Unprotected Left Main Lesions Research Articles

Impact of chronic total occlusion on prognosis in cardiogenic shock due to unprotected left main coronary artery culprit lesion. Insights from the Polish Registry of Acute Coronary Syndromes.

Notwithstanding readily available revascularization, significant advancements in mechanical circulatory support, and pharmacological progress, cardiogenic shock (CS) secondary to unprotected left main culprit lesion-related acute myocardial infarction (ULMCL-related AMI) is associated with very high mortality. In this population, chronic total occlusion (CTO) is relatively frequent. This study sought to assess the association between the presence of CTO and 12-month mortality in patients with CS due to ULMCL-related AMI. The study included consecutive patients admitted for AMI-related CS with ULMCL who underwent percutaneous coronary intervention (PCI) and were enrolled in the prospective Polish Registry of Acute Coronary Syndromes (PL-ACS) between January 2017 and December 2021. The patients were stratified into two groups based on the presence of at least one CTO. The primary endpoint was all-cause death at 12 months. Of the 250 included patients, 60 (24%) patients had one or more CTOs of a major coronary artery (+CTO), and in 190 (76%) patients, the presence of CTO was not observed (-CTO). The 12-month mortality rates for the +CTO and -CTO patients were 85% and 69.8%, respectively (P log-rank = 0.03). After multivariable adjustment for differences in the baseline characteristics, the presence of CTO remained significantly associated with higher 12-month mortality (hazard ratio, 1.423; 95% CI, 1.027-1.973; P = 0.034). Our analysis showed that in patients with CS due to ULMCL-related AMI treated with PCI, the presence of CTO is associated with worse 12-month prognosis.

Acute coronary syndromes with unprotected left main culprit lesion: The perfect storm

Acute coronary syndromes with unprotected left main culprit lesion: The perfect storm

Five-year outcomes of biodegradable versus second-generation durable polymer drug-eluting stents used in complex percutaneous coronary intervention.

There are few data comparing clinical outcomes of complex percutaneous coronary intervention (CPCI) when using biodegradable polymer drug-eluting stents (BP-DES) or second-generation durable polymer drug-eluting stents (DP-DES). The purpose of this study was to investigate the safety and efficacy of BP-DES and compare that with DP-DES in patients with and without CPCI during a 5-year follow-up. Patients who exclusively underwent BP-DES or DP-DES implantation in 2013 at Fuwai hospital were consecutively enrolled and stratified into two categories based on CPCI presence or absence. CPCI included at least one of the following features: unprotected left main lesion, ≥2 lesions treated, ≥2 stents implanted, total stent length >40 mm, moderate-to-severe calcified lesion, chronic total occlusion, or bifurcated target lesion. The primary endpoint was major adverse cardiac events (MACE) including all-cause death, recurrent myocardial infarction, and total coronary revascularization (target lesion revascularization, target vessel revascularization [TVR], and non-TVR) during the 5-year follow-up. The secondary endpoint was total coronary revascularization. Among the 7712 patients included, 4882 (63.3%) underwent CPCI. Compared with non-CPCI patients, CPCI patients had higher 2- and 5-year incidences of MACE and total coronary revascularization. Following multivariable adjustment including stent type, CPCI was an independent predictor of MACE (adjusted hazard ratio [aHR]: 1.151; 95% confidence interval [CI]: 1.017-1.303, P = 0.026) and total coronary revascularization (aHR: 1.199; 95% CI: 1.037-1.388, P = 0.014) at 5 years when comparing with non-CPCI patients. The results were consistent at the 2-year endpoints. In patients with CPCI, BP-DES use was associated with significantly higher MACE rates at 5 years (aHR: 1.256; 95% CI: 1.078-1.462, P = 0.003) and total coronary revascularization (aHR: 1.257; 95% CI: 1.052-1.502, P = 0.012) compared with that of DP-DES, but there was a similar risk at 2 years. However, BP-DES had comparable safety and efficacy profiles including MACE and total coronary revascularization compared with DP-DES in patients with non-CPCI at 2 and 5 years. Patients underwent CPCI remained at a higher risk of mid- to long-term adverse events regardless of the stent type. The effect of BP-DES compared with DP-DES on outcomes was similar between CPCI and non-CPCI patients at 2 years but had inconsistent effects at the 5-year clinical endpoints.

One-stent Versus Two-stent Techniques for Unprotected Distal Left Main Bifurcational Lesions: Early and Late Outcomes

Background and aim: Left main disease account for 3% to 5% of the coronary lesions. PCI on coronary bifurcation lesions is considered a challenge for any cardiologist. These lesions include a wide spectrum of anatomic complexity varying from simple lesions, which can be managed with a single stent, to complex lesions necessitating more complex procedures. The goal of the present study was to compare the clinical outcomes of PCI with single-stent vs. double-stent implantation for the management of ULMCA distal bifurcation lesions. Patients and methods: a total of 60 cases with ULMCA distal bifurcation lesions eligible for PCI were included in the current study. Cases were divided into 2 main groups: one-stent group (20 cases) and two-stents group (40 cases). All patients underwent follow up during hospitalization and post-discharge at 1 and 6 months. Results: Comparison between the study groups as regards the lesional and angiographic characteristics demonstrated that cases in the one-stent group had significantly lower SYNTAX score (21.70 ± 5.58 versus 24.88 ± 4.93, p=0.028) and lower frequency of true bifurcation lesion (65.0 % versus 100.0 %, p0.001) and higher frequency of 1,1.0 Median class (55.0 % versus 7.5 %, p0.001). Besides, both groups had similar early post-interventional outcomes including hematoma and used target vessel revascularization techniques. Also, no significant differences were reported between both groups as regards the 6-month outcome parameters including cardiac death, TV MI, TVR and TL failure. Conclusions: Both single-stent and two-stents techniques are technically feasible and safe techniques for management of ULMCA with comparable outcomes.

Long-term prognosis of culotte versus different crush strategies in management of unprotected left main bifurcation coronary lesions: A meta-analysis.

To assess the long-term clinical effects of Culotte and different Crush techniques in the treatment of unprotected left main bifurcation coronary lesions to determine the best percutaneous coronary intervention strategy. The systematic review and meta-analysis comprised search on PubMed, Embase, Cochrane Library, WanFang Data and the China National Knowledge Infrastructure literature databases to locate randomised controlled trials and cohort studies published in Chinese and/or English language till June 2021 and comprised application of Culotte and Crush stenting techniques for percutaneous coronary intervention in patients with unprotected left main bifurcation coronary lesions. The selected studies were analysed for quality, publication bias and heterogeneity. Of the 197 studies located, 8(4.06%) were subjected to meta-analysis. The incidence of major adverse cardiac events in the Mixed-Crush group was higher than the Culotte group (p=0.02), which, in turn, was higher than the Double Kiss Crush group (p<0.0001), The incidence of target lesion revascularisation in the Culotte group was significantly higher than Double Kiss Crush group (p<0.001). The incidence of myocardial infarction in the Culotte group was higher than the Double Kiss Crush group (p=0.04). The incidence of cardiogenic death in the Double Kiss Crush group was similar to that in the Culotte group (p=0.32). Patients in the Double Kiss Crush group had the most long-term benefits, while those receivingg Mixed Crush had the least long-term benefits.

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

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

Four-Year Outcomes of Unprotected Left Main Lesion PCI with Self-Apposing Stents versus Balloon-Expandable Stents

Abstract Background Left main percutaneous coronary intervention (PCI) has been established as an effective and safe treatment option for left main coronary artery disease. There are data suggesting that different stent platforms can impact the outcomes after left main PCI. The aim of current study was to compare the four-year outcomes of patients with left main stenosis treated by PCI with a balloon-expandable stent or a self-apposing stent. Methods and Results A total of 146 patients with left main stenosis treated by PCI were included, of which 84 (57.5%) had balloon-expandable stents (Group A) and 62 (42.5%) had self-apposing stents (Group B). Baseline SYNTAX scores were higher in Group A than in Group B. Proximal optimization technique was used more often in Group A (45.2% in Group B vs 81.4% in Group A, p&lt;0.001). The same observations were made for kissing balloon postdilation (30.6% Group B vs 62.7% in Group A, p&lt;0.001). Procedural success with TIMI 3 flow was achieved in similar proportions in both groups. Mortality rate and MACE rates at 4-year follow-up were higher in Group B compared to Group A but have not reached statistical significance in univariable or multivariable analysis. Implantation of a self-apposing stent has been an independent predictor for target lesion revascularization rate (TLR) in multivariable analysis (HR 0.06, CI − 1.11–11.7, =0.03). Conclusions In our study, TLR rate was significantly higher in patients with left main lesion treated by PCI with self-apposing stents.

Unraveling the mystique of left main stenting: A bugaboo of coronary intervention

For many years, CABG has been the gold standard treatment for unprotected Left Main (LM) coronary artery lesions. Because of its high artery size and anatomical accessibility, the LM lesion makes a good PCI candidate. Subset PCI has been broadened by the development of Drug-Eluting Stent (DES) as well as fast advances in procedures, devices, and adjunct pharmacotherapies. PCI and CABG had equivalent results in patients with low or moderate coronary complexity for up to fi ve years, according to current research. Most LM bifurcation lesions may be treated successfully with a single provisional stent rather than the more complex two-stent treatment. The unusual instance of a bifurcation lesion, which requires the use of not one, but two stents from the start, is an exception to the norm. Controlling this unusual species and improving treatment outcomes need an integrated strategy involving specialized procedures, additional physiological and morphologic assessment, and hemodynamic devices.

Percutaneous Coronary Intervention in Unprotected Left Main Coronary Artery Lesions.

ResumoFundamentoO advento dos stents farmacológicos permitiu que a intervenção coronariana percutânea apresentasse resultados seguros nas lesões de tronco da artéria coronária esquerda.ObjetivosAnalisar os resultados do tratamento percutâneo da lesão não protegida de tronco da artéria coronária com a utilização de ultrassom intravascular.MétodosEstudo de série de casos consecutivos realizado no período de janeiro de 2010 a dezembro de 2018. Coletaram-se dados clínicos dos pacientes, assim como escores prognósticos e dados da lesão coronariana. Considerou-se de sucesso a lesão residual menor que 50% à angiografia e a área mínima da luz maior que 6 mm 2 ao ultrassom intravascular. O nível de significância adotado foi de 5%.ResultadosAnalisaram-se 107 casos. A lesão multiarterial foi predominante, sendo com maior frequência (39,25%) encontradas lesões em três vasos além do tronco coronariano. O escore SYNTAX apresentou média de 46,80 (DP: 22,95), e 70 (65,42%) pacientes tiveram escore SYNTAX acima de 32 pontos. Considerou-se sucesso angiográfico da intervenção percutânea em 106 (99,06%) pacientes. A taxa geral de evento maior cardíaco e cerebrovascular no desfecho hospitalar foi 6,54%, sendo semelhante nos pacientes com escore SYNTAX ≤ 32 (8,10%) e ≥ 33 (5,71%; p = 0,68) .ConclusõesA intervenção percutânea em casos de lesão não protegida de tronco coronariano foi realizada com segurança e apresentou ótimos resultados. Atingiu-se alto sucesso angiográfico de tratamento guiado pelo ultrassom intravascular. A taxa de eventos cardíacos e cerebrovasculares maiores foi semelhante entre os pacientes de menor e de maior risco.

Percutaneous coronary intervention in acute unprotected left main coronary artery disease: Provisional strategy or two-stent technique?

Background: Primary percutaneous coronary intervention in acute unprotected left main coronary artery disease, however, tends to be a complex procedure as it lasts longer, requires more expertise, and frequently involves critical bifurcation and often results in more than one stent. Here we present a retrospective analysis of a specific group of patients treated with percutaneous coronary intervention in our center. Methods: Retrospectively 55 patients with unprotected left main coronary artery lesions and acute coronary syndrome diagnosis treated with per cutaneous coronary intervention were identified: The two-stent technique was applied in 28 cases, and provisional stenting (PS) was applied in 27 cases. Results: Current smoking (82.1% vs. 48.1%, p=0.007), prior myocardial infarction (35.7% vs. 7.4%, p=0.010) and prior coronary stent implantation history (28.6% vs. 3.7%, p=0.012) were more common in the two-stent technique group. While procedure duration was higher in the two-stent technique group compared to PS (58.21 vs. 33.15, p<0.001), door-balloon time was lower (29.7 vs. 42.1, p=0.006). However, creatinine levels 48-72 hours post-procedure (1.08 vs. 1.33, p=0.422) and in-hospital mortality rates were similar between the two groups (28.6% vs. 14.8%, p=0.229). Conclusion: In the treatment of acute unprotected left main coronary artery with percutaneous coronary intervention, two-stent technique is a viable, effective and safe strategy as it has similar contrast-induced nephropathy and mortality rates compared to provisional strategy.

Predictors of in-hospital mortality in patients with acute myocardial infarction due to unprotected left main trunk lesion: insight from the Tokyo Cardiovascular Care Unit network multicenter registry

Abstract Background Acute myocardial infarction (AMI) due to unprotected left main trunk (LMT) lesion remains a clinical challenge because it requires prompt and efficient revascularization in catastrophic clinical presentation. However, predictors of in-hospital prognosis in patients with LMT-AMI are still not fully understood. Purpose To examine the predictors of in-hospital mortality in patients with LMT-AMI. Methods From 20,257 AMI patients in the Tokyo Cardiovascular Care Unit network registry (comprising 72 hospitals) from 2013 to 2017, we identified 371 (1.8%) eligible LMT-AMI patients without a history of coronary artery bypass grafting (CABG) and divided them into two groups: 254 survivors and 117 non-survivors. Measured variables included patient demographics, vital signs, laboratory data on admission, and in-hospital treatment. The outcome was in-hospital mortality. We performed a multivariable logistic regression analysis for in-hospital mortality with adjustment for the following 9 potential confounders, based on previous studies: (1) age, (2) sex, (3) Killip class, (4) ST elevation, (5) wide QRS (&amp;gt;120 msec), (6) the Thrombolysis in Myocardial Infarction (TIMI) grade on initial coronary angiography, (7) number of vessels with significant stenosis other than LMT, (8) renal dysfunction on admission, and (9) plasma glucose on admission. Results Overall, mean age was 70.6±11.8 years and 81.9% were male. ST-elevation myocardial infarction accounted for 61.8%. Cardiac arrest was observed in 102 (33.6%) patients. Percutaneous coronary intervention and CABG were performed in 302 (81.8%) and 63 (17.0%) patients, respectively. Intra-aortic balloon pumping and veno-arterial extracorporeal membranous oxygenation were used in 288 (77.8%) and 81 (21.9%) patients, respectively. In-hospital mortality was 31.5%. Multivariable logistic regression analysis showed that higher in-hospital mortality was significantly associated with Killip class IV (adjusted odds ratio 3.41 [95% confidence interval 1.36–8.56]; reference: Killip I), TIMI grade 0 (3.51 [1.22–10.14]; reference: TIMI grade 3), renal dysfunction (estimated glomerular filtration &amp;lt;60 mL/min/1.73m2; 6.48 [2.53–16.57]), and high plasma glucose on admission (&amp;gt;150 mg/dl; 3.64 [1.33–9.97]). Age, sex, ST-elevation, wide QRS, and multi-vessel disease were not significantly associated with in-hospital mortality. Conclusions LMT-AMI remains life-threatening in the current era of widely available revascularization. Our results showed that haemodynamic compromise, no coronary flow, renal dysfunction, and high plasma glucose on admission were strong predictors of in-hospital mortality after LMT-AMI. Given the high cardiac arrest rate, more aggressive therapeutic measures including mechanical circulatory support may be required to improve the prognosis of LMT-AMI. Funding Acknowledgement Type of funding source: None

Characteristics, predictors and outcomes after unprotected left main stem primary percutaneous coronary intervention

Abstract Background Reports about outcomes of patients undergoing primary percutaneous coronary intervention (PCI) for unprotected left main (ULM) coronary artery are limited. We aimed to investigate the characteristics, in-hospital and the long-term outcomes of these patients. Methods From a high-volume, single-centre, prospective registry, in a period from 2009–2019, we identified 111 pts (0.96%) who undergone primary PCI for ULM culprit lesion. The short- and the long-term outcomes in this subset was evaluated and compared to 9463 (82.5%) patients undergoing pPCI for lesions located in other segments (Non-LM group). Technical success was defined as final TIMI 3 flow in both, left main and distal vessels, anterior descending and circumflex artery, without significant residual stenosis (&amp;gt;20% following balloon angioplasty or stent implantation) and side branch compromise (residual stenosis &amp;gt;75%). Results Patients with ULM were older and more likely to present as Non-ST-elevation MI (77% vs. 93%; p&amp;lt;0.000) and in cardiogenic shock (40% vs. 2.2%; p&amp;lt;0.000), having less occlusive disease with TIMI 0–1 flow prior to PCI (44% vs. 78%; p&amp;lt;0.000) compared to Non-LM patients. Also, greater procedure complexity was observed with longer lesions &amp;gt;20mm (50% vs. 29%; p&amp;lt;0.000), more intraluminal thrombus (86% vs. 45%; p&amp;lt;0.000), greater number (1,48±0,9 vs. 1,28±0,7; p&amp;lt;0.01) and longer stents (30,5±15,8 vs. 27,4±14,3; p=0.028), more GP IIb/IIIa inhibitors (32% vs. 23%; p=0.022), intra-aortic counterpulsations (7% vs. 0.6%; p&amp;lt;0.000) and contrast media used (202±96 vs. 172±66; p&amp;lt;0.000) in ULM group. Despite obtaining comparable rates of final TIMI 3 flow in main branch (91.9% vs. 95.4%; p=0.084), patients with LMCA had significantly higher in-hospital (27% vs. 4.7%: p&amp;lt;0.000), and one-year all-cause mortality (41% vs. 11%: p&amp;lt;0.000), but for the remaining duration of clinical follow-up (available for 97.8% pts, median duration 51±37 months) survival rates were comparable between ULM and Non-LM pts (18% vs. 15%: p=0.506) (Figure 1). Regression analysis showed that final TIMI 3 in main branch at 30 days (HR 0.05 [95% CI 0.005–0.604]; p=0.018), while peri-procedural cardiogenic shock (hazard ratio (HR) 8.3 [95% CI 2.5–28.1]; p=0.001), creatinine clearance &amp;lt;60 ml/min (HR 7.5 [95% CI 2.3–25.1]; p=0.001) and technical success (HR 0.16 [95% CI 0.45–0.57]; p=0.005) at 5 years, independently predicted mortality in ULM patients. Conclusions Despite performance of primary PCI, patients with MI due to ULM lesions are associated with worse in-hospital and one-year mortality but following that period mortality was comparable to control group. Suboptimal final coronary flow best predicted the 30 day, while peri-procedural cardiogenic shock, renal dysfunction at admission and suboptimal technical procedure result, predicted long-term mortality in these patients. Figure 1 Funding Acknowledgement Type of funding source: None

Four-year outcomes of unprotected left main lesion treated with one-stent versus two-stent technique

Introduction – Most reports on left main bifurcation lesions have demonstrated that treatment with a singlestent strategy is superior to a two-stent strategy but have excluded patients with acute coronary syndromes (ACS). Aims – The aim of the current study was to compare the four year outcomes of patients with unprotected left main coronary artery disease (ULMCAD) treated by percutaneous coronary intervention (PCI) with a one-stent or two-stent strategies in a population including those presenting as ACS. Methods – A total of 135 patients with ULMCAD treated by PCI were included, of which 75 (55.6%) had a one-stent strategy (Group A) and 60 (44.4%) had a two-stent strategy (Group B). Results – Fewer patients in Group A had a TIMI III flow at the end of the procedure (89.4% vs 100%, p=0.03) and complete revascularization (65.3% vs 88.3%, p=0.002). We found a higher early mortality in Group A without reaching statistical significance (13.4% vs 3.3%, p=0.1). Mortality rate at 4-year follow up was higher with Group A after multivariable analysis (adjusted HR 0.36, CI 0.15-0.85, p=0.02). We found no significant differences between the groups in terms of major adverse cardiac event (MACE) (adjusted HR 0.85, CI 0.34-1.48, p=0.7) or target lesion revascularization (TLR) (adjusted HR 1.37, CI 0.42-4.47, p=0.6) at 4-year follow up. Conclusions – Among unselected patients with ULMCAD PCI, with or without ACS, the early mortality rate is similar between one and two-stent strategy. Although, 4 year TLR and MACE rates were similar between the two groups, the 4-year all-cause mortality rate was lower in the two-stent strategy group.

The Impact of Diabetes Mellitus on Clinical Outcomes after Percutaneous Coronary Intervention with Drug-Eluting Stents for Left Main Distal Bifurcation Lesions in Patients with Chronic Kidney Disease

Background: The impact of diabetes mellitus (DM) on clinical outcomes after percutaneous coronary intervention (PCI) for unprotected left main (ULM) distal bifurcation lesions in patients with chronic kidney disease (CKD) is poorly understood in the era of drug-eluting stents (DESs). Objective: We assessed the impact of DM on clinical outcomes after PCI for ULM distal bifurcation lesions in CKD patients compared to patients without DM. Methods: We identified 1,832 consecutive patients who underwent PCI for ULM lesions at New Tokyo Hospital, Matsudo, Japan, San Raffaele Scientific Institute, Milan, Italy, and EMO-GVM, Centro Cuore Columbus, Milan, Italy between January 2005 and August 2015. Of the 1,832 patients, 1,391 were treated with DESs. We excluded 750 patients without CKD and 89 hemodialysis patients. Finally, 552 patients with CKD were included: 219 with DM (DM group) and 333 without DM (no DM group). The primary endpoint was target lesion failure (TLF) at 5 years. TLF was defined as a composite of cardiac death, target lesion revascularization (TLR), and myocardial infarction. Results: Patients in the DM group were more likely to have hypertension, dyslipidemia, peripheral artery disease, and lower ejection fraction and were more frequently using insulin for DM. The TLF rate during the follow-up period was significantly higher in the DM than in the no DM group (adjusted hazard ratio [HR] 1.50; 95% confidence interval [CI] 1.06–2.13; p = 0.023). Cardiac mortality was comparable between both groups (adjusted HR 1.11; 95% CI 0.63–1.95; p = 0.71). The TLR rate was significantly higher in the DM group than in the no DM group (adjusted HR 1.69; 95% CI 1.12–2.54; p = 0.012). Conclusion: DM is strongly associated with adverse event after PCI for ULM distal bifurcation lesions in CKD patients compared to those without DM.

P971Impact of treatment strategy on 1-year outcome for Left Main trifurcation lesions

Abstract Background/Introduction Limited data exist regarding procedural strategy and clinical outcomes after percutaneous coronary intervention (PCI) for unprotected left main (LM) trifurcation lesion. Purpose The aim of this study is to evaluate 1-year clinical outcomes after LM trifurcation PCI comparing different strategies in kissing balloon inflation (KBI). Methods From 1, January, 2011 to 31, March, 2017, patients who underwent LM trifurcation PCI with second generation drug-eluting stent in our center were retrospectively analyzed. They were categorized into single-stent KBT group (KBT in left anterior descending artery [LAD] and left circumflex artery [LCX], or LAD and high lateral branch [HL]) and no-KBT group. Primary endpoint is restenosis in the lesions. Results Among 1301 patients who underwent LM PCI during the study period, 163 patients (12.5%) had a trifurcation lesion. Regarding the number of stents used for the lesions, 1, 2 and 3 stents were used in 75.4%, 22.0% and 2.5%, respectively. Median follow-up period of LM trifurcation patients was 265 days (interquartile range: 81–564). In the no-KBT group (64 patients), 19 patients experienced restenosis of HL and LCX (HL: 8 patients, LCX: 0 patient, and both: 11 patients). In the KBT-group, KBT for LAD and LCX was performed in 47 patients, and of them, 19 patients experienced restenosis of LM-LAD, HL and LCX (HL: 12 patients, LCX: 6 patients and all: 1 patient). On the other hand, in 9 patients with KBT for LAD and HL, there were no restenosis cases at 1-year follow-up. There was no statistically significant difference in restenosis rate between the no-KBI and KBT group (29.6% vs. 40.4%, p=0.69). Restenosis rates in each segments Conclusion After LM trifurcation PCI, restenosis rate at 1-year follow-up was high, and no difference between no-KBT and KBT group overall. However, there was no restenosis case in patients with KBT for LAD and HL.

Intervenção percutânea em lesões de tronco de coronária esquerda não protegido

ABSTRACT Background The opportunity for percutaneous treatment of coronary artery disease in unprotected left main artery has increased. This treatment possibility is based on favorable results in the literature. The objective of this study was to compare the demographic profile and results of percutaneous coronary intervention in patients with unprotected left main coronary artery lesions. Methods The period from 2006 to 2016 was analyzed, divided into three intervals – 2006 to 2008, 2009 to 2011 and 2012 to 2016, based [...]

New Predictors of Early and Late Outcomes after Primary Percutaneous Coronary Intervention in Patients with ST-Segment Elevation Myocardial Infarction and Unprotected Left Main Coronary Artery Culprit Lesion.

Objectives The study evaluated the correlation between baseline SYNTAX Score, Residual SYNTAX Score, and SYNTAX Revascularization Index and long-term outcomes in ST-elevation myocardial infarction (STEMI) patients with primary percutaneous coronary intervention (PCI) on an unprotected left main coronary artery lesion (UPLMCA). Background Previous studies on primary PCI in UPLMCA have identified cardiogenic shock, TIMI 0/1 flow, and cardiac arrest, as prognostic factors of an unfavourable outcome, but the complexity of coronary artery disease and the extent of revascularization have not been thoroughly investigated in these high-risk patients. Methods 30-day, 1-year, and long-term outcomes were analyzed in a cohort of retrospectively selected, 81 consecutive patients with STEMI, and primary PCI on UPLMCA. Results Cardiogenic shock (p=0.001), age (p=0.008), baseline SYNTAX Score II (p=0.006), and SYNTAX Revascularization Index (p=0.046) were independent mortality predictors at one-year follow-up. Besides cardiogenic shock (HR 3.28, p<0.001), TIMI 0/1 flow (HR 2.17, p=0.021) and age (HR 1.03, p=0.006), baseline SYNTAX Score II (HR 1.06, p=0.006), residual SYNTAX Score (HR 1.03, p=0.041), and SYNTAX Revascularization Index (HR 0.9, p=0.011) were independent predictors of mortality at three years of follow-up. In patients with TIMI 0/1 flow, the presence of Rentrop collaterals was an independent predictor for long-term survival (HR 0.24; p=0.049). Conclusions In this study, the complexity of coronary artery disease and the extent of revascularization represent independent mortality predictors at long-term follow-up.

SAFETY AND EFFICACY OF TRANSRADIAL VERSUS TRANSFEMORAL ACCESS FOR PERCUTANEOUS CORONARY INTERVENTION OF UNPROTECTED LEFT MAIN DISEASE: A META- ANALYSIS

Transradial access (TRA) has emerged as an alternative to Transfemoral access (TFA) in percutaneous coronary intervention (PCI) of unprotected left main (ULM) lesions. Evidence is based on retrospective studies with a lack of robust clinical trials. We conducted this meta-analysis to evaluate the

Contemporary Use and Trends in Unprotected Left Main Coronary Artery Percutaneous Coronary Intervention in the United States

Recent data support percutaneous revascularization as an alternative to coronary artery bypass grafting in unprotected left main (ULM) coronary lesions. However, the relevance of these trials to current practice is unclear, as patterns and outcomes of ULM percutaneous coronary intervention (PCI) in contemporary US clinical practice are not well studied. To define the current practice of ULM PCI and its outcomes and compare these with findings reported in clinical trials. This cross-sectional multicenter analysis included data collected from 1662 institutions participating in the National Cardiovascular Data Registry (NCDR) CathPCI Registry between April 2009 and July 2016. Data were collected from 33 128 patients undergoing ULM PCI and 3 309 034 patients undergoing all other PCI. Data were analyzed from June 2017 to May 2018. Patient and procedural characteristics and their temporal trends were compared between ULM PCI and all other PCI. In-hospital major adverse clinical events (ie, death, myocardial infarction, stroke, and emergent coronary artery bypass grafting) were compared using hierarchical logistic regression. Characteristics and outcomes were also compared against clinical trial cohorts. Of the 3 342 162 included patients, 2 223 570 (66.5%) were male, and the mean (SD) age was 64.2 (12.1) years. Unprotected left main PCI represented 1.0% (33 128 of 3 342 162) of all procedures, modestly increasing from 0.7% to 1.3% over time. The mean (SD) annualized ULM PCI volume was 0.5 (1.5) procedures for operators and 3.2 (6.1) procedures for facilities, with only 1808 of 10 971 operators (16.5%) and 892 of 1662 facilities (53.7%) performing an average of 1 or more ULM PCI annually. After adjustment, major adverse clinical events occurred more frequently with ULM PCI compared with all other PCI (odds ratio, 1.46; 95% CI, 1.39-1.53). Compared with clinical trial populations, patients in the CathPCI Registry were older with more comorbid conditions, and adverse events were more frequent. Use of ULM PCI has increased over time, but overall use remains low. These findings suggest that ULM PCI occurs infrequently in the United States and in an older and more comorbid population than that seen in clinical trials.

Safety and Efficacy of Biodegradable Polymer-biolimus-eluting Stents (BP-BES) Compared with Durable Polymer-everolimus-eluting Stents (DP-EES) in Patients Undergoing Complex Percutaneous Coronary Intervention.

Background and ObjectivesThere are no data comparing clinical outcomes of complex percutaneous coronary intervention (PCI) between biodegradable polymer-biolimus-eluting stents (BP-BES) and durable polymer-everolimus-eluting stents (DP-EES). We sought to evaluate the safety and efficacy of BP-BES compared with DP-EES in patients undergoing complex PCI.MethodsPatients enrolled in the SMART-DESK registry were stratified into 2 categories based on the complexity of PCI. Complex PCI was defined as having at least one of the following features: unprotected left main lesion, ≥2 lesions treated, total stent length >40 mm, minimal stent diameter ≤2.5 mm, or bifurcation as target lesion. The primary outcome was target lesion failure (TLF), defined as a composite of cardiac death, target vessel-related myocardial infarction (TV-MI), or target lesion revascularization (TLR) at 2 years of follow-up.ResultsOf 1,999 patients, 1,145 (57.3%) underwent complex PCI: 521 patients were treated with BP-BES and 624 with DP-EES. In propensity-score matching analysis (481 pairs), the risks of TLF (3.8% vs. 5.2%, adjusted hazard ratio [HR], 0.578; 95% confidence interval [CI], 0.246–1.359; p=0.209), cardiac death (2.5% vs. 2.5%, adjusted HR, 0.787; 95% CI, 0.244–2.539; p=0.689), TV-MI (0.5% vs. 0.4%, adjusted HR, 1.128; 95% CI, 0.157–8.093; p=0.905), and TLR (1.1% vs. 2.9%, adjusted HR, 0.390; 95% CI, 0.139–1.095; p=0.074) did not differ between 2 stent groups after complex PCI.ConclusionsClinical outcomes of BP-BES were comparable to those of DP-EES at 2 years after complex PCI. Our data suggest that use of BP-BES is acceptable, even for complex PCI.