Long-Term Outcomes After Stent Implantation for Left Main Coronary Artery (from the Multicenter Assessing Optimal Percutaneous Coronary Intervention for Left Main Coronary Artery Stenting Registry)

Abstract

We assessed long-term outcomes after left main coronary artery (LMCA) stenting based on lesion types and stenting strategies. In the Assessing Optimal percutaneous coronary Intervention for Left Main Coronary Artery stenting registry, we evaluated 1,607 consecutive patients undergoing stent implantation for unprotected LMCA lesions (bifurcation lesions: n = 1318 and nonbifurcation lesions: n = 289). Among the bifurcation lesions, 1,281 lesions were treated with stenting across the bifurcation (bifurcation 1-stent strategy: n = 999 or bifurcation 2-stent strategy: n = 282). Among the nonbifurcation lesions, 219 lesions were treated with nonbifurcation stenting. The median follow-up duration was 4.6 (95% CI 4.5 to 4.8) years. The 5-year risk of bifurcation lesions relative to nonbifurcation lesions was neutral for target lesion revascularization (TLR) (adjusted hazard ratio [HR] 0.82, 95% CI 0.55 to 1.23, p = 0.34) and all-cause death (adjusted HR 1.22, 95% CI 0.87 to 1.71, p = 0.26). The risk of the bifurcation 1-stent strategy relative to nonbifurcation stenting in nonbifurcation lesions was also neutral for TLR (adjusted HR 1.19, 95% CI 0.74 to 1.90, p = 0.47) and all-cause death (adjusted HR 0.81, 95% CI 0.56 to 1.18, p = 0.27). However, the bifurcation 2-stent strategy was associated with worse clinical outcomes than the bifurcation 1-stent strategy in TLR (adjusted HR 1.76, 95% CI 1.23 to 2.52, p = 0.002) and definite or probable stent thrombosis (crude HR 3.50, 95% CI 1.32 to 9.33, p = 0.01), despite neutral risk for all-cause death (adjusted HR 1.00, 95% CI 0.74 to 1.36, p = 0.99). There was no definite or probable very late stent thrombosis up to 5 years. In conclusion, long-term outcomes after stent implantation for unprotected LMCA lesions were not dependent on the bifurcation lesion types but related to the bifurcation stenting strategies with worse outcomes for the bifurcation 2-stent strategy.

Acute Coronary Syndrome With Unprotected Left Main Coronary Artery Culprit ― An Observation From the AOI-LMCA Registry ―

“…3,14-17 In particular, patients with ACS and cardiogenic shock exhibited 40% in-hospital mortality after PCI. 1,9 In this study, the 180-day mortality of patients with ACS with shock was 49.5%, which corroborated previous reports. 1 However, the 180day mortality of the ACS without shock group was 8.6%, which was much lower than in the ACS with shock group.…”

“…The details of the definitions used in this study were reported previously. 9 We defined unprotected LMCA disease as angiographically significant stenosis of the LMCA without patent surgical grafts to the left coronary artery system. We defined cardiogenic shock as Killip class 4 at presentation, indicating systolic blood pressure <90 mmHg and manifestations of hypoperfusion such as oliguria, cyanosis and diaphoresis.…”

Prognostic impact of final kissing balloon technique after crossover stenting for the left main coronary artery: from the AOI-LMCA registry

“…The AOI-LMCA (Assessing Optimal percutaneous coronary Intervention for Left Main Coronary Artery) stenting registry is a retrospective, multicenter registry that enrolled 1809 consecutive patients who underwent LMCA stenting with bare-metal stents or DES in 6 Japanese hospitals experienced with LMCA stenting between November 2004 and December 2012. The protocol and details of patient enrollment have been described elsewhere [ 6 ].…”

“…Secondary outcome measures included all-cause death, cardiac death, sudden death, MI, definite or probable ST, stroke, any coronary revascularization, or major adverse cardiovascular events (MACE: cardiac death, MI, or TLR) at 5-year. Definitions for each endpoint have been previously described in detail [ 6 ].…”

“…Percutaneous coronary intervention (PCI) has been more and more frequently performed in patients with LMCA disease with a low-moderate SYNTAX (SYNergy between percutaneous coronary intervention with TAXus and cardiac surgery) score as an alternative to CABG, due to improvements of drug-eluting stents (DES) and advancing technique [ 4 , 5 ]. A 1-stent strategy is currently considered a standard stenting strategy for LMCA bifurcation lesions, because a 2-stent strategy is associated with higher rates of adverse events such as target lesion revascularization (TLR), and stent thrombosis (ST) [ 6 , 7 ]. However, the role of final kissing balloon technique (FKBT) after crossover stenting for the main branch is controversial for lesions at any bifurcation [ 8 ].…”