Percutaneous coronary intervention for unprotected left main disease in very high risk patients: safety of drug-eluting stents (original) (raw)
Related papers
Coronary Artery Disease, 2024
Background In percutaneous coronary intervention (PCI) procedures for patients with unprotected left main coronary artery (ULMCA) lesions, intravascular ultrasonography (IVUS) guidance has shown potential for enhancing clinical outcomes. However, studies confirming its superiority to conventional angiographic-guided PCI remain few. This study aimed to assess if IVUS-guided PCI for patients with unprotected LMCA stenosis improves clinical outcomes compared to angiographic-guided PCI. Methods This randomized clinical study enrolled 181 patients with ULMCA lesions scheduled for drug-eluting stent implantation. Patients were split into 90 in the IVUS-guided group and 91 in the conventional group. Procedural characteristics, clinical outcomes, and the incidence of major adverse cardiovascular event (MACE) were evaluated for all patients. The risk reduction associated with IVUS-guided PCI was evaluated using a multivariate Cox regression analysis. Results Patients who underwent IVUS demonstrated significantly higher pre-dilatation before stenting (88.9% vs. 72.5%, P = 0.005), post-dilatation balloon diameter (4.46 ± 0.48 vs. 4.21 ± 0.49, P < 0.001), stent diameter (3.9 ± 0.4 vs. 3.7 ± 0.3, P = 0.002), and pressure for post dilatation (18 ± 3 vs. 16 ± 2, P = 0.001). Regarding 12-month outcomes, patients who underwent IVUS demonstrated significantly lower MACE (3.3% vs. 18.7%, P < 0.001) than those who underwent the conventional method. Multivariate Cox regression analysis revealed that IVUS was related to 84.4% risk reduction of 1-year MACE (HR = 0.156, 95% CI = 0.044–0.556, P = 0.004). Conclusion Compared to angiographic-guided PCI, IVUS-guided PCI resulted in improved clinical results and a markedly reduced risk of MACE in patients with ULMCA lesions.
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. '
Catheterization and Cardiovascular Interventions, 2009
Objective: We examined mortality, risk of myocardial infarction (MI), and target lesion revascularization (TLR) in high-risk patients with unprotected left main (LM) percutaneous coronary intervention (PCI) in Western Denmark. Background: PCI of left main coronary artery lesions may be an alternative to coronary artery bypass grafting in high-risk surgical patients. Methods: From January 2005 to May 2007, all patients who had unprotected LM PCI with stent implantation were identified in the Western Denmark Heart Registry. The indications for PCI were: (1) ST segment elevation MI (STEMI), (2) non-STEMI (NSTEMI) or unstable angina, and (3) stable angina. All patients were followed up for 18 months. Results: A total of 344 patients were treated with LM PCI (STEMI: 71, NSTEMI/unstable angina: 157, and stable angina: 116). In STEMI patients, the median logistic EuroSCORE was 22.5 (interquartile range 12.5-39.5), in non-STEMI (NSTEMI)/ unstable angina patients 13.8 (4.8-23.9), and in stable angina patients 4.8 (2.2-10.4). Mortality after 18 months 38.0, 18.5, and 11.2% (P < 0.001) in patients with STEMI, NSTEMI/ unstable angina, and stable angina, respectively. MI after 18 months was 9.9, 6.4, and 6.0% (P 5 ns), respectively. Four subacute and one late definite stent thrombosis were seen. TLR occurred in 5.6, 4.5, and 6.9% (P 5 ns) of patients, respectively. Conclusion: After PCI, patients with STEMI and LM culprit lesion have a high-mortality risk, whereas long-term outcome for patients with NSTEMI and stable angina pectoris is comparable with other high surgical risk patients with unprotected left main lesion. Further, TLR rates and risk of stent thrombosis were low. V C 2009 Wiley-Liss, Inc.
Percutaneous intervention in unprotected left main coronary artery lesions
Journal of Transcatheter Interventions
Background: The opportunity for percutaneous treatment of coronary artery disease in unprotected left main artery has increased. This treatment possibility is based on favorable results in the literature. The objective of this study was to compare the demographic profile and results of percutaneous coronary intervention in patients with unprotected left main coronary artery lesions. Methods: The period from 2006 to 2016 was analyzed, divided into three intervals-2006 to 2008, 2009 to 2011 and 2012 to 2016, based on the database of the Central Nacional de Intervenções Cardiovasculares (CENIC). We verified, in the sample, the influence of variables of interest in relation to mortality. Results: A total of 767 patients were included. Clinical, angiographic and procedural characteristics changed throughout the decade analyzed, mostly regarding greater use of drug-eluting stents. There was no difference in mortality or major adverse cardiovascular events. Acute clinical presentation, left ventricular dysfunction, hemodynamic instability or multivessel coronary artery disease were predictors of mortality by logistic regression analysis. Conclusion: The use of drug-eluting stents to address the unprotected left main coronary artery has increased in contemporary practice. Although no differences were found in cardiac event rates among the periods, it was noted that emergency procedures in unstable patients, patients with left ventricular dysfunction or with multivessel coronary artery disease remained as important predictors of mortality in this challenging scenario.
The American Journal of Cardiology, 2008
Percutaneous coronary intervention (PCI) of the unprotected left main coronary artery (LMCA) is controversial. In 143 patients who underwent PCI of the unprotected LMCA, 30-day mortality was compared with predicted cumulative risk-adjusted perioperative surgical mortality based on logistic European System for Cardiac Operative Risk Evaluation. One-year clinical follow-up was completed in all patients. The overall major adverse cardiac event rate at 1 year was 34.3%, reflecting the high-risk profile of the patient population. Twelve patients (8%) experienced an acute myocardial infarction and 16 (11%) underwent target lesion revascularization. In 31 patients (22%) who died during the first year, median logistic European System for Cardiac Operative Risk Evaluation was 30%. Calculated RRs showed significantly lower 30-day mortality using PCI compared with predicted surgical mortality (RR 0.54, 95% confidence interval 0.31 to 0.86). Angiographic follow-up in 90 of the 118 patients alive at 6 months showed binary restenosis of 6% in patients treated with drug-eluting stents versus 29% in patients receiving bare-metal stents (p <0.01). In conclusion, PCI for unprotected LMCA disease was associated with acceptable short-and medium-term outcomes in patients at low to intermediate risk of bypass surgery. Mortality remains high in very high-risk patients unsuitable for surgery. However, in selected indications, PCI of the LMCA can offer an alternative to surgery, especially when using drug-eluting stents.
Circulation, 2002
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 3.78±0.73 mm and lesion length was 6.6±3.0 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 >15 versus ≤15 (21.4% versus 4.2%, P =0.02) at 3 years. The independent covariate of cardiac death was preserved left ventricular ejecti...