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Kim T, Kang DY, Kim S, Lee JH, Kim AR, Lee Y, Oh HJ, Jang M, Lee J, Kim JH, Lee PH, Ahn JM, Park SJ, Park DW. Impact of Complete or Incomplete Revascularization for Left Main Coronary Disease: The Extended PRECOMBAT Study. JACC. ASIA 2023; 3:65-74. [PMID: 36873760 PMCID: PMC9982224 DOI: 10.1016/j.jacasi.2022.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 10/11/2022] [Accepted: 10/17/2022] [Indexed: 01/26/2023]
Abstract
Background Whether complete revascularization (CR) or incomplete revascularization (IR) may affect long-term outcomes after PCI) and coronary artery bypass grafting (CABG) for left main coronary artery (LMCA) disease is unclear. Objectives The authors sought to assess the impact of CR or IR on 10-year outcomes after PCI or CABG for LMCA disease. Methods In the PRECOMBAT (Premier of Randomized Comparison of Bypass Surgery versus Angioplasty Using Sirolimus-Eluting Stent in Patients with Left Main Coronary Artery Disease) 10-year extended study, the authors evaluated the effect of PCI and CABG on long-term outcomes according to completeness of revascularization. The primary outcome was the incidence of major adverse cardiac or cerebrovascular events (MACCE) (composite of mortality from any cause, myocardial infarction, stroke, or ischemia-driven target vessel revascularization). Results Among 600 randomized patients (PCI, n = 300 and CABG, n = 300), 416 patients (69.3%) had CR and 184 (30.7%) had IR; 68.3% of PCI patients and 70.3% of CABG patients underwent CR, respectively. The 10-year MACCE rates were not significantly different between PCI and CABG among patients with CR (27.8% vs 25.1%, respectively; adjusted HR: 1.19; 95% CI: 0.81-1.73) and among those with IR (31.6% vs 21.3%, respectively; adjusted HR: 1.64; 95% CI: 0.92-2.92) (P for interaction = 0.35). There was also no significant interaction between the status of CR and the relative effect of PCI and CABG on all-cause mortality, serious composite of death, myocardial infarction, or stroke, and repeat revascularization. Conclusions In this 10-year follow-up of PRECOMBAT, the authors found no significant difference between PCI and CABG in the rates of MACCE and all-cause mortality according to CR or IR status. (Ten-Year Outcomes of PRE-COMBAT Trial [PRECOMBAT], NCT03871127; PREmier of Randomized COMparison of Bypass Surgery Versus AngioplasTy Using Sirolimus-Eluting Stent in Patients With Left Main Coronary Artery Disease [PRECOMBAT], NCT00422968).
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Affiliation(s)
- Taesun Kim
- 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
| | - Sehee Kim
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, Seoul, Korea
| | - Jeen Hwa Lee
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ah-Ram Kim
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - YeonJeong Lee
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hyeon Jeong Oh
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Mihee Jang
- 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
| | - Ju Hyeon Kim
- 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
| | - PRECOMBAT Extended Study Investigators
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, Seoul, Korea
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Wang H, Xie X, Zu Q, Lu M, Chen R, Yang Z, Gao Y. One-year outcomes of polymer-free amphilimus-eluting stents versus durable polymer zotarolimus-eluting stents in patients with diabetes mellitus: a meta-analysis. Cardiovasc Diabetol 2022; 21:220. [PMID: 36307791 PMCID: PMC9617297 DOI: 10.1186/s12933-022-01673-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 10/21/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Diabetes mellitus (DM) and cardiovascular diseases often co-exist. Today, percutaneous coronary intervention (PCI) is the preferred revascularization procedure for majority of patients with coronary artery disease. Polymer-free amphilimus-eluting stents (AES) represent a novel elution technology in the current era of drug-eluting stents. In this analysis, we aimed to systematically compare the cardiovascular outcomes which are associated with polymer-free amphilimus-eluting stents (AES) versus the durable polymer zotarolimus-eluting stents (ZES) for the treatment of patients with DM. METHODS Http://www. CLINICALTRIALS gov, EMBASE, Web of Science, MEDLINE, Cochrane database and Google Scholar were searched for publications comparing polymer-free AES versus durable polymer ZES in patients with DM. Selective cardiovascular outcomes were assessed. Statistical analysis was carried out by the latest version of the RevMan software. Risk ratio (RR) with 95% confidence interval (CI) was used to represent the data analysis. RESULTS Four studies with a total number of 1795 participants with DM whereby 912 patients were assigned to be revascularized by the polymer-free AES and 883 patients were assigned to be revascularized by the durable polymer ZES were included in this analysis. In patients with DM, at one year, polymer-free AES were associated with significantly lower risk of major adverse cardiac events (MACEs) (RR: 0.69, 95% CI: 0.54-0.88; P = 0.002) and target lesion failure (TLF) (RR: 0.66, 95% CI: 0.48-0.91; P = 0.01) compared to durable polymer ZES. However, there was no significant change in all-cause mortality (RR: 0.79, 95% CI: 0.51-1.22; P = 0.28), cardiac death and the other cardiovascular outcomes. Similar risk of total stent thrombosis (RR: 1.13, 95% CI: 0.60-2.13; P = 0.70), including definite stent thrombosis (RR: 1.12, 95% CI: 0.38-3.31; P = 0.84), probable stent thrombosis (RR: 0.87, 95% CI: 0.37-2.09; P = 0.76), possible stent thrombosis (RR: 1.19, 95% CI: 0.50-2.87; P = 0.69) and late stent thrombosis (RR: 1.00, 95% CI: 0.17-5.72; P = 1.00) as between polymer-free AES and durable polymer ZES in patients with DM. CONCLUSIONS At 1 year follow-up, polymer-free AES were associated with significantly lower MACEs and TLF compared to durable polymer ZES in these patients with DM, without any increase in mortality, stent thrombosis and other cardiovascular outcomes. However, this analysis is only based on a follow-up time period of one year, therefore, future research should focus on the long term follow-up time period.
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Affiliation(s)
- Hong Wang
- Department of Cardiology, The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, 530021 Guangxi People’s Republic of China
| | - Xiaoya Xie
- Macau University of Science and Technology, Macau, People’s Republic of China
| | - Quannan Zu
- College of Management and Economics, Tianjin University, Tianjin, 300072 People’s Republic of China
| | - Ming Lu
- College of Management and Economics, Tianjin University, Tianjin, 300072 People’s Republic of China
| | - Rongfa Chen
- The State Key Laboratory Management and Control for Complex Systems, Institute of Automation, Chinese Academy of Sciences, Beijing, 100190 People’s Republic of China
| | - Zhiren Yang
- The State Key Laboratory Management and Control for Complex Systems, Institute of Automation, Chinese Academy of Sciences, Beijing, 100190 People’s Republic of China
| | - Yongqiang Gao
- Department of Cardiology, The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, 530021 Guangxi People’s Republic of China
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Abstract
Traditionally, the treatment of left main coronary artery disease is recommended coronary artery bypass grafting because of its superior long-term outcomes compared with medical treatment and plain old balloon angioplasty. However, improvement of percutaneous coronary intervention technique and introduction of drug-eluting stent led to change of treatment strategy of left main coronary artery disease through cumulative data for revascularization that based on clinical evidence.
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Affiliation(s)
- Jinho Lee
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea
| | - Duk-Woo Park
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea.
| | - Seung-Jung Park
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea.
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Yoon Y, Ahn J, Lee JB, Kang D, Park H, Jeong YJ, Lee J, Kim JH, Yang Y, Hyun J, Lee PH, Park D, Park S. Time-Dependent Impact of Sex on the Long-Term Outcomes After Left Main Revascularization. J Am Heart Assoc 2022; 11:e021720. [PMID: 35189706 PMCID: PMC9075067 DOI: 10.1161/jaha.121.021720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 09/28/2021] [Indexed: 11/16/2022]
Abstract
Background There are still limited data about the differential effect of sex on long-term outcomes after percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) for left main coronary artery disease. This extended follow-up study of the MAIN-COMPARE (Ten-Year Outcomes of Stents Versus Coronary-Artery Bypass Grafting for Left Main Coronary Artery Disease) registry evaluated clinical outcomes beyond 10 years. Methods and Results Of 2240 patients with unprotected left main coronary artery disease (PCI=1102 and CABG=1138), all-cause mortality, the composite of death, Q-wave myocardial infarction, or stroke, and target vessel revascularization were separately evaluated in both sexes. Of 2240 patients, 631 (28.2%) were women and 1609 (71.8%) were men. Women had lower 10-year incidences of death and serious composite outcomes than men. The adjusted 10-year risks of adverse outcomes were similar in men. However, the adjusted 10-year risks were different according to a prespecified period in women. In the short-term (0-1 year) period, PCI had a significantly lower risk for serious composite outcomes (adjusted hazard ratio [HR], 0.41; 95% CI, 0.19-0.91; P=0.03) compared with CABG. The adjusted risks for death and serious composite outcomes were significantly higher after PCI than after CABG, during the midterm (1-5 years) period (death; adjusted HR, 3.99; 95% CI, 2.01-7.92; P<0.001 and composite outcome; adjusted HR, 2.93; 95% CI, 1.59-5.39; P=0.001). Beyond 5 years, adjusted risks were similar after PCI and CABG in women. Conclusions In this 10-year extended follow-up study of patients undergoing left main coronary artery revascularization, we observed a time-dependent impact of sex on the long-term outcomes after PCI and CABG, especially in women, with significant interactions. However, these results warrant confirmation on larger series of studies. Registration URl: https://www.clinicaltrials.gov; Unique identifier: NCT02791412.
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Affiliation(s)
- Yong‐Hoon Yoon
- Department of CardiologyChungnam National University Sejong HospitalChungnam National University School of MedicineSejongKorea
| | - Jung‐Min Ahn
- Department of CardiologyAsan Medical CenterUniversity of Ulsan College of MedicineSeoulKorea
| | - Jung Bok Lee
- Department of Clinical Epidemiology & BiostatisticsAsan Medical CenterUniversity of Ulsan College of MedicineSeoulKorea
| | - Do‐Yoon Kang
- Department of CardiologyAsan Medical CenterUniversity of Ulsan College of MedicineSeoulKorea
| | - Hanbit Park
- Department of CardiologyAsan Medical CenterUniversity of Ulsan College of MedicineSeoulKorea
| | - Yeong Jin Jeong
- Department of CardiologyAsan Medical CenterUniversity of Ulsan College of MedicineSeoulKorea
| | - Junghoon Lee
- Department of CardiologyAsan Medical CenterUniversity of Ulsan College of MedicineSeoulKorea
| | - Ju Hyeon Kim
- Department of CardiologyAsan Medical CenterUniversity of Ulsan College of MedicineSeoulKorea
| | - Yujin Yang
- Department of CardiologyAsan Medical CenterUniversity of Ulsan College of MedicineSeoulKorea
| | - Junho Hyun
- Department of CardiologyAsan Medical CenterUniversity of Ulsan College of MedicineSeoulKorea
| | - Pil Hyung Lee
- Department of CardiologyAsan Medical CenterUniversity of Ulsan College of MedicineSeoulKorea
| | - Duk‐Woo Park
- Department of CardiologyAsan Medical CenterUniversity of Ulsan College of MedicineSeoulKorea
| | - Seung‐Jung Park
- Department of CardiologyAsan Medical CenterUniversity of Ulsan College of MedicineSeoulKorea
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5
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Shekhar S, Mohananey D, Villablanca P, Tyagi S, Crestanello JA, Gil IJN, Ramakrishna H. Revascularization Strategies for Stable Left Main Coronary Artery Disease: Analysis of Current Evidence. J Cardiothorac Vasc Anesth 2021; 36:3370-3378. [PMID: 35115224 DOI: 10.1053/j.jvca.2021.12.016] [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: 12/13/2021] [Accepted: 12/14/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Shashank Shekhar
- Department of Cardiovascular Medicine, Heart, and Vascular Institute, Cleveland Clinic, Cleveland, OH
| | - Divyanshu Mohananey
- Department of Cardiovascular Medicine, Medical College of Wisconsin, Milwaukee, WI
| | | | - Sudhi Tyagi
- Department of Cardiovascular Medicine, Medical College of Wisconsin, Milwaukee, WI
| | | | - Iván J Núñez Gil
- Interventional Cardiology Consultant, Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain
| | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
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Jeong YJ, Ahn JM, Hyun J, Lee J, Kim JH, Yang Y, Choe K, Park H, Kang DY, Lee PH, Kang SJ, Lee SW, Kim YH, Lee CW, Park SW, Park SJ, Park DW. Ten-year Outcomes After Drug-Eluting Stents or Bypass Surgery for Left Main Coronary Disease in Patients With and Without Diabetes Mellitus: The PRECOMBAT Extended Follow-Up Study. J Am Heart Assoc 2021; 10:e019834. [PMID: 34238026 PMCID: PMC8483465 DOI: 10.1161/jaha.120.019834] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background Several trials reported differential outcomes after percutaneous coronary intervention with drug‐eluting stents (DES) and coronary‐artery bypass grafting (CABG) for multivessel coronary disease according to the presence of diabetes mellitus (DM). However, it is not well recognized how DM status affects very‐long‐term (10‐year) outcomes after DES and CABG for left main coronary artery disease. Methods and Results In the PRECOMBAT (Premier of Randomized Comparison of Bypass Surgery versus Angioplasty using Sirolimus‐Eluting Stent in Patients with Left Main Coronary Artery Disease) trial, patients with LMCA were randomly assigned to undergo PCI with sirolimus‐eluting stents (n=300) or CABG (n=300). The primary outcome was the incidence of major adverse cardiac or cerebrovascular events (MACCE; a composite of death from any cause, myocardial infarction, stroke, or ischemia‐driven target‐vessel revascularization). Outcomes were examined in patients with (n=192) and without (n=408) medically treated diabetes. The follow‐up was extended to at least 10 years for all patients (median, 11.3 years). The 10‐year rates of MACCE were not significantly different between DES and CABG in patients with DM (36.3% versus 26.7%, respectively; hazard ratio [HR], 1.35; 95% CI, 0.83–2.19; P=0.23) and without DM (25.3% versus 22.9%, respectively; HR, 1.15; 95% CI, 0.79–1.67; P=0.48) (P‐for‐interaction=0.48). There were no significant between‐group differences in composite of death, MI, or stroke, and all‐cause mortality, regardless of DM status. TVR rates were consistently higher after DES than CABG. Conclusions In this 10‐year extended follow‐up of PRECOMBAT, we found no significant difference between DES and CABG with respect to the incidences of MACCE, serious composite outcome, and all‐cause mortality in patients with and without DM with LMCA disease. However, owing to the limited number of patients and no adjustment for multiple testing, overall findings should be considered hypothesis‐generating, highlighting the need for further research. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03871127 and NCT00422968.
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Affiliation(s)
- Yeong Jin Jeong
- Department of Cardiology Asan Medical CenterUniversity of Ulsan College of Medicine Seoul Korea
| | - Jung-Min Ahn
- Department of Cardiology Asan Medical CenterUniversity of Ulsan College of Medicine Seoul Korea
| | - Junho Hyun
- Department of Cardiology Asan Medical CenterUniversity of Ulsan College of Medicine Seoul Korea
| | - Junghoon Lee
- Department of Cardiology Asan Medical CenterUniversity of Ulsan College of Medicine Seoul Korea
| | - Ju Hyeon Kim
- Department of Cardiology Asan Medical CenterUniversity of Ulsan College of Medicine Seoul Korea
| | - Yujin Yang
- Department of Cardiology Asan Medical CenterUniversity of Ulsan College of Medicine Seoul Korea
| | - Kyungjin Choe
- Department of Cardiology Asan Medical CenterUniversity of Ulsan College of Medicine Seoul Korea
| | - Hanbit Park
- Department of Cardiology Asan Medical CenterUniversity of Ulsan College of Medicine Seoul Korea
| | - Do-Yoon Kang
- Department of Cardiology Asan Medical CenterUniversity of Ulsan College of Medicine Seoul Korea
| | - Pil Hyung Lee
- Department of Cardiology Asan Medical CenterUniversity of Ulsan College of Medicine Seoul Korea
| | - Soo-Jin Kang
- Department of Cardiology Asan Medical CenterUniversity of Ulsan College of Medicine Seoul Korea
| | - Seung-Whan Lee
- Department of Cardiology Asan Medical CenterUniversity of Ulsan College of Medicine Seoul Korea
| | - Young-Hak Kim
- Department of Cardiology Asan Medical CenterUniversity of Ulsan College of Medicine Seoul Korea
| | - Cheol Whan Lee
- Department of Cardiology Asan Medical CenterUniversity of Ulsan College of Medicine Seoul Korea
| | - Seong-Wook Park
- Department of Cardiology Asan Medical CenterUniversity of Ulsan College of Medicine Seoul Korea
| | - Seung-Jung Park
- Department of Cardiology Asan Medical CenterUniversity of Ulsan College of Medicine Seoul Korea
| | - Duk-Woo Park
- Department of Cardiology Asan Medical CenterUniversity of Ulsan College of Medicine Seoul Korea
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Gong X, Huang Z, Sun Z, Wang Q, Qian J, Ge L, Ge J. Role of IVUS in the rectification of angiographically judged ramus intermedius and its clinical significance. BMC Cardiovasc Disord 2021; 21:218. [PMID: 33931019 PMCID: PMC8086063 DOI: 10.1186/s12872-021-02034-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 04/16/2021] [Indexed: 11/25/2022] Open
Abstract
Background Due to the technical limitations of coronary artery angiography (CAG), ramus intermedius (RI) is sometimes difficult to distinguish from a high-origin obtuse marginal branch or a high-origin diagonal branch. This study sought to investigate the role of intravascular ultrasonography (IVUS) in the rectification of angiographically judged RI. Methods This study retrospectively analyzed 165 patients who were reported to have an RI based on CAG and underwent IVUS implementation from 02/01/2009 to 31/12/2019 in Zhongshan Hospital, Fudan University. Taking IVUS as the gold standard, we calculated the accuracy of RI identification by CAG and evaluated the impact of RI on revascularization strategy. Results Among the 165 patients, 89 patients (54%) were demonstrated to have an RI on IVUS (IVUS-RI), 32 patients (19%) were identified to have a high-origin diagonal branch on IVUS (IVUS-h-D), and 44 patients (27%) had an actual high-origin obtuse marginal artery on IVUS (IVUS-h-OM). Among 84 patients who underwent one-stent crossover stenting because of left main furcation lesions (48 patients in the IVUS-RI group, 12 patients in the IVUS-h-D group, and 24 in the IVUS-h-OM group), 14.6% of patients in the IVUS-RI group, 33.3% in the IVUS-h-D group and 0% in the IVUS-h-OM group had CAG-RI compromise (P = 0.02), which was defined as severe stenosis of the RI ostium (> 75%) or significant RI flow impairment (TIMI < 3). Conclusions Only 54% of CAG-RIs were confirmed by IVUS, which indicates the necessity of preintervention IVUS to distinguish real RIs from other branches in LM furcation lesions.
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Affiliation(s)
- Xue Gong
- Department of Cardiology, Deltahealth Hospital, Shanghai, 201702, People's Republic of China.,Department of Cardiology, Shanghai Institute of Cardiovascular Disease, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, People's Republic of China
| | - Zheyong Huang
- Department of Cardiology, Shanghai Institute of Cardiovascular Disease, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, People's Republic of China
| | - Zhonghan Sun
- Human Phenome Institute, Fudan University, Shanghai, 200438, People's Republic of China
| | - Qibing Wang
- Department of Cardiology, Shanghai Institute of Cardiovascular Disease, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, People's Republic of China
| | - Juying Qian
- Department of Cardiology, Shanghai Institute of Cardiovascular Disease, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, People's Republic of China
| | - Lei Ge
- Department of Cardiology, Shanghai Institute of Cardiovascular Disease, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, People's Republic of China.
| | - Junbo Ge
- Department of Cardiology, Shanghai Institute of Cardiovascular Disease, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, People's Republic of China.
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Lee CH, Ahn JM, Kang DY, Han M, Park H, Lee PH, Lee SW, Park SW, Park DW, Park SJ. Comparison of simple versus complex stenting in patients with true distal left main bifurcation lesions. Catheter Cardiovasc Interv 2021; 97:776-785. [PMID: 32898318 DOI: 10.1002/ccd.29219] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 07/13/2020] [Accepted: 08/02/2020] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Distal left main (LM) bifurcation disease is one of the most challenging lesion subsets for percutaneous coronary intervention (PCI) and optimal stenting strategy for such complex lesions is still debated. This study aimed to compare clinical outcomes following single versus dual stenting for true distal LM bifurcation lesions. METHODS Patients with true distal LM bifurcation lesions (type 1,1,1 or 0,1,1: both left anterior descending and circumflex artery >2.5 mm diameter) receiving PCI with drug-eluting stents (DES) from two large clinical registries were evaluated. The primary outcome was target-lesion failure (TLF), defined as a composite of cardiac death, target-vessel myocardial infarction (MI), or target-lesion revascularization (TLR). Outcomes were compared with the use of propensity scores and inverse probability-weighting adjustment to reduce treatment selection bias. RESULTS Among 1,002 patients undergoing true distal LM PCI, 440 (43.9%) and 562 (56.1%) were treated with single and dual stents, respectively. The TLF rates at 3 year was 20.3% in the single-stent group and 24.1% in the dual-stenting group (log-rank p = 0.18). The adjusted risk for TLF did not differ significantly between two groups (hazard ratio [HR] with dual-stent vs. single-stent: 1.27, 95% confidence interval [CI]: 0.95-1.71). The adjusted risks for death, MI, repeat revascularization, or stent thrombosis were also similar between the single- and dual-stenting groups. CONCLUSIONS In patients undergoing PCI for true distal LM disease, single- and dual-stent strategies showed a similar adjusted risk of TLF at 3 years. Our findings should be confirmed or refuted through large, randomized clinical trials.
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Affiliation(s)
- Cheol Hyun Lee
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Daegu, South Korea
| | - Jung-Min Ahn
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Do-Yoon Kang
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Minkyu Han
- Division of Biostatistics, Center for Medical Research and Information, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Hanbit Park
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Pil Hyung Lee
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Seung-Whan Lee
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Seong-Wook 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
| | - Seung-Jung Park
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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Park DW, Ahn JM, Park H, Yun SC, Kang DY, Lee PH, Kim YH, Lim DS, Rha SW, Park GM, Gwon HC, Kim HS, Chae IH, Jang Y, Jeong MH, Tahk SJ, Seung KB, Park SJ. Ten-Year Outcomes After Drug-Eluting Stents Versus Coronary Artery Bypass Grafting for Left Main Coronary Disease. Circulation 2020; 141:1437-1446. [DOI: 10.1161/circulationaha.120.046039] [Citation(s) in RCA: 129] [Impact Index Per Article: 32.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background:
Long-term comparative outcomes after percutaneous coronary intervention (PCI) with drug-eluting stents and coronary-artery bypass grafting (CABG) for left main coronary artery disease are highly debated.
Methods:
In the PRECOMBAT trial (Premier of Randomized Comparison of Bypass Surgery versus Angioplasty Using Sirolimus-Eluting Stent in Patients with Left Main Coronary Artery Disease), patients with unprotected left main coronary artery disease were randomly assigned to undergo PCI with sirolimus-eluting stents (n=300) or CABG (n=300) in 13 hospitals in Korea from April 2004 to August 2009. The follow-up was extended to at least 10 years for all patients (median, 11.3 years). The primary outcome was the incidence of major adverse cardiac or cerebrovascular events (composite of death from any cause, myocardial infarction, stroke, or ischemia-driven target-vessel revascularization).
Results:
At 10 years, a primary outcome event occurred in 29.8% of the PCI group and in 24.7% of the CABG group (hazard ratio [HR] with PCI vs CABG, 1.25 [95% CI, 0.93–1.69]). The 10-year incidence of the composite of death, myocardial infarction, or stroke (18.2% vs 17.5%; HR 1.00 [95% CI, 0.70–1.44]) and all-cause mortality (14.5% vs 13.8%; HR 1.13 [95% CI, 0.75–1.70]) were not significantly different between the PCI and CABG groups. Ischemia-driven target-vessel revascularization was more frequent after PCI than after CABG (16.1% vs 8.0%; HR 1.98 [95% CI, 1.21–3.21).
Conclusions:
Ten-year follow-up of the PRECOMBAT trial of patients with left main coronary artery disease randomized to PCI or CABG did not demonstrate significant difference in the incidence of major adverse cardiac or cerebrovascular events. Because the study was underpowered, the results should be considered hypothesis-generating, highlighting the need for further research.
Registration:
URL:
https://www.clinicaltrials.gov
; Unique identifiers: NCT03871127 and NCT00422968.
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Affiliation(s)
- Duk-Woo Park
- Department of Cardiology (D.-W.P., J.-M.A., H.P, D.-Y.K., P.H.L., Y.-H.K., S.-J.P.), Asan Medical Center, Seoul, Korea
| | - Jung-Min Ahn
- Department of Cardiology (D.-W.P., J.-M.A., H.P, D.-Y.K., P.H.L., Y.-H.K., S.-J.P.), Asan Medical Center, Seoul, Korea
| | - Hanbit Park
- Department of Cardiology (D.-W.P., J.-M.A., H.P, D.-Y.K., P.H.L., Y.-H.K., S.-J.P.), Asan Medical Center, Seoul, Korea
| | - Sung-Cheol Yun
- Division of Biostatistics (S.-C.Y.), Asan Medical Center, Seoul, Korea
| | - Do-Yoon Kang
- Department of Cardiology (D.-W.P., J.-M.A., H.P, D.-Y.K., P.H.L., Y.-H.K., S.-J.P.), Asan Medical Center, Seoul, Korea
| | - Pil Hyung Lee
- Department of Cardiology (D.-W.P., J.-M.A., H.P, D.-Y.K., P.H.L., Y.-H.K., S.-J.P.), Asan Medical Center, Seoul, Korea
| | - Young-Hak Kim
- Department of Cardiology (D.-W.P., J.-M.A., H.P, D.-Y.K., P.H.L., Y.-H.K., S.-J.P.), Asan Medical Center, Seoul, Korea
| | - Do-Sun Lim
- Korea University Anam Hospital, Seoul (D.-S.L.)
| | | | | | | | - Hyo-Soo Kim
- Samsung Medical Center, Seoul, Korea (H.-C.G., H.-S.K.)
- Seoul National University Hospital, Korea (H.-S.K.)
| | - In-Ho Chae
- Seoul National University Bundan Hospital, Seongnam, Korea (I.-H.C.)
| | - Yangsoo Jang
- Yonsei University Severance Hospital, Seoul, Korea (Y.J.)
| | - Myung-Ho Jeong
- Chonnam National University Hospital, Gwangju, Korea (M.-H.J.)
| | | | - Ki Bae Seung
- Catholic University of Korea, St. Mary’s Hospital, Seoul (K.B.S.)
| | - Seung-Jung Park
- Department of Cardiology (D.-W.P., J.-M.A., H.P, D.-Y.K., P.H.L., Y.-H.K., S.-J.P.), Asan Medical Center, Seoul, Korea
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10
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Rates and Independent Correlates of 10-Year Major Adverse Events and Mortality in Patients Undergoing Left Main Coronary Arterial Revascularization. Am J Cardiol 2020; 125:1148-1153. [PMID: 32085865 DOI: 10.1016/j.amjcard.2020.01.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Revised: 01/13/2020] [Accepted: 01/17/2020] [Indexed: 11/24/2022]
Abstract
Patients who underwent myocardial revascularization for significant left main coronary artery disease (LMCA) are at high risks of ischemic events and death during follow-up. We sought to determine the independent correlates for very long-term outcomes after LMCA revascularization, which would be clinical value for risk stratification in such high-risk patients. The 10-year rates of clinical outcomes and independent correlates of adverse events were evaluated in 2,240 patients with LMCA disease in the MAIN-COMPARE registry, including 1,102 patients who underwent stenting and 1,138 who underwent coronary artery bypass grafting. The primary outcome was the composite of all-cause death, Q-wave myocardial infarction, or stroke. Secondary outcomes were all-cause mortality and target-vessel revascularization (TVR). The 10-year rates of the primary composite outcome, all-cause mortality, and TVR were 24.7%, 22.2%, and 13.6%, respectively. Age >65 years, diabetes, previous heart failure, cerebrovascular disease, peripheral arterial disease, chronic renal failure, atrial fibrillation, ejection fraction <40%, and distal LMCA bifurcation disease were independent correlates of the primary outcome in the overall population. Several clinical and anatomic parameters were also identified as independent correlates of all-cause death and TVR. Interaction analysis showed no heterogeneities of the effects of variables depending on revascularization type. These clinical descriptors can assist clinicians in identifying high-risk patients within the broad range of risk for patients who underwent LMCA revascularization.
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11
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Jahangiri M, Mani K, Yates MT, Nowell J. The EXCEL Trial: The Surgeons' Perspective. Eur Cardiol 2020; 15:e67. [PMID: 33294035 PMCID: PMC7689871 DOI: 10.15420/ecr.2020.34] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 10/05/2020] [Indexed: 01/06/2023] Open
Abstract
There have been several investigations comparing the efficacy of percutaneous coronary intervention and coronary artery bypass grafting surgery for treatment of left main stem disease. This includes the Evaluation of XIENCE versus Coronary Artery Bypass Graft Surgery for Effectiveness of Left Main Revascularizaton (EXCEL) trial, which has garnered significant controversy surrounding its experimental design and reporting of its results. The authors review the methodology, results, caveats and statements on the EXCEL trial. They also review the other trials in the management of left main stem disease comparing percutaneous coronary intervention with coronary artery bypass grafting, as well as the SYNTAX score and its role in future guidelines for revascularisation. These findings have significant implications for current practice, influencing the growing role for multidisciplinary team meeting and allowing clinicians and patients to make the right choice.
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Affiliation(s)
| | - Krishna Mani
- Department of Cardiac Surgery, St. George's Hospital London, UK
| | - Martin T Yates
- Department of Cardiac Surgery, St. George's Hospital London, UK
| | - Justin Nowell
- Department of Cardiac Surgery, St. George's Hospital London, UK
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12
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Yoon YH, Ahn JM, Kang DY, Park H, Cho SC, Lee PH, Lee SW, Park SW, Park DW, Park SJ. Impact of SYNTAX Score on 10-Year Outcomes After Revascularization for Left Main Coronary Artery Disease. JACC Cardiovasc Interv 2020; 13:361-371. [DOI: 10.1016/j.jcin.2019.10.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 09/06/2019] [Accepted: 10/08/2019] [Indexed: 10/25/2022]
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13
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Codner P, Saada M, Sakhov O, Polad J, Malik FTN, Munir S, Mamas M, Crowley J, Monsegu J, Perez L, Kedev S, Austin D, Roguin A. Proximal Left Anterior Descending Artery Treatment Using a Bioresorbable Polymer Coating Sirolimus-Eluting Stent: Real-World Outcomes From the Multicenter Prospective e-Ultimaster Registry. J Am Heart Assoc 2019; 8:e013786. [PMID: 31787055 PMCID: PMC6912975 DOI: 10.1161/jaha.119.013786] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Guidelines recommend heart team discussion and coronary artery bypass graft consideration in patients with proximal left anterior descending (LAD) artery stenosis. Evidence suggests that outcomes of proximal LAD angioplasty might not differ from treatment of nonproximal LAD locations. We aim to determine clinical outcomes of patients undergoing percutaneous coronary intervention in the proximal LAD segment in comparison with nonproximal LAD angioplasty, using a thin-strut drug-eluting stent. Methods and Results In this analysis of the e-Ultimaster registry, patients undergoing angioplasty in the proximal LAD territory were compared with those treated in nonproximal LAD locations. Multivariate analysis and propensity score were used to adjust for differences among the groups. The primary outcome was target lesion failure: a composite of cardiac death, target-lesion-related myocardial infarction, and/or clinically driven target lesion revascularization at 1-year follow-up. Of the 17 805 patients (mean age, 64.2±11; 76% male), 5452 (30.6%) underwent proximal LAD and 12 353 (69.4%) nonproximal LAD percutaneous coronary intervention. Patients in the proximal LAD group had more multivessel disease (48.7% versus 43.5%; P<0.001) and 2-fold more bifurcations lesions (18.8% versus 9.2%; P<0.0001). After propensity-weighted adjustment, target lesion failure did not differ between the groups (3.3% versus 2.9%; P=0.17 for proximal LAD versus nonproximal LAD angioplasty, respectively). In multivariate analysis, proximal LAD treatment was not an independent predictor of target lesion failure (odds ratio, 1.07; 95% CI, 0.88-1.31; P=0.48). Conclusions At 1-year follow-up, patients had similar clinical outcomes independent of stenting location, questioning whether proximal LAD treatment should be regarded differently from stenting in any other coronary artery territory.
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Affiliation(s)
- Pablo Codner
- Department of Cardiology Hillel Yaffe Medical Center Hadera Israel.,The Rappaport Faculty of Medicine Technion-Israel Institute of Technology Haifa Israel
| | - Majdi Saada
- Department of Cardiology Hillel Yaffe Medical Center Hadera Israel.,The Rappaport Faculty of Medicine Technion-Israel Institute of Technology Haifa Israel
| | - Orazbek Sakhov
- Department of Interventional Cardiology City Heart Center Almaty Kazakhstan
| | - Jawed Polad
- Department of Cardiology Jeroen Bosch Hospital 's-Hertogenbosch The Netherlands
| | - Fazila Tun-Nesa Malik
- Department of Cardiology National Heart Foundation Hospital & Research Institute Dhaka Bangladesh
| | - Shahzad Munir
- Department of Cardiology Royal Wolverhampton Hospital Wolverhampton United Kingdom
| | - Mamas Mamas
- Keele Cardiovascular Research Group Center of Prognosis Research Institute of Primary Care Sciences Keele University Stoke on Trent United Kingdom
| | | | - Jacques Monsegu
- Institut Cardiovasculaire Groupe Hospitalier Mutualiste de Grenoble Grenoble France
| | - Luis Perez
- Hospital Guillermo Grant Benavente Concepcion Chile
| | - Sasko Kedev
- University Clinic of Cardiology Skopje Macedonia
| | - David Austin
- James Cook University Hospital Middleborough United Kingdom
| | - Ariel Roguin
- Department of Cardiology Hillel Yaffe Medical Center Hadera Israel.,The Rappaport Faculty of Medicine Technion-Israel Institute of Technology Haifa Israel
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