Comparison of surgical and medical group survival in patients with left main coronary artery disease. Long-term CASS experience

State-of-the-art percutaneous coronary intervention for left main coronary artery disease in Japan

Percutaneous coronary intervention for left main coronary artery disease (LM-PCI) represents a high-risk yet life-saving procedure that has evolved significantly over the years. This review outlines the current state-of-the-art practices for LM-PCI in Japan in detail, emphasizing the integration of coronary physiology and intracoronary imaging alongside with evidence-based standardized technique using latest drug-eluting stents. These advancements enable precise lesion assessment, stent sizing, and optimal deployment, thereby enhancing procedural safety and efficacy. Despite discrepancies between current guidelines favoring coronary artery bypass grafting and real-world practice trends towards increased LM-PCI adoption, particularly in elderly populations with multiple comorbidities, careful patient selection and procedural planning are critical. Future perspectives include further refining LM-PCI through conducting randomized controlled trials integrating advanced techniques and addressing the issue of ostial left circumflex lesions and nationwide standardization of medical care for LM disease.

Left Main Coronary Artery Calcium and Diabetes Confer Very-High-Risk Equivalence in Coronary Artery Calcium >1,000

BACKGROUND

Although a coronary artery calcium (CAC) of ≥1,000 is a subclinical atherosclerosis threshold to consider combination lipid-lowering therapy, differentiating very high from high atherosclerotic cardiovascular disease (ASCVD) risk in this patient population is not well-defined.

OBJECTIVES

Among persons with a CAC of ≥1,000, the authors sought to identify risk factors equating with very high-risk ASCVD mortality rates.

METHODS

The authors studied 2,246 asymptomatic patients with a CAC of ≥1,000 from the CAC Consortium without a prior ASCVD event. Cox proportional hazards regression modelling was performed for ASCVD mortality during a median follow-up of 11.3 years. Crude ASCVD mortality rates were compared with those reported for secondary prevention trial patients classified as very high risk, defined by ≥2 major ASCVD events or 1 major event and ≥2 high-risk conditions (1.4 per 100 person-years).

RESULTS

The mean age was 66.6 years, 14% were female, and 10% were non-White. The median CAC score was 1,592 and 6% had severe left main (LM) CAC (vessel-specific CAC ≥300). Diabetes (HR: 2.04 [95% CI: 1.47-2.83]) and severe LM CAC (HR: 2.32 [95% CI: 1.51-3.55]) were associated with ASCVD mortality. The ASCVD mortality per 100 person-years for all patients was 0.8 (95% CI: 0.7-0.9), although higher rates were observed for diabetes (1.4 [95% CI: 0.8-1.9]), severe LM CAC (1.3 [95% CI: 0.6-2.0]), and both diabetes and severe LM CAC (7.1 [95% CI: 3.4-10.8]).

CONCLUSIONS

Among asymptomatic patients with a CAC of ≥1,000 without a prior index event, diabetes, and severe LM CAC define very high risk ASCVD, identifying individuals who may benefit from more intensive prevention therapies across several domains, including low-density lipoprotein-cholesterol lowering.

Percutaneous Treatment of Left Main Disease: A Review of Current Status

Percutaneous treatment of the left main coronary artery is one of the most challenging scenarios in interventional cardiology, due to the large portion of myocardium at risk the technical complexity of treating a complex bifurcation with large branches. Our aim is to provide un updated overview of the current indications for percutaneous treatment of the left main, the different techniques and the rationale underlying the choice for provisional versus upfront two-stent strategies, intravascular imaging and physiology guidance in the management of left main disease, and the role of mechanical support devices in complex high-risk PCI.

Towards a common pathway for the treatment of left main disease: contemporary evidence and future directions: Left main disease treatment

There is increasing evidence to support percutaneous treatment of left main (LM) disease. Due to its major clinical impact, any procedure in the left main should be meticulously planned and performed. In this review, we aim to integrate the available evidence into a common treatment pathway, starting with understanding the distinct anatomical features of the left main. A three-level decision-making process is presented. First, in instances of angiographic ambiguity, intravascular ultrasound and fractional flow reserve can be used to decide if revascularisation could be deferred. Second, if revascularisation is indicated, the risks and benefits of percutaneous versus surgical procedures should be evaluated. Third, if percutaneous coronary intervention (PCI) is chosen, the operator should decide between the provisional single-stent versus upfront two-stent strategies. Regardless of the PCI technique selected, it should be performed according to the recommendations of a stepwise procedure utilising proximal optimisation (POT) after each instance of crossover stenting and kissing balloon inflation (KBI) where necessary. In addition to the recognised quality markers such as POT and KBI, we discuss the clinical relevance of the operator's LM PCI experience and the intracoronary imaging guidance when treating patients with left main disease.

Revascularization for Coronary Artery Disease: Principle and Challenges

Coronary revascularization is the most important strategy for coronary artery disease. This review summarizes the current most prevalent approaches for coronary revascularization and discusses the evidence on the mechanisms, indications, techniques, and outcomes of these approaches. Targeting coronary thrombus, fibrinolysis is indicated for patients with diagnosed myocardial infarction and without high risk of severe hemorrhage. The development of fibrinolytic agents has improved the outcomes of ST-elevation myocardial infarction. Percutaneous coronary intervention has become the most frequently performed procedure for coronary artery disease. The evolution of stents plays an important role in the result of the procedure. Coronary artery bypass grafting is the most effective revascularization approach for stenotic coronary arteries. The choice of conduits and surgical techniques are important determinants of patient outcomes. Multidisciplinary decision-making should analyze current evidence, considering the clinical condition of patients, and determine the safety and necessity for coronary revascularization with either PCI or CABG. For coronary artery disease with more complex lesions like left main disease and multivessel disease, CABG results in more complete revascularization than PCI. Furthermore, comorbidities, such as heart failure and diabetes, are always correlated with adverse clinical events, and a routine invasive strategy should be recommended. For patients under revascularization, secondary prevention therapies are also of important value for the prevention of subsequent adverse events.

Prognosis of Percutaneous Intervention of a Left Main Coronary Artery Stenosis Without the Use of Intravascular Imaging

Objectives

The aim of this study was to assess the prognosis in patients with left main coronary artery stenosis one year after percutaneous coronary intervention (PCI).

Methods

Our study included 40 patients who underwent PCI for left main coronary artery stenosis without the use of intravascular ultrasound (IVUS). Patients were followed for a year, and the prognostic effect of PCI on a composite end-point of revascularization, new myocardial infarction, cardiac death, and on all-cause mortality was assessed in multivariable Cox analysis.

Results

The multivariable analysis showed a good prognosis in patients receiving PCI with a total event rate of 7.5%. The independent predictors for major adverse cardiac events (MACE) were diabetes (p = 0.02). Other prognostic factors included in the model were gender, age, smoking, body mass index (BMI), hypertension, the complexity of the vessel, and ejection fraction.

Conclusion

PCI for left main coronary artery stenosis without the use of IVUS has a good prognosis after one year of clinical follow-up.

Percutaneous coronary intervention using drug-eluting stents versus coronary artery bypass graft surgery in left main coronary artery disease an updated meta-analysis of randomized clinical trials

Objectives

To compare the safety and efficacy of percutaneous coronary intervention (PCI) using drug-eluting stent (DES) and coronary artery bypass graft (CABG) for the treatment of left main coronary artery (LMCA) disease.

Background

Several new randomized trials have recently examined the clinical outcomes of PCI and CABG in LMCA disease. However, the results of these studies were inconsistent.

Materials and Methods

We searched five online electronic databases to identify all the randomized clinical trials assessing the outcomes of PCI using DES and CABG in patients with LMCA. The clinical outcomes were the major adverse cardiac and cerebrovascular event (MACCE), all-cause death, myocardial infarction (MI), stroke, and repeat revascularization (RR).

Results

A total of 5 randomized clinical trials with 4595 LMCA patients were included in this meta-analysis. For one year follow-up, the results indicated that PCI were associated with a lower risk of stroke (RR = 0.21, 95% CI = 0.07–0.65, P = 0.007), a higher risk of RR (RR = 1.72, 95% CI = 1.28–2.33, P < 0.001) than CABG. Moreover, for long-term follow-up, there were significant higher risks of MACCE and RR with PCI versus CABG (MACCE: HR = 1.26, 95% CI = 1.11–1.44, P = 0.001; RR: HR = 1.70, 95% CI = 1.42–2.05, P < 0.001). However, there were no significant differences between the two groups in all-cause death and MI risks, regardless of follow-up duration.

Conclusions

PCI is noninferior to CABG in short term follow-up of patients with LMCA disease, but CABG is more safety and efficacy than PCI using DES in long-term follow-up.

Design and rationale for a randomised comparison of everolimus-eluting stents and coronary artery bypass graft surgery in selected patients with left main coronary artery disease: the EXCEL trial

AIMS

Coronary artery bypass graft (CABG) surgery is the standard of care for revascularisation of patients with left main coronary artery disease (LMCAD). Recent studies have suggested that percutaneous coronary intervention (PCI) with drug-eluting stents (DES) may provide comparable outcomes in selected patients with LMCAD without extensive CAD. We therefore designed a trial to investigate whether PCI with XIENCE cobalt-chromium everolimus-eluting stents (CoCr-EES) would result in non-inferior or superior clinical outcomes to CABG in selected patients with LMCAD.

METHODS AND RESULTS

The Evaluation of XIENCE versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization (EXCEL) trial is a prospective, open-label, multicentre, international study of 1,900 randomised subjects. Patients with significant LMCAD with a SYNTAX score ≤32 and local Heart Team consensus that the subject is appropriate for revascularisation by both PCI and CABG are consented and randomised 1:1 to undergo PCI using CoCr-EES or CABG. All patients undergo follow-up for five years. The primary endpoint is the three-year composite rate of death, stroke or myocardial infarction, assessed at a median follow-up of at least three years (with at least two-year follow-up in all patients), powered for sequential non-inferiority and superiority testing.

CONCLUSIONS

The EXCEL study will define the contemporary roles of CABG and PCI using XIENCE CoCr-EES in patients with LMCAD disease with low and intermediate SYNTAX scores.

Impact of left main coronary artery disease on long-term mortality in patients undergoing drug-eluting stent implantation

BACKGROUND

Limited data are available on long-term mortality according to the extent of coronary artery disease (CAD) in patients undergoing percutaneous coronary intervention (PCI) with drug-eluting stent (DES). We assessed long-term mortality DES implantation according to the extent of CAD and the impact of left main CAD alone on mortality among patients undergoing PCI with DES.

METHODS AND RESULTS

A total of 18,716 patients were pooled from real-world PCI registries. The primary outcome was death from any cause. The median follow-up duration was 47.1 (interquartile range 32.8-57.9) months. The presence of left main CAD [adjusted hazard ratio (HR) 1.24, 95% confidence interval (CI) 1.05-1.46, p = 0.012] and the extent of diseased vessels (adjusted HR 1.17, 95% CI 1.08-1.27, p < 0.001) significantly increased the risk of all-cause mortality. Left main CAD alone was associated with a risk of all-cause mortality similar to one- and two-vessel CAD, whereas it was associated with a significantly lower risk of mortality compared with three-vessel CAD (adjusted HR 0.42, 95% CI 0.18-0.98, p = 0.044). Among patients with left main CAD, the risk of mortality tended to increase in proportion with the number of concomitant vessel CAD, but it did not achieve statistical significance.

CONCLUSIONS

Among patients undergoing DES implantation, the risk of mortality increased in a stepwise manner according to the extent of coronary CAD. Left main CAD alone was associated with a risk of long-term mortality similar to one- and two-vessel CAD.

Rationales and choices for the treatment of patients with NYHA class II heart failure

Heart failure (HF) in the United States represents a significant burden for patients and a tremendous strain on the healthcare system. Patients receiving a diagnosis of HF can be placed into 1 of 4 New York Heart Association (NYHA) functional classifications; the greatest proportion of patients are in the NYHA class II category, which is defined as patients having a slight limitation of physical activity but who are comfortable at rest, and for whom ordinary physical activity results in symptoms of HF. Because the severity of NYHA class II HF may be perceived as mild or unalarming by this definition, the urgency to treat this type of HF may be overlooked. However, these patients are optimal candidates for active intervention because their HF is at a critical point on the disease progression continuum when untoward changes can be halted or reversed. This review discusses the physiological consequences of NYHA class II HF with reduced ejection fraction and describes recent clinical trials that have demonstrated a therapeutic benefit for patients in this population. In doing so, we hope to establish that patients with NYHA class II disease merit careful attention and to provide reassurance to the treating community that options are available for these patients.

Meta-Analysis of Randomized Controlled Trials of Percutaneous Coronary Intervention With Drug-Eluting Stents Versus Coronary Artery Bypass Grafting in Left Main Coronary Artery Disease

Few randomized controlled trials (RCTs) and observational studies had shown acceptable short-term efficacy and safety of percutaneous coronary intervention (PCI) with drug-eluting stents (DES) compared with coronary artery bypass grafting (CABG) in selected patients with left main coronary artery disease (LMCAD). We aimed to evaluate long-term outcomes of PCI using DES compared with CABG in patients with LMCAD. On November 1, 2016, we searched available databases for published RCTs directly comparing DES PCI with CABG in patients with LMCAD. Odds ratios (ORs) were used as the metric of choice for treatment effects using a random-effects model. I-squared index was used to assess heterogeneity across trials. Prespecified end points were all-cause mortality, cardiovascular mortality, myocardial infarction (MI), stroke, and repeat revascularization at maximal available follow-up. We identified 5 RCTs including a total of 4,595 patients, with a median follow-up of 60 months. The risk of all-cause mortality (OR 1.01; 95% confidence interval [CI] 0.76 to 1.34) and cardiovascular mortality (OR 1.02; 95% CI 0.73 to 1.42) were comparable between PCI with DES and CABG. Similarly, there were no statistically significant differences between PCI with DES and CABG for MI (OR 1.45; 95% CI 0.87 to 2.40) and stroke (OR 0.87; 95% CI 0.38 to 1.98). Conversely, repeat revascularization was significantly higher with PCI compared with CABG (OR 1.82; 95% CI 1.51 to 2.21). In conclusion, in patients with LMCAD, PCI with DES appears to be a viable alternative to CABG at long-term follow-up, with similar risks of ischemic adverse events (mortality, MI, and stroke) but a higher risk of repeat revascularization.

Reduced duration of dual antiplatelet therapy using an improved drug-eluting stent for percutaneous coronary intervention of the left main artery in a real-world, all-comer population: Rationale and study design of the prospective randomized multicenter IDEAL-LM trial

BACKGROUND

Continuous improvements in stent technology make percutaneous coronary intervention (PCI) a potential alternative to surgery in selected patients with unprotected left main coronary artery (uLMCA) disease. The optimal duration of dual antiplatelet therapy (DAPT) in these patients remains undetermined, and in addition, new stent designs using a bioabsorbable polymer might allow shorter duration of DAPT.

STUDY DESIGN

IDEAL-LM is a prospective, randomized, multicenter study that will enroll 818 patients undergoing uLMCA PCI. Patients will be randomized in a 1:1 fashion to intravascular ultrasound-guided PCI with the novel everolimus-eluting platinum-chromium Synergy stent with a biodegradable polymer (Boston Scientific, Natick, MA) followed by 4 months of DAPT or the everolimus-eluting cobalt-chromium Xience stent (Abbott Vascular, Santa Clara, CA) followed by 12 months of DAPT. The total follow-up period will be 5 years. A subset of 100 patients will undergo optical coherence tomography at 3 months.

END POINTS

The primary end point will be major adverse cardiovascular events (composite of all-cause mortality, myocardial infarction, and ischemia-driven target vessel revascularization) at 2 years. Secondary end points will consist of the individual components of the primary end point, procedural success, a device-oriented composite end point, stent thrombosis as per Academic Research Consortium criteria, and bleeding as per Bleeding Academic Research Consortium criteria.

SUMMARY

IDEAL-LM is designed to assess the safety and efficacy of the novel Synergy stent followed by 4 months of DAPT vs the Xience stent followed by 12 months of DAPT in patients undergoing uLMCA PCI. The study will provide novel insights regarding optimal treatment strategy for patients undergoing PCI of uLMCA disease (www.clinicaltrials.gov, NCT 02303717).

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

INTRODUCTION

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

AIM

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Rationale and design of the Coronary Computed Tomographic Angiography for Selective Cardiac Catheterization: Relation to Cardiovascular Outcomes, Cost Effectiveness and Quality of Life (CONSERVE) trial

Although coronary computed tomography angiography (CCTA) has shown promise as a "gatekeeper" to invasive coronary angiography (ICA) in longitudinal cohort studies, it remains unknown whether the strategy of selective ICA by initial performance of CCTA is either safe or effective when compared with a direct ICA strategy in patients with an American Heart Association (AHA)/American College of Cardiology (ACC) guideline-directed indication for ICA.

OBJECTIVES

The CONSERVE trial is a prospective randomized multicenter trial to determine the clinical effectiveness of "selective catheterization" vs "direct catheterization" strategies for stable patients with suspected but without known coronary artery disease, who meet AHA/ACC guideline indication for ICA.

METHODS

Patients being referred for clinically indicated nonemergent ICA with an AHA/ACC class II guideline indication for ICA will be randomized to either direct catheterization or selective catheterization strategy. Patients in the direct catheterization arm will proceed directly to ICA as planned, whereas patients in the select catheterization arm will undergo initial CCTA, followed by ICA at the discretion of the site physician. All CCTAs and ICAs will be interpreted on site. Follow-up testing and/or therapy after CCTA or ICA will be at the discretion of the site physician.

RESULTS

This trial will report a primary clinical end point of noninferiority rates of major adverse cardiac events, as defined by the composite of death, nonfatal myocardial infarction, unstable angina, stroke, urgent or emergent coronary revascularization, or cardiac hospitalization.

CONCLUSION

The CONSERVE trial will determine whether selective catheterization strategy, based on initial CCTA in patients being referred to ICA, is safe and effective.

Percutaneous Coronary Intervention for Left Main Coronary Artery Disease - A Single Hospital Experience without On-Site Cardiac Surgery

BACKGROUND

To investigate the safety and outcome of percutaneous coronary intervention for left main coronary artery disease in hospital without on-site cardiac surgery.

METHODS

Between January 2007 and December 2010, all patients diagnosed with left main coronary artery disease and refused coronary artery bypass graft surgery in our hospital or a tertiary center, were enrolled. Data including clinical course, angiographic characteristics, and 1- and 3-years outcomes were recorded and analyzed.

RESULTS

Seventy patients (mean age 73.4 ± 10.2 years, 47 male, 23 females) were treated with a mean SYNTAX score of 34.8 ± 12.6 and EuroSCORE of 6.7 ± 3.3. Thirty-two (45.7%) patients had stable angina, 35 (50.0%) had unstable angina/non ST-elevation myocardial infarction, and 3 (4.3%) had ST-elevation Myocardial infarction. Forty-three (61.4%) patients received a single-stent, 26 (37.1%) received two-stents, and 1 (1.4%) received balloon angioplasty. No procedure-related mortalities were noted and no emergency coronary artery bypass graft surgery was required. In the 3-year follow-up period, 2 (2.9%) patients had non-fetal myocardial infarction, 11 (15.7%) had left main target lesion revascularization. The major adverse cardiac and cerebrovascular events rates were 24.3% at 1 year and 37.1% at 3-years. The all-cause mortality rate was 41.4% (29 patients), including 18 (25.7%) cases of septic shock, 7 (10.0%) of sudden cardiac death, 2 (2.8%) of hypovolemic shock due to upper gastrointestinal bleeding, 1 (1.4%) of terminal stage malignancy, and 1 (1.4%) of suffocation at 3 years.

CONCLUSIONS

Percutaneous coronary intervention for patients with left main coronary artery disease was found to be a safe and effective strategy in our hospital without on-site cardiac surgery.

KEY WORDS

Incomplete revascularization; Left main coronary artery (LM); No cardiac surgery; Percutaneous coronary intervention (PCI).

Very Long-term Outcomes and Predictors of Percutaneous Coronary Intervention with Drug-eluting Stents Versus Coronary Artery Bypass Grafting for Patients with Unprotected Left Main Coronary Artery Disease

BACKGROUND

There are limited data on longer-term outcomes (>5 years) for patients with unprotected left main coronary artery (ULMCA) disease who underwent percutaneous coronary intervention (PCI) in the drug-eluting stents (DES) era. This study aimed at comparing the long-term (>5 years) outcomes of patients with ULMCA disease underwent PCI with DES and coronary artery bypass grafting (CABG) and the predictors of adverse events.

METHODS

All consecutive patients with ULMCA disease treated with DES implantation versus CABG in our center, between January 2003 and July 2009, were screened for analyzing. A propensity score analysis was carried out to adjust for potential confounding between the two groups.

RESULTS

Nine hundred and twenty-two patients with ULMCA disease were enrolled for the analyses (DES = 465 vs. CABG = 457). During the median follow-up of 7.1 years (interquartile range 5.3-8.2 years), no difference was found between PCI and CABG in the occurrence of death (P = 0.282) and the composite endpoint of cardiac death, myocardial infarction (MI) and stroke (P = 0.294). Rates of major adverse cardiac and cerebrovascular events were significantly higher in the PCI group (P = 0.014) in large part because of the significantly higher rate of repeat revascularization (P < 0.001). PCI was correlated with the lower occurrence of stroke (P = 0.004). Multivariate analysis showed ejection fraction (EF) (P = 0.012), creatinine (P = 0.016), and prior stroke (P = 0.031) were independent predictors of the composite endpoint of cardiac death, MI, and stroke in the DES group, while age (P = 0.026) and EF (P = 0.002) were independent predictors in the CABG group.

CONCLUSIONS

During a median follow-up of 7.1 years, there was no difference in the rate of death between PCI with DES implantation and CABG in ULMCA lesions in the patient cohort. CABG group was observed to have significantly lower rates of repeat revascularization but higher stroke rates compared with PCI. EF, creatinine, and prior stroke were independent predictors of the composite endpoint of cardiac death, MI, and stroke in the DES group, while age and EF were independent predictors in the CABG group.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

[Percutaneous coronary intervention in stable coronary artery disease]

Percutaneous coronary intervention is a well-established symptomatic therapy of stable coronary artery disease. Using a literature search with special emphasis on the newly-published FAME 2 trial data, the author wanted to explore why percutaneous coronary intervention fails to reduce mortality and myocardial infarction in stable coronary artery disease, as opposed to surgical revascularisation. In the FAME 2 trial, fractional flow reserve-guided percutaneous coronary intervention with second generation drug eluting stents showed a significant reduction in the primary composite endpoint of 2-year mortality, myocardial infarction and unplanned hospitalization with urgent revascularisation as compared to medical therapy alone. In addition, landmark analysis showed that after 8 days, mortality and myocardial infarction were significantly reduced. The author concludes that percutaneous coronary intervention involving fractional flow reserve guidance and modern stents offers symptomatic, as well as prognostic benefit.

Outcome of coronary artery bypass grafting in a tertiary-care center in Pakistan

BACKGROUND

Coronary artery bypass grafting and percutaneous coronary intervention are revascularization options for significant coronary artery disease. While international data support the use of coronary artery bypass in high-risk groups, regional data on outcomes in these groups are rare. We conducted a retrospective study to determine the outcomes of patients undergoing coronary artery bypass for left main and multivessel disease.

METHODS

Two thousand eight hundred and fifty-one patients undergoing coronary artery bypass at the Aga Khan University Hospital from 2006 to 2013 were included; patients undergoing redo surgery were excluded. Demographic data, comorbidities, angiography findings, in-hospital complications, one-month and one-year follow-up were analyzed.

RESULTS

Of the 2851 patients, 568 had left main disease (group 1) and 2283 (group 2) had multivessel disease (≥2 vessels excluding the left main). Group 1 had significantly more chronic lung disease, cardiogenic shock, and congestive heart failure than group 2 (p < 0.001); 50.6% of patients were diabetic and 71.8% were hypertensive. Mortality was 5.1% and 2.2% during hospital stay, 6.5% and 2.6% at 30 days, and 6.7% and 2.7% at 1 year in groups 1 and 2, respectively.

CONCLUSION

Our comparable results and international data advocate revision of the current practice of using percutaneous coronary intervention over coronary artery bypass in the developing world. Institutional results are essential to determine the outcome of coronary artery bypass in high-risk populations with a high burden of diabetes and hypertension. We noted increased complications and mortality in patients with left main rather than multivessel disease.

Invasive assessment modalities of unprotected left main stenosis

Among all coronary lesions, the decision-making process for the treatment of unprotected left main (ULM) stem lesions is still challenging. Indeed, the optimal therapeutic strategy for patients with ULM disease remains controversial: coronary artery bypass grafting was established as the gold standard, but it is without doubt that percutaneous coronary intervention (PCI) performed by experienced operators achieves good results at long term follow up, especially in cases where the ostium and/or shaft of ULM are treated. Thanks to the widespread use of invasive assessment of atherothrombotic ULM stenosis, improved selection of PCI cases and techniques of stenting, better outcomes are now possible. This review seeks to define the place of PCI in ULM disease by describing the different modalities of ULM stenosis assessment.

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

OBJECTIVE

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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