Five-year outcomes after stenting of unprotected left main coronary artery stenosis in patients with normal left ventricular function

Left main PCI: An observational analysis from large single-centre experience

BACKGROUND

Although trials have shown efficacy of unprotected left main percutaneous coronary intervention (uLMPCI), data from Indian subcontinent are lacking. Hence, we planned this observational analysis of single-center uLMPCI data.

OBJECTIVES

To study long-term outcome after uLMPCI and identify predictors of adverse outcome.

METHODS

Case details of 62 consecutive patients of uLMPCI between 2006 and 2013 were retrieved from a computerized database wherein detailed records were maintained.

RESULTS

Mean follow-up duration was 669.8±404.2 days. Procedural success rate was 98.4%. Primary endpoint was composite of major adverse cardiovascular and cerebrovascular events (MACCE), which included cardiac death (CD), cerebrovascular accident (CVA), myocardial infarction (MI), and need for repeat intervention (RI) at three years. MACCE occurred in 13 (20.9%) patients. Cardiac death (CD), (including possible stent thrombosis), RI, and CVA occurred in 6 (9.7%), 5 (8%), and 2 (3.2%) patients, respectively. Overall three-year MACCE-free survival rate was 76.7%. Event-free survival rate was similar among patients who underwent uLMPCI alone and patients who underwent uLMPCI along with additional one-vessel PCI [(88.9% vs 81.8%), p=0.492], while survival rate was lower in patients who underwent uLMPCI along with PCI of additional two or more vessels (40%, p=0.036). Patients with syntax score ≤32 had higher event-free survival rate than those with syntax score >32 [(87.1% vs 33.3%), p=0.001]. Syntax score >32 was the only independent predictor of adverse outcome.

CONCLUSION

uLMPCI is safe and effective alternative to CABG for LM alone and LM plus single-vessel disease with syntax score ≤32.

Comparison of coronary artery bypass grafting with percutaneous coronary intervention for unprotected left main coronary artery disease

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.

Percutaneous coronary intervention of unprotected left main coronary artery disease as culprit lesion in patients with acute myocardial infarction

OBJECTIVES

This study sought to evaluate short- and long-term outcomes of patients undergoing emergency percutaneous coronary intervention (PCI) for acute myocardial infarction due to a culprit lesion in an unprotected left main coronary artery.

METHODS

In this retrospective, 2-center, international observational study, 5,261 patients were admitted between February 2005 and December 2008 with acute myocardial infarction and treated with PCI; of these, 1,277 were ST-segment elevation myocardial infarction and 3,984 non-ST-segment elevation myocardial infarction. We identified 48 patients among this cohort who underwent emergency PCI to an unprotected left main coronary artery culprit lesion.

RESULTS

Mean age was 70 ± 12.5 years, and 45% of the patients presented with ST-segment elevation myocardial infarction or new left bundle branch block. Cardiogenic shock was present in 45%, and distal left main coronary artery disease was present in 71% of patients. Angiographic procedural success was achieved in 92% of patients. Overall in-hospital mortality was 21%, due in all cases to refractory, multiorgan failure. Twenty-five percent experienced major adverse cardiac events, defined as death, myocardial infarction, stent thrombosis, and target vessel revascularization. In patients presenting in cardiogenic shock, in-hospital mortality was 32%. At 1-year follow-up, in-hospital survivors had a mortality rate of 10.5%, whereas 18.4% experienced subsequent major adverse cardiac events. Long-term prognosis was excellent in hospital survivors with a 1-year survival rate of 89.5%.

CONCLUSIONS

Patients with acute myocardial infarction and thrombosis of the unprotected left main coronary artery are a high-risk subgroup with a substantial mortality, particularly if they present in cardiogenic shock. We demonstrate that in these patients, PCI is a feasible treatment option associated with reasonably good outcomes. Long-term prognosis is excellent in hospital survivors with an 89.5% survival rate at 1 year.

Long-term (4-year) outcomes and predictors of adverse cardiac events after sirolimus-eluting stent implantation in unprotected left main coronary artery

The long-term safety and efficiency of sirolimus-eluting stent (SES) treatment in unprotected left main coronary artery (ULMCA) have not yet been ascertained.From 2003 to 2006, 126 consecutive patients with de novo lesions in ULMCA who underwent SES were retrospectively analyzed in a single center in China. During 4-year follow-up, major adverse cardiovascular event (MACE)-free survival was 74.6%. Cardiac death occurred in 5 (4.0%), and target lesion revascularization (TLR) and target vessel revascularization (TVR) occurred in 15 (11.9%) and 24 (19.0%) patients, respectively. One (0.8%) experienced probable stent thrombosis while 1 (0.8%) presented possible stent thrombosis. Impaired LVEF (< 40%) and high surgical risk (Euro score > 6) were the independent predictors of MACEs.PCI with SES for de novo lesions in ULMCA is feasible with a low procedural risk. However, SES was associated with a relatively higher rate of TLR and TVR. Impaired LVEF and high surgical risk were important predictors of MACEs.

Drug-eluting versus bare-metal stents in unprotected left main coronary artery stenosis a meta-analysis

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.

Long-term follow-up after nonurgent percutaneous coronary intervention in unprotected left main coronary arteries

OBJECTIVES

To evaluate the long-term outcomes of the selected patients by the local Heart Team to undergo percutaneous coronary intervention (PCI) of unprotected left main coronary artery (ULMCA) stenosis and to compare patients considered at low surgical risk versus at high surgical risk for coronary artery bypass grafting (CABG).

BACKGROUND

CABG is recommended in patients with ULMCA stenosis according to the AHA/ACC and ESC guidelines, and there are limited data on the long-term outcomes in patients selected by the local Heart Team to undergo PCI.

METHODS

Between 1996 and 2007, 227 patients underwent PCI for ULMCA stenosis based on decision of the local Heart Team and patient's and/or physician's preference. All patients were contacted at 1 year and in November 2008.

RESULTS

Long-term follow-up was up to 8 years with a mean of 3.9 +/- 2.6 years. Overall, the Kaplan-Meier estimate of the composite of cardiac death, myocardial infarction (MI), or target lesion revascularization (TLR) was 14.8% at 1 year, 18.3% at 3 years, and 20.9% at 5 years with no events occurring thereafter. Patients considered at low surgical risk for CABG had a significantly lower incidence of cardiac death or MI compared to patients considered at high surgical risk at 8 years (1.4 vs. 16.8%; 1.4 vs. 14.8%, respectively); however, no significant difference was observed for cardiac death, MI, or TLR (18.6 vs. 24.4%).

CONCLUSIONS

PCI of ULMCA stenosis in patients selected by the Heart Team resulted in good long-term clinical outcomes with most events occurring within the 1st year. Patients considered at low surgical risk for CABG have a significantly better long-term survival than patients at high risk for surgery.

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)

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.

Left main coronary artery stenting in a patient with acute myocardial infarction and cardiogenic shock

Acute total occlusion of left main coronary artery (LMCA) is rarely found in patients presenting with acute coronary syndromes. It is a grave condition with poor prognosis. We present a case of successful stenting of a LMCA lesion in a patient presenting with acute myocardial infarct and cardiogenic shock.

Evidence-based treatment of unprotected left main disease: a critical review of the literature

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.

Utility of cardiac MRI in guiding revascularization therapy in unprotected left main stenosis: a case report

Decision to select unprotected left main (ULM) stenting versus coronary artery bypass grafting surgery (CABG) depends on a multiplicity of factors, one of the most critical of which is myocardial viability. Delayed enhancement cardiac magnetic resonance (CMR) imaging has emerged as a useful means of comprehensively evaluating viable myocardium in postmyocardial infarct patients who require further revascularization. We present a patient with ULM stenosis in whom CMR imaging assisted in the decision to perform percutaneous coronary intervention over CABG.