Is the left main just another artery to FFR?

• This meta‐analysis includes all prospective FFR studies of the left main artery with outcomes.
• Patients who had deferral of revascularization in FFR‐negative stenoses had no difference in cardiovascular events compared with patients who underwent revascularization.
• FFR‐guided revascularization of left main stenosis is safe and effective.

     

Is it necessary to operate quickly in patients with significant left main coronary stenosis?

Although coronary bypass surgery is performed rapidly in the majority of cases of left main coronary stenosis to prevent cardiovascular complications, there is no reported consensus in the literature about the ideal interval between diagnostic coronary angiography and surgery. The aim of this multicenter study was to make an inventory of the serious vascular cardiovascular events which occurred between coronary angiography and surgery to determine possible predictive factors for complications and thereby identify a high risk subgroup requiring immediate revascularisation. The population comprised 283 patients with significant left main coronary disease, out of a total of 8,205 patients who underwent coronary angiography in the university hospitals of Angers, Brest, Nantes, Poitiers and Rennes. A surgical indication was retained in 216 patients. The choice of the operation date depended on clinical data in the presence of an acute coronary syndrome, patients remaining in the intensive care unit and undergoing revascularisation rapidly. Serious cardiac events (death, myocardial infarction, refractory unstable angina and left ventricular failure) occurring while waiting for surgery were rare, observed in only 6.5% of patients. Recent myocardial infarction and, to a lesser degree, unstable angina and/or left ventricular systolic dysfunction, were predictive of serious cardiac complications before surgery. The severity of the left main coronary disease and the association of right coronary disease did not increase the risk of serious cardiac events in the preoperative period. The low incidence of complications demonstrates that this strategy enables patients to wait for surgery with an acceptable risk without having to operate all patients with left main coronary disease as an emergency.     

Is off-pump coronary artery bypass surgery safe for left main coronary artery stenosis?

BACKGROUND: The feasibility of off-pump coronary artery bypass surgery has been well demonstrated. The purpose of the present study was to assess the safety and efficacy of off-pump coronary artery surgery in patients with left main coronary artery disease. METHODS AND RESULTS: Between January 1997 and December 2000, 174 patients with significant left main coronary artery stenosis underwent coronary artery bypass grafting without a pump. During the same period, 991 patients who also had significant left main coronary artery stenosis underwent coronary artery surgery on a pump. The patients in the two groups were matched in preoperative variables except that those in the off-pump group were slightly older, and more required urgent surgery. Hospital mortality was 2/174 and 21/991 in the off-pump and on-pump groups, respectively (p=0.560). The incidence of perioperative myocardial infarction (1.74 v. 14/991, p=0.712), atrial fibrillation (17/174 v 157/991, p=0.050) and blood transfusion requirement (63/174 v. 476/991, p=0.05) were significantly less in the off-pump group. The intubation time (15+/-3 hours v 22+/-4 hours, p=0.001), blood loss (365+/-61 ml v 582+/-76 ml, p<0.001), intensive care unit stay (23+/-10 hours v. 36+/-11 hours, p<0.001) and hospital stay (6+/-4 days v. 9+/-5 days, p <0.001) were also less in the off-pump group. CONCLUSIONS: Off-pump coronary artery bypass surgery is safe and effective for patients with left main coronary artery disease.     

Should we treat patients with moderately severe stenosis of the left main coronary artery and negative FFR results?

BACKGROUND: The prognostic importance of significant left main coronary artery disease is unequivocal. However, moderate lesions of the left main coronary artery (LMCA) are sometimes found in patients presenting significant stenosis in other coronary arteries or equivocal symptoms. The ability of myocardial fractional flow reserve (FFR) to predict coronary events could be useful in the decision-making process in these patients. The present study was designed to investigate the occurrence of cardiac events in patients with coronary syndromes and LMCA stenosis of moderate severity in whom FFR failed to show an haemodynamic significant repercussion of the LMCA. METHODS AND RESULTS: We studied 27 consecutive patients (mean age 62.7 +/- 10.5 years) with moderate stenoses (30-50%) of the LMCA. In seven patients who presented significantly reduced FFR (< 0.75) at the LMCA level (Group A), coronary revascularization of this vessel was performed. In 20 patients with negative FFR (greater than or equal to 0.75) at the LMCA level (Group B), the LMCA stenosis was not revascularized, being the revascularization procedures (if any) limited to other arteries with significant obstructions. During a mean follow-up period of 26.2 +/- 12.1 months, clinical events occurred in 3 patients in the whole group. One patient with positive FFR died during coronary bypass surgery. Two group B patients were surgically revascularized 4 months and 4 years after the initial coronariography. CONCLUSIONS: Patients with coronary lesions of moderate severity on the LMCA and negative FFR may constitute a subgroup of good prognosis in the follow-up. Our findings suggest that negative FFR is a potentially useful indicator of the likelihood of cardiac events, and thus represents a useful aid in clinical decision-making in the hemodynamics laboratory.     

Is it time for elective left main percutaneous coronary intervention to become ‘main stream‘?

Left main (LM) stenting is considered by many to be one of the last frontiers of interventional cardiology. Beginning with the VA cooperative study published in 1976 demonstrating a mortality benefit for patients undergoing coronary artery bypass grafting (CABG), the standard of care for treatment of left main coronary artery disease has been surgical. The most recent 2005 update of the ACC/AHA/SCAI Practice Guidelines on PCI again notes that "CABG using IMA grafting is the 'gold standard' for treatment of unprotected left main disease and has proven benefit on long-term outcomes"     

Is percutaneous coronary intervention as effective as bypass surgery in left main stem coronary artery stenosis?

Recent advances in percutaneous coronary intervention (PCI) have rekindled interest in this treatment modality also in the setting of unprotected left main stenosis. Randomized trials reported a similar risk of death or myocardial infarction between PCI and coronary artery bypass grafting (CABG). However, rates of stroke were higher after CABG, whereas patients undergoing PCI had a higher risk of repeat revascularization. Although CABG remains the standard of care for left main stenosis in current guideline recommendations, PCI is considered a reasonable alternative in patients with low to intermediate anatomical complexity and at increased surgical risk. An interdisciplinary assessment is indispensable in order to choose the best treatment option for each individual patient.     

Is there a role for the left ventricle apical-aortic conduit for acquired aortic stenosis?

BACKGROUND AND AIM OF THE STUDY: Aortic valve replacement (AVR) in patients with a heavily calcified ascending aorta and aortic root, or with conditions that preclude a median sternotomy, poses a formidable challenge. A left ventricle apical-aortic conduit (AAC) is an alternative in these situations. Herein, the authors' experience with AAC in adult patients with acquired aortic stenosis is reported. METHODS: Between 1995 and 2003, 13 patients (mean age 71 years) underwent AAC for severe symptomatic aortic stenosis (mean valve area 0.65 +/- 0.02 cm2). Indications for AAC were heavily calcified ascending aorta and aortic root (n = 5), patent retrosternal mammary grafts (n = 4), calcified ascending aorta and aortic root plus patent retrosternal mammary graft (n = 1), retrosternal colonic interposition (n = 1) and multiple previous sternotomies (n = 2). Seven patients had previous coronary artery bypass grafting (CABG). The mean preoperative left ventricular ejection fraction was 50 +/- 4%. RESULTS: AAC were performed under cardiopulmonary bypass through a left thoracotomy (n = 10), median sternotomy (n = 2) or bilateral thoracotomy (n = 1). Hearts were kept beating (n = 5) or fibrillated (n = 7). Circulatory arrest was used in one patient. Composite Dacron conduits with biological (n = 6), mechanical (n = 4) or homograft (n = 2) valves were used. Distal anastomoses were performed in the descending thoracic aorta (n = 12) or in the left iliac artery (n = 1). Two patients underwent simultaneous CABG. Three patients died in-hospital from ventricular failure (n = 1), intravascular thrombosis (n = 1) and multi-organ failure (n = 1). The mean hospital stay was 26 days. Complications included respiratory failure requiring tracheostomy (n = 2), stroke (n = 1) and re-exploration for bleeding (n = 2). At a mean follow up of 2.1 years, there have been four late deaths; causes of death were congestive heart failure (n = 2), ischemic cardiomyopathy (n = 1) and cancer (n = 1). CONCLUSION: AAC provides an acceptable alternative to AVR in selected patients who are at exceedingly high risk for the standard procedure.     

Asymptomatic severe aortic stenosis with normal left ventricular function – A review

Aortic stenosis (AS) is one of the commonest forms of acquired valvular heart disease. Aortic valve replacement (AVR) is the treatment of choice for symptomatic severe AS. Conservative management is usually advocated for asymptomatic severe AS. But there are data on predictors to identify subsets of asymptomatic AS patients at high risk of cardiac events in whom early surgical intervention is warranted. Non-invasive tests like exercise stress test, exercise echocardiography will help us to identify those who are at high risk of developing early symptoms due to LV dysfunction and also those at high risk of sudden death. In this article, an attempt is made to review the literature on this subset of asymptomatic severe AS to help clinicians to decide regarding the need for early aortic valve replacement in them.