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Khan MR, Kayani WT, Ahmad W, Hira RS, Virani SS, Hamzeh I, Jneid H, Lakkis N, Alam M. Meta-Analysis of Comparison of 5-Year Outcomes of Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting in Patients With Unprotected Left Main Coronary Artery in the Era of Drug-eluting Stents. Am J Cardiol 2017; 120:1514-1520. [PMID: 28886851 DOI: 10.1016/j.amjcard.2017.07.048] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Revised: 07/21/2017] [Accepted: 07/21/2017] [Indexed: 11/30/2022]
Abstract
Patients with unprotected left main coronary artery (ULMCA) disease are increasingly being treated with percutaneous coronary intervention (PCI) using drug-eluting stents (DES), but long-term outcomes comparing PCI with coronary artery bypass grafting (CABG) remain limited. We performed aggregate data meta-analyses of clinical outcomes (all-cause death, nonfatal myocardial infarction, stroke, repeat revascularization, cardiac death, and major adverse cardiac and cerebrovascular events) in studies comparing 5-year outcomes of PCI with DES versus CABG in patients with ULMCA disease. A comprehensive literature search (January 1, 2003 to December 10, 2016) identified 9 studies (6,637 patients). Effect size for individual clinical outcomes was estimated using odds ratio (OR) with 95% confidence intervals (CI) using a random effects model. At 5 years, PCI with DES was associated with equivalent cardiac (OR 0.95, 95% CI 0.62 to 1.46) and all-cause mortality (OR 0.98, 95% CI 0.72 to 1.33), lower rates of stroke (OR 0.50, 95% CI 0.30 to 0.84), and higher rates of repeat revascularization (OR 2.52, 95% CI 1.63 to 3.91); compared with CABG, major adverse cardiac and cerebrovascular events showed a trend favoring CABG but did not reach statistical significance (OR 1.19, 95% CI 0.93 to 1.54). In conclusion, for ULMCA disease, PCI can be considered as a comparably effective and yet less invasive alternative to CABG given the comparable long-term mortality and lower incidences of stroke.
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Affiliation(s)
- Mahin R Khan
- Resident Internal Medicine, McLaren Flint/Michigan State University, Flint, Michigan
| | - Waleed T Kayani
- Department of Medicine, Section of Cardiology, Baylor College of Medicine, Houston, Texas
| | | | - Ravi S Hira
- University of Washington, Seattle, Washington
| | - Salim S Virani
- Department of Medicine, Section of Cardiology, Baylor College of Medicine, Houston, Texas; Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Ihab Hamzeh
- Department of Medicine, Section of Cardiology, Baylor College of Medicine, Houston, Texas
| | - Hani Jneid
- Department of Medicine, Section of Cardiology, Baylor College of Medicine, Houston, Texas; Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Nasser Lakkis
- Department of Medicine, Section of Cardiology, Baylor College of Medicine, Houston, Texas
| | - Mahboob Alam
- Department of Medicine, Section of Cardiology, Baylor College of Medicine, Houston, Texas.
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Therapeutic effect of interventional therapy for unprotected left main coronary artery lesions in aged patients. JOURNAL OF GERIATRIC CARDIOLOGY : JGC 2016; 12:634-40. [PMID: 26788040 PMCID: PMC4712369 DOI: 10.11909/j.issn.1671-5411.2015.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Objective To assesse the therapeutic effect of interventional therapy in aged patients with unprotected left main coronary artery (UPLM) lesions. Methods A total of 61 patients who were over 60 years and accepted interventional therapy of UPLM from January 2012 to November 2013 in our hospital were followed up for average 14.6 months by telephone call or outpatient visits. We analyzed the clinical features data of the interventional therapy and assessed the factors that likely influenced the clinical prognosis. Results The average age of the 61 patients was 73.9 years. The average left ventricular ejection fraction (LVEF) was 47.7%. The median of the estimated glomerular filtration rate (eGFR) was 52 mL/min per 1.73 mm2. The average SYNTAX score was 27.4 and the median of stent length was 36 mm. The cumulative incidence of cardiac death at 30 days and major adverse cardiac events (MACE) after one year was 6.6% and 32.5% estimated by Kaplan-Meier plots respectively. No severe hemorrhagic complications were observed during follow-up period. On multivariate regression analysis with a COX proportional hazards model, LVEF was an independent predictor of cardiac death at 30 days [Hazard ratio (HR): 0.7, P = 0.01]. As for MACE after one year, LVEF and eGFR were both independent predictors (HR: 0.91, P = 0.06 for LVEF, HR: 0.03, P = 0.097 for eGFR). Conclusions The interventional therapy for UPLM was effective and safe in aged patients. LVEF was the only predictor of cardiac death at 30 days, while LVEF and eGFR were both independent predictors of MACE after one year.
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Wei Z, Xie J, Wang K, Kang L, Dai Q, Bai J, Xu B. Comparison of Percutaneous Coronary Intervention Versus Coronary Artery Bypass Graft in Aged Patients With Unprotected Left Main Artery Lesions. Int Heart J 2016; 57:682-688. [DOI: 10.1536/ihj.15-420] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Zhonghai Wei
- Department of Cardiology, Drum Tower Hospital, Medical School of Nanjing University
| | - Jun Xie
- Department of Cardiology, Drum Tower Hospital, Medical School of Nanjing University
| | - Kun Wang
- Department of Cardiology, Drum Tower Hospital, Medical School of Nanjing University
| | - Lina Kang
- Department of Cardiology, Drum Tower Hospital, Medical School of Nanjing University
| | - Qing Dai
- Department of Cardiology, Drum Tower Hospital, Medical School of Nanjing University
| | - Jian Bai
- Department of Cardiology, Drum Tower Hospital, Medical School of Nanjing University
| | - Biao Xu
- Department of Cardiology, Drum Tower Hospital, Medical School of Nanjing University
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Lee PH, Ahn JM, Park SJ. Update on percutaneous intervention for left main coronary artery stenosis. Expert Rev Cardiovasc Ther 2015; 13:933-43. [PMID: 26159652 DOI: 10.1586/14779072.2015.1065730] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Percutaneous coronary intervention (PCI) using drug-eluting stents (DES) is currently considered as a viable alternative to coronary artery bypass graft surgery (CABG) for selected patients with left main coronary artery disease. The updated results of the landmark randomized trials comparing CABG versus PCI demonstrated comparable 5-year outcomes and are in line with the current guidelines that designate PCI as a reasonable treatment in this disease subset. Given that the completed randomized trials did not include contemporary DESs, the upcoming results of the ongoing trials evaluating the performance of new-generation DES compared with CABG (such as the EXCEL trial), may further help to clarify the current role and future recommendations of PCI for left main coronary artery disease. Apart from the recent stent technology, further improvements in outcomes after PCI may be possible when it is used with an integrated approach that combines functional concepts for decision-making, adjunctive imaging support and optimal pharmacotherapies.
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Affiliation(s)
- Pil Hyung Lee
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Osnabrugge RL, Capodanno D, Cummins P, Kappetein P, Serruys PW. Review and recommendations on the current practice of meta-analyses: a guide to appraise the evidence. EUROINTERVENTION 2014; 9:1013-20. [DOI: 10.4244/eijv9i9a172] [Citation(s) in RCA: 8] [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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Comparison of sirolimus-, paclitaxel-, and everolimus-eluting stent in unprotected left main coronary artery percutaneous coronary intervention. J Saudi Heart Assoc 2013; 25:75-8. [PMID: 24174850 DOI: 10.1016/j.jsha.2013.03.001] [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: 12/27/2012] [Revised: 03/01/2013] [Accepted: 03/02/2013] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVES This retrospective study evaluated the outcomes of patients who underwent unprotected left main coronary artery (ULMCA) percutaneous coronary intervention (PCI) with different types of drug-eluting stents (DES). BACKGROUND The standard of care for patients with ULMCA is coronary artery bypass surgery. However, current guidelines recommend PCI in clinical conditions where there is an increased risk of adverse surgical outcomes. Clinical outcomes of patients undergoing ULMCA PCI with different types of drug-eluting stents (DES) are unknown. METHODS Data from a multicenter international registry, which included 239 consecutive patients from four institutions who ULMCA PCI with DES, were collected. RESULTS There were 42 patients receiving paclitaxel-eluting stent (PES), 158 patients receiving sirolimus-eluting stent (SES), and 39 patients receiving everolimus-eluting stent (EES). There was no statistical difference in major adverse cardiovascular events, cardiac death, myocardial infarction, target lesion revascularization, and stent thrombosis among PES, SES, and EES at 30 days and 1 year. CONCLUSIONS There are no differences in clinical events among patients receiving PES, SES, and EES for ULMCA disease.
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Drug-eluting stents or coronary artery bypass grafting for unprotected left main coronary artery disease: a meta-analysis of four randomized trials and seventeen observational studies. Trials 2013; 14:133. [PMID: 23782856 PMCID: PMC3663678 DOI: 10.1186/1745-6215-14-133] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2012] [Accepted: 04/18/2013] [Indexed: 11/20/2022] Open
Abstract
Background The clinical application of drug-eluting stents (DES) or coronary artery bypass grafting (CABG) for unprotected left main coronary artery disease (ULMCAD) is still controversial. The purpose of this meta-analysis was to compare the safety and efficacy between DES and CABG for ULMCAD. Methods Databases of MEDLINE, EMBASE and the Cochrane Library were systematically searched. Results Twenty-one studies with 8,413 patients were included in this meta-analysis. The risk was lower in DES than in CABG groups at the early outcomes of death (risk ratio (RR): 0.49, 95% confidence interval (CI): 0.30–0.78), cerebrovascular events (RR: 0.19, 95% CI: 0.08–0.45) and composite endpoint (RR: 0.53, 95% CI: 0.40–0.70); death after 2 years (RR: 0.81, 95% CI: 0.66–0.99), 4 years (RR: 0.69, 95% CI: 0.53–0.90), 5 years (OR: 0.76, 95% CI: 0.61–0.95) and their total effect (RR: 0.79, 95% CI: 0.71–0.87); composite endpoint 1 year (RR: 0.69, 95% CI: 0.58–0.83), 4 years (RR: 0.69, 95% CI: 0.53–0.88), 5 years (RR: 0.74, 95% CI: 0.59–0.92) and their total effect (RR: 0.78, 95% CI: 0.71–0.85). There were no significant differences in the risk for the early outcomes of myocardial infarction (RR: 0.97, 95% CI: 0.68–1.38), death 1 year (OR: 0.81, 95% CI: 0.57–1.15) and 3 years (OR: 0.85, 95% CI: 0.69–1.04), composite endpoint of 2 years (RR: 0.88, 95% CI: 0.72–1.09) and 3 years (RR: 0.87, 95% CI: 0.73–1.04). Nonetheless, there was a lower risk for revascularization associated with CABG from 1 to 5 years and their total effect (RR: 3.77, 95% CI: 3.35–4.26). There was no difference in death, myocardial infarction, cerebrovascular events or revascularization at 1 year between RCT and observational groups. Conclusions Our meta-analysis indicates that DES has higher safety but higher revascularization than CABG in patients with ULMCAD in the 5 years after intervention.
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Bridgewater B. Almanac 2012: Adult cardiac surgery. ARCHIVOS DE CARDIOLOGIA DE MEXICO 2013; 83:64-71. [PMID: 23453923 DOI: 10.1016/j.acmx.2013.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2013] [Accepted: 01/15/2013] [Indexed: 11/19/2022] Open
Affiliation(s)
- Ben Bridgewater
- University Hospital of South Manchester, Manchester, United Kingdom.
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Bridgewater B. Almanac 2012 adult cardiac surgery: The national society journals present selected research that has driven recent advances in clinical cardiology. Egypt Heart J 2013. [DOI: 10.1016/j.ehj.2012.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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McNulty E. Coronary Artery Bypass Grafting Versus Percutaneous Coronary Intervention for Unprotected Left Main Disease - A Review. Interv Cardiol 2013; 8:14-18. [PMID: 29588745 DOI: 10.15420/icr.2013.8.1.14] [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: 11/04/2022] Open
Abstract
There have been over a dozen studies in the drug-eluting stent era comparing the effectiveness of percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) surgery for the treatment of unprotected left main disease. These studies have been both randomised and observational in nature. While both methodologies provide important insights, careful consideration of their respective strengths and limitations is imperative in generalising their findings.
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Affiliation(s)
- Edward McNulty
- Kaiser San Francisco Medical Center, and Assistant Clinical Professor, University of California San Francisco School of Medicine, San Francisco, California, US
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Spoon DB, Rubinshtein R, Psaltis PJ, Sandhu GS, Lennon R, Rihal CS, Lerman A. Comparison between three-dimensional angiographic reconstruction and intravascular ultrasound: Imaging of the left main coronary artery. Catheter Cardiovasc Interv 2013; 81:1156-61. [DOI: 10.1002/ccd.24733] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2012] [Accepted: 10/24/2012] [Indexed: 11/08/2022]
Affiliation(s)
- Daniel B. Spoon
- Division of Cardiovascular Diseases; Mayo Clinic; Rochester; Minnesota
| | | | - Peter J. Psaltis
- Division of Cardiovascular Diseases; Mayo Clinic; Rochester; Minnesota
| | - Gupreet S. Sandhu
- Division of Cardiovascular Diseases; Mayo Clinic; Rochester; Minnesota
| | | | | | - Amir Lerman
- Division of Cardiovascular Diseases; Mayo Clinic; Rochester; Minnesota
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Bridgewater B. Almanac 2012: adult cardiac surgery: the national society journals present selected research that has driven recent advances in clinical cardiology. Rev Port Cardiol 2013; 32:173-80. [PMID: 23369506 DOI: 10.1016/j.repc.2012.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2012] [Accepted: 11/15/2012] [Indexed: 11/17/2022] Open
Abstract
This review covers the important publications in adult cardiac surgery in the last few years, including the current evidence base for surgical revascularisation and the use of off-pump surgery, bilateral internal mammary arteries and endoscopic vein harvesting. The changes in conventional aortic valve surgery are described alongside the outcomes of clinical trials and registries for transcatheter aortic valve implantation, and the introduction of less invasive and novel approaches of conventional aortic valve replacement surgery. Surgery for mitral valve disease is also considered, with particular reference to surgery for asymptomatic degenerative mitral regurgitation.
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Bridgewater B. Almanac 2012: Adult cardiac surgery: The national society journals present selected research that has driven recent advances in clinical cardiology. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2013. [DOI: 10.1016/j.repce.2013.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Kossaify A, Grollier G. A Case of Left Main Coronary Artery Disease in an Octogenarian Treated Surgically and Complicated by Myocardial Infarction: Decisions, Techniques, Rescue and Final Outcome. CLINICAL MEDICINE INSIGHTS: CASE REPORTS 2013; 6:61-5. [PMID: 23641159 PMCID: PMC3629927 DOI: 10.4137/ccrep.s11542] [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] [Indexed: 11/05/2022] Open
Abstract
We report on an octogenarian patient presenting with an acute coronary syndrome due to significant left main coronary artery disease and severe ostial stenosis of the left anterior descending artery disease. Emergent bypass graft performed with “beating heart” consisted of left internal mammary graft to the mid left anterior descending artery with an “over-stent” anastomosis. The immediate post-operative phase was simple, however the patient presented on post-operative day 8 with extensive anterior myocardial infarction and cardiogenic shock. Emergent coronary angiogram showed subocclusive anastomotic stenosis. Percutaneous coronary intervention was performed on left main, proximal left anterior descending, and proximal circumflex arteries. Subsequently, the patient restored a satisfactory hemodynamic condition. A focus on the importance of decision for management of left main disease especially in octogenarian is presented, along with a review of the pertinent literature.
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Affiliation(s)
- Antoine Kossaify
- USEK-NDS University Hospital, Department of Cardiology, St. Charbel Street, Byblos, Jbeil, Lebanon
| | - Gilles Grollier
- UH-Caen University Hospital, Department of Cardiology, Cote de Nacre, Caen, France
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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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Left Main Percutaneous Coronary Intervention. J Am Coll Cardiol 2012; 60:1605-13. [DOI: 10.1016/j.jacc.2012.01.085] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2011] [Revised: 01/06/2012] [Accepted: 01/20/2012] [Indexed: 11/17/2022]
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Midterm Outcome of Off-Pump Bypass Procedures Versus Drug-Eluting Stent for Unprotected Left Main Coronary Artery Disease. Ann Thorac Surg 2012; 94:15-22. [DOI: 10.1016/j.athoracsur.2012.03.029] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2011] [Revised: 03/09/2012] [Accepted: 03/12/2012] [Indexed: 11/21/2022]
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Sa MPBDO, Soares AMMN, Lustosa PC, Martins WN, Browne F, Ferraz PE, Vasconcelos FP, Lima RC. Meta-analysis of 5674 patients treated with percutaneous coronary intervention and drug-eluting stents or coronary artery bypass graft surgery for unprotected left main coronary artery stenosis. Eur J Cardiothorac Surg 2012; 43:73-80. [DOI: 10.1093/ejcts/ezs204] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
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Palmerini T, Alessi L, Dangas G. Revascularization of unprotected left main coronary artery disease: Strategy selection and systematic risk assessment. Catheter Cardiovasc Interv 2012; 80:199-205. [DOI: 10.1002/ccd.24323] [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] [Received: 10/07/2011] [Accepted: 01/07/2012] [Indexed: 11/11/2022]
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Head SJ, Bogers AJJC, Kappetein AP. Drug-eluting stent implantation for coronary artery disease: current stents and a comparison with bypass surgery. Curr Opin Pharmacol 2012; 12:147-54. [DOI: 10.1016/j.coph.2012.01.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2011] [Accepted: 01/09/2012] [Indexed: 11/16/2022]
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Kajimoto K, Miyauchi K, Yamamoto T, Daida H, Amano A. Meta-analysis of Randomized Controlled Trials on the Treatment of Unprotected Left Main Coronary Artery Disease: One-Year Outcomes with Coronary Artery Bypass Grafting Versus Percutaneous Coronary Artery Intervention with Drug-Eluting Stent. J Card Surg 2012; 27:152-7. [DOI: 10.1111/j.1540-8191.2011.01410.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Puricel S, Adorjan P, Oberhänsli M, Stauffer JC, Moschovitis A, Vogel R, Goy JJ, Müller O, Eeckhout E, Togni M, Wenaweser P, Meier B, Windecker S, Cook S. Clinical outcomes after PCI for acute coronary syndrome in unprotected left main coronary artery disease: insights from the Swiss Acute Left Main Coronary Vessel Percutaneous Management (SALVage) study. EUROINTERVENTION 2012; 7:697-704. [PMID: 21986328 DOI: 10.4244/eijv7i6a112] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS Unprotected left main (ULM) coronary artery disease is encountered in 3%-10% of coronary angiograms and is associated with high mortality. The survival of patients with ULM disease presenting with acute coronary syndromes (ACS) depends on different variables and is lowest in those with cardiogenic shock (CS). The aim of the present study was to estimate the impact of baseline characteristics on the subsequent clinical outcome in patients treated by percutaneous coronary intervention (PCI) of ULM for ACS. METHODS AND RESULTS One hundred and thirty-four patients were retrieved from our database and followed by phone or physician visit. Patients were classified into two groups according to their presentation (CS/STEMI group: patients presenting with CS or ST-elevation myocardial infarction; NSTEMI/UA group: patients with non-STEMI or unstable angina). Data collected were baseline characteristics, procedural information, and clinical outcome. The primary endpoint was all-cause mortality at 6-month follow-up. The secondary end point was a composite of cardiac death, myocardial infarction, and any repeat revascularisation, i.e., major adverse cardiac events (MACE). Kaplan-Meier curves were computed for survival. Logistic regression determined that hypercholesterolaemia (OR 6.22, p=0.03), high pre-procedural TIMI score (OR 3.89, p=0.01), preserved left ventricular ejection fraction (OR 1.07, p=0.01) and LM as culprit lesion (OR 8.57, p=0.01) protected against development of CS. Primary outcome occurred in 44% of patients in the CS/STEMI group compared to 6% in the NSTEMI/UA group (p<0.001). MACE were observed in 30 patients (48%) of the CS/STEMI group and in 12 patients (19%) of the NSTEMI/UA group (p=0.001). CONCLUSIONS Acute coronary syndrome due to critical ULM stenosis is associated with high mortality even after successful PCI. Patients presenting with CS or STEMI are at particular risk.
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Affiliation(s)
- Serban Puricel
- Department of Cardiology, University of Fribourg, Fribourg, Switzerland
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McNulty EJ, Ng W, Spertus JA, Zaroff JG, Yeh RW, Ren XM, Lundstrom RJ. Surgical candidacy and selection biases in nonemergent left main stenting: implications for observational studies. JACC Cardiovasc Interv 2012; 4:1020-7. [PMID: 21939943 DOI: 10.1016/j.jcin.2011.06.010] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2011] [Revised: 06/01/2011] [Accepted: 06/14/2011] [Indexed: 10/17/2022]
Abstract
OBJECTIVES This study sought to characterize reasons for surgical ineligibility in patients undergoing nonemergent unprotected left main (ULM) percutaneous coronary intervention (PCI) and to assess the potential for these reasons to confound comparative effectiveness studies of coronary revascularization. BACKGROUND Although both PCI and coronary artery bypass graft surgery are treatments for ULM disease, some patients are not eligible for both treatments, which may result in treatment selection biases. METHODS In 101 consecutive patients undergoing nonemergent ULM PCI, mixed methods were used to determine the prevalence of treatment selection dictated by surgical ineligibility and to identify the reasons cited for avoiding coronary artery bypass graft surgery. We then determined whether these reasons were captured by the ACC-NCDR (American College of Cardiology-National Cardiovascular Data Registry) Cath-PCI dataset to assess the ability of this registry to account for biases in treatment selection. Finally, the association of surgical eligibility with long-term outcomes after ULM PCI was assessed. RESULTS Treatment selection was dictated by surgical ineligibility in over half the ULM PCI cohort with the majority having reasons for ineligibility not captured by the ACC-NCDR. Surgical ineligibility was a significant predictor of mortality after adjustment for Society of Thoracic Surgeons (hazard ratio [HR]: 5.4, 95% confidence interval [CI]: 1.2 to 25), EuroSCORE (European System for Cardiac Operative Risk Evaluation) (HR: 5.9, 95% CI: 1.3 to 27), or NCDR mortality scores (HR: 6.2, 95% CI: 1.4 to 27). CONCLUSIONS Surgical ineligibility dictating treatment selection is common in patients undergoing nonemergent ULM PCI, occurs on the basis of risk factors not captured by the ACC-NCDR, and is independently associated with worse long-term outcomes after adjusting for standard risk scores.
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Affiliation(s)
- Edward J McNulty
- Division of Cardiology, Kaiser Permanente Medical Center, San Francisco, California 94115, USA.
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Abstract
For several decades of medical history, coronary-artery bypass grafting (CABG) has been regarded as the best treatment option for patients with unprotected left main coronary artery (LMCA) disease, considering lesion priority and its clinical consequences. Over the time, with remarkable advancements in techniques of percutaneous coronary intervention (PCI), supporting devices, and adjunctive pharmacologic therapy, PCI with DES implantation has appeared to be new and alternative option for optimal revascularization therapy for these patients. The available cumulative evidence suggests that the safety outcomes such as mortality or composite of death, myocardial infarction and stroke are similar among PCI and CABG for patients with LMCA disease, the only difference was the rate of repeat revascularization. Current evidence and ongoing large clinical trials may encourage interventional cardiologists to choose PCI with stenting as an alternative revascularization strategy for unprotected LMCA disease in future. Finally, this evidence will change the current clinical practice and the guideline of optimal revascularization strategy for unprotected LMCA disease.
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Affiliation(s)
- Seung-Jung Park
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, 388-1 Poongnap-dong, Songpa-gu, Seoul, 138-736, Korea,
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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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Schwarz N, Schoenburg M, Möllmann H, Kastaun S, Kaps M, Bachmann G, Sammer G, Hamm C, Walther T, Gerriets T. Cognitive decline and ischemic microlesions after coronary catheterization. A comparison to coronary artery bypass grafting. Am Heart J 2011; 162:756-63. [PMID: 21982670 DOI: 10.1016/j.ahj.2011.07.021] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2011] [Accepted: 07/21/2011] [Indexed: 11/30/2022]
Abstract
BACKGROUND Postinterventional cognitive dysfunction (PICD) is a known complication of coronary artery bypass grafting (CABG). However, it is largely unknown whether PICD occurs after coronary catheterization. METHODS Neuropsychologic data were obtained from 37 patients who received coronary catheterization and 47 patients who underwent elective CABG at baseline and 3 months after the interventions. The outcomes were contrasted to 33 healthy volunteers, using analysis of covariance with baseline scores as covariates. Cerebral magnetic resonance imaging with diffusion-weighted imaging (DWI) sequences was performed in 30 catheter and 39 CABG patients 2 to 4 days after the procedures. RESULTS The rate of acute ischemic lesions amounted to 3.3% in the catheter group and to 17.9% in the CABG group. Postinterventional cognitive dysfunction was detected in 2 (of 10) tests in the catheter group as compared with the healthy controls (verbal memory: total recall, t = -2.61 (P = .005) and nonverbal memory, t = -2.60 [P = .005]). The CABG group showed PICD in 7 of 10 tests as compared with the healthy controls (statistics ranging from t = -1.95 [P = .027] to t = -5.14 [P < .001]). Scores of depression/anxiety and health-related quality of life were not associated with PICD (P > .05). CONCLUSIONS As compared with CABG, PICD and cerebral lesions appear to be substantially milder after coronary catheter intervention, but not negligible.
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Affiliation(s)
- Niko Schwarz
- Department of Neurology, Justus Liebig University Giessen, Germany
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Takagi H, Umemoto T. A meta-analysis of randomized trials and adjusted observational studies of drug-eluting stents versus coronary artery bypass grafting for unprotected left main coronary artery disease. Int J Cardiol 2011; 150:341-3. [PMID: 21636153 DOI: 10.1016/j.ijcard.2011.05.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2011] [Accepted: 05/13/2011] [Indexed: 11/24/2022]
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Lee MS, Yang T, Biondi-Zoccai G, Sillano D, Cerrato E, Tarantini G, Xhaxho J, Aragon J, Sheiban I. Long-term outcomes of elective drug-eluting stenting of the unprotected left main coronary artery in patients with normal left ventricular function. Catheter Cardiovasc Interv 2011; 77:945-51. [PMID: 20824773 DOI: 10.1002/ccd.22777] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2010] [Accepted: 08/12/2010] [Indexed: 02/05/2023]
Affiliation(s)
- Michael S Lee
- Division of Cardiology, UCLA Medical Center, Los Angeles, California 90095-171715, USA.
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Zheng S, Zheng Z, Hou J, Hu S. Comparison between Drug-Eluting Stents and Coronary Artery Bypass Grafting for Unprotected Left Main Coronary Artery Disease: A Meta-Analysis of Two Randomized Trials and Thirteen Observational Studies. Cardiology 2011; 118:22-32. [DOI: 10.1159/000324169] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2010] [Accepted: 01/06/2011] [Indexed: 11/19/2022]
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Sachithanandan A, Badmanaban B. Why coronary artery bypass surgery is still the optimal treatment strategy for left main stem disease: an evidence-based review with a Malaysian surgical perspective. HEART ASIA 2011; 3:126-9. [PMID: 27326010 DOI: 10.1136/heartasia-2011-010059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Subscribe] [Scholar Register] [Accepted: 09/06/2011] [Indexed: 11/04/2022]
Affiliation(s)
| | - Balaji Badmanaban
- Department of Cardiothoracic Surgery, Hospital Serdang, Selangor, Malaysia
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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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Lemos P, Kappetein P, Kalil-Filho R, Jatene F. Left main stenting: do we need another study? EUROINTERVENTION 2010; 6 Suppl J:J118-22. [DOI: 10.4244/eijv6supja19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Lee MS, Yang T, Fearon WF, Ho M, Tarantini G, Xhaxho J, Gerosa G, Weston M, Ehdaie A, Rabbani L, Kirtane AJ. Long-term outcomes after percutaneous coronary intervention of left main coronary artery for treatment of cardiac allograft vasculopathy after orthotopic heart transplantation. Am J Cardiol 2010; 106:1086-9. [PMID: 20920643 DOI: 10.1016/j.amjcard.2010.06.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2010] [Revised: 06/03/2010] [Accepted: 06/03/2010] [Indexed: 01/01/2023]
Abstract
The present study evaluated the safety and efficacy of percutaneous coronary intervention (PCI) of the unprotected left main coronary artery (ULMCA) for the treatment of cardiac allograft vasculopathy (CAV) in consecutive unselected patients with orthotopic heart transplantation (OHT). PCI in patients with OHT and develop CAV has been associated with greater restenosis rates compared to PCI in patients with native coronary artery disease. A paucity of short- and long-term data is available from patients with OHT who have undergone PCI for ULMCA disease. The present retrospective, multicenter, international registry included 21 patients with OHT and CAV who underwent ULMCA PCI from 1997 to 2009. Angiographic success was achieved in all patients. Drug-eluting stents were used in 14 of the 21 patients. No major adverse cardiac events or repeat OHT occurred within the first 30 days. At a mean follow-up of 4.9 ± 3.2 years, 3 patients (14%) had died, myocardial infarction had occurred in 1 patient (5%), and target lesion revascularization had been required in 4 patients (19%). Follow-up angiography was performed in 16 patients (76%), and restenosis was observed in 4 (19%). No stent thrombosis of the ULMCA was observed. One patient (5%) underwent coronary artery bypass grafting, and 5 patients (24%) underwent repeat OHT. In conclusion, the results of our study have shown ULMCA PCI to be safe and reasonably effective in patients with OHT and represents a viable treatment strategy for CAV in these patients.
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Affiliation(s)
- Michael S Lee
- Division of Cardiology, University of California, Los Angeles, Medical Center, Los Angeles, California, USA.
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Takagi H, Manabe H, Umemoto T. Percutaneous stenting versus bypass surgery for unprotected left main coronary artery disease. Am J Cardiol 2010; 106:1059. [PMID: 20854975 DOI: 10.1016/j.amjcard.2010.07.003] [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: 05/24/2010] [Accepted: 07/11/2010] [Indexed: 10/19/2022]
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