Hartzler has been a pioneer in percutaneous coronary interventions (PCI) on the unprotected left main (LM) coronary artery [1]. In an early report using only balloon angioplasty, successful LM dilation was achieved in 94% of elective patients and 90% of acute patients. Procedural mortality was 4.3% in elective patients (2.4% and 9.1% in protected and unprotected patients, respectively; P ϭ 0.14) and 50% in the acute subgroup. Long-term follow-up data, available for 98% of patients, revealed actuarial 3-year survival rates of 90% and 36% in elective protected and unprotected subgroups, respectively (P Ͻ 0.0005). In the acute subgroup, three patients (30%) were alive at the time of follow-up; all had undergone coronary artery bypass surgery. Since this study, PCI has been widely applied in the acute setting of myocardial infarction involving disease of the LM [2][3][4][5][6][7][8][9][10][11][12]. Even in the most recent reports, the 6-month survival in patients successfully treated and discharged from the hospital remains below 50% [12,13]. The main factors affecting the long-term outcome in most of these subjects are the left ventricular function and the risk of restenosis. These two elements apply also to patients electively treated [14]. These findings led many authors to consider PCI revascularization of patients with LM disease only if the anatomy is considered at low risk for restenosis (large reference vessel diameter and no involvement of the bifurcation) and if the left ventricular function is preserved [14 -18]. In a very recent series of 270 consecutive patients with normal left ventricular function who underwent PCI on unprotected LM stenosis, the procedural success rate was 98.9%. There were no deaths, three stent thromboses, and three Q-wave myocardial infarctions during the hospitalization. Angiographic follow-up was performed in 237 patients (follow-up rate 87.8%), and the restenosis rate was 21.1%. The reference vessel size was an independent predictor of binary restenosis (P ϭ 0.03). During the follow-up period (over 2 years), there were 20 deaths (8 cardiac, 12 noncardiac). Target and new lesion revascularizations were required in 16.7% and 11.5% of patients, respectively [18].Butman et al. [19] are now reporting case of extreme utilization of PCI on a patient with severe LM disease and dependent on left ventricular assist device. Thanks to the presence of a left ventricular support system (Novacor; left ventricular assist device, or LVAD), implanted 1 year before, the patient underwent an uneventful stenting procedure despite the presence of a high-risk anatomy (distal LM disease and occluded right coronary artery). The establishment of revascularization allowed the removal of the LVAD. The authors do not report the follow-up clinical status of the patient. It is worth mentioning that with current stent technology and delivery systems, most PCI can be performed without any hemodynamic support [15] or in selected cases with intraaortic balloon counterpulsation [14,20]. In this specific report, th...
