Unprotected Left Main Coronary Artery Stenosis Research Articles

TCT-410 Comparison of Coronary Artery Bypass Surgery, Percutaneous Drug-eluting Stent Implantation, and Medical Therapy for Unprotected Left Main Coronary Artery Disease

Background: Unprotected left main coronary artery (ULMCA) disease is considered an indication for revascularization. However, in “real-world” clinical practice some patients receive medical therapy only. The arm of this study was to evaluate long-term results in patients with ULMCA disease in a “real-world” practice. Methods: Between January 2006 and June 2011, 218 stable patients were diagnosed with de novo ULMCA stenosis. 52 (23.9%) patients received medical therapy only, coronary artery bypass grafting (CABG) was performed in 106 (48.6%) patients, percutaneous coronary intervention (PCI) in 60 (27.5%) patients. The composite of death, myocardial infarction, and stroke defined as major adverse cardiac and cerebrovascular events (MACCE) and target vessel revascularization (TVR) were defined as primary endpoints. The median follow-up period was 4 years. Results: Baseline clinical and descriptive morphology of coronary artery disease revealed more comorbidities and more complex anatomies in the medical therapy group compare with CABG and PCI groups. Revascularization might not have been used due to physician's decision (operative risk considered excessive) in 24 (46.2%) cases or when patients refused revascularization in 28 (53.8%) cases. At 4-year follow-up MACCE rate was higher in nonsurgical group (34.6%) compare with CABG (13.2%; p1⁄40.002) and PCI (14.5%; p1⁄40.016) groups, but there was no difference between CABG and PCI groups. Survival in CABG (4.7%; p<0.001) and PCI (5.5%; p1⁄40.009) groups was higher in compare with nonsurgical group (23.1%). On the multivariable Cox regression analysis, coronary revascularization (CABG and PCI) was independent predictor of long-term survival (HR 3.49; 95% CI 1.39-8.75; P<0.001). Conclusions: PCI, like CABG improves survival for patients with unprotected left main coronary artery disease compared with medical therapy only in “real-world” clinical practice.

Outcomes of coronary artery interventions: Comparing coronary artery bypass surgery and percutaneous coronary intervention in patients with unprotected left main stenosis

The purpose of this integrative review is to examine the existing literature comparing short- and long-term outcomes of both coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) in patients with unprotected left main coronary artery (ULMCA) stenosis. CABG has long been considered the standard of treatment for ULMCA stenosis; however, advancements in the use of PCI have made it a viable alternative treatment option. Sixteen articles were selected from a literature search using the PubMed database, with at least 1 year of follow-up and adjustment for established risk factors. The majority of studies found CABG and PCI with stenting to be comparable and equally safe treatment strategies for patients with ULMCA stenosis. Some studies found that PCI had a significantly lower risk for adverse events and mortality compared to CABG. However, a large number of studies found that PCI had a higher rate of target vessel restenosis. Advanced practice nurses have become a prominent and influential part of the healthcare delivery system. As such, advanced practice nurses should be educated on the current research about coronary artery interventions so that they may better screen, treat, and manage this patient population.

GW24-e1822 Primary percutaneous coronary intervention for acute myocardial infarction caused by unprotected left main coronary artery lesions -A single centre study

ObjectivesAcute myocardial infarction (AMI) due to unprotected left main coronary artery (ULMCA) occlusion has a poor prognosis. There is limited results in patients undergoing primary percutaneous coronary intervention (PCI) for...

Is percutaneous coronary intervention of unprotected left main coronary artery via transradial approach feasible for skilled transfemoral operators? Initial experience in an unselected population

The feasibility and efficacy of percutaneous coronary intervention (PCI) of unprotected left main coronary artery (ULMCA) via transradial access (TRA) is still a matter of concern, mainly in an unselected population. We collected data about all PCI performed in patients with ULMCA stenosis by a TRA-dedicated operator and analyzed clinical and procedural characteristics as well as in-hospital and long-term outcomes. From January 2008 to December 2011, 49 PCIs were performed; 27 (55%) via TRA and 22 (45%) via transfemoral access (TFA). Most patients in both groups underwent PCI for acute coronary syndrome (66.7% in the TRA group vs 77.3% in the TFA group, p=0.73). Patients in the TRA group were more hypertensive (81.5% vs 40.9%, p=0.008) and had a higher left ventricular ejection fraction (54.6±10.3 vs 46.1±12.8, p=0.01). There were no significant differences in procedural success (100% in the TRA group vs 90.9% in the TFA group, p=0.38), as well as in procedural time, in fluoroscopic time and in contrast volume. Bleeding complications occurred in 1 patient in the TFA group (4.5%) vs none in the TRA group (p=0.91). In-hospital major adverse cardiac events (MACE) occurred in 1 patient (3.7%) in the TRA group vs 3 (13.6%) in the TFA group (p=0.48). At a follow-up of 32±13 months, MACE occurred in 4 cases (14.8%) in the TRA group vs 7 cases (31.8%) in the TFA group (p=0.28). The PCI of ULMCA via TRA is feasible with good results, provided that a rigorous learning curve was followed and a TRA volume caseload was maintained.

Everolimus- versus sirolimus-eluting stents for the treatment of unprotected left main coronary artery stenosis (results from the EXCELLENT registry)

Data concerning the results of 2nd generation DES in the treatment of unprotected left main coronary artery (ULMCA) stenosis are limited. The aim of this study was to evaluate the efficacy and safety of stenting with everolimus- (EES) with sirolimus-eluting stent (SES) for the treatment of ULMCA stenosis in the "real world" setting. In this multi-center all-comer registry, a total of 275 patients with ULMCA stenosis were analyzed; 160 receiving EES and 115 receiving SES. The primary endpoint was major adverse cardiac events (MACE), defined as death, myocardial infarction, and ischemia-driven target vessel revascularization at 1 year. Baseline characteristics were similar between the two stent groups. At 1 year, the rate of MACE was comparable between the two groups (7.5% for EES vs. 13.9% for SES, HR: 0.55 [0.26-1.17], p = 0.117). However, after multivariable or propensity score adjustment, the risk of MACE was significantly lower for EES compared with that for SES (multivariable adjusted HR: 0.42 [0.19-0.92], p = 0.030; propensity score-adjusted HR: 0.43 [0.20-0.95], p = 0.037). These results were mainly driven from the numerically lower rate of repeat revascularization in the EES group (2.5% for EES vs. 7.0% for SES, p = 0.096). As for hard endpoint (death or myocardial infarction) and stent thrombosis, no differences were found between the 2 groups. In a large cohort of patients receiving ULMCA stenting, the MACE rate was numerically lower in the EES compared with that in the SES (statistically significant only after adjustment), which was mainly driven by significantly lower rates of repeat revascularization.

Acute myocardial infarction due to left main coronary artery disease: A large multicenter national registry

Optimal management of patients with acute myocardial infarction (MI) due to critical stenosis of an unprotected left main coronary artery (ULMCA) is not established. However, data from observational studies and registries encourage to perform percutaneous coronary intervention (PCI) in high risk patients. We investigated gender-related discrepancies, clinical course and prognosis in patients with acute MI and ULMCA as an infarct-related artery. A total of 643 consecutive patients (184 [28.6%] females and 459 [71.4%] males) with acute MI due to critical ULMCA stenosis were selected from the population of 121,526 patients hospitalized due to acute coronary syndromes between 2003 and 2006. The primary endpoints were in-hospital, 30-day, 6-month and 12-month mortality. Women were older than men with significantly higher proportion of women older than 65 and with unfavorable risk profile. The management in men and women was similar. There was no significant gender-related differences in mortality in all follow-up periods. In multivariate analysis cardiogenic shock, pulmonary edema, ST elevation myocardial infarction (STEMI) and advanced age significantly increased mortality, whereas successful PCI decreased mortality. No significant differences in clinical course, treatment and prognosis between men and women were noted. Mortality remained very high in both genders. The most unfavorable prognostic factors were cardiogenic shock, pulmonary edema, STEMI and advanced age. Percutaneous coronary angioplasty is feasible and offers high success rate in this subset of patients.

ASSA13-15-5 Primary Percutaneous Coronary Intervention For Acute Myocardial Infarction Caused by Unprotected Left Main Coronary Artery Lesions -A Single Centre Study

<h3>Background</h3> Acute myocardial infarction (AMI) due to unprotected left main coronary artery (ULMCA) occlusion has a poor prognosis. There are limited results in patients undergoing primary percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI) caused by ULMCA stenosis. Previous studies have reported in-hospital mortality rates of 50%–60%. The purpose of this study was to determine the clinical features and in-hospital outcomes of patients who underwent primary PCI for AMI due to ULMCA lesions. <h3>Methods</h3> Between July 2002 and August 2012, a total of 86 AMI patients (65 male, 75.6%) underwent primary PCI on ULMCA lesions. Among them, 72 (83.7%) patients presented with acute ST elevation myocardial infarction and 14 (16.3%) patients with acute non-ST elevation myocardial infarction. The culprit lesions in all patients located in ULMCA diagnosed by angiography. The target lesion included de novo lesion located in ostial, shaft and distal bifurcation. The indexes of clinical, in-stent thrombosis and major adverse cardiac events (MACE) including death, myocardial infarction or target lesion revascularization were evaluated. <h3>Results</h3> The mean age of patients was 67.6 ± 13.9 years. Cardiogenic shock was observed in 66 (76.7%) patients and cardiac arrest in 16 (18.6%). Prior to commencing PCI, 61 (70.9%) patients received the intra-aortic balloon pump. Angiographic success was achieved in all patients. Lesion location was ostial in 13 (15.2%), body in 25 (29.1%) and distal in 48 (55.8%). After PCI procedure, TIMI III flow were achieved in 79 (91.9%) patients. All patients had the ULMCA successfully dilated. Stent were deployed in 82 (95.3%) patients with drug eluting stent used in 72 (83.7%) patients. In-hospital death occurred in 7 (8.1%) patients [the mortality rate was 10.6% (7/66) in patients with cardiogenic shock]. On univariate analysis, age &gt; 75yeas (<i>P</i> &lt; 0.01), cardiogenic shock (<i>P</i> &lt; 0.0001), and stenting failure (<i>P</i> &lt; 0.01) were associated with in-hospital mortality. <h3>Conclusions</h3> Despite the high mortality rate in patients with cardiogenic shock, our data have shown that primary PCI is a valuable therapeutic strategy for ULMCA in the setting of AMI. But the long-term outcomes should be observed by follow-up.

Long‐term clinical outcomes after unprotected left main coronary artery stenting in an all‐comers patient population

The goal of treating patients with coronary artery disease is to improve survival and relieve symptoms. Several studies have compared the safety and efficacy of left main coronary artery (LMCA) stenting and coronary-artery bypass grafting in case control and randomized trials. In this study we present the long term outcome of stenting unprotected LMCA stenosis in day to day practice in unselected patients. One hundred and fifty eight patients were prospectively recruited with symptomatic unprotected LMCA stenosis undergoing percutaneous coronary intervention (PCI). Using the euroSCORE, each patient's surgical mortality risk was estimated. Study end-points were any major adverse cardiac event (MACE) defined as cardiac death, nonfatal myocardial infarction, or target lesion revascularization at follow-up with either CABG or repeat PCI. The mean follow-up was 54 ± 25 months. The mean euroSCORE was 10.6 ± 13.4 (0.9-71) and the mean SYNTAX score was 39.6 ± 10.7 (10-65). The MACE rate was 11.4% at a mean follow up of 54 months. Six (3.8%) patients suffered postprocedure myocardial infarction. There were 24 (15%) deaths of which 12 were cardiac (mean euroSCORE 21.6 ± 5.5 P < 0.001). Repeat angiography was performed in 88 (55.7%) patients. Seven (4.4%) patients had in-stent restenosis; three occurred in BMS (P = 0.06). Two patients underwent revascularization with CABG and five had successful repeat PCI. In this on-going registry of high risk patients with LMCA stenosis, stenting was found to be safe and clinically effective in maintaining event-free survival.

Clinical Outcome of Unprotected Left Main Coronary Artery Disease in Patients With Acute Myocardial Infarction

The clinical outcome of patients with acute myocardial infarction (MI) with unprotected left main coronary artery (LMCA) stenosis is not fully understood. We sought to assess the outcomes of patients with acute MI who underwent percutaneous coronary intervention (PCI) for unprotected LMCA stenosis. A total of 587 patients enrolled in the Korea Acute Myocardial Infarction Registry with LMCA stenosis were analyzed. Patients with culprit LMCA had higher inhospital mortality than patients with non-culprit LMCA (16.0% versus 8.9%, P = 0.008), but had similar clinical outcomes during a 12-month follow-up. Compared to CABG, PCI using drug-eluting stents (DES) was more frequently performed with similar early and 12-month clinical outcomes. The efficacy of sirolimus-eluting stents, paclitaxel-eluting stents, and zotarolimus-eluting stents were comparable at 12-month clinical follow-up. Predictors of 12-month mortality included mechanical ventilation, cardiogenic shock, age > 65 years, and ejection fraction < 40%. Patients with acute MI and culprit LMCA have higher early mortality than patients with non-culprit LMCA. PCI with DES is frequently performed and the clinical outcome is similar between the 3 types of first-generation DES.

Five-year outcomes following PCI with DES versus CABG for unprotected LM coronary lesions: meta-analysis and meta-regression of 2914 patients

To compare the safety and efficacy at long-term follow-up 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 5-year follow-up after PCI with DES and CABG for the treatment of ULMCA stenosis. Five studies (1 randomized controlled trial and 4 observational studies) were identified and included a total of 2914 patients (1300 for CABG and 1614 for PCI with DES). At 5-year follow-up, there was no significant difference between the CABG and PCI-DES groups in the risk for death (odds ratio [OR] 1.159, P=0.168 for random effect) or the composite endpoint of death, myocardial infarction, or stroke (OR 1.214, P=0.083). The risk for target vessel revascularization (TVR) was significantly lower in the CABG group compared to the PCI-DES group (OR 0.212, P<0.001). The risk of major adverse cardiac and cerebrovascular events (MACCE) was significantly lower in the CABG group compared to the PCI-DES group (OR 0.526, P<0.001). It was observed no publication bias about outcomes and considerably heterogeneity effect about MACCE. CABG surgery remains the best option of treatment for patients with ULMCA disease, with less need of TVR and MACCE rates at long-term follow-up.

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.

Everolimus-Eluting Stent Implantation for Unprotected Left Main Coronary Artery Stenosis: The PRECOMBAT-2 (Premier of Randomized Comparison of Bypass Surgery versus Angioplasty Using Sirolimus-Eluting Stent in Patients with Left Main Coronary Artery Disease) Study

This study sought to evaluate the safety and efficacy of second-generation drug-eluting stents (DES) for patients with unprotected left main coronary artery (ULMCA) stenosis. The clinical benefit of second-generation DES for ULMCA stenosis has not been determined. The authors assessed 334 consecutive patients who received everolimus-eluting stents (EES) for ULMCA stenosis between 2009 and 2010. The 18-month incidence rates of major adverse cardiac or cerebrovascular events (MACCE), including death, myocardial infarction (MI), stroke, or ischemia-driven target vessel revascularization (TVR), were compared with those of a randomized study comparing patients who received sirolimus-eluting stents (SES) (n = 327) or coronary artery bypass grafts (CABG) (n = 272). EES (8.9%) showed a comparable incidence of MACCE as SES (10.8%; adjusted hazard ratio [aHR] of EES: 0.84; 95% confidence interval [CI]: 0.51 to 1.40; p = 0.51) and CABG (6.7%, aHR of EES: 1.40; 95% CI: 0.78 to 2.54; p = 0.26). The composite incidence of death, MI, or stroke also did not differ among patients receiving EES (3.3%), SES (3.7%; aHR of EES: 0.63; 95% CI: 0.27 to 1.47; p = 0.29), and CABG (4.8%; aHR of EES: 0.67; 95% CI: 0.29 to 1.54; p = 0.34). However, the incidence of ischemia-driven TVR in the EES group (6.5%) was higher than in the CABG group (2.6%, aHR of EES: 2.77; 95% CI: 1.17 to 6.58; p = 0.02), but comparable to SES (8.2%, aHR of EES: 1.14; 95% CI: 0.64 to 2.06; p = 0.65). Angiographic restenosis rates were similar in the SES and EES groups (13.8% vs. 9.2%, p = 0.16). Second-generation EES had a similar 18-month risk of MACCE for ULMCA stenosis as first-generation SES or CABG.

Drug-Eluting Stent for Left Main Coronary Artery Disease: The DELTA Registry: A Multicenter Registry Evaluating Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting for Left Main Treatment

The aim of this study was to compare, in a large all-comers registry, major adverse cardiac and cerebrovascular events (MACCE) after percutaneous coronary intervention (PCI) with first-generation drug-eluting stents (DES) versus coronary artery bypass grafting (CABG) in unprotected left main coronary artery (ULMCA) stenosis. Percutaneous coronary intervention with DES implantation in ULMCA has been shown to be a feasible and safe approach at midterm clinical follow-up. All consecutive patients with ULMCA stenosis treated by PCI with DES versus CABG were analyzed in this multinational registry. A propensity score analysis was performed to adjust for baseline differences in the overall cohort. In total 2,775 patients were included: 1,874 were treated with PCI versus 901 with CABG. At 1,295 (interquartile range: 928 to 1,713) days, there were no differences, at the adjusted analysis, in the primary composite endpoint of death, cerebrovascular accidents, and myocardial infarction (MI) (adjusted hazard ratio [HR]: 1.11; 95% confidence interval [CI]: 0.85 to 1.42; p = 0.47), mortality (adjusted HR: 1.16; 95% CI: 0.87 to 1.55; p = 0.32), or composite endpoint of death and MI (adjusted HR: 1.25; 95% CI: 0.95 to 1.64; p = 0.11). An advantage of CABG over PCI was observed in the composite secondary endpoint of MACCE (adjusted HR: 1.64; 95% CI: 1.33 to 2.03; p < 0.0001), driven exclusively by the higher incidence of target vessel revascularization with PCI. In our multinational all-comers registry, no difference was observed in the occurrence of death, cerebrovascular accidents, and MI between PCI and CABG. An advantage of CABG over PCI was observed in the incidence of MACCE, driven by the higher incidence of target vessel revascularization with PCI.

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.

Revascularization of unprotected left main coronary artery disease: Strategy selection and systematic risk assessment

Refinement of interventional techniques, adjunctive pharmacological therapy, and the introduction of drug eluting stents have fostered new interest for the percutaneous treatment of unprotected left main coronary artery (ULMCA) stenosis. Several observational registries, some randomized controlled trials and several meta-analyses have consistently shown no difference in mortality and myocardial infarction between percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) surgery in patients with ULMCA stenosis, but a higher rate of target vessel revascularization in patients treated with PCI. As a consequence, PCI of ULMCA stenosis has been upgraded to class IIa or IIb indication in the current European or American College of Cardiology/American Heart Association practice guidelines. Although these results are promising, they do not still represent enough evidence for extending PCI of ULMCA stenosis to current clinical practice. The EXCEL trial will address the value of PCI in relation to CABG for the treatment of ULMCA stenosis in more than 2000 patients. A major breakthrough of the SYNTAX trial has been the demonstration of an interaction between the coronary complexity and the revascularization strategy, suggesting that optimal risk stratification is a key element when deciding the best strategy of revascularization in this high-risk group of patients. Multidisciplinary team approach remains essential to provide a balanced information to the patient and to offer the beast treatment option.

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.

Percutaneous revascularization of left main

Refinement of interventional techniques, adjunctive pharmacological therapy, and the introduction of drug-eluting stents have fostered new interest for the percutaneous treatment of unprotected left main coronary artery (ULMCA) stenosis. Several observational registries, some randomized trials and several meta-analyses have consistently shown no difference in mortality and myocardial infarction between percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) surgery in patients with ULMCA stenosis, but a higher rate of target vessel revascularization in patients treated with PCI. As a consequence, PCI of ULMCA stenosis has been upgraded to class IIa or IIb indication in the current European or American practice guidelines. However, several critical issues should be properly addressed when pursuing a percutaneous strategy for the treatment of ULMCA stenosis, such as the use of IVUS for procedural guidance, assessment of disease location, optimal technique for distal ULMCA stenosis, risk of stent thrombosis, optimal duration of dual antiplatelet therapy, and the most appropriate strategy for post-procedure follow up. Multidisciplinary team approach remains essential to provide a balanced information to the patient and to offer the beast treatment option.

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.

Comparison of Outcomes of Unprotected Left Main Versus Multivessel Coronary Artery Interventions

Left main coronary artery (LMCA) percutaneous coronary intervention (PCI) has emerged as an appealing alternative to bypass surgery for significant LMCA disease, especially in high-risk candidates. PCI for unprotected LMCA stenosis is currently designated a class IIb indication. Direct comparisons between unprotected LMCA PCI and multivessel PCI are lacking. We aimed to determine the incremental risk associated with unprotected LMCA PCI compared to multivessel PCI. We queried the Cleveland Clinic PCI database to identify patients who underwent unprotected LMCA PCI from 2003 through 2009 and compared these to patients undergoing multivessel PCI in the same period. Patients undergoing PCI for acute myocardial infarction were excluded. Mortality was derived using the Social Security Death Index. Short-term (≤30-day) mortality rates in the LMCA PCI group (n = 468, 1.9%) were similar to the death rate in the multivessel PCI group (n = 1,973, 1.3%, p = 0.3). There was no significant difference in adjusted mortality between the 2 study groups. Stratifying LMCA PCI by the number of concomitant vessel territories treated, there was no significant difference in mortality in any LMCA PCI category (LMCA only, LMCA + 1-vessel PCI, LMCA + multivessel PCI) compared to multivessel PCI. In conclusion, there was comparable short-term and long-term mortality in the LMCA PCI and multivessel PCI groups. LMCA stenting did not appear to incur incremental risk compared to multivessel PCI.

Emergency Management for Critical Left Main Coronary Artery Stenosis

Increased experience and improvements in technology seem to have encouraged the use of percutaneous interventions for left main coronary artery (LMCA) occlusions. There is no consensus, however, and the data are inadequate on whether surgery or percutaneous procedures should be the intervention of choice for critical occlusions. From January 2002 to December 2006, 108 patients with unprotected LMCA stenosis >80% were treated at our center. Eighty-three patients (77%) underwent bypass grafting and 20 (18%) underwent percutaneous intervention for the purpose of myocardial revascularization. We analyzed parameters demonstrated as risk factors for myocardial revascularization and their predicted effects on outcome. Five patients (5%) died following emergency cardiopulmonary resuscitation before any intervention was performed. The early survival rate was 84.1% in the coronary bypass group and 63% in the percutaneous intervention group. The mean (±SD) survival time was 55.7 ± 2.6 months in the bypass group and 7.6 ± 1.3 months in the percutaneous group. The late-survival rate was also significantly higher in the bypass group. The mean late-survival time was 44.5 ± 3.6 months in the bypass group and 2.3 ± 0.8 months in the percutaneous group. Although emergency percutaneous interventions are lifesaving in some cases, these results clearly demonstrate that coronary bypass grafting should be the intervention of choice for myocardial revascularization in patients with critical LMCA occlusion.