Unprotected Left Main Intervention Research Articles

Global Risk Score and Clinical SYNTAX Score as Predictors of Clinical Outcomes of Patients Undergoing Unprotected Left Main Percutaneous Catheter Intervention.

BackgroundRisk stratification is an important component of left main percutaneous catheter intervention (PCI) which has emerged as a feasible alternative to cardiac surgery. We sought to compare the clinical SYNTAX score and the global risk score in predicting outcomes of patients undergoing unprotected left main PCI in our institution.MethodsClinical, angiographic and procedural characteristics of 92 patients who underwent unprotected left main PCI (mean age 62 ± 12.1 years) were analyzed. Patients were risk stratified into tertiles of high, intermediate and low risk using the global risk score (GRS) and the clinical SYNTAX score (CSS) and were prospectively followed up at 1 year for the occurrence of major adverse cardiovascular events (MACEs), defined as a composite of all cause mortality, cardiac mortality, non-fatal myocardial infarction, stroke, coronary artery bypass, and target vessel revascularization.ResultsThere were 26 (28.2%) who experienced MACEs, of which 10 (10.8%) patients died. Multivariable hazards analysis showed that the GRS (hazard ratio (HR) = 5.5, P = 0.001) and CSS (HR = 4.3, P = 0.001) were both independent predictors of MACEs. Kaplan-Meier analysis showed higher incidence of MACEs with the intermediate and higher risk categories compared to those classified as low risk. Receiver-operator characteristic analysis showed that the GRS has better discriminatory ability than the CSS in the prediction of 1 year MACEs (0.891 vs. 0.743, P = 0.007).ConclusionThe GRS and CSS are predictive of outcomes after left main PCI. The GRS appears to have superior predictive and prognostic utility compared to the CSS. This study emphasizes the importance of combining both anatomic and clinical variables for optimum prognostication and management decisions in left main PCI.

Unprotected Left Main Disease and Percutaneous Intervention: A Prototype for Precision Medicine

The SYNTAX Score based on angiographic findings is an actionable risk prediction model helping guide treatment for significant unprotected left main disease. Adding the clinical factor based EuroSCORE to SYNTAX improves outcome prediction for percutaneous coronary intervention of unprotected left main disease. Prediction models are an increasingly useful tool permitting cardiologists to optimize patient outcomes through "personalized" or precision medicine.

Lembe Study: Left Main PCI in Belgaum

Objectives: To study left main registry for Indian population, demographic and procedural characteristic of patient outcomes after unprotected left main percutaneous coronary intervention (uLMPC) and identify the predictors of prognosis. Methods: A total of 109 consecutive patients, who underwent uLMPCI, were analyzed in this single-center registry. All data related to the patient's clinical presentation, procedure and follow-up were collected. Syntax score and medina score were calculated for all patients. Mean follow-up duration of the study was 1 year. Procedural success rate for left main intervention was 100%. Primary endpoint was composite of major adverse cardiovascular and cerebrovascular events (MACCE), including cardiac death (CD), cerebrovascular accident (CVA), myocardial infarction (MI), and need for repeat revascularization and intervention. Results: There was no primary end point noted in our study. Overall one year MACCE-free survival rate was 100%. Secondary end points were seen in 9 (8.2%). Secondary end point were lower in non diabetic patients who underwent uLMPCI with left main alone intervention, single stent in a vessel. Patients with syntax score ≤ 32 had higher event-free secondary end point rate than those with syntax score >32 . Syntax score >32 was found to be significantly correlated to prior PCI/CABG patients, patients with multiple stenting and multiple vessel stenting. Syntax score >32 was the only independent predictor of adverse outcome. Conclusion: uLMPCI is safe and effective treatment alternative to CABG in non diabetic patients with selected LM alone, single vessel and single stent patients with low and intermediate syntax score (≤ 32).

Five-year outcome of consecutive unprotected left main percutaneous coronary interventions

Objectives We aimed to describe the procedural characteristics and 5-year outcome of consecutive patients undergoing unprotected left main coronary artery (ULMCA) percutaneous coronary intervention (PCI) at our tertiary care centre between 1 January 2007 and 31 December 2008.Methods and results 76 patients underwent ULMCA PCI during the study period. Drug-eluting stents were used in 61. The mean EuroSCORE II, additive and logistic EuroSCOREs and SYNTAX score were 14.81, 10.2, 25.25 and 27.3, respectively. 30-day and 5-year mortality were 14.5% and 50%, respectively, with early mortality related exclusively to circulatory causes and late mortality being non-cardiac in 74%. Clinical presentation was a key determinant of 5-year mortality. During follow-up 1 patient suffered a non-fatal myocardial infarction (MI) related to ULMCA in-stent restenosis (ISR), 2 others suffered MI related to non-ULMCA lesions. Definite and probable stent thrombosis occurred in 1 (non-ULMCA stent) and 1, respectively. 3 patients had ULMCA ISR, 14 had non-ULMCA ISR necessitating redo revascularisation.Conclusions ULMCA PCI is a good treatment modality in patients who cannot undergo CABG. Clinical presentation and downstream disease have a major influence on the 5-year outcome.

TCT-263 Impact of Diabetes on Clinical Outcomes in Patients Undergoing Unprotected Left Main Percutaneous Coronary Intervention with Drug-Eluting Stents

TCT-263 Impact of Diabetes on Clinical Outcomes in Patients Undergoing Unprotected Left Main Percutaneous Coronary Intervention with Drug-Eluting Stents

Successful Snare and Retrieval of a Free Intra-Coronary Rotawire During Complex Unprotected Left Main Coronary Artery Bifurcation Percutaneous Coronary Intervention in a High-Risk Individual

Successful Snare and Retrieval of a Free Intra-Coronary Rotawire During Complex Unprotected Left Main Coronary Artery Bifurcation Percutaneous Coronary Intervention in a High-Risk Individual

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

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

27 Clinical outcomes of unprotected left main stem percutaneous coronary intervention in a non-surgical centre

Introduction The aim of our study was to evaluate the clinical efficacy and safety of unprotected LMS percutaneous interventions (PCI) in a non-surgical centre. Methods The data on LMS PCI cases performed over 41 months was collected from local database and discharge summaries. Major adverse cardiovascular events (MACE) were also recorded at 6 and 12 months. Results A total of 147 patients with multiple risk factors had unprotected LMS PCI performed. Demographics were: 73% males with an average age of 70 years. 48% were elective procedures, 31% NSTEMI and 15%PPCI. Bail out stenting was required in 1%. Over 70% of procedures were performed transradially. The average EURO score was 2.89%. The anatomical distribution was: 47% distal LMS, ostial 23% and 22% mid-LMS. Of the lesions 51% involved only the LMS. Additional imaging was used in 41% of PCIs. The mean Syntax score was 34.4. 74% patients had drug eluting stents, followed by bare metal stents (8%), drug eluting balloons (8%) and combo stents. 5% of patients were in cardiogenic shock and 6% had Intra-aortic balloon pump inserted. Procedural success was reported in 96.6% of cases. In-hospital MACE was 3.4%. The MACE rates for 6 months and 12 months were 10.2% and 13.6% respectively. There were 4 in-hospital deaths recorded (2.7%). The study revealed a procedural success of over 95%. The in-hospital MACE was 3.4% and the 12 month MACE rate was comparable to the reported data. Conclusion This study demonstrates that PCI in LMS lesions performed in a non-surgical centre is both safe and effective.

Determinants of excess mortality following unprotected left main stem percutaneous coronary intervention

ObjectiveFor percutaneous coronary intervention (PCI) to the unprotected left main stem (UPLMS), there are limited long-term outcome data. We evaluated 5-year survival for UPLMS PCI cases taking into account background...

Safety and efficacy of lesion preparation with the AngioSculpt Scoring Balloon in left main interventions: the ALSTER Left Main registry.

Left main interventions require optimal initial results for good clinical outcome. Lesion preparation with the AngioSculpt Scoring Balloon (ASB) combined with the provisional T-stenting technique, if proven safe, might lead to better lumen gain and better clinical outcome. The aim of this registry was to investigate the safety and efficacy of the ASB as an option for lesion preparation in unprotected left main interventions (ULMI). Out of the all-comers unprotected left main registry (ULMI ALSTER), 47 patients with elective ULMI fulfilled the inclusion criteria for this study. The endpoints were acute lumen gain and 12-month MACCE. The drop-out rate was 4%. The provisional T-stenting technique was used in 97% of distal ULMI. The interventions were grouped according to use of ASB with an in-house, historical no-ASB patient control group. Lumen gain was 1.63±0.12 mm in the ASB group (n=34) and 1.35±0.12 mm in the no-ASB group (n=8, p=0.26), respectively. The use of the ASB was safe. Intravascular ultrasound (IVUS) data for 21 patients showed numerically greater lumen area gain of 3.14±0.33 mm2 in the ASB group compared to 2.33±0.88 mm2 with the conventional technique. TLR/TVR was 6.6% overall. Twelve-month MACCE was 12.5% (4/32) for ASB and 15.4% (2/13) in the historical control group. Adding ASB lesion preparation to the standard provisional T-stenting technique for ULMI is feasible and safe. Low TLR and TVR rates were observed. Lesion preparation led to a numerically larger lumen gain; the data allow valid power statistics to show this approach as leading to improved outcome in a possible randomised trial.

CRT-200.40 Impact of Left Ventricular Support Device on Surgically Rejected Patients Undergoing Unprotected Left Main Percutaneous Coronary Intervention

In patients undergoing high risk percutaneous coronary intervention (PCI) a percutaneous left ventricular support device is often used, especially in unprotected left main (ULM) disease. For these patients, we sought to determine if there is an impact of device support use on short and long term

TCT-601 Outcomes After Unprotected Left Main Percutaneous Coronary Intervention: Evidence from the Xience V USA Registry

Percutaneous coronary intervention (PCI) for unprotected left main coronary artery (UPLMCA) using first generation drug eluting stents with ostial or mid-shaft lesions have favorable outcomes. The safety and efficacy of Xience V everolimus eluting stent (EES) for this lesion subset is unknown. The

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

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

Unprotected Left-Main Coronary Angioplasty in the Elderly in a High Volume Catheterization Centre without On-Site Surgery Facilities: Immediate and Medium Term Outcome—The Old-Placet Registry

We aim to assess clinical feasibility and efficacy of unprotected left main (ULM) percutaneous coronary intervention (PCI) in patients older than 75 years over a 6-year period and with 2-year follow-up demonstrating that PCI is a feasible revascularization strategy even in absence of on-site cardiothoracic support. Nevertheless, the outcome of these high-risk patients is still hampered by a sensible in-hospital mortality rate. Older patients have a higher mortality at follow-up (10.0 versus 0.8%, P = 0.014), while younger patients have a low mortality after the acute phase (15.7 versus 8.4%, P = 0.15).

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

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

Abstract 15526: Predictors of Elective Support Device Insertion Prior to High Risk Percutaneous Coronary Intervention: Changing Trends between 1993-2013

Introduction: High risk percutaneous coronary interventions (PCI) may be preceded by elective support device insertion, though the evidence for such a practice is relatively weak. We sought to analyze the changing trends and predictors for prophylactic support device insertion in these patients over the last 20 years. Methods: Retrospective analysis of all patients who underwent PCI at Cleveland Clinic between 1993 - 2013 with or without support device insertion was performed. Trends for device insertion in high risk patients undergoing PCI, like those in clinical shock, acute myocardial infarction (MI) and unprotected left main intervention over the last 20 years were reviewed. Predictors for support device insertion in these patients from 1993-2000 were compared to those from 2001-2013. Results: A total of 666 elective support devices were inserted prior to high risk PCI from 1993-2013. Between 1993-2000, acute myocardial infarction (MI) (OR: 10.05), ejection fraction < 40% (OR: 8.31) and unprotected left main intervention (OR: 4.59) were the three most significant predictors for device insertion prophylactically. Between 2001-2013, unprotected left main intervention (OR: 9.91), ejection fraction < 40% (OR: 5.61) and clinical shock (OR: 5.24) were the biggest predictors, with the odds of support device insertion in acute MI in absence of clinical shock reduced to 1.96. Conclusions: There has been a significant decrease in the proportion of high risk PCIs with elective support device insertion, especially in those performed in patients with acute myocardial infarction in absence of shock.

WHAT KINDS OF PATIENTS WITH CORONARY ARTERY DISEASE ARE TREATED WITH MULTIVESSEL PERCUTANEOUS INTERVENTION VERSUS BYPASS SURGERY? A PROVINCE-WIDE FIELD EVALUATION IN QUÉBEC HOSPITALS WITH ON-SITE CARDIAC SURGERY

BACKGROUND: Wide variation across hospitals in choice of revascularization treatment has been observed and outcomes of percutaneous coronary intervention (PCI) versus coronary artery bypass surgery (CABG) are increasingly being examined. Our cardiology evaluation unit was mandated by the Quebec Ministry of Health to evaluate the practice of multivessel revascularization and its outcomes across Quebec’s 8 tertiary cardiac hospitals offering both PCI and CABG. METHODS: We identified all patients who underwent either multivessel ( 2 myocardial territories) PCI or CABG in 2010-12. A maximum of 300 patients treated with CABG and 300 patients treated with PCI (excluding primary PCI) per hospital were randomly selected for chart review. Factors associated with choice of treatment (PCI vs CABG) were identified using multivariate regression analysis. RESULTS: The study cohort included 2016 PCI patients and 2274 CABG patients. At the provincial level, factors associated with treatment by PCI included older age ( 75 years; OR1⁄41.7; 95% CI: 1.4-2.1), female sex (OR1⁄41.8; 95% CI: 1.4-2.2) and previous PCI (OR1⁄42.1; 95% CI: 1.7-2.5). Relative to patients with elective status, those with urgent/ emergent status were more likely to have undergone PCI than CABG (OR1⁄42.0; 95% CI: 1.6-2.4). Factors associated with CABG were arterial hypertension (OR1⁄41.7; 95% CI: 1.42.1), heart failure (OR1⁄43.3; 95% CI: 2.5-4.3) and 3-vessel disease (OR1⁄416.7; 95% CI: 13.9-20.0). Across the 8 hospitals, the proportion of female patients aged 75 ranged from 31 to 54% for both PCI and CABG. The proportion of elective procedures across hospitals ranged from 17% to 35% for PCI and from 26% to 48% for CABG. The proportion of patients treated with PCI for 3-vessel disease varied by hospital from 5% to 19% while it ranged from 60% to 78% for CABG. Diabetes was not associated with choice of treatment. Across the 8 hospitals, prevalence of diabetes varied from 23% to 36% among PCI patients and from 31% to 40% among CABG patients. One in 9 multivessel PCI patients underwent unprotected left main intervention (range 2.5% to 15.2% across hospitals). CONCLUSION: Although CABG was the predominant treatment for 3-vessel disease, use of PCI in these patients was not uncommon and varied widely by hospital. Presence of diabetes did not impact treatment choice. PCI was used more frequently than CABG for non-elective cases. Patient characteristics varied more by hospital for PCI than for CABG. These results point to the importance of appropriate risk adjustment when comparing outcomes by choice of treatment and by hospital.

TCT-68 Predictors of Elective Support Device Insertion Prior to High Risk Percutaneous Coronary Intervention: Changing Trends between 1993–2013

Introduction: High risk percutaneous coronary interventions (PCI) may be preceded by elective support device insertion, though the evidence for such a practice is relatively weak. We sought to analyze the changing trends and predictors for prophylactic support device insertion in these patients over the last 20 years. Methods: Retrospective analysis of all patients who underwent PCI at Cleveland Clinic between 1993 - 2013 with or without support device insertion was performed. Trends for device insertion in high risk patients undergoing PCI, like those in clinical shock, acute myocardial infarction (MI) and unprotected left main intervention over the last 20 years were reviewed. Predictors for support device insertion in these patients from 1993-2000 were compared to those from 2001-2013. Results: A total of 666 elective support devices were inserted prior to high risk PCI from 1993-2013. Between 1993-2000, acute myocardial infarction (MI) (OR: 10.05), ejection fraction < 40% (OR: 8.31) and unprotected le...

Comparative Outcomes After Unprotected Left Main Stem Percutaneous Coronary Intervention: A National Linked Cohort Study of 5,065 Acute and Elective Cases From the BCIS Registry (British Cardiovascular Intervention Society)

The goal of this study was to report outcomes from percutaneous coronary intervention (PCI) to an unprotected left main stem (UPLMS) stenosis according to presenting syndrome, includingST-segment elevation myocardial infarction (STEMI), non-ST-segment elevation acute coronary syndrome (NSTEACS), and chronic stable angina (CSA). There are no published whole-country data concerning patient outcomes following PCI to UPLMS. This study is a prospective national cohort study using data from the British Cardiovascular Intervention Society (BCIS) registry from January 1, 2005, through December 31, 2010. Of 5,065 patients having PCI to an UPLMS, 784 (15.5%) presented with STEMI, 2,381 (47.0%) with NSTEACS, and 1,900 (37.5%) with CSA. Crude 30-day and 1-year mortality rates were STEMI: 28.3%and 37.6%, NSTEACS: 8.9% and 19.5%, and CSA: 1.4% and 7.0%, respectively. Unadjusted in-hospital major adverse cardiovascular and cerebrovascular event rates were STEMI: 26.6%, NSTEACS: 6.6%, and CSA: 3.3%. Risk of 30-day mortality was much greater for STEMI and NSTEACS patients than CSA (STEMI adjusted odds ratio [aOR]: 29.45, 95% confidence interval [CI]: 19.37 to 44.80, NSTEACS aOR: 6.45, 95% CI: 4.27 to 9.76). More than 40% of patients presenting with STEMI had cardiogenic shock, in whom mortality was higher than in STEMI cases without shock (30 days: 52.0% vs. 11.7%, 1year: 61.1% vs. 20.9%). Radial access, compared with the femoral approach, was associated with a lower risk of 30-day mortality (STEMI aOR: 0.37, 95% CI: 0.21 to 0.62; NSTEACS aOR: 0.66, 95% CI: 0.45 to0.97). More than one-half of the patients who received UPLMS PCI were acute where outcomes were much worse than elective cases. Cardiogenic shock is common in STEMI patients, ofwhom more than one-half die at 30 days. The radial approach was associated with reduced early mortality in acute cases.

Percutaneous Circulatory Support with Impella 2.5 During Unprotected Left Main Percutaneous Coronary Intervention with Cardiogenic Shock

An increasing number of patients with complex coronaryartery anatomy, including the left main coronaryartery, are being treated with percutaneous coronaryinterventions.Ventricular assist devices (VADs) may be useful forpatients at risk of developing hemodynamic instabilityor for those with cardiogenic shock (CS) due to acoronary event. Yet, the role and the superiority ofVAD over intraaortic balloon pump (IABP) are notcompletely defined.