Randomized Trial of Stents versus Bypass Surgery for Left Main Coronary Artery Disease

Park, Seung Jung; Kim, Young Hak; Park, Duk‐Woo; Yun, Sung Cheol; Ahn, Jung Min; Song, Hae-Geun; Lee, Jong‐Young; Kim, Won Jang; Kang, Soo Jin; Lee, Seung Whan; Lee, Cheol Whan; Park, Seong Wook; Chung, Cheol Hyun; Lee, Jae Won; Lim, Do Sun; Rha, Seung Woon; Lee, Sang Gon; Gwon, Hyeon Cheol; Kim, Hyo Soo; Chae, In Ho; Jang, Yangsoo; Jeong, Myung Ho; Tahk, Seung Jea; Seung, Ki Bae

doi:10.1056/nejmoa1100452

Cited by 565 publications

(344 citation statements)

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“…Thus in the KoreanPRECOMBAT trial of drug-eluting stenting versus CABG in 600 patients, 8.7% of patients in the stent group and 6.7% in the CABG group met the primary end point (a composite of death, MI, stroke and ischaemiadriven revascularisation at 12 months), a difference significant for the non-inferiority of stenting. 17 As in previous randomised comparisons, the differ ence was driven largely by a higher rate of repeat revascular-isation in stent recipients (9.0% vs 4.2% after 2 years, p=0.02).…”

Section: Left Main Stem Diseasementioning

confidence: 49%

Almanac 2012: Cardiovascular risk scores: The national society journals present selected research that has driven recent advances in clinical cardiology

Meier¹

2013

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Almanah 2012 serijaPercutaneous coronary intervention versus medical treatment P ercutaneous coronary intervention (PCI) has guide line recommendations for treatment of ST elevation and non-ST elevation myocardial infarction (MI).1 However, its role in stable coronary disease has been the subject of reappraisal following publication of the COURAGE trial, which showed that, in patients receiving optimal medical therapy, PCI does not improve cardiovascular outcomes, while incremental benefits for quality of life disappear by 36 months.2 3 A more recent meta-analysis of eight trials of optimal medical therapy versus PCI involving 7229 patients bears out the COURAGE conclusions by showing no significant differences between the groups with regard to death (9.1% vs 8.9%), non-fatal MI (8.1% vs 8.9%), unplanned revascularisation (30.7% vs 21.4%) and persistent angina (33% vs 29%).4 Drug-eluting stents (DESs) were used in only a minority of these patients and may have reduced the need for further revascularisation while improving symptomatic responses. Nevertheless, the meta-analysis reinforces contemporary guideline advice for optimal medical treatment as the initial treatment for stable angina.5 Whether this will change current practice remains to be seen, but early signs are not encouraging. Thus a US registry analysis of patients undergoing PCI before (n=173416) and after (n=293 795) the COURAGE report showed no change in the proportions receiving optimal medical treatment (43.5% vs 44.7%). 6 PCI versus coronary bypass surgery

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Section: Left Main Stem Diseasementioning

confidence: 49%

Almanac 2012: Cardiovascular risk scores: The national society journals present selected research that has driven recent advances in clinical cardiology

Meier¹

2013

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“…17 As in previous randomised comparisons, the difference was driven largely by a higher rate of repeat revascularisation in stent recipients (9.0% vs 4.2% after 2 years, p¼0.02).…”

Section: Thus In the Koreanmentioning

confidence: 56%

Almanac 2012: Interventional cardiology

Meier

2013

Revista Portuguesa de Cardiologia (English Edition)

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The field of interventional cardiology continues to progress quickly. The efficacy of percutaneous interventions with newer generation drug-eluting stents has advanced a lot over the last decade. This improvement in stent performance has broadened the level of indication towards more complex interventions such as left main and multivessel PCI. Major improvements continue in the field of medical co-therapy such as antiplatelet therapies (bivalirudin, prasugrel, ticagrelor) and this will further improve outcomes of PCI. The same is true for intravascular imaging such as ultrasound IVUS and optical coherence tomography OCT. However, interventional cardiology has become a rather broad field, also including alcohol septal ablation for hypertrophic obstructive cardiomyopathy, etc. At the moment, the fastest growing area is the structural interventions, especially for aortic valve stenosis (transcatheter aortic valve implantation TAVI) and for mitral regurgitation (mitral clipping). This review covers recent advances in all these different fields of interventional cardiology. PERCUTANEOUS CORONARY INTERVENTION VERSUS MEDICAL TREATMENTPercutaneous coronary intervention (PCI) has guideline recommendations for treatment of ST elevation and non-ST elevation myocardial infarction (MI). 1 However, its role in stable coronary disease has been the subject of reappraisal following publication of the COURAGE trial, which showed that, in patients receiving optimal medical therapy, PCI does not improve cardiovascular outcomes, while incremental benefits for quality of life disappear by 36 months. A more recent meta-analysis of eight trials of optimal medical therapy versus PCI involving 7229 patients bears out the COURAGE conclusions by showing no significant differences between the groups with regard to death (9.1% vs 8.9%), non-fatal MI (8.1% vs 8.9%), unplanned revascularisation (30.7% vs 21.4%) and persistent angina (33% vs 29%).4 Drug-eluting stents (DESs) were used in only a minority of these patients and may have reduced the need for further revascularisation while improving symptomatic responses. Nevertheless, the meta-analysis reinforces contemporary guideline advice for optimal medical treatment as the initial treatment for stable angina.

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“…7,8) In addition, a recent observational study from Chinese investigators has shown that DES-based PCI was superior to CABG in reducing major adverse cardiac/cerebral events and bleeding complications among aged patients (average age 72.5, range 60-89) with nonprotected LMCA-disease. 9) However, restenosis of the DES implanted in LMCA is not uncommon (reaching 10% to 20%), [10][11][12] and it could theoretically provoke a broad myocardial ischemia, leading to a fatal outcome.…”

Section: Discussionmentioning

confidence: 99%

Rotational Atherectomy Followed by Drug-Coated Balloon Dilation for Left Main In-Stent Restenosis in the Setting of Acute Coronary Syndrome Complicated with Right Coronary Chronic Total Occlusion

et al. 2017

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SummaryAn 83-year-old man presented with recurrent acute coronary syndrome (ACS) at the left main coronary artery (LMCA) complicated with ostial chronic total occlusion (CTO) in the right coronary artery (RCA) (RCA-CTO). At the first LMCA-ACS approximately 1 year earlier, he had undergone LMCA-crossover stenting with a biolimus-eluting stent in the presence of RCA-CTO. At the second LMCA-ACS, we angiographically confirmed severe in-stent restenosis in the distal LMCA, in addition to angled severe stenosis in the just proximal LCx, and performed primary PCI for the LMCA bifurcation lesion under intra-aortic balloon pumping support. Because of difficulty in crossing a guidewire through the just proximal LCx lesion, we first performed rotational atherectomy against the LMCA in-stent eccentric lesion. After successfully crossing the guidewire into the LCx, we added balloon dilation with kissing balloon inflation followed by alternate drug-coated balloon dilation. An eight-month follow-up coronary angiography revealed no further vessel narrowing in the LMCA bifurcation lesion.(Int Heart J 2017; 58: 806-811) Key words: Acute myocardial infarction, Intravascular Ultrasound, Percutaneous coronary intervention S ignificant unprotected left main coronary artery (LMCA) disease in the presence of chronic total occlusion (CTO) in the right coronary artery (RCA) (RCA-CTO) is a deteriorated condition with high morbidity and mortality, 1) and generally remains an absolute candidate for coronary artery bypass grafting (CABG) surgery even during new-generation drug-eluting stent (DES) era. Drug-coated balloon (DCB) has now played a central role in the treatment for in-stent restenosis (ISR) through inhibiting neointimal hyperplasia, 2,3) despite its little evidence for ISR in DES implanted in LMCA. [4][5][6] We describe our experience with an unusual critical case of recurrent acute coronary syndrome (ACS) due to ISR in LMCA complicated with ostial RCA-CTO, in which rotational atherectomy followed by DCB dilation against the LMCA bifurcation lesion could defer a further repeat intervention. Case ReportAn 83-year-old man with repeat ACS was admitted to our hospital due to general fatigue and chest discomfort for 24 hours. His coronary risk factors included hypertension and diabetes mellitus. He had experienced inferior myocardial infarction (MI) 35 years earlier, and undergone percutaneous coronary intervention (PCI) using a bare metal stent (BMS) (Multi-link Penta 2.5/18) for a posterolateral branch of the left circumflex coronary artery (LCx) 12 years before. He had suffered from LMCA-culprit ACS complicated with ostial RCA-CTO ( Figure 1A-C) and undergone LMCA-left anterior descending coronary artery (LAD) crossover stenting with a biolimus-eluting stent (Nobori 3.5/18) under intra-aortic balloon pumping (IABP) support 11 months earlier ( Figure 1D-F). Preprocedural intravascular ultrasound imaging (IVUS) depicted much concentric plaque with partial superficial calcification (Figure 2A), and final IVUS after the stent implantat...

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Randomized Trial of Stents versus Bypass Surgery for Left Main Coronary Artery Disease

Cited by 565 publications

References 34 publications

Almanac 2012: Cardiovascular risk scores: The national society journals present selected research that has driven recent advances in clinical cardiology

Almanac 2012: Cardiovascular risk scores: The national society journals present selected research that has driven recent advances in clinical cardiology

Almanac 2012: Interventional cardiology

Rotational Atherectomy Followed by Drug-Coated Balloon Dilation for Left Main In-Stent Restenosis in the Setting of Acute Coronary Syndrome Complicated with Right Coronary Chronic Total Occlusion

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