Left Main Coronary Intervention Research Articles

DURATION OF DUAL ANTIPLATELET THERAPY AND OUTCOMES AFTER LEFT MAIN PERCUTANEOUS CORONARY INTERVENTION

ObjectivesDespite treatment recommendations for at least 12 months of dual antiplatelet therapy (DAPT) following drug-eluting stent revascularisation, the optimal duration of DAPT after left main percutaneous coronary intervention remains controversial....

Left main coronary intervention: Are we moving too quickly without the appropriate evidence base?

Catheterization and Cardiovascular InterventionsVolume 80, Issue 2 p. 213-214 Coronary Artery Disease Left main coronary intervention: Are we moving too quickly without the appropriate evidence base?† Vasim Farooq MBChB, MRCP, Vasim Farooq MBChB, MRCP Department of Interventional Cardiology, Erasmus University Medical Centre, Thoraxcenter, Rotterdam, The NetherlandsSearch for more papers by this authorPatrick W. Serruys MD, PhD, Corresponding Author Patrick W. Serruys MD, PhD [email protected] Department of Interventional Cardiology, Erasmus University Medical Centre, Thoraxcenter, Rotterdam, The NetherlandsProfessor of Medicine, Head of the Interventional Cardiology Department, Erasmus MC, 's- Gravendijkwal 230, 3015 CE Rotterdam, The NetherlandsSearch for more papers by this author Vasim Farooq MBChB, MRCP, Vasim Farooq MBChB, MRCP Department of Interventional Cardiology, Erasmus University Medical Centre, Thoraxcenter, Rotterdam, The NetherlandsSearch for more papers by this authorPatrick W. Serruys MD, PhD, Corresponding Author Patrick W. Serruys MD, PhD [email protected] Department of Interventional Cardiology, Erasmus University Medical Centre, Thoraxcenter, Rotterdam, The NetherlandsProfessor of Medicine, Head of the Interventional Cardiology Department, Erasmus MC, 's- Gravendijkwal 230, 3015 CE Rotterdam, The NetherlandsSearch for more papers by this author First published: 23 July 2012 https://doi.org/10.1002/ccd.24532 † Conflict of interest: Nothing to report. Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume80, Issue21 August 2012Pages 213-214 SCAI Member Sign in RelatedInformation

Impact of Interventional Strategy for Unprotected Left Main Coronary Artery Percutaneous Coronary Intervention on Long-term Survival

BackgroundPercutaneous coronary intervention (PCI) of unprotected left main coronary artery (ULMCA) is feasible. In cases involving the left anterior descending–left circumflex bifurcation, the optimal interventional strategy remains unclear. Randomized bifurcation trials in the past excluded ULMCA lesions. MethodsA single-centre registry study with retrospective analysis of the interventional protocols and procedural angiograms of 102 patients who underwent stent PCI of ULMCA was performed in order to evaluate the impact of the interventional strategy on long-term survival. ResultsIsolated stenting of the ostium or mid ULMCA without bifurcation stenting was performed in 19 patients. Most interventions (n = 83) involved the left main bifurcation. Distal or bifurcation lesions were treated by provisional T-stenting in cases of single involved ostium (left anterior descending or right circumflex) or systematic T-stenting or V-stenting if both proximal coronary arteries were involved (n = 19). The majority (96%) of patients received drug-eluting stents. The long-term survival (mean follow-up = 3.4 ± 1.7 years) of patients was influenced by the interventional strategy. A single-stent strategy involving the bifurcation without side branch intervention was associated with less-favourable long-term survival (hazard ratio 4.08; 95% confidence interval, 1.91-8.69; multivariable Cox regression analysis). ConclusionsThis prospective observational study suggests that single-stent PCI involving the bifurcation without side branch intervention of ULMCA is possibly associated with higher long-term mortality. ULMCA-PCI involving the bifurcation is possible with similar results compared with isolated PCI of ULMCA shaft or ostium. Large, randomized trials are warranted for comparison of optimal technical approach to LMCA interventions.

AS-175 Is There a Gender Difference in Unprotected Left Main Coronary Intervention Outcomes in Drug-eluting Stent Era?

As a risk factor of coronary artery disease (CAD), gender might be associated with the prognosis following percutaneous coronary intervention (PCI). However, there are limited data regarding the impact of gender on angiographic and clinical outcomes following unprotected left main (LM) coronary intervention.

Incorporation of a Balloon-Cushion Stenting Technique into the Culotte Stenting Technique in Left Main Coronary Artery Bifurcation Interventions

Background: Percutaneous coronary intervention (PCI) for a left main coronary artery (LMCA) with its distal bifurcation lesions remains a challenge. Acute sidebranch occlusion after main branch stenting can potentially lead to catastrophic events. Here we describe a novel balloon-cushion stenting technique to be incorporated into the culotte stenting technique for true LMCA bifurcation lesions to prevent acute sidebranch occlusion. Methods and Results: 1) Predilatation with 2 balloons with kissing for better sidebranch preparation. 2) Balloonstent simultaneous kissing inflation, with a stent in the dominant artery and a 1.5/20 mm balloon from LMCA to the sidebranch. 3) After the stent deployment, a Crusade microcatheter was introduced via wire in the dominant vessel for wire re-crossing of the stent strut. The standard culotte technique and final kissing balloon inflation were then performed. Twelve patients were treated with this balloon-cushion stenting technique (Group A) and 18 patients with the conventional double-stent techniques (Group B). One case of acute sidebranch occlusion occurred in Group B. The amount of contrast medium and procedural time did not differ statistically between the 2 groups. Conclusions: The present study suggests that incorporation of the balloon-cushion stenting technique into the culotte stenting technique for LMCA bifurcation intervention is feasible and effective in avoiding acute sidebranch occlusion.

Left main coronary artery transradial rescue percutaneous coronary intervention for acute myocardial infarction complicated by cardiogenic shock with Impella ventricular mechanical support

Mechanical ventricular assist support and especially Impella device that is implanted via femoral access are considered a cornerstone in the therapeutic arsenal of the management of cardiogenic shock. Indeed, the potent antithrombotic agents administered during acute coronary syndromes constitute potential bleeding risk factors. Transradial interventions are nowadays widely used in ST-elevation myocardial infarction patients. However, some operators feel uncomfortable with the transradial approach when facing cardiogenic shock. We report a case of transradial rescue percutaneous intervention for cardiogenic shock in a young man with support of an Impella device via femoral access.

Left Main Coronary Percutaneous Coronary Intervention (PCI): A Comparison of the Transradial and Transfemoral Approach

Left Main Coronary Percutaneous Coronary Intervention (PCI): A Comparison of the Transradial and Transfemoral Approach

Tools & Techniques: Left main coronary artery percutaneous coronary intervention

Tools & Techniques: Left main coronary artery percutaneous coronary intervention

Iatrogenic Left Internal Mammary Artery to Great Cardiac Vein Anastomosis Treated With Coil Embolization

Inadvertent left internal mammary artery (LIMA)-great cardiac vein (GCV) anastomosis is a rare complication of coronary artery bypass graft surgery. Patients with iatrogenic aortocoronary fistula (ACF) were usually treated surgical repair, percutaneous embolic occlusion with coil or balloon. We report a case of iatrogenic LIMA to GCV anastomosis successfully treated with coil embolization and protected left main coronary intervention through the percutaneous transfemoral approach.

Left Main Stenosis – Where Do We Stand?

The presence of significant left main coronary disease is associated with increased mortality. Limited data examining the role of surgery in patients with a left main stenosis suggest a significant improvement in longevity. With the advent of coronary stenting, particularly the use of drug-eluting stents and improvements in percutaneous technology, left main coronary intervention has become more commonplace. However, despite important advances in the understanding of left main disease, management can be challenging. Many aspects, including the assessment of significance and the need for and choice of intervention (surgical or percutaneous revascularisation), remain unclear. This article serves to facilitate the management of patients with left main coronary disease with a focus on the assessment of lesion significance and the role of percutaneous intervention.

Long‐term outcomes of left main coronary intervention with drug‐eluting stents

Long‐term outcomes of left main coronary intervention with drug‐eluting stents

Multicenter international registry of unprotected left main coronary artery percutaneous coronary intervention with drug‐eluting stents in patients with myocardial infarction

Patients who present with myocardial infarction (MI) and unprotected left main coronary artery (ULMCA) disease represent an extremely high-risk subset of patients. ULMCA percutaneous coronary intervention (PCI) with drug-eluting stents (DES) in MI patients has not been extensively studied. In this retrospective multicenter international registry, we evaluated the clinical outcomes of 62 consecutive patients with MI who underwent ULMCA PCI with DES (23 ST-elevation MI [STEMI] and 39 non-ST-elevation MI [NSTEMI]) from 2002 to 2006. The mean age was 70 +/- 12 years. Cardiogenic shock was present in 24%. The mean EuroSCORE was 10 +/- 8. Angiographic success was achieved in all patients. Overall in-hospital major adverse cardiac event (MACE) rate was 10%, mortality was 8%, all due to cardiac deaths from cardiogenic shock, and one patient suffered a periprocedural MI. At 586 +/- 431 days, 18 patients (29%) experienced MACE, 12 patients (19%) died (the mortality rate was 47% in patients with cardiogenic shock), and target vessel revascularization was performed in four patients, all of whom had distal bifurcation involvement (two patients underwent repeat PCI and two patients underwent bypass surgery). There was no additional MI. Two patients had probable stent thrombosis and one had possible stent thrombosis. Diabetes [hazard ratio (HR) 4.22, 95% confidence interval (CI) (1.07-17.36), P = 0.04), left ventricular ejection fraction [HR 0.94, 95% CI (0.90-0.98), P = 0.005), and intubation [HR 7.00, 95% CI (1.62-30.21), P = 0.009) were significantly associated with increased mortality. Patients with MI and ULMCA disease represent a very high-risk subgroup of patients who are critically ill. PCI with DES appears to be technically feasible, associated with acceptable long-term outcomes, and a reasonable alternative to surgical revascularization for MI patients with ULMCA disease. Randomized trials are needed to determine the ideal revascularization strategy for these patients.

Unprotected Left Main Coronary Intervention with Drug‐Eluting Stents

The accepted treatment of unprotected left main coronary artery disease is coronary artery bypass surgery (CABG). The approval of drug‐eluting stents (DES) has increasingly led to their off‐label use in this patient population. Currently, the data supporting the safety and efficacy of DES for unprotected left main disease are derived from nonrandomized, single‐center studies. Several conclusions can be drawn from these studies despite their inherent limitations. Procedural mortality in elective patients with low surgical risk is minimal. One year mortality and 1 year major adverse cardiac events appear to be similar to that of CABG. Technical difficulty and clinical outcome depend crucially on the anatomic location of the left main obstruction. While DES implantation for ostial and shaft lesions is technically straightforward and provides excellent results over follow‐up, distal left main lesions are technically challenging and efficacy is limited largely by target vessel revascularization, most frequently for restenosis within the branch ostia. A systematic approach to the left main lesion can help provide safe and more effective results. Prospective, randomized trials comparing DES to CABG must be completed before percutaneous coronary intervention for unprotected left main coronary artery disease can be considered standard‐of‐care.

The Clinical Feasibility of Transradial Coronary Intervention in Selective Patients Undergoing Left Main Coronary Intervention

Background and Objectives:The transradial approach has been increasingly used as an alternative to conventional transfemoral intervention. However, there is little data on the efficacy of transradial coronary intervention (TRI) in left main coronary arterial (LMCA) disease. The purpose of this study was to evaluate the feasibility of TRI in selective patients undergoing percutaneous coronary intervention (PCI) for LMCA disease. Subjects and Methods: Between Jan 2003 and May 2005, 83 patients with LMCA stenosis were treated with PCI. Of these, 40 selected patients having undergone TRI were included in this study. Results:The patients included 30 males and 10 females, with a mean age of 61±12 years. There were 28 cases (70%) involving coronary arteries other than the LMCA and 24 cases (60%) with bifurcation lesion involvement. In 28 cases (70%), a 6 Fr sized guiding catheter was used. No case required crossover from TRI to TFI due to procedural failure. During hospitalization, 2 patients who underwent primary PCI in the setting of STEMI died, but there were no other clinical events. Conclusion: In selected patients with LMCA disease, TRI can be a feasible and safe approach for PCI. (Korean Circulation J 2006;36:732-736)

Inflammatory Biomarkers for Prediction of Outcomes After Unprotected Left Main Coronary Intervention

Unprotected left main coronary artery (ULMCA) lesions are candidates for coronary artery bypass surgery because of the high risk of serious adverse periprocedural events and long-term complications associated with percutaneous coronary intervention (PCI). Although coronary stents have improved initial outcomes of PCI with coronary balloon angioplasty, the outcomes of coronary stenting in ULMCA remain mixed, even with the use of drug-eluting stents.1–7 Periprocedural safety and long-term outcomes are excellent in patients at low risk1–7; however, long-term mortality associated with ULMCA stenting is ≈25% in patients at high risk.3 These variations have resulted in studies that evaluated factors influencing ULMCA stenting outcomes. The recent Unprotected Left Main Trunk Investigation Multicenter Assessment (ULTIMA) registry report involved 279 patients, 46% of whom were deemed inoperable or at high surgical risk.3 For the latter patients, the in-hospital mortality rate was 14%, whereas the 1-year incidence rates were 24.2% for all-cause mortality, 20.2% for cardiac mortality, and 9.8% for myocardial infarction (MI). In that study, decreasing left ventricular function (<30%) was inversely related to events. In contrast, for the low-risk ULTIMA registry subset of 89 patients, the 1-year actuarial death rate was 3.4% and the MI rate was 2.3%. Likewise, we reported that the procedural success rate was 99.1%, with no incidence of cardiac death or MI during the follow-up period in selected patients with normal left ventricular function and who were good surgical candidates.1 The risk factors analyzed …

Left Main Coronary Intervention

Left Main Coronary Intervention

Percutaneous Treatment of Protected and Unprotected Left Main Coronary Stenoses With New Devices: Immediate Angiographic Results and Intermediate-Term Follow-Up

Objectives. We sought to evaluate the immediate angiographic results and intermediate-term follow-up after percutaneous treatment of left main coronary stenoses in the new device era.Background. Historically, balloon angioplasty of left main coronary stenoses has been associated with high procedural morbidity and poor long-term results. It is not clear whether new devices are more effective in this anatomic setting.Methods. Between July 1993 and July 1995, we performed initial left main coronary interventions on 46 patients (mean age 67 ± 12 years, 26% women). Quantitative angiography was available for 42 of 46 interventions, and clinical follow-up was obtained for all patients at 1 month, 6 months and 1 year after initial revascularization.Results. Most interventions (42 of 46) were performed in patients with “protected” coronary stenoses to the left coronary system owing to the presence of one or more patent left main coronary grafts. Seventy-seven percent of screened patients were deemed unsuitable for repeat coronary artery bypass surgery. Procedures performed included stenting in 73% of patients (alone in 30% and after rotational atherectomy in 43%), rotational atherectomy in 58% (alone in 15% and before stenting in 43%), directional atherectomy in 4% and angioplasty alone in 7%. Initial procedural success was achieved in all interventions, with no deaths, myocardial infarctions (creatine kinase, MB fraction >50 IU/liter) or emergent bypass surgery. Follow-up data to date (median duration 9 months, range 6 to 19) demonstrate a 98% overall survival rate and a 6-month event-free survival rate of 78% (six target vessel revascularizations [TVRs], four non-TVRs).Conclusions. Treatment of protected left main coronary artery stenoses can be accomplished safely and effectively with new device technology. Intermediate-term follow-up demonstrates an acceptably low rate of death, myocardial infarction or repeat revascularization at 6 months and 1 year.(J Am Coll Cardiol 1997;29:345–52)