Unprotected Left Main Coronary Artery Disease Research Articles

Very long-term outcomes after percutaneous coronary intervention with bare metal stents for unprotected left main coronary artery disease

The aim of this study was to evaluate very long-term clinical outcomes and potential predictors after percutaneous coronary intervention (PCI) with bare metal stents (BMS) for unprotected left main coronary artery disease (ULMCAD). From March 1991 to August 2001, 151 patients who underwent PCI with BMS for ULMCAD were investigated retrospectively. The patient-oriented major adverse cardiac events (MACE) were defined as the occurrence of all-cause death, any MI, and any coronary revascularisation. The median follow-up duration was 10.5 years. The mean age was 69.9±11.5 years, and 106 patients (70.2%) were male. At 10 years, the incidences of cardiac death (CD), target lesion revascularisation (TLR) and patient-oriented MACE were 11.1%, 25.2% and 81.9%, respectively. In multivariate analysis, the pre-reference diameter of the left main trunk (LMT) was significantly associated with TLR (adjusted hazard ratio [HR] [95% confidence interval (CI)], 0.28 [0.14-0.54], p<0.001) and the SYNTAX score remained an independent predictor of patient-oriented MACE (adjusted HR [95% CI], 1.03 [1.007-1.05], p=0.009). The pre-reference diameter of LMT was significantly associated with TLR, and the SYNTAX score significantly predicted the risk of patient-oriented MACE at 10 years. BMS implantation for larger size of ULMCAD with a lower SYNTAX score was feasible for up to 10 years.

Abstract 9396: Bayesian Methods Affirm the Use of Percutaneous Coronary Intervention to Improve Survival in Patients with Unprotected Left Main Coronary Artery Disease

Introduction: Several randomized clinical trials (RCTs) have supported the Class I recommendation for coronary artery bypass grafting (CABG) for unprotected left main coronary artery disease (ULMCAD). In the absence of RCTs directly comparing percutaneous coronary intervention (PCI) with medical therapy (MT) for this indication, the new Class IIa recommendation for PCI to improve survival in selected patients with ULMCAD has been statistically inferred from several studies comparing CABG with PCI. Hypothesis: We tested whether Bayesian approaches supported the recommendation for PCI to improve survival in patients with ULMCAD. Methods: We performed a Bayesian cross-design and network meta-analysis of 12 studies (4 RCTs, 4 observational matched studies and 4 other cohort studies) comparing CABG with PCI (N=4,574 patients) and of 7 studies (2 RCTs and 5 observational studies) comparing CABG with MT (N=3,224 patients). Results: The odds ratios (ORs) for 1-year mortality after PCI versus CABG using Bayesian cross-design meta-analysis were not different among RCTs (OR 0.99, 95% Bayesian credible interval [BCI] 0.67-1.43), matched cohort studies (OR 1.10, 95% BCI 0.76-1.73), and other types of cohort studies (OR 0.93, 95% BCI 0.58-1.35). A network meta-analysis suggested that MT alone is associated with higher 1-year mortality than the use of PCI for patients with ULMCAD (Figure). Conclusions: Bayesian methods support the current revascularization guidelines and suggest that PCI may improve survival over MT alone for patients with ULMCAD. An integrated approach analyzing data from both observational and randomized studies using Bayesian methods may yield new insights to enhance the translation of trial data into clinical practice.

Abstract 8894: Comparison of More Than 3 Years Clinical Outcomes Between Drug-eluting Stent and Bypass Surgery for Unprotected Left Main Coronary Artery Disease: A Meta Analysis of Randomised and Risk Adjusted Studies

Backgrounds: Previous data from meta analysis have reported controversial the short and midterm clinical outcomes between drug-eluting stent (DES) and coronary bypass surgery graft (CABG) for paitents with unprotected left main coronary artery disease (ULMCD). However, the long-term outcomes remain unknown. Methods: A systemic research was carried out in Pubmed, Embase, Cochrane library and scientific sessions of AHA, ACC and ESC (up to April 2012). All randomised and nonrandomised studies after &gt;=3 years of follow-up comparing DES and CABG in ULMCD were included. In order to control the potential confoundings in observational studies, risk adjusted hazard ratio (HR) or odds ratio (OR) by propensity score matching or Cox regresson method was abstracted. Results: 10 eligible studies (2 randomised, 8 nonrandomised) wth 6782 subjects were identified and selected. Mortality, death/MI/stroke and target vessel revascularizaton(TVR) were focused. Pooled analysis revealed that there was no statistical significant difference between DES and CABG in mortality (OR=0.92, 95% confidential interval [CI]: 0.65 to 1.31, P=0.646, heterogeniety test: 0.0%; Fig 1) and death/MI/stroke (OR=1.03, 95% CI: 0.75 to 1.42, P=0.841, heterogeniety test: 0.0%).However, compared with CABG, DES had a significant increased incidence of TVR(OR=3.45, 95% CI: 2.38 to 4.99, P&lt;0.00001, heterogeniety test: 0.0%). No evidence of significant publication bias was observed in mortality (Begg’s test, P=0.245; Egger’s test, P=0.518). Sensitivity analysis of mortality excluding each included study at one time revealed that most individual study was consisted with the direction and size of the overall effect ( all P&gt;0.1). Conclusions: Based on the available evidence, after long-term follow up, the mortality and composite outcome are similar between DES and CABG in patients with ULMCD, however, incidence of TVR is still high in DES comparing with CABG.

A Comparison Between Coronary Artery Bypass Grafting Surgery and Percutaneous Coronary Intervention for the Treatment of Unprotected Left Main Coronary Artery Disease

Unprotected left main coronary artery (ULMCA) disease occurs in 3% to 5% of patients with coronary artery disease and is mainly treated by coronary artery bypass grafting (CABG) surgery. Drug-eluting stents (DESs) have renewed interest for the percutaneous coronary intervention (PCI) treatment of ULMCA stenosis. This study compared the long-term clinical outcome of PCI with DESs or CABG in real world patients with ULMCA disease. PCI with DESs may be a better treatment for ULMCA disease compared with CABG. Consecutive patients who had coronary revascularization because of ULMCA disease in Zhongshan Hospital, from May 2003 to November 2009, were retrospectively enrolled. They were classified in the PCI or the CABG group according to treatments that were given initially. Of 515 patients having follow-up data, 233 were treated by PCI, whereas 282 were treated by CABG. The patients in the CABG group were of older age, had higher European System for Cardiac Operative Risk Evaluation (EuroSCORE) and Synergy Between PCI With Taxus Drug-Eluting Stent and Cardiac Surgery (SYNTAX) scores, and had longer hospitalization stays than the PCI group. At the end of follow-up, there was no difference in major adverse cardiac and cerebrovascular events between the 2 groups. However, the incidence of cardiac death (0.4% vs 4.6%) in the PCI group was less than that in the CABG group, whereas target vessel revascularization (7.3% vs 3.2%) was higher in the PCI group. In ULMCA disease, CABG tends to be chosen in patients with higher risk according to the EuroSCORE and SYNTAX scores. PCI with DESs seemed to have favorable early and long-term clinical outcomes compared with CABG in our center.

Long-term outcomes after percutaneous coronary intervention of unprotected left main coronary disease with drug-eluting stents

Most available data indicates that stenting for unprotected left main coronary artery disease (ULMCA) with drug-eluting stents (DES) is safe and effective. At present, surgery is considered the gold standard for optimal revascularization. The aim of this study was to evaluate the short and long term outcome of patients with ULMCA stenosis who underwent percutaneous coronary intervention (PCI) with DES implantation in a single center. Coronary stents were implanted into ULMCA in 59 patients. Short and long term total mortality and main adverse cardiac events (MACE): cardiac death, myocardial infarction and additional target lesion or non-target lesion revascularization (TLR) were assessed. Mean age was 69 ± 13 (29% were females). 23% were emergency/urgent cases. Angiographic and clinical success of PCI was 100%. 8.5% of the cohort underwent Transcatheter aortic valve implantation for severe inoperable aortic stenosis. 52% have significant distal left main disease requiring two stent bifurcation techniques. Follow-up duration was 23 ± 13 months. In hospital MACE occurred in 10%. In hospital death occurred in 3.4%. Long term total mortality was 11.8%. 3.3% of the cohort died because of non-cardiac problem. Using ARC (academia and research consortium) definition, probable acute stent thrombosis occurred in 5% of the cohort, all of them underwent two stent bifurcation techniques. Considering high risk characteristics of the study group, ULM stenting is feasible, with probably reasonable short and long term outcomes; however, ULM stenting requiring two stent bifurcation techniques should be reserved for patients who are not appropriate surgical candidates.

Risk assessment for percutaneous coronary intervention of the unprotected left main coronary artery in a real-world population

Background Available clinical and angiographic scoring systems fail to predict clinical outcomes in real-world patients undergoing revascularization of the unprotected left main coronary artery (ULMCA).Methods We prospectively assessed major adverse cardiac and cerebrovascular events (MACCE) in a real-world population undergoing percutaneous coronary intervention (PCI) for ULMCA disease. Cumulative risk-adjusted mortality in our patients was compared with expected mortality at 30 days based on logistic EuroSCORE and SYNTAX SCORE. Similarly, we plotted cumulative risk-adjusted MACCE at 1 year based on SYNTAX SCORE. Finally, both scores were combined in 1-year Global Risk Charts, including the use of drug-eluting stents (DES), diabetic status, and several factors precluding coronary surgery.Results Over a 12-year period, 240 patients underwent elective (76%) or urgent (24%) PCI of the ULMCA. Median logistic EuroSCORE and SYNTAX SCORE were 8.7% (3.5; 21) and 23% (14; 31). During the fi rst year of follow-up, 89 patients presented MACCE (37.1%) (46 deaths [19.2%], 18 acute myocardial infarctions [7.5%], 45 revascularizations [18.8%] and 4 strokes [1.7%]). Cumulative risk-adjusted mortality based on individual logistic EuroSCORE and SYNTAX SCORE pointed towards signifi cant overestimation (+19 deaths) and underestimation (-35 deaths) of risk by these respective scoring systems. Similarly, the anatomic SYNTAX SCORE largely underestimated cumulative risk-adjusted MACCE (-60 MACCE). The Global Risk Charts provided a more balanced view on 1-year clinical outcome.Conclusion An integrated risk evaluation combining EuroSCORE, SYNTAX SCORE, diabetic status, stent type and general condition, may predict outcomes more accurately awaiting validation in a larger and multicentre setting.

Meta-Analysis of Three Randomized Trials and Nine Observational Studies Comparing Drug-Eluting Stents Versus Coronary Artery Bypass Grafting for Unprotected Left Main Coronary Artery Disease

Clinical outcomes for unprotected left main coronary artery (ULMCA) disease between coronary artery bypass grafting (CABG) and drug-eluting stents (DESs) remain controversial. We aimed to compare the safety and efficacy of percutaneous coronary intervention (PCI) using DESs with CABG in patients with ULMCA disease. Databases were searched for clinical studies that reported outcomes after PCI with DESs and CABG for treatment of ULMCA disease. End points of this meta-analysis were mortality; composite of death, myocardial infarction (MI), or stroke; and target vessel revascularization at 1-year follow-up. Pooled effects were calculated using fixed-effects model (Mantel-Haenszel method) or random-effects models (Dersimonian-Laird method). Twelve clinical studies (3 randomized trials and 9 observational studies) with 5,079 patients were involved in this study. At 1-year follow-up, there were trends toward lower risk of death (odds ratio [OR] 0.68, 95% confidence interval [CI] 0.45 to 1.02) and the composite end point of death, MI, or stroke (OR 0.70, 95% CI 0.49 to 1.00) in the DES group compared to the CABG group. However, target vessel revascularization was significantly higher in the DES group compared to the CABG group (OR 3.52, 95% CI 2.72 to 4.56). In conclusion, PCI with DESs is associated with favorable outcomes for mortality; composite end point of death, MI, or stroke; and a higher risk of target vessel revascularization compared to CABG in patients with ULMCA disease.

Impact of diabetes mellitus on patients with unprotected left main coronary artery lesion disease treated with either percutaneous coronary intervention or coronary-artery bypass grafting

This study was conducted to evaluate the impact of diabetes on patients with unprotected left main coronary artery (LMCA) disease treated with either percutaneous coronary intervention (PCI) or coronary-artery bypass grafting (CABG). The optimal coronary revascularization strategy in diabetic patients with unprotected LMCA disease remains uncertain. A total of 823 consecutive patients having unprotected LMCA disease, who received drug-eluting stent (DES) (n=331) implantation or underwent CABG (n=492), were retrospectively analyzed. We compared the effects of these two treatments on clinical outcomes [death, cardiac death, myocardial infarction (MI), stroke, target vessel revascularization, and the composite of death, MI, or stroke], according to the patients' diabetic status. After multivariable adjustment, the risk of death [hazard ratio (HR): 1.096, 95% confidence interval (CI): 0.541-2.222; P=0.799] and that of the composite of death, MI, or stroke (HR: 0.769, 95% CI: 0.446-1.328; P=0.346) were similar in the DES and CABG groups. However, the rate of target vessel revascularization was significantly higher in the DES group (HR: 0.169, 95% CI: 0.079-0.358; P<0.001). Incidence of MI (HR: 1.314, 95% CI: 0.238-7.254; P=0.754) and that of the composite of death, MI, or stroke (HR: 1.497, 95% CI: 0.682-3.289; P=0.315) were similar between DES and CABG in the nondiabetic group; however, in the diabetic population incidence of the composite of death, MI, or stroke (HR: 0.31, 95% CI: 0.126-0.761; P=0.011) was significantly higher in the DES compared with the CABG group, driven mainly by the significantly higher rate of MI in the DES group (HR: 0.114, 95% CI: 0.022-0.593; P=0.01). Rate of repeat revascularization was higher with DES compared with CABG in both diabetic and nondiabetic groups. There was a prognostic impact of diabetes mellitus on treatment effects in patients with unprotected LMCA lesions who underwent DES or CABG. For patients with unprotected LMCA lesions, PCI with DES was an acceptable alternative to CABG at risk for higher repeat revascularization in the nondiabetic cohort, whereas in the diabetic cohort PCI with DES was inferior to CABG in terms of both safety and efficacy.

Comparison of Long-Term Outcome After Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting in Patients With Unprotected Left Main Coronary Artery Disease (from the CREDO-Kyoto PCI/CABG Registry Cohort-2)

The long-term outcome of percutaneous coronary intervention (PCI) compared to coronary artery bypass grafting (CABG) for unprotected left main coronary artery disease (ULMCAD) remains to be investigated. We identified 1,005 patients with ULMCAD of 15,939 patients with first coronary revascularization enrolled in the CREDO-Kyoto PCI/CABG Registry Cohort-2. Cumulative 3-year incidence of a composite of death/myocardial infarction (MI)/stroke was significantly higher in the PCI group than in the CABG group (22.7% vs 14.8%, p = 0.0006, log-rank test). However, the adjusted outcome was not different between the PCI and CABG groups (hazard ratio [HR] 1.30, 95% confidence interval [CI] 0.79 to 2.15, p = 0.30). Stratified analysis using the SYNTAX score demonstrated that risk for a composite of death/MI/stroke was not different between the 2 treatment groups in patients with low (<23) and intermediate (23 to 33) SYNTAX scores (adjusted HR 1.70, 95% CI 0.77 to 3.76, p = 0.19; adjusted HR 0.86, 95% CI 0.37 to 1.99, p = 0.72, respectively), whereas in patients with a high SYNTAX score (≥33), it was significantly higher after PCI than after CABG (adjusted HR 2.61, 95% CI 1.32 to 5.16, p = 0.006). In conclusion, risk of PCI for serious adverse events seemed to be comparable to that after CABG in patients with ULMCAD with a low or intermediate SYNTAX score, whereas PCI compared with CABG was associated with a higher risk for serious adverse events in patients with a high SYNTAX score.

Midterm Outcome of Off-Pump Bypass Procedures Versus Drug-Eluting Stent for Unprotected Left Main Coronary Artery Disease

Although surgical revascularization is recommended for the treatment of left main coronary artery (LMCA) disease, percutaneous coronary intervention (PCI) attempts have increased, especially after the introduction of the drug-eluting stent. The goal of this study was to compare the midterm outcomes between drug-eluting stenting and off-pump coronary artery bypass (OPCAB) grafting in LMCA disease. Five hundred twelve consecutive patients with unprotected LMCA disease who underwent OPCAB (N = 269) or drug-eluting stenting (N = 243) were enrolled. We compared major cardiac and cerebrovascular events (MACCEs) in a real-world cohort and in a matching patient cohort (N = 256). The duration of mean follow-up was 38 ± 20 months, and the follow-up rate was 97.7%. In a real-world comparison, the OPCAB group showed better 5-year freedom from MACCEs compared with the stenting group (71.5% ± 4.4% versus 67.6% ± 4.0%; p = 0.031), despite worse patient characteristics. After patient matching, the OPCAB group showed more distinct benefit in 5-year freedom from MACCEs (75.3% ± 6.6% versus 62.8% ± 5.4; p < 0.001), including a significantly lower target vessel revascularization (TVR) rate (p < 0.001). In a subgroup analysis, the benefit of OPCAB regarding 5-year freedom from MACCEs was more clearly defined for lesions of the distal LCMA and in LMCA lesions with multivessel disease (p = 0.015, p = 0.004, respectively). Patients with LMCA disease who were treated with OPCAB showed better 5-year freedom from MACCEs in a real-world practice and in a patient matching cohort compared with the drug-eluting stenting group. TVR was the main factor that made the difference. The benefit of OPCAB was more prominent in distal LMCA lesions and in LMCA lesions with multivessel involvement.

Meta-analysis of 5674 patients treated with percutaneous coronary intervention and drug-eluting stents or coronary artery bypass graft surgery for unprotected left main coronary artery stenosis

To compare the safety and efficacy of coronary artery bypass grafting (CABG) with percutaneous coronary intervention (PCI) using drug-eluting stents (DES) in patients with unprotected left main coronary artery (ULMCA) disease. MEDLINE, EMBASE, CENTRAL/CCTR, SciELO, LILACS, Google Scholar and reference lists of relevant articles were searched for clinical studies that reported outcomes at the 1-year follow-up after PCI with DES and CABG for the treatment of ULMCA stenosis. Sixteen studies (three randomized controlled trials and 13 observational studies) were identified and included a total of 5674 patients (2331 for PCI with DES and 3343 for CABG). At the 1-year follow-up, there was no significant difference between the CABG and DES groups in the risk for death (odds ratio [OR] 0.691, P = 0.051) or the composite endpoint of death, myocardial infarction or stroke (OR 0.832, P = 0.258). The risk for target vessel revascularization (TVR) was significantly higher in the PCI group compared with the CABG group (OR 3.597, P < 0.001). The risk of major adverse cardiac and cerebrovascular events (MACCE) was significantly higher in the PCI group compared with the CABG group (OR 1.607, P < 0.001). A publication bias was observed regarding the outcome of death and also a considerable heterogeneity effect on the composite endpoint of death, myocardial infarction or stroke and MACCE. CABG surgery remains the best option of treatment for patients with ULMCA disease, with less need of TVR and lower MACCE rates.

AS-034 Multivessel and Left Main Coronary Artery Stenting in Comparison with Surgical Revascularization in Patients with Non ST Elevation Acute Coronary Syndrome (The MILESTONE Registry)

Surgical myocardial revascularization (CABG) in patients with multivessel coronary artery disease (MVD) with or without unprotected left main coronary artery disease (ULMCA) is a treatment of choice. On the other hand due to increased perioperative risk with concomitant non-ST elevation acute coronary syndrome (NSTE-ACS) percutaneous coronary intervention (PCI) is becoming a popular method of revascularization. Therefore the aim of this study is to compare early and late results after PCI and CABG in this population.

VERY LONG-TERM OUTCOMES AFTER PERCUTANEOUS CORONARY INTERVENTION WITH BARE-METAL STENTS FOR UNPROTECTED LEFT MAIN CORONARY ARTERY DISEASE

Long-term clinical outcomes and risk factors over 10 years after percutaneous coronary intervention (PCI) with bare-metal stents (BMS) for unprotected left main coronary artery disease (ULMCAD) have not been fully clarified. From March 1991 to August 2001, 151 patients who underwent PCI with BMS

Early and Mid‐Term Clinical Outcome of Emergency PCI in Patients with STEMI due to Unprotected Left Main Coronary Artery Disease

Evaluation of acute and mid-term outcomes of patients with ST-elevation myocardial infarction (STEMI) undergoing emergency PCI due to unprotected left main coronary artery (ULMCA) disease. STEMI patients due to ULMCA disease represent a rare, high risk group. Percutaneous coronary intervention (PCI) may be the preferred strategy of myocardial revascularization but there are few data about this topic. We analyzed 30-day and mid-term mortality of 58 patients with STEMI and ULMCA disease as culprit lesion treated in our centre by emergency PCI between 2000 to 2010. Mean age was 67.3 ± 11.5 years. Thirty (51.7%) patients had cardiogenic shock on admission. PCI success was achieved in 54 patients (93.1%). Mean follow-up was 15.8 ± 10.9 months (median 14, range 6-45). Thirty-day and mid-term mortality rates were 39.7% and 44%. Backward binary logistic regression model identified cardiogenic shock at presentation (OR 12.6, 95% CI 2.97-53.6, P < 0.001), age ≥75 years (OR 5.9, 95% CI 1.3-26.5, P = 0.019) and post-PCI TIMI flow grade <3 (OR 2.9, 95% CI 1.8-5.7 P = 0.02) as independent predictors of 30-day mortality. Cox proportional hazard ratio (HR) identified shock at presentation (HR 5.2, 95% CI 1.8-14.3, P < 0.002), age ≥75 years (HR 3.9, 95% CI 1.8-8.7, P < 0.001), post-PCI TIMI flow grade <3 (HR 4.9, 95% CI 1.6-14.6; P < 0.005) as independent predictors of mid-term mortality. In patients with STEMI and ULMCA as culprit lesion, emergency PCI is a valuable therapeutic strategy. Early and mid-term survival depends on cardiogenic shock, advanced age, and PCI failure. Patients surviving the first month have good mid-term prognosis.

Characteristics and Long-Term Outcomes of Percutaneous Revascularization of Unprotected Left Main Coronary Artery Stenosis in the United States: A Report From the National Cardiovascular Data Registry, 2004 to 2008

This study sought to assess percutaneous coronary intervention (PCI) for unprotected left main coronary artery (ULMCA) stenosis in routine U.S. clinical practice. Percutaneous coronary intervention for ULMCA stenosis is controversial; however, current use and outcomes of ULMCA PCI in routine U.S. clinical practice have not been described. We evaluated 5,627 patients undergoing ULMCA PCI at 693 centers within the National Cardiovascular Data Registry Catheterization Percutaneous Coronary Intervention Registry for temporal trends in PCI use (2004 to 2008), patient characteristics, and in-hospital mortality. Thirty-month mortality and composite major adverse events (death, myocardial infarction, and revascularization) with drug-eluting versus bare-metal stents were compared using inverse probability weighted (IPW) hazard ratios (HRs) in a nonrandomized Medicare-linked (age ≥65 years) patient cohort (n = 2,765). ULMCA PCI was performed in 4.3% of patients with ULMCA stenosis. Unadjusted in-hospital mortality rates ranged from 2.9% for elective cases to 45.1% for emergent/salvage cases. By 30 months, 57.9% of the elderly ULMCA PCI population experienced death, myocardial infarction, or revascularization, and 42.7% died. Patients receiving drug-eluting stents (versus bare-metal stents) had a lower 30-month mortality (IPW HR: 0.84, 95% confidence interval [CI]: 0.73 to 0.96), but the composite of major adverse events were similar (IPW HR: 0.95, 95% CI: 0.84 to 1.06). In the United States, ULMCA PCI is performed in <5% of patients with ULMCA disease and is generally reserved for those at high procedural risk. Adverse events are common in elderly patients and are related to patient and procedural characteristics, including stent type.

New era of left main coronary artery treatment strategy

For several decades of medical history, coronary-artery bypass grafting (CABG) has been regarded as the best treatment option for patients with unprotected left main coronary artery (LMCA) disease, considering lesion priority and its clinical consequences. Over the time, with remarkable advancements in techniques of percutaneous coronary intervention (PCI), supporting devices, and adjunctive pharmacologic therapy, PCI with DES implantation has appeared to be new and alternative option for optimal revascularization therapy for these patients. The available cumulative evidence suggests that the safety outcomes such as mortality or composite of death, myocardial infarction and stroke are similar among PCI and CABG for patients with LMCA disease, the only difference was the rate of repeat revascularization. Current evidence and ongoing large clinical trials may encourage interventional cardiologists to choose PCI with stenting as an alternative revascularization strategy for unprotected LMCA disease in future. Finally, this evidence will change the current clinical practice and the guideline of optimal revascularization strategy for unprotected LMCA disease.

Treatment of Patients with Left Main Coronary Artery Disease

Considering lesion priority and its clinical consequences, coronary artery bypass grafting (CABG) has been a treatment of choice for revascularization in patients with significant left main coronary artery (LMCA) disease, However, with remarkable advancements in techniques of percutaneous coronary intervention (PCI), supporting devices, and adjunctive pharmacologic therapy, PCI with stenting has emerged to be a less invasive and feasible revascularization treatment for these patients. The cumulative evidence suggests that the safety outcomes such as mortality or composite of death, myocardial infarction, and stroke are similar among PCI and CABG, with the only difference being the rate of repeat revascularization. Based on these data, the current guideline of revascularization of LMCA disease has adopted an increasing off-label experience with stenting and clinical studies and been updated to partly approve PCI as a viable alternative (in level of class IIb) in selected patients. The choice of PCI or CABG for unprotected LMCA disease depends on several clinical and anatomic features, ensuring crucial patient selection to be a cornerstone for achieving favorable long-term outcomes. In patients with very complex anatomic features and concomitant diffuse multivessel disease, CABG is preferred so as to avoid procedural and future thrombotic risks and to provide more complete revascularization. By contrast, in patients with relatively simple LMCA disease, such as ostial/shaft LMCA disease, isolated LMCA disease (with or without one or two-vessel involvement), and LMCA disease with low SYNTAX score, PCI is an alternative, and in some cases a preferred, strategy to reduce surgical risks (eg, stroke and in-hospital events following major surgery). For the future, ongoing large clinical trials might also boost interventional cardiologists to select PCI with stenting as an alternative revascularization strategy for unprotected LMCA disease. This evidence will most likely change the current clinical practice and guidelines of optimal revascularization strategy for unprotected LMCA disease.

Comparison of Coronary Artery Bypass Grafting with Percutaneous Coronary Intervention for Unprotected Left Main Coronary Artery Disease

PurposeCoronary artery bypass grafting (CABG) is the optimal treatment option for left main coronary artery disease (LMCAD). However, LMCAD remains a constant topic of discussion between cardiac surgeons and interventional cardiologists. The aim of this study was to assess the efficacy of LMCAD treatments by comparing the mid-term outcomes of CABG and percutaneous coronary intervention (PCI) using bare metal stents or drug-eluting stents (DESs).Materials and MethodsThe study population was comprised of 199 consecutive patients admitted with unprotected LMCAD. All of the patients were assigned to PCI (88 patients) or CABG (111 patients). The primary clinical end point indicated death, stroke of acute coronary syndrome (ACS).ResultsPatients assigned to PCI were at higher operative risk than patients scheduled for CABG (6.49±4.09 vs. 4.81±2.67, p=0.0032). Comparison of the group that received DESs with the CABG group did not reveal any differences in major adverse cardio-cerebral events (MACCE) occurrence (21% vs. 16%, p=NS). Patients in the CABG and PCI groups died with similar frequency (11% vs. 16%, p=NS). The mortality rate in the CABG group was higher than among those treated with DES (11% vs. 3%, p=0.049). The rate of ACS was higher in the PCI group than in the CABG group (13% vs. 4%, p=0.016).ConclusionDespite the fact that patients treated with PCI were at higher operative risk, PCI with DES was shown to be comparable to CABG in terms of mortality, stroke and ACS. However, the frequency of repeat revascularizations remains a constant concern with PCI.

2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention: Executive Summary

Alice K. Jacobs, MD, FACC, FAHA, Chair Jeffrey L. Anderson, MD, FACC, FAHA, Chair-Elect Nancy Albert, PhD, CCNS, CCRN, FAHA Mark A. Creager, MD, FACC, FAHA Steven M. Ettinger, MD, FACC Robert A. Guyton, MD, FACC Jonathan L. Halperin, MD, FACC, FAHA Judith S. Hochman, MD, FACC, FAHA

Early and long-term results of unprotected left main coronary artery stenosis with paclitaxel-eluting stents: the FRIEND (French multicentre registry for stenting of unprotected LMCA stenosis) registry

To evaluate the angiographic and clinical outcome of patients undergoing paclitaxel-eluting stent (PES) implantation for unprotected left main coronary artery (ULMCA) stenosis in a "real-world" multicentre, prospective registry. Percutaneous coronary intervention (PCI) is an increasingly utilised method of revascularisation in patients with ULMCA. A prospective registry including all patients with a significant (>50%) ULMCA stenosis. Of 151 such patients, the target lesion involved the distal bifurcation in 100 patients (66%), which was treated predominantly by a "provisional T-stenting" strategy. In the distal ULMCA disease group, 72% had only one stent implantation while 28% had multiple (either two or three) stents implanted. At a median follow-up of 1,123±80 days, cardiac death occurred in five patients (3.3%) and major adverse cardiac and cerebrovascular events (MACCE) in 32 patients (21.2%). The three-year survival rate was 93.3%. In the drug-eluting stent era, paclitaxel-eluting stent implantation of ULMCA stenosis provided excellent immediate and long-term results in this selected population, suggesting that this approach may be considered as a safe and effective alternative to CABG for selected patients with ULMCA who are treated in experienced institutions performing large numbers of PCI procedures.