 1.03 to 1.09; p = 0.0002), MI (HR: 1.03, 95% CI: 1.02 to 1.05; p < 0.0001), and TVR (HR: 1.03, 95% CI: 1.02 to 1.05; p < 0.0001). The SS affected death, cardiac death, and MI both within the first 30 days after PCI and between 30 days and 1 year, whereas it affected TVR primarily within the first 30 days. The predictive value of an increased SS was consistent among multiple pre-specified subgroups. In patients with non-ST-segment elevation acute coronary syndromes undergoing PCI, the SS is an independent predictor of the 1-year rates of death, cardiac death, MI, and TVR. (Comparison of Angiomax Versus Heparin in Acute Coronary Syndromes [ACS]; NCT00093158).

Drug-eluting stent on left main disease is usually adopted in patients with low SYNTAX score and have good clinical outcomes during 1 year. Real-world single-center experience comparing with coronary artery bypass graft

Background: Current practice guidelines still recommend coronary artery bypass graft (CABG) as the standard treatment in patients with left main coronary disease (LMCD). The purpose of our study is to assess the realworld selection of therapeutic strategy in patients with LMCD and their outcomes using SYNTAX and euroSCORE. Methods: We analyzed data of 100 consecutive patients with significant LMCD treated by percutaneous coronary intervention with DES (n=44) or CABG (n=56). All lesions of the LMCD were de novo lesions. We calculate the SYNTAX score and the euroSCORE and assessed the clinical outcomes during 1 year. Results: Patients baseline characteristics between groups were wellbalanced including logistic euroSCORE (3.54±3.98% in the PCI group and 3.28±2.47% in the CABG group, P=.699). The PCI with DES on LMCD was adopted in patients with low SYNTAX score compared with those of the CABG group (22.0±7.6 vs. 35.9±8.6, P=.000). These differences of the two groups were derived by the number of coronary artery lesion (2.8±1.1 vs. 4.0±1.3 lesions, P=.000) and presence of chronic total occlusion artery [9.0% (4/44) vs. 46.4% (26/56), P=.000]. One-year major adverse cardiac events rates did not differ between the PCI with DES group and the CABG group [6.8% (3/44) vs. 3.5% (2/56), P=.465]. And this result of MACE continued in low–intermediate SYNTAX group [6.6% (1/15) vs. 2.0% (1/49), P=.516]. All MACEs were cardiac death during hospitalization, and further events including cardiac death, nonfatal myocardial infarction and need for revascularization procedures did not develop during the follow-up period after discharge. Mortality rates according to SYNTAX score in all LMCD patients were 2.7% (1/37) of the low-score group (≤22), 3.7% (1/27) of the intermediate-score group (23 to 32), and 8.3% (3/36) of the high-score group (≥33); however, statistical significance was not significant. Conclusions: Single-center real-world experience showed therapeutic strategy by PCI with DES in LMCD was usually adopted in patients with low SYNTAX score and had low incidence of MACE during 1 year. However, CABG still remains the dominant revascularization strategy, especially in the patients with high SYNTAX score. Prospective, long-term, randomized studies to evaluate the clinical outcomes between PCI and CABG are warranted in LMCD with high SYNTAX score.

Rapid Progression of Left Main Coronary Disease Causing Acute Coronary Syndrome

A 72-year-old man presented with atypical chest pain in December 2009. Thereafter, he underwent coronary angiography that revealed no significant stenosis and no thrombosis of any coronary arteries (Figs 1A, 1B), with normal left ventricular function. He was a nonsmoker, non-diabetic, with mild hypercholesterolemia, and mild hypertension that was well-controlled by medication. In June 2010, he presented with acute coronary syndrome with an electrocardiogram that showed non-ST elevation myocardial infarction. A repeat coronary angiography demonstrated rapid progression of atherosclerotic disease, resulting in critical stenosis of the left main

Pronóstico a medio plazo del intervencionismo percutáneo electivo sobre el tronco común de la coronaria izquierda. Experiencia multicéntrica

Introduction and objective Urgent intervention and cardiogenic shock are established as the main prognostic indicators in percutaneous revascularization of unprotected left main coronary disease. The outcome and identification of prognostic factors are less established for elective procedures. The purpose of this study is to assess the short and medium-term outcome after elective percutaneous coronary artery intervention for unprotected left main coronary disease. Methods and results A multicentre sample of 250 consecutive patients was included between January 2004 and March 2008. A high risk EuroScore was observed in 49.6% of cases. There was 0.4% hospital cardiac mortality and after a medium follow up of 19.6 months the rate of major adverse cardiac events was 18.4% (myocardial infarction 2.0%, target vessel revascularization 6.8%, cardiac mortality 9.6%). High risk EuroScore and implantation of two stents for left main lesion were identified as independent predictors of mayor adverse cardiac events during follow up (HR, 2.59; 95%CI, 1.35-5.00; P = .004 and HR, 2.05; 95%CI, 1.05-4.00; P = .035, respectively). Conclusions In our study elective percutaneous coronary intervention for unprotected left main disease is mainly performed on high risk patients resulting in a feasible procedure with favourable short and medium-term results. High risk EuroScore and implantation of two stents for left main lesion are identified as main predictors of events during follow up.

AS-232 Long-Term (5-year) Outcomes of Percutaneous Versus Surgical Revascularization for Unprotected Left Main Coronary Disease in Diabetic Patients

The aim of this study was to evaluate long-term (5-year) clinical outcomes after percutaneous or surgical revascularization in diabetic population with unprotected left main coronary artery (LMCA) disease. Limited information is available on long-term comparative outcomes for diabetic patients with unprotected LMCA disease who underwent stent implantation or coronary artery bypass grafting (CABG).

Management of left main coronary disease

Management of left main coronary disease

SYNTAX Score is associated with worse outcomes after off-pump coronary artery bypass grafting surgery for three-vessel or left main complex coronary disease

The SYNergy between percutaneous intervention with TAXus drug eluting stents and cardiac surgery (SYNTAX) Score is a tool for risk stratification of patients according to the complexity of coronary lesions developed during the SYNTAX trial. We examined the influence of the SYNTAX Score on the incidence of major adverse cardiac and cerebrovascular events. All patients with de novo left main or 3-vessel disease undergoing coronary artery bypass grafting from January 2005 to December 2008 at our institution (Hospital Clínico San Carlos, Madrid, Spain) were retrospectively assessed, and their SYNTAX Score was calculated. The influence of the SYNTAX Score on postprocedural and follow-up mortality and combined major adverse cardiac and cerebrovascular events (including death, myocardial infarction, cerebrovascular accident, and repeat revascularization) was identified by multivariate analysis. Balancing score analysis was performed to eliminate the effect of potential confounders. A total of 716 patients were enrolled. Mean SYNTAX Score was 34.5 (standard deviation, 6.7; range, 11.5-76). Three groups of patients were identified according to the score terciles: low (≤33), intermediate (33-37), and high (>37). These terciles scores differed greatly from those reported by the SYNTAX trial investigators. The multivariate analysis identified that the SYNTAX Score was associated with follow-up mortality (hazard ratio = 1.046, P = .015) and combined early and follow-up major adverse cardiac and cerebrovascular events (odds ratio = 1.079, P < .001; and hazard ratio = 1.034, P = .026, respectively). Balancing score-adjusted analyses demonstrated that the SYNTAX Score was independently associated with early and late major adverse cardiac and cerebrovascular events (odds ratio = 1.65, P < .001; and hazard ratio = 1.034, P = .027, respectively). SYNTAX Score was remarkably high among patients undergoing surgical off-pump myocardial revascularization at our institution. In this subset of patients, a higher SYNTAX Score was associated with a higher incidence of in-hospital and follow-up major adverse cardiac and cerebrovascular events after coronary artery bypass grafting, but not with early or late mortality.

Comparison of single‐ versus two‐stent techniques in treatment of unprotected left main coronary bifurcation disease

This study sought to compare 3-year outcomes of single- versus two-stent techniques in patients with distal unprotected left main coronary artery (LMCA) disease treated with drug-eluting stents (DES). A total of 392 patients with distal unprotected LMCA disease who underwent DES implantation with single- (n = 234) or two- (n = 158) stent techniques were evaluated. The primary end point was major adverse cardiac events (MACE), defined as the composite of death, myocardial infarction (MI), and target lesion revascularization (TLR). The two-stent group was more likely to have extensive coronary artery stenosis. After adjustment with weighted Cox model using the inverse probability of treatment weighting, the 3-year risk of death was similar in the single- and two-stent groups (hazard ratio [HR], 0.77, 95% confidence interval [CI], 0.28-2.13, P = 0.62). However, the 3-year risks of MI (HR, 0.38, 95% CI, 0.19-0.78, P = 0.008), TLR (HR, 0.16, 95% CI, 0.05-0.57, P = 0.005), and MACE (HR, 0.89, 95% CI, 0.22-0.67, P = 0.0007) were significantly lower in the single-stent group. Compared with the two-stent technique, the single-stent technique showed more favorable long-term clinical outcomes in patients with distal unprotected LMCA disease who received DES

233 After acute coronary syndrome, atheroma burden predicts cardiovascular prognosis of patients receiving optimized secondary prevention measures

After an acute coronary syndrome (ACS), pharmacologic therapy and lifestyle intervention (optimal medical therapy, OMT) are efficient in reducing cardiovascular (CV) events. However, even if recommended secondary prevention goals are reached, a subset of patients still present CV events. To identify biological or cardiovascular markers predicting the residual risk of CV events in post-ACS patients receiving OMT. 990 patients benefited from an evaluation of risk factors and atherosclerosis lesions, and optimization of long-term treatment and education. Traditional CV risk factors and atheroma disease markers (intima-media thickness (IMT), carotid atheroma, Ankle Brachial Index (ABI) and number of coronary arteries with >50% stenosis) were evaluated 3 months after ACS. CV events were recorded at follow-up (CV death, ACS, stroke, heart failure, revascularization). At a median follow-up of 20 months, more than 80% of the patients reached recommended prevention goals. 116 total CV events were recorded. Diabetes was the only CV risk factor significantly associated with CV events in multivariate analysis (including age, sex, hypertension, LDL cholesterol, smoking, diabetes and hsCRP); HR 1,61 (1,09–2,39), p = 0,017. In multivariate analysis including CV risk factors and atheroma disease markers (peripheral vascular disease (PVD) defined as ABI<0,9, carotid plaque > 50%, IMT >0,7 mm, 3-vessel and/or left main coronary disease), only PVD remained significantly associated with CV events; HR 1,83 (1,02–3,31), p = 0,04. The number of vascular beds involved was associated with poorer prognosis: HR for 3 vascular-beds disease 3,85 (1,72–8,63) p = 0,001, given 1 vascular-bed disease as a reference group. In post-ACS patients with OMT, PVD and atheroma burden represent powerful prognostic markers of CV events, while diabetes remains the only independent marker of CV events among traditional CV risk factors.

E0425 Clinical and coronary angiography characteristics between young (≤45) and old (>60) patients with coronary artery disease

ObjectiveTo study the clinical Clinical and coronary angiography characteristics between young (≤45) and old (>60) patients with coronary artery disease.MethodsAngiographic and clinical data from A: 176 patients (≤45) selected from...

E0543 Clinical and coronary angiography characteristics between young (60) patients with coronary artery disease

ObjectiveTo study the clinical Clinical and coronary angiography characteristics between young (≤45) and old (>60) patients with coronary artery disease.MethodsAngiographic and clinical data from A: 176 patients (≤45) selected from...

Current diagnosis and management of left main coronary disease

Left main coronary artery (LMCA) disease remains an important risk factor for increased mortality and morbidity at all stages of diagnosis and treatment of coronary artery disease. Left main stem pathology is often silent, with unpredictable presentation: as such it poses diagnostic and management challenges. This article reviews the anatomy, epidemiology and diagnosis of left main stem disease, as well as advances in multidisciplinary concepts of diagnosis and management, and summarises the outcomes of recent prospective studies comparing percutaneous and surgical revascularisation in LMCA disease.

TCT-46: EuroSCORE Predicts Long-term Cardiovascular Events After Percutaneous Coronary Intervention in Patients with Left Main or Multivessel Coronary Artery Disease

TCT-46: EuroSCORE Predicts Long-term Cardiovascular Events After Percutaneous Coronary Intervention in Patients with Left Main or Multivessel Coronary Artery Disease

TCT-68: Long-Term (5-year) Outcomes of Percutaneous Versus Surgical Revascularization for Unprotected Left Main Coronary Disease in Diabetic Patients

TCT-68: Long-Term (5-year) Outcomes of Percutaneous Versus Surgical Revascularization for Unprotected Left Main Coronary Disease in Diabetic Patients

Deleterious impact of diabetes mellitus on early and mid-term results after stent implantation in left main coronary disease

Deleterious impact of diabetes mellitus on early and mid-term results after stent implantation in left main coronary disease

Outcomes in Patients With De Novo Left Main Disease Treated With Either Percutaneous Coronary Intervention Using Paclitaxel-Eluting Stents or Coronary Artery Bypass Graft Treatment in the Synergy Between Percutaneous Coronary Intervention With TAXUS and Cardiac Surgery (SYNTAX) Trial

The prospective, multinational, randomized Synergy Between Percutaneous Coronary Intervention With TAXUS and Cardiac Surgery (SYNTAX) trial was designed to assess the optimal revascularization strategy between percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG), for patients with left main (LM) and/or 3-vessel coronary disease. This observational hypothesis-generating analysis reports the results of a prespecified powered subgroup of 705 randomized patients who had LM disease among the 1800 patients with de novo 3-vessel disease and/or LM disease randomized to PCI with paclitaxel-eluting stents or CABG in the SYNTAX trial. Major adverse cardiac and cerebrovascular event rates at 1 year in LM patients were similar for CABG and PCI (13.7% versus 15.8%; Delta2.1% [95% confidence interval -3.2% to 7.4%]; P=0.44). At 1 year, stroke was significantly higher in the CABG arm (2.7% versus 0.3%; Delta-2.4% [95% confidence interval -4.2% to -0.1%]; P=0.009]), whereas repeat revascularization was significantly higher in the PCI arm (6.5% versus 11.8%; Delta5.3% [95% confidence interval 1.0% to 9.6%]; P=0.02); there was no observed difference between groups for other end points. When patients were scored for anatomic complexity, those with higher baseline SYNTAX scores had significantly worse outcomes with PCI than did patients with low or intermediate SYNTAX scores; outcomes for patients with CABG did not correlate with baseline SYNTAX score, but baseline EuroSCORE significantly predicted outcomes for both treatments. Patients with LM disease who had revascularization with PCI had safety and efficacy outcomes comparable to CABG at 1 year; longer follow-up is required to determine whether these 2 revascularization strategies offer comparable medium-term outcomes in this group of complex patients.

Diagnostic accuracy of 64-slice multidetector computed tomography for selecting coronary artery bypass graft surgery candidates

The objective of our study was to investigate the diagnostic accuracy of computed tomographic coronary angiography for the selection of candidates for coronary artery bypass graft surgery. Institutional review board approval was obtained. We included 172 patients (mean age, 63 years; 127men and 45 women) with a suspicion of coronary artery disease who underwent both computed tomographic coronary angiography and conventional coronary angiography. We established eligible criteria for coronary artery bypass graft surgery based on American College of Cardiology/American Heart Association practice guidelines: 3-vessel disease, left main coronary artery disease, and left main coronary artery equivalent disease. Results of computed tomographic coronary angiography and conventional coronary angiography were reviewed retrospectively by 2 radiologists and 2 cardiologists who were unaware of the other examiners' findings. Diagnostic performances of computed tomographic coronary angiography were calculated, with conventional coronary angiography as the reference standard. The overall sensitivity, specificity, positive predictive value, and negative predictive value of computed tomographic coronary angiography for the selection of coronary artery bypass graft surgery candidates were 85.9%, 96.0%, 93.8%, and 90.7%, respectively. We also obtained high diagnostic performances for 3-vessel disease (sensitivity, 83.1%; specificity, 96.5%; positive predictive value, 92.5%; negative predictive value, 91.6%), left main coronary artery disease (sensitivity, 94.7%; specificity, 96.7%; positive predictive value, 78.3%; negative predictive value, 99.3%), and left main coronary artery equivalent disease (sensitivity, 100%; specificity, 100%; positive predictive value, 100%; negative predictive value, 100%). Patients selected as candidates for coronary artery bypass graft surgery with conventional coronary angiography can also be relatively accurately classified by using computed tomographic coronary angiography with 64-slice multidetector computed tomography.

Major Predictors of Long-Term Clinical Outcomes After Coronary Revascularization in Patients With Unprotected Left Main Coronary Disease

Background— The clinical characteristics that identify high-risk subsets of patients with unprotected left main coronary artery disease undergoing percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) have not been well established. Methods and Results— Between January 2000 and June 2006, 2240 patients with unprotected left main coronary artery disease underwent PCI (n=1102) or CABG (n=1138). Twenty-six preprocedural parameters were evaluated by univariate and multivariate Cox regression analysis to identify independent predictors of all-cause mortality and target-vessel revascularization. Interaction tests were performed to compare heterogeneities of effects of preprocedural parameters depending on the revascularization methods. During follow-up (median of 3.1 years), 187 patients died (78 PCI and 109 CABG) and 149 patients had target-vessel revascularization (121 PCI and 28 CABG). EuroSCORE ≥6 was an independent predictor of death in both groups. Additional independent predictors were chronic renal failure and previous congestive heart failure in the PCI group and age ≥75 years, atrial fibrillation, right coronary artery disease, and left main distal bifurcation disease in the CABG group. Interaction analysis showed no heterogeneities of the effects of variables depending on the revascularization methods. Independent predictors of target-vessel revascularization were acute coronary syndrome and left main distal bifurcation disease in the PCI group and history of coronary intervention in the CABG group. The interaction between previous PCI and treatment remained after adjustment for all independent predictors of target-vessel revascularization (interaction P =0.0345). Conclusions— Several clinical characteristics were identified as important preprocedural predictors of long-term adverse outcomes after percutaneous or surgical revascularization in patients with unprotected left main coronary artery disease.