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Gonzalez PE, Hebbe A, Hussain Y, Khera R, Banerjee S, Plomondon ME, Waldo SW, Pfau SE, Curtis JP, Shah SM. Real-World Experience and Outcomes With Percutaneous Coronary Intervention for Protected Versus Unprotected Left Main Coronary Artery Disease: Insights from the Veteran Affairs Clinical Assessment Reporting and Tracking Program. Am J Cardiol 2024; 222:39-50. [PMID: 38677666 DOI: 10.1016/j.amjcard.2024.04.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 02/22/2024] [Accepted: 04/19/2024] [Indexed: 04/29/2024]
Abstract
The practice patterns and outcomes of protected left main (PLM) and unprotected left main (ULM) percutaneous coronary intervention (PCI) are not well defined in contemporary US clinical practice. Data were collected from all Veteran Affairs catheterization laboratories participating in the Clinical Assessment Reporting and Tracking Program between 2009 and 2019. The analysis included 4,351 patients who underwent left main PCI, of whom 1,306 pairs of PLM and ULM PCI were included in a propensity-matched cohort. Selected temporal trends were also assessed. The primary outcome was major adverse cardiovascular event (MACE) outcomes at 1 year, which was defined as a composite of all-cause mortality, rehospitalization for myocardial infarction (MI), rehospitalization for stroke, or urgent revascularization. Patients who underwent ULM PCI compared with patients who underwent PLM PCI were older (age 71.5 vs 69.2 years, p <0.001), more clinically complex, and more likely to present with acute coronary syndrome. In the propensity-matched cohort, radial access was used more often for ULM PCI (21% [273] vs 14% [185], p <0.001) and ULM PCI was more likely to involve the left main bifurcation (22% vs 14%, p = 0.003) and require mechanical circulatory support (10% [134] vs 1% [17], p <0.001). The 1-year MACEs occurred more frequently with ULM PCI than PLM PCI (22% [289] vs 16% [215], p ≤0.001) and all-cause mortality was also higher (16% [213] vs 10% [125], p ≤0.001). In the matched cohort, there was a low incidence of rehospitalization for MI (4% [48] ULM vs 4% [48] PLM, p = 1.000) or revascularization (7% [94] ULM vs 6% [84] PLM, p = 0.485). In this real-world experience, patients who underwent PLM PCI had better 1-year outcomes than those who underwent ULM PCI; however, in both groups, there was a high rate of mortality and MACEs at 1 year despite a relatively low rate of MI or revascularization.
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Affiliation(s)
- Pedro Engel Gonzalez
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Annika Hebbe
- Veterans Affairs Eastern Colorado Health Care System, Aurora, Colorado; CART Program, Office of Quality and Patient Safety, Veterans Health Administration, Washington, District of Columbia
| | - Yasin Hussain
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut; Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut
| | - Rohan Khera
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
| | - Subhash Banerjee
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas; Veterans Affairs North Texas Health Care System, Dallas, Texas
| | - Mary E Plomondon
- Veterans Affairs Eastern Colorado Health Care System, Aurora, Colorado; CART Program, Office of Quality and Patient Safety, Veterans Health Administration, Washington, District of Columbia
| | - Stephen W Waldo
- Rocky Mountain Regional VA Medical Center, Aurora, Colorado; Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado
| | - Steven E Pfau
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut; Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut
| | - Jeptha P Curtis
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
| | - Samit M Shah
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut; Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut.
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Doolub G, Mamas MA, Dziewierz A, Malinowski KP, Oleś I, Kuleta M, Zdzierak B, Siudak Z. Do two operators improve outcomes in left main percutaneous coronary intervention? Insights from the ORPKI Registry. Minerva Cardiol Angiol 2024; 72:79-86. [PMID: 37870423 DOI: 10.23736/s2724-5683.23.06364-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2023]
Abstract
BACKGROUND Significant left main coronary artery (LMCA) disease is prevalent in 7% of patients undergoing angiography. Limited data exists on the impact of double scrubbing in LMCA PCI. We sought to assess periprocedural outcomes in two-operator LMCA percutaneous coronary intervention (PCI). METHODS Using data from the Polish National Registry of PCI (ORPKI), we collected data on 28,745 patients undergoing LMCA PCI from 154 centers. Patients were divided into two groups based on the number of operators performing PCI (one vs. two operators). RESULTS LMCA PCI was performed by a single operator in 86% of the cases and by two operators in 14% of cases. Patients treated by two operators had a greater comorbidity burden including diabetes mellitus, arterial hypertension, previous myocardial infarction, and previous revascularization. In addition, these were more likely to be treated in high-volume centers, by operators with higher volume of LMCA PCIs. The risk of periprocedural death (2.37% vs. 2.44%; P=0.78), as well as cardiac arrest, coronary artery perforation, no-reflow, and puncture site bleeding was comparable between the two groups. On multivariable analysis, we found that a two-operator strategy was an independent predictor of periprocedural death, with this effect being much more profound in an elective setting (OR=5.13 [1.37-19.26]; P=0.015), compared to an urgent (ACS) setting (OR=1.32 [1.00-1.73]; P=0.047). CONCLUSIONS Our study suggests that a two-operator approach is not necessarily routinely recommended for LMCA interventions, although it can be considered for more complex cases.
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Affiliation(s)
- Gemina Doolub
- Center for Prognosis Research, Institute for Primary Care and Health Sciences, Keele University, Stoke-on-Trent, UK
- Unit of Translational Health Sciences, University of Bristol, Bristol, UK
| | - Mamas A Mamas
- Center for Prognosis Research, Institute for Primary Care and Health Sciences, Keele University, Stoke-on-Trent, UK
| | - Artur Dziewierz
- Jagiellonian University Medical College, Second Department of Cardiology, Institute of Cardiology, Krakow, Poland
- Department of Cardiology and Cardiovascular Interventions, University Hospital of Krakow, Krakow, Poland
| | - Krzysztof P Malinowski
- Jagiellonian University Medical College, Department of Bioinformatics and Telemedicine, Krakow, Poland
- Jagiellonian University Medical College, Digital Medicine and Robotics Center, Krakow, Poland
| | - Izabela Oleś
- Collegium Medicum, Jan Kochanowski University, Kielce, Poland
| | - Martyna Kuleta
- Collegium Medicum, Jan Kochanowski University, Kielce, Poland
| | - Barbara Zdzierak
- Jagiellonian University Medical College, Second Department of Cardiology, Institute of Cardiology, Krakow, Poland
| | - Zbigniew Siudak
- Collegium Medicum, Jan Kochanowski University, Kielce, Poland -
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Gonzalez PE, Hebbe A, Hussain Y, Khera R, Banerjee S, Plomondon ME, Waldo SW, Pfau SE, Curtis JP, Shah SM. Outcomes of Percutaneous Coronary Intervention for Protected versus Unprotected Left Main Coronary Artery Disease: Insights from the VA CART Program. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.10.27.23297698. [PMID: 37961093 PMCID: PMC10635229 DOI: 10.1101/2023.10.27.23297698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
Background Practice patterns and outcomes of protected left main (PLM) and unprotected left main (ULM) percutaneous coronary intervention (PCI), as well as the differences between these types of PCI, are not well defined in real-world clinical practice. Methods Data collected from all Veteran Affairs (VA) catheterization laboratories participating in the Clinical Assessment Reporting and Tracking Program between 2009 and 2019. The analysis included 4,351 patients undergoing left main PCI, of which 1,306 pairs of PLM and ULM PCI were included in a propensity matched cohort. Patients and procedural characteristics were compared between PLM and ULM PCI. Temporal trends were also assessed. Peri-procedural and one-year major adverse cardiovascular events (MACE) were compared using cumulative incidence plots. The primary outcome was MACE outcomes at 1-year, which was defined as a composite of all-cause mortality, rehospitalization for myocardial infarction (MI), rehospitalization for stroke or urgent revascularization. Results ULM PCI patients in comparison to PLM PCI were older (71.5 vs 69.2; P < 0.001), more clinically complex and more likely to present with ACS. In the propensity matched cohort, radial access was used more often for ULM PCI (21% [273] vs. 14% [185], P < 0.001), and ULM PCI was more likely to involve the LM bifurcation (22% vs 14%; P = 0.003) and require mechanical circulatory support (10% [134] vs 1% [17]; P <0.001). One-year MACE occurred more frequently with ULM PCI compared to PLM PCI (22% [289] vs. 16% [215]; P = < 0.001) and all-cause mortality was also higher (16% [213] vs. 10% [125]; P = < 0.001). In the matched cohort there was a low incidence of rehospitalization for MI (4% [48] ULM vs. 4% [48] PLM; P = 1.000) or revascularization (7% [94] ULM vs. 6% [84] PLM; P = 0.485). Conclusions Veterans undergoing PLM PCI had better one-year outcomes than those undergoing ULM PCI, but in both groups there was a high rate of mortality and MACE at one-year despite a relatively low rate of MI or revascularization.
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Affiliation(s)
- Pedro Engel Gonzalez
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Annika Hebbe
- Veterans Affairs Eastern Colorado Health Care System, Aurora, Colorado
- CART Program, Office of Quality and Patient Safety, Veterans Health Administration, Washington, DC
| | - Yasin Hussain
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut
| | - Rohan Khera
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
| | - Subhash Banerjee
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
- Veterans Affairs North Texas Health Care System, Dallas, Texas
| | - Mary E Plomondon
- Veterans Affairs Eastern Colorado Health Care System, Aurora, Colorado
- CART Program, Office of Quality and Patient Safety, Veterans Health Administration, Washington, DC
| | - Stephen W Waldo
- Rocky Mountain Regional VA Medical Center, Aurora, Colorado
- Section of Cardiology, University of Colorado School of Medicine, Aurora, Colorado
| | - Steven E Pfau
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut
| | - Jeptha P Curtis
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
| | - Samit M Shah
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut
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Wool TH, Ashley SC, Gupta VA. Determination of Left Main Coronary Artery Stenosis Through Noninvasive Testing to Guide Revascularization in Ischemic Heart Disease. Am J Cardiol 2023; 204:345-351. [PMID: 37573613 DOI: 10.1016/j.amjcard.2023.07.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 06/05/2023] [Accepted: 07/10/2023] [Indexed: 08/15/2023]
Abstract
Anatomically severe left main coronary artery (LMCA) stenosis (>50%) remains one of the few groups to benefit from early revascularization in stable ischemic heart disease (SIHD). Identification of these patients through widely available noninvasive testing would decrease the need for additional upfront anatomic testing, lowering the overall cost of healthcare. Patients with SIHD who underwent either percutaneous or surgical revascularization over a 7-year period at our institution were retrospectively analyzed and categorized as having LMCA stenosis versus non-LM stenosis. All preceding noninvasive testing, including resting electrocardiogram, echocardiogram, and functional testing was evaluated and compared between groups using chi-square and t test. In total, 806 patients were evaluated. Of those, 121 were identified as having significant LMCA stenosis with 685 patients in the non-LM cohort. Between LMCA versus non-LM cohorts, there were similar rates of electrocardiogram abnormalities (68.9% vs 70.8%, p >0.05), abnormal echocardiograms (72.7% vs 69.7%, p >0.05), abnormal functional testing (83.3% vs 77.4%, p >0.05), and high-risk imaging findings (5.6% vs 4.8%, p >0.05). More importantly, of those with a complete workup, there were similar rates of normal results between the LMCA (3 of 18, 16.7%) and non-LM stenosis (9 of 189, 4.8%) groups. A comprehensive noninvasive profile of patients with IHD failed to identify or exclude patients with anatomically severe LMCA stenosis, necessitating anatomic assessment.
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Affiliation(s)
- Thomas H Wool
- Department of Cardiovascular Medicine, University of Kentucky Medical Center, Lexington, Kentucky.
| | - Sarah C Ashley
- University of Kentucky College of Medicine, University of Kentucky Medical Center, Lexington, Kentucky
| | - Vedant A Gupta
- Department of Cardiovascular Medicine, University of Kentucky Medical Center, Lexington, Kentucky
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Abstract
This review aims to provide a conceptual framework for preoperative evaluation and to highlight the clinical evidence available to support perioperative decision-making.
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Affiliation(s)
- Jeanna D Blitz
- Duke University School of Medicine, Durham, North Carolina
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6
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Su TY, Chen JJ, Chen WS, Chang YH, Lu HHS. Deep learning for myocardial ischemia auxiliary diagnosis using CZT SPECT myocardial perfusion imaging. J Chin Med Assoc 2023; 86:122-130. [PMID: 36306391 DOI: 10.1097/jcma.0000000000000833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND The World Health Organization reported that cardiovascular disease is the most common cause of death worldwide. On average, one person dies of heart disease every 26 min worldwide. Deep learning approaches are characterized by the appropriate combination of abnormal features based on numerous annotated images. The constructed convolutional neural network (CNN) model can identify normal states of reversible and irreversible myocardial defects and alert physicians for further diagnosis. METHODS Cadmium zinc telluride single-photon emission computed tomography myocardial perfusion resting-state images were collected at Chang Gung Memorial Hospital, Kaohsiung Medical Center, Kaohsiung, Taiwan, and were analyzed with a deep learning convolutional neural network to classify myocardial perfusion images for coronary heart diseases. RESULTS In these grey-scale images, the heart blood flow distribution was the most crucial feature. The deep learning technique of You Only Look Once was used to determine the myocardial defect area and crop the images. After surrounding noise had been eliminated, a three-dimensional CNN model was used to identify patients with coronary heart diseases. The prediction area under the curve, accuracy, sensitivity, and specificity was 90.97, 87.08, 86.49, and 87.41%, respectively. CONCLUSION Our prototype system can considerably reduce the time required for image interpretation and improve the quality of medical care. It can assist clinical experts by offering accurate coronary heart disease diagnosis in practice.
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Affiliation(s)
- Ting-Yi Su
- Institute of Statistics, National Yang Ming Chiao Tung University, Hsinchu, Taiwan, ROC
| | - Jui-Jen Chen
- Department of Nuclear Medicine, Chang Gung Memorial Hospital, Kaohsiung Medical Center, Chang Gung University College of Medicine, Kaohsiung, Taiwan, ROC
| | - Wei-Shiang Chen
- Institute of Statistics, National Yang Ming Chiao Tung University, Hsinchu, Taiwan, ROC
| | - Yen-Hsiang Chang
- Department of Nuclear Medicine, Chang Gung Memorial Hospital, Kaohsiung Medical Center, Chang Gung University College of Medicine, Kaohsiung, Taiwan, ROC
| | - Henry Horng-Shing Lu
- Institute of Statistics, National Yang Ming Chiao Tung University, Hsinchu, Taiwan, ROC
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Carande EJ, Protty MB, Verhemel S, Hussein MH, Raman AS, UlHaq Z, Bundhoo S, Cullen J, Ionescu A, Choudhury A, Hussain HI, Hailan A. Predictors of 30‐day and 12‐month mortality in left main stem percutaneous coronary intervention 2016−2020: A study from two UK centers. Catheter Cardiovasc Interv 2022; 100:585-592. [DOI: 10.1002/ccd.30400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 08/01/2022] [Accepted: 08/29/2022] [Indexed: 11/09/2022]
Affiliation(s)
| | - Majd B. Protty
- Systems Immunity University Research Institute Cardiff University Cardiff UK
| | - Sarah Verhemel
- Department of Cardiology The Grange University Hospital Cwmbran UK
| | | | - Ajay S. Raman
- Department of Cardiology Morriston Cardiac Centre Swansea UK
| | - Zia UlHaq
- Department of Cardiology Morriston Cardiac Centre Swansea UK
| | - Shantu Bundhoo
- Department of Cardiology The Grange University Hospital Cwmbran UK
| | - James Cullen
- Department of Cardiology The Grange University Hospital Cwmbran UK
| | - Adrian Ionescu
- Department of Cardiology Morriston Cardiac Centre Swansea UK
| | | | | | - Ahmed Hailan
- Department of Cardiology Morriston Cardiac Centre Swansea UK
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8
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Abdel-Razek O, Jung Y, Jung R, Skanes S, Dhaliwal S, Stotts C, Di Santo P, Goh CY, Verreault-Julien L, Visintini S, Bradley J, Simard T, Ramirez FD, Russo JJ, Froeschl M, Labinaz M, Hibbert B. Safety of same-day discharge in patients with left main percutaneous intervention. Coron Artery Dis 2022; 33:415-418. [PMID: 35170549 PMCID: PMC9239435 DOI: 10.1097/mca.0000000000001121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 12/12/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Omar Abdel-Razek
- CAPITAL Research Group, University of Ottawa Heart Institute, Ottawa
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa
| | - Young Jung
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton
| | - Richard Jung
- CAPITAL Research Group, University of Ottawa Heart Institute, Ottawa
- Vascular Biology and Experimental Medicine Laboratory, University of Ottawa Heart Institute, Ottawa
- Department of Cellular and Molecular Medicine, Faculty of Medicine, University of Ottawa, Ottawa
| | | | - Shan Dhaliwal
- Department of Cellular and Molecular Medicine, Faculty of Medicine, University of Ottawa, Ottawa
| | - Cameron Stotts
- Department of Biochemistry, Microbiology, and Immunology, Faculty of Medicine, University of Ottawa, Ottawa
| | - Pietro Di Santo
- CAPITAL Research Group, University of Ottawa Heart Institute, Ottawa
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa
- Vascular Biology and Experimental Medicine Laboratory, University of Ottawa Heart Institute, Ottawa
- School of Epidemiology and Public Health, University of Ottawa, Ottawa
| | - Cheng Yee Goh
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa
| | | | - Sarah Visintini
- Berkman Library, University of Ottawa Heart Institute, Ottawa, Canada
| | - Jennifer Bradley
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa
| | - Trevor Simard
- CAPITAL Research Group, University of Ottawa Heart Institute, Ottawa
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa
- Department of Cellular and Molecular Medicine, Faculty of Medicine, University of Ottawa, Ottawa
| | - F. Daniel Ramirez
- Vascular Biology and Experimental Medicine Laboratory, University of Ottawa Heart Institute, Ottawa
- Department of Cellular and Molecular Medicine, Faculty of Medicine, University of Ottawa, Ottawa
| | - Juan J. Russo
- CAPITAL Research Group, University of Ottawa Heart Institute, Ottawa
| | - Michael Froeschl
- CAPITAL Research Group, University of Ottawa Heart Institute, Ottawa
| | - Marino Labinaz
- CAPITAL Research Group, University of Ottawa Heart Institute, Ottawa
| | - Benjamin Hibbert
- CAPITAL Research Group, University of Ottawa Heart Institute, Ottawa
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa
- Vascular Biology and Experimental Medicine Laboratory, University of Ottawa Heart Institute, Ottawa
- Department of Cellular and Molecular Medicine, Faculty of Medicine, University of Ottawa, Ottawa
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9
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Kayani WT, Khalid U, Alam M. Predicting Left Main Coronary Artery Stenosis Without Imaging: Are We There Yet? J Am Coll Cardiol 2022; 79:662-664. [PMID: 35177195 DOI: 10.1016/j.jacc.2021.11.054] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 11/30/2021] [Indexed: 11/17/2022]
Affiliation(s)
- Waleed T Kayani
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA.
| | - Umair Khalid
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA; Michael E DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
| | - Mahboob Alam
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
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10
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The Clinical Outcomes of Ventricular Septal Rupture Secondary to Acute Myocardial Infarction: A Retrospective, Observational Trial. J Interv Cardiol 2022; 2021:3900269. [PMID: 34987315 PMCID: PMC8692018 DOI: 10.1155/2021/3900269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 11/17/2021] [Accepted: 11/30/2021] [Indexed: 01/08/2023] Open
Abstract
Background Ventricular septal rupture (VSR) is a severe mechanical complication secondary to acute myocardial infarction (AMI) with a dreadful prognosis. The goal of our study was to evaluate the mortality and to identify the predictors of mortality for this population. Methods From June 2012 to July 2021, patients with VSR secondary to AMI were initially screened for eligibility in this study. The potential risk predictors were determined using appropriate logistic regression models. Results In this retrospective study, a total of 50 cases were included, and 14 patients survived and got discharged successfully. Univariable analyses indicated that the heart rate (HR), white blood cell (WBC) count, neutrophils count, serum glucose, serum creatinine, serum lactic acid, and the closure of rupture were significantly associated with mortality among these special populations. Conclusion This study found that such high mortality in patients with VSR after AMI was significantly correlated with these risk factors representing sympathetic excitation and large infarct size. Coronary revascularization combined with the closure of rupture might be helpful in improving their prognosis.
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11
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Disney L, Ramaiah C, Ramaiah M, Keshavamurthy S. Left Main Coronary Artery Disease in Diabetics: Percutaneous Coronary Intervention or Coronary Artery Bypass Grafting? Int J Angiol 2021; 30:194-201. [PMID: 34776819 DOI: 10.1055/s-0041-1730446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
The choice between coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) for myocardial revascularization in patients with left main disease (LMD) is controversial. There is general agreement that CABG is appropriate for all patients, and PCI is acceptable for those with low-to-intermediate anatomic complexity. However, there is uncertainty about the relative safety and efficacy of PCI in patients with more complex LMD and with comorbidities such as diabetes. No direct comparison trial has focused on revascularization in diabetic patients with LMD, and thus conclusions on the topic are subject to the limitations of subgroup analysis, as well as the heterogeneous exclusion criteria, and methodologies of individual trials. The available evidence suggests that among diabetics, CABG is superior in patients with LMD with SYNTAX (SYNergy between percutaneous coronary intervention with TAXus and dardiac surgery) score greater than 33, distal bifurcation disease, or multivessel disease. PCI may be appropriate in those with less-extensive disease or those with limited life expectancy or high surgical risk.
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Affiliation(s)
- Logan Disney
- University of Kentucky College of Medicine, Lexington, Kentucky
| | | | | | - Suresh Keshavamurthy
- Division of Cardiothoracic Surgery, Department of Surgery, University of Kentucky College of Medicine, Lexington, Kentucky
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12
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Money JE, Muhlestein JB, Mason S, Bair TL, Knowlton KU, Horne BD, Anderson JL. Simplifying the ISCHEMIA trial algorithm for clinical practice: Identifying left main coronary artery disease using coronary artery calcium scans. Am Heart J 2021; 239:129-134. [PMID: 34051172 DOI: 10.1016/j.ahj.2021.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 05/20/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Several recent trials have evaluated invasive versus medical therapy for stable ischemic heart disease. Importantly, patients with significant left main coronary stenosis (LMCS) were excluded from these trials. In the ISCHEMIA trial, these patients were identified by a coronary CT angiogram (CCTA), which adds time, expense, and contrast exposure. We tested whether a coronary artery calcium scan (CACS), a simpler, less expensive test, could replace CCTA to exclude significant LMCS. METHODS We hypothesized that patients with ≥50% LMCS would have a LM CACS score > 0. As a corollary, we postulated that a LM CACS = 0 would exclude patients with LMCS. To test this, we searched Intermountain Healthcare's electronic medical records database for all adult patients who had undergone non-contrast cardiac CT for quantitative CACS scoring prior to invasive coronary angiography (ICA). Patients aged <50 and those with a heart transplant were excluded. Cases with incomplete (qualitative) angiographic reports for LMCS and those with incomplete or discrepant LM CACS results were reviewed and reassessed blinded to CACS or ICA findings, respectively. RESULTS Among 669 candidate patients with CACS followed by ICA, 36 qualifying patients were identified who had a quantitative CACS score and LMCS ≥ 50%. Their age averaged 71.8 years, and 81% were men. Angiographic LMCS averaged 72% (range 50%-99%). Median time between CACS and ICA was 6 days. Total CACS score averaged 2,383 Agatston Units (AU), range 571-6,636. LM CACS score averaged 197 AU, range 31-610. Importantly, no LMCS patient had a LM CACS score of 0 vs 57% (362/633) of non-LMCS controls (P < .00001). CONCLUSIONS Our results support the hypothesis that an easily administered, inexpensive, low radiation CACS can identify a large subset of patients with a very low risk of LMCS who would not have the need for routine CCTA. Using CACS to exclude LMCS may efficiently allow for safe implementation of an initial medical therapy strategy of patients with stable ischemic heart disease in clinical practice. These promising results deserve validation in larger data sets.
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13
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Raghu TR, V A SR, Kharge J, H S NS, Patil RS, Manjunath CN. Feasibility and Outcomes of Left Main to Branch Vessel PCI with Novel Tapered Coronary Stent in a Tertiary Care Centre: A Real World Experience. Cardiovasc Hematol Disord Drug Targets 2021; 21:128-135. [PMID: 34387173 DOI: 10.2174/1871529x21666210812110944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 05/31/2021] [Accepted: 06/24/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To assess the safety and efficacy of Novel tapered (BioMime™ Morph) sirolimus-eluting stent (SES) for left main PCI in a real-world scenario. BACKGROUND Currently no data is available on clinical usefulness of tapered ultrathin stents in left main PCI. METHODS This was a prospective, non-randomised, single centre study carried out between February 2018 and May 2020 at a tertiary cardiac care centre in southern India. The study included patients treated with BioMime Morph tapered stent for distal de novo LMB lesion or ostial LAD/LCX lesions with significant size disparity between reference segments based on the eligibility criteria. Primary endpoint of the study was the cumulative incidence of major adverse cardiovascular events (MACE) composed of cardiac death, myocardial infraction, and clinically driven target-lesion revascularisation at follow-up. RESULTS A total of 41 patients (average age of 54.83±9.81 years) were included in the study. Average SS-2 score was 23.17±5.42. Majority of the lesions (n=31; 75.61%) were of medina class (0.1.0). Provisional single stent strategy was adopted for treatment of LMB lesions. TIMI flow-3 was achieved in 40 patients (97.56%). Median clinical follow-up was 20 months (range 6-34 months) There was no periprocedural complication or MACE during follow-up.
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Affiliation(s)
- T R Raghu
- Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka. India
| | - Sathwik Raj V A
- Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka. India
| | - Jayashre Kharge
- Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka. India
| | - Natraj Setty H S
- Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka. India
| | - Rahul S Patil
- Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka. India
| | - C N Manjunath
- Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka. India
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Differential Factors for Predicting Outcomes in Left Main versus Non-Left Main Coronary Bifurcation Stenting. J Clin Med 2021; 10:jcm10143024. [PMID: 34300190 PMCID: PMC8306985 DOI: 10.3390/jcm10143024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Revised: 06/14/2021] [Accepted: 07/05/2021] [Indexed: 12/19/2022] Open
Abstract
Background: No large-scale study has compared the clinical and angiographic predictors of cardiovascular events in patients with left main bifurcation (LMB) and non-LMB stenting after second-generation DES implantation. Herein, we investigated differential clinical and angiographic factors for predicting outcomes in LMB versus non-LMB stenting. Methods: A total of 2648 patients with bifurcation lesions treated with second-generation DESs from the retrospective patient cohort were divided into an LMB group (n = 935) and a non-LMB group (n = 1713). The primary outcome was the 7-year incidence of target lesion failure (TLF), defined as the composite of cardiac death, myocardial infarction, and target lesion revascularization. Results: The incidence of TLF was 9.8%. Those in the LMB group were associated with a higher risk of TLF (14.2% versus 7.5%, p < 0.001) than those in the non-LMB group. Regarding the LMB group, independent predictors of TLF were chronic kidney disease (CKD), reduced left ventricular ejection fraction (LVEF), and two-stenting. Regarding the non-LMB group, CKD, reduced LVEF, old age, diabetes, and small diameter of the main vessel stent were independent predictors of TLF. Conclusions: The two-stent strategy could potentially increase TLF for the LMB lesions, and achieving the maximal diameter of the main vessel stent could result in better clinical outcomes for non-LMB lesions.
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15
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Beohar N, Chen S, Lembo NJ, Banning AP, Serruys PW, Leon MB, Morice MC, Généreux P, Kandzari DE, Kappetein AP, Sabik JF, Dressler O, McAndrew T, Zhang Z, Stone GW. Impact of lesion preparation strategies on outcomes of left main PCI: The EXCEL trial. Catheter Cardiovasc Interv 2021; 98:24-32. [PMID: 32592450 DOI: 10.1002/ccd.29116] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 06/08/2020] [Indexed: 11/09/2022]
Abstract
OBJECTIVES We examined outcomes according to lesion preparation strategy (LPS) in patients with left main coronary artery (LMCA) percutaneous coronary intervention (PCI) in the EXCEL trial. BACKGROUND The optimal LPS for LMCA PCI is unclear. METHODS We categorized LPS hierarchically (high to low) as: (a) rotational atherectomy (RA); (b) cutting or scoring balloon (CSB); (c) balloon angioplasty (BAL); and d) direct stenting (DIR). The primary endpoint was 3-year MACE; all-cause death, stroke, or myocardial infarction. RESULTS Among 938 patients undergoing LMCA PCI, RA was performed in 6.0%, CSB 9.5%, BAL 71.3%, and DIR 13.2%. In patients treated with DIR, BAL, CSB, and RA, respectively, there was a progressive increase in SYNTAX score, LMCA complex bifurcation, trifurcation or calcification, number of stents, and total stent length. Any procedural complication occurred in 10.4% of cases overall, with the lowest rate in the DIR (7.4%) and highest in the RA group (16.1%) (ptrend = .22). There were no significant differences in the 3-year rates of MACE (from RA to DIR: 17.9%, 20.2%, 14.5%, 14.7%; p = .50) or ischemia-driven revascularization (from RA to DIR: 16.8%, 10.8%, 12.3%, 14.2%; p = .65). The adjusted 3-year rates of MACE did not differ according to LPS. CONCLUSIONS The comparable 3-year outcomes suggest that appropriate lesion preparation may be able to overcome the increased risks of complex LMCA lesion morphology.
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Affiliation(s)
- Nirat Beohar
- Columbia University Division of Cardiology at the Mount Sinai Medical Center, Miami Beach, Florida, USA
| | - Shmuel Chen
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA.,New York-Presbyterian/Columbia University Irving Medical Center, New York, New York, USA
| | - Nicholas J Lembo
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA.,New York-Presbyterian/Columbia University Irving Medical Center, New York, New York, USA
| | | | - Patrick W Serruys
- Department of Cardiology, NUIG, National University of Ireland, Galway, Ireland.,Imperial College of Science Technology and Medicine, London, UK
| | - Martin B Leon
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA.,New York-Presbyterian/Columbia University Irving Medical Center, New York, New York, USA
| | - Marie-Claude Morice
- Ramsay Générale de Santé, Institut Cardiovasculaire Paris Sud, Paris, France
| | - Philippe Généreux
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA.,Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, New Jersey, USA.,Hôpital du Sacré-Coeur de Montréal, Montreal, Quebec, Canada
| | | | | | - Joseph F Sabik
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Ovidiu Dressler
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA
| | - Thomas McAndrew
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA
| | - Zixuan Zhang
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA
| | - Gregg W Stone
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA.,The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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16
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Wang Y, Chen R, Ding J, Yang L, Chen J, Huang B. Predictive value of pressure ulcer risk for obstructive coronary artery disease. Nurs Open 2021; 8:1848-1855. [PMID: 33675186 PMCID: PMC8186705 DOI: 10.1002/nop2.835] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 02/02/2021] [Accepted: 02/06/2021] [Indexed: 02/05/2023] Open
Abstract
AIM To investigate the relationship between pressure ulcers risk and severity of obstructive coronary artery disease (CAD) by invasive coronary angiography. DESIGN Cross-sectional study. METHODS A total of 193 consecutive patients with underlying pressure ulcers risk who underwent invasive coronary angiography were enrolled. Subjects were divided into three groups according to severity of coronary artery stenosis. Pressure ulcers risk score, fall risk score, self-care ability score and cardiovascular risk factors were compared among the three groups. Multivariate regression analysis and receiver operating curve analysis were performed to explore the diagnostic value of Braden score for left main or three-vessel disease. RESULTS Patients with more severe CAD had higher pressure ulcers risk. The percentage of high-pressure ulcers risk was highest in left main or three-vessel disease group, compared with control group and single- or two-vessel disease group. After adjusting for age, body mass index, diabetes, chronic kidney disease and other confounding factors, Braden score was an independent predictor of left main or three-vessel disease. Moreover, higher Braden score had a moderate area under the curve for excluding more severe CAD. In conclusion, among patients planning for coronary angiography, pressure ulcers risk assessment is conducive to predict the severity of obstructive CAD.
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Affiliation(s)
- Yao Wang
- Department of Cardiology, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, China
| | - Ran Chen
- Department of Cardiology, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, China
| | - Jie Ding
- Department of Cardiology, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, China
| | - Lu Yang
- Department of Cardiology, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, China
| | - Jiaojiao Chen
- Department of Cardiology, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, China
| | - Baotao Huang
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
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17
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Glazier JJ, Ramos-Parra B, Kaki A. Therapeutic Options for Left Main, Left Main Equivalent, and Three-Vessel Disease. Int J Angiol 2021; 30:76-82. [PMID: 34025098 DOI: 10.1055/s-0041-1723977] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Patients with left main, left main equivalent, and three-vessel coronary artery disease (CAD) represent an overlapping spectrum of patients with advanced CAD that is associated with an adverse prognosis. Guideline-directed medical therapy is a necessary but often insufficient treatment option, as such patients frequently need mechanical revascularization by either coronary artery bypass graft (CABG) surgery or percutaneous coronary intervention (PCI). In patients with advanced CAD presenting with acute myocardial infarction, PCI, of course, is the preferred treatment option. For stable patients with advanced CAD, CABG surgery remains the standard of care. However, observations from the SYNergy between Percutaneous Coronary Intervention with TAXus and Cardiac Surgery (SYNTAX) trial suggest that PCI may be a useful alternative in patients with three-vessel disease with a low SYNTAX score as well as in patients with left main disease and a low or intermediate SYNTAX score. In the subset of patients with diabetes mellitus, the Future Revascularization Evaluation in Patients with Diabetes Mellitus: Optimal Management of Multivessel Disease trial unequivocally demonstrated the superiority of CABG surgery in improving outcomes. The findings of the recently published Everolimus-Eluting Stent System versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization and Nordic-Baltic-British Left Main Revascularization study trials point to a favorable role for PCI in certain low-to-moderate risk patients with left main stem disease.
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Affiliation(s)
- James J Glazier
- Department of Cardiology, Detroit Medical Center, Heart Hospital, Wayne State University, Detroit, Michigan
| | - Bayoan Ramos-Parra
- Department of Cardiology, Detroit Medical Center, Heart Hospital, Wayne State University, Detroit, Michigan
| | - Amir Kaki
- Department of Cardiology, Detroit Medical Center, Heart Hospital, Wayne State University, Detroit, Michigan.,Department of Cardiology, Ascension St. John Hospital, Detroit, Michigan
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18
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Gallone G, D'Ascenzo F, Conrotto F, Costa F, Capodanno D, Muscoli S, Chieffo A, Yoichi I, Pennacchi M, Quadri G, Nuñez-Gil I, Bocchino PP, Piroli F, De Filippo O, Rolfo C, Wojakowski W, Trabattoni D, Huczek Z, Venuti G, Montabone A, Rognoni A, Parma R, Figini F, Mitomo S, Boccuzzi G, Mattesini A, Cerrato E, Wańha W, Smolka G, Cortese B, Ryan N, Bo M, di Mario C, Varbella F, Burzotta F, Sheiban I, Escaned J, Helft G, De Ferrari GM. Accuracy of the PARIS score and PCI complexity to predict ischemic events in patients treated with very thin stents in unprotected left main or coronary bifurcations. Catheter Cardiovasc Interv 2021; 97:E227-E236. [PMID: 32438488 DOI: 10.1002/ccd.28972] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 04/07/2020] [Accepted: 05/04/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND The PARIS risk score (PARIS-rs) and percutaneous coronary intervention complexity (PCI-c) predict clinical and procedural residual ischemic risk following PCI. Their accuracy in patients undergoing unprotected left main (ULM) or bifurcation PCI has not been assessed. METHODS The predictive performances of the PARIS-rs (categorized as low, intermediate, and high) and PCI-c (according to guideline-endorsed criteria) were evaluated in 3,002 patients undergoing ULM/bifurcation PCI with very thin strut stents. RESULTS After 16 (12-22) months, increasing PARIS-rs (8.8% vs. 14.1% vs. 27.4%, p < .001) and PCI-c (15.2% vs. 11%, p = .025) were associated with higher rates of major adverse cardiac events ([MACE], a composite of death, myocardial infarction [MI], and target vessel revascularization), driven by MI/death for PARIS-rs and target lesion revascularization/stent thrombosis for PCI-c (area under the curves for MACE: PARIS-rs 0.60 vs. PCI-c 0.52, p-for-difference < .001). PCI-c accuracy for MACE was higher in low-clinical-risk patients; while PARIS-rs was more accurate in low-procedural-risk patients. ≥12-month dual antiplatelet therapy (DAPT) was associated with a lower MACE rate in high PARIS-rs patients, (adjusted-hazard ratio 0.42 [95% CI: 0.22-0.83], p = .012), with no benefit in low to intermediate PARIS-rs patients. No incremental benefit with longer DAPT was observed in complex PCI. CONCLUSIONS In the setting of ULM/bifurcation PCI, the residual ischemic risk is better predicted by a clinical risk estimator than by PCI complexity, which rather appears to reflect stent/procedure-related events. Careful procedural risk estimation is warranted in patients at low clinical risk, where PCI complexity may substantially contribute to the overall residual ischemic risk.
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Affiliation(s)
- Guglielmo Gallone
- Division of Cardiology, Department of Internal Medicine, Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - Fabrizio D'Ascenzo
- Division of Cardiology, Department of Internal Medicine, Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - Federico Conrotto
- Division of Cardiology, Department of Internal Medicine, Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - Francesco Costa
- Department of Clinical and Experimental Medicine, Policlinic "G. Martino", University of Messina, Messina, Italy
| | - Davide Capodanno
- Division of Cardiology, Ferrarotto Hospital, University of Catania, Catania, Italy
| | - Saverio Muscoli
- Department of Cardiovascular Disease, Tor Vergata University of Rome, Rome, Italy
| | - Alaide Chieffo
- Unit of Cardiovascular Interventions, IRCCS San Raffaele Hospital, Milan, Italy
| | - Imori Yoichi
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | - Mauro Pennacchi
- Department of Cardiovascular, Respiratory and Morphologic Sciences, Policlinico Umberto I, "Sapienza" University of Rome, Rome, Italy
| | - Giorgio Quadri
- Department of Cardiology, Infermi Hospital, Rivoli, Italy
| | - Ivan Nuñez-Gil
- Hospital Clínico San Carlos, IDISSC, and Universidad Complutense de Madrid, Madrid, Spain
| | - Pier Paolo Bocchino
- Division of Cardiology, Department of Internal Medicine, Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - Francesco Piroli
- Division of Cardiology, Department of Internal Medicine, Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - Ovidio De Filippo
- Division of Cardiology, Department of Internal Medicine, Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - Cristina Rolfo
- Department of Cardiology, Infermi Hospital, Rivoli, Italy
| | - Wojciech Wojakowski
- Division of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
| | - Daniela Trabattoni
- Department of Cardiovascular Sciences, Centro Cardiologico Monzino, IRCCS, Milan, Italy
| | | | - Giuseppe Venuti
- Division of Cardiology, Ferrarotto Hospital, University of Catania, Catania, Italy
| | | | - Andrea Rognoni
- Coronary Care Unit and Catheterization Laboratory, A.O.U. Maggiore della Carità, Novara, Italy
| | - Radoslaw Parma
- Division of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
| | | | - Satoru Mitomo
- Unit of Cardiovascular Interventions, IRCCS San Raffaele Hospital, Milan, Italy
| | | | - Alessio Mattesini
- Division of Structural Interventional Cardiology, Careggi University Hospital, Florence, Italy
| | - Enrico Cerrato
- Department of Cardiology, Infermi Hospital, Rivoli, Italy
| | - Wojciech Wańha
- Division of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
| | - Grzegorz Smolka
- Division of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
| | - Bernardo Cortese
- Interventional Cardiology Unit, ASST Fatebenefratelli-Sacco, Milan, Italy
| | - Nicola Ryan
- Hospital Clínico San Carlos, IDISSC, and Universidad Complutense de Madrid, Madrid, Spain
| | - Mario Bo
- Section of Geriatrics, Department of Medical Sciences, Università degli Studi di Torino, A.O.U. Città della Salute e della Scienza di Torino, Turin, Italy
| | - Carlo di Mario
- Division of Structural Interventional Cardiology, Careggi University Hospital, Florence, Italy
| | | | - Francesco Burzotta
- Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy
| | | | - Javier Escaned
- Hospital Clínico San Carlos, IDISSC, and Universidad Complutense de Madrid, Madrid, Spain
| | - Gerard Helft
- Pierre and Marie Curie University, Paris, France
| | - Gaetano Maria De Ferrari
- Division of Cardiology, Department of Internal Medicine, Città della Salute e della Scienza, University of Turin, Turin, Italy
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19
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Azzalini L, Stone GW. Percutaneous Coronary Intervention or Surgery for Unprotected Left Main Disease: EXCEL Trial at 5 Years. Interv Cardiol Clin 2020; 9:419-432. [PMID: 32921366 DOI: 10.1016/j.iccl.2020.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Although coronary artery bypass graft (CABG) surgery traditionally has been considered the gold standard for left main revascularization, percutaneous coronary intervention has evolved in the past decades so that it now represents a valid alternative to CABG in a large proportion of cases. The landmark Evaluation of XIENCE versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization (EXCEL) trial is the largest contemporary randomized comparison assessing the impact of revascularization strategies for left main disease. This review discusses the background, rationale, design, results, and implications of the EXCEL trial.
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Affiliation(s)
- Lorenzo Azzalini
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, NY 10029, USA. https://twitter.com/SportsDoc2009
| | - Gregg W Stone
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, NY 10029, USA; The Cardiovascular Research Foundation, New York, NY, USA.
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20
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Kalil RAK, Sant´Anna RT, Salles FBD. Controversies in the Indications of Percutaneous Angioplasty Or Coronary Artery Bypass Grafting In The Treatment Of Left Main Disease. INTERNATIONAL JOURNAL OF CARDIOVASCULAR SCIENCES 2020. [DOI: 10.36660/ijcs.20200037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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21
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Validation of bifurcation DEFINITION criteria and comparison of stenting strategies in true left main bifurcation lesions. Sci Rep 2020; 10:10461. [PMID: 32591602 PMCID: PMC7320001 DOI: 10.1038/s41598-020-67369-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 06/05/2020] [Indexed: 11/24/2022] Open
Abstract
There are controversies on optimal stenting strategy regarding true left main (LM) bifurcation lesions. The present study compared 1- and 2-stenting strategy for patients with true LM bifurcation lesions as differentiated by DEFINITION criteria. 928 patients with true LM bifurcation lesions (Medina 1,1,1 or 0,1,1) treated with DES were enrolled consecutively. 297 (32.0%) patients were identified as complex LM bifurcation, and 631 (68.0%) patients into simple LM bifurcation group according to DEFINTION criteria. Patients in complex vs. simple LM bifurcation group had significantly higher major adverse cardiac event (MACE, including cardiac death, myocardial infarction [MI] and ischemia-driven target vessel revascularization) rate at 30 days (7.8% vs. 4.0%, p = 0.01), 1 year (10.3% vs. 6.4%, p = 0.04), and numerically at 3 years (14.2% vs. 10.1%, p = 0.07), which was mainly driven by increased MI. Moreover, patients in the 2-stent strategy group had strong trend towards lower incidence of cardiac death in both complex LM bifurcation group (2.0% vs. 5.9%, p = 0.08) and simple LM bifurcation group (1.9% vs. 4.5%, p = 0.07). In conclusion, the complex bifurcation lesion criteria established in DEFINITION study was able to risk-stratify LM bifurcation patients. Two-stent technique yielded numerically lower 3-year cardiac mortality regardless of LM bifurcation complexity.
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22
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Evaluation of Left Main Coronary Artery Using Optical Frequency Domain Imaging and Its Pitfalls. J Interv Cardiol 2020; 2020:4817239. [PMID: 32581660 PMCID: PMC7306070 DOI: 10.1155/2020/4817239] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Accepted: 05/21/2020] [Indexed: 11/09/2022] Open
Abstract
Objectives We aimed to assess the quality of optical frequency domain imaging (OFDI) of the left main (LM) arterial wall and describe and analyse potential artefacts in this setting. Background OFDI is increasingly used to assess ambiguous lesions and optimize LM percutaneous coronary intervention. However, its ability to provide artefact-free high-quality images of coronary ostia and large segments such as the LM remains uncertain. Methods We included 42 consecutive patients who underwent OFDI, including LM imaging. Each OFDI frame was subdivided into four quadrants and analysed. The number of quadrants with artifacts was calculated within the proximal, mid, and distal LM and the first 5 mm of the left anterior descending artery (LAD) and/or left circumflex artery (LCX). Results The quadrants analysis showed an overall artifact rate of 8.9%, mostly out-of-field (45.1%) or residual blood (44.7%) artefacts. Most artifacts were located in the proximal LM (18.6%) with a stepwise reduction of artifact rates towards distal segments (mid LM 5.8%; distal LM 3.6%, ostial LAD 2.6%, and ostial LCX 0%; p < 0.001). While 20 (48.8%) patients had angiographically visible plaques, OFDI showed plaques in 32 patients (76.2%; p=0.007). Conclusion OFDI can accurately evaluate the LM and detect and assess angiographically unvisualized atherosclerotic plaques providing accurate assessment of >90% of the quadrants of the LM and the ostia of its bifurcation branches. However, artifacts mainly located in the proximal LM and decreasing distally in a stepwise fashion should be considered in the interpretation of OFDI in this setting.
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23
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Chiarito M, Mehilli J. Left main coronary artery disease: when and how to perform PCI? Minerva Cardioangiol 2020; 68:405-414. [PMID: 32107900 DOI: 10.23736/s0026-4725.20.05198-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Left main coronary artery (LMCA) disease has been reported in up to 10% of all patients with coronary artery disease (CAD) and in the majority of cases are associated with severe three-vessel CAD. Among patients with chronic coronary syndrome revascularization of significant LMCA disease improves prognosis, while there is a debate about which revascularization strategy, CABG surgery or percutaneous coronary interventions to use. We do a review of the available evidence about the impact of LMCA lesions on patient prognosis according to CAD extension and clinical presentation, the outcome after percutaneous or surgical revascularization, the procedural challenges of LMCA PCI and the available armamentarium to optimally treat this relevant population.
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Affiliation(s)
- Mauro Chiarito
- Cardio Center, Humanitas Research Hospital, Rozzano, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Julinda Mehilli
- Department of Cardiology, Munich University Hospital, Ludwig-Maximilians University, Munich, Germany - .,German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany
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25
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Choi KH, Song YB, Lee JM, Park TK, Yang JH, Hahn JY, Choi JH, Choi SH, Kim HS, Chun WJ, Hur SH, Han SH, Rha SW, Chae IH, Jeong JO, Heo JH, Yoon J, Lim DS, Park JS, Hong MK, Doh JH, Cha KS, Kim DI, Lee SY, Chang K, Hwang BH, Choi SY, Jeong MH, Hong SJ, Nam CW, Koo BK, Gwon HC. Prognostic Effects of Treatment Strategies for Left Main Versus Non-Left Main Bifurcation Percutaneous Coronary Intervention With Current-Generation Drug-Eluting Stent. Circ Cardiovasc Interv 2020; 13:e008543. [DOI: 10.1161/circinterventions.119.008543] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Although 1-stent with provisional approach is the preferred strategy for the treatment of bifurcation lesions, the optimal treatment strategy according to lesion location is still debatable. This study aimed to identify whether clinical outcomes according to treatment strategy differed between left main (LM) and non-LM bifurcation lesions in the second-generation drug-eluting stent era.
Methods:
The Coronary Bifurcation Stenting registry III is a retrospective multicenter registry of 2648 patients with bifurcation lesions who underwent percutaneous coronary intervention with second-generation drug-eluting stent. Among the study population, 935 (35.3%) patients had an LM bifurcation lesion. The primary outcome was target lesion failure, a composite of cardiac death, myocardial infarction, and target lesion revascularization.
Results:
Median follow-up duration was 53 months. LM bifurcation was associated with a higher risk of target lesion failure (HR
adj
, 1.846 [95% CI, 1.317–2.588];
P
<0.001) than non-LM bifurcation. Two-stent strategy was more frequently applied in patients with LM bifurcation than in patients with non-LM bifurcation (27.1% versus 11.7%;
P
<0.001). In the LM bifurcation group, compared with the 1-stent strategy, the 2-stent strategy showed a significantly higher risk of target lesion failure (2-stent versus 1-stent, 17.4% versus 10.6%; HR
adj
, 1.848 [95% CI, 1.045–3.266];
P
=0.035), mainly driven by the higher rate of target lesion revascularization (15.3% versus 5.5%; HR
adj
, 2.698 [95% CI, 1.276–5.706];
P
=0.009). However, the risk of cardiac death or myocardial infarction did not differ between the 2 groups (4.4% versus 6.6%; HR
adj
, 0.694 [95% CI, 0.306–1.572];
P
=0.381). For patients with non-LM-bifurcation, there was no significant difference in the rate of target lesion failure between 1-stent and 2-stent strategies (5.6% versus 6.3%; HR
adj
, 0.925 [95% CI, 0.428–2.001];
P
=0.843).
Conclusions:
Even in the second-generation drug-eluting stent era, the 1-stent strategy, if possible, should initially be considered the preferred approach for the treatment of LM bifurcation lesions.
Registration:
URL:
https://www.clinicaltrials.gov
. Unique identifier: NCT03068494.
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Affiliation(s)
- Ki Hong Choi
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea (K.H.C., Y.B.S., J.M.L., T.K.P., J.H.Y., J.-Y.H., J.-H.C., S.-H.C., H.-C.G.)
| | - Young Bin Song
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea (K.H.C., Y.B.S., J.M.L., T.K.P., J.H.Y., J.-Y.H., J.-H.C., S.-H.C., H.-C.G.)
| | - Joo Myung Lee
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea (K.H.C., Y.B.S., J.M.L., T.K.P., J.H.Y., J.-Y.H., J.-H.C., S.-H.C., H.-C.G.)
| | - Taek Kyu Park
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea (K.H.C., Y.B.S., J.M.L., T.K.P., J.H.Y., J.-Y.H., J.-H.C., S.-H.C., H.-C.G.)
| | - Jeong Hoon Yang
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea (K.H.C., Y.B.S., J.M.L., T.K.P., J.H.Y., J.-Y.H., J.-H.C., S.-H.C., H.-C.G.)
| | - Joo-Yong Hahn
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea (K.H.C., Y.B.S., J.M.L., T.K.P., J.H.Y., J.-Y.H., J.-H.C., S.-H.C., H.-C.G.)
| | - Jin-Ho Choi
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea (K.H.C., Y.B.S., J.M.L., T.K.P., J.H.Y., J.-Y.H., J.-H.C., S.-H.C., H.-C.G.)
| | - Seung-Hyuk Choi
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea (K.H.C., Y.B.S., J.M.L., T.K.P., J.H.Y., J.-Y.H., J.-H.C., S.-H.C., H.-C.G.)
| | - Hyo-Soo Kim
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Republic of Korea (H.-S.K., B.-K.K.)
| | - Woo Jung Chun
- Division of Cardiology, Department of Internal Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Republic of Korea (W.J.C.)
| | - Seung-Ho Hur
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Medical Center, Daegu, Republic of Korea (S.-H.H.)
| | - Seung Hwan Han
- Division of Cardiology, Department of Internal Medicine, Gachon University Gil Hospital, Incheon, Republic of Korea (S.H.H.)
| | - Seung-Woon Rha
- Division of Cardiology, Department of Internal Medicine, Korea University Guro Hospital, Seoul, Republic of Korea (S.-W.R.)
| | - In-Ho Chae
- Division of Cardiology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, Republic of Korea (I.-H.C.)
| | - Jin-Ok Jeong
- Division of Cardiology, Department of Medicine, Chungnam National University Hospital, Daejeon, Republic of Korea (J.-O.J.)
| | - Jung Ho Heo
- Division of Cardiology, Department of Internal Medicine, Kosin University Gospel Hospital, Kosin University College of Medicine, Busan, Republic of Korea (J.H.H.)
| | - Junghan Yoon
- Division of Cardiology, Department of Internal Medicine, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Republic of Korea (J.Y.)
| | - Do-Sun Lim
- Division of Cardiology, Department of Internal Medicine, Korea University Anam Hospital, Seoul, Republic of Korea (D.-S.L., S.-J.H.)
| | - Jong-Seon Park
- Division of Cardiology, Department of Internal Medicine, Yeungnam University Medical Center, Daegu, Republic of Korea (J.-S.P.)
| | - Myeong-Ki Hong
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea (M.-K.H.)
| | - Joon-Hyung Doh
- Division of Cardiology, Department of Internal Medicine, Inje University Ilsan Paik Hospital, Goyang, Republic of Korea (J.-H.D.)
| | - Kwang Soo Cha
- Division of Cardiology, Department of Internal Medicine, Pusan National University Hospital, Busan, Republic of Korea (K.S.C.)
| | - Doo-Il Kim
- Division of Cardiology, Department of Internal Medicine, Inje University Haeundae Paik Hospital, Goyang, Republic of Korea (D.-I.K.)
| | - Sang Yeub Lee
- Division of Cardiology, Department of Internal Medicine, Chungbuk National University College of Medicine, Cheongju, Republic of Korea (S.Y.L.)
| | - Kiyuk Chang
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea, Republic of Korea (K.C.)
| | - Byung-Hee Hwang
- Division of Cardiology, Department of Internal Medicine, St. Paul’s Hospital, The Catholic University of Korea, Seoul, Republic of Korea (B.-H.H.)
| | - So-Yeon Choi
- Division of Cardiology, Department of Internal Medicine, Ajou University Hospital, Suwon, Republic of Korea (S.-Y.C.)
| | - Myung Ho Jeong
- Division of Cardiology, Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Korea (M.H.J.)
| | - Soon-Jun Hong
- Division of Cardiology, Department of Internal Medicine, Korea University Anam Hospital, Seoul, Republic of Korea (D.-S.L., S.-J.H.)
| | | | - Bon-Kwon Koo
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Republic of Korea (H.-S.K., B.-K.K.)
| | - Hyeon-Cheol Gwon
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea (K.H.C., Y.B.S., J.M.L., T.K.P., J.H.Y., J.-Y.H., J.-H.C., S.-H.C., H.-C.G.)
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26
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Valle JA, Tamez H, Abbott JD, Moussa ID, Messenger JC, Waldo SW, Kennedy KF, Masoudi FA, Yeh RW. Contemporary Use and Trends in Unprotected Left Main Coronary Artery Percutaneous Coronary Intervention in the United States: An Analysis of the National Cardiovascular Data Registry Research to Practice Initiative. JAMA Cardiol 2020; 4:100-109. [PMID: 30601910 DOI: 10.1001/jamacardio.2018.4376] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance 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. Objective To define the current practice of ULM PCI and its outcomes and compare these with findings reported in clinical trials. Design, Setting, and Participants 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. Main Outcomes and Measures 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. Results 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. Conclusions and Relevance 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.
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Affiliation(s)
- Javier A Valle
- Rocky Mountain Veterans Affairs Medical Center, Aurora, Colorado.,University of Colorado School of Medicine, Aurora
| | - Hector Tamez
- Richard and Susan Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - J Dawn Abbott
- Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Issam D Moussa
- Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | | | - Stephen W Waldo
- Rocky Mountain Veterans Affairs Medical Center, Aurora, Colorado.,University of Colorado School of Medicine, Aurora
| | | | | | - Robert W Yeh
- Richard and Susan Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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27
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Paul TK. Percutaneous Coronary Intervention Versus Coronary Artery Bypass Graft in Left Main Revascularisation. Heart Int 2020; 14:11-12. [DOI: 10.17925/hi.2020.14.1.11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 02/25/2020] [Indexed: 11/24/2022] Open
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28
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Revascularization for Coronary Artery Disease: Principle and Challenges. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2020; 1177:75-100. [PMID: 32246444 DOI: 10.1007/978-981-15-2517-9_3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Coronary revascularization is the most important strategy for coronary artery disease. This review summarizes the current most prevalent approaches for coronary revascularization and discusses the evidence on the mechanisms, indications, techniques, and outcomes of these approaches. Targeting coronary thrombus, fibrinolysis is indicated for patients with diagnosed myocardial infarction and without high risk of severe hemorrhage. The development of fibrinolytic agents has improved the outcomes of ST-elevation myocardial infarction. Percutaneous coronary intervention has become the most frequently performed procedure for coronary artery disease. The evolution of stents plays an important role in the result of the procedure. Coronary artery bypass grafting is the most effective revascularization approach for stenotic coronary arteries. The choice of conduits and surgical techniques are important determinants of patient outcomes. Multidisciplinary decision-making should analyze current evidence, considering the clinical condition of patients, and determine the safety and necessity for coronary revascularization with either PCI or CABG. For coronary artery disease with more complex lesions like left main disease and multivessel disease, CABG results in more complete revascularization than PCI. Furthermore, comorbidities, such as heart failure and diabetes, are always correlated with adverse clinical events, and a routine invasive strategy should be recommended. For patients under revascularization, secondary prevention therapies are also of important value for the prevention of subsequent adverse events.
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29
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Wang TKM, Kerr A, Kasargod C, Chan D, Cicovic S, Dimalapang E, Webster M, Somaratne J. Percutaneous Coronary Intervention for Left Main Coronary Disease in New Zealand: National Linkage Study of Characteristics and In-Hospital Outcomes (ANZACS-QI 38). CARDIOVASCULAR REVASCULARIZATION MEDICINE 2019; 21:573-579. [PMID: 31481307 DOI: 10.1016/j.carrev.2019.08.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 08/16/2019] [Accepted: 08/19/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Approximately 5% of coronary angiographies detect LMS disease >50%. Recent randomized trials showed PCI has comparable outcomes to coronary artery bypass grafting (CABG) in low or intermediate risk candidates. In clinical practice, PCI is frequently utilized in those with prohibitive surgical risk. We reviewed contemporary national results of percutaneous coronary intervention (PCI) for left main coronary disease (LMS) disease in New Zealand. METHODS All patients undergoing PCI for LMS disease from 01/09/2014-24/09/2017 were extracted from the All New Zealand Acute Coronary Syndrome-Quality Improvement registry with national dataset linkage, analyzing characteristics and in-hospital outcomes. RESULTS The cohort included 469 patients, mean age 70.8 ± 10.7 years, male 331 (71%), and the majority 339 (72%) were unprotected LMS. Indications include ST-elevation myocardial infarction (STEMI) 83 (18%) and NSTEMI or unstable angina 229 (49%). Compared with protected LMS, unprotected LMS were more likely to present with an acute coronary syndrome (73% versus 48%, P < 0.001), and to die in-hospital (9.4% versus 3.9%, P = 0.045). In those with unprotected LMS, in-hospital mortality after acute STEMI PCI was higher than for other indications (21.1% versus 6.1%, P < 0.001). Independent predictors of in-hospital death and major adverse cardiovascular events included STEMI, femoral access and worse renal function. CONCLUSION Our LMS PCI cohort had high mortality rates, especially those presenting with STEMI and an unprotected LMS. This reflects the contemporary real-world practice of LMS PCI being predominantly performed in high risk patients which differs from randomized trial populations, and this should be considered before comparing with CABG outcomes.
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Affiliation(s)
- Tom Kai Ming Wang
- Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand; Department of Cardiology, Middlemore Hospital, Auckland, New Zealand.
| | - Andrew Kerr
- Department of Cardiology, Middlemore Hospital, Auckland, New Zealand; Department of Medicine, University of Auckland, Auckland, New Zealand
| | - Chethan Kasargod
- Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand
| | - Daniel Chan
- Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand
| | - Sergej Cicovic
- Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand
| | - Eliazar Dimalapang
- Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand
| | - Mark Webster
- Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand
| | - Jithendra Somaratne
- Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand
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30
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Intravascular ultrasound-guided drug-eluting stent implantation for patients with unprotected left main coronary artery lesions: A single-center randomized trial. Anatol J Cardiol 2019; 21:83-90. [PMID: 30694800 PMCID: PMC6457420 DOI: 10.14744/anatoljcardiol.2018.21447] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Objective: Intravascular ultrasound (IVUS) has developed as a preferable choice for optimizing the stenting procedures mainly because it will have good access to vessel size, lesion length, or severity accurately. However, it still remains unclear about the benefits of IVUS guidance in drug-eluting stent (DES) implantation for patients with unprotected left main coronary artery (ULMCA) stenosis. The aim of the present study was to evaluate the clinical outcomes with respect to IVUS-guided DES implantation for these patients. Methods: A total of 336 consecutive patients from December 2010 to December 2015 were enrolled in the study. The patients were then randomly assigned into two groups: IVUS-guided group (n=167) and control group (n=169). The primary endpoint was the incidence of composite major adverse cardiac events (MACEs), including cardiac death, myocardial infarction (MI), and target vessel revascularization (TVR). The risk of stent thrombosis (ST) was chosen as the safety endpoint. Results: After a 1-year follow-up, the occurrence of composite MACE in the IVUS-guided group was significantly lower than that in the control group (13.2% vs. 21.9%, p=0.031), which might mainly result from the significant reduction in the risk of cardiac death (1.8% vs. 5.9%, p=0.048). Dramatically, the risk of MI did not differ significantly between the two groups (11.4% vs. 13.6%, p=0.478), though a tended reduction in TVR was observed under IVUS guidance (4.2% vs. 8.9%, p=0.068). There was no statistical significance between the two groups with respect to the risk of target lesion revascularization (IVUS-guided vs. control: 1.2% vs. 3.0%, p=0.239) and ST (IVUS-guided vs. control: 1.2% vs. 3.0%, p=0.246). Conclusion: The possible feasibility of IVUS-guided DES implantation for patients with ULMCA stenosis was supported by the present study. Larger and more powerful randomized trials were still warranted to research the whole benefits of IVUS guidance for these patients.
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31
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Ahmed Z, Bravo CA, Mori M, Rios Herrera SA, Gluud C, Kataria R, Zarich SW, Hirji SA, Desai NR, Bhatt DL. Coronary artery bypass grafting surgery versus percutaneous coronary intervention for coronary artery disease. Hippokratia 2019. [DOI: 10.1002/14651858.cd013374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Zain Ahmed
- Yale School of Medicine; Department of Cardiovascular Medicine; New Haven USA
| | - Claudio A Bravo
- Albert Einstein College of Medicine, Montefiore Medical Center; Montefiore Einstein Center for Heart & Vascular Care; 111 East 210th Street Bronx New York USA 10467
| | - Makoto Mori
- Yale School of Medicine; Department of Cardiac Surgery; New Haven USA
| | | | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital; Cochrane Hepato-Biliary Group; Blegdamsvej 9 Copenhagen Denmark DK-2100
| | - Rachna Kataria
- Montefiore Medical Center, Albert Einstein College of Medicine; Department of Cardiovascular Disease; Bronx NY USA
| | - Stuart W Zarich
- Yale School of Medicine; Department of Cardiology; New Haven USA
| | - Sameer A Hirji
- Brigham and Women's Hospital, Harvard Medical School; Department of Surgery; 75 Francis Street Boston MA USA 02115
| | - Nihar R Desai
- Yale School of Medicine; Department of Cardiovascular Medicine; New Haven USA
| | - Deepak L Bhatt
- Brigham and Women's Hospital; Heart & Vascular Centre; 75 Francis Street Boston MA USA 02115
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32
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Abstract
PURPOSE OF REVIEW Non-ST-elevation myocardial infarction (NSTEMI) is an urgent medical condition that requires prompt application of simultaneous pharmacologic and non-pharmacologic therapies. The variation in patient clinical characteristics coupled with the multitude of treatment modalities makes optimal and timely management challenging. This review summarizes risk stratification of patients, the role and timing of revascularization, and highlights important considerations in the revascularization approach with attention to individual patient characteristics. RECENT FINDINGS The early invasive management of NSTEMI has fostered a reduction in future ischemic events. Risk calculators are helpful in determining which patients should receive early invasive management. As many patients have multivessel disease, identifying the true culprit lesion can be challenging. Special attention should be given to those at the highest risk, such as diabetics, patients with renal failure, and those with left main disease. In patients with acute coronary syndrome, the decision and mode of revascularization should carefully integrate the patient's clinical characteristics as well as the complexity of the coronary anatomy.
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Affiliation(s)
- Bennet George
- Division of Cardiovascular Medicine, Gill Heart and Vascular Institute, University of Kentucky, 900 S. Limestone Street, 326 Wethington Bldg, Lexington, KY, 40536-0200, USA
| | - Naoki Misumida
- Division of Cardiovascular Medicine, Gill Heart and Vascular Institute, University of Kentucky, 900 S. Limestone Street, 326 Wethington Bldg, Lexington, KY, 40536-0200, USA
| | - Khaled M Ziada
- Division of Cardiovascular Medicine, Gill Heart and Vascular Institute, University of Kentucky, 900 S. Limestone Street, 326 Wethington Bldg, Lexington, KY, 40536-0200, USA.
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33
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Taha Y, Patel RAG, Bagai J, Sachdeva R, Kumar G, Prasad A, Nathan S, Paul TK. Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting in Treatment of Unprotected Left Main Stenosis. Curr Cardiol Rep 2019; 21:27. [PMID: 30880360 DOI: 10.1007/s11886-019-1113-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
PURPOSE OF REVIEW This article reviews the latest data on unprotected left main (ULM) percutaneous coronary intervention (PCI) versus coronary artery bypass graft (CABG) surgery, with a focus on the NOBLE and EXCEL trials. RECENT FINDINGS In EXCEL trial, the primary endpoint at 3 years was 15.4% in the PCI group and 14.7% in the CABG group (p = 0.02 for non-inferiority of PCI versus CABG). In NOBLE, the primary endpoint at 5 years was 28% and 18% for PCI and CABG, respectively (HR 1.51, CI 1.13-2.0, which did not meet the criteria for non-inferiority of PCI to CABG; p for superiority of CABG was 0.0044). Higher repeat revascularization and non-procedural myocardial infarction were noted in PCI group but there was no difference in all-cause or cardiac mortality between the two groups. A heart team approach with appropriate patient selection, careful assessment of LM lesions, and meticulous procedural technique makes PCI a valid alternative to CABG for ULM stenosis.
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Affiliation(s)
- Yasir Taha
- Morehouse School of Medicine, Atlanta, GA, USA
| | | | - Jayant Bagai
- Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Gautam Kumar
- Emory University School of Medicine, Atlanta, GA, USA
| | - Anand Prasad
- University of Texas at San Antonio, San Antonio, TX, USA
| | | | - Timir K Paul
- Division of Cardiology, Department of Internal Medicine, East Tennessee State University, 329 N State of Franklin Rd, Johnson City, TN, 37604, USA.
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34
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Bajaj NS, Patel N, Kalra R, Marogil P, Bhardwaj A, Arora G, Arora P. Percutaneous coronary intervention vs. coronary artery bypass grafting for left main revascularization: an updated meta-analysis. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2018; 3:173-182. [PMID: 28838092 DOI: 10.1093/ehjqcco/qcx008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Accepted: 03/14/2017] [Indexed: 12/25/2022]
Abstract
Aims The optimal revascularization strategy for left main coronary artery disease (LMD) remains controversial, especially with two recent randomized controlled trials showing conflicting results. We sought to address this controversy with our analysis. Methods and results Comprehensive literature search was performed. We compared percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) for LMD revascularization using standard meta-analytic techniques. A 21% higher risk of long-term major adverse cardiac and cerebrovascular event [MACCE; composite of death, myocardial infarction (MI), stroke, and repeat revascularization] was observed in patients undergoing PCI in comparison with CABG [risk ratio (RR) 1.21, 95% confidence interval (CI) 1.05-1.40]. This risk was driven by higher rate of repeat revascularization in those undergoing PCI (RR 1.61, 95% CI 1.34-1.95). On the contrary, MACCE rates at 30 days were lower in PCI when compared with CABG (RR 0.55, 95% CI 0.39-0.76), which was driven by lower rates of stroke in the PCI arm (RR 0.41, 95% CI 0.17-0.98). At 1 year, lower stroke rates (RR 0.21, 95% CI 0.08-0.59) in the PCI arm were balanced by higher repeat revascularization rates in those undergoing PCI (RR 1.78, 95% CI 1.33-2.37), resulting in a clinical equipoise in MACCE rates between the two revascularization strategies. There was no difference in death or MI between PCI when compared with CABG at any time point. Conclusion Outcomes of CABG vs. PCI for LMD revascularization vary over time. Therefore, individualized decisions need to be made for LMD revascularization using the heart team approach.
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Affiliation(s)
- Navkaranbir S Bajaj
- Division of Cardiovascular Medicine, Department of Radiology, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115, USA.,Division of Cardiovascular Diseases, Department of Medicine, University of Alabama at Birmingham, 1900 University Boulevard Birmingham, AL 35233, USA
| | - Nirav Patel
- Division of Cardiovascular Diseases, Department of Medicine, University of Alabama at Birmingham, 1900 University Boulevard Birmingham, AL 35233, USA
| | - Rajat Kalra
- Cardiovascular Division, University of Minnesota, 420 Delaware St SE, Minneapolis, MN 55455, USA
| | - Peter Marogil
- Department of Internal Medicine, Brookwood Baptist Health, 2010 Brookwood Medical Center Drive Birmingham, AL 35209, USA
| | - Ashwanikumar Bhardwaj
- Division of Cardiovascular Diseases, Department of Medicine, University of Alabama at Birmingham, 1900 University Boulevard Birmingham, AL 35233, USA
| | - Garima Arora
- Division of Cardiovascular Diseases, Department of Medicine, University of Alabama at Birmingham, 1900 University Boulevard Birmingham, AL 35233, USA
| | - Pankaj Arora
- Division of Cardiovascular Diseases, Department of Medicine, University of Alabama at Birmingham, 1900 University Boulevard Birmingham, AL 35233, USA.,Section of Cardiology, Birmingham Veterans Affairs Medical Center, 700 19th St S, Birmingham, AL 35233, USA
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35
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Percutaneous Left Main Coronary Intervention: A Review of Plaque Modification in Left Main Percutaneous Coronary Intervention. J Clin Med 2018; 7:jcm7070180. [PMID: 30041422 PMCID: PMC6068647 DOI: 10.3390/jcm7070180] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Revised: 07/19/2018] [Accepted: 07/20/2018] [Indexed: 12/01/2022] Open
Abstract
Left main coronary artery (LMCA) stenosis has long been recognized as a marker of increased morbidity and mortality. Current treatment algorithms for LMCA stenosis consider both percutaneous coronary intervention (PCI) with drug eluting stents (DES) and coronary bypass surgery, each with advantages based on individual patient characteristics. Since the LMCA is the largest artery in the coronary tree, plaque volume and calcification is greater than other coronary segments and often extends to the distal bifurcation segment. In LMCA bifurcation lesions, larger minimal stent area is strongly associated with better outcome in the DES era. Plaque modification strategies such as rotational, orbital, or laser atherectomy are effective mechanisms to reduce plaque volume and alter compliance, facilitating stent delivery and stent expansion. We present a case of a calcified, medina class 1,1,1 LMCA lesion where intravascular ultrasound (IVUS) and orbital atherectomy were employed for optimal results. In this context, we review the evidence of plaque modification devices and the rationale for their use in unprotected left main PCI.
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Weir-McCall JR, Blanke P, Sellers SL, Ahmadi AA, Andreini D, Budoff MJ, Cademartiri F, Chinnaiyan K, Choi JH, Chun EJ, Conte E, Gottlieb I, Hadamitzky M, Kim YJ, Lee BK, Lee SE, Maffei E, Marques H, Pontone G, Raff GL, Shin S, Sung JM, Stone P, Samady H, Virmani R, Narula J, Berman DS, Shaw LJ, Bax JJ, Lin FY, Min JK, Chang HJ, Leipsic JA. Impact of Non-obstructive left main disease on the progression of coronary artery disease: A PARADIGM substudy. J Cardiovasc Comput Tomogr 2018; 12:231-237. [DOI: 10.1016/j.jcct.2018.05.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Revised: 05/10/2018] [Accepted: 05/13/2018] [Indexed: 01/17/2023]
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Operator Experience and Outcomes After Left Main Percutaneous Coronary Intervention. Curr Cardiol Rep 2018; 20:29. [PMID: 29572751 DOI: 10.1007/s11886-018-0972-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
PURPOSE OF REVIEW This review was performed with the goal of summarizing the role of operator experience in the treatment of severe left main stenosis by percutaneous intervention techniques. RECENT FINDINGS The Evaluation of XIENCE versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization (EXCEL) trial demonstrated that percutaneous coronary intervention and coronary artery bypass grafting had similar clinical outcomes for severe left main disease. However, PCI of the left main coronary stenosis is considered to be a high-risk intervention because of the large area of myocardium at jeopardy that can quickly cause hemodynamic compromise. Operator experience and familiarity with the use of hemodynamic support devices, plaque modification techniques, and intravascular imaging tools is associated with better clinical outcomes. In patients with severe left main stenosis undergoing percutaneous coronary intervention by high-volume operators, the clinical outcomes are superior.
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Ali WE, Vaidya SR, Ejeh SU, Okoroafor KU. Meta-analysis study comparing percutaneous coronary intervention/drug eluting stent versus coronary artery bypass surgery of unprotected left main coronary artery disease: Clinical outcomes during short-term versus long-term (> 1 year) follow-up. Medicine (Baltimore) 2018; 97:e9909. [PMID: 29443766 PMCID: PMC5839846 DOI: 10.1097/md.0000000000009909] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Results on the safety and long-term efficacy of drug-eluting stent placement in unprotected left main coronary artery disease (ULMCAD) compared with those of coronary artery bypass surgery (CABG) remain inconsistent across randomized clinical trials and recent meta-analysis studies. We aimed to compare the clinical outcomes and safety over short- and long-term follow-ups by conducting a meta-analysis of large pooled data from randomized controlled trials and up-to-date observational studies. METHODS A systematic review of PubMed, Google Scholar, Medline, and reference lists of related articles was performed for studies conducted in the drug-eluting stent era, to compare percutaneous coronary intervention (PCI) with CABG in ULMCAD. The primary outcome was major adverse cardiovascular and cerebrovascular events (MACCE), myocardial infarction (MI), stroke, all-cause mortality, and revascularization after at least 1-year follow-up. In-hospital and 30-day clinical outcomes were considered secondary outcomes. Furthermore, a subgroup analysis of studies with ≥5 years follow-up was performed to test the sustainability of clinical outcomes. RESULTS A total of 29 studies were extracted with 21,832 patients (10,424 in PCI vs 11,408 in CABG). Pooled analysis demonstrated remarkable differences in long-term follow-up (≥1 year) MACCE (odds ratio [OR] 1.42, 95% CI 1.27-1.59), P < .00001), repeat revascularization (OR 3.00, 95% CI 2.41-3.73, P < .00001), and MI (OR 1.32, 95% CI 1.14-1.53, P = .0002), favoring CABG over PCI. However, stroke risk was significantly lower in the PCI group. Subgroup analysis of studies with ≥5 years follow-up showed similar outcomes except for the noninferiority outcome of MACCE in the PCI arm. However, the PCI group proved good safety profile after a minimum of 30-day follow-up with lower MACCE outcome. CONCLUSION PCI for ULMCAD can be applied with attentiveness in carefully selected patients. MI and the need for revascularization remain drawbacks and areas of concern among previous studies. Nonetheless, it has been proven safe during short-term follow-up.
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Affiliation(s)
- Waleed E. Ali
- Department of Internal Medicine, Cape Fear Valley Medical Center, affiliated with Campbell University School of Osteopathic Medicine
- Department of Medicine—Cardiology, Cape Fear Valley Medical Center, Fayetteville, NC
| | - Satyanarayana R. Vaidya
- Department of Internal Medicine, Cape Fear Valley Medical Center, affiliated with Campbell University School of Osteopathic Medicine
- Department of Medicine—Cardiology, Cape Fear Valley Medical Center, Fayetteville, NC
| | - Sylvester U. Ejeh
- Department of Internal Medicine, Cape Fear Valley Medical Center, affiliated with Campbell University School of Osteopathic Medicine
- Department of Medicine—Cardiology, Cape Fear Valley Medical Center, Fayetteville, NC
| | - Kingsley U. Okoroafor
- Department of Medicine—Cardiology, Cape Fear Valley Medical Center, Fayetteville, NC
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Kim HL, Oh SW, Lee H, Kim HJ, Kim YN, Lim WH, Seo JB, Kim SH, Kim MA, Zo JH. Findings of Single-Photon Emission Computed Tomography and Its Relation with Quantitative Coronary Angiography in Patients with Significant Stenosis of the Left Main Coronary Artery. Korean J Radiol 2018; 19:101-110. [PMID: 29354006 PMCID: PMC5768490 DOI: 10.3348/kjr.2018.19.1.101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Accepted: 07/18/2017] [Indexed: 11/29/2022] Open
Abstract
Objective Unrecognized left main coronary artery disease (LMCD) is often fatal; however, accuracy of non-invasive tests for diagnosing LMCD is still unsatisfactory. This study was performed to elucidate single-photon emission computed tomography (SPECT) detection of LMCD using quantitative coronary angiography (QCA) data. Materials and Methods Fifty-five patients (39 men; mean age, 68.1 ± 10.9 years) diagnosed with significant left main (LM) stenosis (≥ 50%) by invasive coronary angiography (ICA) were retrospectively reviewed. All study patients underwent SPECT with pharmacologic stress within 30 days of ICA. All coronary lesions were quantified via QCA, and SPECT findings were compared with QCA results. Results Only four patients (7.3%) had isolated LMCD; all others had combined significant stenosis (≥ 70%) of one or more other epicardial coronary arteries. Patients with more severe coronary artery disease tended to have higher values for summed difference scores in a greater number of regions, but the specific pattern was not clearly defined. Summed stress score of SPECT did not differ according to LM stenosis severity. Only three patients (5.4%) had a typical LM pattern of reversible perfusion defect on SPECT. A significant negative linear correlation between stenosis severity and stress perfusion percent was found in the left anterior descending artery region (r = −0.455, p < 0.001) but not in the left circumflex artery. Conclusion Single-photon emission computed tomography findings were heterogeneous, not specific and poorly correlated to QCA data in patients with significant LMCD. This may be due to highly prevalent significant stenosis of other epicardial coronary arteries.
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Affiliation(s)
- Hack-Lyoung Kim
- Division of Cardiology, Department of Internal Medicine, Boramae Medical Center, Seoul National University College of Medicine, Seoul 07061, Korea
| | - So Won Oh
- Department of Nuclear Medicine, Boramae Medical Center, Seoul National University College of Medicine, Seoul 07061, Korea
| | - Hyunjong Lee
- Department of Nuclear Medicine, Boramae Medical Center, Seoul National University College of Medicine, Seoul 07061, Korea
| | - Hee Jun Kim
- Cardiovascular Center, Boramae Hospital, Seoul 07061, Korea
| | - You Nui Kim
- Cardiovascular Center, Boramae Hospital, Seoul 07061, Korea
| | - Woo-Hyun Lim
- Division of Cardiology, Department of Internal Medicine, Boramae Medical Center, Seoul National University College of Medicine, Seoul 07061, Korea
| | - Jae-Bin Seo
- Division of Cardiology, Department of Internal Medicine, Boramae Medical Center, Seoul National University College of Medicine, Seoul 07061, Korea
| | - Sang-Hyun Kim
- Division of Cardiology, Department of Internal Medicine, Boramae Medical Center, Seoul National University College of Medicine, Seoul 07061, Korea
| | - Myung-A Kim
- Division of Cardiology, Department of Internal Medicine, Boramae Medical Center, Seoul National University College of Medicine, Seoul 07061, Korea
| | - Joo-Hee Zo
- Division of Cardiology, Department of Internal Medicine, Boramae Medical Center, Seoul National University College of Medicine, Seoul 07061, Korea
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Al-Hijji M, El Sabbagh A, Holmes DR. Revascularization for Left Main and Multivessel Coronary Artery Disease: Current Status and Future Prospects after the EXCEL and NOBLE Trials. Korean Circ J 2018; 48:447-462. [PMID: 29856140 PMCID: PMC5986745 DOI: 10.4070/kcj.2018.0078] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Accepted: 04/18/2018] [Indexed: 11/21/2022] Open
Abstract
Revascularization of severe left main and multivessel coronary artery disease has been shown to improve survival in both stable ischemic heart disease and acute coronary syndrome. While revascularization with coronary artery bypass surgery for these disease entities carries class I recommendation in most current guidelines, recent trials has shown potential comparable survival and cardiovascular outcomes between percutaneous and surgical interventions in patients with less complex coronary anatomy. Despite the conflicting results observed in the most recent left main revascularization trials, Everolimus-Eluting Stents or Bypass Surgery for Left Main Coronary Artery Disease (EXCEL) and Nordic-Baltic-British left main revascularization (NOBLE), both treatment strategies remain important for the management of left main disease (LMD) and multivessel disease (MVD) reflecting on the importance of heart team discussion. This review is focused on revascularization of LMD and MVD in patients who are not presenting with ST-segment elevation myocardial infarction, encompassing the evidence from historic and contemporary trials which shaped up current practices. This review discusses the heart team approach to guide decision making, including special populations that are not represented in clinical trials.
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Affiliation(s)
- Mohammed Al-Hijji
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - David R Holmes
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA.
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Moore P, Burrage M, Garrahy P, Lim R, McCann A, Camuglia A. Drug-Eluting Stents Versus Coronary Artery Bypass Grafts for Left Main Coronary Disease: A Meta-Analysis and Review of Randomised Controlled Trials. Heart Lung Circ 2017; 27:1437-1445. [PMID: 29102437 DOI: 10.1016/j.hlc.2017.09.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 06/05/2017] [Accepted: 09/04/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Revascularisation of left main coronary artery (LMCA) disease can be potentially managed with percutaneous coronary intervention (PCI) or coronary artery bypass graft surgery (CABG). Recent randomised controlled trial (RCT) data have added to the literature on this subject and this meta-analysis aims to assess the state of the data to assist in guiding patient treatment decisions. METHODS A systematic literature search of Cochrane Library, EMBASE, OVID, and PubMed Medline was performed. Randomised controlled trials of patients with LMCA disease undergoing PCI with drug eluting stents or CABG were included. Clinical outcomes and adverse events were assessed and analysed. RESULTS Four suitable RCTs of adequate quality and follow-up were identified. The incidence of major adverse cardiac and cerebrovascular events (MACCE) at 3 to 5 years of follow-up was significantly increased with PCI compared to CABG (23.3% vs 18.2%, OR 1.37; 95% CI: 1.18-1.58; p=<0.0001; I2=0%) and was largely driven by more repeat revascularisation procedures among patients treated with PCI. There was no statistically significant difference in rates of mortality, myocardial infarction or stroke (either individually or when these outcomes were combined as a composite endpoint). CONCLUSIONS Coronary artery bypass grafting and PCI both represent reasonable treatment modalities for LMCA disease in appropriately selected patients. However, where CABG is feasible it offers superior long-term freedom from repeat revascularisation. Longer-term follow-up is required to further clarify the durability of mortality outcomes, especially in patients treated with PCI.
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Affiliation(s)
- Peter Moore
- Department of Cardiology, Princess Alexandra Hospital, Brisbane, Qld, Australia; School of Medicine, University of Queensland, Brisbane, Qld, Australia.
| | - Matthew Burrage
- Department of Cardiology, Princess Alexandra Hospital, Brisbane, Qld, Australia; School of Medicine, University of Queensland, Brisbane, Qld, Australia
| | - Paul Garrahy
- Department of Cardiology, Princess Alexandra Hospital, Brisbane, Qld, Australia; School of Medicine, University of Queensland, Brisbane, Qld, Australia
| | - Richard Lim
- Department of Cardiology, Princess Alexandra Hospital, Brisbane, Qld, Australia; School of Medicine, University of Queensland, Brisbane, Qld, Australia
| | - Andrew McCann
- Department of Cardiology, Princess Alexandra Hospital, Brisbane, Qld, Australia; School of Medicine, University of Queensland, Brisbane, Qld, Australia
| | - Anthony Camuglia
- Department of Cardiology, Princess Alexandra Hospital, Brisbane, Qld, Australia; School of Medicine, University of Queensland, Brisbane, Qld, Australia
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Chen SL, Zhang JJ, Han Y, Kan J, Chen L, Qiu C, Jiang T, Tao L, Zeng H, Li L, Xia Y, Gao C, Santoso T, Paiboon C, Wang Y, Kwan TW, Ye F, Tian N, Liu Z, Lin S, Lu C, Wen S, Hong L, Zhang Q, Sheiban I, Xu Y, Wang L, Rab TS, Li Z, Cheng G, Cui L, Leon MB, Stone GW. Double Kissing Crush Versus Provisional Stenting for Left Main Distal Bifurcation Lesions: DKCRUSH-V Randomized Trial. J Am Coll Cardiol 2017; 70:2605-2617. [PMID: 29096915 DOI: 10.1016/j.jacc.2017.09.1066] [Citation(s) in RCA: 215] [Impact Index Per Article: 30.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Revised: 09/15/2017] [Accepted: 09/17/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND Provisional stenting (PS) is the most common technique used to treat distal left main (LM) bifurcation lesions in patients with unprotected LM coronary artery disease undergoing percutaneous coronary intervention. The double kissing (DK) crush planned 2-stent technique has been shown to improve clinical outcomes in non-LM bifurcations compared with PS, and in LM bifurcations compared with culotte stenting, but has never been compared with PS in LM bifurcation lesions. OBJECTIVES The authors sought to determine whether a planned DK crush 2-stent technique is superior to PS for patients with true distal LM bifurcation lesions. METHODS The authors randomized 482 patients from 26 centers in 5 countries with true distal LM bifurcation lesions (Medina 1,1,1 or 0,1,1) to PS (n = 242) or DK crush stenting (n = 240). The primary endpoint was the 1-year composite rate of target lesion failure (TLF): cardiac death, target vessel myocardial infarction, or clinically driven target lesion revascularization. Routine 13-month angiographic follow-up was scheduled after ascertainment of the primary endpoint. RESULTS TLF within 1 year occurred in 26 patients (10.7%) assigned to PS, and in 12 patients (5.0%) assigned to DK crush (hazard ratio: 0.42; 95% confidence interval: 0.21 to 0.85; p = 0.02). Compared with PS, DK crush also resulted in lower rates of target vessel myocardial infarction I (2.9% vs. 0.4%; p = 0.03) and definite or probable stent thrombosis (3.3% vs. 0.4%; p = 0.02). Clinically driven target lesion revascularization (7.9% vs. 3.8%; p = 0.06) and angiographic restenosis within the LM complex (14.6% vs. 7.1%; p = 0.10) also tended to be less frequent with DK crush compared with PS. There was no significant difference in cardiac death between the groups. CONCLUSIONS In the present multicenter randomized trial, percutaneous coronary intervention of true distal LM bifurcation lesions using a planned DK crush 2-stent strategy resulted in a lower rate of TLF at 1 year than a PS strategy. (Double Kissing and Double Crush Versus Provisional T Stenting Technique for the Treatment of Unprotected Distal Left Main True Bifurcation Lesions: A Randomized, International, Multi-Center Clinical Trial [DKCRUSH-V]; ChiCTR-TRC-11001213).
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Affiliation(s)
- Shao-Liang Chen
- Division of Cardiology, Nanjing First Hospital and Key Laboratory of Targeted Intervention of Cardiovascular Disease, Collaboratory Innovation Center for Cardiovascular Disease Translational Medicine, Nanjing Medical University, Nanjing, China.
| | - Jue-Jie Zhang
- Division of Cardiology, Nanjing First Hospital and Key Laboratory of Targeted Intervention of Cardiovascular Disease, Collaboratory Innovation Center for Cardiovascular Disease Translational Medicine, Nanjing Medical University, Nanjing, China
| | - Yaling Han
- Division of Cardiology, Shenyang Northern Hospital, Shenyang, China
| | - Jing Kan
- Division of Cardiology, Nanjing First Hospital and Key Laboratory of Targeted Intervention of Cardiovascular Disease, Collaboratory Innovation Center for Cardiovascular Disease Translational Medicine, Nanjing Medical University, Nanjing, China
| | - Lianglong Chen
- Division of Cardiology, United Hospital, Fujian Medical University, Fuzhou, China
| | - Chunguang Qiu
- Division of Cardiology, Zhengzhou University First Hospital, Zhengzhou, China
| | - Tiemin Jiang
- Division of Cardiology, Armed Police Medical University, Tianjin, China
| | - Ling Tao
- Division of Cardiology, Xijin Hospital, 4th Military Medical University, Xi'an, China
| | - Hesong Zeng
- Division of Cardiology, Wuhan Tongji Hospital, United Medical University, Wuhan, China
| | - Li Li
- Division of Cardiology, Guangzhou Red Cross Hospital, Guangzhou, Guangdong, China
| | - Yong Xia
- Division of Cardiology, Xuzhou Medical University Affiliated Hospital, Xuzhou, China
| | - Chuanyu Gao
- Division of Cardiology, Henan Provincial People's Hospital, Zhengzhou, China
| | - Teguh Santoso
- Division of Cardiology, Medistra Hospital, University of Indonesia Medical School, Jakarda, Indonesia
| | | | - Yan Wang
- Division of Cardiology, Zhongshan Hospital, Xiamen University, Xiamen, China
| | - Tak W Kwan
- Division of Cardiology, Beth Israel Hospital, New York, New York
| | - Fei Ye
- Division of Cardiology, Nanjing Heart Center, Nanjing, China
| | - Nailiang Tian
- Division of Cardiology, Nanjing Heart Center, Nanjing, China
| | - Zhizhong Liu
- Division of Cardiology, Nanjing First Hospital and Key Laboratory of Targeted Intervention of Cardiovascular Disease, Collaboratory Innovation Center for Cardiovascular Disease Translational Medicine, Nanjing Medical University, Nanjing, China
| | - Song Lin
- Division of Cardiology, Nanjing Heart Center, Nanjing, China
| | - Chengzhi Lu
- Division of Cardiology, Tianjin 1(st) Central Hospital, Tianjin, China
| | - Shangyu Wen
- Division of Cardiology, Daqin Oil General Hospital, Daqin, China
| | - Lang Hong
- Division of Cardiology, Jiangxi Provincial People's Hospital, Nanchang, China
| | - Qi Zhang
- Division of Cardiology, Shanghai East Hospital, Shanghai, China
| | - Imad Sheiban
- Division of Cardiology, Pederzoli Hospital-Peschiera del Garda, Verona, Italy
| | - Yawei Xu
- Division of Cardiology, Shanghai 10th People's Hospital, Shanghai, China
| | - Lefeng Wang
- Division of Cardiology, Beijing Chaoyang Hospital, Beijing, China
| | - Tanveer S Rab
- Division of Cardiology, Emory University Hospital, Atlanta, Georgia
| | - Zhanquan Li
- Division of Cardiology, Liaoning Provincial People's Hospital, Shenyang, China
| | - Guanchang Cheng
- Division of Cardiology, Huaihe Hospital, Henan University, Kaifeng, China
| | - Lianqun Cui
- Division of Cardiology, Shandong Provincial Hospital, Shandong University, Jinan, China
| | - Martin B Leon
- Division of Cardiology, Columbia University Medical Center and the Cardiovascular Research Foundation, New York, New York
| | - Gregg W Stone
- Division of Cardiology, Columbia University Medical Center and the Cardiovascular Research Foundation, New York, New York.
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Schwann TA. The Surgical Treatment of Coronary Artery Occlusive Disease: Modern Treatment Strategies for an Age Old Problem. Surg Clin North Am 2017; 97:835-865. [PMID: 28728719 DOI: 10.1016/j.suc.2017.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Coronary artery disease remains a formidable challenge to clinicians. Percutaneous interventions and surgical techniques for myocardial revascularization continue to improve. Concurrently, in light of emerging data, multiple practice guidelines have been published guiding clinicians in their therapeutic decisions. The multidisciplinary Heart Team concept needs to be embraced by all cardiovascular providers to optimize patient outcomes.
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Affiliation(s)
- Thomas A Schwann
- Department of Surgery, University of Toledo College of Medicine & Life Sciences, 3000 Arlington Avenue, Toledo, OH 43614, USA.
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Schreiber T, Wah Htun W, Blank N, Telila T, Mercado N, Briasoulis A, Kaki A, Kondur A, Munir A, Grines C. Real-world supported unprotected left main percutaneous coronary intervention with impella device; data from the USpella registry. Catheter Cardiovasc Interv 2017; 90:576-581. [PMID: 28417594 DOI: 10.1002/ccd.26979] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Accepted: 01/17/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND Patients with left main (LM) coronary artery disease are increasingly being treated with percutaneous revascularization (PCI). The safety, feasibility, and efficacy of unprotected LM intervention (ULMI) with hemodynamic support by Impella device have not been evaluated previously. OBJECTIVE Using a large retrospective single center database from the USpella registry, we evaluated the safety, feasibility, and potential benefits of periprocedural left ventricular assist with axial flow Impella 2.5 and Impella CP (Abiomed Inc. Danvers, Mass) during ULMI. METHODS We analyzed a total of 127 consecutive patients who received hemodynamic support with Impella (2.5 or CP) for ULMI from August 2008 to July 2015. Safety, feasibility and efficacy end points included procedural success rates, in-hospital and 30-day major adverse cardiovascular event (MACE) rates. RESULTS Among 127 patients who received hemodynamic support for ULMI (mean age 69.98 ± 10.7 years, 71% men, and mean left ventricular ejection fraction 28.74 ± 15.55%, Society of Thoracic Surgeons' mortality/morbidity 4/23%) the in-hospital and 30 days mortality rates were 1.43% (2/140) and 2.1% (3/141), respectively. The average baseline and post PCI (residual) syntax scores were 31.4 and 7.86, respectively, (P < 0.001). Only one patient (0.8%) had vascular complication that required surgery; 2.36% (3/127) had hematoma and 3.9% (5/127) had bleeding that required transfusion. CONCLUSION This large singe center retrospective evaluation of USpella registry substantiates and strongly supports the feasibility, safety, and hemodynamic usefulness of Impella device for ULMI with acceptable in-hospital and 30-day MACE rates. © 2017 Wiley Periodicals, Inc.
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Affiliation(s)
- Theodore Schreiber
- Wayne State University/Detroit Medical Center, Heart Hospital, Detroit, Michigan
| | - Wah Wah Htun
- Wayne State University/Detroit Medical Center, Heart Hospital, Detroit, Michigan
| | - Nimrod Blank
- Wayne State University/Detroit Medical Center, Heart Hospital, Detroit, Michigan
| | - Tesfaye Telila
- Wayne State University/Detroit Medical Center, Heart Hospital, Detroit, Michigan
| | - Nestor Mercado
- Wayne State University/Detroit Medical Center, Heart Hospital, Detroit, Michigan
| | | | - Amir Kaki
- Wayne State University/Detroit Medical Center, Heart Hospital, Detroit, Michigan
| | - Ashok Kondur
- Wayne State University/Detroit Medical Center, Heart Hospital, Detroit, Michigan
| | - Ahmad Munir
- Wayne State University/Detroit Medical Center, Heart Hospital, Detroit, Michigan
| | - Cindy Grines
- Wayne State University/Detroit Medical Center, Heart Hospital, Detroit, Michigan
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Tsai TH, Cheng CI. Stenting or bypass surgery for unprotected left main coronary artery disease-still a long rally to go. J Thorac Dis 2016; 8:2292-2295. [PMID: 27746958 DOI: 10.21037/jtd.2016.08.42] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Tzu-Hsien Tsai
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Cheng-I Cheng
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan, Chang Gung University College of Medicine, Kaohsiung, Taiwan
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Munkholm-Larsen S, Yan TD. Percutaneous coronary intervention versus bypass grafting in left main coronary artery disease. J Thorac Dis 2016; 8:2677-2679. [PMID: 27867541 PMCID: PMC5107448 DOI: 10.21037/jtd.2016.10.50] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2016] [Accepted: 10/05/2016] [Indexed: 11/06/2022]
Affiliation(s)
| | - Tristan D. Yan
- Collaborative Research Group, Macquarie University, Sydney, Australia
- University of Sydney, Sydney Adventist Hospital, Wahroonga, NSW, Australia
- University of Sydney, Central Clinical School, Royal Prince Alfred Hospital, Sydney, Australia
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Lee JY, Ahn JM, Park DW, Kang SJ, Kim YH, Lee SW, Lee CW, Park SW, Park SJ. Impact of exercise-based cardiac rehabilitation on long-term clinical outcomes in patients with left main coronary artery stenosis. Eur J Prev Cardiol 2016; 23:1804-1813. [PMID: 27369843 DOI: 10.1177/2047487316658570] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 06/15/2016] [Indexed: 11/15/2022]
Abstract
BACKGROUND Cardiac rehabilitation may reduce cardiovascular mortality and morbidity rates in patients with coronary artery disease. The specific relationship between cardiac rehabilitation participation and left main coronary artery stenosis is unknown. DESIGN Prospective registry analysis. METHODS Data from a registry of 3120 patients with left main coronary artery stenosis, collected between 1995 and 2010, were analyzed. A total of 596 patients (19.6%) had participated in a cardiac rehabilitation program. RESULTS The crude seven-year mortality, cardiovascular mortality, target-vessel revascularization and myocardial infarction rates were significantly lower in the cardiac rehabilitation than in the non-rehabilitation group, and the incidence of stroke tended to be lower in the cardiac rehabilitation group. Multivariate analysis showed that cardiac rehabilitation was associated with significantly lower risks of mortality (hazard ratio (HR), 0.70; 95% confidence interval (CI), 0.49-1.00; p = 0.05) and cardiovascular mortality (HR, 0.69; 95% CI, 0.48-0.97; p = 0.03). However, the adjusted HR of myocardial infarction, target-vessel revascularization and stroke did not differ significantly. Propensity score-matched analysis of 507 pairs showed that cardiac rehabilitation was associated with significant decreases in mortality (HR, 0.62; 95% CI, 0.43-0.89; p = 0.009) and cardiovascular mortality (HR, 0.54; 95% CI, 0.36-0.80; p = 0.002) but had no beneficial effects on myocardial infarction, target-vessel revascularization or stroke. CONCLUSIONS Exercise-based cardiac rehabilitation participation was associated with significant decreases in mortality. Our findings show that cardiac rehabilitation programs should be implemented in standard management for patients with left main coronary artery stenosis.
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Affiliation(s)
- Jong-Young Lee
- Division of Cardiology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jung-Min Ahn
- Division of Cardiology, Department of Internal Medicine, Asan Medical Center, College of Medicine University of Ulsan, Seoul, Republic of Korea
| | - Duk-Woo Park
- Division of Cardiology, Department of Internal Medicine, Asan Medical Center, College of Medicine University of Ulsan, Seoul, Republic of Korea
| | - Soo-Jin Kang
- Division of Cardiology, Department of Internal Medicine, Asan Medical Center, College of Medicine University of Ulsan, Seoul, Republic of Korea
| | - Young-Hak Kim
- Division of Cardiology, Department of Internal Medicine, Asan Medical Center, College of Medicine University of Ulsan, Seoul, Republic of Korea
| | - Seung-Whan Lee
- Division of Cardiology, Department of Internal Medicine, Asan Medical Center, College of Medicine University of Ulsan, Seoul, Republic of Korea
| | - Cheol Whan Lee
- Division of Cardiology, Department of Internal Medicine, Asan Medical Center, College of Medicine University of Ulsan, Seoul, Republic of Korea
| | - Seong-Wook Park
- Division of Cardiology, Department of Internal Medicine, Asan Medical Center, College of Medicine University of Ulsan, Seoul, Republic of Korea
| | - Seung-Jung Park
- Division of Cardiology, Department of Internal Medicine, Asan Medical Center, College of Medicine University of Ulsan, Seoul, Republic of Korea
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48
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Ellwein L, Marks DS, Migrino RQ, Foley WD, Sherman S, LaDisa JF. Image-based quantification of 3D morphology for bifurcations in the left coronary artery: Application to stent design. Catheter Cardiovasc Interv 2016; 87:1244-55. [PMID: 27251470 DOI: 10.1002/ccd.26247] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Revised: 07/21/2015] [Accepted: 09/05/2015] [Indexed: 12/31/2022]
Abstract
BACKGROUND Improved strategies for stent-based treatment of coronary artery disease at bifurcations require a greater understanding of artery morphology. OBJECTIVE We developed a workflow to quantify morphology in the left main coronary (LMCA), left anterior descending (LAD), and left circumflex (LCX) artery bifurcations. METHODS Computational models of each bifurcation were created for 55 patients using computed tomography images in 3D segmentation software. Metrics including cross-sectional area, length, eccentricity, taper, curvature, planarity, branching law parameters, and bifurcation angles were assessed using open-sources software and custom applications. Geometric characterization was performed by comparison of means, correlation, and linear discriminant analysis (LDA). RESULTS Differences between metrics suggest dedicated or multistent approaches should be tailored for each bifurcation. For example, the side branch of the LCX (i.e., obtuse marginal; OM) was longer than that of the LMCA (i.e., LCXprox) and LAD (i.e., first diagonal; D1). Bifurcation metrics for some locations (e.g., LMCA Finet ratio) provide results and confidence intervals agreeing with prior findings, while revised metric values are presented for others (e.g., LAD and LCX). LDA revealed several metrics that differentiate between artery locations (e.g., LMCA vs. D1, LMCA vs. OM, LADprox vs. D1, and LCXprox vs. D1). CONCLUSIONS These results provide a foundation for elucidating common parameters from healthy coronary arteries and could be leveraged in the future for treating diseased arteries. Collectively the current results may ultimately be used for design iterations that improve outcomes following implantation of future dedicated bifurcation stents. © 2015 Wiley Periodicals, Inc.
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Affiliation(s)
- Laura Ellwein
- Department of Mathematics and Applied Mathematics, Virginia Commonwealth University, Richmond, VA
| | - David S Marks
- Department of Cardiovascular Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Raymond Q Migrino
- Department of Cardiovascular Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin.,Department of Medicine, VA Health Care System, Phoenix, Arizona
| | - W Dennis Foley
- Department of Radiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Sara Sherman
- Department of Mathematics and Applied Mathematics, Virginia Commonwealth University, Richmond, VA
| | - John F LaDisa
- Department of Mathematics and Applied Mathematics, Virginia Commonwealth University, Richmond, VA.,Department of Cardiovascular Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin.,Biotechnology and Bioengineering Center, Medical College of Wisconsin, Milwaukee, Wisconsin
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49
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Abstract
Significant unprotected left main stem (ULMS) disease is in approximately 5% to 7% of patients undergoing coronary angiography. Historically, coronary artery bypass grafting has been the gold standard treatment of these patients. With recent advances in stent technology, adjunctive pharmacotherapy, and operator experience, percutaneous coronary intervention (PCI) is increasingly regarded as a viable alternative treatment option, especially in patients with favorable coronary anatomy (low and intermediate SYNTAX (Synergy Between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery) scores). This article aims to discuss the evidence supporting PCI for ULMS disease, current guidelines, and technical aspects.
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Affiliation(s)
- Neil Ruparelia
- Department of Interventional Cardiology San Raffaele Scientific Institute, Via Olgettina 60, Milan 20132, Italy; Department of Cardiology Imperial College, Du Cane Road, London W12 0HS, UK
| | - Alaide Chieffo
- Department of Interventional Cardiology San Raffaele Scientific Institute, Via Olgettina 60, Milan 20132, Italy.
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50
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Campos CM, Christiansen EH, Stone GW, Serruys PW. The EXCEL and NOBLE trials: similarities, contrasts and future perspectives for left main revascularisation. EUROINTERVENTION 2016; 11 Suppl V:V115-9. [PMID: 25983143 DOI: 10.4244/eijv11sva26] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Unprotected left main coronary artery (ULMCA) stenosis has relatively high prevalence and exposes patients to a high risk for adverse cardiovascular events. The optimal revascularisation strategy (coronary artery bypass surgery [CABG] or percutaneous coronary intervention [PCI]) for patients with complex coronary artery disease is a topic of continuing debate. The introduction of the newer-generation drug-eluting stents (DES) -with documented improvements in both safety and efficacy- has prompted the interventional community to design two new dedicated randomised trials comparing CABG and PCI: the NOBLE (Coronary Artery Bypass Grafting Vs Drug Eluting Stent Percutaneous Coronary Angioplasty in the Treatment of Unprotected Left Main Stenosis) and EXCEL (Evaluation of XIENCE Everolimus Eluting Stent Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) trials. The aims of the present review are to describe the similarities and contrasts between these two trials as well to explore their future implications in ULMCA treatment.
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Affiliation(s)
- Carlos M Campos
- Erasmus University Medical Center, Rotterdam, The Netherlands
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