Long-term clinical outcomes of sirolimus- versus paclitaxel-eluting stents for patients with unprotected left main coronary artery disease: analysis of the MAIN-COMPARE (revascularization for unprotected left main coronary artery stenosis: comparison of percutaneous coronary angioplasty versus surgical revascularization) registry

Percutaneous coronary artery intervention in unprotected left main coronary artery disease: one-year outcome Egyptian registry

Background

Left main coronary artery lesions are associated with jeopardy of an outsized area of the myocardium, causing a high incidence of morbidity and mortality. Optimal treatment of coronary bifurcation anatomy remains highly debatable, whether by provisional or two-stent technique. This prospective observational study was designed to investigate the one-year clinical outcomes of unprotected left main coronary artery disease revascularization by percutaneous coronary intervention in a “real-world” setting among Egyptian patients in a prospective single-center registry (at Ain Shams University Hospitals).

Results

This study included 163 patients who underwent PCI to LM lesions between May 1, 2020, and the end of April in Ain Shams University hospitals. Patients were dichotomized into two groups according to their intended stenting technique, whether provisional or two-stent technique. A total of 142 underwent provisional stenting while 21 were designated for the two-stent technique, mainly DK crush (double kissing). Among the patients with intended provisional stenting, 34 patients underwent the TAP technique. Patients were followed up for the primary endpoints, at the in-hospital setting, at 30 days, and after 1 year. In-hospital death was encountered in 6.34% of cases undergoing provisional stenting, among which 5.36% were due to a cardiovascular cause. Total MACCE was found to be 2.96% in the provisional stenting group versus 4.76% in the two-stent group. Overall, MACCE at 1 year was found to be 22.31% in the provisional group and 30% in the two-stent group (p-value0.57). TVF was recognized in 10% of cases treated by provisional stenting and 30% of cases treated by the two-stent technique (p-value 0.023).

Conclusions

LM coronary artery lesions treatment by PCI is considered a safe and beneficial solution. Provisional stenting is the preferred approach bearing in mind that bail-out procedures may be sought in case the SB needs further treatment. Adjunctive assessment by IVUS or FFR may help achieve better outcomes, and efforts should be performed to facilitate their feasibility.

Ten-year outcomes of early generation sirolimus- versus paclitaxel-eluting stents in patients with left main coronary artery disease

To compare 10-year outcomes after implantation of sirolimus-eluting stents (SES) versus paclitaxel-eluting stents (PES) for left main coronary artery (LMCA) stenosis. Very long-term outcome data of patients with LMCA disease treated with drug-eluting stents (DES) have not been well described. In 10-year extended follow-up of the MAINCOMPARE registry, we evaluated 778 patients with unprotected LMCA stenosis who were treated with SES (n = 607) or PES (n = 171) between January 2000 and June 2006. The primary composite outcome (a composite of death, myocardial infarction [MI] or target-vessel revascularization [TVR]) was compared with an inverse-probability-of-treatment-weighting (IPTW) adjustment. Clinical events have linearly accumulated over 10 years. At 10 years, there were no significant differences between SES and PES in the observed rates of the primary composite outcome (42.0% vs. 47.4%; hazard ratio [HR] 0.85; 95% confidence interval [CI] 0.66-1.10), and definite stent thrombosis (ST) (1.9% vs. 1.8%; HR 1.02, 95% CI 0.28-3.64). In the IPTW-adjusted analyses, there were no significant differences between SES and PES in the risks for the primary composite outcome (HR 0.89, 95% CI 0.65-1.14) or definite ST (adjusted HR 1.05, 95% CI 0.29-3.90). In patients who underwent DES implantation, high overall adverse clinical event rates (with a linearly increasing event rate over time) were observed during extended follow-up. At 10 years, there were no measurable differences in outcomes between patients treated with SES vs. PES for LMCA disease. The incidence of stent thrombosis was quite low and comparable between the groups.

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.

Application of Enhanced Recovery After Surgery in Single-incision Laparoscopic Distal Gastrectomy

BACKGROUND

Recently, enhanced recovery after surgery (ERAS) was widely used in the perioperative management of gastric cancer. The study aimed to evaluate the safety and effectiveness of ERAS in single-incision laparoscopic distal gastrectomy (SIDG).

MATERIALS AND METHODS

A total of 90 patients who received laparoscopic gastric cancer resection were divided into 3 groups: group A (n=30), underwent traditional multiport laparoscopic distal gastrectomy with conventional perioperative management; group B (n=30) underwent traditional multiport laparoscopic distal gastrectomy with ERAS concept; and group C (n=30), underwent SIDG with ERAS concept. Clinical data and gut function were assessed in 3 groups.

RESULTS

There were no significant differences in terms of postoperative complication, number of resected lymph nodes and blood loss among 3 groups. However, operation time was longer (P=0.003) and treatment cost was higher (P<0.001) in group C than that in group A and B. Group C had faster recovery of bowel function (P<0.001), shorter postoperative hospital stay (P=0.002), and less postoperative complication (P=0.044) than those in group A. There were no significant differences in terms of recovery of bowel function and postoperative hospital stay between group C and B (all P>0.05). The white blood cell counts were lower than group A and B (all P<0.05) and C-reactive protein in group C were lower than group A (P<0.05) and B (P>0.05).

CONCLUSIONS

The findings suggest that SIDG with ERAS may be a feasible and safe procedure for early gastric cancer because it provides a favorable cosmetic result while not compromising postoperative complications, number of resected lymph nodes, and blood loss.

Current application and bioavailability of drug-eluting stents

INTRODUCTION

Drug-eluting stents (DES) were developed to reduce the restenosis rate of bare metal stents (BMS) and comprises three main components: i) a metallic scaffold; ii) an antiproliferative drug to reduce or abolish the formation of the neointima; and iii) the polymer, which both enables and controls drug elution into the vessel wall. Over the years, growing evidence has been reported on the safety and efficacy for different indications of DES.

AREAS COVERED

Since the introduction of first-generation DES, the technology has been refined, including changes in the alloy, stent design, polymer, drug and drug dose. In 2014, we will usher in a third generation of DES, which will include biodegradable polymers, polymer-free DES and bioabsorbable scaffolds.

EXPERT OPINION

In recent years, considerable progress has been made in DES development. The BMS platform set the groundwork for the development of metal scaffolds with drug-eluting capability to prevent restenosis. Importantly, extensive research has shown long-term safety and efficacy of the newer generation DES. Available data suggest that DES can be safely and effectively used to treat a complex subset of patients and lesions, including patients presenting with acute myocardial infarction, lesions in saphenous vein grafts, chronic total occlusions, multivessel disease, small vessels, long lesions and bifurcations. One of the safety targets is to eliminate stent thrombosis.

Comparison of paclitaxel-eluting stents (Taxus) and everolimus-eluting stents (Xience) in left main coronary artery disease with 3 years follow-up (from the ESTROFA-LM registry)

Evidence regarding therapy with drug-eluting stents in the left main coronary artery (LM) is based mostly on trials performed with first-generation drug-eluting stents. The aim of this study was to evaluate long-term clinical outcomes after treatment for unprotected LM disease with paclitaxel-eluting stents (PES) and everolimus-eluting stents (EES). The ESTROFA-LM is a multicenter retrospective registry including consecutive patients with unprotected LM disease treated with PES or EES. A total of 770 patients have been included at 21 centers, 415 with treated PES and 355 with EES. Treatment with 2 stents was more frequent with PES (17% vs 10.4%, p = 0.007), whereas intravascular ultrasound was more frequently used with EES (35.2% vs 26%, p = 0.006). The 3-year death and infarction survival rates were 86.1% for PES and 87.3% for EES (p = 0.50) and for death, infarction, and target lesion revascularization were 83.6% versus 82% (p = 0.60), respectively. Definite or probable thrombosis was 1.6% for PES and 1.4% for EES (p = 0.80). The use of 2 stents, age, diabetes, and acute coronary syndromes were independent predictors of mortality. In the subgroup of distal lesions, the use of intravascular ultrasound was an independent predictor of better outcome. Comparison of propensity score-matched groups did not yield differences between the 2 stents. In conclusion, the results of this multicenter registry show comparable safety and efficacy at 3 years for PES and EES in the treatment of LM disease. The use of bifurcation stenting techniques in distal lesions was a relevant independent predictor for events. The use of intravascular ultrasound appears to have a positive impact on patients treated for LM distal disease.

Stenting of left main coronary artery stenosis: A to Z

For several decades, coronary artery bypass grafting (CABG) has been considered as the gold standard treatment of unprotected left main coronary artery (LMCA) disease. The marked improvement in technique and technology makes percutaneous coronary interventions (PCIs) feasible for patients with unprotected LMCA stenosis. The recent introduction of drug-eluting stents (DESs), together with advances in periprocedural and postprocedural adjunctive pharmacotherapies, has improved outcomes of PCIs of these lesions. Recent studies comparing efficacy and safety of PCIs using drug-eluting stents and CABG revealed comparable results in terms of safety and a lower need for repeat revascularisation for CABG. Patient selection for both the techniques directly impacts clinical outcome. Despite improvement in stent technology and operator experience, management can be challenging especially in LMCA bifurcation lesions and, therefore, an integrated approach combining advanced devices, tailored techniques, adjunctive support of physiological evaluation, and adjunctive pharmacological agents should be reinforced to improve clinical outcome.

Percutaneous revascularization of left main: role of imaging, techniques, and adjunct pharmacology

Refinement of interventional techniques, adjunctive pharmacological therapy, and the introduction of drug-eluting stents have fostered new interest for the percutaneous treatment of unprotected left main coronary artery (ULMCA) stenosis. Several observational registries, some randomized trials and several meta-analyses have consistently shown no difference in mortality and myocardial infarction between percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) surgery in patients with ULMCA stenosis, but a higher rate of target vessel revascularization in patients treated with PCI. As a consequence, PCI of ULMCA stenosis has been upgraded to class IIa or IIb indication in the current European or American practice guidelines. However, several critical issues should be properly addressed when pursuing a percutaneous strategy for the treatment of ULMCA stenosis, such as the use of IVUS for procedural guidance, assessment of disease location, optimal technique for distal ULMCA stenosis, risk of stent thrombosis, optimal duration of dual antiplatelet therapy, and the most appropriate strategy for post-procedure follow up. Multidisciplinary team approach remains essential to provide a balanced information to the patient and to offer the beast treatment option.

Impact of Exercise-based Cardiac Rehabilitation on In-stent Restenosis with Different Generations of Drug Eluting Stent

Objective

To compare the rate of restenosis between a cardiac rehabilitation (CR) group and a control group within three different generations of drug eluting stents (DES).

Method

Patients who received DES due to an acute coronary syndrome were included. They were divided into a CR group and a control group. The CR group received six to eight weeks of early cardiac rehabilitation program in a hospital setting, and sustained a self-exercise program for six months in a community. The control group was instructed to exercise by themselves after leaving the hospital. Nine months after the first onset of disease, we implemented a coronary angiography and compared the two groups. In addition, we divided the patients into three subgroups according to the generation of DES, and compared the rate of restenosis between the CR group and control group within these three subgroups.

Results

At 9 months, in-stent restenosis, measured as an in-segment late luminal loss (LLL) of the stented coronary area, was smaller in the CR group (n=52) 0.16±0.42 mm compared to the control group (n=51) 0.39±0.78 mm (p<0.05). A reduction of LLL in the CR group compared to the control group was consistent among the three different generations of DES.

Conclusion

The CR program is strongly associated with a significant reduction in LLL in the stented coronary segments, regardless of the generation of DES.

Comparison of the predictive value of EuroSCORE, SYNTAX score, and clinical SYNTAX score for outcomes of patients undergoing percutaneous coronary intervention for unprotected left main coronary artery disease

OBJECTIVES

We aimed to assess the prognostic values of the EuroSCORE, SYNTAX score, and the novel Clinical SYNTAX score (CSS) for 30-day and 1-year outcomes in patients undergoing left main (LM) percutaneous coronary intervention (PCI).

BACKGROUND

PCI has become an alternative treatment for LM coronary artery disease, and risk scoring system might be beneficial for pre-PCI risk stratification.

METHODS AND RESULTS

We enrolled 198 consecutive patients with unprotected LM disease undergoing PCI (mean age 71.5 ± 10.7 years). The CSS was calculated by multiplying the SYNTAX Score to (age/left ventricular ejection fraction +1 for each 10 mL the estimated glomerular filtration rate <60 mL/min per 1.73 m(2)). The endpoints were 30-day, and 1-year all-cause death and major adverse cardiovascular events (MACE), which were defined as all-cause death, nonfatal MI, and clinical-driven target vessel revascularization. Comparing with the SYNTAX score, the predictive accuracy of CSS for 30-day and 1-year all-cause death and MACE were significantly higher (c-statistics, CSS versus SYNTAX score: P < 0.01 for 30-day and 1-year all-cause death; P < 0.05 for 30-day and 1-year MACE, respectively). Furthermore, in the multivariate Cox regression analysis, both EuroSCORE and CSS were identified as the independent predictors of 30-day and 1-year all-cause death and MACE, but the SYNTAX score was not.

CONCLUSIONS

In the general practice among a high-risk population undergoing LM PCI, EuroSCORE and CSS might be independent predictors for 30-day and 1-year all-cause death and MACE. Furthermore, the CSS had a superior discriminatory ability in predicting the 30-day and 1-year clinical outcomes comparing with the SYNTAX score.

Treatment of patients with left main coronary artery disease

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.

[Left main intervention: options and limitations in interventional cardiology]

Revascularisation is indicated in patients with left main stenosis (LMS) because of its known positive effect on long-term survival. Coronary artery bypass graft (CABG) surgery has been the traditional procedure of choice for LMS patients, with percutaneous coronary intervention (PCI) being reserved for high-risk surgical patients or for those who have one or more functioning distal bypass grafts (i.e. "protected" left main PCI). Recent studies have re-examined the role of PCI in LMS, however, leading to a recent Class II recommendation for its use in selected patients. The SYNTAX Trial demonstrated that PCI can be performed with good results in the following patient subgroups: patients with isolated LMS, particularly if confined to the ostium; patients with concomitant LMS and isolated single vessel disease; patients with a SYNTAX score of <33; and patients who are at high risk for conventional CABG surgery. Patients with complex coronary anatomy (SYNTAX score >33) or those with concomitant double- or triple-vessel disease are more suited to CABG surgery. Patients who undergo PCI for LMS should be treated in specialized centers with surgical back-up, preferably with patient management decisions being made by a "heart team" consisting of at least one cardiologist and one cardiac surgeon. Ongoing studies are being performed using the hard clinical endpoints of death, myocardial infarction, and stroke in order to further compare the results of PCI vs CABG in LMS patients.

Long-term outcomes of sirolimus-eluting stents vs. paclitaxel-eluting stents in unprotected left main coronary artery bifurcation lesions

BACKGROUND

The treatment of unprotected left main coronary artery (uLMCA) bifurcation lesions remains challenging.

HYPOTHESIS

We hypothesized that the type of drug-eluting stent would correlate with clinical outcomes for the treatment of uLMCA bifurcation lesions.

METHODS

One hundred fifteen patients who underwent stent implantation using a provisional T-stenting technique with sirolimus-eluting stents (SES) or paclitaxel-eluting stents (PES) for uLMCA bifurcation lesions were enrolled. A major adverse cardiac event (MACE) was defined as a composite of cardiac death, myocardial infarction, or target lesion revascularization.

RESULTS

Ninety-four patients were treated with SES and 21 patients with PES. Baseline characteristics were similar between the 2 groups. Angiographic follow-up was performed in 99 (86%) patients. Late loss in the LMCA to the left anterior descending coronary artery was significantly lower in the SES group than in the PES group (0.28 ± 0.54 mm vs 1.03 ± 0.45 mm, P<0.001). One case of stent thrombosis occurred in the SES group. During follow-up with a median of 712 days, the SES group had a lower MACE compared with the PES group (10.6% vs. 28.6%, P = 0.032). Cox proportional hazards models including age, sex, diabetes, acute coronary syndrome, true bifurcation, stenting strategy, and type of drug-eluting stent used (SES vs. PES) demonstrated that stent type was the only predictor of MACE (hazard ratio of PES vs SES: 3.88, 95% confidence interval: 1.29-11.67, P = 0.016).

CONCLUSIONS

According to the results of the present study, SES may be associated with more favorable outcomes than PES for stenting of uLMCA bifurcation, which should be further studied by larger trials.

Recent perspective on coronary bifurcation intervention: statement of the "Bifurcation Club in KOKURA"

The treatment of coronary bifurcation lesion remains a challenging issue even in the drug-eluting stent era. Frequent restenosis and stent thrombosis have been recently shown to be related not only to geometrical gap or stent structural deformation but also to rheological disturbance. Low wall shear stress at the lateral side of the bifurcation is likely to cause atherosclerotic changes due to easy access of the macrophages that induce chemical mediators. The turbulent flow over stent metal may facilitate accumulation of platelets, which results in thrombosis. The jailed strut and excess metal overlap may increase these risks. Since dramatic changes of the coronary flow pattern at the bifurcation are closely related to the genesis of atherosclerosis, future bifurcation intervention technique should be considered to restore the original physiological state as well as the anatomical structure. This article summarizes the global consensus of the members of the Asian Bifurcation Club and European Bifurcation Club at the KOKURA meeting. It also provides a perspective of basic sciences relating to bifurcation anatomy, physiology, and pathology, in the search for a best strategy for bifurcation intervention.

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.

C-peptide fragments stimulate glucose utilization in diabetic rats

Studies of C-peptide cellular effects show that not only the full-length native peptide but also specific C-terminal fragments are biologically active in in vitro systems. In the present study, the effect of five C-peptide fragments and the native peptide on whole-body glucose turnover was studied in streptozotocin diabetic rats using the insulin clamp technique. Insulin was infused intravenously at 18 pmol kg(-1) min(-1) for 90 min and blood glucose concentration was clamped at 8 and 4 mM in diabetic and non-diabetic animals. A steady state was reached during the last 30 min of the study period. Rat C-peptide II and fragments comprising residues 27-31 and 28-31 were effective in augmenting glucose turnover in diabetic rats (+100% to 150%), while no significant effects were seen for segments 1-26, 11-19 and 11-15. The metabolic clearance rate for glucose during infusion of C-peptide or fragments 27-31 and 28-31 in diabetic rats was similar to that seen in non-diabetic animals. We conclude that C-terminal tetra- and pentapeptides, but not fragments from the middle segment of C-peptide, are as effective as the full-length peptide in stimulating whole-body glucose turnover in diabetic rats.