Controversies in the Indications of Percutaneous Angioplasty Or Coronary Artery Bypass Grafting In The Treatment Of Left Main Disease (original) (raw)
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Revista de Chimie
The aim of our study was to assess the percutaneous coronary angioplasty versus coronary artery bypass grafting in the treatment of the left main coronary artery disease. The study was a prospective, analytical, observational descriptive one, it included a total number of 83 patients, consecutively included in order to avoid bias, for a period of three years between October 2012 and December 2015. The follow-up was performed for 3 years, initially at one month, then at an interval of three to six months. The primary clinical endpoint was mortality of any cause of the patients included in the study. Other main objectives assessed in our study were symptomatic ischemic heart disease manifested with angina pectoris, the need for myocardial revascularization, nonfatal myocardial infarction, and reduction of left ventricular ejection fraction. In patients with LMCAD, we noticed an increase in mortality in patients with PCI vs. CABG, recurrence of angina pectoris, acute myocardial infarct...
Journal of Cardiovascular Medicine, 2018
BACKGROUND Treatment of patients with ULMCA (unprotected left main coronary artery disease) with percutaneous coronary intervention (PCI) has been compared with coronary artery bypass graft (CABG), without conclusive results. METHODS All randomized controlled trials (RCTs) and observational studies with multivariate analysis comparing PCI and CABG for ULMCA were included. Major cardiovascular events (MACEs, composite of all-cause death, MI, definite or probable ST, target vessel revascularization and stroke) were the primary end points, whereas its single components were the secondary ones, along with stent thrombosis, graft occlusion and in-hospital death and stroke. Subgroup analyses were performed according to Syntax score. RESULTS Six RCTs (4717 patients) and 20 observational studies with multivariate adjustment (14 597 patients) were included. After 5 (3-5.5) years, MACE rate was higher for PCI [odds ratio (OR) 1.10, 95% confidence interval (CI) 1.07-1.14], without difference in death, whereas more relevant risk of MI was because of observational studies. Coronary stenting increased risk of revascularization (OR 1.52; 95% CI 1.34-1.72). At meta-regression, performance of PCI was improved by use of intra-coronary imaging and worsened by first generation stents, whereas two arterial grafts increased benefit of CABG. For patients with Syntax score less than 22, MACE rates did not differ, whereas for higher values, CABG reduced MACE because of lower risk of revascularization. Incidence of graft occlusion was 3.24% (2.25-4.23), whereas 2.13% (1.28-2.98: all CI 95%) of patients experienced stent thrombosis. CONCLUSION Surgical revascularization reduces risk of revascularization for ULMCA patients, especially for those with Syntax score greater than 22, with a higher risk of in-hospital death. Intra-coronary imaging and use of arterial grafts improved performance of revascularization strategies.
Interventional Cardiology Review, 2013
There have been over a dozen studies in the drug-eluting stent era comparing the effectiveness of percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) surgery for the treatment of unprotected left main disease. These studies have been both randomised and observational in nature. While both methodologies provide important insights, careful consideration of their respective strengths and limitations is imperative in generalising their findings.
Left Main Coronary Artery Interventions
Interventional Cardiology Review
The management of left main coronary artery (LMCA) disease has evolved over the past two decades. Historically, coronary artery bypass grafting (CABG) surgery has been the gold standard for the treatment of LMCA disease. However, with the advancements in percutaneous coronary interventions (PCIs) and stent technology, PCI in select patients has achieved comparable outcomes to CABG. As such, this has led to changes in the American College of Cardiology and European Society of Cardiology guidelines, which recommend that PCI might be an alternative to CABG in select patients. In this review article, we describe the historical perspective and early experience with coronary interventions of LMCA disease, landmark clinical trials and their effect on guidelines, and the role of intravascular imaging in the management of LMCA lesions.
Kardiologia Polska, 2013
Background: Left main stenosis (LMS) occurs in 5-7% of patients with coronary artery disease. Half of patients with left main coronary artery (LMCA) disease die within few years after the diagnosis. Aim: To evaluate survival of patients with LMCA disease treated with coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), or managed medically due to lack of consent for CABG or being considered unsuitable candidates for CABG/PCI. Methods: In 2006-2008, a significant LMS was found in 257 (5.14%) patients, and 98.44% of these patients were followed up for on average 15.1 months. The patients were divided into 5 groups according to the treatment used. CABG was performed in 67% of patients, PCI of an unprotected LMS in 8% of patients, and 12% of patients were treated with PCI after a previous CABG (protected LMS). The remaining patients were managed medically: 4% were not considered suitable for CABG, and 9% did not give their consent for CABG. Results: Total mortality in the overall study group (n = 253) was 14.6%. Multivessel disease was more frequent in the CABG group (60.9% vs. 15.8%, p < 0.001). Mortality in CABG and PCI groups was comparable (11.4% vs. 15.8%). Patients in the PCI group were more frequently hospitalised due to recurrent angina (21.1% vs. 3.0%, p < 0.001) and the need for repeated revascularisation (15.8% vs. 1.2%, p < 0.001). Compared to the CABG group, patients considered not suitable for CABG had lower left ventricular ejection fraction (LVEF) (36.55% vs. 51.04%, p < 0.001) and a higher mortality risk as estimated by the EuroScore. Mortality among patients deemed unsuitable for CABG was 54.6% (p < 0.001) and myocardial infarctions were observed more frequently in this group (18.2% vs. 2.4%, p < 0.01). In comparison to the CABG group, patients who did not consent to CABG were older (71.04 vs. 65.99 years, p = 0.027), had lower LVEF (44.05% vs. 51.04%, p = 0.004), were less frequently hospitalised due to acute coronary syndromes (17.4% vs. 40.8%, p = 0.03), and had a smaller degree of LMS (63% vs. 71%, p = 0.027). Mortality in this group was comparable to the CABG group (17.4% vs. 11.4%). The majority of patients who underwent previous CABG needed repeated revascularisation: PCI of a protected LMS was performed in 27% of patients, PCI of other native coronary arteries in 39% of patients, and PCI of a bypass graft in 7% of patients. Conclusions: PCI of unprotected LMCA may be an equally effective revascularisation method as CABG. High mortality (55%) due to concomitant diseases was observed among patients with LMS who were deemed unsuitable candidates for CABG. Prognosis among patients who declined CABG was relatively good and might have been related to the small number of patients and different patient characteristics in this group.
Coronary Artery Bypass Graft for Left Main Coronary Artery Disease
Journal of King Abdulaziz University - Medical Sciences
Because left main coronary artery disease carries a high risk of morbidity and mortality, this retrospective study will review the data and results of surgical management of left main coronary artery disease, in King Abdulaziz University Hospital. 448 patients underwent coronary bypass graft into two groups, left main group (50) patients and non-left main group (398) patients. Preoperative data, risk factors and cardiac catheterization findings were compared in between the two groups in addition to perioperative morbidity and mortality. Patients in the left main group were younger in age with significantly lower ejection fraction and more risk factors (hypertension, dyslipidemia, and smoking). In our study the left main group patients had higher mortality than non-left main patients [4 patients = 8%, 6 patients = 1.8%]; the most common cause of perioperative mortality in the left main group was low cardiac output state, and the most common complications were perioperative myocardial...
Stenting versus surgery for significant left main disease
Current cardiology reports, 2015
For decades, coronary artery bypass grafting (CABG) has been the choice of revascularization strategy for significant left main coronary artery (LMCA) disease. However, with marked technological advances in less invasive percutaneous strategies, such as drug-eluting stents, and potent adjunctive pharmacology, percutaneous coronary intervention (PCI) has been increasingly accepted as an alternative to CABG for selected cases with LMCA disease. The available evidence from randomized clinical trials and adequately sized, real-world registries suggest that hard clinical endpoints (death, myocardial infarction, or stroke) were comparable between two treatment strategies at short- and mid-term follow-up, while higher rate of repeat revascularization are observed after PCI. Current guidelines state that PCI for LMCA disease is reasonable in patients with low to intermediate anatomic complexity and those who are at increased surgical risk. Ongoing large-sized clinical trials comparing newer...
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.