Left Main Coronary Disease Research Articles

Harnessing drug-coated balloons for the management of left main coronary disease: A promising strategy?

Harnessing drug-coated balloons for the management of left main coronary disease: A promising strategy?

Treatment delay and outcomes of ST-segment elevation myocardial infarction treated by primary percutaneous coronary intervention during the COVID-19 era in South Korea.

Background/AimsLittle is known about the clinical characteristics and treatment outcomes of ST-segment elevation myocardial infarction (STEMI) in Korea during the coronavirus disease 2019 (COVID-19) era. We aimed to evaluate the clinical characteristics and treatment outcomes of patients with STEMI in the COVID-19 era.MethodsA total of 588 consecutive patients with STEMI who underwent primary percutaneous coronary intervention were included in this study. The patients were categorized into the COVID-19 (from January 20, 2020 to December 31, 2020) and control groups (from January 20, 2019 to December 31, 2019).ResultsThe COVID-19 group showed pre-hospital and in-hospital delays than the control group. The control group underwent more thrombus aspiration and had a higher proportion of left main coronary artery diseases, while the COVID-19 group had a higher proportion of multivessel diseases with a marked increase in the number and total length of stents than the control group. As for the prescribed medications, the COVID-19 group was administered more beta-blockers, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, and statins than the control group. The clinical outcomes were comparable between the groups, except for higher incidences of atrioventricular block and temporary pacemaker implantation in the COVID-19 group.ConclusionsReperfusion after STEMI treatment during the COVID-19 period was delayed; therefore, efforts should be made to improve on reperfusion.

The Outcome of LM PCI: A Single Center Experience of First 50 Cases without In-site IVUS Facility

Introduction: Left main disease (LMD) is related to significant morbidity and mortality. This study was done to evaluate the clinical major adverse cardiovascular event (MACE), including unstable angina, myocardial infarction, heart failure, target vessel revascularization, stroke and death in patients undergoing left main stem stenting without availability of in-site intravascular imaging (IVUS). Methods & Materials: It was a prospective observational study done in National Institute of Cardiovascular Diseases & Hospital (NICVD) from March 2014 to June 2019. Our study included 50 patients who underwent Percutaneous Coronary Intervention for left main disease without use of IVUS. All the patients were followed up for 1 year & 2 years, one patient was lost to follow-up. Outcomes included in MACE were death, myocardial infarction, unstable angina, heart failure, stroke and target vessel revascularization (TVR). Results: Fifty patients (mean age 58.4 ± 4.1 years, 44 male, 06 female) were treated with a mean SYNTAX score of 24.8 ± 2.6. Thirty two (64%) patients had stable angina, 17 (34%) had unstable angina/non ST-elevation myocardial infarction, and 1 (02%) had ST-elevation Myocardial infarction. Among the risk factors, 21(42%) had DM, 33 (66%) were hypertensive, 22 (44%) were smoker, 19 (38%) had dyslipidemia, 09 (18%) had previous h/o MI, 11 (22%) had family h/o CAD & 01 (02%) had previous h/o CVD. Preprocedural LVEF was 49.92± 6.60 % and post procedural 54.84 ± 4.55% which showed significant improvement of LVEF after PCI (p=0.003). Most of the patients presented with LM with SVD (82%). Among all patients, 39 (78%) underwent complete revascularization in compare to 11 (22%) had incomplete revascularization. Thirty eight (76%) patients received a single-stent DES and 12 (24%) received two-stents DES. Among double stent strategy, majority underwent TAP (50%). All access was femoral & No reflow phenomena were found in any of the patients during the procedure. No perioperative mortalities were noted and no urgent coronary bypass graft surgery was required. One patient was lost to follow-up. After 1-year follow-up period, 1 (02%) patients had non-fatal myocardial infarction, 7 (14%) had episodes of unstable angina (UA) and 3 (06%) had heart failure (HF). After 2-years there was no new MI but 09 (18%) had UA & 4 (08%) patients had HF episode in total. TLR was 2 (04%) in first year and 3 (06%) in 2nd year. Total mortality was 1(02%) in first year & 3(06%) in 2nd year. The multivariable analysis showed a good prognosis in patients receiving LM PCI with a total event rate of 28% & mortality 6%. A multivariate regression analysis with risk factors for coronary artery disease as predictive variables showed that high SYNTAX score (p = 0.013), incomplete revascularization (p=0.002) & low post procedural LVEF (p= 0.001) was an independent predictor of MACE. Conclusion: Percutaneous coronary intervention of left main coronary disease without use of IVUS showed good prognosis after 1-year & 2-years follow-up. It would not only save a procedure time for physicians but also prevent a financial burden on patients if they cannot afford intravascular imaging. Bangladesh Heart Journal 2022; 37(1): 1-9

Appropriateness criteria for the use of cardiac computed tomography, SIC-SIRM part 2: acute chest pain evaluation; stent and coronary artery bypass graft patency evaluation; planning of coronary revascularization and transcatheter valve procedures; cardiomyopathies, electrophysiological applications, cardiac masses, cardio-oncology and pericardial diseases evaluation.

In the past 20 years, cardiac computed tomography (CCT) has become a pivotal technique for the noninvasive diagnostic workup of coronary and cardiac diseases. Continuous technical and methodological improvements, combined with fast growing scientific evidence, have progressively expanded the clinical role of CCT. Randomized clinical trials documented the value of CCT in increasing the cost-effectiveness of the management of patients with acute chest pain presenting in the emergency department, also during the pandemic. Beyond the evaluation of stents and surgical graft patency, the anatomical and functional coronary imaging have the potential to guide treatment decision-making and planning for complex left main and three-vessel coronary disease. Furthermore, there has been an increasing demand to use CCT for preinterventional planning in minimally invasive procedures, such as transcatheter valve implantation and mitral valve repair. Yet, the use of CCT as a roadmap for tailored electrophysiological procedures has gained increasing importance to assure maximum success. In the meantime, innovations and advanced postprocessing tools have generated new potential applications of CCT from the simple coronary anatomy to the complete assessment of structural, functional and pathophysiological biomarkers of cardiac disease. In this complex and revolutionary scenario, it is urgently needed to provide an updated guide for the appropriate use of CCT in different clinical settings. This manuscript, endorsed by the Italian Society of Cardiology (SIC) and the Italian Society of Medical and Interventional Radiology (SIRM), represents the second of two consensus documents collecting the expert opinion of cardiologists and radiologists about current appropriate use of CCT.

Immediate complete revascularization showed better outcome in out-of-hospital cardiac arrest survivors with left main or triple-vessel coronary diseases

This study aimed to evaluate the prevalence of left main or triple vessel coronary artery disease (CAD) in comatose out-of-hospital cardiac arrest (OHCA) survivors and assessed their outcome based on the revascularization strategy. This multicenter, retrospective, observational registry-based study was conducted at 9 Korean tertiary care hospitals. Adult comatose OHCA survivors with left main or triple vessel CAD documented by immediate (≤ 2 h) coronary angiography after return of spontaneous circulation between 2011 and 2019 were included. The primary outcome was neurologically intact survival at 1-month. Among 727 OHCA patients, 150 (25%) had left main or triple vessel CAD and underwent complete (N = 32), incomplete (N = 78), and no immediate (N = 40) revascularization, respectively. The rate of neurologically intact survival at 1 month was significantly different among the groups (53%, 32%, and 23% for complete, incomplete, and no immediate revascularization groups, respectively; P = 0.02). After adjustment using the inverse probability of treatment weighting, complete revascularization was associated with neurologically intact survival at 1 month (odds ratio, 2.635; P = 0.01). Left main or triple vessel CAD is not uncommon in OHCA patients. The complete revascularization was associated with better outcome. Further clinical trials to confirm the best revascularization strategy are needed.

Prognostic Value of Sex After Revascularization for Left Main Coronary Disease: Extended PRECOMBAT Study.

Female subjects have poorer outcomes in left main coronary artery (LMCA) disease compared with male subjects. However, limited information is available on the long-term prognostic impact of sex and sex-treatment interactions in patients with LMCA disease undergoing coronary revascularization. The goal of this study was to investigate the long-term effects of sex and related differential outcomes after percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) in LMCA disease. The extended PRECOMBAT (Premier of Randomized Comparison of Bypass Surgery versus Angioplasty Using Sirolimus-Eluting Stent in Patients with Left Main Coronary Artery Disease) trial evaluated the >10-year clinical outcomes in patients with LMCA disease randomized to undergo PCI with drug-eluting stents (n=300) or CABG (n=300). The primary outcome was major adverse cardiac or cerebrovascular events (MACCE) (composite of death, myocardial infarction, stroke, or ischemia-driven target vessel revascularization) at 10 years. Of the 600 patients, 459 (76.5%) were male. The 10-year rates of MACCE were similar between male and female subjects in the overall cohort (27.3% vs 27.0%; adjusted hazard ratio [aHR]: 1.06; 95% confidence interval [CI]: 0.70-1.59), the PCI arm (30.6% vs 27.1%; aHR: 1.19; 95%CI: 0.69-2.05), and the CABG arm (24.0% vs 26.9%; aHR: 0.93; 95%CI: 0.53-1.62). The 10-year risks for MACCE did not significantly differ between PCI and CABG in both male (aHR: 1.37; 95%CI: 0.95-1.97) and female (aHR: 1.07; 95%CI: 0.56-2.07) subjects. There was no significant sex-treatment interaction regarding the adjusted risk of MACCE at 10 years (P for interaction=0.52). In this 10-year follow-up of the PRECOMBAT trial, there was no sex-related impact on the long-term risk of MACCE after PCI and CABG for LMCA disease. (Ten-Year Outcomes of PRECOMBAT Trial; NCT03871127).

Coronary Artery Bypass Grafting Versus Percutaneous Coronary Intervention in Patients with Distal Left Main Coronary Disease

Coronary Artery Bypass Grafting Versus Percutaneous Coronary Intervention in Patients with Distal Left Main Coronary Disease

Mini-Crush Technique in Left Main Coronary Bifurcation: A Case Report

Percutaneous coronary intervention of Left Main (LM) coronary artery bifurcation disease remains technically challenging. Despite the plethora of techniques in current practice and guidelines advocating provisional strategy (one-stent or main branch-stent only), controversy still persists regarding the two-stent techniques.Moreover, there is improved mindfulness towards various factors affecting LM treatment such as patient selection, stent characteristics, risk stratification, optimum imaging, as well as vessel preparation. The latest generation stent with ultra-thin struts have been safe and efficient in the treatment of LM bifurcation lesions, as they have upgraded designs that aid in the expansion of their diameters to larger extent. Additionally, being ultra-thin leads to lower metal load at the carina, thus improving the long-term outcomes. The authors here present with the case of a 42-year-old patient with LM bifurcation disease who was successfully managed with mini-crush technique using ultra-thin Tetriflex Sirolimus-Eluting Stents (SES). The case depicts that optimum amalgamation of ultrathin strut stents implantation and mini-crush technique would provide very favourable results.

Abstract 10868: Risk Factors and Long-Term Outcomes of Cardiogenic Shock in Young Patients with Myocardial Infarction - The Mass General Brigham Young-MI Registry

Introduction: Cardiogenic shock complicating acute myocardial infarction (CS-AMI) is associated with high morbidity and mortality, yet data among younger individuals are limited. Methods: Retrospective cohort study of consecutive AMI patients aged 18-50 years admitted to 2 tertiary care academic centers from 2000-2016. CS was determined by physician review of electronic health records (EHR) using the SCAI CS classification system. Baseline characteristics, treatment and outcomes including all-cause mortality (ACM), cardiovascular mortality (CVM) and 1-year hospitalization for heart failure (HHF) were adjudicated by physicians using EHR and death records. Mahalanobis distance matching was used to define a comparator group in the non-CS cohort. Results: The study included 2097 AMI patients (mean age 44 ± 5.1 years, 74% white, 81% male), with CS-AMI identified in 148 (7%) patients. There were no significant differences in age, sex or race between groups, although CS-AMI patients were more likely to have public or no insurance (p=0.02). Independent factors associated with CS-AMI included female sex, STEMI at presentation, out of hospital cardiac arrest, left main coronary disease, diabetes and peripheral artery disease. Over a median follow up of 11.2 years, compared to 461 matched non-CS-AMI patients and controlling for relevant covariates, CS-AMI patients had significantly higher ACM (aHR 2.84, p<0.001), CVM (aHR 4.09, p<0.001), and 1-year HHF (aHR 6.18, p=0.001) (Figure 1). In landmark analyses, CS-AMI patients who survived to discharge continued to have significantly higher risk of CVM (aHR 2.76, p=0.016) compared with matched non-CS AMI patients. All results were similar in the full cohort comparison. Conclusion: Cardiogenic shock is infrequent amongst young AMI patients, but associated with substantially higher overall and post-discharge mortality, and 1-year heart failure hospitalizations after AMI compared to those without cardiogenic shock.

TCT-66 Choice and Outcomes of Left Main Coronary Disease Revascularization Strategies in England Before and After the COVID-19 Era

TCT-66 Choice and Outcomes of Left Main Coronary Disease Revascularization Strategies in England Before and After the COVID-19 Era

Left main coronary disease at the bifurcation: should the pendulum swing back towards the provisional stenting approach?

This editorial refers to ‘The European Bifurcation Club Left Main Coronary Stent study: a randomized comparison of stepwise provisional vs. systematic dual stenting strategies (EBC MAIN)’, by D. Hildick-Smith et al., doi:10.1093/eurheartj/ehab283. Simplicity, simplicity, simplicity! --Henry David Thoreau, Walden, 1854 Revascularization of severe left main disease is a class I guideline recommendation to improve survival.1 When percutaneous coronary intervention (PCI) is chosen as the method of revascularization, and the lesion involves the left main distal bifurcation, the age-old question remains—one or two stents upfront? In the past decade, Dr Shao-Liang Chen and colleagues have refuted Thoreau’s counsel, demonstrating elegantly in the DKCRUSH-V and DEFINITION II studies that left main bifurcation disease is better treated with an upfront two-stent approach rather than a provisional one-stent approach.2–4 However, these outstanding results were predicated on using the double kiss crush stenting, a technique that requires significant expertise to...

Contribution of Current Comorbid Conditions to Carotid Artery Stenosis in Patients Undergoing Coronary Artery Bypass and Stroke Distribution in Carotid Artery Stenosis Groups.

The aim of this study was to contribute to the issue of "Who should we perform Doppler ultrasonography on?" and determine the contribution of comorbid diseases to the development of carotid artery stenosis (CAS) and preoperative CAS by examining comorbid diseases in patients undergoing coronary artery bypass graft operation (CABG) and also discussing the effect of carotid stenosis levels on postoperative stroke. Between 2011-2015, a total of 921 patients who underwent cardiac surgery retrospectively were examined. Of these, 594 CABG patients aged 60 and over who underwent preoperative carotid Doppler examination were analyzed. Sixty-five percent of patients were male, and 35% were female. The mean age was 69.3 years. Sixty-nine percent of patients were in the 0-29% stenosis group, 12.9% in the 30-49% group, 14.6% in the 50-69% group, 3% in the 70-99% group, and 0.3% in the 100% occlusion group. Peripheral artery disease (PAD), age, gender, and diabetes mellitus (DM) were found to have significant (P < 0.05) effects on the occurrence of CAS. CAS increased by 0.9% with an increase of one year in age, 10.8% with the presence of PAD, 3% with male sex, 3.8% with presence of chronic obstructive pulmonery disease (COPD), 1.9% with presence of left main coronary disease (LMCAD), and 0.9% with presence of hypertension. In the decision tree analysis, the rate of 50% and above CAS in the presence of PAH + DM and age older than 65 years was 62.5%. Cerebrovascular accident (CVA) distribution was 2.1% in the 0-29% group, 2.5% in the 30-49% group, 4.5% in the 50-69% group, and 11.1% in the 70-99% group. Postoperative CVA was not observed in 10 patients who underwent carotid endarterectomy (CE). Postoperative CVA developed in six patients with 50% or more stenosis who did not undergo CE. For the preoperative detection of CAS in patients undergoing CABG, the association of advanced age, PAD, DM, male gender, COPD, LMCAD, and hypertension risk factors should be considered. We suggest that carotid screening should be performed in those over 65 years of age and with PAD+DM. Studies with large populations are needed to observe the effects of aortic atherosclerosis load, surgical procedure, and unilateral/bilateral CAS presence on the development of stroke in patients with severe CAS and postoperative CVA.

Correlation of Intravascular Ultrasound and Instantaneous Wave-Free Ratio in Patients With Intermediate Left Main Coronary Artery Disease.

There is great degree of interobserver variability in the visual angiographic assessment of left main coronary disease (LMCD). Fractional flow reserve and intravascular ultrasound are often used in this setting. The use of instantaneous wave-free ratio (iFR) for evaluation of LMCD has not been well studied. The aim of this study is to evaluate the use of iFR in the assessment of angiographically intermediate LMCD. This is an international multicenter retrospective observational study of patients who underwent both iFR and intravascular ultrasound evaluation for angiographically intermediate LMCD. An independent core laboratory performed blinded off-line analysis of all intravascular ultrasound data. A minimum lumen area of 6 mm2 was used as the cutoff for significant disease. One hundred twenty-five patients (mean age, 68.4±9.5 years, 84.8% male) were included in this analysis. Receiver operating curve analysis showed that an iFR of ≤0.89 identified minimum lumen area <6 mm2 with an area under the curve of 0.77 (77% sensitivity, 66% specificity; P<0.0001). Among the 69 patients without ostial left anterior descending artery or left circumflex artery disease, receiver operating curve analysis showed that an iFR of ≤0.89 identified minimum lumen area <6 mm2 with an area under the curve of 0.84 (70% sensitivity, 84% specificity; P<0.0001). The correlation was not significantly different when the body surface area was considered. In this study, in patients with intermediate LMCD, iFR of ≤0.89 correlates with intravascular ultrasound minimum lumen area <6 mm2 regardless of body surface area. The current study supports the use of iFR for the evaluation of intermediate LMCD.

PCV13 A Cost Effectiveness Study of Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting in Egypt for Patients with Previously Untreated Three-Vessel or Left MAIN Coronary Artery Disease: Markov MODEL.

Percutaneous Coronary Intervention (PCI) with implantation has become one of the most frequently performed therapeutic procedures in medicine, yet Coronary Artery Bypass Grafting (CABG) is the standard of care for patients with three – vessel or left main coronary disease. This cost effectiveness study is comparing PCI versus CABG in this group of patients.

Very Long-term Safety and Effectiveness of Drug-Eluting or Bare-Metal Stents for Left Main Coronary Disease

BackgroundLimited data are available on the long-term outcomes of drug-eluting stents (DES) vs bare-metal stents (BMS) in patients with left main coronary artery (LMCA) disease. MethodsIn this observational cohort of the Revascularization for Unprotected Left Main Coronary Artery Stenosis: Comparison of Percutaneous Coronary Angioplasty vs Surgical Revascularization (MAIN-COMPARE) registry, we evaluated patients with unprotected LMCA stenosis who received DES or BMS between January 2000 and June 2006. The primary outcome was a composite of all-cause death or myocardial infarction (MI) at 10 years. Adjusted outcomes were compared using propensity scores and inverse probability of treatment weighting. ResultsA total of 1102 patients underwent DES (n = 784) or BMS (n = 318) during the study period. At 10 years, the adjusted rate of the primary outcome was significantly lower in DES group than in the BMS group (27.9% vs 37.0%; hazard ratio [HR], 0.71; 95% confidence interval [CI], 0.53-0.94; P = 0.02). The adjusted 10-year mortality rate was significantly lower in DES group than in the BMS group (20.6% vs 29.6%; HR, 0.65; 95% CI, 0.46-0.91; P = 0.01), whereas the 10-year rate of MI was similar between the 2 groups (9.9% vs 11.0%; HR, 0.93; 95% CI, 0.54-1.59; P = 0.78). DES use was associated with a significant reduction in the rate of target-lesion revascularization (10.2% vs 21.8%; HR, 0.41; 95% CI, 0.27-0.61; P < 0.001). ConclusionsIn this 10-year follow-up study in patients with LMCA disease, DES use was associated with a significant reduction in the rate of the composite of death or MI, mortality, and target-lesion revascularization, when compared with BMS.

Impact of renin-angiotensin system inhibitors after revascularization of patients with left main coronary artery disease.

There is a paucity of data regarding the effect of inhibition of the renin-angiotensin system on outcomes after percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG). We sought to examine long-term outcomes of patients with left main coronary disease (LMCAD) randomized to PCI with fluoropolymer-based cobalt-chromium everolimus-eluting stents or CABG according to treatment at discharge with angiotensin-converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB) in the large-scale, multicenter, randomized EXCEL trial. EXCEL randomized 1905 patients with LMCAD of low and intermediate anatomical complexity (visually-assessed SYNTAX score ≤32) to PCI (n = 948) versus CABG (n = 957). Patients were categorized according to whether they were treated with ACEI/ARB at discharge; their outcomes from discharge to 5 years were examined using multivariable logistic regression with an offset for follow-up time. Among 1775 patients discharged alive with known ACEI/ARB treatment status, 896 (50.5%) were treated with one of these agents. Among those treated with ACEI/ARB, the 5-year rate of all-cause death was similar after PCI or CABG (10.7% versus 9.8% respectively, adjOR, 0.94; 95% CI, 0.56-1.57) in contrast to patients not treated with ACEI/ARB (15.0% versus 7.8%, respectively, adjOR, 2.20; 95% CI, 1.32-3.67) (Pinteraction = 0.02). Significant interactions between treatment arm (PCI versus CABG) and ACEI/ARB treatment status were also found for cardiovascular death (Pinteraction = 0.03), ischemia-driven revascularization (Pinteraction = 0.03), target vessel revascularization (Pinteraction = 0.007) and target vessel failure (Pinteraction = 0.0009). In the EXCEL trial, the postdischarge rates of death and revascularization after 5 years were similar after PCI and CABG in patients with LMCAD treated with ACEI/ARB at discharge. In contrast, event rates were higher after PCI versus CABG in those not so treated.

Matched Analysis of Surgical Versus Percutaneous Revascularization for Left Main Coronary Disease

BackgroundPercutaneous coronary intervention (PCI) is being performed more frequently for left main coronary artery disease (LMCAD). This study evaluated a real-world propensity-matched analysis of surgical vs percutaneous revascularization for LMCAD. MethodsAdults (≥18 years of age) at a single academic institution undergoing coronary artery bypass grafting (CABG) or PCI for left main stenosis greater than or equal to 50% between 2010 and 2018 were examined. Greedy propensity-matching techniques were used to generate well-matched cohorts, and Kaplan-Meier analysis was used to compare survival. Multivariable Cox models were created for 5-year mortality and major adverse cardiac and cerebrovascular events (MACCE). ResultsA total of 1091 patients with LMCAD were identified (898 CABG, 193 PCI). Patients undergoing PCI were significantly older (77 years of age vs 68 years of age; P < .001), more likely to have heart failure (26.94% vs 13.14%; P < .001), and less likely to have 3-vessel disease (42.49% vs 65.59%; P < .001). Propensity matching yielded 215 CABG and 134 PCI well-matched patients. In the matched analysis, 1-year (77.61% vs 88.37%) and 5-year (48.77% vs 75.62%) survival were lower with PCI. Rates of MACCE at 5 years were also higher with PCI (64.93% vs 32.56%; P < .001). Rates of both myocardial infarction (19.40% vs 7.44%; P = .001) and repeat revascularization (26.12% vs 7.91%; P < .001) were higher with PCI. After risk adjustment, CABG remained associated with reduced risk of mortality (hazard ratio, 0.40; 95% confidence interval, 0.29-0.54; P < .001) and MACCE (hazard ratio, 0.37; 95% confidence interval, 0.28-0.48; P < .001) at 5 years. ConclusionsThis real-world, propensity-matched analysis demonstrates substantial advantages in survival and MACCE with CABG for LMCAD, supporting surgical revascularization in this clinical setting in appropriate operative candidates.

The impact of percutaneous coronary intervention versus coronary artery bypass grafting surgery in left main coronary disease

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Although coronary artery bypass grafting (CABG) has been considered the gold-standard method for the treatment for left main stable ischemic coronary disease (s-LMCAD), percutaneous coronary intervention (PCI) has shown good results. Objective To evaluate patients with s-LMCAD who performed CABG or PCI and compare their outcomes. Study design Single center, retrospective study that included all s-LMCAD patients who performed LM PCI or CABG between January 2015 and November 2018 (n = 35 in the PCI group and 35 in the CABG group after propensity score and matches in a ratio of 1:1). Clinical and imaging information of patients was collected, relating to the pre- and post-procedure and with 3 years of follow-up (FUP). Results Overall, baseline clinical and angiographic characteristics were balanced between the groups. The PCI group had higher prevalence of previous coronary disease (54.3%% vs 28.6%, p = 0.029) and chronic obstructive pulmonary disease (22.9% vs 5.7%, p = 0.04). The anatomical complexity estimated through the calculation of the SYNTAX score showed no significant differences between groups (16 vs 19, p = 0.151). 50% of PCI group performed IVUS, 2.8% OCT and 2.8% FFR. All CABG grafts used were arterial. There were no registries of events during hospitalization. At 30 days, cardiovascular-mortality was higher in the PCI group than in CABG group (n = 2 (5.56%) vs 0, respectively), representing all cases of cardiovascular death in PCI group through the 3-years follow-up. In CABG group, cardiovascular-related death was more substantial at 3 years. At 3 years of FUP, no significant differences were found between the PCI and CABG groups in MACCE (hazard ratio (HR) of the PCI group, 2,786; confidence interval (CI) of 95%, 0.873 to 8,889; p = 0.084). However, patients submitted to PCI with a SYNTAX score≥23 had worse MACCE results (HR 9.022, 95% CI, 1,054 to 77.210; p = 0,045), though a large confidence interval was also registered. Though not significantly different, cardiac-related hospital admissions were more frequent in the CABG group (18 (25.00%) vs 6 (16.67%) in the PCI group), but occurred more acutely in the PCI group (&amp;lt; 30 days). Stroke events happened more frequently in the CABG group, with a total of 4 cases reported (5.56%) whereas in the PCI group none happened. Myocardial infarction rate was also higher in the PCI group (2, 5.71%) and 1 happened in the first 30 days which was related to a target lesion failure. Revascularization through PCI due to restenosis had only 1 (2.78%) case registered. Graft failure happened in only 1 patient. Conclusion In conclusion, for the treatment of patients with stable s-LMCAD and low anatomical complexity, PCI was noninferior to CABG. Our results suggest that PCI is an acceptable alternative to CABG for patients with stable left main coronary artery disease, except for the ones with high anatomical complexity.

Revascularisation strategies in patients with significant left main coronary disease during the COVID-19 pandemic.

BackgroundThere are limited data on the impact of the COVID‐19 pandemic on left main (LM) coronary revascularisation activity, choice of revascularisation strategy, and post‐procedural outcomes.MethodsAll patients with LM disease (≥50% stenosis) undergoing coronary revascularisation in England between January 1, 2017 and August 19, 2020 were included (n = 22,235), stratified by time‐period (pre‐COVID: 01/01/2017–29/2/2020; COVID: 1/3/2020–19/8/2020) and revascularisation strategy (percutaneous coronary intervention (PCI) vs. coronary artery bypass grafting (CABG). Logistic regression models were performed to examine odds ratio (OR) of 1) receipt of CABG (vs. PCI) and 2) in‐hospital and 30‐day postprocedural mortality, in the COVID‐19 period (vs. pre‐COVID).ResultsThere was a decline of 1,354 LM revascularisation procedures between March 1, 2020 and July 31, 2020 compared with previous years' (2017–2019) averages (−48.8%). An increased utilization of PCI over CABG was observed in the COVID period (receipt of CABG vs. PCI: OR 0.46 [0.39, 0.53] compared with 2017), consistent across all age groups. No difference in adjusted in‐hospital or 30‐day mortality was observed between pre‐COVID and COVID periods for both PCI (odds ratio (OR): 0.72 [0.51. 1.02] and 0.83 [0.62, 1.11], respectively) and CABG (OR 0.98 [0.45, 2.14] and 1.51 [0.77, 2.98], respectively) groups.ConclusionLM revascularisation activity has significantly declined during the COVID period, with a shift towards PCI as the preferred strategy. Postprocedural mortality within each revascularisation group was similar in the pre‐COVID and COVID periods, reflecting maintenance in quality of outcomes during the pandemic. Future measures are required to safely restore LM revascularisation activity to pre‐COVID levels.

Impact of time factor and patient characteristics on the efficacy of PCI vs CABG for left main coronary disease: A meta-analysis.

Background:The impact of time factor and patient characteristics on the efficacy of percutaneous coronary intervention (PCI) with drug-eluting stents vs. coronary-artery bypass grafting (CABG) for left main coronary disease is unclear.Methods:We searched PubMed and Embase for related trials. Two outcomes of interest were major adverse cardiac or cerebrovascular events (MACCE, defined as a composite of all-cause mortality, myocardial infarction, stroke, or unplanned revascularization) and a composite of all-cause mortality, myocardial infarction, or stroke. We conducted random-effects meta-analysis stratified by follow-up duration and 7 factors of interest related to patient characteristics. Random-effects meta-regression was performed to calculate P values for trend and those for subgroup differences.Results:We included 11 articles from 5 trials. Compared with CABG, PCI increased MACCE at the end of 3-year (hazard ratio [HR] 1.21, 95% confidence interval [CI] 1.04-1.40, I2 = 0) and 5-year (HR 1.33, 95% CI 1.20–1.48, I2 = 0) follow-up, but did not increase all-cause mortality, myocardial infarction, or stroke. The logarithm of HR of PCI vs CABG for MACCE increased as follow-up duration increased (β = 0.057, P = .025). PCI vs CABG consistently increased 5-year MACCE across various subgroups defined by 7 factors of interest (Psubgroup ranged from .156 to .830).Conclusions:The long-term benefit of CABG vs PCI on MACCE in patients with left main coronary disease is consistent across patients with different clinical characteristics. The relative benefit of CABG on MACCE is driven by that of CABG on unplanned revascularization, and becomes greater as time goes on.