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Park S, Park SJ, Park DW. Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting for Revascularization of Left Main Coronary Artery Disease. Korean Circ J 2023; 53:113-133. [PMID: 36914602 PMCID: PMC10011221 DOI: 10.4070/kcj.2022.0333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Accepted: 01/24/2023] [Indexed: 03/03/2023] Open
Abstract
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.
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Affiliation(s)
- Sangwoo Park
- Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Seung-Jung Park
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Duk-Woo Park
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
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Park S, Park SJ, Park DW. Percutaneous Coronary Intervention for Left Main Coronary Artery Disease: Present Status and Future Perspectives. JACC. ASIA 2022; 2:119-138. [PMID: 36339118 PMCID: PMC9627854 DOI: 10.1016/j.jacasi.2021.12.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 12/09/2021] [Accepted: 12/17/2021] [Indexed: 11/26/2022]
Abstract
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.
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Key Words
- BMS, bare-metal stent(s)
- CABG, coronary artery bypass grafting
- CAD, coronary artery disease
- DAPT, dual antiplatelet therapy
- DES, drug-eluting stent(s)
- DK, double-kissing
- FFR, fractional flow reserve
- IVUS, intravascular ultrasound
- LAD, left anterior descending artery
- LCX, left circumflex artery
- LMCA, left main coronary artery
- LVEF, left ventricular ejection fraction
- MACCE, major adverse cardiac or cerebrovascular events
- MI, myocardial infarction
- MLA, minimal lumen area
- PCI, percutaneous coronary intervention
- RCT, randomized clinical trial
- coronary artery bypass grafting
- iFR, instantaneous wave-free ratio
- left main coronary artery disease
- percutaneous coronary intervention
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Affiliation(s)
- Sangwoo Park
- Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, South Korea
| | - Seung-Jung Park
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Duk-Woo Park
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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Mukherjee D. Is Percutaneous Coronary Intervention Now the Default Revascularization Strategy for Unprotected Left Main Coronary Artery Stenosis? J Am Heart Assoc 2022; 11:e025748. [PMID: 35352567 PMCID: PMC9075449 DOI: 10.1161/jaha.122.025748] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Debabrata Mukherjee
- Division of Cardiovascular Medicine Texas Tech University Health Sciences Center El Paso TX
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Kang DY, Ahn JM, Yun SC, Park H, Cho SC, Kim TO, Park S, Lee PH, Lee SW, Park SW, Park DW, Park SJ. Long-Term Clinical Impact of Intravascular Ultrasound Guidance in Stenting for Left Main Coronary Artery Disease. Circ Cardiovasc Interv 2021; 14:e011011. [PMID: 34665659 DOI: 10.1161/circinterventions.121.011011] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Do-Yoon Kang
- Department of Cardiology (D.-Y.K., J.-M.A., H.P., S.-C.C., T.O.K., S.P., P.H.L., S.-W.L., S.-W.P., D.-W.P., S.-J.P.), Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jung-Min Ahn
- Department of Cardiology (D.-Y.K., J.-M.A., H.P., S.-C.C., T.O.K., S.P., P.H.L., S.-W.L., S.-W.P., D.-W.P., S.-J.P.), Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung-Cheol Yun
- Division of Biostatistics (S.-C.Y.), Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hanbit Park
- Department of Cardiology (D.-Y.K., J.-M.A., H.P., S.-C.C., T.O.K., S.P., P.H.L., S.-W.L., S.-W.P., D.-W.P., S.-J.P.), Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang-Cheol Cho
- Department of Cardiology (D.-Y.K., J.-M.A., H.P., S.-C.C., T.O.K., S.P., P.H.L., S.-W.L., S.-W.P., D.-W.P., S.-J.P.), Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Tae Oh Kim
- Department of Cardiology (D.-Y.K., J.-M.A., H.P., S.-C.C., T.O.K., S.P., P.H.L., S.-W.L., S.-W.P., D.-W.P., S.-J.P.), Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sangwoo Park
- Department of Cardiology (D.-Y.K., J.-M.A., H.P., S.-C.C., T.O.K., S.P., P.H.L., S.-W.L., S.-W.P., D.-W.P., S.-J.P.), Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Pil Hyung Lee
- Department of Cardiology (D.-Y.K., J.-M.A., H.P., S.-C.C., T.O.K., S.P., P.H.L., S.-W.L., S.-W.P., D.-W.P., S.-J.P.), Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seung-Whan Lee
- Department of Cardiology (D.-Y.K., J.-M.A., H.P., S.-C.C., T.O.K., S.P., P.H.L., S.-W.L., S.-W.P., D.-W.P., S.-J.P.), Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seong-Wook Park
- Department of Cardiology (D.-Y.K., J.-M.A., H.P., S.-C.C., T.O.K., S.P., P.H.L., S.-W.L., S.-W.P., D.-W.P., S.-J.P.), Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Duk-Woo Park
- Department of Cardiology (D.-Y.K., J.-M.A., H.P., S.-C.C., T.O.K., S.P., P.H.L., S.-W.L., S.-W.P., D.-W.P., S.-J.P.), Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seung-Jung Park
- Department of Cardiology (D.-Y.K., J.-M.A., H.P., S.-C.C., T.O.K., S.P., P.H.L., S.-W.L., S.-W.P., D.-W.P., S.-J.P.), Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Hyun J, Kim JH, Jeong Y, Choe K, Lee J, Yang Y, Kim TO, Park H, Cho SC, Ko E, Kang DY, Lee PH, Ahn JM, Park SJ, Park DW. Long-Term Outcomes After PCI or CABG for Left Main Coronary Artery Disease According to Lesion Location. JACC Cardiovasc Interv 2021; 13:2825-2836. [PMID: 33357520 DOI: 10.1016/j.jcin.2020.08.021] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 08/12/2020] [Accepted: 08/18/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVES The aim of this study was to investigate the impact of lesion site (ostial or shaft vs. distal bifurcation) on long-term outcomes after percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) for left main coronary artery (LMCA) disease. BACKGROUND Long-term comparative data after PCI and CABG for LMCA disease according to lesion site are limited. METHODS Patients from the MAIN-COMPARE (Revascularization for Unprotected Left Main Coronary Artery Stenosis: Comparison of Percutaneous Coronary Angioplasty Versus Surgical Revascularization) registry were analyzed, comparing adverse outcomes (all-cause mortality [a composite outcome of death, Q-wave myocardial infarction, or stroke] and target vessel revascularization) between PCI and CABG according to LMCA lesion location during a median follow-up period of 12.0 years. RESULTS In overall population, the adjusted risks for death and serious composite outcome were higher after PCI than after CABG for distal bifurcation disease, which was mainly separated beyond 5 years. These outcomes were not different for ostial or shaft disease. When comparing drug-eluting stents (DES) and CABG, the adjusted risks for death and serious composite outcome progressively diverged beyond 5 years after DES compared with CABG for distal bifurcation disease (death: hazard ratio: 1.78; 95% confidence interval: 1.22 to 2.59; composite outcome: hazard ratio: 1.94; 95% confidence interval: 1.35 to 2.79). This difference was driven mainly by PCI with a 2-stent technique for distal bifurcation. In contrast, the adjusted risks for these outcomes were similar between DES and CABG for ostial or shaft disease. CONCLUSIONS Among patients with distal LMCA bifurcation disease, CABG showed lower mortality and serious composite outcome rates compared with DES beyond 5 years. However, there were no between-group differences in these outcomes among patients with ostial or shaft LMCA disease.
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Affiliation(s)
- Junho Hyun
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ju Hyeon Kim
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yeongjin Jeong
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - KyungJin Choe
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Junghoon Lee
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yujin Yang
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Tae Oh Kim
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hanbit Park
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang-Cheol Cho
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Euihong Ko
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Do-Yoon Kang
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Pil Hyung Lee
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jung-Min Ahn
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seung-Jung Park
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Duk-Woo Park
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
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Cho SC, Park DW, Park SJ. Percutaneous Coronary Intervention and Coronary Artery Bypass Grafting for the Treatment of Left Main Coronary Artery Disease. Korean Circ J 2019; 49:369-383. [PMID: 31074210 PMCID: PMC6511529 DOI: 10.4070/kcj.2019.0112] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 04/10/2019] [Indexed: 12/15/2022] Open
Abstract
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.
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Affiliation(s)
- Sang Cheol Cho
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Duk Woo Park
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seung Jung Park
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
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7
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Gurm HS. Left Main Stenting: Joining the Mainstream. JACC Cardiovasc Interv 2018; 11:2492-2494. [PMID: 30573060 DOI: 10.1016/j.jcin.2018.10.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 10/23/2018] [Indexed: 10/27/2022]
Affiliation(s)
- Hitinder S Gurm
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan.
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10-Year Outcomes of Stents Versus Coronary Artery Bypass Grafting for Left Main Coronary Artery Disease. J Am Coll Cardiol 2018; 72:2813-2822. [DOI: 10.1016/j.jacc.2018.09.012] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 09/12/2018] [Accepted: 09/12/2018] [Indexed: 11/21/2022]
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Park DW, Ahn JM, Park SJ, Taggart DP. Percutaneous coronary intervention in left main disease: SYNTAX, PRECOMBAT, EXCEL and NOBLE-combined cardiology and cardiac surgery perspective. Ann Cardiothorac Surg 2018; 7:521-526. [PMID: 30094217 DOI: 10.21037/acs.2018.04.04] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
- Duk-Woo Park
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jung-Min Ahn
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seung-Jung Park
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - David P Taggart
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
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Park DW, Park SJ. Percutaneous Coronary Intervention of Left Main Disease. Circ Cardiovasc Interv 2017; 10:CIRCINTERVENTIONS.117.004792. [DOI: 10.1161/circinterventions.117.004792] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Accepted: 05/09/2017] [Indexed: 12/20/2022]
Abstract
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.
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Affiliation(s)
- Duk-Woo Park
- From the Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seung-Jung Park
- From the Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Ahn JM, Park SJ. No More Debate Over Left Main Stenting Versus Bypass Surgery. JACC Cardiovasc Interv 2016; 9:328-330. [PMID: 26892081 DOI: 10.1016/j.jcin.2015.12.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Revised: 12/15/2015] [Accepted: 12/17/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Jung-Min Ahn
- Division of Cardiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Seung-Jung Park
- Division of Cardiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea.
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Rampat R, Hildick-Smith D. Left Main Stem Percutaneous Coronary Intervention - Data and Ongoing Trials. Interv Cardiol 2015; 10:132-135. [PMID: 29588688 DOI: 10.15420/icr.2015.10.03.132] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Left main stem (LMS) disease is associated with significant morbidity and mortality. Traditionally coronary artery bypass grafting (CABG) has been the gold standard for treatment of these lesions. However over the past decade, percutaneous coronary intervention (PCI) has assumed a more prominent role in the treatment of LMS disease. With the advent of newer drug-eluting stents (DES) with an improved risk factor profile, better intravascular imaging modalities and careful patient selection, the use of PCI in this cohort is expanding. We review the current data to support this and discuss the on-going trials that will hopefully shed more light into the management of this complex disease.
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Affiliation(s)
- Rajiv Rampat
- Sussex Cardiac Centre, Brighton and Sussex University Hospitals, Brighton, U
| | - David Hildick-Smith
- Sussex Cardiac Centre, Brighton and Sussex University Hospitals, Brighton, U
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15
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Park SJ, Ahn JM, Kim YH. How to Optimize Left Main Percutaneous Coronary Intervention. JACC Cardiovasc Interv 2014; 7:731-2. [DOI: 10.1016/j.jcin.2014.05.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2014] [Accepted: 05/20/2014] [Indexed: 11/15/2022]
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Hsieh IC, Lin PJ, Chang SH, Hsieh MJ, Lin FC, Wu D, Chen CC. 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. Heart Surg Forum 2014; 17:E47-53. [PMID: 24631991 DOI: 10.1532/hsf98.2013282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
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.
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Affiliation(s)
- I-Chang Hsieh
- Section of Cardiology, Department of Internal Medicine and Percutaneous Coronary Intervention (PCI) Center, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Pyng-Jing Lin
- Department of Cardiovascular Surgery, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Shang-Hung Chang
- Section of Cardiology, Department of Internal Medicine and Percutaneous Coronary Intervention (PCI) Center, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Ming-Jer Hsieh
- Section of Cardiology, Department of Internal Medicine and Percutaneous Coronary Intervention (PCI) Center, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Fen-Chiung Lin
- Section of Cardiology, Department of Internal Medicine and Percutaneous Coronary Intervention (PCI) Center, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Delon Wu
- Section of Cardiology, Department of Internal Medicine and Percutaneous Coronary Intervention (PCI) Center, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Chun-Chi Chen
- Section of Cardiology, Department of Internal Medicine and Percutaneous Coronary Intervention (PCI) Center, Chang Gung University College of Medicine, Taoyuan, Taiwan
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Park SJ, Kim YH. Percutaneous coronary intervention as an alternative to bypass surgery for unprotected LMCA stenosis. Expert Rev Cardiovasc Ther 2014; 6:1107-14. [DOI: 10.1586/14779072.6.8.1107] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Choi YJ, Kim U, Lee JS, Park WJ, Lee SH, Park JS, Shin DG, Kim YJ. A case of extrinsic compression of the left main coronary artery secondary to pulmonary artery dilatation. J Korean Med Sci 2013; 28:1543-8. [PMID: 24133364 PMCID: PMC3792613 DOI: 10.3346/jkms.2013.28.10.1543] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2013] [Accepted: 05/03/2013] [Indexed: 11/20/2022] Open
Abstract
Extrinsic compression of the left main coronary artery (LMCA) secondary to pulmonary artery dilatation is a rare syndrome. Most cases of pulmonary artery hypertension but no atherosclerotic risk factors rarely undergo coronary angiography, and hence, diagnoses are seldom made and proper management is often delayed in these patients. We describe a patient that presented with pulmonary hypertension, clinical angina, and extrinsic compression of the LMCA by the pulmonary artery, who was treated successfully by percutaneous coronary intervention. Follow-up coronary angiography showed patent stent in the LMCA in the proximity of the dilated main pulmonary artery. This case reminds us that coronary angiography and percutaneous coronary intervention should be considered in pulmonary hypertension patients presenting with angina or left ventricular dysfunction.
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Affiliation(s)
- Yoon-Jung Choi
- Division of Cardiology, Department of Internal Medicine, Yeungnam University Medical Center, Daegu, Korea
| | - Ung Kim
- Division of Cardiology, Department of Internal Medicine, Yeungnam University Medical Center, Daegu, Korea
| | - Jin-Sung Lee
- Division of Cardiology, Department of Internal Medicine, Yeungnam University Medical Center, Daegu, Korea
| | - Won-Jong Park
- Division of Cardiology, Department of Internal Medicine, Yeungnam University Medical Center, Daegu, Korea
| | - Sang-Hee Lee
- Division of Cardiology, Department of Internal Medicine, Yeungnam University Medical Center, Daegu, Korea
| | - Jong-Seon Park
- Division of Cardiology, Department of Internal Medicine, Yeungnam University Medical Center, Daegu, Korea
| | - Dong-Gu Shin
- Division of Cardiology, Department of Internal Medicine, Yeungnam University Medical Center, Daegu, Korea
| | - Young-Jo Kim
- Division of Cardiology, Department of Internal Medicine, Yeungnam University Medical Center, Daegu, Korea
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Abdelmalak HD, Omar HR, Mangar D, Camporesi EM. Unprotected left main coronary stenting as alternative therapy to coronary bypass surgery in high surgical risk acute coronary syndrome patients. Ther Adv Cardiovasc Dis 2013; 7:214-23. [DOI: 10.1177/1753944713488637] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Acute coronary syndrome has a high mortality rate that dramatically increases in the presence of left main coronary artery (LMCA) disease. Over the past decades, coronary artery bypass graft (CABG) surgery has been commonly accepted as the standard of care for patients with LMCA stenosis and is still considered the first-line treatment in current practice guidelines. Percutaneous coronary intervention (PCI) of protected and unprotected LMCA has gained popularity and is increasingly utilized with comparable outcomes to CABG in randomized controlled trials. In-stent restenosis and the need for revascularization provide the main obstacle to LMCA revascularization. The advent of better PCI equipment, stents, ablative devices, intravascular ultrasound, hemodynamic support devices and antithrombotic agents have ignited a renewed interest in the practice of LMCA PCI, especially for high surgical risk patients who are neither candidates nor agreeable to CABG surgery. Herein, we review the studies comparing unprotected LMCA stenting with CABG surgery in regard to 3 main endpoints: mortality, major adverse events and the incidence of repeat revascularization.
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Affiliation(s)
- Hany D. Abdelmalak
- Cardiology Department, Advocate Illinois Masonic Medical Center. Chicago, Illinois, USA
| | - Hesham R. Omar
- Internal Medicine Department, Mercy Hospital and Medical Center, 2525 South Michigan Avenue, Chicago, IL 60616, USA
| | - Devanand Mangar
- Anesthesia Department, Tampa General Hospital, Tampa, Florida, USA
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Baglini R, Amaducci A, D'Ancona G. Left Main Coronary In-Stent Intimal Hyperplasia and Hemodynamics as Detected by Contrast-Enhanced Transesophageal Echocardiography. Echocardiography 2013; 30:317-23. [DOI: 10.1111/echo.12040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- Roberto Baglini
- Department of Interventional Cardiology; Ismett/UPMC; Palermo; Italy
| | - Andrea Amaducci
- Department of Interventional Cardiology; Ismett/UPMC; Palermo; Italy
| | - Giuseppe D'Ancona
- Department of Interventional Cardiology; Ismett/UPMC; Palermo; Italy
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Ergenoglu MU, Yerebakan H, Demirsoy E. Extrinsic Compression of the Left Main Coronary Artery: A Case of Atrial Septal Defect with Enlarged Pulmonary Artery. Heart Surg Forum 2012; 15:E158-60. [DOI: 10.1532/hsf98.20111144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
We report the case of an adult referred to our center with an initial diagnosis of stenosis of the left main coronary artery (LMCA). A preoperative investigation disclosed an atrial septal defect (ASD) with pulmonary artery hypertension. The angiographic studies confirmed the diagnosis and showed external compression of the LMCA by an enlarged pulmonary artery. Surgical closure of the ASD and tricuspid valve ring annuloplasty with coronary artery bypass surgery (left internal mammary artery to left anterior descending artery) were undertaken. Six months after the surgery, the patient is doing well.
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Sábl P, Hraboš V, Horák D, Šembera Z, Polášek R. Rotational atherectomy of critical left main stenosis in NSTE-ACS complicated with cardiogenic shock. COR ET VASA 2012. [DOI: 10.1016/j.crvasa.2012.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Rath PC, Purohit BV. Left Main Coronary Artery Disease- Management Strategy. APOLLO MEDICINE 2011. [DOI: 10.1016/s0976-0016(11)60075-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
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Abstract
Coronary artery disease with left main stenosis is associated with the highest mortality of any coronary lesion. Studies in the 1970s and 1980s comparing coronary artery bypass grafting (CABG) and medical therapy showed a significant survival benefit with revascularization. In the angioplasty era, initial experience with percutaneous intervention was associated with poor clinical outcomes. As a result, percutaneous coronary intervention (PCI) was restricted to patients who were considered inoperable, or those with prior CABG with a functional graft to the left anterior descending or circumflex artery ("protected left main disease"). With the introduction of drug-eluting stents, there are new studies demonstrating comparable survival in patients who were revascularized using PCI and CABG, although percutaneous revascularization is associated with a higher rate of repeat revascularization. In the SYNTAX (Synergy between PCI with Taxus and Cardiac Surgery) trial, the combined incidence of death, myocardial infarction, and stroke was similar between the CABG and PCI groups; however, the stroke rate was higher in the CABG group. The degree and extent of disease as defined by the SYNTAX scoring system has allowed for stratification of risk and improved assignment of patients with left main stenosis to either PCI or CABG.
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Lee JY, Park DW, Kim YH, Yun SC, Kim WJ, Kang SJ, Lee SW, Lee CW, Park SW, Park SJ. Incidence, Predictors, Treatment, and Long-Term Prognosis of Patients With Restenosis After Drug-Eluting Stent Implantation for Unprotected Left Main Coronary Artery Disease. J Am Coll Cardiol 2011; 57:1349-58. [PMID: 21414531 DOI: 10.1016/j.jacc.2010.10.041] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2010] [Revised: 10/04/2010] [Accepted: 10/04/2010] [Indexed: 11/24/2022]
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Qarawani D, Menachem N, Ganem D, Hasin Y. Unprotected left main stenting, short- and long-term outcomes. ACTA ACUST UNITED AC 2010; 12:124-9. [PMID: 21039084 DOI: 10.3109/17482941.2010.528430] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Coronary bypass surgery is recommended for the treatment of left main coronary stenosis. Recently a percutaneous approach has been described as a feasible option. OBJECTIVES To present the in-hospital and long-term clinical and angiographic outcome of a consecutive group of patients undergoing stenting for unprotected left main coronary artery (LMCA) disease, and to compare the clinical and angiographic outcomes of drug-eluting stent (DES) versus metal stent (BMS). METHODS 238 consecutive patients underwent unprotected LMCA stenting. 165 received BMS and 73 received DES. Most patients (88.7%) presented with acute coronary syndrome. Clinical (100%) and angiographic (84%) follow-up was obtained. RESULTS Patients' presentation: STEMI (7.2%), non-STEMI (13.5%), unstable angina (67.6%), stable angina (11.7%). Procedural success rate was 100%. In-hospital mortality was 2.1%, all in patients presented with unstable hemodynamic conditions. None of the patients needed emergent CABG. In the long-term follow-up (average three years) there were 12 deaths (5%), 3 patients required CABG and 25 patients required TVR. The overall angiographic LM restenosis rate show a trend toward lower rate in the DES group than the BMS group (9.6% versus 13.8%, P = 0.08). There was no difference in one year mortality (4.1% versus 4.2%) and AMI (2.7% versus 2.8%) between DES and BMS. CONCLUSIONS Stenting for LM stenosis can be performed safely with acceptable in hospital and long-term outcome. Reconsideration of current guidelines should be considered. Drug-eluting stent implantation for unprotected LMCA stenosis appears safe with regard to acute and long-term complications and is more effective in preventing restenosis compared to BMS implantation.
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Ellis SG. Percutaneous left main invention an evolving perspective. JACC Cardiovasc Interv 2010; 3:642-7. [PMID: 20630457 DOI: 10.1016/j.jcin.2010.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2010] [Accepted: 04/17/2010] [Indexed: 10/19/2022]
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Beijk MAM, Rittersma SZH, Koch KT, Henriques JPS, Baan J, Vis MM, Hoekstra F, Tijssen JGP, Piek JJ, Kloek JJ, de Mol BAJM, de Winter RJ. Long-term follow-up after nonurgent percutaneous coronary intervention in unprotected left main coronary arteries. Catheter Cardiovasc Interv 2010; 75:1026-36. [PMID: 20517965 DOI: 10.1002/ccd.22404] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
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.
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Affiliation(s)
- Marcel A M Beijk
- Department of Cardiology, University of Amsterdam, Amsterdam, The Netherlands
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Park SJ, Park DW. Percutaneous coronary intervention with stent implantation versus coronary artery bypass surgery for treatment of left main coronary artery disease: is it time to change guidelines? Circ Cardiovasc Interv 2010; 2:59-68. [PMID: 20031694 DOI: 10.1161/circinterventions.108.831701] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
On the basis of clinical trials comparing coronary-artery bypass grafting (CABG) with medical therapy, current guideline recommend CABG as the treatment of choice for patients with asymptomatic ischemia, stable angina, or unstable angina/non-ST elevation myocardial infarction who have left main coronary artery disease. Percutaneous coronary intervention can be selectively performed in patients who are candidates for revascularization but who are ineligible for CABG. However, because of advances in periprocedural and postprocedural medical care in patients undergoing either CABG or percutaneous coronary intervention with stenting, new evaluation, and a review of current indications, may be required to determine the standard of care for patients with left main coronary artery disease. Current evidences indicate that stenting results in mortality and morbidity rates that compared favorably with those seen after CABG, suggesting that a current guideline (the Class III recommendation of percutaneous coronary intervention for unprotected left main coronary artery disease) may no longer be justified. Data from several extensive registries and a large clinical trial may have prompted many interventional cardiologists to select percutaneous coronary intervention with stenting as an alternative revascularization strategy for such patients. In addition, these data may inform future guidelines and support the need for well-designed, adequately powered, prospective, randomized trials comparing the 2 revascularization strategies. The cumulative evidence from ongoing and future clinical trials will change the current clinical practice of revascularization for unprotected left main coronary artery disease, which was introduced several decades ago and which has continued to date without major revision.
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Affiliation(s)
- Seung-Jung Park
- Division of Cardiology, University of Ulsan College of Medicine, Asan Medical Center, Songpa-Gu, Seoul, Korea.
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Kang SH, Park KH, Choi DJ, Park KW, Chung WY, Lim C, Kim KB, Kim HS. Coronary artery bypass grafting versus drug-eluting stent implantation for left main coronary artery disease (from a two-center registry). Am J Cardiol 2010; 105:343-51. [PMID: 20102946 DOI: 10.1016/j.amjcard.2009.09.036] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2009] [Revised: 09/22/2009] [Accepted: 09/22/2009] [Indexed: 01/22/2023]
Abstract
Recent studies have suggested that percutaneous coronary intervention (PCI) in patients with unprotected left main coronary artery (LMCA) disease renders outcomes comparable to those from coronary artery bypass grafting (CABG). It is necessary to stratify individual patient risk and select the optimal revascularization strategy. We compared the clinical outcomes of patients with unprotected LMCA disease who had undergone PCI with drug-eluting stents or CABG. We identified 462 patients who were treated from January 2003 to December 2006 for unprotected LMCA or LMCA-equivalent disease: 257 had undergone CABG and 205 had undergone PCI with drug-eluting stents. Analyses using propensity scores were performed to minimize the selection bias in the present observational study. After a median follow-up of 33.5 months, no significant difference was found between the CABG and PCI groups in the risk of death (12.1% vs 14.1%, respectively; p = 0.428) or the risk of a composite of death, myocardial infarction, or cerebrovascular accident (17.5% vs 20.0%, respectively; p = 0.434). The rate of major adverse cardiac and cerebrovascular events was significantly lower in the CABG group than in the PCI group (21.8% vs 35.1%, respectively; p = 0.001); the difference was mainly driven by a decrease in the rate of repeat revascularizations (5.1% vs 22.4%; p <0.001). The analyses after propensity score adjustment and matching corroborated the crude group results. In conclusion, PCI with drug-eluting stents showed a safety profile comparable to that of CABG in patients with unprotected LMCA disease. However, the risk of repeat revascularization was significantly greater in the PCI group.
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Affiliation(s)
- Si-Hyuck Kang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Republic of Korea
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Abstract
Based on data comparing coronary-artery bypass grafting (CABG) with medical therapy, the current guidelines recommend CABG as the treatment of choice for patients with left main coronary artery (LMCA) disease. Percutaneous coronary intervention (PCI) can be selectively performed in patients who are candidates for revascularization but who are ineligible for CABG. Current evidence indicates that stenting results in mortality and morbidity rates compared favorably with those seen after CABG. Data from several extensive registries and a large clinical trial may have prompted many interventional cardiologists to choose PCI with stenting as an alternative treatment option for such patients. In addition, these data may inform future guidelines and support the need for well-designed, adequately powered, prospective, randomized trials comparing the two revascularization strategies.
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Affiliation(s)
- Seung-Jung Park
- Division of Cardiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea.
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Lee JY, Park DW, Yun SC, Lee SW, Kim YH, Lee CW, Hong MK, Park SW, Park SJ. 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. J Am Coll Cardiol 2009; 54:853-9. [PMID: 19695467 DOI: 10.1016/j.jacc.2009.04.071] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2009] [Revised: 04/06/2009] [Accepted: 04/06/2009] [Indexed: 11/15/2022]
Abstract
OBJECTIVES The aim of this study was to evaluate long-term clinical outcomes after implantation of sirolimus-eluting stents (SES) or paclitaxel-eluting stents (PES) among patients with unprotected left main coronary artery (LMCA) disease. BACKGROUND There have been few comparisons of long-term outcomes among currently available drug-eluting stents (DES) for the treatment of LMCA disease. METHODS A total of 858 consecutive patients with unprotected LMCA stenosis were treated with SES (n = 669) or PES (n = 189) between May 2003 and June 2006. Primary outcome was the composite of death, myocardial infarction (MI), or target vessel revascularization (TVR). RESULTS Baseline clinical and angiographic characteristics were similar in the 2 groups. During 3 years of follow-up, the adjusted risk of primary composite outcome was similar among the groups (SES vs. PES: 25.8% vs. 25.7%, hazard ratio [HR]: 0.95, 95% confidence interval [CI]: 0.64 to 1.41, p = 0.79). The 2 groups also showed a comparable adjusted rate of each component of outcome: death (9.1% vs. 11.0%, HR: 0.92, 95% CI: 0.47 to 1.80, p = 0.82), MI (8.1% vs. 8.0%, HR: 0.80, 95% CI: 0.43 to 1.48, p = 0.47), and TVR (12.1% vs. 10.6%, HR: 1.10, 95% CI: 0.53 to 2.29, p = 0.81). The 3-year rates of definite or probable stent thrombosis were 0.6% in the SES group and 1.6% in the PES group (adjusted p = 0.18). CONCLUSIONS In consecutive patients with unprotected LMCA disease undergoing DES implantation, SES and PES showed similar long-term clinical outcomes in terms of death, MI, repeat revascularization, and stent thrombosis.
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Affiliation(s)
- Jong-Young Lee
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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THOMPSON CRAIGA, SIDHU MANDEEPS, BROWN JEREMIAHR, SABIR SAJJADA, FLOYD KEVINC, DE VRIES JAMEST, JAYNE JOHNE, FRIEDMAN BRUCEJ, HETTLEMAN BRUCED, NILES NATHANIELW, ROBB JOHNF, MALENKA DAVIDJ, KAPLAN AARONV. Classification and Atherosclerosis Distribution in Patients with Left Main Coronary Disease. J Interv Cardiol 2009; 22:431-6. [DOI: 10.1111/j.1540-8183.2009.00490.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Montalescot G, Brieger D, Eagle KA, Anderson FA, FitzGerald G, Lee MS, Steg PG, Avezum A, Goodman SG, Gore JM. Unprotected left main revascularization in patients with acute coronary syndromes. Eur Heart J 2009; 30:2308-17. [PMID: 19720640 DOI: 10.1093/eurheartj/ehp353] [Citation(s) in RCA: 91] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
AIMS In acute coronary syndromes (ACS), the optimal revascularization strategy for unprotected left main coronary disease (ULMCD) has been little studied. The objectives of the present study were to describe the practice of ULMCD revascularization in ACS patients and its evolution over an 8-year period, analyse the prognosis of this population and determine the effect of revascularization on outcome. METHODS AND RESULTS Of 43 018 patients enrolled in the Global Registry of Acute Coronary Events (GRACE) between 2000 and 2007, 1799 had significant ULMCD and underwent percutaneous coronary intervention (PCI) alone (n = 514), coronary artery bypass graft (CABG) alone (n = 612), or no revascularization (n = 673). Mortality was 7.7% in hospital and 14% at 6 months. Over the 8-year study, the GRACE risk score remained constant, but there was a steady shift to more PCI than CABG over time. Patients undergoing PCI presented more frequently with ST-segment elevation myocardial infarction (STEMI), after cardiac arrest, or in cardiogenic shock; 48% of PCI patients underwent revascularization on the day of admission vs. 5.1% in the CABG group. After adjustment, revascularization was associated with an early hazard of hospital death vs. no revascularization, significant for PCI (hazard ratio (HR) 2.60, 95% confidence interval (CI) 1.62-4.18) but not for CABG (1.26, 0.72-2.22). From discharge to 6 months, both PCI (HR 0.45, 95% CI 0.23-0.85) and CABG (0.11, 0.04-0.28) were significantly associated with improved survival in comparison with an initial strategy of no revascularization. Coronary artery bypass graft revascularization was associated with a five-fold increase in stroke compared with the other two groups. CONCLUSION Unprotected left main coronary disease in ACS is associated with high mortality, especially in patients with STEMI and/or haemodynamic or arrhythmic instability. Percutaneous coronary intervention is now the most common revascularization strategy and preferred in higher risk patients. Coronary artery bypass graft is often delayed and performed in lower risk patients, leading to good 6-month survival. The two approaches therefore appear complementary.
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Affiliation(s)
- Gilles Montalescot
- Institut de Cardiologie, Bureau 2-236, Centre Hospitalier Universitaire Pitié-Salpêtrière, 47 Blvd de l'Hôpital, 75013 Paris, France.
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Topaz O, Polkampally PR, Mohanty PK, Rizk M, Bangs J, Bernardo NL. Excimer laser debulking for percutaneous coronary intervention in left main coronary artery disease. Lasers Med Sci 2009; 24:955-60. [DOI: 10.1007/s10103-009-0650-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2009] [Accepted: 01/29/2009] [Indexed: 10/21/2022]
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MAAGH PETRA, WICKENBROCK I, SCHRAGE M, TRAPPE HJ, MEISSNER A. Acute Simultaneous Proximal Occlusion of Two Major Coronary Arteries in Acute Myocardial Infarction: Successful Treatment with Percutaneous Coronary Intervention. J Interv Cardiol 2008; 21:483-92. [DOI: 10.1111/j.1540-8183.2008.00394.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Barragan P, Fajadet J, Sheiban I, Serruys P, Colombo A, Seabra-Gomes R, Goy JJ, Cook S, Rubino P, Lefèvre T. Elective implantation of sirolimus-eluting stents for bifurcated and non-bifurcated unprotected left main coronary artery lesions: clinical outcomes at one year. EUROINTERVENTION 2008; 4:262-70. [DOI: 10.4244/eijv4i2a46] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Comparison of Coronary Artery Bypass Surgery and Percutaneous Drug-Eluting Stent Implantation for Treatment of Left Main Coronary Artery Stenosis. JACC Cardiovasc Interv 2008; 1:236-45. [DOI: 10.1016/j.jcin.2008.02.007] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2007] [Revised: 02/25/2008] [Accepted: 02/29/2008] [Indexed: 11/22/2022]
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Seung KB, Park DW, Kim YH, Lee SW, Lee CW, Hong MK, Park SW, Yun SC, Gwon HC, Jeong MH, Jang Y, Kim HS, Kim PJ, Seong IW, Park HS, Ahn T, Chae IH, Tahk SJ, Chung WS, Park SJ. Stents versus coronary-artery bypass grafting for left main coronary artery disease. N Engl J Med 2008; 358:1781-92. [PMID: 18378517 DOI: 10.1056/nejmoa0801441] [Citation(s) in RCA: 393] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Several studies have compared the treatment effects of coronary stenting and coronary-artery bypass grafting (CABG). However, there are limited data regarding the long-term outcomes of these two interventions for patients with unprotected left main coronary artery disease. METHODS We evaluated 1102 patients with unprotected left main coronary artery disease who underwent stent implantation and 1138 patients who underwent CABG in Korea between January 2000 and June 2006. We compared adverse outcomes (death; a composite outcome of death, Q-wave myocardial infarction, or stroke; and target-vessel revascularization) with the use of propensity-score matching in the overall cohort and in separate subgroups according to type of stent. RESULTS In the overall matched cohort, there was no significant difference between the stenting and CABG groups in the risk of death (hazard ratio for the stenting group, 1.18; 95% confidence interval [CI], 0.77 to 1.80) or the risk of the composite outcome (hazard ratio for the stenting group, 1.10; 95% CI, 0.75 to 1.62). The rates of target-vessel revascularization were significantly higher in the group that received stents than in the group that underwent CABG (hazard ratio, 4.76; 95% CI, 2.80 to 8.11). Comparisons of the group that received bare-metal stents with the group that underwent CABG and of the group that received drug-eluting stents with the group that underwent CABG produced similar results, although there was a trend toward higher rates of death and the composite end point in the group that received drug-eluting stents. CONCLUSIONS In a cohort of patients with unprotected left main coronary artery disease, we found no significant difference in rates of death or of the composite end point of death, Q-wave myocardial infarction, or stroke between patients receiving stents and those undergoing CABG. However, stenting, even with drug-eluting stents, was associated with higher rates of target-vessel revascularization than was CABG.
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Affiliation(s)
- Ki Bae Seung
- Catholic University of Korea, St. Mary's Hospital, Gangnam, Korea
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Immediate and long-term outcomes of drug-eluting stent implantation for unprotected left main coronary artery disease: comparison with bare-metal stent implantation. Am Heart J 2008; 155:553-61. [PMID: 18294496 DOI: 10.1016/j.ahj.2007.10.030] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2007] [Accepted: 10/24/2007] [Indexed: 11/23/2022]
Abstract
BACKGROUND The efficacy and safety of drug-eluting stent (DES) implantation for unprotected left main coronary artery (LMCA) disease remain to be established in different clinical settings. METHODS Elective DES implantation for unprotected LMCA stenosis was performed in 220 patients at the Fu Wai Hospital, China, from April 2003 to February 2006. Data derived from the latter group were compared with those derived from 224 patients treated with bare-metal stents (BMSs) before March 2003 in a Chinese registry of unprotected LMCA stenting. RESULTS Compared with the historical BMS control group, the DES group had more multivessel disease and underwent more bifurcation stenting. The inhospital major adverse cardiac events were significantly higher in the DES than in the BMS recipients (4.1% vs 0.9%, P = .030) because of more complex lesions and procedures in the DES group. During the 15-month mean follow-up period, cumulative cardiac death (0.5% vs 4.9%, P = .004), target-vessel revascularization (5.9% vs 11.6%, P = .034), and major adverse cardiac event (9.5% vs 16.5%, P = .029) rates were significantly lower in the DES than in the BMS group. There was no significant difference in clinical efficacy between sirolimus- and paclitaxel-eluting stents. Angiographic follow-up was performed in 46.4% of DES and 45.7% of BMS recipients, respectively; and the binary restenosis rate was significantly lower in the DES versus the BMS control group (16.7% vs 31.4%, P = .014). CONCLUSIONS Based on this comparison with a historical control, DES implantation for unprotected LMCA appears safe in selected patients and might be more effective in preventing major adverse cardiac events compared with BMS implantation over a mean follow-up period of 15 months.
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Kim HS, Kim YH, Lee SW, Park DW, Lee CW, Hong MK, Kim JJ, Park SW, Park SJ. Safety and effectiveness of sirolimus-eluting stent implantation for in-stent restenosis of the unprotected left main coronary artery. Int J Cardiol 2008; 124:118-20. [PMID: 17383034 DOI: 10.1016/j.ijcard.2006.11.197] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2006] [Accepted: 11/18/2006] [Indexed: 11/30/2022]
Abstract
The present study examined the alternative treatment of sirolimus-eluting stent (SES) implantation for in-stent restenosis (ISR) of the unprotected left main coronary artery (LMCA). Twelve patients underwent SES deployment for bare-metal ISR in the LMCA. ISR were 24+/-11 mm in length and located at the ostial (n=1) and distal (n=11) portion of LMCA. Bifurcation lesions were treated with one of three techniques: the stent crossing the left circumflex artery (n=7), kissing stenting (n=2) or the Crush technique (n=2). All procedures were performed using intravascular ultrasound guidance. Periprocedural CK-MB elevation > or = 3 times normal occurred in 2 patients. There were no cases of significant narrowing in the left circumflex artery after the procedure. At the one-year follow-up, one patient died and there were no incidents of myocardial infarction or target lesion revascularization. The present study suggests that SES implantation may be a feasible therapeutic option for treating ISR in unprotected LMCA.
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Buszman PE, Kiesz SR, Bochenek A, Peszek-Przybyla E, Szkrobka I, Debinski M, Bialkowska B, Dudek D, Gruszka A, Zurakowski A, Milewski K, Wilczynski M, Rzeszutko L, Buszman P, Szymszal J, Martin JL, Tendera M. Acute and Late Outcomes of Unprotected Left Main Stenting in Comparison With Surgical Revascularization. J Am Coll Cardiol 2008; 51:538-45. [PMID: 18237682 DOI: 10.1016/j.jacc.2007.09.054] [Citation(s) in RCA: 266] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2007] [Revised: 09/10/2007] [Accepted: 09/17/2007] [Indexed: 10/22/2022]
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Abstract
Patients with stenosis of the left main coronary artery present difficult challenges. The risks associated with this lesion have been known since the early days of angiography when patients were found to have increased mortality during follow-up. This information led to the general guidelines that surgical revascularization should be considered the treatment of choice in patients with significant left main coronary artery stenosis. Current advances in invasive cardiology have brought important information to the field. Intravascular ultrasound is now used routinely to evaluate angiographically indeterminate lesions with criteria now set forward as to what constitutes an indication for revascularization. Stents have even further dramatically changed the landscape. There are substantial issues, however, that need to addressed. These include the following: (1) the effect of specific lesion location on outcome - it is known that patients with distal bifurcation left main disease have worse outcome; (2) the potential for subacute thrombosis of the left main coronary artery; (3) the impact of left ventricular function and patient comorbidities irrespective of the degree and location of left main coronary artery stenosis; and (4) the risk-benefit ratio of stenting versus coronary artery bypass graft surgery. These issues are currently being addressed in two seminally important trials including the SYNTAX trial, which randomizes patients with left main and/or three-vessel disease to either coronary artery bypass graft surgery or a TAXUS drug-eluting stent. This trial is in the final stages of patient recruitment and will have important implications for the field. The other trial is the COMBAT trial, which is focused exclusively on left main coronary artery stenosis and randomizes patients with left main coronary artery disease either to a Sirolimus-eluting stent (Cypher, Johnson and Johnson Cordis, USA) or to coronary artery bypass graft surgery. The field of left main coronary artery disease continues to expand in terms of the evidence available for optimal patient evaluation and selection of treatment modalities.
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Gauthier N, Le May MR. Percutaneous coronary intervention for left main coronary artery disease. Expert Rev Cardiovasc Ther 2007; 5:213-20. [PMID: 17338666 DOI: 10.1586/14779072.5.2.213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Coronary artery bypass surgery is the currently accepted treatment for unprotected left main coronary artery disease. Currently, the data supporting the safety and efficacy of stents for unprotected left main coronary disease are derived mostly from nonrandomized, single-center studies or registries. These results appear promising but large randomized trials are needed to guide therapy of this potentially lethal disease.
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Affiliation(s)
- Nadine Gauthier
- University of Ottawa, Division of Cardiology, Ottawa, Ontario, Canada.
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Lee BK, Hong MK, Lee CW, Choi BR, Kim MJ, Park KH, Kim YH, Han KH, Kim JJ, Park SW, Park SJ. Five-year outcomes after stenting of unprotected left main coronary artery stenosis in patients with normal left ventricular function. Int J Cardiol 2007; 115:208-13. [PMID: 16904209 DOI: 10.1016/j.ijcard.2006.02.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2005] [Revised: 01/05/2006] [Accepted: 02/24/2006] [Indexed: 11/17/2022]
Abstract
BACKGROUND We analyzed the long-term (5-year) outcome of patients treated with stenting for unprotected left main coronary artery (LMCA) stenosis. METHODS Between January 1995 and September 2001, 187 consecutive patients with unprotected LMCA stenosis and normal left ventricular function underwent elective stenting. Patients were examined or interviewed after 1, 3 and 6 months, and every 4 months thereafter for the occurrence of major adverse cardiac events (MACE), including death, myocardial infarction (MI) and target lesion revascularization (TLR). RESULTS The procedural success rate was 99.5%. During hospitalization, there were no deaths and only one stent thrombosis. Six-month angiography in 162 patients (follow-up rate, 86.6%) showed a restenosis rate of 33.3%. During 5-year follow-up, there were 13 deaths (6 cardiac, 7 noncardiac) and 2 nonfatal MI. TLRs were required in 36 (20.9%) patients and new lesion revascularizations were required in 13 (5.0%) patients. At 1, 3 and 5 years, the cumulative probabilities for freedom from MACE were 79.9+/-1.8%, 77.5+/-2.5% and 77.5+/-2.5%, respectively. CONCLUSION The initial favorable outcomes of patients with normal left ventricular function after stenting of unprotected LMCA stenosis were sustained for up to 5 years.
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Affiliation(s)
- Bong-Ki Lee
- Department of Internal Medicine, Kangwon National University Hospital, Kangwon National University College of Medicine, Chunchon, Kangwon-do, Korea
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Jim MH, Chow WH, Ho HH. Stenting of Unprotected Distal Left Main Coronary Artery Bifurcation Stenoses Using Modified Crush Technique with Double Kissing Balloon Inflation (Sleeve Technique): Immediate Procedure Result and Early Clinical Outcome. J Interv Cardiol 2007; 20:17-22. [PMID: 17300392 DOI: 10.1111/j.1540-8183.2007.00217.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Sleeve technique is a modified version of the crush technique. It is specifically designed to increase the success rate of final kissing balloon inflation, which used to be a major limitation of the latter. OBJECTIVE This study sought to look at the feasibility, safety, and early clinical outcome of sleeve technique in stenting of unprotected distal left main coronary artery (LMCA) bifurcation stenoses. METHODS From August 2005 to April 2006, 12 consecutive patients with symptomatic distal LMCA bifurcation stenoses of diameter narrowing > or =50%, who refused coronary artery bypass graft surgery, were treated with two-stent strategy using the sleeve technique. RESULTS Eleven patients (91.7%) were male, with a mean age of 64.4 +/- 9.3 years. Intravenous abciximab was given to 10 patients (83.3%). The baseline reference vessel diameters of the main vessel and side branch were 3.32 +/- 0.44 and 3.00 +/- 0.58 mm, respectively. After intervention, the minimal luminal diameter was increased from 0.99 +/- 0.46 to 3.26 +/- 0.28 mm and 1.43 +/- 0.71 to 2.93 +/- 0.45 mm in the main vessel and side branch, respectively. The intervention procedure was successful in all patients with 100% final kissing balloon inflation rate. The average procedure time was 58.6 +/- 20.5 minutes. Two patients had a small non-Q myocardial infarction postprocedure. The resultant major adverse cardiac event rate was 16.7% at 30 days after the procedure. CONCLUSIONS Sleeve technique is a safe and feasible approach in the stenting of distal LMCA bifurcation stenoses.
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Affiliation(s)
- Man-Hong Jim
- Cardiac Medical Unit, Grantham Hospital, Hong Kong.
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Botman CJ, Post H, Penn O, Pijls N. Value of magnetic resonance imaging, angiography, and fractional flow reserve to evaluate the left main coronary artery after direct surgical angioplasty. Ann Thorac Surg 2007; 83:490-4. [PMID: 17257974 DOI: 10.1016/j.athoracsur.2006.09.071] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2006] [Revised: 09/19/2006] [Accepted: 09/20/2006] [Indexed: 11/18/2022]
Abstract
BACKGROUND Direct surgical angioplasty of the left main coronary artery is aimed to restore a more physiologic blood flow through the left main coronary artery compared with conventional bypass surgery and allows subsequent percutaneous coronary interventions of more distal coronary lesions. Some data on anatomic evaluation with coronary angiography and magnetic resonance imaging (MRI) are known, and we conducted a study to report the physiologic evaluation. METHODS Coronary angiography, MRI, and fractional flow reserve measurements were performed in 18 patients 8 years after direct surgical angioplasty of the left main coronary artery. RESULTS At coronary angiography and MRI, a dilated funnel-shaped left main coronary artery was seen in all 18 patients, but both methods failed to demonstrate a flow-limiting lesion in the distal left main coronary artery in 1 patient. The functional severity was shown by fractional flow reserve measurement, and subsequently, this patient underwent repeated bypass grafting surgery. CONCLUSIONS After long-term follow-up, 17 of 18 patients had an excellent result of direct surgical angioplasty of the left main coronary artery. MRI is a safe and noninvasive way to visualize the left main coronary artery after direct surgical angioplasty, but quantitative assessment of a lesion is not reliable. Fractional flow reserve measurements are mandatory to evaluate the hemodynamic properties of the left main coronary artery after direct surgical angioplasty.
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Affiliation(s)
- Cornelis J Botman
- Department of Cardiology, Catharina Hospital, Eindhoven, The Netherlands.
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Barlis P, Tanigawa J, Kaplan S, di Mario C. Complex Coronary Interventions: Unprotected Left Main and Bifurcation Lesions. J Interv Cardiol 2006; 19:510-24. [PMID: 17107366 DOI: 10.1111/j.1540-8183.2006.00203.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Percutaneous coronary intervention has moved forward with great speed since the advent of stents and now more recently the introduction of drug-eluting technologies. This has seen the modern interventional cardiologist tackle more and more complex coronary lesions, of which unprotected left main (ULM) and bifurcations still remain challenging and controversial. ULM coronary artery stenosis traditionally remains a surgical indication although there have been recent reports and studies demonstrating the feasibility of a percutaneous strategy in select patient groups. Furthermore, drug-eluting stents have shown great benefit in reducing the problem of restenosis and have also become the mainstay treatment modality for bifurcation lesions with a choice between one- or two-stent strategies determined by the extent of disease burden in the main vessel and side branch and the response of the side branch ostium following treatment of the main vessel. This article will provide a contemporary review of percutaneous intervention for these two lesion subsets and describe the relative merits of each of the different strategies in current use with a glimpse into what the future may hold.
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Affiliation(s)
- Peter Barlis
- Department of Cardiology, Royal Brompton Hospital, Sydney Street, London SW3 6NP, United Kingdom
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