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

Outcome and selection of revascularization strategy in left main coronary artery stenosis

OBJECTIVES

To investigate clinical outcome in unselected real-life patients with unprotected left main coronary artery (ULMCA) stenosis and determine factors associated with selection of revascularization strategy.

DESIGN

Consecutive patients with ULMCA stenosis at our institution in 2009-2013 (n = 308) were retrospectively analyzed with propensity score adjusted Cox proportional hazards models for outcome. Baseline characteristics in relation to selection of revascularization strategy were analyzed with multivariate logistic regression.

RESULTS

Patients that underwent PCI (n = 94) had a higher risk of major adverse cardiac and cerebrovascular events (MACCE; adjusted HR 2.13 [95% CI 1.08-4.19]) than patients that had CABG surgery but there was no difference in the combination of death and MI (adjusted HR 1.17 [95% CI 0.50-2.75]). Later year of index angiography, age, Euroscore II and angiographer favoring PCI was associated with PCI as revascularization strategy. Higher SYNTAX score, higher systolic blood pressure and angiographer favoring CABG was associated with CABG.

CONCLUSIONS

In consecutive patients with ULMCA stenosis PCI is associated with higher MACCE rates than CABG but there is no difference in death and MI. Later year of index angiography, higher age, lower systolic blood pressure, higher predicted per-procedural surgical risk, less complex coronary anatomy and angiographer favoring PCI increased the probability of revascularization with PCI instead of CABG.

Percutaneous coronary intervention using drug-eluting stents versus coronary artery bypass graft surgery in left main coronary artery disease an updated meta-analysis of randomized clinical trials

Objectives

To compare the safety and efficacy of percutaneous coronary intervention (PCI) using drug-eluting stent (DES) and coronary artery bypass graft (CABG) for the treatment of left main coronary artery (LMCA) disease.

Background

Several new randomized trials have recently examined the clinical outcomes of PCI and CABG in LMCA disease. However, the results of these studies were inconsistent.

Materials and Methods

We searched five online electronic databases to identify all the randomized clinical trials assessing the outcomes of PCI using DES and CABG in patients with LMCA. The clinical outcomes were the major adverse cardiac and cerebrovascular event (MACCE), all-cause death, myocardial infarction (MI), stroke, and repeat revascularization (RR).

Results

A total of 5 randomized clinical trials with 4595 LMCA patients were included in this meta-analysis. For one year follow-up, the results indicated that PCI were associated with a lower risk of stroke (RR = 0.21, 95% CI = 0.07–0.65, P = 0.007), a higher risk of RR (RR = 1.72, 95% CI = 1.28–2.33, P < 0.001) than CABG. Moreover, for long-term follow-up, there were significant higher risks of MACCE and RR with PCI versus CABG (MACCE: HR = 1.26, 95% CI = 1.11–1.44, P = 0.001; RR: HR = 1.70, 95% CI = 1.42–2.05, P < 0.001). However, there were no significant differences between the two groups in all-cause death and MI risks, regardless of follow-up duration.

Conclusions

PCI is noninferior to CABG in short term follow-up of patients with LMCA disease, but CABG is more safety and efficacy than PCI using DES in long-term follow-up.

Unprotected Left Main Disease: Indications and Optimal Strategies for Percutaneous Intervention

OPINION STATEMENT

Although the incidence of left main (LM) coronary artery disease is relatively low in patients undergoing routine angiography, it is a common presentation in patients with acute coronary syndromes. With the current interventional tools and techniques, percutaneous intervention for LM disease has become a viable alternative to the traditional coronary artery bypass grafting. Factors that contribute to the success and appropriateness of percutaneous intervention for LM disease include coronary anatomy and patient-specific factors such as left ventricular function. Multiple considerations should be taken into account prior to intervention, including hemodynamic support if necessary, intravascular imaging to guide therapy, and stent technique. This review provides an overview of the current body of literature to support the use of percutaneous intervention in LM disease and serves as guideline for the interventionalist approaching LM revascularization.

The heart team of cardiovascular care

The management of complex cardiovascular disease has changed markedly with the development of new strategies of care, an increasing amount of scientific evidence-based data and appropriate use criteria. Applying this plethora of information and synthesizing it for presentation and recommendations to the patient and family have assumed central importance. To facilitate this process of patient centric evidence-based care multidisciplinary Heart Teams have become identified as cornerstones. While specific strategies for implementation of these teams will vary, this broad approach will become the standard of cardiovascular care.