Results and Long-Term Predictors of Adverse Clinical Events After Elective Percutaneous Interventions on Unprotected Left Main Coronary Artery

Abstract

Background-The safety and efficacy of percutaneous coronary intervention of de novo lesions in unprotected left main coronary arteries remains an unresolved issue. Methods and Results-We analyzed 67 consecutive patients treated with the following devices: 39 with stents, 12 with rotational atherectomy plus stents, 13 with directional coronary atherectomy plus stents (a total of 64 patients were treated with stents), and 3 patients with directional coronary atherectomy only. The reference vessel size was 3.78Ϯ0.73 mm and lesion length was 6.6Ϯ3.0 mm. In-hospital complications were 2 coronary artery bypass grafts (CABGs) (3.0%), 2 Q-wave myocardial infarctions (MIs) (3.0%), and 3 non-Q-wave MIs (4.5%); there were no deaths. The estimated cardiac survival at 3 years was 91%. The cardiac mortality rate was higher in patients with Parsonnet score Ͼ15 versus Յ15 (21.4% versus 4.2%, Pϭ0.02) at 3 years. The independent covariate of cardiac death was preserved left ventricular ejection fraction; for combined cardiac events (cardiac death, MI, repeat revascularization) it was large reference vessel size. Follow-up angiography at 5Ϯ2 months in 85% of eligible patients revealed 31.4% restenosis. Extending the follow-up to 31Ϯ23 months (19 patients with follow-up beyond 3 years) the cumulative event rates were 11 deaths (16.4%), 8 of them cardiac (11.9%), 2 (3.0%) MI, and 16 (23.9%) repeat revascularizations (CABG in 5 patients). Conclusions-Elective

Bail‐out stenting for left main coronary artery dissection during catheter‐based procedure: Acute and long‐term results

“…Previous studies of patients undergoing elective stenting for significant LMCA stenosis have shown that some patients inevitably developed angiographic restenosis; 7,13,14 this was not the case in this present study. This discrepancy may be explained by angiographically minimal plaque at the LMCA in this group of patients, a finding supported in a previous study 15 showing that neointima proliferation in stented coronary artery lesions correlated positively with preintervention plaque burden.…”

2009 Focused Updates: ACC/AHA Guidelines for the Management of Patients With ST‐Elevation Myocardial Infarction (Updating the 2004 Guideline and 2007 Focused Update) and ACC/AHA/SCAI Guidelines on Percutaneous Coronary Intervention (Updating the 2005 Guideline and 2007 Focused Update)

“…Moreover, because the overall study did not reach its primary end point, subset analyses are less robust; because noninferiority was not proven in this cohort, specific information for each subgroup is of an observational nature and is hypothesis-generating. 138,[140][141][142][143][144] and for patients with factors (such as severe lung disease, prior thoracic surgery, or poor bypass graft targets) that would make CABG a high-risk procedure or unlikely to be successful. Conversely, CABG surgery for unprotected left main CAD may be relatively more favorable for patients with left main CAD plus multivessel disease, 21 distal/bifurcation left main coronary artery lesions, 138,[140][141][142][143][144] or low surgical risk with a good chance of technical success.…”

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

“…Previous studies have noted that long-term follow-up is affected by a relatively high incidence of events such as cardiac death, MI, and re-intervention. 6) In fact, two patients in the PCI group had ischemia-driven TVR at the second year.…”

“…[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.…”