Initial and long-term results of directional coronary atherectomy in unprotected left main coronary artery

Angioplasty in the unprotected left main coronary artery (LMCA) has been controversial. Recently, several studies have suggested that new procedures and devices such as directional coronary atherectomy (DCA) and stents may change this situation. Although there are many reports of unprotected LMCA stenting, there are few reports of DCA of this lesion. Therefore, initial and long-term results were evaluated in 101 patients who underwent DCA for unprotected LMCA in our hospital. Emergency procedures were performed in 15 patients and electively in 86 patients. Scheduled angiographic follow-up was routinely performed, and all patients were clinically followed for >4 months after DCA. Technical success was achieved in 99%, and in-hospital outcomes were cardiac death (2%), noncardiac death (4%), Q-wave myocardial infarction (1%), non-Q-wave myocardial infarction (8.9%), coronary artery bypass grafting (0%), and repeat angioplasty (4%). In-hospital results varied considerably, depending on presentation. In-hospital mortality was significantly higher in the emergency, left ventricular ejection fraction < or =35%, and high-risk surgical subgroups. The angiographic restenosis rate was 20.4% at follow-up, and its predictor was postminimal lumen diameter by multivariate analysis. Mean clinical follow-up was 2.8 years; estimated 1- and 3-year survival rates were 87% and 80.7%, respectively. The cardiac survival rate of the low-risk surgical subgroup was significantly higher than that of the high-risk surgical subgroup (p <0.05). Thus, our data show that DCA can be performed safely and effectively in unprotected LMCA with an acceptable low restenosis rate and high survival rate.     

无保护左主干病变经皮冠状动脉介入治疗的近期和远期疗效

目的　探讨无保护左主干病变 (UPLMT)经皮冠状动脉介入治疗 (PCI)的近、远期疗效。方法　自 1992年 12月至 2 0 0 2年 12月期间 ,对 174例UPLMT行PCI,其中定向斑块旋切术 (DCA) 12 1例 ,支架术 5 3例。其中 85例被列为不能耐受冠状动脉旁路移植术 (CABG)或外科手术高危。术后半年内每月至少门诊复查一次 ,以后定期随诊、电话随访。术后 3、6、12月行冠状动脉造影复查。结果　PCI术均获血管造影成功。住院期间主要不良心脏事件 (MACE) 16例 (9 2 % ) ,15 8例 (90 8% )获操作成功。术后半年随访发现死亡 17例 (9 8% ) ;其中心源性死亡 8例 (4 6 % ) ,均发生于不能耐受CABG或外科手术高危组。半年内有 15 2例患者接受冠状动脉造影复查 ,其中有 36例 (2 3 7% )行血管重建。Kaplan Meier生存分析显示 :PCI术后 1年、3年生存率 (免于死亡 )分别为 89 7%、84 5 % ,术后 1年、3年免于心脏事件的生存率分别为 6 3 8%、5 7 5 %。结论　对UPLMT ,尤其是开口部、体部病变 ,PCI的近期疗效可以接受 ,但术后主要心脏事件 (如血管重建、心肌梗死、死亡等 )有待进一步减少。     

Predictors of prognosis after angioplasty in the unprotected left main coronary artery

OBJECTIVES: The short-term and long-term predictors of outcome after coronary angioplasty in the unprotected left main coronary artery were investigated. METHODS: The procedure was performed in 122 consecutive patients for de novo lesions without myocardial infarction in our hospital between April 1986 and October 1998, including 16 emergency cases. Procedures were directional coronary atherectomy (73 patients), balloon angioplasty (31 patients), and stent implantation (18 patients). There were 101 males and mean age was 68 +/- 10 years. Follow-up angiography was performed in 98% of discharged patients, and all patients were clinically followed up for more than 1 year. Clinical and angiographic predictors of in-hospital and long-term outcome were evaluated. RESULTS: The in-hospital mortality was 5.7% (7 of 122 patients). Multivariate analysis revealed that more patients were admitted as emergency cases (57% vs 10%, p = 0.0088), with left ventricular ejection fraction < or = 35% (57% vs 22%, p = 0.029) and renal failure (43% vs 3%, p = 0.0004) finally died. Mean follow-up period was 3.5 years. Estimated survival rate was 77.1%, and cardiac-death free survival rate was 81.0% at 5 years by the Kaplan-Meier method. Univariate analysis showed that the predictors of cardiac death were emergency angioplasty, renal failure, decreased left ventricular ejection fraction, multivessel disease and unstable angina and/or congestive heart failure. Cox's regression model showed that renal failure (p = 0.0004) and multivessel disease (p = 0.0075) were significant predictors of long-term prognosis. CONCLUSIONS: Renal failure was the strongest predictor of outcome after unprotected left main coronary artery angioplasty.     

Primary angioplasty of unprotected left main coronary artery for acute anterolateral myocardial infarction

BACKGROUND: Mortality of acute unprotected left main coronary artery (LMCA) occlusion is very high. The objectives of this analysis were to determine the effect of primary angioplasty and the impact of cardiogenic shock on unprotected LMCA occlusion-induced acute anterolateral myocardial infarction (AAMI). METHODS: Of 1,736 consecutive patients with acute myocardial infarction (AMI), 38 (2.2%) had LMCA occlusion-induced AAMI with Thrombolysis in Myocardial Infarction (TIMI) flow less than or equal to 2. All were given primary angioplasty. RESULTS: Of these 38 patients, 17 (45%) were discharged, and 21 (55%) died in-hospital. Cardiogenic shock was overt in 28 patients; 47.1% of the survival group and 95.2% of the mortality group (p=0.0008). On arrival, the survival-group had higher pH (7.40+/-0.10 vs. 7.30+/-0.14; p=0.013) and base excess (-4.5+/-3.9 vs. -10.4+/-6.0 mEq/L; p=0.0013). In the survival group reperfusion was successful in 100% of patients, as opposed to 57.1% in the mortality group (p=0.0020), and the incident of stenting was not different between the two groups (64.7% vs. 71.4%, p=0.66). Shock patients had lower successful angioplasty rate (67.9% vs. 100%, p=0.040), higher in-hospital mortality (71.4% vs. 10.0%, p=0.0008), and higher 1-year mortality rates (p=0.0064), than stable patients. All shock patients with failed angioplasty died, but the mortality rate was 57.9% (p=0.021) when angioplasty was successful. CONCLUSIONS: Patients presenting with AAMI, LMCA occlusion, and cardiogenic shock have poor survival regardless of primary angioplasty in conjunction with coronary stents. Nevertheless, primary angioplasty is a feasible and effective procedure, and it may save lives in this clinical setting.     

Role of new devices for angioplasty in the unprotected left main coronary artery]

OBJECTIVES: Angioplasty for the unprotected left main trunk remains controversial, but new procedures and devices such as directional coronary atherectomy and stenting have improved the results. We compared the results of angioplasty with the inflexible balloon and new devices. METHODS: The procedures were performed in 239 consecutive lesions in 160 patients between April 1986 and March 2000. This study excluded emergency cases and repeat angioplasty cases, and included 120 initial and elective cases. Initial and long-term results were compared between the balloon group (n = 29) and the new device group (n = 91). RESULTS: Lesion success rate was lower in the balloon group (90% vs 100%, p < 0.05), but there were no significant differences in in-hospital results including cardiac death (0% vs 0%), noncardiac death (0% vs 3.3%), Q-wave myocardial infarction (0% vs 2.2%), non-Q wave myocardial infarction (3.4% vs 6.6%), bypass surgery (0% vs 0%) and repeat angioplasty (6.9% vs 1.1%). Quantitative angiography showed significant improvements in minimal lumen diameter (mean 2.17 vs 3.16 mm, p < 0.001) and percentage diameter stenosis (mean 31% vs 13%, p < 0.001) in the new device group after the procedures. The minimum lumen diameter remained larger at 3 (p < 0.001) and 6 months (p < 0.05) in the new device group. Therefore, angiographic restenosis rate was higher in the balloon group (55% vs 21%, p < 0.005). Five-year survival rate showed no significant difference between the groups (75.0% vs 83.8%). CONCLUSIONS: New devices significantly improved the minimal lumen diameter after angioplasty for unprotected left main trunk disease, and lead to significant improvement of restenosis rate at follow-up.     

Stenting of unprotected left main coronary artery stenosis

Unprotected left main stenosis greater than 50% has traditionally been managed with coronary artery bypass surgery. There is now emerging evidence to support a percutaneous strategy adopting drug-eluting stents, especially in patients at high risk for surgery. This paper will review recent outcomes of both bare-metal and drug-eluting stent use for unprotected left main stenosis and summarise results of an Australian registry. Results of studies comparing the percutaneous approach to surgery will also be reviewed together with ESC and AHA/ACC current guidelines. Although percutaneous intervention of unprotected left main has been shown to be a safe and feasible procedure, unanswered questions remain. Large multi-centre randomised trials underway comparing percutaneous to surgical intervention will help clarify these ongoing issues.     

无保护左主干病变的介入治疗及随访结果

目的 :探讨无保护左主干病变患者冠状动脉 (冠脉 )内支架术的近、远期疗效。方法 :共选择 8例均无冠脉搭桥术史的左主干病变患者行冠脉内支架术 ,其中左主干近中段病变 5例 ,远段分叉病变 3例 ,其中 2例的左室射血分数 <4 0 % ,总结分析其临床、左主干病变特点、手术成功率及随访结果。结果 :左主干支架术的成功率为 10 0 % ,无残余狭窄或残余狭窄率 <10 % ,无任何严重并发症如支架内血栓形成、急性心肌梗死、紧急外科冠脉搭桥术或死亡等。术后随访 5～ 15 (10± 3.5 )个月 ,无一例死亡。临床心绞痛复发 1例 ,重复冠脉造影证明为前降支的新生病变所致 ;2例左室功能不全患者的左室射血分数提高了 15 %以上 ;5例复查了冠脉造影 ,其中 4例的原支架内基本无再狭窄 ;1例有 30 %再狭窄 (为前述症状复发的患者 )。结论 :支架置入术治疗无保护左主干病变疗效显著 ,是值得考虑的治疗手段 ;正确的病例选择和娴熟的操作技巧是手术成功的关键     

Percutaneous intervention of unprotected left main coronary artery

Successful percutaneous intervention of unprotected left main coronary artery (LMCA) in lieu of surgical revascularization represents the next wave of challenges that the field of interventional cardiology will try to overcome. Significant LMCA stenosis, commonly secondary to atherosclerosis, is seen in about 4-10% of cases presenting to the cardiac catheterization laboratory. Currently, the vast majority of these patients undergo surgical revascularization unless there are prohibitive reasons for surgical revascularization. Several challenges of percutaneous revascularization have been overcome with stents, intravascular brachytherapy, and other technical improvements. Yet, several remaining limitations of percutaneous intervention, such as in-stent restenosis, have to be improved further before randomized clinical trials of surgical and percutaneous revascularization of unprotected LMCA disease can be contemplated to establish a new standard of care.     

Immediate and long-term outcomes of stent implantation for unprotected left main coronary artery disease

Left main coronary artery (LMCA) disease is now uniformly treated with coronary artery bypass grafting (CABG). However, some patients with LMCA disease do not receive CABG because of high operative risks. The advent of stent implantation has permitted a non-operative improvement in myocardial blood flow in many patients with single- and multi-vessel coronary artery disease. However, the outcomes of stent implantation for unprotected LMCA disease are still unclear. Stent implantation was performed for unprotected LMCA disease in 13 patients; eight patients had high operative risk and five patients had refused CABG. The primary success rate was 100% (13/13 patients). One patient (8%) developed a non-Q-wave myocardial infarction after LMCA stenting. Repeat angiography was obtained in five patients (38%) with recurrent angina, and three patients (23%) received repeated percutaneous transluminal coronary angioplasty (PTCA) for LMCA restenosis. In the follow-up period of 18±3 months, 12 patients (92%) remained in satisfactory condition with no further need for surgical intervention. One patient (8%) ultimately required CABG, and she died after CABG at 3 months after LMCA stenting. In conclusion, although CABG remains the standard treatment for LMCA disease, the present study demonstrates that stent implantation is a safe and clinically beneficial revascularization procedure for unprotected LMCA disease in patients who have high operative risk as well as those who refuse CABG.     

Percutaneous coronary intervention of unprotected left main coronary artery disease

Data have emerged demonstrating the safety and efficacy of percutaneous coronary intervention (PCI) of the unprotected left main (ULM) artery. The 2009 American College of Cardiology/American Heart Association/Society for Cardiovascular Angiography and Interventions focused guidelines for PCI no longer state that ULM PCI is contraindicated in patients with anatomic conditions that are associated with a low risk of procedural complications and clinical conditions that predict an increased risk of adverse surgical outcomes. ULM PCI should be performed by operators with experience in the management of the anatomic complexities of left main and multivessel disease, specifically in issues relating to bifurcation disease, calcification, and hemodynamic support. Patients with ostial or shaft disease have lower risk of restenosis compared with distal bifurcation disease. Drug‐eluting stents (DES) should be used whenever possible as they reduce clinical restenosis. Intravascular ultrasound is an integral component of the procedure as it provides accurate assessment of lesion severity and can confirm optimal stent expansion and apposition. Compliance with dual antiplatelet therapy for at least 12 months is essential if DES are used. A collaborative, multidisciplinary approach with a “Heart Team” represented by a cardiac surgeon, interventional cardiologist, and non‐invasive cardiologist may optimize patient education and objective decision making when obtaining informed consent. Application of clinical and angiographic variables into risk models facilitates appropriate patient selection. Randomized clinical trials will address unanswered issues and help build consensus between cardiology and surgical societies to inform clinical decision making and optimize the outcomes for patients with ULM coronary artery disease. © 2011 Wiley Periodicals, Inc.     

Predictors of improvement in left ventricular function after initially successful angioplasty of unprotected left main coronary artery stenoses

BACKGROUND: Percutaneous coronary intervention (PCI) has been increasingly applied to unprotected left main coronary artery (LMCA) lesions, with varied procedural success and clinical outcomes. However, the effect of PCI on left ventricular performance is still unclear, and there are no clinical studies assessing factors that influence left ventricular ejection fraction (LVEF) in these cases. METHODS: Between April 1986 and August 2002, de novo PCI was performed for unprotected LMCA stenoses in 199 patients. Close clinical and angiographic follow-up were conducted after the procedure. RESULTS: One hundred eighty patients survived over six months and analysis of paired left ventriculography was possible in 175 patients. Improvement in LVEF was observed in the entire population (52.9?±?15.7% to 56.1?±?14.3%, p?= 0.048). The LVEF change was 6.7?± 9.5% (p?&lt;?0.01) in group with baseline LVEF?≤??50% and 0.7?±?6.7 % (p?=?NS) in group with LVEF?&gt;?50%. There was significant intergroup difference (p?&lt;?0.001). Patients with baseline diameter stenosis ≥60% had an improvement of 5.3?±?8.3% (p?&lt;?0.05) whereas those with stenosis?&lt;?60% had no improvement (2.0?±?8.4%, p?=?NS). CK-MB elevation ≥3 times normal after PCI had a significant inverse association with improvement in LVEF (p?&lt;?0.05). Multivariate analysis revealed baseline LVEF ≤?50% was the only independent predictor of improvement in LVEF (standard estimate?=?3.509, 95% CI: 2.164-4.854, p?&lt;?0.001). CONCLUSIONS: Successful PCI procedure is associated with significant improvement in LVEF, especially in patients with depressed left ventricular function. (Int J Cardiovasc Intervent 2004; 6: 119-127)     

选择性左冠状动脉主干病变的介入治疗

目的冠状动脉旁路移植术(CABG)是多支血管病变血运重建的最佳方法,是无保护性左冠状动脉主干(LMCA)病变的标准治疗.本研究探讨无保护性LMCA病变介入治疗的疗效和可行性.方法总结分析1996年10月～2000年8月间20例住院的冠心病左主干病变患者接受直接支架术治疗.入选患者例行左室造影(LVEF>45%),冠状动脉血管成形术及其疗效评判采用常规标准,合并右冠脉严重弥漫狭窄病变或前降支(LAD)与回旋支(LCX)同时严重狭窄者不行该术.结果 20例中男17例、女3例,年龄42～71(平均64±12)岁,临床呈心绞痛Ⅱ-Ⅲ级,其中合并高血压9例、糖尿病(2型)1例.冠脉造影显示,左冠脉主干病变呈单纯狭窄者8例,其中近中段狭窄(50%～80%)者6例、开口狭窄(50%～60%)者2例,左主干夹层分离者2例,动脉瘤者1例,合并LAD或LCX病变(狭均>70%)者9例(狭窄50%～70%).全部患者左主干病变均进行直接支架术,其中6例伴LAD或LCX病变者先行PTCA或支架术后再进行左主干病变的支架置入术.置入左主干内的支架均为管状宽径短支架,16例为4.0 mm×9 mm(直径×长度)支架,3例为3.5 mm×9 mm支架,1例冠状动脉瘤者应用4.5 mm×9mm支架.左主干支架术成功率为100%,无残余狭窄或残余狭窄<10%,无任何并发症如支架血栓形成、急性心肌梗死、紧急CABG及死亡等.9例合并LAD(6例)或LCX(3例)狭窄者,先行LAD或LCX的PTCA术,其中3例PTCA术后残余狭窄<20%,5例残余狭窄30%～40%者中2例置入3.0×16mm支架、1例3.5×20mm支架、1例3.0×14 mm支架,1例LCX开口后狭窄(75%)者因PTCA后发生夹层放置3.5×12 mm支架,造影示夹层消失,无残余狭窄.冠状动脉瘤行带膜支架术者造影示瘤体消失,左主干管壁平整.随访1～4年,14例心绞痛发作消失、6例心绞痛复发但显著减轻(心绞痛Ⅰ级),后者有4例于术后半年～1年内复查冠脉造影提示早期再狭窄,其中2例单纯LMCA再狭窄者再次行冠脉血管成形术、2例LMCA合并LAD再狭窄者行CABG手术,无急性心肌梗塞或死亡等严重心脏事件发生,患者均能维持正常生活.结论本研究结果表明,选择性无保护性左冠状动脉主干病变支架术在临床上切实可行、疗效显著,可以是继CABG的另一治疗选择.     

Percutaneous coronary intervention for unprotected left main coronary artery stenosis

Hemodynamically significant left main coronary artery stenosis (LMCA) is found in around 4% of diagnostic coronary angiograms and is known as unprotected LMCA stenosis if the left coronary artery and left circumflex artery has no previous patent grafts. Previous randomized studies have demonstrated a significant reduction in mortality when revascularization by coronary artery bypass graft (CABG) surgery was undertaken compared with medical treatment. Therefore, current practice guidelines do not recommend percutaneous coronary intervention (PCI) for such a lesion because of the proven benefit of surgery and high rates of restenosis with the use of bare metal stents. However, with the advent of drug-eluting stents (DES), the long term outcomes of PCI with DES to treat unprotected LMCA stenoses have been acceptable. Therefore, apart from the current guidelines, PCI for treatment of unprotected LMCA stenosis is often undertaken in individuals who are at a very high risk of CABG or refuse to undergo a sternotomy. Future randomized studies comparing CABG vs PCI using DES for treatment of unprotected LMCA stenosis would be a great advance in clinical knowledge for the adoption of appropriate treatment.     

无保护左主干病变血运重建的临床评价

冠脉旁路移植术为无保护左主干病变的首选治疗。随着经皮冠脉介入治疗技术的进步,在有选择的无保护左主干患者中,PCI与CABG的疗效相当。本文对无保护左主干病变几种血运重建方法进行综述。     

Emergency angioplasty of the left main coronary artery

During urgent cardiac catheterization total occlusion of a severe left main coronary artery stenosis occurred, leading to profound cardiogenic shock. The patient survived, after prompt left main coronary angioplasty was performed, followed by emergency coronary bypass surgery.     

经桡动脉行无保护左主干病变介入治疗

目的:回顾性总结29例冠状动脉造影发现为无保护左主干开口及体部狭窄病例的冠脉介入治疗(PCI)资料,以探讨手术的安全性和可行性。方法:术前给予常规药物治疗,经桡动脉途径行PCI,观察桡动脉穿刺成功率、PCI即刻成功率、手术时间、支架扩张时间和扩张压力、住院期间严重并发症发生率、出院前心绞痛发作情况评估及术前心电图(ECG)特点分析。结果:29例患者桡动脉穿刺成功率和PCI即刻成功率均为100%,手术时间25～50(38±8)min,支架扩张时间3～7(5±1.3)s,支架扩张压力14～20(16.0±1.9)atm(1atm=101.325kPa),住院期间无严重并发症发生,前臂肿胀3例,术后心绞痛显著缓解。术前胸痛发作时ECG特点:典型"左主干"心电图17例,胸前导联ST-T改变者10例,间歇性左束支阻滞2例。结论:经桡动脉途径对无保护左主干开口和体部病变行PCI治疗,成功率高,安全有效。     

无保护左主干病变支架介入治疗后冠状动脉造影随访结果分析

目的观察无保护左主干病变,应用药物洗脱支架介入治疗后冠状动脉造影随访结果,并分析其影响因素。方法选择无保护左主干病变患者150例,其中48例在平均(10.0±7.5)个月进行了冠状动脉造影复查,根据冠状动脉造影显示有无狭窄分为:再狭窄组12例和无再狭窄组36例。结果与无再狭窄组比较,再狭窄组患者随访时最小管腔直径明显减小[(2.7±1.0)mm vs (3.5±0.4)mm,P=0.0001]、直径狭窄率明显升高[(31.4±26.4)% vs (8.3±5.3)%,P=0.0000]、晚期管腔丢失明显升高[(0.8±0.7)mm vs (0.2±0.3)mm,P=0.0000];双支架置入术的再狭窄率明显高于单支架置入术[(75.0% vs 13.9%),P=0.0011]。结论左主干远端分叉病变双支架置入术的疗效较差,冠状动脉旁路移植术应作为首选。