Multicenter international registry of unprotected left main coronary artery percutaneous coronary intervention with drug‐eluting stents in patients with myocardial infarction

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 ± 12 years. Cardiogenic shock was present in 24%. The mean EuroSCORE was 10 ± 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 ± 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 = 0.04), left ventricular ejection fraction [HR 0.94, 95% CI (0.90–0.98), P = 0.005), and intubation [HR 7.00, 95% CI (1.62–30.21), P = 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. © 2008 Wiley‐Liss, Inc.     

Percutaneous coronary intervention for acute myocardial infarction due to unprotected left main coronary artery occlusion

Acute myocardial infarction (AMI) due to unprotected left main coronary artery (ULMCA) occlusion is an uncommon clinical entity, but often leads to severe clinical deterioration, with devastating sequalae including fatal arrhythmias, abrupt and severe circulatory failure, and sudden cardiac death. Recent guidelines have promoted treatment with percutaneous coronary intervention (PCI) as a class IIa recommendation alongside coronary artery bypass grafting (CABG), but the data are still unclear regarding optimal revascularization strategy for patients with ST‐segment elevation myocardial infarction (STEMI) and non‐STEMI (NSTEMI) with ULMCA culprit. PCI has the advantages of offering rapid reperfusion to critically ill patients, often those with prohibitive risk for surgical revascularization, with acceptable short‐ and long‐term outcomes. Recent studies demonstrate that PCI of the ULMCA is a viable alternative to CABG for appropriate patient populations, including those with ULMCA occlusion and those in cardiogenic shock, Thrombolysis In Myocardial Infarction (TIMI) flow grade 3, and significant comorbidities. A randomized trial comparing PCI with CABG is needed to clarify the ideal revascularization strategy, though the clinical picture of these critically ill patients may preclude such studies. © 2014 Wiley Periodicals, Inc.     

Predictors of long‐term outcomes after bypass grafting versus drug‐eluting stent implantation for left main or multivessel coronary artery disease

Background : We assessed predictors of long‐term outcomes after coronary artery bypass grafting (CABG) versus those after percutaneous coronary intervention (PCI) with drug‐eluting stents (DES) in 3,230 patients with left main or multivessel coronary artery disease (CAD). Methods and Results : Data were pooled from the BEST, PRECOMBAT, and SYNTAX trials. Age, chronic kidney disease, chronic obstructive lung disease, left ventricular dysfunction, and peripheral arterial disease (PAD) were common predictors of all‐cause mortality. Diabetes mellitus, previous myocardial infarction (MI), and SYNTAX score were independent predictors of all‐cause mortality in the PCI group, but not in the CABG group. In the CABG group, age was the only risk factor for MI; left ventricular dysfunction, hypertension, and PAD were risk factors for stroke. On the other hand, in the PCI group, incomplete revascularization and previous MI were risk factors for MI; age and previous stroke for stroke. In addition, chronic kidney disease significantly correlated with a composite outcome of death, MI, or stroke in the CABG group, and incomplete revascularization and previous MI in the PCI group. Conclusions : Simple clinical variables and SYNTAX score differentially predict long‐term outcomes after CABG versus those after PCI with DES for left main or multivessel CAD. Those predictors might help to guide the choice of revascularization strategy. © 2017 Wiley Periodicals, Inc.     

Revascularization of unprotected left main coronary artery disease: Strategy selection and systematic risk assessment

Refinement of interventional techniques, adjunctive pharmacological therapy, and the introduction of drug eluting stents have fostered new interest for the percutaneous treatment of unprotected left main coronary artery (ULMCA) stenosis. Several observational registries, some randomized controlled trials and several meta‐analyses have consistently shown no difference in mortality and myocardial infarction between percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) surgery in patients with ULMCA stenosis, but a higher rate of target vessel revascularization in patients treated with PCI. As a consequence, PCI of ULMCA stenosis has been upgraded to class IIa or IIb indication in the current European or American College of Cardiology/American Heart Association practice guidelines. Although these results are promising, they do not still represent enough evidence for extending PCI of ULMCA stenosis to current clinical practice. The EXCEL trial will address the value of PCI in relation to CABG for the treatment of ULMCA stenosis in more than 2000 patients. A major breakthrough of the SYNTAX trial has been the demonstration of an interaction between the coronary complexity and the revascularization strategy, suggesting that optimal risk stratification is a key element when deciding the best strategy of revascularization in this high‐risk group of patients. Multidisciplinary team approach remains essential to provide a balanced information to the patient and to offer the beast treatment option. © 2012 Wiley Periodicals, Inc.     

Long‐term clinical outcomes after drug‐eluting stent implantation in unprotected left main coronary artery disease

Objective: To investigate long‐term outcomes of unprotected left main coronary artery (ULMCA) disease treatment using drug‐eluting stents (DES). Background: In several studies, DES implantation in ULMCA appeared safe and effective at mid‐term; however, to date, there is limited long‐term data. Methods : All consecutive patients undergoing sirolimus‐ or paclitaxel‐eluting stent implantation in ULMCA disease at a single institution were evaluated. The primary endpoint was long‐term major adverse cardiac events (MACE) defined as cardiac death, nonfatal myocardial infarction, or target lesion revascularization (TLR). Stent thrombosis (ST), according to Academic Research Consortium definitions, was also evaluated. Results: A total of 210 patients were assessed. In‐hospital MACE rate was 1%. During a mean follow‐up of 28.0 ± 14.5 months, MACE occurred in 26 patients (12.5%): cardiac death in nine patients (4.3%) and TLR in 17 patients (8.2%). The cumulative MACE‐free survival rate was 89.0, 87.4, and 85.4% at 1, 2, and 3 years, respectively. ST occurred in three patients (1.4%): one case was definite and the other two were probable/possible ST; there were no cases of very late ST. Binary restenosis occurred in 8.3%. The EuroScore >6 was the only independent predictor of MACE [hazard ratio (HR) 2.24, 95% confidence interval (CI) 1.05–4.77, P = 0.04]. There was a trend toward an increased risk of MACE associated with distal ULMCA location (HR 2.14, 95% CI 0.87–5.29, P = 0.10). Conclusions: Our study showed DES implantation in ULMCA to be feasible, safe, and effective at long term. Randomized trials comparing percutaneous versus surgical revascularization are warranted to define the treatment of choice for ULMCA disease. © 2009 Wiley‐Liss, Inc.     

旁路移植术和介入治疗无保护左主干病变的疗效分析

目的:分析无保护左主干病变(ULMCA)经外科旁路移植术(CABG)和冠状动脉介入术(PCI)治疗的临床效果。方法:回顾性分析ULMCA196例,其中PCI95例,CABG105例,比较2组围术期并发症,左心室大小和心功能,主要心血管事件(MACE)。结果:围术期死亡:PCI组4例,占4.4%,CABG组8例,占7.6%;主动脉球囊反搏使用:PCI组12例(13.2%),CABG组23例(22.0%);MACE:PCI组15例(16.5%),CABG组22例(21.0%),P<0.05;平均随访(13±5)个月,PCI组死亡3例,免于MACE77.6%,MACE19例(22.4%),CABG组死亡3例,免于MACE87.6%,MACE12例(12.4%),射血分数改变PCI组1.2%±0.7%,CABG组2.3%±1.1%,P<0.05;左心室舒张末期直径大小变化PCI组(3.5±0.2)mm,CABG组(4.6±0.7)mm,P<0.03,纽约心功能分级PCI组(2.5±0.6)级,CABG组(1.5±0.3)级,P<0.02。结论:PCI和CABG术对ULMCA治疗都有较好的近、远期结果,但围术期PCI疗效优于CABG,对左主干累及分叉病变,CABG则优于PCI。     

A Comparison Between Coronary Artery Bypass Grafting Surgery and Percutaneous Coronary Intervention for the Treatment of Unprotected Left Main Coronary Artery Disease

Background:

Unprotected left main coronary artery (ULMCA) disease occurs in 3% to 5% of patients with coronary artery disease and is mainly treated by coronary artery bypass grafting (CABG) surgery. Drug‐eluting stents (DESs) have renewed interest for the percutaneous coronary intervention (PCI) treatment of ULMCA stenosis. This study compared the long‐term clinical outcome of PCI with DESs or CABG in real world patients with ULMCA disease.

Hypothesis:

PCI with DESs may be a better treatment for ULMCA disease compared with CABG.

Methods:

Consecutive patients who had coronary revascularization because of ULMCA disease in Zhongshan Hospital, from May 2003 to November 2009, were retrospectively enrolled. They were classified in the PCI or the CABG group according to treatments that were given initially. Of 515 patients having follow‐up data, 233 were treated by PCI, whereas 282 were treated by CABG. The patients in the CABG group were of older age, had higher European System for Cardiac Operative Risk Evaluation (EuroSCORE) and Synergy Between PCI With Taxus Drug‐Eluting Stent and Cardiac Surgery (SYNTAX) scores, and had longer hospitalization stays than the PCI group.

Results:

At the end of follow‐up, there was no difference in major adverse cardiac and cerebrovascular events between the 2 groups. However, the incidence of cardiac death (0.4% vs 4.6%) in the PCI group was less than that in the CABG group, whereas target vessel revascularization (7.3% vs 3.2%) was higher in the PCI group.

Conclusions:

In ULMCA disease, CABG tends to be chosen in patients with higher risk according to the EuroSCORE and SYNTAX scores. PCI with DESs seemed to have favorable early and long‐term clinical outcomes compared with CABG in our center. Clin. Cardiol. 2012 DOI: 10.1002/clc.22070 Qing Qin, MD, and Juying Qian, MD, contributed equally to this work. The authors have no funding, financial relationships, or conflicts of interest to disclose.     

Percutaneous left main coronary disease treatment without on‐site surgery back‐up in patients with acute coronary syndromes

Background : Best revascularization strategy in patients with acute coronary syndromes (ACS) and unprotected left main (ULM) coronary disease is still debate reflecting lack of convincing data. Objectives : To assess clinical feasibility and efficacy of ULM percutaneous coronary intervention (PCI) in patients with ACS and describe the practice of a center without on‐site surgical back‐up over a 7‐year period. Methods : Data on high‐risk patients with ACSs undergoing percutaneous ULM treatment were prospectively collected in an independent registry. Primary end‐points of this study were immediate and long‐term outcomes expressed as target lesion failure (TLF, composite of cardiac death, myocardial infarction (MI), and target lesion revascularization). Results : Between January 2003 and January 2010, 200 consecutive patients were included in this study. Angiographic success was obtained in 95% of patients but procedural success was 87% primarily affected by an 11% of in‐hospital cardiac mortality. At median follow‐up of 26 months (IQ 10–47), the overall TLF rate was 28.5%, with 16.0% of cardiac death, 7.0% of MI, and 10.5% of clinically driven target lesion revascularization rates. Cumulative definite/probable stent thrombosis was 3.5%. Elevated EuroSCORE value and pre‐procedural hemodynamic instability were the strongest predictors of TLF. Temporal trend analysis showed progressive but not significant improvement for both immediate (P = 0.110) and long‐term (P = 0.073) outcomes over the study period. Conclusions : This single‐center study based on current clinical practice in patient with ULM disease and ACS confirmed PCI as feasible revascularization strategy in absence of on‐site cardio‐thoracic support. Nevertheless, the outcome of these high‐risk patients is still hampered by a sensible in‐hospital mortality rate. © 2011 Wiley Periodicals, Inc.     

Assisted circulation using the TandemHeart® during very high‐risk PCI of the unprotected left main coronary artery in patients declined for CABG

Objectives: In a single center experience, we retrospectively evaluated the short‐term safety and efficacy of the TandemHeart® percutaneous transseptal left ventricular assist (PTVA®) system to deliver extracorporeal circulatory support during catheter based treatment of the unprotected left main coronary artery (ULMCA). Background: Percutaneous Coronary Intervention (PCI) of the ULMCA usually has been restricted to patients who are hemodynamically unstable or ineligible for coronary artery bypass grafting (CABG). High‐risk patients for CABG should be considered at increased risk for PCI as well. In these patients the TandemHeart PTVA System (p‐LVAD) may provide a valuable safeguard to reduce procedural risks. Methods and Results: Between July 2002 and May 2008 the TandemHeart was used in 9 very high risk patients (Logistic Euro score: 13.64 (7.46–29.67); Syntax score:43 (41–50); Mayo Clinic Risk score (MCRS) 7 (6–8); age: median 65 (range 55–71) undergoing elective PCI for the novo lesions on the ULMCA. All patients were declined for CABG by a heart team. A ‘‘true’’ percutaneous insertion technique was used in all patients, technical success rate was 100%. The median (range) time for implementation of circulatory support was 27 min (24–30). A median (range) pump flow up to 4.36 (3.40–5.54) L/min was achieved with significant reduction of left ventricular filling pressures, pulmonary capillary wedge pressure and a small increase of systemic arterial pressures. Median (range) duration of support was 93 min (50.4–102). Successful weaning was achieved in all patients. There was no in hospital death, survival at 6 months was (89%), whereas vascular access site complications were seen in 4 patients (44.4%). Conclusions: In very high risk PCI, assisted circulation using the TandemHeart‐PTVA provides effective, total left ventricular support and may contribute to a reduced procedural risk and improved survival. The rate of device related cardiac and vascular complications was acceptable. © 2009 Wiley‐Liss, Inc.     

Percutaneous coronary intervention in unprotected left main coronary artery stenosis: Mid-term outcomes of a single-center observational study

BackgroundPercutaneous coronary intervention (PCI) is an appropriate alternative to coronary artery bypass grafting (CABG) for revascularization of unprotected left main coronary artery (ULMCA) disease in patients with low-to–intermediate anatomic complexity or when the patient refuses CABG even after adequate counselling by heart team. We assessed the safety, in-hospital and mid-term outcomes of ULMCA stenting with drug-eluting stents (DES) in Indian patients.MethodsOur study was a retrospective analysis of patients who had undergone ULMCA PCI at a tertiary center, between March 2011 and February 2020. Clinical characteristics, procedural data, and follow-up data were analyzed. The primary outcome was a composite of major adverse cardiovascular and cerebrovascular events (MACCE) during the hospital stay and at follow-up. The median follow-up was 2.8 years (interquartile range: 1.5–4.1 years).Results661 patients (mean age, 63.5 ± 10.9 years) had undergone ULMCA PCI. The mean SYNTAX score was 27.9 ± 10.4 and the mean LVEF was 58.0 ± 11.1%. 3-vessel disease and distal lesions were noted in 54% and 70.6% patients, respectively. The incidence of in-hospital MACCE was 1.8% and the MACCE during follow-up was 11.5% (including 48 [8.4%] cardiac deaths). The overall survival rates after one, three, five, and nine years were 94%, 88%, 84%, and 82%, respectively. The multivariate analysis revealed that age >65 years and high SYNTAX scores were independent predictors of mid to long-term mortality.ConclusionULMCA PCI with DES is safe and has acceptable in-hospital and mid-term outcomes among patients with low-to–intermediate SYNTAX score.     

Comparison of three treatment strategies for patients with triple‐vessel coronary disease and left ventricular dysfunction

Introduction

Current guidelines recommend coronary artery bypass grafting (CABG) for patients with multivessel coronary disease and left ventricular (LV) dysfunction. However, some patients undergo percutaneous coronary intervention (PCI) or solely medical therapy (MT) in actual practice. The comparison of long‐term outcomes of these three treatment strategies in real world is unclear.

Methods

A total of 699 consecutive patients in a single centre from 2004 to 2011 who had TVD and LV ejection fraction ≤40%, no prior PCI or CABG and had completed a median 6.2‐year follow‐up were evaluated. The primary endpoint was all‐cause death. The secondary endpoints included cardiac death, major adverse cardiovascular and cerebrovascular events (MACCE; composite of all‐cause death, myocardial infarction, repeat revascularization, or stroke), and the individual components of the composite endpoint.

Results

One hundred forty‐two patients (20.3%) underwent PCI, 201 (28.8%) underwent CABG while 356 (50.9%) received MT alone. MT alone was associated with the worst survival (P < 0.001). Compared with PCI, CABG was associated with a similar risk of all‐cause death (hazard ratio [HR], 0.86; 95% confidence interval [CI], 0.52‐1.41; P = 0.54) but lower risks of cardiac death (HR, 0.47; 95%CI, 0.25‐0.91; P = 0.03), repeat revascularization (HR, 0.29; 95%CI, 0.10‐0.85; P = 0.02), and MACCE (HR, 0.63; 95%CI, 0.43‐0.93; P = 0.02).

Conclusions

For patients with TVD and LV dysfunction, both CABG and PCI were associated with a lower risk of mortality compared with MT alone. Compared with PCI, CABG has a lower risk of cardiac death, repeat revascularization, and MACCE.

     

Comparison of coronary artery bypass surgery with percutaneous coronary intervention with drug-eluting stents for unprotected left main coronary artery disease.

OBJECTIVES: This study evaluated the clinical outcomes of consecutive, selected patients treated with coronary artery bypass graft (CABG) surgery or percutaneous coronary intervention (PCI) with drug-eluting stents (DES) for unprotected left main coronary artery (ULMCA) disease. BACKGROUND: Although recent data suggest that PCI with DES provides better clinical outcomes compared to bare-metal stenting for ULMCA disease, there is a paucity of data comparing PCI with DES to CABG. METHODS: Since April 2003, when DES first became available at our institution, 123 patients underwent CABG, and 50 patients underwent PCI with DES for ULMCA disease. RESULTS: High-risk patients (Parsonnet score >15) comprised 46% of the CABG group and 64% of the PCI group (p = 0.04). The 30-day major adverse cardiac and cerebrovascular event (MACCE) rate for CABG and PCI was 17% and 2% (p < 0.01), respectively. The mean follow-up was 6.7 +/- 6.2 months in the CABG group and 5.6 +/- 3.9 months in the PCI group (p = 0.26). The estimated MACCE-free survival at six months and one year was 83% and 75% in the CABG group versus 89% and 83% in the PCI group (p = 0.20). By multivariable Cox regression, Parsonnet score, diabetes, and CABG were independent predictors of MACCE. CONCLUSIONS: Despite a higher percentage of high-risk patients, PCI with DES for ULMCA disease was not associated with an increase in immediate or medium-term complications compared with CABG. Our data suggest that a randomized comparison between the two revascularization strategies for ULMCA may be warranted.     

Comparison of sirolimus-, paclitaxel-, and everolimus-eluting stent in unprotected left main coronary artery percutaneous coronary intervention

ObjectivesThis retrospective study evaluated the outcomes of patients who underwent unprotected left main coronary artery (ULMCA) percutaneous coronary intervention (PCI) with different types of drug-eluting stents (DES).BackgroundThe standard of care for patients with ULMCA is coronary artery bypass surgery. However, current guidelines recommend PCI in clinical conditions where there is an increased risk of adverse surgical outcomes. Clinical outcomes of patients undergoing ULMCA PCI with different types of drug-eluting stents (DES) are unknown.MethodsData from a multicenter international registry, which included 239 consecutive patients from four institutions who ULMCA PCI with DES, were collected.ResultsThere were 42 patients receiving paclitaxel-eluting stent (PES), 158 patients receiving sirolimus-eluting stent (SES), and 39 patients receiving everolimus-eluting stent (EES). There was no statistical difference in major adverse cardiovascular events, cardiac death, myocardial infarction, target lesion revascularization, and stent thrombosis among PES, SES, and EES at 30 days and 1 year.ConclusionsThere are no differences in clinical events among patients receiving PES, SES, and EES for ULMCA disease.     

The PREHAMI (PREsillion™ in high‐risk acute myocardial infarction) registry

Objectives : To evaluate the efficacy of the new Cobalt–Chromium (Co‐Cr) Presillion? stent for the treatment of high‐risk acute myocardial infarction (MI) patients. Background : Percutaneous coronary intervention (PCI) with stent represents the gold standard treatment for acute MI. Methods and Results : We enrolled patients with high‐risk acute MI (either ST‐segment elevation MI or non‐ST‐segment elevation MI) treated with PCI using a new Co‐Cr bare metal stent with closed cells design and limited balloon compliance. We considered high‐risk features as one of the following: age ≥70 years, ejection fraction ≤35%, glomerular filtration rate ≤60 mL/min, diabetes mellitus, rescue PCI, or chronic atrial fibrillation or other conditions requiring long‐term oral anticoagulation therapy. Primary outcome of the study was rate of major adverse cardiac events (MACE) defined as all‐cause death, new MI, and target‐vessel revascularization. A total of 129 consecutive patients were enrolled (69 ± 11 years, 74% men): 71 (55%) patients with ST‐segment elevation MI and 58 (45%) patients with non‐ST‐segment elevation MI. A total of 153 vessels (169 lesions and 179 stents) were treated. The device success rate was high (98.8%). In‐hospital MACE rate was 5.4% mainly because of death associated with the acute MI. At 1‐year follow‐up, the MACE rate was 17.3%, with 11% all‐cause death (7.9% of cardiac origin), 0.6% of stent thrombosis, and 4.6% target‐vessel revascularization. Conclusions : The use of the Co‐Cr Presillion stent in patients with high‐risk acute MI treated invasively seems to be safe and efficacious with optimal deliverability and good long‐term outcomes and represents a good option in the treatment of these patients. © 2011 Wiley‐Liss, Inc.     

Percutaneous revascularization of left main

Refinement of interventional techniques, adjunctive pharmacological therapy, and the introduction of drug‐eluting stents have fostered new interest for the percutaneous treatment of unprotected left main coronary artery (ULMCA) stenosis. Several observational registries, some randomized trials and several meta‐analyses have consistently shown no difference in mortality and myocardial infarction between percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) surgery in patients with ULMCA stenosis, but a higher rate of target vessel revascularization in patients treated with PCI. As a consequence, PCI of ULMCA stenosis has been upgraded to class IIa or IIb indication in the current European or American practice guidelines. However, several critical issues should be properly addressed when pursuing a percutaneous strategy for the treatment of ULMCA stenosis, such as the use of IVUS for procedural guidance, assessment of disease location, optimal technique for distal ULMCA stenosis, risk of stent thrombosis, optimal duration of dual antiplatelet therapy, and the most appropriate strategy for post‐procedure follow up. Multidisciplinary team approach remains essential to provide a balanced information to the patient and to offer the beast treatment option. © 2011 Wiley Periodicals, Inc.     

Hybrid coronary revascularization for the treatment of left main coronary stenosis: a feasibility study

Objective : To determine the feasibility of a hybrid coronary revascularization (HCR) approach for the treatment of left main (LM) coronary artery stenosis. Background : The recommended therapy for significant LM stenosis is coronary artery bypass grafting (CABG). Percutaneous coronary intervention (PCI) of unprotected LM lesions is reserved for patients at high risk for complications with CABG. HCR in LM disease has not been studied. Methods : Twenty‐two consecutive patients with LM stenosis >70% underwent staged HCR. Following a robotic or thoracoscopic‐assisted minimally invasive left internal mammary artery (LIMA) to left anterior descending artery (LAD) coronary bypass, PCI of the LM, and non‐LAD targets was performed after angiographic confirmation of LIMA patency. Intravascular ultrasound confirmed optimal stent deployment. Thirty‐day adverse outcomes and long term follow up was obtained. Results : In the 22 patients with LM lesions, 6 were ostial, 5 mid, and 11 distal. LIMA patency was FitzGibbon A in all cases. LM stenting was successful in all patients with drug‐eluting stents (DES) placed in 21 of 22 cases. Three patients underwent stent implantation in the right coronary artery. There were no 30‐day major adverse cardiac or cerebrovascular events. At a mean of 38.8 ± 22 months postprocedure, 21 patients were alive without reintervention; one death occurred at 454 days. Conclusions : HCR for LM coronary disease is a feasible alternative to CABG and unprotected LM PCI. This approach combines the long‐term durability of a LIMA‐LAD bypass with the less invasive option of PCI in non‐LAD targets with DES. © 2011 Wiley Periodicals, Inc.     

Validating the EXCEL hypothesis: A propensity score matched 3‐year comparison of percutaneous coronary intervention versus coronary artery bypass graft in left main patients with SYNTAX score ≤32

Objectives : The aim of this study is to verify the study hypothesis of the EXCEL trial by comparing percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) in an EXCEL‐like population of patients. Background : The upcoming EXCEL trial will test the hypothesis that left main patients with SYNTAX score ≤32 experience similar rates of 3‐year death, myocardial infarction (MI), or cerebrovascular accidents (CVA) following revascularization by PCI or CABG. Methods : We compared the 3‐year rates of death/MI/CVA and death/MI/CVA/target vessel revascularization (MACCE) in 556 patients with left main disease and SYNTAX score ≤32 undergoing PCI (n = 285) or CABG (n = 271). To account for confounders, outcome parameters underwent extensive statistical adjustment. Results : The unadjusted incidence of death/MI/CVA was similar between PCI and CABG (12.7% vs. 8.4%, P = 0.892), while MACCE were higher in the PCI group compared to the CABG group (27.0% vs. 11.8%, P < 0.001). After propensity score matching, PCI was not associated with a significant increase in the rate of death/MI/CVA (11.8% vs. 10.7%, P = 0.948), while MACCE were more frequently noted among patients treated with PCI (28.8% vs. 14.1%, P = 0.002). Adjustment by means of SYNTAX score and EUROSCORE, covariates with and without propensity score, and propensity score alone did not change significantly these findings. Conclusions : In an EXCEL‐like cohort of patients with left main disease, there seems to be a clinical equipoise between PCI and CABG in terms of death/MI/CVA. However, even in patients with SYNTAX score ≤32, CABG is superior to PCI when target vessel revascularization is included in the combined endpoint. © 2011 Wiley‐Liss, Inc.     

高龄无保护左主干病变不宜行冠状动脉搭桥患者介入治疗效果评价

目的:冠状动脉旁路移植术(CABG)一直是左主干病变的首选治疗,关于高龄左主干病变但不宜行CABG治疗的患者临床研究较少。本研究针对这一特殊人群进行经皮冠状动脉介入术(PCI)治疗后的临床情况进行随访。方法:入选年龄≥75岁不宜行CABG治疗的无保护左主干病变患者,随访患者的临床终点事件,死亡、心源性死亡、心肌梗死及靶血管重建。结果:研究共入选115例高龄左主干病变患者。平均年龄(78.3±2.6)岁,平均Syntax评分和Euroscore评分为(29.3±6.1)和(7.8±4.2),随访总病死率是9.5%,心源性死亡、心肌梗死及靶血管重建率分别为7%,6.1%及6.1%,MACCE事件发生率为16.5%。男性和慢性肾功能不全与全因死亡显著相关。结论:PCI治疗为高龄不宜行CABG治疗的左主干患者提供了α-选择。男性和慢性肾功能不全与全因死亡显著相关。     

冠状动脉旁路移植术和药物支架植入术远期疗效的比较

目的比较冠心病患者非药物治疗手段冠状动脉旁路移植术（CABG）和经皮冠状动脉介入治疗（PCI）术后的桥血管和支架的再通率。方法CABG术后和药物支架植入术后再次出现心绞痛症状的冠心病患者各40例,其年龄、性别、心肌梗死、高血压、高脂血症、心功能不全、脑卒中、药物治疗病史具有可比性。通过冠状动脉造影术比较两组患者的桥血管和药物支架的效率和寿命的远期效果。结果与行CABG患者的桥血管比较,行PCI患者的药物支架远期狭窄或者闭塞率降低34．3％。与行CABG患者的左乳内动脉（LIMA）桥血管比较,行PCI患者的左前降支的药物支架远期狭窄或者闭塞率降低14．8％。与行CABG患者的左回旋支和右冠状动脉静脉桥血管比较,行PCI患者的左回旋支以及右冠状动脉的药物支架远期狭窄或者闭塞率降低49．8％。结论冠状动脉药物支架植入术的远期通畅率较CABG明显增高,冠状动脉药物支架植入术的药物支架的效率和寿命要优于CABG的桥血管。     

In‐hospital and long‐term outcomes of percutaneous balloon aortic valvuloplasty with concomitant percutaneous coronary intervention in patients with severe aortic stenosis

Background

Severe aortic stenosis (AS) often coexists with significant coronary artery disease.

Objective

To evaluate procedural complications and long‐term outcomes of patients with severe AS undergoing balloon aortic valvuloplasty (BAV) and percutaneous coronary intervention (PCI).

Methods

A total of 97 patients with severe AS underwent 104 BAVs as palliative procedure, bridge to definitive treatment, or before urgent non‐cardiac surgery. Patients were followed‐up for at least 12 months.

Results

Of the 97 patients, 34 (35.0%) underwent standalone BAV, 45 (46.4%) underwent BAV with coronary angiography, and 18 (18.6%) BAV with PCI. There were no differences in baseline characteristics and indications for BAV among the groups (P > 0.05). No higher risk of complications after BAV performed with concomitant coronary angiography/PCI was observed. Transcatheter aortic valve implantation was performed after BAV in 13 (13.4%) patients and surgical aortic valve replacement in three (3.1%) patients. In spite of no difference in in‐hospital mortality (5.6% vs. 8.9%; P = 0.76), patients with BAV and concomitant PCI had lower long‐term mortality than patients with BAV and concomitant coronary angiography (28.5% vs. 51.0%; P = 0.03). In multivariable Cox analysis adjusted for age, sex, and body mass index, the Society of Thoracic Surgeons Predicted Risk of Mortality score was identified as the only independent predictor of long‐term mortality for all patients (HR: 1.09, 95%CI: 1.04‐1.15, P = 0.0006).

Conclusions

Concomitant PCI or coronary angiography performed with BAV may not increase the risk of major and vascular complications. Patients with BAV and concomitant PCI may have better survival than patients with BAV and concomitant coronary angiography.