Significant Left Main Coronary Artery Research Articles

Current spectrum and outcomes of infarct-related cardiogenic shock: insights from the CULPRIT-SHOCK registry and randomized controlled trial.

We analysed consecutive patients with acute myocardial infarction complicated by cardiogenic shock (CS) who were enrolled into the CULPRIT-SHOCK randomized controlled trial (RCT) and those with exclusion criteria who were included into the accompanying registry. In total, 1075 patients with infarct-related CS were screened for CULPRIT-SHOCK in 83 specialized centres in Europe; 369 of them had exclusion criteria for the RCT and were enrolled into the registry. Patients were followed over 1 year. The mean age was 68 years and 260 (25%) were women. 13.5%, 30.9%, and 55.6% had one-vessel, two-vessel, and three-vessel coronary artery disease (CAD), respectively. Significant left main (LM) coronary artery stenosis was present in 8.0%. 54.2% of the patients had cardiac arrest before admission. Thrombolysis in myocardial infarction (TIMI) 3 patency of the infarct vessel after percutaneous coronary intervention was achieved in 83.6% of all patients. Mechanical circulatory support was applied in one-third of patients. Total mortality after 30 days and 1 year was 47.6% and 52.9%. Mortality after 1 year was highest in patients with LM coronary artery stenosis (63.5%), followed by three-vessel (56.6%), two-vessel (49.8%), and one-vessel CAD (38.6%), respectively. Mechanical complications were rare (21/1008; 2.1%) but associated with a high mortality of 66.7% after 1 year. In specialized centres in Europe, short- and long-term mortality of patients with infarct-related CS treated with an invasive strategy is still high and mainly depends on the extent of CAD. Therefore, there is still a need for improvement of care to improve the prognosis of infarct-related CS.

Long-Term Results of Stenting in Patients with Hemodynamically Significant Lesions of the Left Main Coronary Artery

The aim. To study the long-term results of stenting in patients with coronary artery disease with hemodynamically significant left main coronary artery (LMCA) stenoses.
 Materials and methods. The study included 67 patients (56 men, 11 women) with a mean age of 63 ± 2.1 years.
 Results. Among the 67 patients included in the study, 29 patients (43.3%) underwent percutaneous coronary inter-vention using a single-stent technique. These were patients with ostial LMCA lesions, lesions of the middle third of the LMCA and some patients with Medina 1.1.0; 1.0.1; 1.0.0; 0.1.0; 0.0.1 lesions of the distal part of the LMCA. The median follow-up was 2 years. Using a questionnaire, we managed to establish contact with 25 patients (86.2%). Among these, 1 patient (3.4%) died of non-cardiac causes and 7 patients (24.1%) had a recurrence of angina within 2 years. The causes of angina recurrence in 2 cases (6.9%) were restenosis in the stent with transition to the mouth of the side branch, which required repeated stenting of the LMCA with transition to the left circumflex artery. In 5 patients (17.2%), angina recur-rence was associated with progression of coronary atherosclerosis of another localization.
 Among 67 patients with LMCA stenting, the two-stent technique was used in 38 patients (56.7%). These were pa-tients with Medina 1.1.0; 1.0.1; 1.0.0; 0.1.0; 0.0.1 lesions of the distal part of the LMCA. The median follow-up was 2 years. Using a questionnaire, we managed to contact 35 patients (92.1%). Among these, 4 patients (10.5%) died, but only one of them due to cardiac causes (2.6%), and 3 patients (7.9%) had recurrent angina within 2 years, two of whom underwent stenting by the T and protrusion (TAP) technique and one by culotte. The first two patients underwent angioplasty of restenosis in stents using balloons with a therapeutic coating. In the last patient, stent recoil in the left circumflex artery mouth was observed due to severe calcification, so this patient underwent re-implantation of the stent system in the recoil zone.
 Conclusions. The problem of choosing a method of revascularization for patients with hemodynamically significant LMCA lesions remains controversial to this day, despite the wide range of evidence. Doctors should jointly decide on the choice of treatment methodology solely in the interests of the patient, taking into account all the factors that may affect the patient’s quality of life in the long term.

Clinical Echocardiographic And Angiographic Profile Of Patients With Significant Left Main Coronary Artery Stenosis

Clinical Echocardiographic And Angiographic Profile Of Patients With Significant Left Main Coronary Artery Stenosis

Percutaneous treatment of left main coronary artery disease - temporal trends from large registry and ten-year follow-up. a single centre experience

Abstract Background Due to a large amount of jeopardized myocardium, patients with significant left main coronary artery (LMCA) stenosis have an increased risk of death. For years coronary artery bypass grafting has been considered as the treatment of choice. Recent years brought evidence that led to the reconsideration of percutaneous coronary intervention (PCI) as a valuable alternative. Purpose The purpose of this study was to assess temporal trends in clinical practice and analyse the very long-term outcomes of LMCA PCI in a large tertiary hospital in Poland. Methods Group of 998 individuals undergoing LMCA PCI was selected from medical records of 44,989 patients hospitalized in years 2008-2021. Data on mortality were obtained from the Centre for Information Technology. Temporal trends were calculated for period 2008-2014 as compared to 2015-2021. The 10-year event rate was calculated with the Kaplan-Meier estimator, univariate (ULR), and multivariate logistic regression (MLR). Results The rate of LMCA PCI increased from 2.21% in 2008 to 6.88% in 2021 (p<0.001). 736 (73.8%) patients were male, the median age was 71 years (interquartile range 16). 409 (41.0%) of patients presented with acute coronary syndrome (ACS), 545 (54.6%) with chronic coronary syndrome (CCS). In the analysed periods concomitant diabetes mellitus (DM) rate increased from 27.44% to 42.5% (p<0.001), use of intravascular imaging (IVI) increased from 22.28% to 42.72% (p<0.001), use of rotational atherectomy increased from 8.36% to 18.94% (p<0.001). The 30-day mortality decreased from 10.31% to 4.23% (p<0.001), and 1-year mortality decreased from 18.66% to 12.05% (p=0.007). In the 10-year follow-up 399 (40.0%) patients died. In ULR, death was associated with femoral access (OR 1.766, 95% CI 1.308-2.386) and absorbed radiation dose (OR for increase in 1 Gy 1.192, 95% CI 1.080-1.304). The provisional stenting yielded better performance than two-stent techniques (OR 0.635, 95% CI 0.491-0.821). In MLR, death at 10 years was associated with age (OR 1.028, 95% CI 1.007-1.050), ACS (OR 1.725, 95% CI 1.134-2.624), atrial fibrillation (OR 1.540, 95% CI 1.002-2.367), lower glomerular filtration rate (OR for decrease in 1 ml/min/1.73 m2 1.011, 95% CI 1.001-1.022), and lower left ventricular ejection fraction (OR for decrease in 1% 1.045, 95% CI 1.029-1.060). Better outcomes were associated with previous revascularization (OR 0.668, 95% CI 0.453-0.986), use of IVI (OR 0.518, 95% CI 0.353-0.759), drug-eluting stents (OR 0.238, 95% CI 0.106-0.536) and bigger balloon diameter used for stent optimization (OR for increase in 1 mm 0.889, 95% CI 0.801-0.986). Conclusions In the analysed period the rate of LMCA PCI, number of complex procedures, and co-morbidities increased, yet the prognosis has improved. The 10-year death rate analysis revealed that advancements in percutaneous device technology and procedural techniques are associated with more favourable outcomes.

Abstract 14555: Early Predictors That Identify Patients With Significant Left Main and Three-Vessel Coronary Artery Disease in Non-ST Elevation Acute Coronary Syndrome: Validating the MADISON Score

Introduction: In patients with non-ST elevation acute coronary syndrome (NSTE-ACS), identifying those with a high probability of having high-risk disease such as left main (LM) or three-vessel disease (3VD) could influence decisions to preload with P2Y12 inhibitors and timing of coronary angiography. The MADISON score was developed to predict LM/3VD on coronary angiography in patients with NSTE-ACS. In this study, we validated the MADISON score using data from an external cohort. Methods: The MADISON score was first developed using a retrospective cohort of 1700 patients presenting with NSTE-ACS at the University of Wisconsin-Madison (UW) (2011-2018). Those with prior CABG, cardiac arrest/shock, and bleeding on initial presentation were excluded from the analysis. Multivariable estimates were employed and model performance was assessed using receiver operating characteristic curve analysis. The score was then validated using a retrospective Houston Methodist Hospital (HMH) cohort of 622 patients (2019-2022). Results: The MADISON score variables and their adjusted odds ratios (95% CI) are presented in Figure 1A. Risk categories and corresponding LM/3VD probabilities are presented in Figure 1B. In the UW cohort, the area under the curve (AUC) was 0.68 (0.65-0.71) (Figure 2A). Interestingly, the AUC was also 0.68 (0.64-0.72) in the HMH validation cohort (Figure 2B). Conclusions: The MADISON score performed well and similarly between 2 large, independent cohorts in predicting patients most likely to have LM/3VD. The MADISON score is a simple and practical tool to guide decisions. Prospective validation of the score is planned to evaluate its impact on clinical outcomes.

Abstract 11389: Circulating Aldosterone is an Independent Risk Marker for Left Main Coronary Artery Disease

Background: Elevated plasma aldosterone concentrations reflect remodeling of the vascular wall and increased cardiovascular risk, whereas data from the left main coronary artery (LMCA) are lacking. Patients with stenosis of the LMCA present difficult challenges. Therefore, the aim of this study was to investigate the relationship between plasma aldosterone concentrations and LMCA in patients with hypertension. Methods: We recruited hypertensive patients with LMCA with assessed plasma aldosterone concentrations before disease onset from the hospital between 2018 and 2022 and set them as the case group. Simultaneously, an age- and gender-matched cohort with plasma aldosterone concentration measurements but without LMCA was selected as the control group using a ratio of 1:3. Multivariable logistic regression analysis was used to assess the relationship of plasma aldosterone concentrations with LMCA. Angiographically significant LMCA stenosis is defined as luminal diameter stenosis ≥ 50%. Results: A total of 608 hypertensive patients were identified in this study, including 152 cases and 456 controls. The mean age of the patients was 60.8 ± 17.5 years, and 389 (64.0%) were men. Compared with the control group, the case group exhibited significantly higher plasma aldosterone concentrations (15.38 versus 9.68 ng/dL, P =0.009). In logistic regression analysis, higher plasma aldosterone concentrations showed 2.73-fold higher odds (95% confidence interval [CI], 1.35-3.68, P =0.003) for the presence of LMCA, which was significant in the adjusted model (odds ratio, 2.02 [95% CI, 1.18-2.97], P =0.008). In a stratified analysis, males with coronary artery disease and women of all ages showed a relationship between the two. The link between the two was unaffected by sensitivity analysis that excluded those who were exposed to interfering substances during the measurement of plasma aldosterone concentration and those who had primary aldosteronism. Conclusions: This study indicated that higher plasma aldosterone levels were associated with an increased risk of LMCA in patients with hypertension, even in the absence of primary aldosteronism. Interventional studies are needed to elucidate the health effect of treatments to lower aldosterone levels.

Do two operators improve outcomes in left main percutaneous coronary intervention? Insights from the ORPKI Registry.

Significant left main coronary artery (LMCA) disease is prevalent in 7% of patients undergoing angiography. Limited data exists on the impact of double scrubbing in LMCA PCI. We sought to assess periprocedural outcomes in two-operator LMCA percutaneous coronary intervention (PCI). Using data from the Polish National Registry of PCI (ORPKI), we collected data on 28,745 patients undergoing LMCA PCI from 154 centers. Patients were divided into two groups based on the number of operators performing PCI (one vs. two operators). LMCA PCI was performed by a single operator in 86% of the cases and by two operators in 14% of cases. Patients treated by two operators had a greater comorbidity burden including diabetes mellitus, arterial hypertension, previous myocardial infarction, and previous revascularization. In addition, these were more likely to be treated in high-volume centers, by operators with higher volume of LMCA PCIs. The risk of periprocedural death (2.37% vs. 2.44%; P=0.78), as well as cardiac arrest, coronary artery perforation, no-reflow, and puncture site bleeding was comparable between the two groups. On multivariable analysis, we found that a two-operator strategy was an independent predictor of periprocedural death, with this effect being much more profound in an elective setting (OR=5.13 [1.37-19.26]; P=0.015), compared to an urgent (ACS) setting (OR=1.32 [1.00-1.73]; P=0.047). Our study suggests that a two-operator approach is not necessarily routinely recommended for LMCA interventions, although it can be considered for more complex cases.

Determination of Left Main Coronary Artery Stenosis Through Noninvasive Testing to Guide Revascularization in Ischemic Heart Disease

Anatomically severe left main coronary artery (LMCA) stenosis (>50%) remains one of the few groups to benefit from early revascularization in stable ischemic heart disease (SIHD). Identification of these patients through widely available noninvasive testing would decrease the need for additional upfront anatomic testing, lowering the overall cost of healthcare. Patients with SIHD who underwent either percutaneous or surgical revascularization over a 7-year period at our institution were retrospectively analyzed and categorized as having LMCA stenosis versus non-LM stenosis. All preceding noninvasive testing, including resting electrocardiogram, echocardiogram, and functional testing was evaluated and compared between groups using chi-square and t test. In total, 806 patients were evaluated. Of those, 121 were identified as having significant LMCA stenosis with 685 patients in the non-LM cohort. Between LMCA versus non-LM cohorts, there were similar rates of electrocardiogram abnormalities (68.9% vs 70.8%, p >0.05), abnormal echocardiograms (72.7% vs 69.7%, p >0.05), abnormal functional testing (83.3% vs 77.4%, p >0.05), and high-risk imaging findings (5.6% vs 4.8%, p >0.05). More importantly, of those with a complete workup, there were similar rates of normal results between the LMCA (3 of 18, 16.7%) and non-LM stenosis (9 of 189, 4.8%) groups. A comprehensive noninvasive profile of patients with IHD failed to identify or exclude patients with anatomically severe LMCA stenosis, necessitating anatomic assessment.

Clinical Characteristics and Outcomes following Percutaneous Coronary Intervention in Unprotected Left Main Disease: A Single-Center Study

Background: Hemodynamically significant unprotected left main (LM) coronary artery disease is a high-risk clinical condition because of the large area of myocardium at risk, and it requires prompt revascularization. Percutaneous coronary intervention (PCI) is an appropriate alternative to coronary artery bypass grafting (CABG) for revascularization of unprotected LM disease in patients with low-to-intermediate anatomic complexity or when the patient refuses CABG after adequate counseling by the heart team. Methods: We retrospectively evaluated 201 patients receiving left main (LM) provisional one-stent or two-stent procedures, and we assessed the clinical characteristics and outcomes of patients undergoing unprotected LM PCI. Results: The mean age was 66.5 ± 9.9 years, and 72% were male. The majority of the subjects presented several cardiovascular risk factors, among which arterial hypertension (179 patients, 89.5%) and dyslipidemia (173 patients, 86.5%) were the most frequent. Out of all patients, 162 (81.8%) underwent revascularization by using the one-stent technique, while the two-stent technique was used in 36 patients (18.2%). The median value of fractional flow reserve (FFR) of the side branch was 0.9 [0.85-0.95], and 135 patients (67.1%) showed a value of FFR > 0.8. One hundred nine patients (54.2%) had a stent enhancement side branch length (SESBL) > 2, with median values of 2.5 mm2 [2.1-3]. Regarding angiographic parameters, the LM area as assessed by intravascular ultrasound (IVUS) or optical coherence tomography (OCT) and the grade of stenosis as assessed by quantitative coronary angiography (QCA) were similar between groups. However, patients who required revascularization by using the two-stent technique presented more frequently with intermediate rather than low SYNTAX scores (69.4% vs. 28.4%, p < 0.0001). Also, the same group required kissing balloon inflation (KBI) more frequently (69.4% vs. 30%, p < 0.001). There were no differences regarding the success of revascularization between the use of the one-stent or two-stent technique. FFR was able to predict a SESBL > 2 mm. The cut-off value for FFR to afford the highest degree of sensitivity (74.5%) and specificity (47%) for a SESBL > 2 was >0.86, indicating a moderate accuracy (AUC = 0.61, 95% CI 0.525-0.690, p = 0.036). Conclusions: Unprotected left main PCI is a safe and effective revascularization option amongst a complex and morbid population. There were no differences regarding the success of revascularization between the use of the one-stent or two-stent technique, and there was no significant impact of KBI on side branch FFR measurements but lower side branch FFR values were correlated with angiographic side branch compromise.

Gender differences in clinical characteristics, angiographic profile, and outcomes of left main coronary artery disease

Context: Left main coronary artery (LMCA) disease is associated with high morbidity and mortality in spite of advances in management. There is a paucity of data on the gender differences in LMCA disease. Aims: We aimed to study the clinical characteristics, angiographic profile, and outcome of coronary artery disease patients with significant LMCA disease. Settings and Design: This is a prospective observational study among patients with significant LMCA disease undergoing coronary angiography in a tertiary care center. Subjects and Methods: We compared clinical, angiographic characteristics among male and female patients with significant LMCA disease and followed up for 4 months. Statistical Analysis Used: Differences between the groups were compared with Student's t-test for parametric continuous variables. Chi-square test was applied for estimating the occurrence of categorical variables. Pearson's correlation coefficient was used to test the relationship between parameters. Results: Among 100 consecutive patients with LMCA disease, 70 were males and 30 were females. Chronic stable angina was the most common presentation. Distal LMCA was the most common site. Isolated LMCA disease was less compared to LMCA + multivessel disease. Coronary artery bypass grafting was the predominant management strategy. Mortality rates at 6 months were higher in females compared to males (20% vs. 3.3%). Conclusions: LMCA disease has mostly similar angiographic and clinical characteristics among males and females. LMCA disease is associated with high mortality in females compared to males.

Impact of residual coronary lesions on outcomes of myocardial infarction patients with multi-vessel disease

Abstract Background Interest grew in residual disease burden after percutaneous coronary intervention (PCI). The residual SYNTAX score (rSS) is a strong prognostic factor of coronary events and all-cause death in patients who underwent PCI. Its derivative, the SYNTAX Revascularisation Index (SRI), has been used in determining the proportion of coronary artery disease (CAD) that has been treated and has been shown to have prognostic utility in PCI for patients with multi-vessel disease (MVD). Purpose We sought to assess the use of the rSS and the SRI as predictors for in-hospital outcomes and up to two-year follow-up outcomes in patients with MVD who underwent PCI in the setting of ST-Elevation Myocardial Infarction (STEMI) or Non-STEMI (NSTEMI). Methods We recruited 149 patients with either STEMI or NSTEMI in the setting of MVD who underwent PCI. We divided them into tertiles, based on their rSS and SRI values, respectively. We calculated bSS and rSS using the latest version of the web-based calculator, and from these scores we calculated SRI. The endpoints were: In-hospital composite MACE and its components, in-hospital mortality, follow-up MACE, and follow-up all-cause mortality up to 2-years. Results RSS and SRI were not significant predictors of in-hospital death or MACE, while hypertension, ST-segment resolution, LVEF, and significant left main coronary artery (LMCA) lesions were independent predictors of in-hospital MACE. At two-year follow-up, Kaplan-Meier analysis showed significantly increased incidence of death and MACE within the third rSS tertile (rSS &amp;gt;12) compared to the other tertiles (log rank p&amp;lt;0.001), while there was no significant difference between the three SRI tertiles. RSS and SRI were predictors of death and MACE on univariate Cox regression analysis. On multivariate Cox regression, rSS was an independent predictor for MACE (HR=1.0696, 95% CI: 1.0147–1.1275, p=0.0123) and all-cause mortality (HR=1.1114, 95% CI: 1.0430–1.1842, p=0.0011). Of notice, all patients with complete revascularisation survived throughout the entire follow-up period. Conclusions The rSS and SRI were poor predictors of in-hospital death and MACE, while they were good predictors of death and MACE at two-year follow-up, with better overall performance for rSS in comparison to SRI. Patients with rSS values &amp;gt;12 showed significantly higher incidence of MACE and all-cause mortality at two years. The best prognosis was achieved with complete revascularisation. Funding Acknowledgement Type of funding sources: None.

Impact of Coronary Chronic Total Occlusion on Long-term Clinical Outcome in Patients with Unprotected Left Main Disease Undergoing Percutaneous Coronary Intervention

Objectives: Reported data regarding the prevalence, prognostic impact, and safety and efficacy of revascularization of coronary chronic total occlusion (CTO) in patients with left main coronary artery (LMCA) disease who undergo percutaneous coronary intervention (PCI) are scarce. The aim of the present study was to compare clinical outcomes among patients with LMCA disease undergoing PCI. Outcomes were compared between those with and without coronary CTO and between those with CTO who had successful and unsuccessful CTO recanalization procedures. Methods: All consecutive patients with significant LMCA disease (&gt;50% stenosis at coronary angiography) who underwent PCI between July 2014 and December 2018 were retrospectively included in our study. The primary endpoint of the study was long-term mortality. Secondary endpoints included the incidence of myocardial infarction, repeat percutaneous or surgical revascularization, stroke, and stent thrombosis. Results: Between July 2014 and December 2018, 578 patients underwent PCI for LMCA disease at Pederzoli Hospital and University of Turin were enrolled. They were divided into 3 groups: group A: 374 (65%) patients without CTO, group B: 108 (19%) patients with untreated or unsuccessfully treated CTO, and group C: 96 (17%) patients with successfully treated CTO. At a median follow-up of (1090 ± 279) days, there were no statistically significant differences between the groups in terms of the primary and secondary endpoints. However, there was a trend towards higher mortality in patients with untreated or unsuccessfully treated CTO (13% vs. 19% vs. 14% in groups A, B, and C, respectively; P = 0.12). The primary and secondary endpoints were further analyzed based on the presence or absence of myocardial viability: subgroup C1: 54 (56%) patients with successful percutaneous transluminal coronary angioplasty (PTCA) having viability, and subgroup C2: 42 (44%) patients with successful PTCA not having viability. There was a trend toward a statistically significant higher rate of death among patients in group B, who underwent unsuccessful recanalization with viable myocardium (19% vs. 9% vs. 19% in groups B, C1, and C2, respectively, P = 0.05). On multivariable analysis, the propensity for successful revascularization of CTO was associated with a reduced risk of death (P = 0.01; odds ratio, 0.75; 95% confidence interval: 0.62–0.87). Conclusions: Among patients with LMCA disease undergoing PCI, CTO represents a common finding associated with worse prognosis. Successful revascularization of CTO in patients with viable myocardium appears to significantly improve prognosis.

Cost-Effectiveness of Percutaneous Coronary Intervention Versus Bypass Surgery for Patients With Left Main Disease: Results From the EXCEL Trial.

The EXCEL trial (Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) demonstrated in patients with left main coronary artery disease, no significant difference between coronary artery bypass graft surgery (CABG) and percutaneous coronary intervention (PCI) with everolimus-eluting stents for the composite end point of death, stroke, or myocardial infarction at 5 years. However, all-cause mortality at 5 years was higher with PCI. Long-term cost-effectiveness of these 2 strategies has heretofore not been evaluated. From 2010 to 2014, 1905 patients with left main coronary artery disease were randomized to CABG (n=957) or PCI (n=948). Costs ($2019) were assessed over 5 years using resource-based costing and Medicare reimbursement rates. Health utilities were assessed using the EuroQOL 5-dimension questionnaire. Five-year EXCEL data in combination with US lifetables were used to develop a Markov model to evaluate lifetime cost-effectiveness. An incremental cost-effectiveness ratio <$50 000 per quality-adjusted life year (QALY) gained was considered highly cost-effective. Index revascularization procedure costs were $4,850/patient higher with CABG, and total costs for the index hospitalization were $17 610/patient higher with CABG ($32 297 versus $19 687, P<0.001). Cumulative 5-year costs were $20 449/patient higher with CABG. CABG was projected to increase lifetime costs by $21 551 while increasing quality-adjusted life expectancy by 0.49 QALYs, yielding an incremental cost-effectiveness ratio of $44 235/QALY. In a post hoc sensitivity analysis using mortality hazard ratios from a meta-analysis of all randomized CABG versus PCI in left main disease trials, the gain associated with CABG was 0.08 to 0.14 QALYs, resulting in an incremental cost-effectiveness ratio of $139 775 to $232 710/QALY gained. Based on data from the EXCEL trial, CABG is an economically attractive revascularization strategy compared with PCI over a lifetime horizon for patients with significant left main coronary artery disease. However, this conclusion is sensitive to the long-term mortality rates with the 2 strategies, and CABG is no longer highly cost-effective when substituting the pooled treatment effect from the 4 major PCI versus CABG trials for left main disease. URL: https://www. gov; Unique identifier: NCT01205776.

Prevalence of Angiographically Significant Left Main Disease at a Tertiary Care Hospital in Karachi; A Large Cardiac Interventional Study

Objective: To determine the prevalence of significant left main coronary artery disease (Stenosis more than 50%) at NICVD Karachi. Method: We conducted this observational cross-sectional study retrospectively at NICVD Karachi. Our institution analyzed both emergency and elective coronary angiography data from 5th July 2018 to 5th July 2020 for the existence of significant left main coronary artery disease. A study of coronary artery disease only included patients with significant left main coronary artery disease. Approximately 50% stenosis was considered significant left main coronary artery disease. Results: A total of 10,828 patients were selected for the study population, out of the total of 8975 males and 1853 female patients who underwent coronary angiography during our mentioned period at NICVD Karachi, 327 patients (3%) showed significant left main coronary artery disease. 277 patients (83%) were male and 50(17%) were female. About 50% of patients were between the ages of 60 -80 years old Minimum age was 32 years and the maximum age was 95 years. Hypertensive were 5197 (48%) and diabetes was 2480 (22.9%). The maximum number of patients in CCS grade II angina is about 239 (73.0%). Conclusion: High prevalence of disease in the Left major coronary artery is associated with greater mortality and morbidity in our CAD patients. Keywords: Coronary artery diseases, left main coronary artery, coronary intervention, coronary angiography

Percutaneous Coronary Intervention forLeft Main Coronary Artery Disease: Present Status and Future Perspectives.

For several decades, coronary artery bypass grafting has been regarded as the standard choice of revascularization for significant left main coronary artery (LMCA) disease. However, in conjunction with remarkable advancement of device technology and adjunctive pharmacology, percutaneous coronary intervention (PCI) offers a more expeditious approach with rapid recovery and is a safe and effective alternative in appropriately selected patients with LMCA disease. Several landmark randomized clinical trials showed that PCI with drug-eluting stents for LMCA disease is a safe option with similar long-term survival rates to coronary artery bypass grafting surgery, especially in those with low and intermediate anatomic risk. Although it is expected that the updated evidence from recent randomized clinical trials will determine the next guidelines for the foreseeable future, there are still unresolved and unmet issues of LMCA revascularization and PCI strategy. This paper provides a comprehensive review on the evolution and an update on the management of LMCA disease.

Análise dos desfechos em intervenção coronária percutânea de tronco de coronária esquerda não protegido

Background: Significant lesions in the left main coronary artery are found in approximately 5% of patients undergoing coronary angiography, with most cases involving multiple vessels and affecting the distal bifurcation. A coronary artery bypass graft surgery is considered the preferred treatment for unprotected left main coronary artery lesions. However, with the advancement of techniques and the introduction of new drug-eluting stents, percutaneous coronary intervention has been considered a viable strategy, with favorable results. The objective of this study was to analyze the outcomes in patients with unprotected left main coronary artery lesions undergoing percutaneous coronary intervention. Methods: Electronic data from patients undergoing percutaneous coronary intervention between December 2017 and January 2020 at a single center were analyzed to assess clinical and angiographic characteristics and clinical outcomes. Results: A total of 103 patients with significant unprotected left main coronary artery lesions were included; in that, 66% were male, 88.3% were hypertensive, and 87.4% had normal ventricular function. Lesions involving the bifurcation were identified in 73.8% of patients, 36.9% had concomitant lesions in the three major epicardial vessels, and 42.7% had an intermediate SYNTAX score (23 to 32 points). Angiographic success was achieved in 100% of cases, with four (3.9%) adverse cardiac and cerebrovascular events, with 2.9% mortality. Conclusion: Hospital results support percutaneous coronary intervention as a safe procedure, with excellent angiographic results and low rates of adverse cardiac and cerebrovascular events. We concluded that PCI is an option to coronary artery bypass graft surgery and is a very viable option for surgical treatment of unprotected left main coronary artery lesions.

Association of aVR ST-elevation with outcomes in patients with acute coronary syndrome

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Evaluation of the lead aVR in the diagnosis of acute coronary syndrome has been neglected before.1 However, there is evidence that an ST segment elevation in that lead correlates to a significant coronary artery disease.1,2 This study aimed to determine the association with clinical outcomes of an aVR ST elevation in patients with acute coronary syndrome. Purpose Identify patients who are at high risk on presentation at the emergency department. Methods This was a retrospective cohort study. Patients aged 19 years and above who were diagnosed with either unstable angina, non ST-elevation MI or ST elevation MI were eligible subjects. The medical records of patients in a tertiary referral government hospital were evaluated. The independent variable was the lead aVR ST elevation, while the primary outcome was the in-hospital mortality. Descriptive statistics was used to summarise the demographic and clinical characteristics of the patients. Frequency and proportion was used for categorical variables, median and inter quartile range for non-normally distributed continuous variables, and mean and standard deviation for normally distributed continuous variables. Independent Sample T-test and Fisher’s Exact test was used to determine the difference of mean and frequency, respectively, between patients with and without in-hospital outcomes. Odds ratio and corresponding 95% confidence intervals from binary logistic regression was computed to determine significant predictors of in-hospital outcomes. Missing variables was neither replaced nor estimated. Null hypotheses was rejected at 0.05α-level of significance. Results There were a total of 108 patients included. Most subjects were males and aged 57-62 years old. Majority had NSTE-ACS and STEMI at presentation. Lead aVR ST elevation group had an OR of 17 (95% CI 4.38-67.50 and p &amp;lt; 0.001) for in-hospital mortality, compared to the group without. On coronary angiogram, these patients had either a significant left main coronary artery disease or a multi-vessel coronary artery disease. Conclusion The presence of a lead aVR ST segment elevation in patients with acute coronary syndrome at presentation in the emergency department is associated with increased in-hospital mortality.

Use of Non-Invasive Coronary Artery Assessment in Transcatheter Aortic Valve Replacement, A Feasibility Study

Transcatheter aortic valve replacement (TAVR) is increasing in use of management of aortic valve disease, especially in elderly and co-morbid patients. Traditionally, invasive assessment of coronary arteries is recommended peri-procedurally in these patients. Non-invasive computerised tomography (CT) imaging may be sufficient in evaluating prognostically significant coronary disease in these patients. This feasibility study aimed to compare the use of CT imaging to invasive assessment of prognostically significant coronary disease in TAVR patients. CT imaging and invasive coronary angiography were compared in TAVR patients at the Princess Alexandra Hospital (PAH) from 2016 to present. Prognostically significant (left main coronary artery or proximal large vessel disease) coronary disease will be independently evaluated by cardiologists and compared between CT imaging and invasive coronary angiography. A total of 244 patients were included in the analysis, 136 of these were male. They had a mean age of 80.3±5.5yrs and a mean EURO II surgical risk score of 4.6±4.4%. Utilising CT imaging 2 patients proceeded to TAVR without undergoing invasive coronary artery assessment. Although only preliminary, this feasibility study shows that CT imaging holds the potential to exclude prognostically significant coronary artery disease in TAVR patients, reducing the risks associated with invasive coronary angiography in these patients.

PCI vs. CABG for Left Main Coronary Artery Disease

Patients with significant left main coronary artery disease (LMCAD) traditionally have been treated with coronary artery bypass graft surgery (CABG) —

Diagnostic Performance of Frequency-Domain Optical Coherence Tomography to Predict Functionally Significant Left Main Coronary Artery Stenosis.

Aims The aim of this study was to assess the safety and diagnostic efficacy of frequency-domain optical coherence tomography (FD-OCT) in identifying functional severity of the left main coronary artery (LM) stenosis determined by fractional flow reserve (FFR). Methods and Results 101 patients with LM lesion (20–70% diameter stenosis angiographically) underwent FFR measurement and FD-OCT imaging of the LM. The following parameters were measured by FD-OCT in the LM: reference lumen area (RLA), reference lumen diameter (RLD), minimum lumen area (MLA), minimum lumen diameter (MLD), % lumen area stenosis, and % diameter stenosis. The LM lesions were analyzable by FD-OCT in 88/101 (87.1%) patients. FFR at maximum hyperemia was ≤0.80 in 39/88 (44.3%) patients. FFR values were correlated significantly with FD-OCT-derived LM lumen parameters. An MLA cutoff value of 5.38 mm2 had the highest sensitivity and specificity of 82% and 81%, respectively, followed by an MLD of 2.43 mm (sensitivity 77%, specificity 72%) and AS of 60% (sensitivity 72%, specificity 72%) for predicting FFR <0.80. Conclusions FD-OCT is a safe and feasible imaging technique for the assessment of LM stenosis. An FD-OCT-derived MLA of ≤5.38 mm2 strongly predicts the functional severity of an LM lesion.