Sirolimus-eluting stent implantation for unprotected left main coronary artery stenosis

Management of failed stenting of the unprotected left main coronary artery

Percutaneous coronary intervention (PCI) is increasingly accepted as treatment for unprotected left main coronary artery (ULMCA) disease especially in those patients who are unsuitable for cardiac surgery. Treatment of any stent failure is associated with increased complexity and worse clinical outcomes when compared with de novo lesion revascularization. Intracoronary imaging has provided new insight into mechanisms of stent failure and treatment options have developed considerably over the last decade. There is paucity of evidence on the management strategy for stent failure in the specific setting of ULMCA. Treating any left main with PCI requires careful consideration and consequently treatment of failed stents in ULMCA is complex and provides unique challenges. Consequently, we provide an overview of ULMCA stent failure, proposing a tailored algorithm to guide best management and decision in daily clinical practice, with a special focus on intracoronary imaging characterization of causal mechanisms and specific technical and procedural considerations.

Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting for Revascularization of Left Main Coronary Artery Disease

Owing to a large-jeopardized myocardium, left main coronary artery disease (LMCAD) represents the substantial high-risk anatomical subset of obstructive coronary artery disease. For several decades, coronary artery bypass grafting (CABG) has been the "gold standard" treatment for LMCAD. Along with advances in CABG, percutaneous coronary intervention (PCI) has also dramatically evolved over time in conjunction with advances in the stent or device technology, adjunct pharmacotherapy, accumulated experiences, and practice changes, establishing its position as a safe, reasonable treatment option for such a complex disease. Until recently, several randomized clinical trials, meta-analyses, and observational registries comparing PCI and CABG for LMCAD have shown comparable long-term survival with tradeoffs between early and late risk-benefit of each treatment. Despite this, there are still several unmet issues for revascularization strategy and management for LMCAD. This review article summarized updated knowledge on evolution and clinical evidence on the treatment of LMCAD, with a focus on the comparison of state-of-the-art PCI with CABG.

Percutaneous Coronary Intervention for Left Main Coronary Artery Disease: Present Status and Future Perspectives

For several decades, coronary artery bypass grafting has been regarded as the standard choice of revascularization for significant left main coronary artery (LMCA) disease. However, in conjunction with remarkable advancement of device technology and adjunctive pharmacology, percutaneous coronary intervention (PCI) offers a more expeditious approach with rapid recovery and is a safe and effective alternative in appropriately selected patients with LMCA disease. Several landmark randomized clinical trials showed that PCI with drug-eluting stents for LMCA disease is a safe option with similar long-term survival rates to coronary artery bypass grafting surgery, especially in those with low and intermediate anatomic risk. Although it is expected that the updated evidence from recent randomized clinical trials will determine the next guidelines for the foreseeable future, there are still unresolved and unmet issues of LMCA revascularization and PCI strategy. This paper provides a comprehensive review on the evolution and an update on the management of LMCA disease.

Impact of directional coronary atherectomy followed by drug-coated balloon strategy to avoid the complex stenting for bifurcation lesions

Although the simple single stenting rather than complex double stenting is recommended on percutaneous coronary intervention (PCI) for bifurcation lesions, double stenting cannot always be avoided. We investigated the impact of directional coronary atherectomy (DCA), followed by drug-coated balloon (DCB) treatment to reduce the number of stents and avoid complex stenting in PCI for bifurcation lesions and short-term patency. DCA treatment without stents was attempted for 27 bifurcation lesions in 25 patients, of those, 26 bifurcation lesions in 24 patients were successfully treated and 3-month follow-up angiography and optical coherence tomography (OCT) were performed. Sixteen lesions (59.3%) were related to left main trunk distal bifurcations, and 7 (25.9%) were true bifurcation lesions. Among the true bifurcation lesions, 4 lesions (57.1%) needed 1 stent, and the other 3 lesions (42.9%) needed no stents. Among the non-true bifurcation lesions, 1 lesion (5.0%) needed bailout stent and other lesions (95.0%) needed no stents. According to DCA followed by DCB treatment, the angiographic mean diameter stenosis improved from 65.5 ± 15.0% to 7.8 ± 9.8%, and the mean plaque area in intravascular ultrasound improved from 80.4 ± 10.5% to 39.0 ± 11.5%, respectively. Angiographic and OCT late lumen loss values were 0.2 ± 0.6 mm and 1.4 ± 1.9 mm, respectively. No patient had in-hospital major adverse cardiac events (MACE) and 3-month MACE. In conclusion, compared with standard provisional side branch stenting strategy, DCA followed by DCB treatment might reduce the number of stents, avoid complex stenting for major bifurcation lesions and provide good short-term outcomes.

Age-Stratified Outcome in Treatment of Left Main Coronary Artery Stenosis: A NOBLE Trial Substudy

BACKGROUND

In the treatment of left main coronary artery (LMCA) disease, patients' age may affect the clinical outcome after percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). This study stratified the clinical outcome according to the age of patients treated for LMCA stenosis with PCI or CABG in the Nordic-Baltic-British Left Main Revascularization (NOBLE) study.

METHODS

Patients with LMCA disease were enrolled in 36 centers in northern Europe and randomized 1:1 to treatment by PCI or CABG. Eligible patients had stable angina pectoris, unstable angina pectoris, or non-ST elevation myocardial infarction. The primary endpoint was major adverse cardiac or cerebrovascular events (MACCEs), a composite of all-cause mortality, nonprocedural myocardial infarction, any repeat coronary revascularization, and stroke. Age-stratified analysis was performed for the groups younger and older than 67 years and for patients older than 80 years.

RESULTS

For patients ≥67 years, the 5-year MACCEs were 35.7 versus 22.3% (hazard ratio [HR] 1.72 [95% confidence interval [CI] 1.27-2.33], p = 0.0004) for PCI versus CABG. The difference in MACCEs was driven by more myocardial infarctions (10.8 vs. 3.8% HR 3.01 [95% CI 1.52-5.96], p = 0.0009) and more repeat revascularizations (19.5 vs. 10.0% HR 2.01 [95% CI 1.29-3.12], p = 0.002). In patients younger than 67 years, MACCE was 20.5 versus 15.3% (HR 1.38 [95% CI 0.93-2.06], p = 0.11 for PCI versus CABG. All-cause mortality was similar after PCI and CABG in both age-groups. On multivariate analysis, age was a predictor of MACCE, along with PCI, diabetes, and SYNTAX score.

CONCLUSIONS

As the overall NOBLE results show revascularization of LMCA disease, age of 67 years or older was associated with lower 5-year MACCE after CABG compared to PCI. Clinical outcomes were not significantly different in the subgroup younger than 67 years, although no significant interaction was present between age and treatment. Mortality was similar for all subgroups (ClinicalTrials.gov identifier: NCT01496651).

Long-Term Clinical Outcomes of Unprotected Left Main Percutaneous Coronary Intervention: A Large Single-Centre Experience

Aims

This study sought to report the 10-year clinical outcomes of patients who underwent unprotected left main (LM) percutaneous coronary intervention (PCI) in a large centre.

Methods and Results

A total of 913 consecutive patients who underwent unprotected LM PCI from January 2004 to December 2008 at Fu Wai Hospital were retrospectively analysed; the mean age was 60.0 ± 10.9 years, females accounted for 22% of patients, diabetes was present in 27.7% of patients, and an LM bifurcation lesion occurred in 82.9% of patients. During the median follow-up of 9.7 years, major adverse cardiac or cerebrovascular events (MACCEs) occurred in 25.6% (234) of patients, and the rates of all-cause death, myocardial infarction, and stroke were 14.9%, 11.0%, and 7.1%, respectively. Cardiac death occurred in only 7.9% of patients. The estimated event rate was 41.9% for death/myocardial infarction/any revascularization and 45.9% for death/MI/stroke/any revascularization. Definite/probable stent thrombosis occurred in 4.3% (39) of patients. According to the subgroup analysis, IVUS-guided PCI was associated with less long-term MACCEs. Further multivariate analysis identified that age and LVEF<40% were the only independent predictors for 10-year death. Age, LVEF<40%, creatinine clearance, and incomplete revascularization were independent predictors for death/MI, while a two-stent strategy, diabetes, a transradial approach, and the use of bare metal stents (BMSs) or first-generation drug-eluting stents (DESs) were not.

Conclusions

Unprotected LM PCI in a large cohort of consecutive patients in a single large centre demonstrated favourable long-term outcomes up to 10 years even with the use of BMSs and first-generation of DESs.

Bilateral internal thoracic artery grafting in patients with left main disease: a single-center experience

OBJECTIVE

We compared early and long-term outcomes between bilateral internal thoracic artery (BITA) grafting and single internal thoracic artery (SITA) grafting in patients with LM disease.

METHODS

We evaluated the outcomes of all patients with LM disease who underwent revascularization in our center during 1996-2011. Variables that were adjusted for in a multivariate analysis and in propensity matching included age, sex, comorbid diseases, repeat operation, the number of diseased vessels, other conduits used, the use of sequential grafting, the number of grafts constructed, and the operative era (1996-2000 vs. 2001-2011).

RESULTS

In total, 949 patients with LM disease underwent BITA grafting and 564 underwent SITA grafting during the study period. SITA patients were more often female and more likely to have comorbidities such as chronic obstructive pulmonary disease, ejection fraction <30%, recent myocardial infarction, diabetes, congestive heart failure, chronic renal failure, and peripheral vascular disease, and to have undergone an emergency operation. We found no statistically significant difference between the SITA and BITA groups in 30-day mortality (4.8% vs. 3.3%, P = 0.136), sternal wound infection (2.0% vs. 2.4%, P = 0.548), and stroke (3.2% vs. 4.4%, P = 0.234). BITA patients had improved long-term survival (70.1% vs. 52.0% p<0.001), median follow-up of 15 years. In multivariate analysis, after propensity score matching (477 matched pairs), this finding was not statistically significant (P = 0.135).

CONCLUSION

This study did not demonstrate a clear benefit of BITA grafts among patients with LM disease.

Percutaneous Coronary Intervention and Coronary Artery Bypass Grafting for the Treatment of Left Main Coronary Artery Disease

Severe stenosis of the left main coronary artery (LMCA) generally occurs as a result of atherosclerosis and compromises the blood supply to a wide area of myocardium, thereby increasing the risk of serious adverse cardiac events. Current revascularization strategies for patients with significant LMCA disease include coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI), both of which have a range of advantages and disadvantages. In general, PCI is associated with a lower rate of periprocedural adverse events and provides more rapid recovery, while CABG provides more durable revascularization. Most clinical trials comparing PCI and CABG for the treatment of LMCA disease have shown PCI to be non-inferior to CABG with respect to mortality and the serious composite outcome of death, myocardial infarction, or stroke in patients with low-to-intermediate anatomical complexities. Remarkable advancements in PCI standards, including safer and more effective stents, adjunctive intravascular imaging or physiologic evaluation, and antithrombotic treatment, may have contributed to these favorable results. This review provides an update on the current management of LMCA disease with an emphasis on clinical data and academic and clinical knowledge that supports the use of PCI in an increasing proportion of patients with LMCA disease.

[Angioplasty of the unprotected left main trunk: short and medium term outcomes]

Introduction

Notre but était de déterminer le devenir des patients traités par angioplastie du tronc commun non protégé de l'artère coronaire gauche.

Méthodes

Une étude rétrospective a porté sur tous les patients traités par angioplastie du tronc commun non protégé de la coronaire gauche entre janvier 2004 et juin 2009. Les données cliniques et angiographiques ont été recueillies sur les dossiers médicaux, complétées par un entretien téléphonique avec le patient ou ses médecins.

Résultats

Quarante-huit patients d'âge moyen de 68,50±14,06 ans ont été inclus. Les syndromes coronariens aigus étaient le principal motif d'admission (75%). Les lésions du tronc étaient distales (77,1%) et pluritronculaires (64,6%). Un stent nu a été implanté chez 73% des patients. Après un suivi moyen de 22 mois, le taux d'événements cardiovasculaires majeurs a été de 31,3% dont 20,8% de resténose et 14,6% de revascularisation. Le taux de décès hospitalier a été de 4,2%. Les facteurs prédictifs d'événements cardiovasculaires majeurs ont été un EuroSCORE ≥ 10 et les antécédents cardiovasculaires.

Conclusion

L'angioplastie du tronc commun est une alternative dans les situations d'urgence ou en cas de contre-indication de la chirurgie. Le risque évolutif des patients est lié à leur risque global avant angioplastie.

The DELTA 2 Registry: A Multicenter Registry Evaluating Percutaneous Coronary Intervention With New-Generation Drug-Eluting Stents in Patients With Obstructive Left Main Coronary Artery Disease

OBJECTIVES

The aim of this study was to evaluate clinical outcomes of unprotected left main coronary artery percutaneous coronary intervention (PCI) with new-generation drug-eluting stents in a "real world" population.

BACKGROUND

PCI of the unprotected left main coronary artery is currently recommended as an alternative to coronary artery bypass grafting (CABG) in selected patients.

METHODS

All consecutive patients with unprotected left main coronary artery stenosis treated by PCI with second-generation drug-eluting stents were analyzed in this international, all-comers, multicenter registry. The results were compared with those from the historical DELTA 1 (Drug Eluting Stent for Left Main Coronary Artery) CABG cohort using propensity score stratification. The primary endpoint was the composite of death, myocardial infarction (MI), or stroke at the median time of follow-up.

RESULTS

A total of 3,986 patients were included. The mean age was 69.6 ± 10.9 years, diabetes was present in 30.8%, and 21% of the patients presented with acute MI. The distal left main coronary artery was involved in 84.6% of the lesions. At a median of 501 days (≈17 months) of follow-up, the occurrence of the primary endpoint of death, MI, or cerebrovascular accident was lower in the PCI DELTA 2 group compared with the historical DELTA 1 CABG cohort (10.3% vs. 11.6%; adjusted hazard ratio: 0.73; 95% confidence interval: 0.55 to 0.98; p = 0.03). Of note, an advantage of PCI was observed with respect to cerebrovascular accident (0.8% vs. 2.0%; adjusted hazard ratio: 0.37; 95% confidence interval: 0.16 to 0.86; p = 0.02), while an advantage of CABG was observed with respect to target vessel revascularization (14.2% vs. 2.9%; adjusted hazard ratio: 3.32; 95% confidence interval: 2.12 to 5.18; p < 0.0001).

CONCLUSIONS

After a median follow-up period of 17 months, PCI with new-generation drug-eluting stents was associated with an overall low rate of the composite endpoint of death, MI, or cerebrovascular accident.

Percutaneous coronary intervention in left main disease: SYNTAX, PRECOMBAT, EXCEL and NOBLE-combined cardiology and cardiac surgery perspective

Although coronary-artery bypass grafting (CABG) is the standard choice of revascularization for significant left main coronary artery (LMCA) disease, percutaneous coronary intervention (PCI) for LMCA disease has been widely expanded with adoption of drug-eluting stents (DES). Several small- and moderate-sized trials of CABG and first-generation DES showed that PCI might be a good alternative for selected patients with LMCA disease. However, these early trials were relatively underpowered and comparative results of contemporary DES and CABG were clearly required. Subsequently, two large-sized trials comparing CABG and contemporary DES (EXCEL and NOBLE) were conducted, but these trials showed conflicting results with regards to the effects of PCI and CABG on clinical outcomes, which raises further uncertainty on the optimal revascularization for LMCA disease. This article serves to summarize the key findings of landmark clinical trials, to share our knowledge and experience and to express personal opinions on current controversies in the treatment of LMCA disease.

The Current State of Left Main Percutaneous Coronary Intervention

PURPOSE OF REVIEW

While coronary artery bypass grafting (CABG) remains the standard of care, advances in stenting technology and procedural technique are changing the role of percutaneous coronary intervention (PCI) in the treatment of severe left main coronary artery (LMCA) disease. We review contemporary evidence comparing PCI and CABG for the treatment of severe LMCA disease, discuss optimal techniques during left main PCI, and provide guidance on studied revascularization strategies within specific patient subgroups.

RECENT FINDINGS

Results from randomized control trials of patients treated with PCI or CABG for severe LMCA disease demonstrate comparable short- and mid-term rates of death, myocardial infarction (MI), and stroke, but increased rates of repeat or target-vessel revascularization after PCI. Though extended follow-up data has suggested lower long-term rates of MI and stroke in patients with severe LMCA disease treated with CABG, results from patients undergoing PCI with second-generation drug-eluting stents (DES) demonstrate non-inferiority in these outcomes. These findings are generalizable to patients with severe LMCA disease having low to intermediate anatomic complexity. Intravascular ultrasound and double kissing (DK) crush stenting also reduce adverse event rates among patients undergoing left main PCI and improve long-term outcomes. In patients with severe LMCA disease having low to intermediate anatomic complexity, both CABG and PCI with second-generation DES are effective methods of revascularization with comparable long-term rates of death, MI, and stroke. The roles of multi-vessel coronary artery disease and anatomic complexity on long-term outcomes after CABG or PCI for severe LMCA disease remain under investigation.

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

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.

Long-term outcomes of bypass grafting versus drug-eluting stenting for left main coronary artery disease: Results from the IRIS-MAIN registry

There are limited data on comparative outcomes and its determinants following coronary artery bypass graft surgery (CABG) and percutaneous coronary intervention (PCI) with drug-eluting stents (DES) for left main coronary artery disease (LMCAD) in a real-world setting.

METHODS

A total of 3,504 consecutive patients with LMCAD treated with CABG (n=1,301) or PCI with DES (n=2,203) from the IRIS-MAIN registry were analyzed. The relative treatment effect of one strategy over another was assessed by propensity-score matching method. The primary outcome was a composite of death, myocardial infarction, or stroke.

RESULTS

Median follow-up duration was 4.7 years. In the matched cohort, both groups demonstrated a similar risk for the primary outcome (adjusted hazard ratio [HR]: 0.94; 95% CI: 0.77-1.15; P=.54). Compared with CABG, PCI exhibited higher risks of myocardial infarction (HR: 2.11; 95% CI: 1.16-3.83; P=.01) and repeated revascularization (HR: 5.95; 95% CI: 3.94-8.98; P<.001). In the overall population, age, presence of chronic kidney disease, and low ejection fraction (<40%) were key clinical predictors of primary outcome regardless of the treatment strategy. However, factors deemed to be associated with perioperative morbidity were determinants of primary outcome in the CABG group, whereas those generally associated with the severity of atherosclerotic coronary artery disease were strong predictors in the PCI group.

CONCLUSIONS

Among patients with significant LMCAD, the long-term risk of the composite outcome of death, myocardial infarction, or stroke was similar between CABG and PCI. Clinical variables that differentially predict adverse outcomes might be useful in triaging appropriate revascularization strategy.

Radiation Therapy Induced Cardiovascular Disease

Contemporary treatment modalities for malignancy including radiation therapy have led to improved survival. However treatment related complications manifesting later in life including cardiovascular disease has led to survivors exhibiting a lower long term survival rate, when compared to age matched controls. This narrative review will discuss the pathophysiology, risk factors, clinical presentation, management and preventative techniques related to radiotherapy-induced cardiotoxicity.

CFD analysis of strut influence on blood flow in stent-implanted left main coronary artery bifurcation

We numerically studied blood flows in a simulated branching pipe of coronary artery bifurcation, which is affected by stent implantation. We found that stent struts provide effects as guide vanes and blockages on the flow into circumflex branch. The former effect increases the flow rate and shear stress on the arteriosclerosis-prone site. The blockage effect may overwhelm the guide effect depending on a strut position against the inflow.

Percutaneous Coronary Intervention of Left Main Disease

For nearly half a century, coronary artery bypass grafting has been the standard treatment for patients with obstructive left main coronary artery (LMCA) disease. However, there has been considerable evolution in the field of percutaneous coronary intervention, and especially, percutaneous coronary intervention for LMCA disease has been rapidly expanded with adoption of drug-eluting stents. Some, but not all randomized trials, have shown that percutaneous coronary intervention with drug-eluting stents might be a suitable alternative for selected patients with LMCA disease instead of bypass surgery. However, none of previous trials involving early-generation drug-eluting stents was sufficiently powered and comparative trials using contemporary drug-eluting stents were limited. Recently, primary results of 2 new trials of EXCEL (Evaluation of XIENCE Everolimus Eluting Stent Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) and NOBLE (Nordic-Baltic-British Left Main Revascularization Study) were reported. However, these trials showed conflicting results, which might pose uncertainty on the optimal revascularization strategy for LMCA disease. In this article, with the incorporation of a key review on evolution of LMCA treatment, we summarize the similarity or disparity of the EXCEL and NOBLE trials, focus on how they relate to previous trials in the field, and finally speculate on how the treatment strategy may be changed or recommended for LMCA treatment.

Percutaneous coronary intervention vs coronary artery bypass grafting for left main coronary artery disease? A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

It is not clear whether percutaneous coronary intervention (PCI) is as effective and safe as coronary artery bypass grafting (CABG) for left main coronary artery disease. We aimed to perform a systematic review and meta-analysis of all randomized controlled trials (RCTs) that compared PCI and CABG in left main coronary disease.

METHODS

We searched PubMed, EMBASE, Cochrane, Scopus and relevant references for RCTs (inception through, November 20, 2016 without language restrictions) and performed meta-analysis using random-effects model. All-cause mortality, myocardial infarction, revascularization rate, stroke, and major adverse cardiac and cerebrovascular events (MACCE) were the measured outcomes.

RESULTS

Six RCTs with a total population of 4700 were analyzed. There was no difference in all-cause mortality at 30-day, one-year, and five-year (1.8% vs 1.1%; OR 0.60; 95% CI: 0.26-1.39; P=.23; I² =9%) follow-up between PCI and CABG. CABG group had less myocardial infarction (MI) at five-year follow-up than PCI (5% vs 2.5%; OR 2.04; CI: 1.30-3.19; P=.002; I² =1%). Revascularization rate favored CABG in one-year (8.6% vs 4.5%; OR 2; CI: 1.46-2.73; P<.0001; I² =45%) and five-year (15.9% vs 9.9%; OR 1.73; CI: 1.36-2.20; P<.0001; I² =0%) follow-up. Although stroke rate was lower in PCI group at 1 year, there was no difference in longer follow-up. MACCE at 5 years favored CABG (24% vs 18%; OR 1.45; CI: 1.19-1.76; P=.0001; I² =0%). On subgroup analysis, MACCE were not different between two groups in low-to-intermediate SYNTAX group while it was higher for PCI group with high SYNTAX group.

CONCLUSION

Percutaneous coronary intervention could be as safe and effective as CABG in a select group of left main coronary artery disease patients.

Comparison of clinical outcomes after drug-eluting stent implantation in diabetic versus nondiabetic patients in China: A retrospective study

Diabetes mellitus (DM) has been proved to be a predictor of adverse outcomes after percutaneous coronary intervention (PCI). Drug-eluting stents (DESs) could reduce the adverse events in DM patients. In this study, we aimed to analyze the clinical outcome after DES implantation in diabetic versus nondiabetic patients in China. Totally, 200 Chinese DM patients and 400 Chinese non-DM patients were enrolled in this retrospective study. Compared with non-DM patients, DM patients were more likely to have a higher incidence of cardiac death (3.5% vs. 1.0%, P = .048), stent thrombosis (2.5% vs. 0.5%, P = .044), target lesion revascularization (6.0% vs. 1.8%, P = .005), target vessel failure (15.5% vs. 8.0%, P < .001), target lesion failure (14.0% vs. 4.3%, P < .001), myocardial infarction (4.5% vs. 1.5%, P = .030), and major adverse cardiac events (12.5% vs. 5.0%, P = .001) at 2-year follow-up. However, the incidence of target vessel revascularization (7.5% vs. 5.5%, P = .340) was similar between DB and non-DB patients. Patients with DB (hazard ratio [HR] = 2.54, P = .001), older than 80 years (HR = 1.33, P = .027) with hypercholesterolemia (HR = 1.03, P < .001), serum creatinine >177 μmol/L (HR = 3.04, P = .011), a history of cerebral vascular accident (HR = 4.29, P = .010), or a history of myocardial infarction (HR = 31.4, P < .001) were more likely to experience adverse events. In China, DM could also be served as an independent predictor of adverse outcomes after DES implantation. These patients should be reexamined more frequently.

Study of Short and Intermediate Term Clinical Outcomes of Patients with Protected and Unprotected LMCA Stenting

INTRODUCTION

Significant unprotected Left Main Coronary Artery (LMCA) disease is detected in 5%-7% of cases undergoing Coronary Angiography (CAG). Present guidelines have revealed the significance of anatomical location in left main artery stenosis and syntax scores for determination of Major Adverse Cardiac Events (MACE). Debate still persists over the best treatment regarding outcomes of Coronary Artery Bypass Grafting (CABG) and LMCA stenting for patients with LMCA disease.

AIM

Aim of the study was to evaluate short and intermediate term clinical outcomes of Percutaneous Coronary Intervention (PCI) in LMCA disease in respect to mortality, Cerebrovascular Accidents (CVA), reinfarction, stent restenosis and need for repeat target lesion revascularization.

MATERIALS AND METHODS

From July 2013 to February 2015, 50 patients underwent LMCA stenting. All patients underwent detailed clinical assessment, detailed 2D echocardiographic assessment. Syntax score was calculated in all patients. Clinical in hospital and outpatient follow up was obtained at one, three, six, nine months and one year.

RESULTS

Mean age was 53.14±9.60 years. On CAG 16 (32%) patients had ostial LMCA lesion, 8 (16%) had mid LMCA lesion, distal LMCA was diseased in 6 (12%). In emergency situation, two bail out LMCA stenting were done for treatment of LMCA dissection. A total of 42 (84%) patients had low syntax score, 6 (12%) had intermediate and 2 (4%) had high syntax score. Only LMCA stenting was done in 22 (44%) patients, LMCA to Left Anterior Descending (LAD) stenting was done in 22 (44%) and LMCA to Left Circumflex (LCX) stenting was done in 6 (12%) patients. Drug-Eluting Stent (DES) was used in 35 (70%) cases while Bare-Metal Stent (BMS) was used in 15 (30%). An 8% mortality and 8% target lesion revascularization rate were observed in our study.

CONCLUSION

Our study revealed that LMCA stenting is a safe and feasible alternative mode of revascularization in selected patients. Patients most suitable for LMCA stenting in our study were those with isolated ostial/mid LMCA disease, with protected LMCA disease and those who underwent elective stenting procedure.

Percutaneous coronary angioplasty versus coronary artery bypass grafting in treatment of unprotected left main stenosis (NOBLE): a prospective, randomised, open-label, non-inferiority trial

BACKGROUND

Coronary artery bypass grafting (CABG) is the standard treatment for revascularisation in patients with left main coronary artery disease, but use of percutaneous coronary intervention (PCI) for this indication is increasing. We aimed to compare PCI and CABG for treatment of left main coronary artery disease.

METHODS

In this prospective, randomised, open-label, non-inferiority trial, patients with left main coronary artery disease were enrolled in 36 centres in northern Europe and randomised 1:1 to treatment with PCI or CABG. Eligible patients had stable angina pectoris, unstable angina pectoris, or non-ST-elevation myocardial infarction. Exclusion criteria were ST-elevation myocardial infarction within 24 h, being considered too high risk for CABG or PCI, or expected survival of less than 1 year. The primary endpoint was major adverse cardiac or cerebrovascular events (MACCE), a composite of all-cause mortality, non-procedural myocardial infarction, any repeat coronary revascularisation, and stroke. Non-inferiority of PCI to CABG required the lower end of the 95% CI not to exceed a hazard ratio (HR) of 1·35 after up to 5 years of follow-up. The intention-to-treat principle was used in the analysis if not specified otherwise. This trial is registered with ClinicalTrials.gov identifier, number NCT01496651.

FINDINGS

Between Dec 9, 2008, and Jan 21, 2015, 1201 patients were randomly assigned, 598 to PCI and 603 to CABG, and 592 in each group entered analysis by intention to treat. Kaplan-Meier 5 year estimates of MACCE were 29% for PCI (121 events) and 19% for CABG (81 events), HR 1·48 (95% CI 1·11-1·96), exceeding the limit for non-inferiority, and CABG was significantly better than PCI (p=0·0066). As-treated estimates were 28% versus 19% (1·55, 1·18-2·04, p=0·0015). Comparing PCI with CABG, 5 year estimates were 12% versus 9% (1·07, 0·67-1·72, p=0·77) for all-cause mortality, 7% versus 2% (2·88, 1·40-5·90, p=0·0040) for non-procedural myocardial infarction, 16% versus 10% (1·50, 1·04-2·17, p=0·032) for any revascularisation, and 5% versus 2% (2·25, 0·93-5·48, p=0·073) for stroke.

INTERPRETATION

The findings of this study suggest that CABG might be better than PCI for treatment of left main stem coronary artery disease.

FUNDING

Biosensors, Aarhus University Hospital, and participating sites.

Two-year outcomes following unprotected left main stenting with first vs. new-generation drug-eluting stents: the FINE registry

AIMS

To assess two-year outcomes following first vs. new-generation drug-eluting stent (DES) implantation in unprotected left main (ULMCA) percutaneous coronary intervention.

METHODS AND RESULTS

All eligible patients from our two-centre registry treated with first and new-generation DES from October 2006 to November 2010 were analysed. The study objective was major adverse cardiac events (MACE), defined as all-cause mortality, target vessel revascularisation (TVR) and myocardial infarction (MI) at two years. In total, 186 patients were included: 93 (50.0%) treated with first vs. 93 (50.0%) with new-generation DES. No differences were observed in baseline clinical characteristics except for higher EuroSCORE with new-generation DES (3.6±2.5 vs. 4.6±2.7; p=0.007). No significant difference was observed in stenting techniques; two stents were used respectively in 53.8% vs. 44.1% (p=0.187). Notably, intravascular ultrasound guidance was more frequent with new-generation DES (46.2% vs. 61.3%; p=0.040). At 730.0 (interquartile range 365.5-1,224.5) days, there was a trend towards improved MACE with new-generation DES (31.2% vs. 19.6%; p=0.070) and a significant reduction in TVR (23.7% vs. 12.0%; p=0.038) and MI (4.3% vs. 0%; p=0.044). Notably, there were four cases of definite stent thrombosis (ST) with first vs. none with new-generation DES (p=0.044).

CONCLUSIONS

In our study, new-generation DES had a trend for less MACE and improved results with regard to MI, TVR and definite ST at two-year follow-up.

Left Main Percutaneous Coronary Intervention

Significant unprotected left main stem (ULMS) disease is in approximately 5% to 7% of patients undergoing coronary angiography. Historically, coronary artery bypass grafting has been the gold standard treatment of these patients. With recent advances in stent technology, adjunctive pharmacotherapy, and operator experience, percutaneous coronary intervention (PCI) is increasingly regarded as a viable alternative treatment option, especially in patients with favorable coronary anatomy (low and intermediate SYNTAX (Synergy Between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery) scores). This article aims to discuss the evidence supporting PCI for ULMS disease, current guidelines, and technical aspects.

Effect of stents coated with a combination of sirolimus and alpha-lipoic acid in a porcine coronary restenosis model

The aim of this study was to evaluate antiproliferative sirolimus- and antioxidative alpha-lipoic acid (ALA)-eluting stents using biodegradable polymer [poly-L-lactic acid (PLA)] in a porcine coronary overstretch restenosis model. Forty coronary arteries of 20 pigs were randomized into four groups in which the coronary arteries had a bare metal stent (BMS, n = 10), ALA-eluting stent with PLA (AES, n = 10), sirolimus-eluting stent with PLA (SES, n = 10), or sirolimus- and ALA-eluting stent with PLA (SAS, n = 10). A histopathological analysis was performed 28 days after the stenting. The ALA and sirolimus released slowly over 30 days. There were no significant differences between groups in the injury or inflammation score; however, there were significant differences in the percent area of stenosis (56.2 ± 11.78% in BMS vs. 51.5 ± 12.20% in AES vs. 34.7 ± 7.23% in SES vs. 28.7 ± 7.30% in SAS, P < 0.0001) and fibrin score [1.0 (range 1.0-1.0) in BMS vs. 1.0 (range 1.0-1.0) in AES vs. 2.0 (range 2.0-2.0) in SES vs. 2.0 (range 2.0-2.0) in SAS, P < 0.0001] between the four groups. The percent area of stenosis based on micro-computed tomography corresponded with the restenosis rates based on histopathological stenosis in different proportions in the four groups (54.8 ± 7.88% in BMS vs. 50.4 ± 14.87% in AES vs. 34.5 ± 7.22% in SES vs. 28.9 ± 7.22% in SAS, P < 0.05). SAS showed a better neointimal inhibitory effect than BMS, AES, and SES at 1 month after stenting in a porcine coronary restenosis model. Therefore, SAS with PLA can be a useful drug combination for coronary stent coating to suppress neointimal hyperplasia.

Angioplasty of unprotected left main coronary stenosis: Real world experience of a single-operator group from eastern India

Background

Coronary artery bypass graft surgery is the standard treatment of unprotected left main coronary stenosis (ULMCA). However, in the real world scenario, many of these patients are unfit for CABG or prefer angioplasty as an alternative when offered the choice.

Methods

A total of 86 clinically stable patients with ULMCA stenosis who were unfit or unwilling for CABG underwent PCI with DES at two tertiary care centers in Kolkata. Patients were followed up prospectively for a median of 34.6 months for major adverse cardiovascular events. Angiographic follow-up was done after 1 year of index procedure or earlier, if indicated.

Results

Fifty-five patients (64%) had distal left main stenosis. Two-stent technique was used in 19 patients (22%) and single-stent technique in 36 patients (42%) with distal left main lesion. Thirteen patients (15.1%) had left ventricular ejection fraction (LVEF) of ≤45%. There was no in-hospital death, MI, or stent thrombosis. During follow-up, major adverse cardiac event (MACE) occurred in 9 patients (10.5%). Our study revealed significantly greater MACE in patients with distal left main lesion with LVEF ≤45% (50% vs 6.38%, p = 0.0002), high SYNTAX score (36.36% vs 6.82%, p = 0.008), and diabetes (17.95% vs 0.00%, p = 0.07). Overall, also patients with Diabetes, LVEF ≤ 45%, and SYNTAX score >32 had significantly higher MACE. Use of IC Stent, IVUS, or procedural strategy in distal lesion did not affect MACE.

Conclusion

In selective patients with low-intermediate SYNTAX score and without diabetes and LV dysfunction, ULMCA PCI with DES is feasible.

The Impact of Routine Angiographic Follow-Up in a Population of Patients Undergoing Percutaneous Coronary Intervention Within the Left Main Coronary Artery

Prognostic value of angiographic follow-up in patients undergoing percutaneous coronary interventions (PCIs) of the left main coronary artery (LMCA) still remains uncertain. The aim of the study was to compare clinical characteristics, mortality, and major cardiovascular events in patients with versus without angiographic follow-up after PCI of the LMCA as well as to identify independent risk factors for death after PCI of the LMCA. Study population consisted of 217 patients of 290 consecutive participants who underwent PCI of the LMCA and subsequently were divided into 2 groups: angiographic follow-up group (angio FU group, n = 155) and clinical follow-up group (clinical FU group, n = 62). In angio FU group, significantly lower mortality (19.4% vs 32.3%, P < .05) and higher repeated revascularization rates (PCI: 46.5% vs 8.1%, P < .001 and coronary artery bypass grafting: 12.9% vs 1.6%, P < .05) were observed. Independent risk factors for death were as follows: metal stent implantation (hazard ratio [HR]: 2.753), no angiographic follow-up (HR: 1.959), and an increase in serum creatinine level of 1 μmol/L (HR: 1.006). These preliminary data suggest that the lack of angiographic follow-up after PCI of the LMCA may result in higher long-term mortality.

Comparison of the efficacy of drug-eluting stents versus bare-metal stents for the treatment of left main coronary artery disease

Background:

Recent studies reported that percutaneous coronary intervention with stent implantation was safe and feasible for the treatment of left main coronary artery (LMCA) disease in select patients. However, it is unclear whether drug-eluting stents (DESs) have better outcomes in patients with LMCA disease compared with bare-metal stent (BMS) during long-term follow-up in Chinese populations.

Methods:

From a perspective multicenter registry, 1136 consecutive patients, who underwent BMS or DES implantation for unprotected LMCA stenosis, were divided into two groups: 1007 underwent DES implantation, and 129 underwent BMS implantation. The primary outcome was the rate of major adverse cardiac events (MACEs), including cardiovascular (CV) death, myocardial infarction (MI), and target lesion revascularization (TLR) at 5 years postimplantation.

Results:

Patients in the DES group were older and more likely to have hyperlipidemia and bifurcation lesions. They had smaller vessels and longer lesions than patients in the BMS group. In the adjusted cohort of patients, the DES group had significantly lower 5 years rates of MACE (19.4% vs. 31.8%, P = 0.022), CV death (7.0% vs. 14.7%, P = 0.045), and MI (5.4% vs. 12.4%, P = 0.049) than the BMS group. There were no significant differences in the rate of TLR (10.9% vs. 17.8%, P = 0.110) and stent thrombosis (4.7% vs. 3.9%, P = 0.758). The rates of MACE (80.6% vs. 68.2%, P = 0.023), CV death (93.0% vs. 85.3%, P = 0.045), TLR (84.5% vs. 72.1%, P = 0.014), and MI (89.9% vs. 80.6%, P = 0.029) free survival were significantly higher in the DES group than in the BMS group. When the propensity score was included as a covariate in the Cox model, the adjusted hazard ratios for the risk of CV death and MI were 0.41 (95% confidence interval [CI]: 0.21–0.63, P = 0.029) and 0.29 (95% CI: 0.08–0.92, P = 0.037), respectively.

Conclusions:

DES implantation was associated with more favorable clinical outcomes than BMS implantation for the treatment of LMCA disease even though there was no significant difference in the rate of TLR between the two groups.

STENTING STRATEGY AND FOLLOW-UP RESULTS OF MULTI-CENTER REGISTRY IN FUKUSHIMA CITY FOR LEFT MAIN CORONARY ARTERY DISEASE: BARE METAL STENT VERSUS DRUG-ELUTING STENT

An appropriate treatment strategy for left main trunk (LMT) lesions is still controversial in the drug-eluting stent (DES) era. Consecutive LMT stenting cases (n = 155) between January 2008 and January 2013 in 4 hospitals in Fukushima city were retrospectively analyzed. We excluded the patients suffering from cardiogenic shock before the stenting procedure. Among those cases, 60 patients had acute coronary syndrome, and remaining 95 had stable angina pectoris. Out of 155 cases, 45 patients were treated with bare metal stents (BMSs) and 110 patients were treated with DESs. All cases were succeeded in the initial procedure. Mean stent size of BMS was 3.85 ± 0.34 mm while that of DES was 3.46 ± 0.17 mm (P<0.001). At the follow up coronary angiography (255-day on average), % stenosis of BMS group was 26.6 ± 15.0% and that of DES group was 20.4 ± 12.6% (P = 0.006). The mean observation period for clinical events was 738.8 ± 480.3 days. Major adverse cardiac events-free rates for each group were compared and no significant differences were evident between the 2 groups (11.1% vs. 19.1%, ns). The present study demonstrated that use of BMSs would be a viable option in the treatment of LMT lesions when it is possible to use a large-sized stent (>3.5 mm).

Intravascular Ultrasound for the Diagnosis and Treatment of Left Main Coronary Artery Disease

Limitations of angiography for assessment of coronary artery disease are well-known, but are more evident and relevant in the left main coronary artery (LMCA) segment given the amount of myocardium this vessel subtends and the risks associated with the presence of atherosclerosis and subsequent intervention. Intravascular ultrasound (IVUS) characterizes the severity of luminal narrowing, plaque morphology, and plaque extension into the distal bifurcation. Once the indication for percutaneous intervention (PCI) is established, information provided by IVUS is crucial to plan treatment and optimize results. IVUS-guided PCI with drug-eluting stents improves clinical outcomes, particularly in patients with distal left main disease.

Drug-eluting stents in unprotected left main coronary artery disease

Though coronary bypass graft surgery (CABG) has traditionally been the cornerstone of therapy in patients with unprotected left main coronary artery (ULMCA) disease, recent evidence supports the use of percutaneous coronary intervention in appropriate patients. Indeed in patients with ULMCA disease, drug-eluting stents (DES) have shown similar incidence of hard end points, fewer periprocedural complications and lower stroke rates compared with CABG, though at the cost of increased revascularization with time. Furthermore, the availability of newer efficacious and safer DES as well as improvements in diagnostic tools, percutaneous techniques and, importantly, a better patient selection, allowed percutaneous coronary intervention a viable alternative to CABG of left main-patients with low disease complexity; however, even in this interventional era characterized by efficacious DES, patients with ULMCA disease remain a challenging high-risk population where outcomes strongly depend on clinical characteristics, anatomical disease complexity and extension and operator's experience. This review summarizes the role of DES in ULMCA disease patients.

Comparison of percutaneous coronary intervention (with drug-eluting stents) versus coronary artery bypass grafting in women with severe narrowing of the left main coronary artery (from the Women-Drug-Eluting stent for LefT main coronary Artery disease Registry)

Women typically present with coronary artery disease later than men with more unfavorable clinical and anatomic characteristics. It is unknown whether differences exist in women undergoing treatment for unprotected left main coronary artery (ULMCA) disease. Our aim was to evaluate long-term clinical outcomes in women treated with percutaneous coronary intervention (PCI) with drug-eluting stents versus coronary artery bypass grafting (CABG). All consecutive women from the Drug-Eluting stent for LefT main coronary Artery disease registry with ULMCA disease were analyzed. A propensity matching was performed to adjust for baseline differences. In total, 817 women were included: 489 (59.8%) underwent treatment with PCI with drug-eluting stents versus 328 (40.2%) with CABG. Propensity score matching identified 175 matched pairs, and at long-term follow-up there were no differences in all-cause (odds ratio [OR] 0.722, 95% confidence interval [CI] 0.357 to 1.461, p=0.365) or cardiovascular (OR 1.100, 95% CI 0.455 to 2.660, p=0.832) mortality, myocardial infarction (MI; OR 0.362, 95% CI 0.094 to 1.388, p=0.138), or cerebrovascular accident (CVA; OR 1.200, 95% CI 0.359 to 4.007, p=0.767) resulting in no difference in the primary study objective of death, MI, or CVA (OR 0.711, 95% CI 0.387 to 1.308, p=0.273). However, there was an advantage of CABG in major adverse cardiovascular and cerebrovascular events (OR 0.429, 95% CI 0.254 to 0.723, p=0.001), driven exclusively by target vessel revascularization (OR 0.185, 95% CI 0.079 to 0.432, p<0.001). In women with significant ULMCA disease, no difference was observed after PCI or CABG in death, MI, and CVA at long-term follow-up.

Dual protection therapy with staged coronary artery bypass surgery and stenting in patients with left main coronary artery stenosis: long-term results from a single center

OBJECTIVE

We evaluated the efficacy and safety of dual protection therapy with staged coronary artery bypass grafting (CABG) and bare-metal stenting (BMS) in patients with left main coronary artery (LMCA) disease.

BACKGROUND

CABG is currently the preferred therapy for complex LMCA disease; however, the long-term patency rates of these grafts are unsatisfactory, and stenting alone for LMCA may be associated with the potentially fatal consequences of stent thrombosis or restenosis.

METHODS

Between January 1997 and October 2005, 42 patients underwent staged bypass surgery and BMS, with the latter procedure performed 2 weeks after the initial CABG. Of these patients, 40 received left internal mammary artery (LIMA) grafts, 34 saphenous vein grafts, 6 radial artery grafts, and 3 right IMA (RIMA) grafts. Minimally invasive bypass surgery was performed in 10 patients.

RESULTS

There were no operative complications. Forty-two stents were implanted in 42 lesions without complications. During the follow-up period of 135 ± 55 months, 1 patient died of cancer, 2 of cardiac causes, and 5 patients (12%) experienced target lesion revascularization. The target vessel failure rate was 24%. Forty patients (95%) underwent a 6-month angiographic follow-up. Restenosis was noted in 7 patients (18%). Reocclusion was also noted in 5 LIMA grafts, 5 saphenous vein grafts, 1 radial artery graft, and 1 RIMA graft. Only 1 patient experienced both restenosis of LM stenting and total occlusion of the 2 bypass grafts.

CONCLUSIONS

Dual protection therapy with staged CABG and stenting is not an appropriate therapeutic strategy because of unacceptable graft patency rate. A higher occlusive rate of the bypass grafts may result from decreased blood flow because of competing blood flow between the bypass graft and the native coronary vessel.

Acute coronary syndrome as a result of left main coronary artery stenosis after aortic valve replacement. A report of three cases

Acute coronary syndrome (ACS) as a result of iatrogenic coronary ostial stenosis (ICOS) is a rare but potentially life-threatening complication of aortic valve replacement (AVR). We present three cases of patients with ACS shortly after AVR, in whom ICOS were revealed. They refused an operation and thus they were treated with percutaneous coronary intervention. The potential pathomechanisms of ICOS and treatment options are discussed.