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Bhogal S, Zhang C, Aladin AI, Mintz GS, Waksman R. Provisional Versus Dual Stenting of Left Main Coronary Artery Bifurcation Lesions (from a Comprehensive Meta-Analysis). Am J Cardiol 2022; 185:10-17. [DOI: 10.1016/j.amjcard.2022.09.012] [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: 04/28/2022] [Revised: 08/24/2022] [Accepted: 09/09/2022] [Indexed: 11/17/2022]
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Estevão-Costa MI, Sanz-Soler R, Johanningmeier B, Eble JA. Snake venom components in medicine: From the symbolic rod of Asclepius to tangible medical research and application. Int J Biochem Cell Biol 2018; 104:94-113. [PMID: 30261311 DOI: 10.1016/j.biocel.2018.09.011] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 09/03/2018] [Accepted: 09/19/2018] [Indexed: 12/21/2022]
Abstract
Both mythologically and logically, snakes have always fascinated man. Snakes have attracted both awe and fear not only because of the elegant movement of their limbless bodies, but also because of the potency of their deadly venoms. Practically, in 2017, the world health organization (WHO) listed snake envenomation as a high priority neglected disease, as snakes inflict up to 2.7 million poisonous bites, around 100.000 casualties, and about three times as many invalidities on man. The venoms of poisonous snakes are a cocktail of potent compounds which specifically and avidly target numerous essential molecules with high efficacy. The individual effects of all venom toxins integrate into lethal dysfunctions of almost any organ system. It is this efficacy and specificity of each venom component, which after analysis of its structure and activity may serve as a potential lead structure for chemical imitation. Such toxin mimetics may help in influencing a specific body function pharmaceutically for the sake of man's health. In this review article, we will give some examples of snake venom components which have spurred the development of novel pharmaceutical compounds. Moreover, we will provide examples where such snake toxin-derived mimetics are in clinical use, trials, or consideration for further pharmaceutical exploitation, especially in the fields of hemostasis, thrombosis, coagulation, and metastasis. Thus, it becomes clear why a snake captured its symbolic place at the Asclepius rod with good reason still nowadays.
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Affiliation(s)
- Maria-Inacia Estevão-Costa
- Institute of Physiological Chemistry and Pathobiochemistry, University of Münster, Waldeyerstr. 15, 48149, Münster, Germany
| | - Raquel Sanz-Soler
- Institute of Physiological Chemistry and Pathobiochemistry, University of Münster, Waldeyerstr. 15, 48149, Münster, Germany
| | - Benjamin Johanningmeier
- Institute of Physiological Chemistry and Pathobiochemistry, University of Münster, Waldeyerstr. 15, 48149, Münster, Germany
| | - Johannes A Eble
- Institute of Physiological Chemistry and Pathobiochemistry, University of Münster, Waldeyerstr. 15, 48149, Münster, Germany.
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Li J, Patel SM, Parikh MA, Parikh SA. Unprotected Left Main Disease: Indications and Optimal Strategies for Percutaneous Intervention. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2016; 18:19. [PMID: 26874707 DOI: 10.1007/s11936-016-0441-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
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.
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Affiliation(s)
- Jun Li
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, USA.,Division of Cardiovascular Medicine, Harrington Heart and Vascular Institute, University Hospitals Case Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44106, USA
| | - Sandeep M Patel
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, USA.,Division of Cardiovascular Medicine, Harrington Heart and Vascular Institute, University Hospitals Case Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44106, USA
| | - Manish A Parikh
- Center for Interventional Vascular Therapy, Division of Cardiology, NY Presbyterian Hospital/Columbia University Medical Center, New York, NY, USA
| | - Sahil A Parikh
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, USA. .,Division of Cardiovascular Medicine, Harrington Heart and Vascular Institute, University Hospitals Case Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44106, USA.
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Gao Z, Xu B, Yang YJ, Qiao SB, Wu YJ, Chen T, Xu L, Yuan JQ, Chen J, Qin XW, Yao M, Liu HB, You SJ, Zhao YL, Yan HB, Chen JL, Gao RL. Effect of final kissing balloon dilatation after one-stent technique at left-main bifurcation: a single center data. Chin Med J (Engl) 2015; 128:733-9. [PMID: 25758264 PMCID: PMC4833974 DOI: 10.4103/0366-6999.152468] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Background: Whether final kissing balloon (FKB) dilatation after one-stent implantation at left-main (LM) bifurcation site remains unclear. Therefore, this large sample and long-term follow-up study comparatively assessed the impact of FKB in patients with unprotected LM disease treated with one-stent strategy. Methods: Total 1528 consecutive patients underwent LM percutaneous coronary intervention in one center from January 2004 to December 2010 were enrolled; among them, 790 patients treated with one drug-eluting stent crossover LM to left anterior descending (LAD) with FKB (n = 230) or no FKB (n = 560) were comparatively analyzed. Primary outcome was the rate of major adverse cardiovascular events, defined as a composite of death, myocardial infarction (MI) and target vessel revascularization (TVR). Results: Overall, The prevalence of true bifurcation lesions, which included Medina classification (1,1,1), (1,0,1), or (0,1,1), was similar between-groups (non-FKB: 37.0% vs. FKB: 39.6%, P = 0.49). At mean 4 years follow-up, rates of major adverse cardiovascular events (non-FKB: 10.0% vs. FKB: 7.8%, P = 0.33), death, MI and TVR were not significantly different between-groups. In multivariate propensity-matched regression analysis, FKB was not an independent predictor of adverse outcomes. Conclusions: For patients treated with one-stent crossover LM to LAD, clinical outcomes appear similar between FKB and non-FKB strategy.
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Affiliation(s)
| | | | - Yue-Jin Yang
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Beijing 100037, China
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Gao Z, Xu B, Yang Y, Qiao S, Wu Y, Chen T, Xu L, Yuan J, Chen J, Gao RL. Comparison between one-stent versus two-stent technique for treatment of left main bifurcation lesions: A large single-center data. Catheter Cardiovasc Interv 2015; 85:1132-8. [PMID: 25614097 DOI: 10.1002/ccd.25849] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Accepted: 01/18/2015] [Indexed: 11/07/2022]
Affiliation(s)
- Zhan Gao
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Bo Xu
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Yuejin Yang
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Shubin Qiao
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Yongjian Wu
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Tao Chen
- Department of Epidemiology and Biostatistics, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Liang Xu
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Jinqing Yuan
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Jue Chen
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Run-lin Gao
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Beijing, China
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Park SJ, Kim YH. Percutaneous coronary intervention as an alternative to bypass surgery for unprotected LMCA stenosis. Expert Rev Cardiovasc Ther 2014; 6:1107-14. [DOI: 10.1586/14779072.6.8.1107] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Xiu J, Choi SY, Mintz GS, Araki H, Masuda N, Morino Y, Sonoda S, Tahk SJ, Ochiai M, Maehara A. Three-dimensional intravascular ultrasound evaluation of carina and plaque shift at the distal left main coronary artery bifurcation after treatment with a one-stent cross-over technique. Catheter Cardiovasc Interv 2013; 81:1142-9. [PMID: 23008216 DOI: 10.1002/ccd.24681] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2012] [Accepted: 09/16/2012] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To assess the geometrical changes in the distal left main coronary artery (LMCA), left anterior descending (LAD), and left circumflex (LCX) that occur after a distal LMCA lesion is treated using a one-stent cross-over strategy. BACKGROUND Morphological changes after stent implantation into distal LMCA lesions are not fully understood. METHODS We used pre- and postintervention three-dimensional intravascular ultrasound of both the LAD and LCX as well as of the LMCA to evaluate distal LMCA lesions after a 1-stent cross-over strategy. In 38 distal LMCA bifurcation lesions, cross-sectional measurements were performed every 1 mm over a 5-mm segment in the LAD and LCX distal to the carina and over the entire LMCA proximal to the carina. RESULTS The increase in lumen volume correlated with the increase in external elastic membrane volumes: R = 0.917, P < 0.001, in the LMCA and R = 0.785, P < 0.001, in the LAD with no decrease in plaque volume except at the distal end of the LMCA (P = 0.081) and at the LAD carina (P = 0.11). The LCX lumen area decreased significantly at the LCX carina from 5.9 ± 2.0 mm(2) to 5.3 ± 1.9 mm(2) (P < 0.01); however, the response was variable from a 4.0 mm(2) decrease to a 1.8 mm(2) increase in lumen area. While the change in LCX lumen area at the carina correlated with the change in vessel area (R = 0.791, P < 0.001), there was also a small increase in plaque area at the LCX carina from 6.4 ± 2.9 mm(2) to 6.8 ± 2.9 mm(2) (P < 0.01). CONCLUSIONS LMCA bifurcation lumen changes after cross-over single-stent implantation were determined primarily by conformational changes in vessel geometry.
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Affiliation(s)
- Jiancheng Xiu
- Cardiology Department, Nanfang Hospital, Southern Medical University, Guangzhou, China
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CHEEMA ASIMN, JOLLY SANJITS, BURSTEIN JASONM, SHARIEFF WASEEM, MOHAMMAD ATIF, YEOH EUNICE, MANCINI GJOHN, CANTOR WARRENJ, KUTRYK MICHAELJ, STRAUSS BRADLEYH, CHISHOLM ROBERTJ. Angiographic and Clinical Outcomes after Implantation of Drug Eluting Stents in Bifurcation Lesions with Crush or Kissing Stent Technique. J Interv Cardiol 2013; 26:145-52. [DOI: 10.1111/j.1540-8183.2013.12022.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- ASIM N. CHEEMA
- Terrence Donnelly Heart Center, Division of Cardiology, St. Michael's Hospital; Toronto, Ontario; Canada
| | - SANJIT S. JOLLY
- Terrence Donnelly Heart Center, Division of Cardiology, St. Michael's Hospital; Toronto, Ontario; Canada
| | - JASON M. BURSTEIN
- Terrence Donnelly Heart Center, Division of Cardiology, St. Michael's Hospital; Toronto, Ontario; Canada
| | | | - ATIF MOHAMMAD
- Terrence Donnelly Heart Center, Division of Cardiology, St. Michael's Hospital; Toronto, Ontario; Canada
| | - EUNICE YEOH
- Cardiovascular Imaging Research Core Laboratory, Vancouver General Hospital; Vancouver, British Columbia; Canada
| | - G.B. JOHN MANCINI
- Cardiovascular Imaging Research Core Laboratory, Vancouver General Hospital; Vancouver, British Columbia; Canada
| | - WARREN J. CANTOR
- Terrence Donnelly Heart Center, Division of Cardiology, St. Michael's Hospital; Toronto, Ontario; Canada
| | - MICHAEL J.B. KUTRYK
- Terrence Donnelly Heart Center, Division of Cardiology, St. Michael's Hospital; Toronto, Ontario; Canada
| | - BRADLEY H. STRAUSS
- Terrence Donnelly Heart Center, Division of Cardiology, St. Michael's Hospital; Toronto, Ontario; Canada
| | - ROBERT J. CHISHOLM
- Terrence Donnelly Heart Center, Division of Cardiology, St. Michael's Hospital; Toronto, Ontario; Canada
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Jang SJ, Park DW, Kim WJ, Kim YH, Yun SC, Kang SJ, Lee SW, Lee CW, Park SW, Park SJ. Differential long-term outcomes of zotarolimus-eluting stents compared with sirolimus-eluting and paclitaxel-eluting stents in diabetic and nondiabetic patients: Two-year subgroup analysis of the ZEST randomized trial. Catheter Cardiovasc Interv 2013; 81:1106-14. [DOI: 10.1002/ccd.24603] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2012] [Accepted: 08/09/2012] [Indexed: 11/07/2022]
Affiliation(s)
- Sun-Joo Jang
- Department of Cardiology; Center for Medical Research and Information; University of Ulsan College of Medicine; Asan Medical Center; Seoul; Korea
| | - Duk-Woo Park
- Department of Cardiology; Center for Medical Research and Information; University of Ulsan College of Medicine; Asan Medical Center; Seoul; Korea
| | - Won-Jang Kim
- Department of Cardiology; Center for Medical Research and Information; University of Ulsan College of Medicine; Asan Medical Center; Seoul; Korea
| | - Young-Hak Kim
- Department of Cardiology; Center for Medical Research and Information; University of Ulsan College of Medicine; Asan Medical Center; Seoul; Korea
| | - Sung-Cheol Yun
- Division of Biostatistics; Center for Medical Research and Information; University of Ulsan College of Medicine; Asan Medical Center; Seoul; Korea
| | - Soo-Jin Kang
- Department of Cardiology; Center for Medical Research and Information; University of Ulsan College of Medicine; Asan Medical Center; Seoul; Korea
| | - Seung-Whan Lee
- Department of Cardiology; Center for Medical Research and Information; University of Ulsan College of Medicine; Asan Medical Center; Seoul; Korea
| | - Cheol Whan Lee
- Department of Cardiology; Center for Medical Research and Information; University of Ulsan College of Medicine; Asan Medical Center; Seoul; Korea
| | - Seong-Wook Park
- Department of Cardiology; Center for Medical Research and Information; University of Ulsan College of Medicine; Asan Medical Center; Seoul; Korea
| | - Seung-Jung Park
- Department of Cardiology; Center for Medical Research and Information; University of Ulsan College of Medicine; Asan Medical Center; Seoul; Korea
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Park SJ, Ahn JM, Kang SJ. Unprotected left main percutaneous coronary intervention: integrated use of fractional flow reserve and intravascular ultrasound. J Am Heart Assoc 2012; 1:e004556. [PMID: 23316329 PMCID: PMC3540662 DOI: 10.1161/jaha.112.004556] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2012] [Accepted: 10/09/2012] [Indexed: 01/25/2023]
Affiliation(s)
- Seung-Jung Park
- Heart Institute, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Korea.
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Siotia A, Morton AC, Malkin CJ, Raina T, Gunn J. Simultaneous kissing drug-eluting stents to treat unprotected left main stem bifurcation disease: medium term outcome in 150 consecutive patients. EUROINTERVENTION 2012; 8:691-700. [DOI: 10.4244/eijv8i6a108] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Palmerini T, Alessi L, Rizzo N, Dangas G. Percutaneous revascularization of left main: role of imaging, techniques, and adjunct pharmacology. Catheter Cardiovasc Interv 2012; 79:990-9. [PMID: 21805577 DOI: 10.1002/ccd.23241] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2011] [Accepted: 05/15/2011] [Indexed: 11/09/2022]
Abstract
Refinement of interventional techniques, adjunctive pharmacological therapy, and the introduction of drug-eluting stents have fostered new interest for the percutaneous treatment of unprotected left main coronary artery (ULMCA) stenosis. Several observational registries, some randomized trials and several meta-analyses have consistently shown no difference in mortality and myocardial infarction between percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) surgery in patients with ULMCA stenosis, but a higher rate of target vessel revascularization in patients treated with PCI. As a consequence, PCI of ULMCA stenosis has been upgraded to class IIa or IIb indication in the current European or American practice guidelines. However, several critical issues should be properly addressed when pursuing a percutaneous strategy for the treatment of ULMCA stenosis, such as the use of IVUS for procedural guidance, assessment of disease location, optimal technique for distal ULMCA stenosis, risk of stent thrombosis, optimal duration of dual antiplatelet therapy, and the most appropriate strategy for post-procedure follow up. Multidisciplinary team approach remains essential to provide a balanced information to the patient and to offer the beast treatment option.
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Affiliation(s)
- Tullio Palmerini
- Istituto di Cardiologia, Policlinico S. Orsola, University of Bologna, Bologna, Italy
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Kawecki D, Morawiec B, Fudal M, Milejski W, Jacheć W, Nowalany-Kozielska E. Comparison of coronary artery bypass grafting with percutaneous coronary intervention for unprotected left main coronary artery disease. Yonsei Med J 2012; 53:58-67. [PMID: 22187233 PMCID: PMC3250341 DOI: 10.3349/ymj.2012.53.1.58] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
PURPOSE Coronary artery bypass grafting (CABG) is the optimal treatment option for left main coronary artery disease (LMCAD). However, LMCAD remains a constant topic of discussion between cardiac surgeons and interventional cardiologists. The aim of this study was to assess the efficacy of LMCAD treatments by comparing the mid-term outcomes of CABG and percutaneous coronary intervention (PCI) using bare metal stents or drug-eluting stents (DESs). MATERIALS AND METHODS The study population was comprised of 199 consecutive patients admitted with unprotected LMCAD. All of the patients were assigned to PCI (88 patients) or CABG (111 patients). The primary clinical end point indicated death, stroke of acute coronary syndrome (ACS). RESULTS Patients assigned to PCI were at higher operative risk than patients scheduled for CABG (6.49 ± 4.09 vs. 4.81 ± 2.67, p=0.0032). Comparison of the group that received DESs with the CABG group did not reveal any differences in major adverse cardio-cerebral events (MACCE) occurrence (21% vs. 16%, p=NS). Patients in the CABG and PCI groups died with similar frequency (11% vs. 16%, p=NS). The mortality rate in the CABG group was higher than among those treated with DES (11% vs. 3%, p=0.049). The rate of ACS was higher in the PCI group than in the CABG group (13% vs. 4%, p=0.016). CONCLUSION Despite the fact that patients treated with PCI were at higher operative risk, PCI with DES was shown to be comparable to CABG in terms of mortality, stroke and ACS. However, the frequency of repeat revascularizations remains a constant concern with PCI.
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Affiliation(s)
- Damian Kawecki
- 2nd Department of Cardiology, Zabrze, Medical University of Silesia, Katowice, 10 M. Curie-Skłodowskiej Str., 41-800 Zabrze, Poland.
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Park SJ, Park DW. Treatment of patients with left main coronary artery disease. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2011; 14:108-16. [PMID: 22134853 DOI: 10.1007/s11936-011-0159-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OPINION STATEMENT Considering lesion priority and its clinical consequences, coronary artery bypass grafting (CABG) has been a treatment of choice for revascularization in patients with significant left main coronary artery (LMCA) disease, However, with remarkable advancements in techniques of percutaneous coronary intervention (PCI), supporting devices, and adjunctive pharmacologic therapy, PCI with stenting has emerged to be a less invasive and feasible revascularization treatment for these patients. The cumulative evidence suggests that the safety outcomes such as mortality or composite of death, myocardial infarction, and stroke are similar among PCI and CABG, with the only difference being the rate of repeat revascularization. Based on these data, the current guideline of revascularization of LMCA disease has adopted an increasing off-label experience with stenting and clinical studies and been updated to partly approve PCI as a viable alternative (in level of class IIb) in selected patients. The choice of PCI or CABG for unprotected LMCA disease depends on several clinical and anatomic features, ensuring crucial patient selection to be a cornerstone for achieving favorable long-term outcomes. In patients with very complex anatomic features and concomitant diffuse multivessel disease, CABG is preferred so as to avoid procedural and future thrombotic risks and to provide more complete revascularization. By contrast, in patients with relatively simple LMCA disease, such as ostial/shaft LMCA disease, isolated LMCA disease (with or without one or two-vessel involvement), and LMCA disease with low SYNTAX score, PCI is an alternative, and in some cases a preferred, strategy to reduce surgical risks (eg, stroke and in-hospital events following major surgery). For the future, ongoing large clinical trials might also boost interventional cardiologists to select PCI with stenting as an alternative revascularization strategy for unprotected LMCA disease. This evidence will most likely change the current clinical practice and guidelines of optimal revascularization strategy for unprotected LMCA disease.
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Affiliation(s)
- Seung-Jung Park
- Division of Cardiology, University of Ulsan College of Medicine, Asan Medical Center, 388-1 Poongnap-dong, Songpa-gu, Seoul, 138-736, Korea,
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Kandzari DE, Ormiston JA. Revascularization for unprotected left main coronary artery disease: an evolution in clinical decision making. Curr Cardiol Rep 2011; 13:424-31. [PMID: 21728016 PMCID: PMC3163816 DOI: 10.1007/s11886-011-0196-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Coronary artery bypass grafting (CABG) has been considered the standard therapy for unprotected (nonrevascularized) left main coronary disease (ULM). However, increasing experience with ULM percutaneous coronary intervention (PCI) has resulted in high procedural success and favorable early and late clinical outcomes. In particular, reduction in clinical restenosis with drug-eluting stents, evolution of procedural technique, and demonstration of favorable outcomes from comparative trials with CABG have promoted consideration of PCI as an alternative revascularization strategy in selected patients with ULM disease. This review summarizes the results from comparative studies examining PCI versus CABG for ULM disease, discusses changing indications for ULM PCI and identifies outstanding issues that must be considered before further advancing treatment recommendations.
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[Left main intervention: options and limitations in interventional cardiology]. Herz 2011; 36:214-20. [PMID: 21567223 DOI: 10.1007/s00059-011-3460-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Revascularisation is indicated in patients with left main stenosis (LMS) because of its known positive effect on long-term survival. Coronary artery bypass graft (CABG) surgery has been the traditional procedure of choice for LMS patients, with percutaneous coronary intervention (PCI) being reserved for high-risk surgical patients or for those who have one or more functioning distal bypass grafts (i.e. "protected" left main PCI). Recent studies have re-examined the role of PCI in LMS, however, leading to a recent Class II recommendation for its use in selected patients. The SYNTAX Trial demonstrated that PCI can be performed with good results in the following patient subgroups: patients with isolated LMS, particularly if confined to the ostium; patients with concomitant LMS and isolated single vessel disease; patients with a SYNTAX score of <33; and patients who are at high risk for conventional CABG surgery. Patients with complex coronary anatomy (SYNTAX score >33) or those with concomitant double- or triple-vessel disease are more suited to CABG surgery. Patients who undergo PCI for LMS should be treated in specialized centers with surgical back-up, preferably with patient management decisions being made by a "heart team" consisting of at least one cardiologist and one cardiac surgeon. Ongoing studies are being performed using the hard clinical endpoints of death, myocardial infarction, and stroke in order to further compare the results of PCI vs CABG in LMS patients.
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Chieffo A, Magni V, Colombo A. Percutaneous Coronary Intervention in Unprotected Left Main. Interv Cardiol 2011. [DOI: 10.1002/9781444319446.ch18] [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] Open
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Zamani P, Kinlay S. Long-term risk of clinical events from stenting side branches of coronary bifurcation lesions with drug-eluting and bare-metal stents: An observational meta-analysis. Catheter Cardiovasc Interv 2011; 77:202-12. [DOI: 10.1002/ccd.22750] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Kim WJ, Kim YH, Park DW, Yun SC, Lee JY, Kang SJ, Lee SW, Lee CW, Park SW, Park SJ. Comparison of single- versus two-stent techniques in treatment of unprotected left main coronary bifurcation disease. Catheter Cardiovasc Interv 2011; 77:775-82. [PMID: 21520380 DOI: 10.1002/ccd.22915] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2010] [Accepted: 11/22/2010] [Indexed: 01/19/2023]
Abstract
BACKGROUND This study sought to compare 3-year outcomes of single- versus two-stent techniques in patients with distal unprotected left main coronary artery (LMCA) disease treated with drug-eluting stents (DES). METHODS AND RESULTS A total of 392 patients with distal unprotected LMCA disease who underwent DES implantation with single- (n = 234) or two- (n = 158) stent techniques were evaluated. The primary end point was major adverse cardiac events (MACE), defined as the composite of death, myocardial infarction (MI), and target lesion revascularization (TLR). The two-stent group was more likely to have extensive coronary artery stenosis. After adjustment with weighted Cox model using the inverse probability of treatment weighting, the 3-year risk of death was similar in the single- and two-stent groups (hazard ratio [HR], 0.77, 95% confidence interval [CI], 0.28-2.13, P = 0.62). However, the 3-year risks of MI (HR, 0.38, 95% CI, 0.19-0.78, P = 0.008), TLR (HR, 0.16, 95% CI, 0.05-0.57, P = 0.005), and MACE (HR, 0.89, 95% CI, 0.22-0.67, P = 0.0007) were significantly lower in the single-stent group. CONCLUSION Compared with the two-stent technique, the single-stent technique showed more favorable long-term clinical outcomes in patients with distal unprotected LMCA disease who received DES
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Affiliation(s)
- Won-Jang Kim
- Department of Cardiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
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Hsueh SK, Wu CJ, Fang HY, Hsieh YK, Fang CY, Chen CJ, Chen SM, Yang CH, Yip HK, Chen MC, Fu M, Cheng CI. Comparison of Drug-Eluting Stent With Bare Metal Stent for Distal De Novo Unprotected Left Main Coronary Artery Stenosis - A Propensity Score-Matched Cohort Study -. Circ J 2011; 75:290-8. [DOI: 10.1253/circj.cj-10-0468] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Shu-Kai Hsueh
- Chang Gung University College of Medicine
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Kaohsiung Medical Center
| | - Chiung-Jen Wu
- Chang Gung University College of Medicine
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Kaohsiung Medical Center
| | - Hsiu-Yu Fang
- Chang Gung University College of Medicine
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Kaohsiung Medical Center
| | - Yuan-Kai Hsieh
- Chang Gung University College of Medicine
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Kaohsiung Medical Center
| | - Chih-Yuan Fang
- Chang Gung University College of Medicine
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Kaohsiung Medical Center
| | - Chien-Jen Chen
- Chang Gung University College of Medicine
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Kaohsiung Medical Center
| | - Shyh-Ming Chen
- Chang Gung University College of Medicine
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Kaohsiung Medical Center
| | - Cheng-Hsu Yang
- Chang Gung University College of Medicine
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Kaohsiung Medical Center
| | - Hon-Kan Yip
- Chang Gung University College of Medicine
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Kaohsiung Medical Center
| | - Mien-Cheng Chen
- Chang Gung University College of Medicine
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Kaohsiung Medical Center
| | - Morgan Fu
- Chang Gung University College of Medicine
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Kaohsiung Medical Center
| | - Cheng-I Cheng
- Chang Gung University College of Medicine
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Kaohsiung Medical Center
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Affiliation(s)
- Seung-Jung Park
- Division of Cardiology, University of Ulsan College of Medicine, Asan Medical Center
| | - Duk-Woo Park
- Division of Cardiology, University of Ulsan College of Medicine, Asan Medical Center
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Pandya SB, Kim YH, Meyers SN, Davidson CJ, Flaherty JD, Park DW, Mediratta A, Pieper K, Reyes E, Bonow RO, Park SJ, Beohar N. Drug-eluting versus bare-metal stents in unprotected left main coronary artery stenosis a meta-analysis. JACC Cardiovasc Interv 2010; 3:602-11. [PMID: 20630453 DOI: 10.1016/j.jcin.2010.03.019] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2010] [Accepted: 03/18/2010] [Indexed: 12/31/2022]
Abstract
OBJECTIVES We undertook a meta-analysis to assess outcomes for drug-eluting stents (DES) and bare-metal stents (BMS) in percutaneous coronary intervention for unprotected left main coronary artery (ULMCA) stenosis. BACKGROUND Uncertainty exists regarding the relative performance of DES versus BMS in percutaneous coronary intervention for unprotected left main coronary stenosis. METHODS Of a total of 838 studies, 44 met inclusion criteria (n = 10,342). The co-primary end points were mortality, myocardial infarction (MI), target vessel/lesion revascularization (TVR/TLR), and major adverse cardiac events (MACE: mortality, MI, TVR/TLR). RESULTS Event rates for DES and BMS were calculated at 6 to 12 months, at 2 years, and at 3 years. Crude event rates at 3 years were mortality (8.8% and 12.7%), MI (4.0% and 3.4%), TVR/TLR (8.0% and 16.4%), and MACE (21.4% and 31.6%). Nine studies were included in a comparative analysis (n = 5,081). At 6 to 12 months the adjusted odds ratio (OR) for DES versus BMS were: mortality 0.94 (95% confidence interval [CI]: 0.06 to 15.48; p = 0.97), MI 0.64 (95% CI: 0.19 to 2.17; p = 0.47), TVR/TLR 0.10 (95% CI: 0.01 to 0.84; p = 0.01), and MACE 0.34 (95% CI: 0.15 to 0.78; p = 0.01). At 2 years, the OR for DES versus BMS were: mortality 0.42 (95% CI: 0.28 to 0.62; p < 0.01), MI 0.16 (95% CI: 0.01 to 3.53; p = 0.13), and MACE 0.31 (95% CI: 0.15 to 0.66; p < 0.01). At 3 years, the OR for DES versus BMS were: mortality 0.70 (95% CI: 0.53 to 0.92; p = 0.01), MI 0.49 (95% CI: 0.26 to 0.92; p = 0.03), TVR/TLR 0.46 (95% CI: 0.30 to 0.69; p < 0.01), and MACE 0.78 (95% CI: 0.57 to 1.07; p = 0.12). CONCLUSIONS Our meta-analysis suggests that DES is associated with favorable outcomes for mortality, MI, TVR/TLR, and MACE as compared to BMS in percutaneous coronary intervention for unprotected left main coronary artery stenosis.
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Affiliation(s)
- Sanjay B Pandya
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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Chen SL, Zhang JJ, Ye F, Liu ZZ, Zhu ZS, Lin S, Tian NL, Fang WY, Chen YD, Sun XW, Wei M, Shan SJ, Kan J, Qian J, Yang S, Yuan ZB, Kwan TW, Hu DY. Crush stenting with drug-eluting stents: relevance of coronary bifurcation lesion location on angiographic and clinical outcomes. Clin Cardiol 2010; 33:E32-9. [PMID: 20857513 DOI: 10.1002/clc.20544] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2008] [Accepted: 09/18/2008] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Data on the relevance of the location of coronary bifurcation lesions treated by crush stenting with outcomes were limited. HYPOTHESIS We hypothesized that the location of the bifurcation lesion correlated with clinical outcome. METHOD A total of 212 patients with 230 true bifurcation lesions treated by crush stenting with drug-eluting stents (DES) were assessed prospectively. Surveillance quantitative angiographies were indexed at 8 months after procedure. Primary endpoint was major adverse cardiac events (MACE), defined as cardiac death, myocardial infarction, and target lesion revascularization (TLR). RESULTS Patients in the distal right coronary artery (RCAd) group were characterized by higher proportions of prior myocardial infarction and very tortuous lesions. However, lesions in the RCAd group, compared to those of other groups, had the lowest late lumen loss, with resultant lowest incidence of MACE at a mean follow-up of 268±35 days. Independent predictors of MACE included unsatisfied kissing (KUS; hazard ratio [HR]: 12.14, 95% confidence interval [CI]: 4.01-12.10, P = .001) and non-RCA lesion (HR: 20.69, 95% CI: 5.05-22.38, P = .001), while those of TLR were KUS (HR: 10.21, 95% CI: 0.01-0.34, P = .002), bifurcation angle (HR: 4.728, 95% CI: 2.541-4.109, P = .001), and non-RCA lesion (HR: 16.05, 95%CI: 1.01-4.83, P = .001). CONCLUSIONS Classical crush stenting with drug-eluting stents is associated with significantly better outcomes in RCAd. Quality of kissing inflation is mandatory to improve outcome.
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Beohar N, Meyers SN, Erdogan A, Harinstein ME, Pieper K, Gagnon S, Davidson CJ. Off-label use of drug-eluting versus bare metal stents: a lesion-specific systematic review of long-term outcomes. J Interv Cardiol 2010; 23:528-45. [PMID: 20735712 DOI: 10.1111/j.1540-8183.2010.00588.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE The purpose of this systematic review was to evaluate differences in lesion-specific outcomes with the "off-label" use of drug-eluting stents (DES) versus bare metal stents (BMS). METHODS MEDLINE, PubMed, the Cochrane databases, and other Web were searched for studies evaluating off-label use of DES and BMS with the same characteristics. Of 1,258 abstracts or manuscripts reviewed, 112 studies were included (total N = 23,438). Studies were excluded if patients received both types of stent or no stent; lesion type was unknown; lesion-specific outcomes for ≥6 months were unavailable; or <25 patients were enrolled. RESULTS Overall mortality at 6-12 months was approximately 3% for BMS and DES for off-label use. Increase in mortality was greater from 6-12 months to 2 years with BMS than with DES (3.3%-9.1%; 2.8%-4.1%); however, rates were similar at 3 years (BMS: 18.8%; DES:15.3%). Myocardial Infarction rates were similar for both types at 6-12 months (BMS: 6.5%; DES: 6.0%). Overall rates of stent thrombosis were 1.8% and 1.7% for BMS and DES, respectively. Similar or slightly lower rates of stent thrombosis were seen for most lesion types, except higher rates for small vessels for BMS (5.2%) and true bifurcation for DES (3.3%). Rates of target lesion revascularization (TLR) were 7.5% for BMS and 19.6% for DES at 6-12 months. At 2-years TLR remained lower than DES. When the combined group was compared to registry data alone, similar values were seen. CONCLUSIONS Rates of mortality, myocardial infarction (MI), and stent thrombosis were similar in patients receiving BMS or DES, while TLR rates were lower in DES patients.
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Affiliation(s)
- Nirat Beohar
- Division of Cardiology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois 60611, USA.
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Bartorelli AL, Trabattoni D, Kaplan AV. Challenges and innovations in coronary bifurcation stenting: the Tryton™ side-branch stent. Interv Cardiol 2010. [DOI: 10.2217/ica.10.55] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Unprotected Left Main Coronary Disease and ST-Segment Elevation Myocardial Infarction. JACC Cardiovasc Interv 2010; 3:791-5. [PMID: 20723848 DOI: 10.1016/j.jcin.2010.06.005] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2010] [Revised: 05/18/2010] [Accepted: 05/31/2010] [Indexed: 02/05/2023]
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Girasis C, Serruys PW, Onuma Y, Colombo A, Holmes DR, Feldman TE, Bass EJ, Leadley K, Dawkins KD, Morice MC. 3-Dimensional bifurcation angle analysis in patients with left main disease: a substudy of the SYNTAX trial (SYNergy Between Percutaneous Coronary Intervention with TAXus and Cardiac Surgery). JACC Cardiovasc Interv 2010; 3:41-8. [PMID: 20129567 DOI: 10.1016/j.jcin.2009.10.019] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2009] [Revised: 10/21/2009] [Accepted: 10/22/2009] [Indexed: 11/25/2022]
Abstract
OBJECTIVES We explore the bifurcation angle (BA) parameters of the left main coronary artery (LM), the effect of percutaneous coronary intervention (PCI) on this angulation, and the impact of BA on clinical outcome. BACKGROUND The BA is emerging as a predictor of outcome after PCI of bifurcation lesions. Three-dimensional (3D) quantitative coronary angiography (QCA) overcomes the shortcomings of 2-dimensional analysis and provides reliable data. METHODS This is a substudy of the SYNTAX (SYNergy Between Percutaneous Coronary Intervention With TAXus and Cardiac Surgery) trial. The cineangiograms of the 354 patients who underwent PCI of their LM stem were analyzed with 3D QCA software (CardiOp-B, Paieon Medical, Ltd., Rosh Ha'ayin, Israel). The proximal BA (between LM and left circumflex [LCX]) and the distal BA (between left anterior descending and LCX) were computed in end-diastole and end-systole, both before and after PCI. The cumulative major adverse cardiac and cardiovascular event (MACCE) rates throughout the 12-month period after randomization were stratified across pre-PCI distal BA values and compared accordingly. RESULTS Complete analysis was feasible in 266 (75.1%) patients. Proximal and distal BA had mean pre-PCI end-diastolic values of 105.9 +/- 21.7 degrees and 95.6 +/- 23.6 degrees , respectively, and were inversely correlated (r = -0.75, p < 0.001). During systolic motion of the heart there was an enlargement of the proximal angle and a reduction of the distal angle (DeltaBA -8.2 degrees and 8.5 degrees , respectively, p < 0.001 for both). The PCI resulted in a mean decrease in the distal BA (DeltaBA 4.5 degrees , p < 0.001). The MACCE rates did not differ across distal BA values; freedom from MACCE at 12 months was 82.8%, 85.4%, and 81.1% (p = 0.74) for diastolic values (first through third tertile). CONCLUSIONS Left main BA analysis with 3D QCA is feasible. Both proximal and distal angles are affected by cardiac motion; PCI modifies the distal angle. There is no clear difference in event rates across pre-PCI distal BA values.
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Affiliation(s)
- Chrysafios Girasis
- Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
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Park SJ, Kim YH. Percutaneous coronary intervention for unprotected left main coronary artery stenosis. World J Cardiol 2010; 2:78-88. [PMID: 21160702 PMCID: PMC2998877 DOI: 10.4330/wjc.v2.i4.78] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2010] [Revised: 04/05/2010] [Accepted: 04/09/2010] [Indexed: 02/07/2023] Open
Abstract
Hemodynamically significant left main coronary artery stenosis (LMCA) is found in around 4% of diagnostic coronary angiograms and is known as unprotected LMCA stenosis if the left coronary artery and left circumflex artery has no previous patent grafts. Previous randomized studies have demonstrated a significant reduction in mortality when revascularization by coronary artery bypass graft (CABG) surgery was undertaken compared with medical treatment. Therefore, current practice guidelines do not recommend percutaneous coronary intervention (PCI) for such a lesion because of the proven benefit of surgery and high rates of restenosis with the use of bare metal stents. However, with the advent of drug-eluting stents (DES), the long term outcomes of PCI with DES to treat unprotected LMCA stenoses have been acceptable. Therefore, apart from the current guidelines, PCI for treatment of unprotected LMCA stenosis is often undertaken in individuals who are at a very high risk of CABG or refuse to undergo a sternotomy. Future randomized studies comparing CABG vs PCI using DES for treatment of unprotected LMCA stenosis would be a great advance in clinical knowledge for the adoption of appropriate treatment.
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Affiliation(s)
- Seung-Jung Park
- Seung-Jung Park, Young-Hak Kim, Cardiac Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul 138-736, South Korea
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Lee MS, Yang T, Dhoot J, Liao H. Meta-analysis of clinical studies comparing coronary artery bypass grafting with percutaneous coronary intervention and drug-eluting stents in patients with unprotected left main coronary artery narrowings. Am J Cardiol 2010; 105:1070-5. [PMID: 20381655 DOI: 10.1016/j.amjcard.2009.12.007] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2009] [Revised: 12/03/2009] [Accepted: 12/03/2009] [Indexed: 11/19/2022]
Abstract
The aim of this study was to compare the safety and efficacy of coronary artery bypass grafting (CABG) with percutaneous coronary intervention (PCI) using drug-eluting stents (DES) in patients with unprotected left main coronary artery (ULMCA) disease. The current American College of Cardiology and American Heart Association guidelines recommend CABG for the treatment of patients with ULMCA disease on the basis of clinical trials demonstrating a survival benefit with CABG compared to medical therapy. DES reduce the rate of target vessel revascularization compared with bare-metal stents in ULMCA PCI and may be a safe alternative to CABG. A meta-analysis was conducted of clinical studies comparing CABG and PCI with DES for ULMCA disease with respect to death; the composite of death, myocardial infarction, or stroke; and target vessel revascularization at 1 year follow-up. The analysis included 2,905 patients from 8 clinical studies (2 randomized trials and 6 nonrandomized studies). At 1-year follow-up, there was no significant difference between the CABG and DES groups in the risk for death (odds ratio [OR] 1.12, 95% confidence interval [CI] 0.80 to 1.56) or the composite end point of death, myocardial infarction, or stroke (OR 1.25, 95% CI 0.86 to 1.82). The risk for target vessel revascularization was significantly lower in the CABG group compared to the PCI group (OR 0.44, 95% CI 0.32 to 0.59). In conclusion, PCI with DES is safe and could represent a good alternative to CABG for selected cases in patients with ULMCA disease.
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Affiliation(s)
- Michael S Lee
- Division of Cardiology, David Geffen School of Medicine, University of California, Los Angeles, CA, USA.
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Affiliation(s)
- Antonio Colombo
- From the Interventional Cardiology Unit (A.C., R.A.L.), San Raffaele Scientific Institute, Milan, Italy; Interventional Cardiology Unit (A.C., R.A.L.), EMO GVM Centro Cuore Columbus, Milan, Italy; Imperial College Healthcare NHS Trust (R.A.L.), London, England
| | - Rasha Al-Lamee
- From the Interventional Cardiology Unit (A.C., R.A.L.), San Raffaele Scientific Institute, Milan, Italy; Interventional Cardiology Unit (A.C., R.A.L.), EMO GVM Centro Cuore Columbus, Milan, Italy; Imperial College Healthcare NHS Trust (R.A.L.), London, England
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Park SJ, Park DW. Percutaneous coronary intervention with stent implantation versus coronary artery bypass surgery for treatment of left main coronary artery disease: is it time to change guidelines? Circ Cardiovasc Interv 2010; 2:59-68. [PMID: 20031694 DOI: 10.1161/circinterventions.108.831701] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
On the basis of clinical trials comparing coronary-artery bypass grafting (CABG) with medical therapy, current guideline recommend CABG as the treatment of choice for patients with asymptomatic ischemia, stable angina, or unstable angina/non-ST elevation myocardial infarction who have left main coronary artery disease. Percutaneous coronary intervention can be selectively performed in patients who are candidates for revascularization but who are ineligible for CABG. However, because of advances in periprocedural and postprocedural medical care in patients undergoing either CABG or percutaneous coronary intervention with stenting, new evaluation, and a review of current indications, may be required to determine the standard of care for patients with left main coronary artery disease. Current evidences indicate that stenting results in mortality and morbidity rates that compared favorably with those seen after CABG, suggesting that a current guideline (the Class III recommendation of percutaneous coronary intervention for unprotected left main coronary artery disease) may no longer be justified. Data from several extensive registries and a large clinical trial may have prompted many interventional cardiologists to select percutaneous coronary intervention with stenting as an alternative revascularization strategy for such patients. In addition, these data may inform future guidelines and support the need for well-designed, adequately powered, prospective, randomized trials comparing the 2 revascularization strategies. The cumulative evidence from ongoing and future clinical trials will change the current clinical practice of revascularization for unprotected left main coronary artery disease, which was introduced several decades ago and which has continued to date without major revision.
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Affiliation(s)
- Seung-Jung Park
- Division of Cardiology, University of Ulsan College of Medicine, Asan Medical Center, Songpa-Gu, Seoul, Korea.
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Park SJ, Kim YH. Percutaneous Coronary Intervention for Unprotected Left Main Coronary Artery Stenosis. Cardiol Clin 2010; 28:81-95. [DOI: 10.1016/j.ccl.2009.09.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Niccoli G, Ferrante G, Porto I, Burzotta F, Leone AM, Mongiardo R, Mazzari MA, Trani C, Rebuzzi AG, Crea F. Coronary bifurcation lesions: To stent one branch or both? A meta-analysis of patients treated with drug eluting stents. Int J Cardiol 2010; 139:80-91. [DOI: 10.1016/j.ijcard.2008.10.016] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2007] [Revised: 09/02/2008] [Accepted: 10/12/2008] [Indexed: 11/29/2022]
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Athappan G, Ponniah T, Jeyaseelan L. True coronary bifurcation lesions: meta-analysis and review of literature. J Cardiovasc Med (Hagerstown) 2010; 11:103-10. [DOI: 10.2459/jcm.0b013e32832ffc85] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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37
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Park SJ, Kim YH. Percutaneous coronary intervention for unprotected left main coronary artery stenosis. Interv Cardiol 2009. [DOI: 10.2217/ica.09.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Kandzari DE, Colombo A, Park SJ, Tommaso CL, Ellis SG, Guzman LA, Teirstein PS, Tamburino C, Ormiston J, Stone GW, Dangas GD, Popma JJ, Bass TA. Revascularization for Unprotected Left Main Disease. J Am Coll Cardiol 2009; 54:1576-88. [PMID: 19833256 DOI: 10.1016/j.jacc.2009.07.021] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2009] [Revised: 07/13/2009] [Accepted: 07/21/2009] [Indexed: 11/26/2022]
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Meliga E, Garcia-Garcia H, Valgimigli M, Chieffo A, Biondi-Zoccai G, Maree A, Gonzalo N, Cook S, Marra S, Moretti C, De Servi S, Palacios I, Windecker S, van Domburg R, Colombo A, Sheiban I, Serruys P. Impact of drug-eluting stent selection on long-term clinical outcomes in patients treated for unprotected left main coronary artery disease: The sirolimus vs paclitaxel drug-eluting stent for left main registry (SP-DELFT). Int J Cardiol 2009; 137:16-21. [PMID: 18687481 DOI: 10.1016/j.ijcard.2008.06.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2008] [Revised: 05/07/2008] [Accepted: 06/01/2008] [Indexed: 02/08/2023]
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Tamburino C, Angiolillo DJ, Capranzano P, Di Salvo M, Ussia G, La Manna A, Guzman LA, Galassi AR, Bass TA. Long-term clinical outcomes after drug-eluting stent implantation in unprotected left main coronary artery disease. Catheter Cardiovasc Interv 2009; 73:291-8. [DOI: 10.1002/ccd.21840] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Palmerini T, Marzocchi A, Tamburino C, Sheiban I, Margheri M, Vecchi G, Sangiorgi G, Santarelli A, Bartorelli A, Briguori C, Vignali L, Di Pede F, Ramondo A, Inglese L, De Carlo M, Falsini G, Benassi A, Palmieri C, Filippone V, Sangiorgi D, Barlocco F, De Servi S. Impact of Bifurcation Technique on 2-Year Clinical Outcomes in 773 Patients With Distal Unprotected Left Main Coronary Artery Stenosis Treated With Drug-Eluting Stents. Circ Cardiovasc Interv 2008; 1:185-92. [PMID: 20031677 DOI: 10.1161/circinterventions.108.800631] [Citation(s) in RCA: 98] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Distal unprotected left main coronary artery (ULMCA) stenosis represents a technical challenge for interventional cardiologists. In this study, we compared 2-year clinical outcomes of different stenting strategies in patients with distal ULMCA stenosis treated with drug-eluting stents.
Methods and Results—
The survey promoted by the Italian Society of Invasive Cardiology on ULMCA stenosis was an observational study on patients with ULMCA stenosis treated with percutaneous coronary intervention. In this study, we selected patients with distal ULMCA stenosis treated with drug-eluting stents. Seven hundred seventy-three patients were eligible for this study: 456 were treated with 1 stent (group 1) and 317 with 2 stents (group 2). The primary end point of the study was the incidence of major adverse cardiac events (MACEs), defined as the occurrence of mortality, myocardial infarction, and target lesion revascularization. During a 2-year follow-up, risk-adjusted survival free from MACE was significantly higher in patients in group 1 than in patients in group 2. The propensity-adjusted hazard ratio for the risk of 2-year MACE in patients in group 1 versus group 2 was 0.53 (95% CI, 0.37 to 0.76). The propensity-adjusted hazard ratio for the risk of 2-year cardiac mortality and myocardial infarction in patients in group 1 versus group 2 was 0.38 (95% CI, 0.17 to 0.85).
Conclusions—
Compared with the 2-stent technique, the 1-stent technique is associated with a better 2-year MACE-free survival. The stenting strategy is a prognostic factor that should be taken into account when deciding the optimal revascularization treatment.
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Affiliation(s)
- Tullio Palmerini
- From the Istituto di Cardiologia (T.P., A.M., D.S.), Policlinico S. Orsola, Università di Bologna, Italy; Dipartimento di Cardiologia (C.T.), Ospedale Ferrarotto, Università di Catania, Italy; Divisione di Cardiologia (I.S.), Università di Torino, Italy; Dipartimento Cardiovascolare (M.M.), Ospedale Careggi, Università di Firenze, Italy; Dipartimento di Cardiologia (G.V.), Ospedale S. Maria delle Croci, Ravenna, Italy; Centro Emocolumbus (G.S.), Milano, Italy; Dipartimento di Cardiologia (A.S.),
| | - Antonio Marzocchi
- From the Istituto di Cardiologia (T.P., A.M., D.S.), Policlinico S. Orsola, Università di Bologna, Italy; Dipartimento di Cardiologia (C.T.), Ospedale Ferrarotto, Università di Catania, Italy; Divisione di Cardiologia (I.S.), Università di Torino, Italy; Dipartimento Cardiovascolare (M.M.), Ospedale Careggi, Università di Firenze, Italy; Dipartimento di Cardiologia (G.V.), Ospedale S. Maria delle Croci, Ravenna, Italy; Centro Emocolumbus (G.S.), Milano, Italy; Dipartimento di Cardiologia (A.S.),
| | - Corrado Tamburino
- From the Istituto di Cardiologia (T.P., A.M., D.S.), Policlinico S. Orsola, Università di Bologna, Italy; Dipartimento di Cardiologia (C.T.), Ospedale Ferrarotto, Università di Catania, Italy; Divisione di Cardiologia (I.S.), Università di Torino, Italy; Dipartimento Cardiovascolare (M.M.), Ospedale Careggi, Università di Firenze, Italy; Dipartimento di Cardiologia (G.V.), Ospedale S. Maria delle Croci, Ravenna, Italy; Centro Emocolumbus (G.S.), Milano, Italy; Dipartimento di Cardiologia (A.S.),
| | - Imad Sheiban
- From the Istituto di Cardiologia (T.P., A.M., D.S.), Policlinico S. Orsola, Università di Bologna, Italy; Dipartimento di Cardiologia (C.T.), Ospedale Ferrarotto, Università di Catania, Italy; Divisione di Cardiologia (I.S.), Università di Torino, Italy; Dipartimento Cardiovascolare (M.M.), Ospedale Careggi, Università di Firenze, Italy; Dipartimento di Cardiologia (G.V.), Ospedale S. Maria delle Croci, Ravenna, Italy; Centro Emocolumbus (G.S.), Milano, Italy; Dipartimento di Cardiologia (A.S.),
| | - Massimo Margheri
- From the Istituto di Cardiologia (T.P., A.M., D.S.), Policlinico S. Orsola, Università di Bologna, Italy; Dipartimento di Cardiologia (C.T.), Ospedale Ferrarotto, Università di Catania, Italy; Divisione di Cardiologia (I.S.), Università di Torino, Italy; Dipartimento Cardiovascolare (M.M.), Ospedale Careggi, Università di Firenze, Italy; Dipartimento di Cardiologia (G.V.), Ospedale S. Maria delle Croci, Ravenna, Italy; Centro Emocolumbus (G.S.), Milano, Italy; Dipartimento di Cardiologia (A.S.),
| | - Giuseppe Vecchi
- From the Istituto di Cardiologia (T.P., A.M., D.S.), Policlinico S. Orsola, Università di Bologna, Italy; Dipartimento di Cardiologia (C.T.), Ospedale Ferrarotto, Università di Catania, Italy; Divisione di Cardiologia (I.S.), Università di Torino, Italy; Dipartimento Cardiovascolare (M.M.), Ospedale Careggi, Università di Firenze, Italy; Dipartimento di Cardiologia (G.V.), Ospedale S. Maria delle Croci, Ravenna, Italy; Centro Emocolumbus (G.S.), Milano, Italy; Dipartimento di Cardiologia (A.S.),
| | - Giuseppe Sangiorgi
- From the Istituto di Cardiologia (T.P., A.M., D.S.), Policlinico S. Orsola, Università di Bologna, Italy; Dipartimento di Cardiologia (C.T.), Ospedale Ferrarotto, Università di Catania, Italy; Divisione di Cardiologia (I.S.), Università di Torino, Italy; Dipartimento Cardiovascolare (M.M.), Ospedale Careggi, Università di Firenze, Italy; Dipartimento di Cardiologia (G.V.), Ospedale S. Maria delle Croci, Ravenna, Italy; Centro Emocolumbus (G.S.), Milano, Italy; Dipartimento di Cardiologia (A.S.),
| | - Andrea Santarelli
- From the Istituto di Cardiologia (T.P., A.M., D.S.), Policlinico S. Orsola, Università di Bologna, Italy; Dipartimento di Cardiologia (C.T.), Ospedale Ferrarotto, Università di Catania, Italy; Divisione di Cardiologia (I.S.), Università di Torino, Italy; Dipartimento Cardiovascolare (M.M.), Ospedale Careggi, Università di Firenze, Italy; Dipartimento di Cardiologia (G.V.), Ospedale S. Maria delle Croci, Ravenna, Italy; Centro Emocolumbus (G.S.), Milano, Italy; Dipartimento di Cardiologia (A.S.),
| | - Antonio Bartorelli
- From the Istituto di Cardiologia (T.P., A.M., D.S.), Policlinico S. Orsola, Università di Bologna, Italy; Dipartimento di Cardiologia (C.T.), Ospedale Ferrarotto, Università di Catania, Italy; Divisione di Cardiologia (I.S.), Università di Torino, Italy; Dipartimento Cardiovascolare (M.M.), Ospedale Careggi, Università di Firenze, Italy; Dipartimento di Cardiologia (G.V.), Ospedale S. Maria delle Croci, Ravenna, Italy; Centro Emocolumbus (G.S.), Milano, Italy; Dipartimento di Cardiologia (A.S.),
| | - Carlo Briguori
- From the Istituto di Cardiologia (T.P., A.M., D.S.), Policlinico S. Orsola, Università di Bologna, Italy; Dipartimento di Cardiologia (C.T.), Ospedale Ferrarotto, Università di Catania, Italy; Divisione di Cardiologia (I.S.), Università di Torino, Italy; Dipartimento Cardiovascolare (M.M.), Ospedale Careggi, Università di Firenze, Italy; Dipartimento di Cardiologia (G.V.), Ospedale S. Maria delle Croci, Ravenna, Italy; Centro Emocolumbus (G.S.), Milano, Italy; Dipartimento di Cardiologia (A.S.),
| | - Luigi Vignali
- From the Istituto di Cardiologia (T.P., A.M., D.S.), Policlinico S. Orsola, Università di Bologna, Italy; Dipartimento di Cardiologia (C.T.), Ospedale Ferrarotto, Università di Catania, Italy; Divisione di Cardiologia (I.S.), Università di Torino, Italy; Dipartimento Cardiovascolare (M.M.), Ospedale Careggi, Università di Firenze, Italy; Dipartimento di Cardiologia (G.V.), Ospedale S. Maria delle Croci, Ravenna, Italy; Centro Emocolumbus (G.S.), Milano, Italy; Dipartimento di Cardiologia (A.S.),
| | - Francesco Di Pede
- From the Istituto di Cardiologia (T.P., A.M., D.S.), Policlinico S. Orsola, Università di Bologna, Italy; Dipartimento di Cardiologia (C.T.), Ospedale Ferrarotto, Università di Catania, Italy; Divisione di Cardiologia (I.S.), Università di Torino, Italy; Dipartimento Cardiovascolare (M.M.), Ospedale Careggi, Università di Firenze, Italy; Dipartimento di Cardiologia (G.V.), Ospedale S. Maria delle Croci, Ravenna, Italy; Centro Emocolumbus (G.S.), Milano, Italy; Dipartimento di Cardiologia (A.S.),
| | - Angelo Ramondo
- From the Istituto di Cardiologia (T.P., A.M., D.S.), Policlinico S. Orsola, Università di Bologna, Italy; Dipartimento di Cardiologia (C.T.), Ospedale Ferrarotto, Università di Catania, Italy; Divisione di Cardiologia (I.S.), Università di Torino, Italy; Dipartimento Cardiovascolare (M.M.), Ospedale Careggi, Università di Firenze, Italy; Dipartimento di Cardiologia (G.V.), Ospedale S. Maria delle Croci, Ravenna, Italy; Centro Emocolumbus (G.S.), Milano, Italy; Dipartimento di Cardiologia (A.S.),
| | - Luigi Inglese
- From the Istituto di Cardiologia (T.P., A.M., D.S.), Policlinico S. Orsola, Università di Bologna, Italy; Dipartimento di Cardiologia (C.T.), Ospedale Ferrarotto, Università di Catania, Italy; Divisione di Cardiologia (I.S.), Università di Torino, Italy; Dipartimento Cardiovascolare (M.M.), Ospedale Careggi, Università di Firenze, Italy; Dipartimento di Cardiologia (G.V.), Ospedale S. Maria delle Croci, Ravenna, Italy; Centro Emocolumbus (G.S.), Milano, Italy; Dipartimento di Cardiologia (A.S.),
| | - Marco De Carlo
- From the Istituto di Cardiologia (T.P., A.M., D.S.), Policlinico S. Orsola, Università di Bologna, Italy; Dipartimento di Cardiologia (C.T.), Ospedale Ferrarotto, Università di Catania, Italy; Divisione di Cardiologia (I.S.), Università di Torino, Italy; Dipartimento Cardiovascolare (M.M.), Ospedale Careggi, Università di Firenze, Italy; Dipartimento di Cardiologia (G.V.), Ospedale S. Maria delle Croci, Ravenna, Italy; Centro Emocolumbus (G.S.), Milano, Italy; Dipartimento di Cardiologia (A.S.),
| | - Giovanni Falsini
- From the Istituto di Cardiologia (T.P., A.M., D.S.), Policlinico S. Orsola, Università di Bologna, Italy; Dipartimento di Cardiologia (C.T.), Ospedale Ferrarotto, Università di Catania, Italy; Divisione di Cardiologia (I.S.), Università di Torino, Italy; Dipartimento Cardiovascolare (M.M.), Ospedale Careggi, Università di Firenze, Italy; Dipartimento di Cardiologia (G.V.), Ospedale S. Maria delle Croci, Ravenna, Italy; Centro Emocolumbus (G.S.), Milano, Italy; Dipartimento di Cardiologia (A.S.),
| | - Alberto Benassi
- From the Istituto di Cardiologia (T.P., A.M., D.S.), Policlinico S. Orsola, Università di Bologna, Italy; Dipartimento di Cardiologia (C.T.), Ospedale Ferrarotto, Università di Catania, Italy; Divisione di Cardiologia (I.S.), Università di Torino, Italy; Dipartimento Cardiovascolare (M.M.), Ospedale Careggi, Università di Firenze, Italy; Dipartimento di Cardiologia (G.V.), Ospedale S. Maria delle Croci, Ravenna, Italy; Centro Emocolumbus (G.S.), Milano, Italy; Dipartimento di Cardiologia (A.S.),
| | - Cataldo Palmieri
- From the Istituto di Cardiologia (T.P., A.M., D.S.), Policlinico S. Orsola, Università di Bologna, Italy; Dipartimento di Cardiologia (C.T.), Ospedale Ferrarotto, Università di Catania, Italy; Divisione di Cardiologia (I.S.), Università di Torino, Italy; Dipartimento Cardiovascolare (M.M.), Ospedale Careggi, Università di Firenze, Italy; Dipartimento di Cardiologia (G.V.), Ospedale S. Maria delle Croci, Ravenna, Italy; Centro Emocolumbus (G.S.), Milano, Italy; Dipartimento di Cardiologia (A.S.),
| | - Vincenzo Filippone
- From the Istituto di Cardiologia (T.P., A.M., D.S.), Policlinico S. Orsola, Università di Bologna, Italy; Dipartimento di Cardiologia (C.T.), Ospedale Ferrarotto, Università di Catania, Italy; Divisione di Cardiologia (I.S.), Università di Torino, Italy; Dipartimento Cardiovascolare (M.M.), Ospedale Careggi, Università di Firenze, Italy; Dipartimento di Cardiologia (G.V.), Ospedale S. Maria delle Croci, Ravenna, Italy; Centro Emocolumbus (G.S.), Milano, Italy; Dipartimento di Cardiologia (A.S.),
| | - Diego Sangiorgi
- From the Istituto di Cardiologia (T.P., A.M., D.S.), Policlinico S. Orsola, Università di Bologna, Italy; Dipartimento di Cardiologia (C.T.), Ospedale Ferrarotto, Università di Catania, Italy; Divisione di Cardiologia (I.S.), Università di Torino, Italy; Dipartimento Cardiovascolare (M.M.), Ospedale Careggi, Università di Firenze, Italy; Dipartimento di Cardiologia (G.V.), Ospedale S. Maria delle Croci, Ravenna, Italy; Centro Emocolumbus (G.S.), Milano, Italy; Dipartimento di Cardiologia (A.S.),
| | - Fabio Barlocco
- From the Istituto di Cardiologia (T.P., A.M., D.S.), Policlinico S. Orsola, Università di Bologna, Italy; Dipartimento di Cardiologia (C.T.), Ospedale Ferrarotto, Università di Catania, Italy; Divisione di Cardiologia (I.S.), Università di Torino, Italy; Dipartimento Cardiovascolare (M.M.), Ospedale Careggi, Università di Firenze, Italy; Dipartimento di Cardiologia (G.V.), Ospedale S. Maria delle Croci, Ravenna, Italy; Centro Emocolumbus (G.S.), Milano, Italy; Dipartimento di Cardiologia (A.S.),
| | - Stefano De Servi
- From the Istituto di Cardiologia (T.P., A.M., D.S.), Policlinico S. Orsola, Università di Bologna, Italy; Dipartimento di Cardiologia (C.T.), Ospedale Ferrarotto, Università di Catania, Italy; Divisione di Cardiologia (I.S.), Università di Torino, Italy; Dipartimento Cardiovascolare (M.M.), Ospedale Careggi, Università di Firenze, Italy; Dipartimento di Cardiologia (G.V.), Ospedale S. Maria delle Croci, Ravenna, Italy; Centro Emocolumbus (G.S.), Milano, Italy; Dipartimento di Cardiologia (A.S.),
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Wu XM, Liu CP, Lin WC, Kao HL. Long-term outcome of percutaneous coronary intervention for unprotected left main coronary artery disease. Int J Cardiol 2008; 138:272-6. [PMID: 18804295 DOI: 10.1016/j.ijcard.2008.08.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2008] [Accepted: 08/08/2008] [Indexed: 10/21/2022]
Abstract
OBJECTIVES The aim of this study is to evaluate the in-hospital, 30 day and long-term outcomes after percutaneous coronary intervention for unprotected left main coronary artery disease. BACKGROUNDS Left main coronary artery (LMCA) diseases stenosis is a strong indication for coronary artery bypass grafting (CABG). With improved device technology, percutaneous coronary intervention (PCI) with drug-eluting stent (DES) stents had been recently advocated as an alternative procedure for the unprotected LMCA disease. METHODS Between January 2003 and February 2007, all unprotected LMCA PCI procedures were retrospectively collected. Outcomes were obtained by chart record review and telephone interview. RESULTS Fifty five consecutive patients with >50% diameter stenosis of LMCA undergoing PCI were analyzed. Indications for a percutaneous strategy were prohibitive surgical risks, or patient/physician preference. The procedural success rate was 98%. 41 patients (75%) received DES implantation. The majority of cases (n=33) were treated with a double-stent strategy. There were no in-hospital deaths. The clinical follow-up time was 867+/-410 days (range 20-1715). 18 (29%) patients experienced major adverse cardiac events, including 3 (5%) deaths, 4 (7%) myocardial infarctions, and 12 (21.8%) target lesion revascularizations (TLR) during follow-up. Multivariate analysis revealed hyperlipidemia (Hazard ratio, HR=6.2, p=0.024) and bifurcation involvement (HR=4.4, p=0.008) were independent predictors for MACE. CONCLUSIONS Our results showed that PCI with stenting was an acceptable treatment option for patients with LMCA stenosis. Involvement of the LMCA bifurcation remains a predictor for unfavorable outcome.
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Affiliation(s)
- Xue-Ming Wu
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
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Meliga E, Garcia-Garcia HM, Valgimigli M, Chieffo A, Biondi-Zoccai G, Maree AO, Cook S, Reardon L, Moretti C, De Servi S, Palacios IF, Windecker S, Colombo A, van Domburg R, Sheiban I, Serruys PW. Longest Available Clinical Outcomes After Drug-Eluting Stent Implantation for Unprotected Left Main Coronary Artery Disease. J Am Coll Cardiol 2008; 51:2212-9. [PMID: 18534266 DOI: 10.1016/j.jacc.2008.03.020] [Citation(s) in RCA: 118] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2007] [Revised: 02/28/2008] [Accepted: 03/04/2008] [Indexed: 02/05/2023]
Affiliation(s)
- Emanuele Meliga
- Department of Interventional Cardiology, Erasmus Medical Centre, Erasmus University, Rotterdam, The Netherlands
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Kim YH, Dangas GD, Solinas E, Aoki J, Parise H, Kimura M, Franklin-Bond T, Dasgupta NK, Kirtane AJ, Moussa I, Lansky AJ, Collins M, Stone GW, Leon MB, Moses JW, Mehran R. Effectiveness of drug-eluting stent implantation for patients with unprotected left main coronary artery stenosis. Am J Cardiol 2008; 101:801-6. [PMID: 18328844 DOI: 10.1016/j.amjcard.2007.10.052] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2007] [Revised: 10/09/2007] [Accepted: 10/09/2007] [Indexed: 01/23/2023]
Abstract
This study was aimed to evaluate outcomes of patients with unprotected left main coronary artery (LMCA) stenosis who were treated with drug-eluting stents. Sixty-three consecutive patients with unprotected LMCA stenosis were treated with sirolimus-eluting stents in 52 (83%) patients and paclitaxel-eluting stents in 11 (17%) patients, in whom percutaneous intervention was considered the sole alternative because of high surgical risk and/or patient preference. Urgent percutaneous coronary intervention within 24 hours after angiography was performed in 6 (10%) patients. The patients were predominantly at high surgical risk with 35 (56%) having EuroSCORE >6 and 39 (62%) having Parsonnet score >15. Involvement of the distal LMCA was observed in 46 (73%) patients. Procedural success was achieved in all patients. Intravascular ultrasound was used in 51 (81%) patients. Single-stenting strategy was adopted in 36 (78%) patients with bifurcation stenosis. There were no death, Q-wave myocardial infarction, stent thrombosis, or urgent repeat revascularization events during hospitalization. Over a mean follow-up of 11.7 +/- 7.7 months, 18 (29%) patients experienced major adverse cardiac events, including 3 (5%) deaths, 7 (11%) myocardial infarctions, and 10 (16%) target lesion revascularizations. Stent thrombosis developed in 1 (0.6%) patient at 35 days after the procedure. Bifurcation involvement was an independent predictor of major adverse cardiac events by multivariate analysis (hazard ratio 12.90, 95% confidence interval 1.36 to 122.45, p = 0.0259). In conclusion, drug-eluting stent placement for unprotected LMCA stenosis may be a feasible therapeutic alternative in patients at high surgical risk. However, bifurcation stenosis remains a significant predictor of unfavorable clinical outcome.
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Immediate and long-term outcomes of drug-eluting stent implantation for unprotected left main coronary artery disease: comparison with bare-metal stent implantation. Am Heart J 2008; 155:553-61. [PMID: 18294496 DOI: 10.1016/j.ahj.2007.10.030] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2007] [Accepted: 10/24/2007] [Indexed: 11/23/2022]
Abstract
BACKGROUND The efficacy and safety of drug-eluting stent (DES) implantation for unprotected left main coronary artery (LMCA) disease remain to be established in different clinical settings. METHODS Elective DES implantation for unprotected LMCA stenosis was performed in 220 patients at the Fu Wai Hospital, China, from April 2003 to February 2006. Data derived from the latter group were compared with those derived from 224 patients treated with bare-metal stents (BMSs) before March 2003 in a Chinese registry of unprotected LMCA stenting. RESULTS Compared with the historical BMS control group, the DES group had more multivessel disease and underwent more bifurcation stenting. The inhospital major adverse cardiac events were significantly higher in the DES than in the BMS recipients (4.1% vs 0.9%, P = .030) because of more complex lesions and procedures in the DES group. During the 15-month mean follow-up period, cumulative cardiac death (0.5% vs 4.9%, P = .004), target-vessel revascularization (5.9% vs 11.6%, P = .034), and major adverse cardiac event (9.5% vs 16.5%, P = .029) rates were significantly lower in the DES than in the BMS group. There was no significant difference in clinical efficacy between sirolimus- and paclitaxel-eluting stents. Angiographic follow-up was performed in 46.4% of DES and 45.7% of BMS recipients, respectively; and the binary restenosis rate was significantly lower in the DES versus the BMS control group (16.7% vs 31.4%, P = .014). CONCLUSIONS Based on this comparison with a historical control, DES implantation for unprotected LMCA appears safe in selected patients and might be more effective in preventing major adverse cardiac events compared with BMS implantation over a mean follow-up period of 15 months.
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Buszman PE, Kiesz SR, Bochenek A, Peszek-Przybyla E, Szkrobka I, Debinski M, Bialkowska B, Dudek D, Gruszka A, Zurakowski A, Milewski K, Wilczynski M, Rzeszutko L, Buszman P, Szymszal J, Martin JL, Tendera M. Acute and Late Outcomes of Unprotected Left Main Stenting in Comparison With Surgical Revascularization. J Am Coll Cardiol 2008; 51:538-45. [PMID: 18237682 DOI: 10.1016/j.jacc.2007.09.054] [Citation(s) in RCA: 266] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2007] [Revised: 09/10/2007] [Accepted: 09/17/2007] [Indexed: 10/22/2022]
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Park SJ. Which is the most appropriate stenting technique with drug-eluting stent for unprotected left main bifurcation stenosis? Catheter Cardiovasc Interv 2008; 71:173-4. [PMID: 18327833 DOI: 10.1002/ccd.21476] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Chen S, Zhang J, Ye F, Chen Y, Fang W, Wei M, He B, Sun X, Yang S, Kwan TW. Final kissing balloon inflation by classic crush stenting did not improve the clinical outcomes for the treatment of unprotected left main bifurcation lesions: The importance of double-kissing crush technique. Catheter Cardiovasc Interv 2008; 71:166-72. [DOI: 10.1002/ccd.21317] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Sharis P, Shammas NW. Evidence-based treatment of unprotected left main disease: a critical review of the literature. Curr Atheroscler Rep 2007; 9:397-400. [PMID: 18001623 DOI: 10.1007/s11883-007-0051-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Bypass surgery is currently the standard therapy for unprotected left main (UPLM) disease because it has been shown in randomized, long-term follow-up trials to reduce mortality compared with medical treatment. Early data in treating UPLM disease with bare metal stents has shown a high rate of restenosis and major adverse events. With the advent of drug-eluting stents (DES), stenting for treatment of UPLM disease has recently gained more acceptance among interventional cardiologists. DES have been shown to be superior to bare metal stents in reducing restenosis after treatment of UPLM disease. Also, observational and small randomized studies have shown promising short-term outcomes with the use of DES compared with bypass surgery. Furthermore, ostial left main (LM) stenting with DES appears to have superior outcome when compared with stenting of the distal LM at the bifurcation. These studies, however, are small, with significant selection biases and with limited follow-up. Large randomized trials are currently being performed to compare LM stenting with DES versus bypass surgery. UPLM stenting at this time needs to be reserved for high-risk surgical patients until more conclusive data about its safety and effectiveness become available from large randomized trials.
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Affiliation(s)
- Peter Sharis
- Midwest Cardiovascular Reseach Foundation, Cardiovascular Medicine, PC, Davenport, IA 5280, USA
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Pavlakis G, de Man F, Hamer B, Doevendans P, Stella PR. Registry on a new T technique for bifurcation coronary lesions: the Utrech-"T"- experience. EUROINTERVENTION 2007; 3:262-8. [PMID: 19758948 DOI: 10.4244/eijv3i2a45] [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] [Indexed: 11/23/2022]
Abstract
AIMS The goal of this study was to clinically evaluate the effectiveness of a new coronary stenting approach for bifurcation lesions designed to provide adequate main and side-branch ostial scaffolding and provide a simplified technique. METHODS AND RESULTS The technique was used in 100 consecutive patients with suitable bifurcation lesions. Sequential placement of two stents was performed in all patients, resulting in complete coverage of the bifurcation ostium and carina with minimal crushing of a small portion of the side-branch stent. Clinical follow-up was done for a six months period. The rate of clinically driven target vessel revascularisation at six months was 4%. One patient died during follow-up. Subacute thrombosis occurred in two patients. CONCLUSIONS Treatment of bifurcation lesions using this new approach is feasible, with a low rate of procedural and clinical events. Larger trials with angiographic follow-up are necessary to prove the potential advantage of this approach relatively to the currently used techniques for the treatment of coronary bifurcations.
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Affiliation(s)
- Georgios Pavlakis
- Department of Interventional Cardiology; Heart Lung Center, University Medical Center, Utrecht, The Netherlands
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