Left Main PCI Research Articles

Ulembe study: Unprotected left main PCI study at 3 years follow up

ObjectivesTo study left main registry for Indian population, demographic and procedural characteristic of patient outcomes after uLMPCI and identify the predictors of prognosis in 109 patients at long term follow up. MethodsA total of 109 consecutive patients, who underwent uLMPCI, were analyzed in this single-center registry. All data related to the patient's clinical presentation, procedure and follow-up were collected. Syntax score and medina score were calculated for all patients. Mean follow-up duration of the study was 3 year. Procedural success rate for left main intervention was 100%. Primary endpoint was composite of major adverse cardiovascular and cerebrovascular events (MACCE), including cardiac death (CD), cerebrovascular accident (CVA), myocardial infarction (MI), and need for repeat revascularization and intervention. ResultsPatients with syntax score ≤32 had higher event-free secondary end point rate than those with syntax score >32. Syntax score >32 was found to be significantly correlated to prior PCI/CABG patients, patients with multiple stenting and multiple vessel stenting. Syntax score >32 and diabetes were the independent predictor of MACCE at long term follow up of 3 years. ConclusionuLMPCI is safe and effective treatment alternative to CABG in non diabetic patients with selected LM alone, single vessel and single stent patients with low and intermediate syntax score(≤32)at 3 years.

PREDICTORS OF LEFT MAIN CORONARY ARTERY STENT DIMENSIONS: AN EXCEL TRIAL INTRAVASCULAR ULTRASOUND SUBSTUDY

A small minimum stent area (MSA) after left main (LM) PCI has been associated with poor clinical outcomes. The predictors of (LM) stent MSA have not been described. EXCEL was a multicenter, randomized trial comparing PCI with everolimus-eluting stents (n=948) to CABG (n=957) in pts with LM disease

Left main true bifurcation PCI: In the aftermath of DKCRUSH V trial: The case for modifying Medina terminology to include complexity of LMCA anatomy.

Left main true bifurcation PCI: In the aftermath of DKCRUSH V trial: The case for modifying Medina terminology to include complexity of LMCA anatomy.

TCT-182 Outcomes Following Left Main PCI vs. CABG in Patients With Cerebrovascular Disease: Results From the EXCEL Trial

Patients with cerebrovascular disease (CEVD) requiring revascularization are often referred to PCI rather than CABG. There is a paucity of data regarding the impact of cerebrovascular disease in pts with left main coronary artery disease (LMCAD) following revascularization. In the EXCEL trial, pts

TCT-179 Outcomes After Left Main PCI Versus CABG According to Ostial/Shaft Versus Distal Bifurcation Involvement: Insights From the EXCEL Trial

In the EXCEL trial, pts with left main coronary artery disease (LMCAD) and low or intermediate SYNTAX scores revascularized with everolimus-eluting stents (EES) vs. CABG had similar rates of the composite primary endpoint (death, MI, or stroke) at 3 years, but with greater ischemia-driven

TCT-181 Outcomes of Left Main PCI vs CABG According the Number of Diseased Coronary Arteries: The EXCEL trial

In the large-scale international, multicenter, randomized EXCEL trial, PCI with everolimus-eluting stents (EES) was non-inferior to CABG for the treatment of pts with left main (LM) coronary artery disease and SYNTAX score ≤32. Given variability in SYNTAX score assessment, the non-LM number of

25A complex left main PCI in the setting of disastrous intrapartum STEMI. thrombus , dissection, no-reflow and perforation. multiple complications in disguise

25A complex left main PCI in the setting of disastrous intrapartum STEMI. thrombus , dissection, no-reflow and perforation. multiple complications in disguise

Unprotected left main intervention for surgery-ineligible patients with coronary artery disease—Usefulness of micro-CT images for stent

BackgroundPercutaneous coronary intervention (PCI) for unprotected left main truncus (LMT) lesions is controversial. Inoperable status with advanced age, renal dysfunction, frailty, or patient request may require an unprotected left main PCI. PCI for LMT is not recommended in the typical clinical situation; however, when it is the only feasible option, the performance is not bad. We demonstrated the result of a cobalt-chromium everolimus-eluting stent (CoCr-EES) in the LMT stenting and serial changes via micro-computed tomography (μCT). μCT is an established imaging technique used for high-resolution, non-destructive assessment of vascular samples. The technique has drawn increasing interest for investigations of atherosclerotic arteries in both humans and animal models. There are no reports regarding the linkage between clinical results and μCT images. Methods and resultsBetween January 2009 and December 2014, we recruited 118 consecutive, unprotected LMT stenting cases in our institution. We examined the clinical outcomes and angiographic results with a CoCr-EES compared with a first-generation drug-eluting stent. The primary endpoint of this registry was the rate of one-year major adverse cardiac events (MACE). The one-year MACE rate was 2.54%; this did not include the CoCr-EES. We established LMT bifurcation models (mini-crush and culotte) using a CoCr-EES and obtained μCT images of the CoCr-EES. The images showed no deformation or strut apposition. ConclusionCoCr-EES performed well in LMT in our institution and according to μCT.μCT images may be useful for anatomical simulation in stent deployment.

Over-expansion capacity and stent design model: An update with contemporary DES platforms

BackgroundPreviously, we examined the difference in stent designs across different sizes for six widely used Drug Eluting Stents (DESs).Although stent post-dilatation to larger diameter is commonly done, typically in the setting of long tapering segment or left-main PCI, there is an increasing recognition that information with regard to the different stent model designs has a critical impact on overexpansion results.This study aims to provide an update on stent model designs for contemporary DES platforms as well as test overexpansion results under with oversized post-dilatation. Methods and resultsWe studied 6 different contemporary commercially available DES platforms: Synergy, Xience Xpedition, Ultimaster, Orsiro, Resolute Onyx and Biomatrix Alpha. We investigated for each platform the difference in stent designs across different sizes and results obtained after post-expansion with larger balloon sizes. The stents were deployed at nominal diameter and subsequently over expanded using increasingly large post dilatation balloon sizes (4.0, 5.0 and 6.0mm at 14ATM). Light microscopy was used to measure the changes in stent geometry and lumen diameter after over-expansion.For each respective DES platform, the MLD observed after overexpansion of the largest stent size available with a 6.0mm balloon was 5.7mm for Synergy, 5.6mm for Xience, 5.2mm for Orsiro, 5.8mm for Ultimaster, 5.5mm for 4mm Onyx (5.9mm for the 5mm XL size) and 5.8mm for BioMatrix Chroma. ConclusionThis update presents valuable novel insights that may be helpful for careful selection of stent size for contemporary DES based on model designs. Such information is especially critical in left main bifurcation stenosis treatment where overexpansion to larger oversized diameter may be required to ensure full stent apposition.

TCTAP C-038 Left Main PCI with Triple Bifurcations

### Patient initials or identifier number TPK ### Relevant clinical history and physical exam Patient was a 56 years old insurance sale. He was admitted for inferior STEMI with RV infarction. Emergent PCI was done to RCA. Echo showed mildly impaired LV function. His liver and renal function tests

TCT-473 Two-year outcomes of Japan unprotected left main coronary artery disease PCI strategy on new generation stents (J-Lesson) registry

The SYNTAX study showed significant improvement in the efficacy of PCI using 1st generation DES for unprotected left main coronary artery (LMCA) disease. It has been proposed that the 2nd generation DES will provide better PCI outcomes for LMCA compared with SYNTAX trial. In Japan, PCI was

Left main PCI: An observational analysis from large single-centre experience

BackgroundAlthough trials have shown efficacy of unprotected left main percutaneous coronary intervention (uLMPCI), data from Indian subcontinent are lacking. Hence, we planned this observational analysis of single-center uLMPCI data. ObjectivesTo study long-term outcome after uLMPCI and identify predictors of adverse outcome. MethodsCase details of 62 consecutive patients of uLMPCI between 2006 and 2013 were retrieved from a computerized database wherein detailed records were maintained. ResultsMean follow-up duration was 669.8±404.2 days. Procedural success rate was 98.4%. Primary endpoint was composite of major adverse cardiovascular and cerebrovascular events (MACCE), which included cardiac death (CD), cerebrovascular accident (CVA), myocardial infarction (MI), and need for repeat intervention (RI) at three years. MACCE occurred in 13 (20.9%) patients. Cardiac death (CD), (including possible stent thrombosis), RI, and CVA occurred in 6 (9.7%), 5 (8%), and 2 (3.2%) patients, respectively. Overall three-year MACCE-free survival rate was 76.7%. Event-free survival rate was similar among patients who underwent uLMPCI alone and patients who underwent uLMPCI along with additional one-vessel PCI [(88.9% vs 81.8%), p=0.492], while survival rate was lower in patients who underwent uLMPCI along with PCI of additional two or more vessels (40%, p=0.036). Patients with syntax score ≤32 had higher event-free survival rate than those with syntax score >32 [(87.1% vs 33.3%), p=0.001]. Syntax score >32 was the only independent predictor of adverse outcome. ConclusionuLMPCI is safe and effective alternative to CABG for LM alone and LM plus single-vessel disease with syntax score ≤32.

TCTAP A-144 Left Main PCI in a Peripheral Centre Without IABP: Immediate and Long Term Results

TCTAP A-144 Left Main PCI in a Peripheral Centre Without IABP: Immediate and Long Term Results

Unprotected left main percutaneous coronary intervention in acute coronary syndromes with extracorporeal life support backup.

Background. Left main PCI is superior to coronary bypass surgery in selected patients. Registry data, however, suggest significant early adverse event rates associated with unprotected left main PCI. We aimed to evaluate safety of an extracorporeal life support (ECLS) as backup system during PCI. Methods. We report a registry study of 16 high-risk patients presenting with acute coronary syndromes undergoing unprotected left main PCI with an ECLS backup. Results. Seven patients (43.8%) presented with an acute myocardial infarction while 9 patients (56.3%) had unstable angina. Unprotected left main PCI could be successfully performed in all 16 patients. Mortality or thromboembolic event rates were zero within the index hospital stay. General anesthesia was necessary only in 5 patients (31.3%). Access site bleeding requiring transfusion was encountered in 4 patients (25.0%). Three patients (18.8%) developed access site complications requiring surgical intervention. All patients were ECLS-free after 96 hours. Conclusions. Unprotected left main PCI could be safely and effectively performed after ECLS implantation as backup in acute coronary syndromes in our patient collectively. Vascular access site complications however need to be considered when applying ECLS as backup system.

0293: Predictors of major cardiovascular events during unprotected left main PCI

PCI has become increasingly practiced in left main stenosis (LMS). The purpose of this study was to determine predictors of mid term major cardiovascular events in 110 cases of unprotected left main PCI. Clinical and angiographic data were collected retrospectively for all patients with LMS, admitted to the cardiology center of Sfax between 2002 and 2013 and for which urgent or scheduled percutaneous revascularization was performed. The occurrence of cardiovascular events, or MACCE: death, MI, heart failure, angina or stroke recurrence was assessed at 12 months. During the study period, 110 patients underwent an unprotected LM PCI. These patients were predominantly male (72.7%). The death rate intra – hospital was 4.5% and 12 months mortality was 3.6%. 31 patients (28.2%) had nonfatal events during follow up. The clinical presentation at admission and diabetes were MACCE predictors at 12 months (p=0.04 and 0.05 successively). The distal LM location with bifurcation involvement, the multivessel disease associated and a high Syntax score> 32 are predictors of the occurrence of MACCE in the medium term (p=0,03; p=0001; and p=0001 successively). The type and length of the stent used in the LMS are also predictors of the occurrence of MACCE (49.1% for BMS versus 9.8% for DES, p<0.001). The unprotected LM PCI became promising thanks to developpemet of angioplasty techniques and equipement especially intracoronary imaging.

LEFT MAIN INTERVENTIOIN IN A STANDALONE PCI CENTRE - A RECENT 5 YEAR EXPERIENCE

LEFT MAIN INTERVENTIOIN IN A STANDALONE PCI CENTRE - A RECENT 5 YEAR EXPERIENCE

Abstract 19241: Evolving Techniques and Outcomes in Left Main Pci With Des

Objective: To evaluate the impact of technical evolutions on clinical outcomes for patients undergoing percutaneous coronary intervention (PCI) with drug eluting stent (DES) for left main (LM) disease. Background: PCI techniques and materials are improving. Those evolutions could have a positive clinical impact for patients undergoing PCI for LM disease. Methods: We compared baseline characteristics, procedural and clinical outcomes in 601 consecutive patients undergoing PCI for LM stenosis with DES from 2004 to 2009. Patients were analyzed in 3 separate groups according to the PCI timing: 2004/2005 (group 1); 2006/2007 (group 2); 2008/2009 (group 3). The primary outcome was death at 1-year. Results: Comparing to 2004/2005, patients undergoing PCI in 2008/2009 were at higher risk (Logistic Euroscore 8.4±0.7% in group 3 vs. 7.4±0.6% in group 1; p=0.045). The radial approach was increasingly used (28.2% in 2004/2005; 34.2% in 2006/2007 and 61.4% in 2008/2009; p&lt;0.0001), a predilation was more frequently performed (32.1% in 2004/2005; 42.7% in 2006/2007 and 45.8% in 2008/2009; p=0.046) and a second generation DES was more frequently used (38.2% in group 3 vs. 0% in group 1; p&lt;0.0001). The stent diameter significantly increased with time (3.5±0.02mm in group 1; 3.6±0.02mm in group 2; 3.7±0.02mm in group 3; p&lt;0.0001) and a post dilation was more often performed (32.1% in group 1; 37.9% in group 2; 46.4% in group 3; p=0.021). One-year mortality is significantly decreasing with time (9.9% in 2004/2005; 8.9% in 2006/2007; 4.1% in 2008/2009; p=0.028), and this difference is driven by fewer deaths in patients treated for distal LM (13.2% in 2004/2005; 8.6% in 2006/2007; 4.2% in 2008/2009; p=0.033). Conclusion: In this observational study, clinical outcome are improving for patients undergoing LM PCI with DES, because of fewer death at one year for patients with a distal LM lesion.

TCT-418 Confirmation of the Prognostic Capability of the SYNTAX Score-II Among 1,528 Patients who Underwent Left Main PCI

TCT-418 Confirmation of the Prognostic Capability of the SYNTAX Score-II Among 1,528 Patients who Underwent Left Main PCI

Is the assessment of short-term outcome after PCI in the setting of cardiogenic shock reliable by inhospital mortality data? A report from the Belgian registry of PCI

Background: In many registries dealing with cardiac interventions, inhospital mortality is used for short-term outcome measurement, thereby missing events after hospital discharge at home or transferal on their hospital. We hypothesized that the lack of information on survival status influences outcome measurements by comparing the cumulative event rate and the Kaplan-Meier method. Methods: According to the Belgian Working Group of Invasive Cardiology (BWGIC) database, 2390 PCI procedures were performed in Belgium in the setting of cardiogenic shock (representing 1.9% of all PCI procedures) during the 5-year period (01.01.2006 – 31.12.2010). Subsequently 459 patients (19.2%) were transferred alive to referring/revalidation centers (ranges: 6 – 35%). Mean age: 68.2±12.7 y; female gender: 30%; renal failure: 7%; active/former smoker: 28%/18%; CRR prior to PCI: 48.5%, hemodynamic support: 61%; 1 vessel disease: 31%, 0 VD: 30%; 3 VD: 37%; left main PCI: 8%; PCI on saphenous grafts: 2%. Inhospital complications: stroke: 1.5%; emergency CABG: 3.2%; mortality: 41.2%. Results: In the BWGIC database, survival status at 30 days were known for 1189 patients (930 deaths + 259 still in hospital), 459 patients were transferred and 1742 were discharged alive at home. The 30-day inhospital mortality was 39% by the cumulative event rate (Crudemortality) and 51% by the Kaplan-Meier method. The lack of information on survival status (in 51% of the cases) at 30 days has a major impact on the outcome assessment. The discordance between the 2 methods started at day 4 after the PCI and increased progressively to the absolute difference of 12% at 30 days. These differences were found in all centers ranging from 4-23%. We found a significant relationship between the transfer rate and the difference between 30-day crude mortality – KM mortality (spearman r: 0.579). Multivariate analysis revealed male gender (OR: 0.78) and smoking (OR: 0.91) predicting better prognosis, whereas age, renal failure, CPR, extent of CAD, left main PCI were marker of poorer prognosis. Conclusions: In this large Belgian multicenter registry on PCI procedures in the setting of cardiogenic shock, the Crude 30-day hospital mortality underestimates Kaplan-Meier event rates by approximally 30%. The available inhospital data seem of limited value to perform quality control or benchmarking. These observations emphasize the need for 30-day survival status in all cases after invasive procedures, ideally by automate feedback from the national institute for statistics.

Long-term outcomes of unprotected left main stem PCI in STEMI

Purpose: ST-elevation myocardial infarction due to the left main coronary artery disease is one of the most life-threatening conditions in daily clinical practice. Methods: Of the 1127 PCIs performed in STEMI patients at our hospital from January 1, 2009 to December 31, 2011, the left main stem was the culprit lesion in 43 (3.8%) cases. A retrospective analysis of treatment of 43 patients (mean age was 64.7±6.5 years, 74.4% were males) presenting with STEMI due to the left main disease that underwent PCI at a single high-volume center was performed. The study end points included in-hospital mortality and the rate of major adverse cardiac and cerebrovascular events (MACCE), defined as composite of death, myocardial infarction, stroke and repeat revascularization at a mean 26.7±9.2 (range 13-43) months of follow-up. Results: The median time from symptoms onset to balloon was 75 minutes with an interquartile range of 55 to 115 minutes. Sixteen (37.2%) patients presented with cardiogenic shock at admission, 21 (48.8%) patients had an acute pulmonary edema. Angiographically, 7 (16.3%) patients had an acute occlusion of left main stem, 28 (65.1%) – distal left main disease, 6 (14.0%) – isolated left main disease, 8 (18.6%) – chronic total occlusion of the right coronary artery. Intra-aortic balloon pump was used in all cases. Drug-eluting stents were implanted in 39 (90.7%) patients. Multi-vessel PCI in acute phase was performed in 14 (32.6%) patients. TIMI III flow was achieved in 97.7% cases. The in-hospital mortality rate was 11.6%. At 26.7±9.2 months of follow up there were 3/38 (7.9%) deaths, 4/38 (10.5%) new myocardial infarctions, 12/38 (31.6%) patients were performed CABG, 7/38 (18.4%) patients had staged PCI of non-culprit lesions. One (2.6%) patient had a minor stroke after CABG. At 26.7±9.2 months of follow up the overall rate of MACCE was 62.8%. Conclusions: Unprotected left main coronary artery PCI in STEMI is technically feasible in most patients and provides rapid reperfusion to critically ill patients with acceptable short-term and long-term outcomes. PCI of the noninfarct-related arteries in acute setting in patients with multi-vessel coronary disease should be considered in patients that remain hemodynamically unstable after left main stenting. The high rate of MACCE at 26.7±9.2 months of follow up is largely driven by the high incidence of repeat revascularization and can be explained by the intention to provide complete revascularization after stabilization of left main STEMI patients with concomitant multi-vessel coronary disease.