Long-term clinical outcomes after unprotected left main trunk percutaneous revascularization in 279 patients

Abstract

for the ULTIMA Investigators* Background-Percutaneous coronary revascularization (PCI) has been increasingly applied to unprotected left main trunk (LMT) lesions, with varied long-term success. This study attempts to define the predictors of outcome in this population. Methods and Results-Two hundred seventy-nine consecutive patients who had LMT PCI at 1 of 25 sites between 1993 and 1998 were studied. Forty-six percent of these patients were deemed inoperable or at high surgical risk. Thirty-eight patients (13.7%) died in hospital, and the rest were followed up for a mean of 19 months. The 1-year incidence was 24.2% for all-cause mortality, 20.2% for cardiac mortality, 9.8% for myocardial infarction, and 9.4% for CABG. Independent correlates of all-cause mortality were left ventricular ejection fraction Յ30%, mitral regurgitation grade 3 or 4, presentation with myocardial infarction and shock, creatinine Ն2.0 mg/dL, and severe lesion calcification. For the 32% of patients Ͻ65 years old with left ventricular ejection fraction Ͼ30% and without shock, the prevalence of these adverse risk factors was low. No periprocedural deaths were observed in this low-risk subset, and the 1-year mortality was only 3.4%. Conclusions-Patients undergoing unprotected LMT PCI have frequent serious comorbidities and consequently have high event rates. PCI may be an alternative to CABG for a select proportion of elective patients and may also be appropriate for highly symptomatic inoperable patients. Meticulous follow-up of hospital survivors is required because of the rather high mortality during the first few months after treatment.

Correlations Between Fractional Flow Reserve and Intravascular Ultrasound in Patients With an Ambiguous Left Main Coronary Artery Stenosis

“…2 A critical stenosis in this artery is best treated by surgical revascularization, [3][4][5][6] although percutaneous revascularization may emerge as a viable alternative in selected patient populations. 7,8 Long-term follow-up data indicate that bypass surgery for a significant LMCS is superior to medical therapy alone, offering a vastly better reduction in mortality. 9 -11 On the other hand, too early an operation for a nonsignificant LMCS could lead to inappropriate use of available grafts and the premature closure of either the native vessel or the graft.…”

Percutaneous Coronary Intervention Versus Coronary Artery Bypass Graft Surgery for the Treatment of Unprotected Left Main Coronary Artery Stenosis In-Hospital and One Year Outcome After Emergent and Elective Treatments

“…However, the cardiac mortality rate increases to 13.7% when emergency PCIs are included. 4) Although this study included both emergency and elective PCI cases, the inhospital mortality rate was only 5%. The one-year MACE rate of 5% for stenting of unprotected LMCA disease recorded in the present study differed from that of a previous report by Lopez, et al 17) The low rate of both mortality and MACE is impressive.…”

“…[3][4][5] Despite the feasibility and the high procedural success rate of percutaneous LMCA intervention, the long-term incidence of adverse events in the predrug eluting stent (DES) "era" is reportedly unacceptably high in this subset of patients. [4][5][6] Current guidelines recommend surgical revascularization for LMCA stenosis.…”

Left Main Coronary Artery Disease: Current Status and Management

“…В период с 1999 по 2003 гг. был опубликован ряд ис-следований, суммарно включающих более 1100 паци-ентов, посвященных применению стандартных метал-лических стентов у пациентов со стенозом ствола ЛКА [25,27]. Уровень госпитальной летальности составил от 0 до 14%, при этом частота повторной реваскуляриза-ции была от 0 до 20%.…”