Characteristics and Long-Term Outcomes of Percutaneous Revascularization of Unprotected Left Main Coronary Artery Stenosis in the United States (original) (raw)
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Catheterization and Cardiovascular Interventions, 2011
Objectives: To evaluate the early and long-term outcomes of patients with normal left ventricular function who undergo elective unprotected left main coronary artery (ULMCA) percutaneous coronary intervention (PCI) with drug-eluting stents (DES). Background: Although the standard of care for patients with ULMCA disease is coronary artery bypass surgery, the current guidelines recommend PCI in clinical conditions that predict an increased risk of adverse surgical outcomes. The long-term outcomes of patients with low risk of adverse surgical outcomes who undergo PCI are unknown. Methods: Data from a multicenter international registry, which included 221 consecutive patients from four institutions with normal left ventricular function who underwent elective ULMCA PCI with DES from 2002 to 2009, were collected. Results: There was no cardiac death, Qwave myocardial infarction, target lesion revascularization (TLR), stent thrombosis, or stroke within the first 30 days. Seven (3%) patients had periprocedural myocardial infarction. Follow-up angiography was performed in 136 (62%) patients. Kaplan-Meier eventfree survival curves at 1 year for cardiac death and TLR rates were 97.7% 6 1.0% and 92.9% 6 1.8%, respectively. At the mean follow-up of 44.8 6 22.8 months, the event-free rates for cardiac death and TLR were 95.5% 6 1.5% and 88.9% 6 2.3%, respectively. Multivariate analyses identified the predictors of cardiac death: age ! 75 years (P 5 0.015) and history of myocardial infarction (P 5 0.017). Conclusions: Elective ULMCA PCI with DES in patients with normal left ventricular function is safe and effective with excellent short-term outcomes and favorable long-term outcomes and may be a viable option for low-risk patients with normal left ventricular function. V C 2011 Wiley-Liss, Inc.
The American Journal of Cardiology, 2012
Percutaneous coronary intervention (PCI) with drug-eluting stents is an accepted alternative to surgery for the treatment of unprotected left main coronary artery (ULMCA) disease, but the long-term outcome in elderly patients is unclear. Aim of our study was to compare the clinical outcomes of octogenarians with ULMCA disease treated either with PCI with drug-eluting stents or coronary artery bypass grafting (CABG). The primary study end point was the composite of death, cerebrovascular accident, and myocardial infarction at follow-up. A total of 304 consecutive patients with ULMCA stenosis treated with PCI or CABG and aged ‡80 years were selected and analyzed in a large multinational registry. Two hundred eighteen were treated with PCI and 86 with CABG. During the hospitalization, a trend toward a higher mortality rate was reported in PCI-treated patients (3.5% vs 7.3%, p [ 0.32). At a median follow-up of 1,088 days, the incidence of the primary end point was similar in the 2 groups (32.6% vs 30.2%, p [ 0.69). Incidence of target vessel revascularization at follow-up was higher in PCI-treated patients (10% vs 4.2%, p [ 0.05). At multivariate analysis, left ventricular ejection fraction was the only independent predictor of the primary end point (hazard ratio 0.95, 95% confidence interval 0.91 to 0.98, p [ 0.001). After adjustment with propensity score, the revascularization strategy was not significantly correlated to the incidence of the primary end point (hazard ratio 0.98, 95% confidence interval 0.57 to 1.71, p [ 0.95). In octogenarians, no difference was observed in the occurrence of the primary end point after PCI or CABG for the treatment of ULMCA disease. However, the rate of target vessel revascularization was higher in the PCI group. Ó 2014 Elsevier Inc. All rights reserved. (Am J Cardiol 2014;-:-e-)
Jacc-cardiovascular Interventions, 2014
Objectives This study sought to evaluate the impact of anatomic and procedural variables on the outcome of the unprotected left main coronary artery (uLMCA) itself after drug-eluting stent (DES) implantation. Background There is a controversial debate regarding when and how to perform percutaneous coronary intervention (PCI) for an uLMCA stenosis. Methods This analysis is based on a randomized study of 607 patients undergoing PCI for uLMCA, randomized 1:1 to receive paclitaxel-or sirolimus-eluting stents. We evaluated the impact of the SYNTAX score, uLMCA anatomy, and stenting technique on in-stent restenosis (ISR), target lesion revascularization (TLR), and the 3-year outcomes. Results The 3-year cardiac mortality rate was 5.8%; 235 (39%) patients had a true bifurcation lesion (TBL), and the median SYNTAX score was 27. TBL was associated with a higher need for multiple stents (72% vs. 37%, p < 0.001). TBL was a significant predictor of ISR (23% vs. 14%, p ¼ 0.008) and for TLR (18% vs. 9%, p < 0.001). The need for multiple stents was a predictor of ISR (22% vs. 13%, p ¼ 0.005) and for TLR (16% vs. 9%, p ¼ 0.005). Culotte stenting showed better results compared with T-stenting for ISR (21% vs. 56%, p ¼ 0.02) and for TLR (15% vs. 56%, p < 0.001). We observed a significant association between uLMCA-TLR and SYNTAX scores (9.2% for scores 22, 14.9% for scores 23 to 32, and 13.0% for scores !33, p ¼ 0.008). Conclusions PCI of uLMCA lesions with DES is safe and effective out to 3 years. TBL and multiple stents were independent predictors for ISR. In the multivariate analysis, independent predictors for TLR were TBL, age, and EuroSCORE (European System for Cardiac Operative Risk Evaluation).
Catheterization and Cardiovascular Interventions, 2009
Background: Patients who present with myocardial infarction (MI) and unprotected left main coronary artery (ULMCA) disease represent an extremely high-risk subset of patients. ULMCA percutaneous coronary intervention (PCI) with drug-eluting stents (DES) in MI patients has not been extensively studied. Methods: In this retrospective multicenter international registry, we evaluated the clinical outcomes of 62 consecutive patients with MI who underwent ULMCA PCI with DES (23 ST-elevation MI [STEMI] and 39 non-ST-elevation MI [NSTEMI]) from 2002 to 2006. Results: The mean age was 70 6 12 years. Cardiogenic shock was present in 24%. The mean EuroSCORE was 10 6 8. Angiographic success was achieved in all patients. Overall in-hospital major adverse cardiac event (MACE) rate was 10%, mortality was 8%, all due to cardiac deaths from cardiogenic shock, and one patient suffered a periprocedural MI. At 586 6 431 days, 18 patients (29%) experienced MACE, 12 patients (19%) died (the mortality rate was 47% in patients with cardiogenic shock), and target vessel revascularization was performed in four patients, all of whom had distal bifurcation involvement (two patients underwent repeat PCI and two patients underwent bypass surgery). There was no additional MI. Two patients had probable stent thrombosis and one had possible stent thrombosis. Diabetes [hazard ratio (HR) 4.22, 95% confidence interval (CI) (1.07-17.36), P 5 0.04), left ventricular ejection fraction [HR 0.94, 95% CI (0.90-0.98), P 5 0.005), and intubation [HR 7.00,, P 5 0.009) were significantly associated with increased mortality. Conclusions: Patients with MI and ULMCA disease represent a very high-risk subgroup of patients who are critically ill. PCI with DES appears to be technically feasible, associated with acceptable long-term outcomes, and a reasonable alternative to surgical revascularization for MI patients with ULMCA disease. Randomized trials are needed to determine the ideal revascularization strategy for these patients. '
European Journal of Cardio-Thoracic Surgery, 2012
OBJECTIVES: To compare the safety and efficacy of coronary artery bypass grafting (CABG) with percutaneous coronary intervention (PCI) using drug-eluting stents (DES) in patients with unprotected left main coronary artery (ULMCA) disease. METHODS: MEDLINE, EMBASE, CENTRAL/CCTR, SciELO, LILACS, Google Scholar and reference lists of relevant articles were searched for clinical studies that reported outcomes at the 1-year follow-up after PCI with DES and CABG for the treatment of ULMCA stenosis. Sixteen studies (three randomized controlled trials and 13 observational studies) were identified and included a total of 5674 patients (2331 for PCI with DES and 3343 for CABG). RESULTS: At the 1-year follow-up, there was no significant difference between the CABG and DES groups in the risk for death (odds ratio [OR] 0.691, P = 0.051) or the composite endpoint of death, myocardial infarction or stroke (OR 0.832, P = 0.258). The risk for target vessel revascularization (TVR) was significantly higher in the PCI group compared with the CABG group (OR 3.597, P < 0.001). The risk of major adverse cardiac and cerebrovascular events (MACCE) was significantly higher in the PCI group compared with the CABG group (OR 1.607, P < 0.001). A publication bias was observed regarding the outcome of death and also a considerable heterogeneity effect on the composite endpoint of death, myocardial infarction or stroke and MACCE. CONCLUSIONS: CABG surgery remains the best option of treatment for patients with ULMCA disease, with less need of TVR and lower MACCE rates.
The American Journal of Cardiology, 2012
disease is complex because of patient and lesion factors; however, limited data exist on the outcomes of drug-eluting stent (DES) use for this indication. DEScover is a prospective observational study that enrolled consecutive patients with PCI in 2005. In-hospital and 1-year statuses were analyzed for 6,172 patients treated with DES according to LM and coronary artery bypass grafting (CABG) statuses (PLM, n ؍ 93; previous CABG native vessel non-LM, n ؍ 722; no previous CABG, n ؍ 5,357). Cumulative event rates were calculated by the Kaplan-Meier method. Cox proportional hazards regression was used for multivariable analysis of adverse events. Baseline clinical, angiographic, and procedural variables differed significantly among groups, with patients with previous CABG, PLM, and non-LM having higher risk characteristics. In patients with previous CABG, after adjustment with CABG non-LM as a reference group, there were no significant differences in 1-year risk of any adverse event except a trend toward a greater risk of myocardial infarction (MI) in patients with PLM (adjusted hazard ratio 2.4, confidence interval 0.95 to 6.2, p ؍ 0.06). However, patients after CABG (PLM and non-LM) compared to patients without previous CABG had a similar adjusted risk of death, MI, and stent thrombosis; an increased risk of target lesion revascularization (adjusted hazard ratio 1.79, confidence interval 1.2 to 2.6, p ؍ 0.003), target vessel revascularization and death/MI/target vessel revascularization; and a lower risk of CABG (adjusted hazard ratio 0.25, confidence interval 0.09 to 0.67, p ؍ 0.006). In conclusion, status after CABG rather than PLM location increases the risk of repeat revascularization with PCI in DES-treated patients. © 2012 Elsevier Inc. All rights reserved. (Am J Cardiol 2012;109:466 -470) * Serum cholesterol Ͼ240 mg/100 mL or on medical therapy.