Left Main Coronary Disease Research Articles

Ostial left main disease tackled with a percutaneous coronary intervention using a second-generation drug-eluting stent: A case report

Abstract: The hospital emergency admitted a middle-aged male who had previously undergone stenting in the left anterior descending (LAD) and right coronary arteries due to severe central chest pain radiating to both arms. A two-dimensional color Doppler echocardiogram showed septal hypokinesia, and coronary angiography showed a 70% ostial left main (LM) stenosis. The LAD coronary artery had a patent stent, but the mid-right coronary artery had a totally occluded stent. The chest pain increased during coronary angiography, and the patient consented to percutaneous coronary intervention (PCI) with a second-generation drug-eluting stent. The patient was discharged in a stable condition. The evolution and the current approach of PCI compared to coronary artery bypass grafting surgery for LM coronary disease based on randomized trials are discussed.

TCT-76 Percutaneous Coronary Intervention in High-Risk Patients With High Syntax Score Left Main Coronary Disease: 17-Year Long-Term Follow-Up Real World Experience of a Single Center Without On-Site Cardiac Surgery

TCT-76 Percutaneous Coronary Intervention in High-Risk Patients With High Syntax Score Left Main Coronary Disease: 17-Year Long-Term Follow-Up Real World Experience of a Single Center Without On-Site Cardiac Surgery

Prevalence and Risk Factors of Renal Artery Stenosis in Patients Undergoing Simultaneous Coronary and Renal Artery Angiography: A Systematic Review and Meta-Analysis of 31,689 Patients from 31 Studies.

Background/Objectives: Renal artery stenosis (RAS) is associated with coronary artery disease (CAD), exacerbation of arterial hypertension, and progression to heart failure, but remains frequently unrecognized in clinical practice. Methods: We conducted a systematic review and meta-analysis of studies by pooling data of patients undergoing CAG due to suspected or stable CAD that received a bilateral renal artery angiography. Results: A total of 31 studies with 31,689 patients were included (mean age 63.2 ± 8.7 years, 20.9% were female). Overall, 13.4% (95%CI 10.5-16.7%) of patients undergoing coronary angiography had significant RAS, with 6.5% (95% CI 4.5-8.9%) and 3.7% (95%CI 2.5-5.2%) having severe and bilateral RAS. The mean weighted proportion of patients with three-vessel coronary disease (3VD) was 25.1 (95%CI 19.6-30.9%) while 4.2% (95%CI 2.6-6.2%) had left main (LM) coronary disease. Patients with RAS compared to those without RAS were significantly older (mean difference, MD 4.2 years (95%CI 3.8-4.6)). The relative risk of RAS was greater for the female sex (risk ratio, 95%CI; RR 1.3, 1.03-1.57), presence of diabetes (RR 1.2, 1.10-1.36), arterial hypertension (RR 1.3, 1.21-1.46), dyslipidemia (RR 1.1, 1.06-1.14), peripheral artery disease (PAD) (RR 2.1, 1.40-3.16), chronic kidney disease (CKD) (RR 2.6, 2.04-3.37), 3VD (RR 1.6, 1.30-1.87), and LM disease (RR 1.8, 1.28-2.47). Smoking had a neutral effect on the risk of RAS occurrence (RR 1.0, 0.94-1.06). Conclusions: RAS is common in patients undergoing coronary angiography. CKD, PAD, older age, and severe CAD were among the strongest predictors for the presence of significant RAS.

A Systematic Review and Meta-Analysis of 35,409 Patients Undergoing PCI versus CABG for Unprotected Left Main Coronary Artery Diseases.

Patients with unprotected left main (UPLM) disease who underwent percutaneous coronary intervention (PCI) were found to have inconsistent results compared to those treated with coronary artery bypass grafting (CABG). We identified and enrolled randomized controlled trials (RCTs) and observational studies (OSs) comparing PCI versus CABG for UPLM disease. A meta-analysis was performed using Stata 17.0. The primary endpoints were major adverse cardiovascular and cerebrovascular events (MACCEs). Additionally, all-cause death, cardiac death, myocardial infarction (MI), stroke, target vessel revascularization (TVR), and stent thrombosis (ST) were included as secondary endpoints. The odds ratios and 95% confidence intervals (CIs) were calculated. Sensitivity analyses were implemented if 50% or p 0.01. Publication bias analysis was conducted if more than 10 studies were included. A total of 5 RCTs and 18 OSs involving 35,409 patients were included. The CABG strategy had a significantly lower incidence of MACCEs, primarily due to TVR. A significantly lower stroke rate was observed with the PCI strategy, as well as a significantly lower all-cause death, cardiac death, MI, and ST rate compared with the CABG strategy. MACCE rates were significantly lower in patients who underwent CABG, primarily due to TVR, but stroke rates were higher. RCTs with different study types need further investigation to confirm the most effective strategy.

Multiple arterial vs. single arterial coronary artery bypass grafting: sex-related differences in outcomes.

Uncertainty exists over whether multiple arterial grafting has a sex-related association with survival after coronary artery bypass grafting. This study aims to compare the long-term survival of using multiple arterial grafting vs. single arterial grafting in women and men undergoing coronary artery bypass grafting. The retrospective study used the Australian and New Zealand Society of Cardiothoracic Surgical Database with linkage to the National Death Index. Patients from 2001 to 2020 were identified. Sex-stratified, inverse probability weighted Cox proportional hazard model was used to facilitate survival comparisons. The primary outcome was all-cause mortality. A total number of 54 275 adult patients receiving at least two grafts in primary isolated bypass operations were analysed. The entire study cohort consisted of 10 693 (19.7%) female patients and 29 711 (54.7%) multiple arterial grafting procedures. At a median (interquartile range) postoperative follow-up of 4.9 (2.3-8.4) years, mortality was significantly lower in male patients undergoing multiarterial than single arterial procedures (adjusted hazard ratio 0.82; 95% confidence interval 0.77-0.87; P < .001). The survival benefit was also significant for females (adjusted hazard ratio 0.83; 95% confidence interval 0.76-0.91; P < .001) at a median (interquartile range) follow-up of 5.2 (2.4-8.7) years. The interaction model from Cox regression suggested insignificant subgroup effect from sex (P = .08) on the observed survival advantage. The survival benefits associated with multiple arterial grafting were consistent across all sex-stratified subgroups except for female patients with left main coronary disease. Compared to single arterial grafting, multiple arterial revascularization is associated with improved long-term survival for women as well as men.

Left main coronary artery disease treated with beating heart surgery: 10-year single center results.

Left main (LM) coronary disease is believed to represent a complex, advanced, and potentially life-threatening atherosclerotic syndrome that can be treated by either percutaneous or surgical interventions. Despite its satisfactory results, the declined number of off-pump coronary artery bypass grafting (OPCAB) is observed. To compare 10-year survival and point out possible mortality risk factors in patients referred for left main and multivessel OPCAB surgery followed by transit time bypass measurements. There were 159 patients (128 (81%) men and 31 (19%) women) in a median age of 66 (60-70) years enrolled in retrospective analysis who were referred to surgical intervention due to left main (51, 32%) and multivessel (108, 68%) disease. The regression analysis for long-term mortality risk and the Kaplan-Meyer survival curve were analyzed. Multivariable analysis pointed female sex (HR = 1.08, 95% CI: 1.03-1.14, p = 0.001) and diabetes mellitus (HR = 6.33, 95% CI: 1.86-21.52, p = 0.003) as possible risk factors for 10-year mortality risk. There was no significant difference in Kaplan-Meyer 10-year mortality comparison between left main and multivessel disease patients treated by off-pump surgical revascularization (HR = 0.93, 95% CI: 0.40-2.13, p = 0.86). Off-pump surgery in the left main disease, compared to multivessel disease, represents a safe surgical technique with satisfactory long-term results. The female sex and diabetes mellitus were found as possible risk factors for 10-year mortality risk in multivariable analysis.

Coronary Artery Bypass Surgery: Evidence-Based Practice.

Coronary artery bypass graft (CABG) surgery remains a pivotal cornerstone, offering established symptomatic alleviation and prognostic advantages for patients grappling with complex multivessel and left main coronary artery diseases. Despite the lucid guidance laid out by contemporary guidelines regarding the choice between CABG and percutaneous coronary intervention (PCI), a notable hesitation persists among certain patients, characterized by psychological reservations, knowledge gaps, or individual beliefs that sway their inclination toward surgical intervention. This comprehensive review critically synthesizes the prevailing guidelines, modern practices, and outcomes pertaining to CABG surgery, delving into an array of techniques and advancements poised to enhance both short-term and enduring surgical outcomes. The exploration encompasses advances in on-pump and off-pump procedures, conduit selection strategies encompassing the bilateral utilization of internal mammary artery and radial artery conduits, meticulous graft evaluation methodologies, and the panorama of minimally invasive approaches, including those assisted by robotic technology. Furthermore, the review navigates the terrain of hybrid coronary revascularization, shedding light on the pivotal roles of shared decision-making and the heart team in shaping treatment pathways. As a comprehensive compendium, this review not only navigates the intricate landscape of CABG surgery but also aligns it with contemporary practices, envisioning its trajectory within the evolving currents of healthcare dynamics.

Comparative efficacy on outcomes of C-CABG, OPCAB, and ONBEAT in coronary heart disease: a systematic review and network meta-analysis of randomized controlled trials.

Coronary artery bypass grafting (CABG) remains the gold standard for the treatment of multivessel and left main coronary heart disease. However, the current evidence about the optimal surgical revascularization strategy is inconsistent and is not sufficient to allow for definite conclusions. Thus, this topic needs to be extensively discussed. The aim of this present study was to compare the clinical outcomes of off-pump CABG (OPCAB), conventional on-pump CABG (C-CABG), and on-pump beating heart (ONBEAT) CABG via an updated systematic review and network meta-analysis of randomized controlled trials. PubMed, Web of Science, and the Cochrane Central Registry were searched for relevant randomized controlled trials that were published in English before 1 December 2021. Published trials that included patients who received OPCAB, C-CABG, and ONBEAT CABG were selected. Two authors independently screened the search results, assessed the full texts to identify eligible studies and the risk of bias of the included studies, and extracted data. All processes followed the Preferred Reporting Items for Systematic Review and Meta-analysis of Individual Participant Data. The primary outcome was postoperative mortality in patients who underwent C-CABG, OPCAB, or ONBEAT CABG. The secondary outcomes were postoperative myocardial infarction, stroke, and renal impairment in the three groups. The time point for analysis of outcomes was all time periods during the postoperative follow-up. A total of 39385 patients (83496.2 person-years) in 65 studies who fulfilled the prespecified criteria were included. In the network meta-analysis, OPCAB was associated with an increase of 12% in the risk of all-cause mortality when compared with C-CABG [odds ratio (OR): 1.12; 95% CI: 1.04-1.21], a reduction of 49% in the risk of myocardial infarction when compared with ONBEAT (OR: 0.51; 95% CI: 0.26-0.99), a reduction of 16% in the risk of stroke when compared with C-CABG (OR: 0.84; 95% CI: 0.72-0.99) and a similar risk of renal impairment when compared with C-CABG and ONBEAT. OPCAB was associated with higher all-cause mortality but lower postoperative stroke compared with C-CABG. OPCAB was associated with a lower postoperative myocardial infarction than that of ONBEAT. Early mortality was comparable among OPCAB, ONBEAT, and C-CABG.

Comparison of Early Outcome of Off-pump and Conventional Coronary Artery Bypass Graft Surgery in Patients with Left Main Coronary Artery Disease with Left Ventricular Dysfunction

Left Main (LM) coronary artery disease and left ventricular dysfunction both are important predictors of in-hospital mortality. To avoid the harmful effects of cardio pulmonary bypass (CPB), many cardiac surgeons are using Offpump Coronary Artery Bypass (OPCAB) as an effective alternative to conventional CABG (CCAB) even in these sub-groups of patients. This study performed in the National Institute of Cardiovascular Diseases (NICVD) evaluated the early outcomes of OPCAB in terms of mortality and major post-operative morbidities and compared them with that of CCAB in patients with left main coronary artery diseases with left ventricular (LV) dysfunction. Total 120 patients with left main coronary artery disease with reduced left ventricular ejection fraction (&lt;_40%) were allocated into two groups: a) 60 patients who underwent OPCAB and b) another 60 patients who underwent conventional CABG between January 2012 and December 2017. All risk factors and co-morbidities were homogenously distributed between the two groups. Majority of the patients had triple vessel disease. Nearly three-quarters (73.3%) of patients in OPCAB group and 80% in CCAB group received 3 grafts (p=0.470). The mean total operative time (p&lt; 0.001), intubation times (p&lt;0.001), blood losses (p &lt; 0.001); requirements for blood and blood products (p &lt; 0.0010), intensive care unit stays (p&lt;0.001) and hospital stays (p&lt; 0.001) were all significantly lower in the OPCAB group. OPCAB is a safe and effective operative revascularization procedure for patients with left main coronary artery disease with left ventricular dysfunction and is associated with reduced morbidity.&#x0D; Bangabandhu Sheikh Mujib Med. Coll. J. 2022;1(1):04-08

Non-reperfused ST-elevation myocardial infarction: notions from a low-to-middle-income country.

The objective of the study was to analyze the differences between survivors and non-survivors with non-reperfused ST-segment elevation myocardial infarction (STEMI) and to identify the predictors of in-hospital mortality. A retrospective cohort study included non-reperfused STEMI patients from October 2005 to August 2020. Patients were classified into survivors and non-survivors. We compared patient characteristics, treatments, and outcomes among the groups and identified factors associated with in-hospital mortality. We included 2442 patients with non-reperfused STEMI and we found a mortality of 12.7% versus 7.2% in reperfused STEMI. The main reason for non-reperfusion was delayed presentation (96.1%). Non-survivors were older, more often women, and had diabetes, hypertension, or atrial fibrillation. The left main coronary disease was more frequent in non-survivors as well as three-vessel disease. Non-survivors developed more in-hospital heart failure, reinfarction, atrioventricular block, bleeding, stroke, and death. The main predictors for in-hospital mortality were renal dysfunction (HR 3.41), systolic blood pressure < 100 mmHg (HR 2.26), and left ventricle ejection fraction < 40% (HR 1.97). Mortality and adverse outcomes occur more frequently in non-reperfused STEMI. Non-survivors tend to be older, with more comorbidities, and have more adverse in-hospital outcomes.

Physiology-guided PCI versus CABG for left main coronary artery disease: insights from the DEFINE-LM registry

There have been no studies comparing clinical outcomes of physiology-guided revascularization in patients with unprotected left main coronary disease (ULMD) between percutaneous coronary intervention (PCI) vs. coronary artery bypass grafting (CABG). The aim of this study was to assess the long-term clinical outcomes between PCI and CABG of patients with physiologically significant ULMD. From an international multicenter registry of ULMD patients interrogated with instantaneous wave-free ratio (iFR), we analyzed data from 151 patients (85 PCI vs. 66 CABG) who underwent revascularization according to the cutoff value of iFR ≤ 0.89. Propensity score matching was employed to adjust for baseline clinical characteristics. The primary endpoint was a composite of all-cause death, non-fatal myocardial infarction, and ischemia-driven target lesion revascularization. The secondary endpoints were the individual components of the primary endpoint. Mean age was 66.6 (± 9.2) years, 79.2% male. Mean SYNTAX score was 22.6 (± 8.4) and median iFR was 0.83 (IQR 0.74–0.87). After performing propensity score matching analysis, 48 patients treated with CABG were matched to those who underwent PCI. At a median follow-up period of 2.8 years, the primary endpoint occurred in 8.3% in PCI group and 20.8% in CABG group, respectively (HR 3.80; 95% CI 1.04–13.9; p = 0.043). There was no difference in each component of the primary event (p > 0.05 for all). Within the present study, iFR-guided PCI was associated with lower cardiovascular events rate in patients with ULMD and intermediate SYNTAX score, as compared to CABG.Graphical abstractState-of-the-art PCI vs. CABG for ULMD. Study design and primary endpoint in patients with physiologically significant ULMD. MACE was defined as the composite of all-cause death, non-fatal myocardial infarction, and target lesion revascularization. The blue line denotes the PCI arm, and the red line denotes the CABG arm. PCI was associated with significantly lower risk of MACE than CABG. CABG: coronary artery bypass grafting; iFR: instantaneous wave-free ratio; MACE: major adverse cardiovascular events; PCI: percutaneous coronary intervention; ULMD: unprotected left main coronary artery disease.

Long-term clinical outcomes of percutaneous coronary intervention for ostial left main coronary artery disease.

There are limited data regarding the long-term prognosis of percutaneous coronary intervention treatment for left main (LM) ostial stenosis. The present study sought to investigate the long-term clinical outcomes and risk factors for adverse events in LM ostial lesions following drug-eluting stent implantation (DES) in a large cohort of an LM registry database. Patients presenting with LM coronary disease from January 2004 to December 2016 at Fuwai Hospital were included. The primary endpoint was target vessel failure (TVF), a composite endpoint of cardiac death, target vessel myocardial infarction and target vessel revascularisation. Cox proportional hazards models were constructed to identify independent predictors. Among 4,625 LM patients, 627 (13.6%) patients were identified with LM ostial lesions. There were more female patients in the ostial group (31.3%), compared with the shaft (18.1%) and bifurcation groups (19.9%) (p<0.0001). Among patients with DES implantation, 3-year TVF occurred in 44 patients (7.5%) in the ostial group, which is comparable with the other two groups. Myocardial infarction (MI) was significantly lower in the ostial group (2.0%) compared with the bifurcation group (4.2%) (p=0.02), especially for MI events originating in the LM vessel (p=0.02). For patients with ostial LM disease who received percutaneous coronary intervention (PCI) treatment, procedural complications were an independent risk factor for long-term cardiac death or MI, while a more recent PCI proved to be a protective factor. PCI treatment for ostial LM lesions achieved favourable long-term outcomes, with a similar MI risk compared with the mid-shaft group but a significantly lower risk of MI compared with the distal group.

Clinical research of drug-coated balloon after rotational atherectomy for severe coronary artery calcification

BackgroundCurrent research results show that drug-coated balloons (DCB) have unique advantages in the treatment of in-stent restenosis, small vessel disease, bifurcation lesions, and de novo lesions, but the data regarding rotational atherectomy (RA) followed by DCB treatment in calcified lesions, especially severe coronary artery calcification (CAC), are limited.MethodsA retrospective study was conducted on 318 individuals with severe CAC who underwent RA-assisted PCI at the First Affiliated Hospital of Zhengzhou University from May 2018 to July 2021. Among them, 57 patients (RA/DCB group) were treated with DCB, and 261 patients (RA/DES group) were treated with drug-eluting stents (DES). The two groups' clinical baseline data, lesion characteristics, intraoperative complications, in-hospital adverse events, and major adverse cardiovascular and cerebrovascular events (MACCE) were compared throughout the follow-up period.ResultsThe baseline clinical data, intraoperative complications, and in-hospital adverse events were not significantly different between the two groups. The anatomical categories in the RA/DES group were more complex and included left main coronary disease, bifurcation disease, and multivessel disease. Although target lesion revascularization (13.79% vs. 7.02%) and MACCE (18.77% vs. 12.28%) occurred more frequently in the RA/DES group than in the RA/DCB group, there was no statistically significant difference (p > 0.05). Multivariate Cox regression analysis showed that bifurcation lesions (HR 2.284, 95% CI 1.063–4.908, p = 0.034), total length of DCB/DES (HR 1.023, 95% CI 1.005–1.047, p = 0.014) and SYNTAX score (HR 1.047, 95% CI 1.013–1.082, p = 0.006) were independent risk factors for MACCE during the follow-up period.ConclusionDrug-coated balloon treatment after rotational atherectomy appears safe and effective in selected severe coronary artery calcification.

Antiplatelet therapy after complex percutaneous coronary intervention and in left main coronary disease. Not all lesions are the same

Antiplatelet therapy after complex percutaneous coronary intervention and in left main coronary disease. Not all lesions are the same

Real-World Examination of Revascularization Strategies for Left Main Coronary Disease in Ontario, Canada

BackgroundRandomized trials have compared percutaneous coronary intervention and coronary artery bypass grafting (CABG) in patients with left main coronary artery disease undergoing nonemergent revascularization. However, there is a paucity of real-world contemporary observational studies comparing percutaneous coronary intervention (PCI) and CABG. ObjectivesThe purpose of this study was to compare the long-term clinical outcomes of CABG versus PCI in patients with left main coronary disease. MethodsClinical and administrative databases for Ontario, Canada, were linked to obtain records of all patients with angiographic evidence of left main coronary artery disease (≥50% stenosis) treated with either isolated CABG or PCI from 2008 to 2020. Emergent, cardiogenic shock, and ST-segment elevation myocardial infarction patients were excluded. Baseline characteristics of patients were compared and 1:1 propensity score matching was performed. Late mortality and major adverse cardiac and cerebrovascular events were compared between the matched groups using a Cox proportional hazard model. ResultsAfter exclusions, 1,299 and 21,287 patients underwent PCI and CABG, respectively. Prior to matching, PCI patients were older (age 75.2 vs 68.0 years) and more likely to be women (34.6% vs 20.1%), although they had less CAD burden. Propensity score matching on 25 baseline covariates yielded 1,128 well-matched pairs. There was no difference in early mortality between PCI and CABG (5.5% vs 3.9%; P = 0.075). Over 7-year follow-up, all-cause mortality (53.6% vs 35.2%; HR: 1.63; 95% CI: 1.42-1.87; P < 0.001) and major adverse cardiac and cerebrovascular events (66.8% vs 48.6%; HR: 1.77; 95% CI: 1.57-2.00) were significantly higher with PCI than CABG. ConclusionsCABG was the most common revascularization strategy in this real-world registry. Patients undergoing PCI were much older and of higher risk at baseline. After matching, there was no difference in early mortality but improved late survival and freedom from major adverse cardiac and cerebrovascular events with CABG.

Controversies in cardiac surgery: left main coronary disease, arterial myocardial revascularization, and prosthetic valves in dialysis.

Controversies in cardiac surgery: left main coronary disease, arterial myocardial revascularization, and prosthetic valves in dialysis.

Abstract 12626: A Systematic Review and Meta-analysis of Factors Associated With Long-Term Mortality in Adults After Coronary Artery Bypass Graft Surgery

Background: With an ageing and increasingly multi-morbid population, the use of coronary artery bypass grafting (CABG) is expected to increase. As short-term CABG mortality rates have decreased, estimating long-term outcomes for patients with specific risk factors has become more relevant. Previous single observational studies have identified risk factors for adverse long-term outcomes, such as older age and diabetes. Purpose: Understanding the pre-operative characteristics that affect late mortality post-CABG can lead to effective risk stratification and enhancement of secondary prevention programmes, thereby aiming to improve long-term prognosis after the procedure. Methods: MEDLINE, Embase, Google Scholar, and Cochrane electronic databases were searched to identify all relevant articles evaluating associations between pre-operative risk factors and long-term mortality (≥5 years ) post-CABG. Studies with &lt;500 patients were excluded. Results: From 1193 potentially eligible articles, 43 studies met the inclusion criteria. A total of 360,481 patients, with an average follow-up of 10 years, were included, representing an approximate cumulative total of 3,604,810 person-years. After pooling adjusted hazard ratios, 6 major risk factors were found to be independently associated with long-term mortality after CABG: age, ischaemia (peripheral vascular disease, prior cerebrovascular accident, left main stem coronary disease), diabetes mellitus, atrial fibrillation, renal impairment (chronic kidney disease and dialysis-dependent chronic kidney disease), and impaired left ventricular function (reduced LV ejection fraction or prior heart failure) (see Table 1). Conclusion: We have identified six groups of risk factors for long-term mortality post-CABG. Further work is needed to assess whether the influence of these risk factors varies over time and if targeted interventions for high-risk groups lead to improved long-term mortality.

Coronary artery bypass grafting versus percutaneous coronary intervention with stenting for multivessel coronary artery disease without left main coronary disease:reconstructed individual patient data

Abstract Background and aims Data are emerging on 10-year mortality comparing coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) with stenting for multivessel disease (MVD) without left main (LM) involvement. We conducted an updated two-stage meta-analysis using reconstructed individual patient data to compare long-term mortality between CABG and PCI for patients with MVD without significant LM coronary disease. Methods Medline and Embase databases were searched for articles comparing CABG with PCI for MVD. A two-stage meta-analysis was conducted using reconstructed patient level survival data for all-cause mortality with subgroups by SYNTAX score. The shared-frailty and stratified Cox models were fitted to compare survival endpoints. Results We screened 1496 studies and included six randomized controlled trials with 7181 patients. PCI was associated with greater 10-year all-cause mortality risk (HR: 1.282, CI: 1.118–1.469, p&amp;lt;0.001) compared with CABG. In patients with low SYNTAX score, 10-year all-cause mortality after PCI was comparable to CABG (HR: 1.102, 0.822–1.479, p=0.516). However, in patients with moderate to high SYNTAX score, 10-year all-cause mortality was significantly higher after PCI compared with CABG (HR: 1.444, 1.122–1.858, p&amp;lt;0.001; HR: 1.856, 1.380–2.497, p&amp;lt;0.001 respectively). Conclusion This updated reconstructed individual patient-data meta-analysis revealed a sustained lower cumulative all-cause mortality of CABG over PCI for multivessel disease without LM involvement. Funding Acknowledgement Type of funding sources: None.

The brain-before-heart strategy for coronary artery bypass grafting in the severely atherosclerotic aorta: A single-institution experience.

Severe atherosclerosis of the ascending aorta (SAA) in patients undergoing surgical revascularization by coronary artery bypass grafting (CABG) is becoming an increasing problem as more elderly patients are diagnosed with coronary artery disease. Strokes and other neurologic insults are common complications in this group, with devastating impacts on outcomes and prognoses. Early detection of the atherosclerotic aorta and the application of a stroke prevention protocol will reduce the risk of stroke in patients with SAA. In 2012, we adopted a protocol devised to preemptively detect and manage patients suspected of having SAA. From the time of the application of the protocol, we compared the immediate and late outcomes of CABG in SAA in the 8 years preceding the protocol in a "control" group (30 patients) and in the 8 years following the protocol in a "brain" group (69 patients). More patients with SAA were detected after the initiation of the protocol. They had significantly more history of stroke, renal dysfunction, and left main coronary disease. The percutaneous coronary intervention was utilized more after the protocol (26% vs. 7%) and there was far less utilization of replacement of the ascending aorta (12% vs. 37%). Postoperative stroke rates were significantly less after the protocol (2% vs. 18%), with an almost twofold reduction in stroke associated with SAA even after risk adjustment. The composite endpoints of cardiac death, nonfatal myocardial infarction, and stroke were significantly reduced after initiating the protocol at a median of 2.3 years from the time of revascularization. Early detection of SAA and individualized therapeutic strategies for revascularization is effective in reducing athero-embolic brain injury and are associated with better prognosis.

Left Ventricular Support for Unprotected Left Main Coronary Artery Interventions (The Dayton Heart and Vascular Impella Registry).

Coronary artery bypass grafting is the standard of care for patients with obstructive left main (LM) coronary disease. In poor surgical candidates, high-risk percutaneous coronary artery intervention (PCI) is an alternative. We investigated a retrospective cohort of patients who underwent LM PCI from January 2010 to March 2014 (n = 89). Obstructive LM disease was defined as 50% angiographic obstruction of luminal flow, and the primary endpoint was inhospital mortality. Ventricular assist device (VAD) was defined as the use of either intra-aortic balloon pump (IABP) or Impella 2.5 devices before, during, or following PCI. A total of 89 patients with LM PCI were divided into those with (n = 39) and without (n = 50) VAD support. The former group was further divided into those with support from either Impella 2.5 (n = 28) or IABP (n = 11). Age, race, and gender did not differ between patients who received unassisted LM-PCI from those with VAD support (P = 0.142, 1.0, and 0.776, respectively). The angiographic stenosis of atherosclerotic lesions in LM, proximal left anterior descending artery, and other native/surgical coronary vessels was similar between the groups. The duration of hospitalization was significantly longer for patients with VAD support compared to those without (7.19 ± 6.89 vs. 2.78 ± 3.39, P < 0.001). The incidence of cardiogenic shock and inhospital mortality was significantly higher in the VAD group (P = 0.009 and 0.001, respectively). Overall, inhospital mortality was 9% (8/89). The IABP and Impella 2.5 groups had mortality proportions of 46% (5/11) and 11% (3/28), respectively; P = 0.028. For all patients, inhospital mortality was higher for those with versus without cardiogenic shock (56% or 5/9 vs. 4% or 3/80; P < 0.001), and for those with versus without left ventricular systolic function <40% (17% vs. 2%;P < 0.025). In a selected group of patients with LM disease, unsupported PCI appears to be a feasible and safe procedure. In high-risk patients, the use of Impella 2.5 appears to be superior to IABP in LM PCI resulting in favorable short-term outcomes.