Treatment Of Left Main Disease Research Articles

Percutaneous Coronary Intervention of Left Main Disease: Outcome After 1-year Follow-up at a Tertiary Hospital in Vietnam.

Left main (LM) coronary artery disease (CAD) is a severe condition that can lead to severe outcomes. Treatment options include medication, coronary artery bypass graft surgery (CABG) and percutaneous coronary intervention (PCI). Recent advancements in PCI techniques position it as a viable alternative to CABG for LM revascularisation. This prospective observational study evaluated outcomes after PCI for LM CAD, encompassing in-hospital and post-discharge mortality, in a single-centre registry in Vietnam. Our research involved 59 patients who underwent PCI for LM lesions, with an average age of 66.7 ±1.5 years, who were divided into two groups based on presentation diagnosis - acute coronary syndrome or chronic coronary syndrome. After PCI, one individual was diagnosed with contrast-induced nephropathy and one with cardiac shock. There were two cases of in-hospital mortality in the acute coronary syndrome group and one in the chronic coronary syndrome group giving a rate of major adverse cardiac and cerebrovascular events (MACCE) of 5.1%. After a 12-month follow-up, the MACCE rate increased to 18.6%. Triple vessel coronary artery disease and troponin I elevation exhibited significant associations with adverse in-hospital outcomes (p<0.05). PCI for LM coronary artery disease is considered a safe treatment option, demonstrating relatively favourable in-hospital and mid-term outcomes. It presents a viable alternative for patients in need of revascularisation, particularly in cases where CABG is not the preferred choice. Clinical indicators, such as triple vessel coronary artery disease and elevated troponin I levels, may serve as predictors of adverse outcomes during hospitalisation.

Benefits of coronary artery bypass grafting over percutaneous coronary intervention in left main disease: the strength of the evidence.

Benefits of coronary artery bypass grafting over percutaneous coronary intervention in left main disease: the strength of the evidence.

Proximal optimization technique and percutaneous coronary intervention for left main disease: POTENTIAL-LM.

Optimal stent deployment in left main (LM) bifurcation is paramount, and incomplete stent apposition may cause major adverse cardiac events (MACE). Bench studies show that the proximal optimization technique (POT) provides the best stent apposition. We aimed to investigate the impact of POT on clinical outcomes in patients treated for unprotected LM (ULM) disease at our institution. We identified 162 patients who underwent percutaneous coronary intervention (PCI) for ULM coronary disease in the Cardio-FR database. Out of these, 99 (61%) had undergone POT, while 63 patients were treated without POT. The primary outcome was the bifurcation-oriented composite endpoint (BOCE) of cardiac death, target-bifurcation myocardial infarction and target-bifurcation revascularization at maximal follow-up. Mean age was 76 years, and 69% presented with acute coronary syndrome. Mean follow-up was 2.25 years (822 days). The BOCE occurred in 43 (27%) of which 20 (20%) in the POT group and 23 (37%) in the no-POT group (p = 0.009). Cardiac death occurred in 15 (15%) patients in the POT- and 17 (27%) in no-POT group (p = 0.26). Target bifurcation revascularization occurred in 4 (4%) patients in the POT- and 6 (10%) patients in the no-POT group (p = 0.19). POT In the multivariate analysis, POT was the strongest parameter and was associated with BOCE, cardiac death, occurrence of any revascularization and all-cause mortality. The POT improves clinical outcomes. These findings strongly support the systematic use of POT in patients undergoing ULM-PCI.

Impact of Target Lesion Revascularization on Long-Term Mortality After Percutaneous Coronary Intervention for Left Main Disease

BackgroundAlthough target lesion revascularization (TLR) after percutaneous coronary intervention (PCI) for unprotected left main coronary artery (LMCA) disease is not rare, its timing of occurrence and prognostic impact on long-term mortality is uncertain. ObjectivesThis study sought to investigate TLR incidence over time and its impact on mortality after PCI with drug-eluting stents (DES) for LMCA disease. MethodsUsing a pooled data from 4 multicenter observational registries (IRIS-DES [Interventional Cardiology Research Incorporation Society-Drug-Eluting Stents], IRIS-MAIN [Interventional Cardiology Research Incorporation Society-Left MAIN Revascularization], MAIN-COMPARE [Revascularization for Unprotected Left Main Coronary Artery Stenosis: Comparison of Percutaneous Coronary Angioplasty Versus Surgical Revascularization], and PRECOMBAT [PREmier of Randomized COMparison of Bypass Surgery versus AngioplasTy Using Drug-Eluting Stent in Patients with Left Main Coronary Artery Disease]), we evaluated 1,397 patients with LMCA disease treated with DES and available long-term mortality data. The association between TLR and the 10-year risk of mortality was examined by multivariable Cox proportional hazards regression, with TLR as a time-varying covariate. ResultsDuring maximum follow-up of 10 years (median 6.8 years), TLR occurred in 118 patients and its 10-year cumulative incidence was 10.8%. TLR mostly occurred within 2 years after initial PCI and decreased over time: early-stage TLR (within 2 years) in 73 (61.9%) patients and late-stage TLR (beyond 2 years) in 45 (38.1%) patients. Among all TLR patients, 23 patients underwent coronary artery bypass grafting and 95 underwent repeat PCI. In the time-varying multivariable Cox model, the presence of TLR was not significantly associated with an increased risk of mortality (adjusted HR: 0.90; 95% CI: 0.50-1.63; P = 0.73). ConclusionsAlthough the incidence of ischemia-driven TLR was mostly common within 2 years after left main PCI, TLR occurred steadily during the 10-year follow-up period. However, given that such patients were optimally revascularized, the prognostic impact of TLR on mortality was not substantial. (Evaluation of the First, Second, and New Drug-Eluting Stents in Routine Clinical Practice [IRIS-DES]; NCT01186133; Observational Study for Left Main Disease Treatment [IRIS-MAIN]; NCT01341327; Ten-Year Outcomes of Stents Versus Coronary-Artery Bypass Grafting for Left Main Coronary Artery Disease [MAIN COMPARE]; NCT02791412; Bypass Surgery Versus Angioplasty Using Sirolimus-Eluting Stent in Patients With Left Main Coronary Artery Disease [PRECOMBAT]; NCT00422968)

TCT-232 Percutaneous Coronary Intervention for Left Main Disease in High Bleeding Risk: Outcomes From a Subanalysis of the Delta 2 Registry

TCT-232 Percutaneous Coronary Intervention for Left Main Disease in High Bleeding Risk: Outcomes From a Subanalysis of the Delta 2 Registry

Percutaneous Treatment of Left Main Disease: A Review of Current Status.

Percutaneous treatment of the left main coronary artery is one of the most challenging scenarios in interventional cardiology, due to the large portion of myocardium at risk the technical complexity of treating a complex bifurcation with large branches. Our aim is to provide un updated overview of the current indications for percutaneous treatment of the left main, the different techniques and the rationale underlying the choice for provisional versus upfront two-stent strategies, intravascular imaging and physiology guidance in the management of left main disease, and the role of mechanical support devices in complex high-risk PCI.

Comparing results of bypass surgery and percutaneous coronary intervention for left main disease by surgical revascularization pump strategy

ObjectiveWe performed a post hoc analysis of the Evaluation of XIENCE versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization (EXCEL) trial to determine the effect an on-versus off-pump strategy had on outcomes when compared with percutaneous coronary intervention. MethodsAll randomized patients in EXCEL (n = 1905) were included. The outcomes of interest were the primary end point composite of death from any cause, stroke, or myocardial infarction; the composite study end point or ischemia-driven revascularization; and the rate of death from any cause at 5 years. Event rates were based on Kaplan–Meier estimates in time-to-first-event analyses. ResultsPropensity matching resulted in groups of 1142 patients (571 each) for on-pump coronary artery bypass grafting versus percutaneous coronary intervention and 472 patients (236 each) for off-pump coronary artery bypass grafting versus percutaneous coronary intervention. In the on-pump coronary artery bypass grafting versus percutaneous coronary intervention matched groups, the composite end point was similar (18.0% vs 22.1%, P = .19) and the composite end point or ischemia-driven revascularization (23.3% vs 31.0%, P = .01) was lower, and mortality (7.6% vs 11.8%, P = .025) was lower in the on-pump coronary artery bypass grafting group at 5 years. In the off-pump coronary artery bypass grafting versus percutaneous coronary intervention matched groups, the composite end point (19.4% vs 22.2%, P = .47), composite end point or ischemia-driven revascularization (25.9% vs 34.2%, P = .07), and mortality (12.5% vs 14.2%, P = .59) were similar at 5 years. ConclusionsIn the EXCEL trial, on-pump coronary artery bypass grafting was associated with a decreased 5-year rate of the composite outcome of death, stroke, myocardial infarction, or ischemia-driven revascularization, and decreased mortality when compared with percutaneous coronary intervention, whereas outcomes of off-pump coronary artery bypass grafting were similar to percutaneous coronary intervention.

Cardiac surgery is still necessary in the treatment of left main disease

Cardiac surgery is still necessary in the treatment of left main disease

TCT-149 Does the Involvement of Left Circumflex Coronary Artery Ostium Affect Prognosis in Patients Undergoing Percutaneous Coronary Intervention for Left Main Disease?

TCT-149 Does the Involvement of Left Circumflex Coronary Artery Ostium Affect Prognosis in Patients Undergoing Percutaneous Coronary Intervention for Left Main Disease?

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 &amp; Materials: It was a prospective observational study done in National Institute of Cardiovascular Diseases &amp; 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 &amp; 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 &amp; 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 &amp; 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 &amp; 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 &amp; 3(06%) in 2nd year. The multivariable analysis showed a good prognosis in patients receiving LM PCI with a total event rate of 28% &amp; 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) &amp; 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 &amp; 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

The Contemporary Management of Left Main Coronary Artery Disease.

The 'gold standard' in the management of left main coronary artery disease has historically been coronary artery bypass surgery. Recent innovations in drug-eluting stent technology coupled with the increasing utility of physiology and imaging guidance for procedures have led to an evolving role of percutaneous coronary intervention in left main disease of low and intermediate anatomical complexity. This revascularization modality carries the clear advantage of being less invasive and significantly reduced recovery times. This practice is currently supported by international guidelines, however, it remains a controversial topic in the field of interventional cardiology, and the long-term outcomes of a percutaneous strategy have been questioned. This review describes the current evidence base for the assessment and choice of intervention in left main coronary artery disease. The percutaneous revascularization techniques and use of imaging to optimize procedures and improve clinical outcomes have been discussed.

Towards a common pathway for the treatment of left main disease: contemporary evidence and future directions: Left main disease treatment.

There is increasing evidence to support percutaneous treatment of left main (LM) disease. Due to its major clinical impact, any procedure in the left main should be meticulously planned and performed. In this review, we aim to integrate the available evidence into a common treatment pathway, starting with understanding the distinct anatomical features of the left main. A three-level decision-making process is presented. First, in instances of angiographic ambiguity, intravascular ultrasound and fractional flow reserve can be used to decide if revascularisation could be deferred. Second, if revascularisation is indicated, the risks and benefits of percutaneous versus surgical procedures should be evaluated. Third, if percutaneous coronary intervention (PCI) is chosen, the operator should decide between the provisional single-stent versus upfront two-stent strategies. Regardless of the PCI technique selected, it should be performed according to the recommendations of a stepwise procedure utilising proximal optimisation (POT) after each instance of crossover stenting and kissing balloon inflation (KBI) where necessary. In addition to the recognised quality markers such as POT and KBI, we discuss the clinical relevance of the operator's LM PCI experience and the intracoronary imaging guidance when treating patients with left main disease.

Debate: The role of percutaneous coronary intervention for left main disease after EXCEL and NOBEL trials

To compare the mortality associated with percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in patients with non–ST elevation acute coronary syndrome (NSTE-ACS).We searched publications from PubMed, Embase, Web of Science, and the Cochrane Library from inception until December 23, 2020. All randomized clinical trials (RCTs) and observational studies comparing all-cause mortality after treatment with CABG versus PCI for patients with NSTE-ACS with minimum follow-up of 6 months were included. Restricted mean survival time (RMST) differences from RCTs and adjusted RMST differences from observational studies were computed by reconstructing time-to-event data from published Kaplan–Meier curves. Extracted hazard ratios (HRs) were also assessed as a secondary analysis.Our systematic review included an individual participant data analysis of 3 RCTs and 8 observational studies. A meta-regression showed a significant association between log-transformed HRs and duration of follow-up (−0.009 [95% confidence interval (CI), −0.002 to −0.016] log-HR per 1-year longer follow-up; P = .037), suggesting a violation of the proportional hazard assumption. Analysis of 6 studies with available RMST data showed a significant inverse association between adjusted RMST differences and cutoff years (slope, −0.028 [95% CI, −0.042 to −0.013] year difference per 1-year longer cutoff; P < .005), suggesting a longer survival benefit in the CABG arm compared with the PCI arm with longer follow-up.There was a trend toward a benefit of CABG compared with PCI in the longer follow-up in patients with NSTE-ACS. A large, well-designed RCT with longer follow-up is needed to obtain definitive evidence on this topic.

Coronary artery bypass grafting versus percutaneous coronary intervention for left main disease in chronic kidney disease patients: a meta-analysis

Abstract Background Limited data exist on the optimal revascularization strategy for patients with left main coronary artery disease (LMCAD) and chronic kidney disease (CKD). We conducted a meta-analysis to compare the outcomes of coronary artery bypass grafting (CABG) versus percutaneous coronary intervention (PCI) in this population. Methods Multiple electronic databases were queried for studies comparing CABG and PCI in CKD patients undergoing LMCAD (&amp;gt;50% diameter stenosis) revascularization. CKD was defined as estimated glomerular filtration rate of &amp;lt;60 ml/min/1.73 m2. The primary outcome was long-term major adverse cardiac and cerebrovascular events (MACCE), which was a composite of cardiovascular death, myocardial infarction (MI), stroke and repeat revascularization. Secondary outcomes included all-cause mortality, MI, stroke and repeat revascularization. Odds ratios (OR) and 95% confidence intervals (CI) were calculated. The analysis was performed using the DerSimonian and Laird random effect model. Results Six studies (4 observational, 2 randomized controlled trials) met inclusion criteria with a total of 2051 patients (CABG: 977, PCI: 1074). Patients undergoing CABG had a higher incidence of multi-vessel disease (74.7% vs 65.7%, p=0.01). At a mean follow-up of 3.4±1.1 years, MACCE was significantly lower in the CABG group (OR = 0.70, 95% CI 0.57–0.87; p=0.001) (Figure 1). The odds of MI or repeat revascularization were lower with CABG, whereas the odds of stroke were higher; no statistically-significant difference was seen in all-cause mortality. Conclusion This meta-analysis shows that CABG is associated with lower rates of MACCE and MI but with a higher rate of stroke compared to PCI in LMCAD patients with CKD. Funding Acknowledgement Type of funding source: None

TCT CONNECT-308 Impact of High Troponin Elevation After Percutaneous Coronary Intervention for Left Main Disease: Does It Affect Patients Prognosis?

TCT CONNECT-308 Impact of High Troponin Elevation After Percutaneous Coronary Intervention for Left Main Disease: Does It Affect Patients Prognosis?

Coronary Artery Bypass Grafting Versus Percutaneous Coronary Intervention for Left Main Disease in Chronic Kidney Disease Patients

Coronary Artery Bypass Grafting Versus Percutaneous Coronary Intervention for Left Main Disease in Chronic Kidney Disease Patients

Controversies in the Indications of Percutaneous Angioplasty Or Coronary Artery Bypass Grafting In The Treatment Of Left Main Disease

Introduction Left main coronary artery (LMCA) disease is a high-risk clinical situation, since this artery is responsible for the irrigation of more than two-thirds of the myocardial tissue, LMCA disease is associated with increased risk of adverse cardiac events. Traditionally, the gold standard of treatment for significant LMCA disase, understood as a stenosis> 50%, is coronary artery bypass grafting (CABG) surgery. – The technological evolution of percutaneous treatment and its safe application for LMCA disease in the PRECOMBAT study made [...]

Transradial versus transfemoral percutaneous coronary intervention of left main disease: A systematic review and meta-analysis of observational studies.

To assess the efficacy and safety of transradial (TR) versus transfemoral (TF) percutaneous coronary intervention (PCI) in left main (LM) lesion. TR-PCI is the preferred approach compared with TF approach because of less bleeding risk. LM-PCI is often challenging because of the anatomical complexity and uniqueness of supplying a large myocardium territory. We performed a systematic review and meta-analysis to assess the safety and efficacy of TR-PCI compared with TF-PCI of the LM lesions. A comprehensive literature search of PUBMED, EMBASE, and Cochrane database was conducted to identify studies that reported the comparable outcomes between both approaches. Odds ratio (OR) and 95% confidence interval (CI) was calculated using the Mantel-Haenszel method. A total of eight studies were included in the quantitative meta-analysis. TR-PCI resulted in lower bleeding risk (OR 0.31, 95%CI 0.18-0.52, P < 0.01, I2 = 0%) while maintaining similar procedural success rate, target lesion revascularization, myocardial infarction, stent thrombosis, and all-cause mortality during the study follow-up period. TR-PCI may achieve similar efficacy with decreased bleeding risk compared to TF-PCI in LM lesions. When operator experience and anatomical complexity are favorable, TR approach is an attractive alternative access over TF approach in LM-PCI.

Percutaneous Coronary Intervention of Left Main Disease: Pre- and Post-EXCEL (Evaluation of XIENCE Everolimus Eluting Stent Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) and NOBLE (Nordic-Baltic-British Left Main Revascularization Study) Era.

For nearly half a century, coronary artery bypass grafting has been the standard treatment for patients with obstructive left main coronary artery (LMCA) disease. However, there has been considerable evolution in the field of percutaneous coronary intervention, and especially, percutaneous coronary intervention for LMCA disease has been rapidly expanded with adoption of drug-eluting stents. Some, but not all randomized trials, have shown that percutaneous coronary intervention with drug-eluting stents might be a suitable alternative for selected patients with LMCA disease instead of bypass surgery. However, none of previous trials involving early-generation drug-eluting stents was sufficiently powered and comparative trials using contemporary drug-eluting stents were limited. Recently, primary results of 2 new trials of EXCEL (Evaluation of XIENCE Everolimus Eluting Stent Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) and NOBLE (Nordic-Baltic-British Left Main Revascularization Study) were reported. However, these trials showed conflicting results, which might pose uncertainty on the optimal revascularization strategy for LMCA disease. In this article, with the incorporation of a key review on evolution of LMCA treatment, we summarize the similarity or disparity of the EXCEL and NOBLE trials, focus on how they relate to previous trials in the field, and finally speculate on how the treatment strategy may be changed or recommended for LMCA treatment.

Usefulness of sheathless guide catheter for the percutaneous coronary intervention of left main disease by radial approach

Usefulness of sheathless guide catheter for the percutaneous coronary intervention of left main disease by radial approach