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Almas T, Afzal A, Fatima H, Yaqoob S, Ahmad Jarullah F, Ahmed Abbasi Z, Farooqui A, Jaffar D, Batool A, Ahmed S, Sara Azmat N, Afzal F, Zafar Khan S, Fatima K. Safety and efficacy of percutaneous coronary intervention versus coronary artery bypass graft in patients with STEMI and unprotected left main stem disease: A systematic review & meta-analysis. IJC HEART & VASCULATURE 2022; 40:101041. [PMID: 35655530 PMCID: PMC9152298 DOI: 10.1016/j.ijcha.2022.101041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 04/20/2022] [Accepted: 04/21/2022] [Indexed: 11/17/2022]
Abstract
The advent of percutaneous coronary intervention (PCI) has caused much debate about the optimal revascularization method for LMCAD. Several studies have previously been conducted comparing PCI versus CABG for LMCAD, however most of these have only taken into account randomized controlled trials (RCTs), while ignoring observational studies. This study takes data from both RCTs and observational studies to obtain a better comparison of the two revascularization techniques. It is the first meta-analysis to report data for various adverse outcomes after 10 years of follow-up.
Introduction Owing to its large area of supply, left main coronary artery disease (LMCAD) has the highest mortality rate among coronary artery lesions, resulting in debate about its optimal revascularization technique. This meta-analysis compares percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG) for the treatment of LMCAD. Method MEDLINE, TRIP, and Cochrane Central databases were queried from their inception until 25 April 2021, to determine MACCE (major adverse cardiac and cardiovascular events), all-cause mortality, repeat revascularization, myocardial infarction (MI) and stroke rates post-revascularization for different follow-ups. 7 RCTs and 50 observational studies having 56,701 patients were included. A random-effects model was used with effect sizes calculated as odds ratios (odds ratio, OR). Results In the short term (1 year), PCI had significantly higher repeat revascularizations (OR = 3.58, 95% CI 2.47–5.20; p < 0.00001), but lower strokes (OR = 0.55, 95% CI 0.38–0.81; p = 0.002). In the intermediate term (2–5 years), PCI had significantly higher rates of repeat revascularizations (OR = 3.47, 95% CI 2.72–4.44; p < 0.00001) and MI (OR = 1.39, 95% CI 1.17–1.64; p = 0.0002), but significantly lower strokes (OR = 0.54, 95% CI 0.42–0.70; p < 0.0001). PCI also had significantly higher repeat revascularizations (OR = 2.58, 95% CI 1.89–3.52; p < 0.00001) in the long term (≥5 years), while in the very long term (≥10 years), PCI had significantly lower all-cause mortalities (OR = 0.77, 95% CI 0.61–0.96; p = 0.02). Conclusion PCI was safer than CABG for patients with stroke for most follow-ups, while CABG was associated with lower repeat revascularizations. However, further research is required to determine PCI’s safety over CABG for reducing post-surgery MI.
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Malaiapan Y, Leung M, White AJ. The role of intravascular ultrasound in percutaneous coronary intervention of complex coronary lesions. Cardiovasc Diagn Ther 2020; 10:1371-1388. [PMID: 33224763 DOI: 10.21037/cdt-20-189] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Intravascular ultrasound (IVUS) is a catheter-based coronary imaging technique. It utilises the emission & subsequent detection of reflected high frequency (30-60 MHz) sound waves to create high resolution, cross-sectional images of the coronary artery. IVUS has been the cornerstone of intracoronary imaging for more than two decades. When compared to the invasive coronary angiogram which studies only the silhouette of the contrast-filled artery lumen, IVUS also crucially images the vessel wall. Because of this capability, IVUS has greatly facilitated understanding of the coronary atherosclerosis process. Such insights from IVUS reveal how commonly and extensively plain angiography underestimates the true extent of coronary plaque, the characteristics of plaques prone to rupture and cause acute coronary syndromes (lipid rich, thin cap atheroma), and a realisation of the widespread occurrence of vessel remodelling in response to atherosclerosis. Similarly, IVUS has historically provided salutary mechanistic insights that have guided many of the incremental advances in the techniques of percutaneous coronary intervention (PCI). Examples include mechanisms of in-stent restenosis, and the importance of high-pressure post-dilatation of stents to ensure adequate stent apposition and thereby reduce the occurrence of stent thrombosis. IVUS also greatly facilitates the choice of correct diameter and length of stent to implant. Overall, a compelling body of evidence indicates that use of intravascular ultrasound in PCI helps to achieve optimal technical results and to mitigate the risk of adverse cardiac events. In this review, the role of intravascular ultrasound as an adjunct to PCI in complex coronary lesions is explored. The complex coronary situations discussed are the left main stem, ostial stenoses, bifurcation stenoses, thrombotic lesions, the chronically occluded coronary artery, and calcified coronary artery disease. By thorough review of the available evidence, we establish that the advantages of IVUS guidance are particularly evident in each of these complex CAD subsets. In particular, some consider the use of IVUS to be almost mandatory in left main PCI. A comparison with other intracoronary imaging techniques is also explored.
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Affiliation(s)
- Yuvaraj Malaiapan
- Monash Heart, Monash Medical Centre, Clayton, VIC, Australia.,Department of Medicine, Monash University, Clayton, VIC, Australia
| | - Michael Leung
- Monash Heart, Monash Medical Centre, Clayton, VIC, Australia.,Department of Medicine, Monash University, Clayton, VIC, Australia
| | - Anthony J White
- Monash Heart, Monash Medical Centre, Clayton, VIC, Australia.,Department of Medicine, Monash University, Clayton, VIC, Australia
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3
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Wang Z, Zhan B, Bao H, Huang X, Wu Y, Liang Q, Zhang W, Jiang L, Cheng X. Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting in Unprotected Left Main Coronary Artery Stenosis. Am J Med Sci 2019; 357:230-241. [DOI: 10.1016/j.amjms.2018.12.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Revised: 12/15/2018] [Accepted: 12/18/2018] [Indexed: 01/23/2023]
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4
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Wańha W, Mielczarek M, Smolka G, Roleder T, Jaguszewski M, Ciećwierz D, Tomasiewicz B, Kubler P, Gorol J, Chmielecki M, Bartuś S, Navarese EP, Kasprzak M, Sukiennik A, Kubica J, Lekston A, Hawranek M, Reczuch K, Gruchała M, Ochała A, Wojakowski W. Safety and efficacy of self-apposing Stentys drug-eluting stent in left main coronary artery PCI: Multicentre LM-STENTYS registry. Catheter Cardiovasc Interv 2019; 93:574-582. [PMID: 30311397 DOI: 10.1002/ccd.27876] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 06/26/2018] [Accepted: 08/26/2018] [Indexed: 11/10/2022]
Abstract
BACKGROUND There is a paucity of data on left main (LM) percutaneous coronary intervention (PCI) therapy with dedicated DES platforms. The LM-STENTYS is a multicenter registry aimed at evaluating clinical outcome after PCI of LM performed with a self-apposing Stentys DES implantation. METHODS The registry consists of 175 consecutive patients treated with Stentys DES implanted to LM. The primary endpoint was the composite of major adverse cardiac and cerebral events (MACCE) defined as cardiac death, myocardial infarction (MI), target lesion revascularization (TLR), and stroke assessed after 1 year. The secondary endpoint was stent thrombosis (ST) at 1 year. RESULTS The median age was 69 years (IQR, 62-78 years). Acute coronary syndrome (ACS) was the presenting diagnosis in 117 (66.9%) patients [74 (63.2%) unstable angina, 31 (26.5%) NSTEMI, 12 (10.3%) STEMI] and stable angina (SA) was present in 58 (33.1%) patients. The median SYNTAX score was 23.0 (IQR, 18.7-32.2) in the SA group and 25.0 (IQR, 20.0-30.7) in the ACS group. During 1-year follow-up in the SA group two (3.4%) MACCE occurred, both of them were cardiac deaths. In ACS patients there were 19 (16.2%) MACCE [9 (7.7%) cardiac deaths, 11 (9.4%) MIs, 11(9.4%) TLR, 1(0.9%) stroke]. Altogether, three (1.7%) cases of acute ST were noted, all of them in ACS subset. CONCLUSION LM PCI using self-apposing Stentys DES showed favorable clinical outcomes at 1-year in patients with SA. Events of ST in the ACS group warrant further research.
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Affiliation(s)
- Wojciech Wańha
- Department of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
| | | | - Grzegorz Smolka
- Department of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
| | - Tomasz Roleder
- Department of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
| | - Miłosz Jaguszewski
- First Department of Cardiology, Medical University of Gdańsk, Gdańsk, Poland
| | - Dariusz Ciećwierz
- First Department of Cardiology, Medical University of Gdańsk, Gdańsk, Poland
| | - Brunon Tomasiewicz
- Military Hospital, Wroclaw, Poland.,Department of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Piotr Kubler
- Military Hospital, Wroclaw, Poland.,Department of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Jarosław Gorol
- Third Department of Cardiology, Medical University of Katowice, Zabrze, Poland
| | - Michał Chmielecki
- First Department of Cardiology, Medical University of Gdańsk, Gdańsk, Poland
| | - Stanisław Bartuś
- Second Department of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Eliano Pio Navarese
- INOVA Heart and Vascular Institute, Virginia.,Interventional Cardiology and Cardiovascular Medicine Research, Cardiovascular Research Center, Mater Dei Hospital, Bari, Italy.,SIRIO MEDICINE Research Network, Düsseldorf, Germany
| | - Michał Kasprzak
- Department of Cardiology Nicolaus Copernicus University, Collegium Medicum, Bydgoszcz, Poland
| | - Adam Sukiennik
- Department of Cardiology Nicolaus Copernicus University, Collegium Medicum, Bydgoszcz, Poland
| | - Jacek Kubica
- Department of Cardiology Nicolaus Copernicus University, Collegium Medicum, Bydgoszcz, Poland
| | - Andrzej Lekston
- Third Department of Cardiology, Medical University of Katowice, Zabrze, Poland
| | - Michał Hawranek
- Third Department of Cardiology, Medical University of Katowice, Zabrze, Poland
| | - Krzysztof Reczuch
- Military Hospital, Wroclaw, Poland.,Department of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Marcin Gruchała
- First Department of Cardiology, Medical University of Gdańsk, Gdańsk, Poland
| | - Andrzej Ochała
- Department of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
| | - Wojciech Wojakowski
- Department of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
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Mehrotra S, Mishra S, Paramasivam G. Imaging during percutaneous coronary intervention for optimizing outcomes. Indian Heart J 2018; 70 Suppl 3:S456-S465. [PMID: 30595307 PMCID: PMC6309719 DOI: 10.1016/j.ihj.2018.08.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2017] [Revised: 08/02/2018] [Accepted: 08/09/2018] [Indexed: 01/29/2023] Open
Abstract
Angiography is the current gold standard for imaging during percutaneous coronary interventions but has significant limitations. Catheter-based intravascular imaging techniques such as intravascular ultrasound and the more recent optical coherence tomography have the potential to overcome these limitations and thus optimize clinical outcomes. In this update, we discussed the current applications of the available imaging techniques, existing evidence, continuing unmet needs, and potential areas for further research.
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Affiliation(s)
| | | | - Ganesh Paramasivam
- Kasturba Medical College, Manipal Academy of Higher Education, Manipal, India
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6
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Ali WE, Vaidya SR, Ejeh SU, Okoroafor KU. Meta-analysis study comparing percutaneous coronary intervention/drug eluting stent versus coronary artery bypass surgery of unprotected left main coronary artery disease: Clinical outcomes during short-term versus long-term (> 1 year) follow-up. Medicine (Baltimore) 2018; 97:e9909. [PMID: 29443766 PMCID: PMC5839846 DOI: 10.1097/md.0000000000009909] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Results on the safety and long-term efficacy of drug-eluting stent placement in unprotected left main coronary artery disease (ULMCAD) compared with those of coronary artery bypass surgery (CABG) remain inconsistent across randomized clinical trials and recent meta-analysis studies. We aimed to compare the clinical outcomes and safety over short- and long-term follow-ups by conducting a meta-analysis of large pooled data from randomized controlled trials and up-to-date observational studies. METHODS A systematic review of PubMed, Google Scholar, Medline, and reference lists of related articles was performed for studies conducted in the drug-eluting stent era, to compare percutaneous coronary intervention (PCI) with CABG in ULMCAD. The primary outcome was major adverse cardiovascular and cerebrovascular events (MACCE), myocardial infarction (MI), stroke, all-cause mortality, and revascularization after at least 1-year follow-up. In-hospital and 30-day clinical outcomes were considered secondary outcomes. Furthermore, a subgroup analysis of studies with ≥5 years follow-up was performed to test the sustainability of clinical outcomes. RESULTS A total of 29 studies were extracted with 21,832 patients (10,424 in PCI vs 11,408 in CABG). Pooled analysis demonstrated remarkable differences in long-term follow-up (≥1 year) MACCE (odds ratio [OR] 1.42, 95% CI 1.27-1.59), P < .00001), repeat revascularization (OR 3.00, 95% CI 2.41-3.73, P < .00001), and MI (OR 1.32, 95% CI 1.14-1.53, P = .0002), favoring CABG over PCI. However, stroke risk was significantly lower in the PCI group. Subgroup analysis of studies with ≥5 years follow-up showed similar outcomes except for the noninferiority outcome of MACCE in the PCI arm. However, the PCI group proved good safety profile after a minimum of 30-day follow-up with lower MACCE outcome. CONCLUSION PCI for ULMCAD can be applied with attentiveness in carefully selected patients. MI and the need for revascularization remain drawbacks and areas of concern among previous studies. Nonetheless, it has been proven safe during short-term follow-up.
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Affiliation(s)
- Waleed E. Ali
- Department of Internal Medicine, Cape Fear Valley Medical Center, affiliated with Campbell University School of Osteopathic Medicine
- Department of Medicine—Cardiology, Cape Fear Valley Medical Center, Fayetteville, NC
| | - Satyanarayana R. Vaidya
- Department of Internal Medicine, Cape Fear Valley Medical Center, affiliated with Campbell University School of Osteopathic Medicine
- Department of Medicine—Cardiology, Cape Fear Valley Medical Center, Fayetteville, NC
| | - Sylvester U. Ejeh
- Department of Internal Medicine, Cape Fear Valley Medical Center, affiliated with Campbell University School of Osteopathic Medicine
- Department of Medicine—Cardiology, Cape Fear Valley Medical Center, Fayetteville, NC
| | - Kingsley U. Okoroafor
- Department of Medicine—Cardiology, Cape Fear Valley Medical Center, Fayetteville, NC
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7
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Su CS, Chen YW, Shen CH, Liu TJ, Chang Y, Lee WL. Clinical outcomes of left main coronary artery disease patients undergoing three different revascularization approaches. Medicine (Baltimore) 2018; 97:e9778. [PMID: 29443740 PMCID: PMC5839844 DOI: 10.1097/md.0000000000009778] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Significant unprotected left main (LM) coronary artery disease is frequently associated with severe multivessel disease and increased mortality and morbidity compared with non-LM coronary artery disease. This study compared the clinical outcomes of patients with LM disease who received percutaneous coronary intervention (PCI) with stenting, conventional coronary-artery bypass grafting (C-CABG), and robot-assisted CABG (R-CABG).This retrospective study analyzed 472 consecutive LM disease patients who underwent three different revascularization approaches at a tertiary medical center between January 2005 and November 2013.Of the 472 LM disease patients, 139 received R-CABG, 147 received C-CABG, and 186 received PCI. The need for target vessel revascularization (TVR) was highest in the PCI group. The R-CABG group had significantly lower rates of in-hospital and follow-up all-cause deaths compared with the other 2 groups (1.4% vs. 3.4% and 9.7%, P = .0058; 13.7% vs. 29.3% and 29.6%, P = .0023, respectively). Patients in the R-CABG group had significantly lower rates of intra-aortic balloon pump assistance, and shorter duration of ICU and total hospital stay compared to patients in the C-CABG group. However, revascularization modality, SYNTAX scores, and residual SYNTAX scores were not independent predictors of in-hospital or long-term mortality.In this cohort of LM disease patients treated at a tertiary medical center, PCI is a reasonable choice in patients with less lesion complexity but who are older and have comorbidities. R-CABG is feasible in stable LM disease patients with high SYNTAX scores, and is an effective alternative to C-CABG in LM disease patients with few risk factors. However, revascularization modality per se was not a determinant for long-term mortality in our real-world practice.
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Affiliation(s)
- Chieh-Shou Su
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung
- Institute of Clinical Medicine, and Department of Medicine, National Yang-Ming University School of Medicine, Taipei
| | - Yu-Wei Chen
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung
- Division of Cardiology, Department of Internal Medicine, Taichung Veterans General Hospital Chiayi Branch, Chiayi
| | - Ching-Hui Shen
- Department of Anesthesiology, Taichung Veterans General Hospital, Taichung
- Department of Surgery
| | - Tsun-Jui Liu
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung
- Department of Surgery
- Department of Medicine, National Yang Ming University School of Medicine, Taipei, Taiwan
| | - Yen Chang
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung
- Department of Surgery
| | - Wen-Lieng Lee
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung
- Department of Surgery
- Department of Medicine, National Yang Ming University School of Medicine, Taipei, Taiwan
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Sharma SP, Dahal K, Khatra J, Rosenfeld A, Lee J. Percutaneous coronary intervention vs coronary artery bypass grafting for left main coronary artery disease? A systematic review and meta-analysis of randomized controlled trials. Cardiovasc Ther 2017; 35. [PMID: 28371437 DOI: 10.1111/1755-5922.12260] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2016] [Revised: 03/08/2017] [Accepted: 03/22/2017] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND It is not clear whether percutaneous coronary intervention (PCI) is as effective and safe as coronary artery bypass grafting (CABG) for left main coronary artery disease. We aimed to perform a systematic review and meta-analysis of all randomized controlled trials (RCTs) that compared PCI and CABG in left main coronary disease. METHODS We searched PubMed, EMBASE, Cochrane, Scopus and relevant references for RCTs (inception through, November 20, 2016 without language restrictions) and performed meta-analysis using random-effects model. All-cause mortality, myocardial infarction, revascularization rate, stroke, and major adverse cardiac and cerebrovascular events (MACCE) were the measured outcomes. RESULTS Six RCTs with a total population of 4700 were analyzed. There was no difference in all-cause mortality at 30-day, one-year, and five-year (1.8% vs 1.1%; OR 0.60; 95% CI: 0.26-1.39; P=.23; I2 =9%) follow-up between PCI and CABG. CABG group had less myocardial infarction (MI) at five-year follow-up than PCI (5% vs 2.5%; OR 2.04; CI: 1.30-3.19; P=.002; I2 =1%). Revascularization rate favored CABG in one-year (8.6% vs 4.5%; OR 2; CI: 1.46-2.73; P<.0001; I2 =45%) and five-year (15.9% vs 9.9%; OR 1.73; CI: 1.36-2.20; P<.0001; I2 =0%) follow-up. Although stroke rate was lower in PCI group at 1 year, there was no difference in longer follow-up. MACCE at 5 years favored CABG (24% vs 18%; OR 1.45; CI: 1.19-1.76; P=.0001; I2 =0%). On subgroup analysis, MACCE were not different between two groups in low-to-intermediate SYNTAX group while it was higher for PCI group with high SYNTAX group. CONCLUSION Percutaneous coronary intervention could be as safe and effective as CABG in a select group of left main coronary artery disease patients.
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Affiliation(s)
| | - Khagendra Dahal
- Division of Cardiology, Louisiana State University Health Science Center, Shreveport, LA, USA
| | | | | | - Juyong Lee
- Division of Interventional Cardiology, Section of Cardiology, University of Connecticut, Farmington, CT, USA
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9
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Naqvi SY, Klein J, Saha T, McCormick DJ, Goldberg S. Comparison of Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting for Unprotected Left Main Coronary Artery Disease. Am J Cardiol 2017; 119:520-527. [PMID: 28012553 DOI: 10.1016/j.amjcard.2016.11.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Revised: 11/01/2016] [Accepted: 11/01/2016] [Indexed: 11/26/2022]
Abstract
Coronary artery bypass grafting (CABG) decreases mortality in patients with significant left main (LM) coronary artery disease and for years remained the therapy of choice for patients with this ominous lesion. Advances in percutaneous coronary intervention (PCI) have enabled it to become an alternative to CABG. The results of observational registries and randomized comparisons have shown the safety and efficacy of PCI in appropriately selected patients with low or intermediate angiographic risk scores. Furthermore, the use of physiological measures of flow limitation and the use of intracoronary imaging techniques has added benefit and improved outcomes. The use of fractional flow reserve to more accurately evaluate the significance of intermediate lesions and guide the extent of revascularization has been an important refinement. Intravascular ultrasound and optical coherence tomography assessment of optimal stent deployment has led to reductions in restenosis. Newer generation stents, combined with improvements in specific techniques, especially at the LM bifurcation have extended PCI to more complex anatomic scenarios. The availability of left ventricular support devices in patients with complex coronary anatomy and severely depressed left ventricular function has added a margin of safety to LM and multivessel intervention. Randomized comparisons of CABG with PCI in carefully selected patients, using contemporaneous surgical and interventional techniques and optimal medical therapy, will further aid heart teams in the decision-making process. In conclusion, this review will give a concise overview of the management of unprotected LM disease.
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10
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Buchanan GL, Chieffo A, Colombo A. Percutaneous Coronary Intervention in Unprotected Left Main. Interv Cardiol 2016. [DOI: 10.1002/9781118983652.ch15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Affiliation(s)
- Gill Louise Buchanan
- Department of Cardiology; North Cumbria University NHS Trust; Carlisle United Kingdom
| | - Alaide Chieffo
- Interventional Cardiology Unit; San Raffaele Scientific Hospital; Milan Italy
| | - Antonio Colombo
- Interventional Cardiology Unit; San Raffaele Scientific Hospital; Milan Italy
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11
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Abstract
Significant unprotected left main stem (ULMS) disease is in approximately 5% to 7% of patients undergoing coronary angiography. Historically, coronary artery bypass grafting has been the gold standard treatment of these patients. With recent advances in stent technology, adjunctive pharmacotherapy, and operator experience, percutaneous coronary intervention (PCI) is increasingly regarded as a viable alternative treatment option, especially in patients with favorable coronary anatomy (low and intermediate SYNTAX (Synergy Between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery) scores). This article aims to discuss the evidence supporting PCI for ULMS disease, current guidelines, and technical aspects.
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Affiliation(s)
- Neil Ruparelia
- Department of Interventional Cardiology San Raffaele Scientific Institute, Via Olgettina 60, Milan 20132, Italy; Department of Cardiology Imperial College, Du Cane Road, London W12 0HS, UK
| | - Alaide Chieffo
- Department of Interventional Cardiology San Raffaele Scientific Institute, Via Olgettina 60, Milan 20132, Italy.
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12
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Li J, Patel SM, Parikh MA, Parikh SA. Unprotected Left Main Disease: Indications and Optimal Strategies for Percutaneous Intervention. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2016; 18:19. [PMID: 26874707 DOI: 10.1007/s11936-016-0441-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OPINION STATEMENT Although the incidence of left main (LM) coronary artery disease is relatively low in patients undergoing routine angiography, it is a common presentation in patients with acute coronary syndromes. With the current interventional tools and techniques, percutaneous intervention for LM disease has become a viable alternative to the traditional coronary artery bypass grafting. Factors that contribute to the success and appropriateness of percutaneous intervention for LM disease include coronary anatomy and patient-specific factors such as left ventricular function. Multiple considerations should be taken into account prior to intervention, including hemodynamic support if necessary, intravascular imaging to guide therapy, and stent technique. This review provides an overview of the current body of literature to support the use of percutaneous intervention in LM disease and serves as guideline for the interventionalist approaching LM revascularization.
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Affiliation(s)
- Jun Li
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, USA.,Division of Cardiovascular Medicine, Harrington Heart and Vascular Institute, University Hospitals Case Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44106, USA
| | - Sandeep M Patel
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, USA.,Division of Cardiovascular Medicine, Harrington Heart and Vascular Institute, University Hospitals Case Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44106, USA
| | - Manish A Parikh
- Center for Interventional Vascular Therapy, Division of Cardiology, NY Presbyterian Hospital/Columbia University Medical Center, New York, NY, USA
| | - Sahil A Parikh
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, USA. .,Division of Cardiovascular Medicine, Harrington Heart and Vascular Institute, University Hospitals Case Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44106, USA.
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13
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Therapeutic effect of interventional therapy for unprotected left main coronary artery lesions in aged patients. JOURNAL OF GERIATRIC CARDIOLOGY : JGC 2016; 12:634-40. [PMID: 26788040 PMCID: PMC4712369 DOI: 10.11909/j.issn.1671-5411.2015.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Objective To assesse the therapeutic effect of interventional therapy in aged patients with unprotected left main coronary artery (UPLM) lesions. Methods A total of 61 patients who were over 60 years and accepted interventional therapy of UPLM from January 2012 to November 2013 in our hospital were followed up for average 14.6 months by telephone call or outpatient visits. We analyzed the clinical features data of the interventional therapy and assessed the factors that likely influenced the clinical prognosis. Results The average age of the 61 patients was 73.9 years. The average left ventricular ejection fraction (LVEF) was 47.7%. The median of the estimated glomerular filtration rate (eGFR) was 52 mL/min per 1.73 mm2. The average SYNTAX score was 27.4 and the median of stent length was 36 mm. The cumulative incidence of cardiac death at 30 days and major adverse cardiac events (MACE) after one year was 6.6% and 32.5% estimated by Kaplan-Meier plots respectively. No severe hemorrhagic complications were observed during follow-up period. On multivariate regression analysis with a COX proportional hazards model, LVEF was an independent predictor of cardiac death at 30 days [Hazard ratio (HR): 0.7, P = 0.01]. As for MACE after one year, LVEF and eGFR were both independent predictors (HR: 0.91, P = 0.06 for LVEF, HR: 0.03, P = 0.097 for eGFR). Conclusions The interventional therapy for UPLM was effective and safe in aged patients. LVEF was the only predictor of cardiac death at 30 days, while LVEF and eGFR were both independent predictors of MACE after one year.
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Lee PH, Ahn JM, Park SJ. Update on percutaneous intervention for left main coronary artery stenosis. Expert Rev Cardiovasc Ther 2015; 13:933-43. [PMID: 26159652 DOI: 10.1586/14779072.2015.1065730] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Percutaneous coronary intervention (PCI) using drug-eluting stents (DES) is currently considered as a viable alternative to coronary artery bypass graft surgery (CABG) for selected patients with left main coronary artery disease. The updated results of the landmark randomized trials comparing CABG versus PCI demonstrated comparable 5-year outcomes and are in line with the current guidelines that designate PCI as a reasonable treatment in this disease subset. Given that the completed randomized trials did not include contemporary DESs, the upcoming results of the ongoing trials evaluating the performance of new-generation DES compared with CABG (such as the EXCEL trial), may further help to clarify the current role and future recommendations of PCI for left main coronary artery disease. Apart from the recent stent technology, further improvements in outcomes after PCI may be possible when it is used with an integrated approach that combines functional concepts for decision-making, adjunctive imaging support and optimal pharmacotherapies.
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Affiliation(s)
- Pil Hyung Lee
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Coronary Artery Surgery Versus Percutaneous Coronary Intervention in Octogenarians: Long-Term Results. Ann Thorac Surg 2015; 99:567-74. [DOI: 10.1016/j.athoracsur.2014.09.019] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2014] [Revised: 09/05/2014] [Accepted: 09/09/2014] [Indexed: 11/20/2022]
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Fleisher LA, Fleischmann KE, Auerbach AD, Barnason SA, Beckman JA, Bozkurt B, Davila-Roman VG, Gerhard-Herman MD, Holly TA, Kane GC, Marine JE, Nelson MT, Spencer CC, Thompson A, Ting HH, Uretsky BF, Wijeysundera DN. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. Developed in collaboration with the American College of Surgeons, American Society of Anesthesiologists, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Anesthesiologists, and Society of Vascular Medicine Endorsed by the Society of Hospital Medicine. J Nucl Cardiol 2015; 22:162-215. [PMID: 25523415 DOI: 10.1007/s12350-014-0025-z] [Citation(s) in RCA: 110] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Fleisher LA, Fleischmann KE, Auerbach AD, Barnason SA, Beckman JA, Bozkurt B, Davila-Roman VG, Gerhard-Herman MD, Holly TA, Kane GC, Marine JE, Nelson MT, Spencer CC, Thompson A, Ting HH, Uretsky BF, Wijeysundera DN. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. J Am Coll Cardiol 2014; 64:e77-137. [PMID: 25091544 DOI: 10.1016/j.jacc.2014.07.944] [Citation(s) in RCA: 809] [Impact Index Per Article: 80.9] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Sibbald M, Chan W, Daly P, Horlick E, Ing D, Ivanov J, Mackie K, Osten MD, Overgaard CB, Džavík V. Long-term outcome of unprotected left main stenting: a Canadian tertiary care experience. Can J Cardiol 2014; 30:1407-14. [PMID: 25442439 DOI: 10.1016/j.cjca.2014.05.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Revised: 05/09/2014] [Accepted: 05/15/2014] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND Coronary stenting is increasingly used to treat unprotected left main disease in selected patients. However, there is a paucity of data on the long-term outcome of these patients in a Canadian context outside of clinical trials. METHODS We retrospectively reviewed all provincially-insured patients undergoing left main coronary stenting at a large tertiary referral centre from 2000-2011. Pre-procedural angiograms were reviewed to identify the location of left main disease, and extent of concomitant coronary disease quantified by calculating Synergy Between Percutaneous Coronary Intervention With TAXUS Drug-Eluting Stent and Cardiac Surgery (SYNTAX) scores for each patient. In-hospital death and major adverse cardiac event (MACE) rates were evaluated as were long-term death and MACE rates obtained via linkage of our institutional registry with the Ontario health claims database. RESULTS Two hundred twenty-one patients underwent unprotected left main stenting with 29 (13.1%) in-hospital death and 34 (15.4%) a MACE. At an average follow-up of 3.1 ± 2.8 years, 109 patients (49.3%) died and 151 (68.3%) experienced a MACE. Higher SYNTAX tertile and use of bare metal rather than drug-eluting stents was associated with increased rates of in-hospital and long-term death. CONCLUSIONS This study reports, to our knowledge, the largest Canadian cohort of unprotected left main stenting over more than a decade. Coronary stenting was associated with acceptable in-hospital event rates, but poor long-term outcomes, reflecting the higher-risk population traditionally selected for this procedure.
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Affiliation(s)
- Matthew Sibbald
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - William Chan
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Paul Daly
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Eric Horlick
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Douglas Ing
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Joan Ivanov
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Karen Mackie
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Mark D Osten
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | | | - Vladimír Džavík
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada.
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2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery: Executive Summary. J Am Coll Cardiol 2014. [DOI: 10.1016/j.jacc.2014.07.945] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Abstract
Though coronary bypass graft surgery (CABG) has traditionally been the cornerstone of therapy in patients with unprotected left main coronary artery (ULMCA) disease, recent evidence supports the use of percutaneous coronary intervention in appropriate patients. Indeed in patients with ULMCA disease, drug-eluting stents (DES) have shown similar incidence of hard end points, fewer periprocedural complications and lower stroke rates compared with CABG, though at the cost of increased revascularization with time. Furthermore, the availability of newer efficacious and safer DES as well as improvements in diagnostic tools, percutaneous techniques and, importantly, a better patient selection, allowed percutaneous coronary intervention a viable alternative to CABG of left main-patients with low disease complexity; however, even in this interventional era characterized by efficacious DES, patients with ULMCA disease remain a challenging high-risk population where outcomes strongly depend on clinical characteristics, anatomical disease complexity and extension and operator's experience. This review summarizes the role of DES in ULMCA disease patients.
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Affiliation(s)
- Chiara Bernelli
- Interventional Cardiology Unit, Azienda Ospedaliera Papa Giovanni XXIII, Piazza OMS 1, Bergamo, Italy
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Fleisher LA, Fleischmann KE, Auerbach AD, Barnason SA, Beckman JA, Bozkurt B, Davila-Roman VG, Gerhard-Herman MD, Holly TA, Kane GC, Marine JE, Nelson MT, Spencer CC, Thompson A, Ting HH, Uretsky BF, Wijeysundera DN. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014; 130:2215-45. [PMID: 25085962 DOI: 10.1161/cir.0000000000000105] [Citation(s) in RCA: 456] [Impact Index Per Article: 45.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Fleisher LA, Fleischmann KE, Auerbach AD, Barnason SA, Beckman JA, Bozkurt B, Davila-Roman VG, Gerhard-Herman MD, Holly TA, Kane GC, Marine JE, Nelson MT, Spencer CC, Thompson A, Ting HH, Uretsky BF, Wijeysundera DN. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014; 130:e278-333. [PMID: 25085961 DOI: 10.1161/cir.0000000000000106] [Citation(s) in RCA: 209] [Impact Index Per Article: 20.9] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Buchanan GL, Chieffo A, Meliga E, Mehran R, Park SJ, Onuma Y, Capranzano P, Valgimigli M, Narbute I, Makkar RR, Palacios IF, Kim YH, Buszman PP, Chakravarty T, Sheiban I, Naber C, Margey R, Agnihotri A, Marra S, Capodanno D, Allgar V, Leon MB, Moses JW, Fajadet J, Lefevre T, Morice MC, Erglis A, Tamburino C, Alfieri O, Serruys PW, Colombo A. Comparison of percutaneous coronary intervention (with drug-eluting stents) versus coronary artery bypass grafting in women with severe narrowing of the left main coronary artery (from the Women-Drug-Eluting stent for LefT main coronary Artery disease Registry). Am J Cardiol 2014; 113:1348-55. [PMID: 24581924 DOI: 10.1016/j.amjcard.2014.01.409] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2013] [Revised: 01/11/2014] [Accepted: 01/11/2014] [Indexed: 10/25/2022]
Abstract
Women typically present with coronary artery disease later than men with more unfavorable clinical and anatomic characteristics. It is unknown whether differences exist in women undergoing treatment for unprotected left main coronary artery (ULMCA) disease. Our aim was to evaluate long-term clinical outcomes in women treated with percutaneous coronary intervention (PCI) with drug-eluting stents versus coronary artery bypass grafting (CABG). All consecutive women from the Drug-Eluting stent for LefT main coronary Artery disease registry with ULMCA disease were analyzed. A propensity matching was performed to adjust for baseline differences. In total, 817 women were included: 489 (59.8%) underwent treatment with PCI with drug-eluting stents versus 328 (40.2%) with CABG. Propensity score matching identified 175 matched pairs, and at long-term follow-up there were no differences in all-cause (odds ratio [OR] 0.722, 95% confidence interval [CI] 0.357 to 1.461, p=0.365) or cardiovascular (OR 1.100, 95% CI 0.455 to 2.660, p=0.832) mortality, myocardial infarction (MI; OR 0.362, 95% CI 0.094 to 1.388, p=0.138), or cerebrovascular accident (CVA; OR 1.200, 95% CI 0.359 to 4.007, p=0.767) resulting in no difference in the primary study objective of death, MI, or CVA (OR 0.711, 95% CI 0.387 to 1.308, p=0.273). However, there was an advantage of CABG in major adverse cardiovascular and cerebrovascular events (OR 0.429, 95% CI 0.254 to 0.723, p=0.001), driven exclusively by target vessel revascularization (OR 0.185, 95% CI 0.079 to 0.432, p<0.001). In women with significant ULMCA disease, no difference was observed after PCI or CABG in death, MI, and CVA at long-term follow-up.
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Abdelmalak HD, Omar HR, Mangar D, Camporesi EM. Unprotected left main coronary stenting as alternative therapy to coronary bypass surgery in high surgical risk acute coronary syndrome patients. Ther Adv Cardiovasc Dis 2013; 7:214-23. [DOI: 10.1177/1753944713488637] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Acute coronary syndrome has a high mortality rate that dramatically increases in the presence of left main coronary artery (LMCA) disease. Over the past decades, coronary artery bypass graft (CABG) surgery has been commonly accepted as the standard of care for patients with LMCA stenosis and is still considered the first-line treatment in current practice guidelines. Percutaneous coronary intervention (PCI) of protected and unprotected LMCA has gained popularity and is increasingly utilized with comparable outcomes to CABG in randomized controlled trials. In-stent restenosis and the need for revascularization provide the main obstacle to LMCA revascularization. The advent of better PCI equipment, stents, ablative devices, intravascular ultrasound, hemodynamic support devices and antithrombotic agents have ignited a renewed interest in the practice of LMCA PCI, especially for high surgical risk patients who are neither candidates nor agreeable to CABG surgery. Herein, we review the studies comparing unprotected LMCA stenting with CABG surgery in regard to 3 main endpoints: mortality, major adverse events and the incidence of repeat revascularization.
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Affiliation(s)
- Hany D. Abdelmalak
- Cardiology Department, Advocate Illinois Masonic Medical Center. Chicago, Illinois, USA
| | - Hesham R. Omar
- Internal Medicine Department, Mercy Hospital and Medical Center, 2525 South Michigan Avenue, Chicago, IL 60616, USA
| | - Devanand Mangar
- Anesthesia Department, Tampa General Hospital, Tampa, Florida, USA
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Bittl JA, He Y, Jacobs AK, Yancy CW, Normand SLT. Bayesian Methods Affirm the Use of Percutaneous Coronary Intervention to Improve Survival in Patients With Unprotected Left Main Coronary Artery Disease. Circulation 2013; 127:2177-85. [DOI: 10.1161/circulationaha.112.000646] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- John A. Bittl
- From the Ocala Heart Institute, Munroe Regional Medical Center, Ocala, FL (J.A.B.); Department of Health Care Policy, Harvard Medical School, Boston, MA (Y.H., S.-L.T.N.); Department of Medicine, Section of Cardiology, Boston Medical Center, Boston, MA (A.K.J.); Department of Medicine, Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL (C.W.Y.); and Department of Biostatistics, Harvard School of Public Health, Boston, MA (S.-L.T.N.)
| | - Yulei He
- From the Ocala Heart Institute, Munroe Regional Medical Center, Ocala, FL (J.A.B.); Department of Health Care Policy, Harvard Medical School, Boston, MA (Y.H., S.-L.T.N.); Department of Medicine, Section of Cardiology, Boston Medical Center, Boston, MA (A.K.J.); Department of Medicine, Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL (C.W.Y.); and Department of Biostatistics, Harvard School of Public Health, Boston, MA (S.-L.T.N.)
| | - Alice K. Jacobs
- From the Ocala Heart Institute, Munroe Regional Medical Center, Ocala, FL (J.A.B.); Department of Health Care Policy, Harvard Medical School, Boston, MA (Y.H., S.-L.T.N.); Department of Medicine, Section of Cardiology, Boston Medical Center, Boston, MA (A.K.J.); Department of Medicine, Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL (C.W.Y.); and Department of Biostatistics, Harvard School of Public Health, Boston, MA (S.-L.T.N.)
| | - Clyde W. Yancy
- From the Ocala Heart Institute, Munroe Regional Medical Center, Ocala, FL (J.A.B.); Department of Health Care Policy, Harvard Medical School, Boston, MA (Y.H., S.-L.T.N.); Department of Medicine, Section of Cardiology, Boston Medical Center, Boston, MA (A.K.J.); Department of Medicine, Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL (C.W.Y.); and Department of Biostatistics, Harvard School of Public Health, Boston, MA (S.-L.T.N.)
| | - Sharon-Lise T. Normand
- From the Ocala Heart Institute, Munroe Regional Medical Center, Ocala, FL (J.A.B.); Department of Health Care Policy, Harvard Medical School, Boston, MA (Y.H., S.-L.T.N.); Department of Medicine, Section of Cardiology, Boston Medical Center, Boston, MA (A.K.J.); Department of Medicine, Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL (C.W.Y.); and Department of Biostatistics, Harvard School of Public Health, Boston, MA (S.-L.T.N.)
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Drug-eluting stents or coronary artery bypass grafting for unprotected left main coronary artery disease: a meta-analysis of four randomized trials and seventeen observational studies. Trials 2013; 14:133. [PMID: 23782856 PMCID: PMC3663678 DOI: 10.1186/1745-6215-14-133] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2012] [Accepted: 04/18/2013] [Indexed: 11/20/2022] Open
Abstract
Background The clinical application of drug-eluting stents (DES) or coronary artery bypass grafting (CABG) for unprotected left main coronary artery disease (ULMCAD) is still controversial. The purpose of this meta-analysis was to compare the safety and efficacy between DES and CABG for ULMCAD. Methods Databases of MEDLINE, EMBASE and the Cochrane Library were systematically searched. Results Twenty-one studies with 8,413 patients were included in this meta-analysis. The risk was lower in DES than in CABG groups at the early outcomes of death (risk ratio (RR): 0.49, 95% confidence interval (CI): 0.30–0.78), cerebrovascular events (RR: 0.19, 95% CI: 0.08–0.45) and composite endpoint (RR: 0.53, 95% CI: 0.40–0.70); death after 2 years (RR: 0.81, 95% CI: 0.66–0.99), 4 years (RR: 0.69, 95% CI: 0.53–0.90), 5 years (OR: 0.76, 95% CI: 0.61–0.95) and their total effect (RR: 0.79, 95% CI: 0.71–0.87); composite endpoint 1 year (RR: 0.69, 95% CI: 0.58–0.83), 4 years (RR: 0.69, 95% CI: 0.53–0.88), 5 years (RR: 0.74, 95% CI: 0.59–0.92) and their total effect (RR: 0.78, 95% CI: 0.71–0.85). There were no significant differences in the risk for the early outcomes of myocardial infarction (RR: 0.97, 95% CI: 0.68–1.38), death 1 year (OR: 0.81, 95% CI: 0.57–1.15) and 3 years (OR: 0.85, 95% CI: 0.69–1.04), composite endpoint of 2 years (RR: 0.88, 95% CI: 0.72–1.09) and 3 years (RR: 0.87, 95% CI: 0.73–1.04). Nonetheless, there was a lower risk for revascularization associated with CABG from 1 to 5 years and their total effect (RR: 3.77, 95% CI: 3.35–4.26). There was no difference in death, myocardial infarction, cerebrovascular events or revascularization at 1 year between RCT and observational groups. Conclusions Our meta-analysis indicates that DES has higher safety but higher revascularization than CABG in patients with ULMCAD in the 5 years after intervention.
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Analysis of Stroke Occurring in the SYNTAX Trial Comparing Coronary Artery Bypass Surgery and Percutaneous Coronary Intervention in the Treatment of Complex Coronary Artery Disease. JACC Cardiovasc Interv 2013; 6:344-54. [DOI: 10.1016/j.jcin.2012.11.010] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2012] [Revised: 11/20/2012] [Accepted: 11/29/2012] [Indexed: 11/22/2022]
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McNulty E. Coronary Artery Bypass Grafting Versus Percutaneous Coronary Intervention for Unprotected Left Main Disease - A Review. Interv Cardiol 2013; 8:14-18. [PMID: 29588745 DOI: 10.15420/icr.2013.8.1.14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
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.
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Affiliation(s)
- Edward McNulty
- Kaiser San Francisco Medical Center, and Assistant Clinical Professor, University of California San Francisco School of Medicine, San Francisco, California, US
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Malkin CJ, Ghobrial MSA, Raina T, Siotia A, Morton AC, Gunn J. Impact of incomplete revascularization in patients undergoing PCI for unprotected left main stem stenosis. Catheter Cardiovasc Interv 2013; 81:939-46. [PMID: 23074075 DOI: 10.1002/ccd.24695] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2012] [Accepted: 10/05/2012] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Percutaneous revascularization of patients with multivessel and left main stem (LMS) disease may be incomplete and the impact of this is not well reported and may influence outcome. In this study we assessed the role of completeness of revascularization upon outcome after PCI for unprotected left main stem (uLMS) PCI in the "real world." MATERIALS AND METHOD Consecutive patients (n = 353) with uLMS disease were treated by PCI by a single operator with a policy of maximal feasible revascularization between 2000 and 2011. The SYNTAX score was calculated before and after PCI (residual SYNTAX score) to gauge the completeness of revascularization. The endpoints were mortality and repeat revascularization. RESULTS Mean age was 69 ± 11 years, baseline SYNTAX score was 33.4 ± 15, 53% were nonelective, 10% were in cardiogenic shock, and 45% were not surgical candidates. LMS bifurcation was involved in 74% and 2.0 ± 0.9 other vessels were diseased. Complete revascularization was achieved in 49% and was associated with reduced mortality compared with incomplete, at 30 days [5(2.9%) v 23(13%)], 1 year [9(5%) v 34(19%)], and 3 years [14(8%) v 46(26%)]; all P < 0.0001). Median rSYNTAX score was 1(0-11), 1-year survival for the lowest, middle and highest tertiles of rSYNTAX were 1.7%, 3.1% and 7.3% (P < 0.0001), respectively. In multivariate analysis postprocedure rSYNTAX score independently predicted outcome but preprocedural SYNTAX score did not. CONCLUSIONS For unselected patients with uLMS treated by PCI, completeness of revascularization is associated with superior survival. The rSYNTAX score, a novel index of completeness of revascularization, independently predicts survival. Baseline SYNTAX score does not.
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Affiliation(s)
- Chris J Malkin
- Department of Cardiology, Northern General Hospital, Sheffield, United Kingdom
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Dash D. Stenting of left main coronary artery stenosis: A to Z. HEART ASIA 2013; 5:18-27. [PMID: 27326065 DOI: 10.1136/heartasia-2012-010218] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2012] [Revised: 12/26/2012] [Accepted: 12/28/2012] [Indexed: 11/03/2022]
Abstract
For several decades, coronary artery bypass grafting (CABG) has been considered as the gold standard treatment of unprotected left main coronary artery (LMCA) disease. The marked improvement in technique and technology makes percutaneous coronary interventions (PCIs) feasible for patients with unprotected LMCA stenosis. The recent introduction of drug-eluting stents (DESs), together with advances in periprocedural and postprocedural adjunctive pharmacotherapies, has improved outcomes of PCIs of these lesions. Recent studies comparing efficacy and safety of PCIs using drug-eluting stents and CABG revealed comparable results in terms of safety and a lower need for repeat revascularisation for CABG. Patient selection for both the techniques directly impacts clinical outcome. Despite improvement in stent technology and operator experience, management can be challenging especially in LMCA bifurcation lesions and, therefore, an integrated approach combining advanced devices, tailored techniques, adjunctive support of physiological evaluation, and adjunctive pharmacological agents should be reinforced to improve clinical outcome.
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Affiliation(s)
- Debabrata Dash
- Department of Cardiology , Fortis Raheja Hospital, Cumballa Hill Hospital , Mumbai, Maharastra , India
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Park SJ, Ahn JM, Kang SJ. Unprotected left main percutaneous coronary intervention: integrated use of fractional flow reserve and intravascular ultrasound. J Am Heart Assoc 2012; 1:e004556. [PMID: 23316329 PMCID: PMC3540662 DOI: 10.1161/jaha.112.004556] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2012] [Accepted: 10/09/2012] [Indexed: 01/25/2023]
Affiliation(s)
- Seung-Jung Park
- Heart Institute, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Korea.
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Jiang WB, Zhao W, Huang H, Li CL, Zhang JH, Wang Y, Fu GS. Meta-analysis of effectiveness of first-generation drug-eluting stents versus coronary artery bypass grafting for unprotected left main coronary disease. Am J Cardiol 2012; 110:1764-72. [PMID: 23078911 DOI: 10.1016/j.amjcard.2012.08.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2012] [Revised: 08/13/2012] [Accepted: 08/13/2012] [Indexed: 02/04/2023]
Abstract
It is controversial whether drug-eluting stents (DESs) are safe and effective when generalized to "real-world" patients with unprotected left main coronary artery disease. This meta-analysis compared the safety and efficacy of DESs to coronary artery bypass grafting (CABG) in real-world patients with unprotected left main coronary artery. We identified comparative, observational, DES versus CABG studies published from January 2000 through May 2012. All studies included ≥100 patients and reported end points with follow-ups ≥6 months. We included adjusted risk estimates and, when no adjusted estimate was available, crude estimates. Data were grouped according to follow-up times of ≤2, ≤3, and >3 years. We included data from 25 observational studies representing 7,230 patients. No differences were detected between CABG and DES in overall mortality (≤2 years, adjusted risk ratio [RR], 0.83, 95% confidence interval [CI] 0.53 to 1.28; ≤3 years, adjusted RR 0.60, 95% CI 0.20 to 1.66; >3 years, adjusted RR 0.58, 95% CI 0.29 to 1.17) or in major adverse cardiac and cerebrovascular events (≤2 years, adjusted RR 1.22, 95% CI 0.86 to 1.73; ≤3 years, adjusted RR 1.70, 95% CI 1.35 to 2.15; >3 years, adjusted RR 1.23, 95% CI 0.87 to 1.73). Compared to DESs, CABG showed a significant decrease in target vessel revascularization (≤2 years, adjusted RR 3.72, 95% CI 2.50 to 5.52; ≤3 years, adjusted RR 3.92, 95% CI 2.54 to 6.04; >3 years, adjusted RR 3.45, 95% CI 2.14 to 5.57). In conclusion, DESs and CABG were not significantly different in short- and long-term rates of death or major cardiovascular/cerebrovascular events, but DESs showed a higher risk of target vessel revascularization compared to CABG.
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Affiliation(s)
- Wen-Bing Jiang
- Department of Cardiology, Wenzhou Third People's Hospital, Wenzhou, Zhejiang, China
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Mylotte D, Meftout B, Moynagh A, Vaquerizo B, Darremont O, Silvestri M, Louvard Y, Leymarie JL, Morice MC, Lefèvre T, Garot P. Unprotected left main stenting in the real world: five-year outcomes of the French Left Main Taxus registry. EUROINTERVENTION 2012; 8:970-81. [DOI: 10.4244/eijv8i8a147] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Fihn SD, Gardin JM, Abrams J, Berra K, Blankenship JC, Dallas AP, Douglas PS, Foody JM, Gerber TC, Hinderliter AL, King SB, Kligfield PD, Krumholz HM, Kwong RY, Lim MJ, Linderbaum JA, Mack MJ, Munger MA, Prager RL, Sabik JF, Shaw LJ, Sikkema JD, Smith CR, Smith SC, Spertus JA, Williams SV. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease: Executive Summary. J Am Coll Cardiol 2012. [DOI: 10.1016/j.jacc.2012.07.012] [Citation(s) in RCA: 114] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Fihn SD, Gardin JM, Abrams J, Berra K, Blankenship JC, Dallas AP, Douglas PS, Foody JM, Gerber TC, Hinderliter AL, King SB, Kligfield PD, Krumholz HM, Kwong RYK, Lim MJ, Linderbaum JA, Mack MJ, Munger MA, Prager RL, Sabik JF, Shaw LJ, Sikkema JD, Smith CR, Smith SC, Spertus JA, Williams SV. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: executive summary: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2012. [PMID: 23182125 DOI: 10.1016/j.jacc.2012.07.013] [Citation(s) in RCA: 1225] [Impact Index Per Article: 102.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Fihn SD, Gardin JM, Abrams J, Berra K, Blankenship JC, Dallas AP, Douglas PS, Foody JM, Gerber TC, Hinderliter AL, King SB, Kligfield PD, Krumholz HM, Kwong RYK, Lim MJ, Linderbaum JA, Mack MJ, Munger MA, Prager RL, Sabik JF, Shaw LJ, Sikkema JD, Smith CR, Smith SC, Spertus JA, Williams SV, Anderson JL. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2012; 126:e354-471. [PMID: 23166211 DOI: 10.1161/cir.0b013e318277d6a0] [Citation(s) in RCA: 465] [Impact Index Per Article: 38.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Fihn SD, Gardin JM, Abrams J, Berra K, Blankenship JC, Dallas AP, Douglas PS, Foody JM, Gerber TC, Hinderliter AL, King SB, Kligfield PD, Krumholz HM, Kwong RYK, Lim MJ, Linderbaum JA, Mack MJ, Munger MA, Prager RL, Sabik JF, Shaw LJ, Sikkema JD, Smith CR, Smith SC, Spertus JA, Williams SV. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: executive summary: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2012; 126:3097-137. [PMID: 23166210 DOI: 10.1161/cir.0b013e3182776f83] [Citation(s) in RCA: 274] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Jang JS, Choi KN, Jin HY, Seo JS, Yang TH, Kim DK, Kim DS, Urm SH, Chun JH, Kang SJ, Park DW, Lee SW, Kim YH, Lee CW, Park SW, Park SJ. Meta-analysis of three randomized trials and nine observational studies comparing drug-eluting stents versus coronary artery bypass grafting for unprotected left main coronary artery disease. Am J Cardiol 2012; 110:1411-8. [PMID: 22877423 DOI: 10.1016/j.amjcard.2012.06.051] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2012] [Revised: 06/25/2012] [Accepted: 06/25/2012] [Indexed: 11/26/2022]
Abstract
Clinical outcomes for unprotected left main coronary artery (ULMCA) disease between coronary artery bypass grafting (CABG) and drug-eluting stents (DESs) remain controversial. We aimed to compare the safety and efficacy of percutaneous coronary intervention (PCI) using DESs with CABG in patients with ULMCA disease. Databases were searched for clinical studies that reported outcomes after PCI with DESs and CABG for treatment of ULMCA disease. End points of this meta-analysis were mortality; composite of death, myocardial infarction (MI), or stroke; and target vessel revascularization at 1-year follow-up. Pooled effects were calculated using fixed-effects model (Mantel-Haenszel method) or random-effects models (Dersimonian-Laird method). Twelve clinical studies (3 randomized trials and 9 observational studies) with 5,079 patients were involved in this study. At 1-year follow-up, there were trends toward lower risk of death (odds ratio [OR] 0.68, 95% confidence interval [CI] 0.45 to 1.02) and the composite end point of death, MI, or stroke (OR 0.70, 95% CI 0.49 to 1.00) in the DES group compared to the CABG group. However, target vessel revascularization was significantly higher in the DES group compared to the CABG group (OR 3.52, 95% CI 2.72 to 4.56). In conclusion, PCI with DESs is associated with favorable outcomes for mortality; composite end point of death, MI, or stroke; and a higher risk of target vessel revascularization compared to CABG in patients with ULMCA disease.
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Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, Chambers CE, Ellis SG, Guyton RA, Hollenberg SM, Khot UN, Lange RA, Mauri L, Mehran R, Moussa ID, Mukherjee D, Nallamothu BK, Ting HH. 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. Catheter Cardiovasc Interv 2012; 79:453-95. [PMID: 22328235 DOI: 10.1002/ccd.23438] [Citation(s) in RCA: 125] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Palmerini T, Alessi L, Rizzo N, Dangas G. Percutaneous revascularization of left main: role of imaging, techniques, and adjunct pharmacology. Catheter Cardiovasc Interv 2012; 79:990-9. [PMID: 21805577 DOI: 10.1002/ccd.23241] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2011] [Accepted: 05/15/2011] [Indexed: 11/09/2022]
Abstract
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.
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Affiliation(s)
- Tullio Palmerini
- Istituto di Cardiologia, Policlinico S. Orsola, University of Bologna, Bologna, Italy
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Sa MPBDO, Soares AMMN, Lustosa PC, Martins WN, Browne F, Ferraz PE, Vasconcelos FP, Lima RC. Meta-analysis of 5674 patients treated with percutaneous coronary intervention and drug-eluting stents or coronary artery bypass graft surgery for unprotected left main coronary artery stenosis. Eur J Cardiothorac Surg 2012; 43:73-80. [DOI: 10.1093/ejcts/ezs204] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
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Palmerini T, Alessi L, Dangas G. Revascularization of unprotected left main coronary artery disease: Strategy selection and systematic risk assessment. Catheter Cardiovasc Interv 2012; 80:199-205. [DOI: 10.1002/ccd.24323] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2011] [Accepted: 01/07/2012] [Indexed: 11/11/2022]
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Desch S, Boudriot E, Rastan A, Buszman P, Bochenek A, Mohr F, Schuler G, Thiele H. Bypass surgery versus percutaneous coronary intervention for the treatment of unprotected left main disease. Herz 2012; 38:48-56. [DOI: 10.1007/s00059-012-3596-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2011] [Revised: 01/29/2012] [Accepted: 01/30/2012] [Indexed: 01/29/2023]
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Cao C, Manganas C, Bannon P, Vallely M, Yan TD. Drug-eluting stents versus coronary artery bypass graft surgery in left main coronary artery disease: a meta-analysis of early outcomes from randomized and nonrandomized studies. J Thorac Cardiovasc Surg 2012; 145:738-47. [PMID: 22405674 DOI: 10.1016/j.jtcvs.2012.02.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2011] [Revised: 01/15/2012] [Accepted: 02/03/2012] [Indexed: 01/06/2023]
Abstract
OBJECTIVE The present meta-analysis aimed to compare the short-term safety and efficacy of drug-eluting stents and coronary artery bypass graft surgery for patients with left main coronary artery disease. METHODS Fourteen relevant studies were identified from 5 electronic databases. End points included mortality, stroke, myocardial infarction, repeat revascularization, and major adverse cardiac and cerebrovascular events. RESULTS Results indicate that all-cause mortality was similar between drug-eluting stents and coronary artery bypass grafting at 30 days and at follow-up beyond 1 year. Likewise, the incidence of myocardial infarction was similar between drug-eluting stents and coronary artery bypass grafting at 12 months and at follow-up beyond 1 year. However, drug-eluting stents were associated with a lower incidence of all-cause mortality at 12 months and a higher incidence of myocardial infarction at 30 days compared with coronary artery bypass grafting. Drug-eluting stents were consistently associated with a higher incidence of repeat revascularization, whereas coronary artery bypass grafting had a higher incidence of stroke. The incidence of major adverse cardiac and cerebrovascular events was similar between the 2 groups at 30 days but higher for drug-eluting stents at 12 months and beyond. CONCLUSIONS Patients treated by drug-eluting stents in randomized controlled trials and observational studies in the current literature are often a preselected subgroup with less complex lesions compared with the overall target population. Results drawn from these studies should be viewed with caution. Coronary artery bypass grafting is associated with a lower incidence of major adverse cardiac and cerebrovascular events at 1 year and beyond, and thus should be regarded as the standard of treatment. However, drug-eluting stents may have a role for selected patients with percutaneously amenable left main disease who are poor surgical candidates.
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Affiliation(s)
- Christopher Cao
- The Baird Institute for Applied Heart and Lung Surgical Research, Sydney, Australia
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Hillis LD, Smith PK, Anderson JL, Bittl JA, Bridges CR, Byrne JG, Cigarroa JE, DiSesa VJ, Hiratzka LF, Hutter AM, Jessen ME, Keeley EC, Lahey SJ, Lange RA, London MJ, Mack MJ, Patel MR, Puskas JD, Sabik JF, Selnes O, Shahian DM, Trost JC, Winniford MD, Jacobs AK, Anderson JL, Albert N, Creager MA, Ettinger SM, Guyton RA, Halperin JL, Hochman JS, Kushner FG, Ohman EM, Stevenson W, Yancy CW. 2011 ACCF/AHA guideline for coronary artery bypass graft surgery: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Thorac Cardiovasc Surg 2012; 143:4-34. [PMID: 22172748 DOI: 10.1016/j.jtcvs.2011.10.015] [Citation(s) in RCA: 197] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Abstract
For several decades of medical history, coronary-artery bypass grafting (CABG) has been regarded as the best treatment option for patients with unprotected left main coronary artery (LMCA) disease, considering lesion priority and its clinical consequences. Over the time, with remarkable advancements in techniques of percutaneous coronary intervention (PCI), supporting devices, and adjunctive pharmacologic therapy, PCI with DES implantation has appeared to be new and alternative option for optimal revascularization therapy for these patients. The available cumulative evidence suggests that the safety outcomes such as mortality or composite of death, myocardial infarction and stroke are similar among PCI and CABG for patients with LMCA disease, the only difference was the rate of repeat revascularization. Current evidence and ongoing large clinical trials may encourage interventional cardiologists to choose PCI with stenting as an alternative revascularization strategy for unprotected LMCA disease in future. Finally, this evidence will change the current clinical practice and the guideline of optimal revascularization strategy for unprotected LMCA disease.
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Affiliation(s)
- Seung-Jung Park
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, 388-1 Poongnap-dong, Songpa-gu, Seoul, 138-736, Korea,
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Kawecki D, Morawiec B, Fudal M, Milejski W, Jacheć W, Nowalany-Kozielska E. Comparison of coronary artery bypass grafting with percutaneous coronary intervention for unprotected left main coronary artery disease. Yonsei Med J 2012; 53:58-67. [PMID: 22187233 PMCID: PMC3250341 DOI: 10.3349/ymj.2012.53.1.58] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
PURPOSE Coronary artery bypass grafting (CABG) is the optimal treatment option for left main coronary artery disease (LMCAD). However, LMCAD remains a constant topic of discussion between cardiac surgeons and interventional cardiologists. The aim of this study was to assess the efficacy of LMCAD treatments by comparing the mid-term outcomes of CABG and percutaneous coronary intervention (PCI) using bare metal stents or drug-eluting stents (DESs). MATERIALS AND METHODS The study population was comprised of 199 consecutive patients admitted with unprotected LMCAD. All of the patients were assigned to PCI (88 patients) or CABG (111 patients). The primary clinical end point indicated death, stroke of acute coronary syndrome (ACS). RESULTS Patients assigned to PCI were at higher operative risk than patients scheduled for CABG (6.49 ± 4.09 vs. 4.81 ± 2.67, p=0.0032). Comparison of the group that received DESs with the CABG group did not reveal any differences in major adverse cardio-cerebral events (MACCE) occurrence (21% vs. 16%, p=NS). Patients in the CABG and PCI groups died with similar frequency (11% vs. 16%, p=NS). The mortality rate in the CABG group was higher than among those treated with DES (11% vs. 3%, p=0.049). The rate of ACS was higher in the PCI group than in the CABG group (13% vs. 4%, p=0.016). CONCLUSION Despite the fact that patients treated with PCI were at higher operative risk, PCI with DES was shown to be comparable to CABG in terms of mortality, stroke and ACS. However, the frequency of repeat revascularizations remains a constant concern with PCI.
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Affiliation(s)
- Damian Kawecki
- 2nd Department of Cardiology, Zabrze, Medical University of Silesia, Katowice, 10 M. Curie-Skłodowskiej Str., 41-800 Zabrze, Poland.
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Park SJ, Park DW. Treatment of patients with left main coronary artery disease. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2011; 14:108-16. [PMID: 22134853 DOI: 10.1007/s11936-011-0159-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OPINION STATEMENT Considering lesion priority and its clinical consequences, coronary artery bypass grafting (CABG) has been a treatment of choice for revascularization in patients with significant left main coronary artery (LMCA) disease, However, with remarkable advancements in techniques of percutaneous coronary intervention (PCI), supporting devices, and adjunctive pharmacologic therapy, PCI with stenting has emerged to be a less invasive and feasible revascularization treatment for these patients. The cumulative evidence suggests that the safety outcomes such as mortality or composite of death, myocardial infarction, and stroke are similar among PCI and CABG, with the only difference being the rate of repeat revascularization. Based on these data, the current guideline of revascularization of LMCA disease has adopted an increasing off-label experience with stenting and clinical studies and been updated to partly approve PCI as a viable alternative (in level of class IIb) in selected patients. The choice of PCI or CABG for unprotected LMCA disease depends on several clinical and anatomic features, ensuring crucial patient selection to be a cornerstone for achieving favorable long-term outcomes. In patients with very complex anatomic features and concomitant diffuse multivessel disease, CABG is preferred so as to avoid procedural and future thrombotic risks and to provide more complete revascularization. By contrast, in patients with relatively simple LMCA disease, such as ostial/shaft LMCA disease, isolated LMCA disease (with or without one or two-vessel involvement), and LMCA disease with low SYNTAX score, PCI is an alternative, and in some cases a preferred, strategy to reduce surgical risks (eg, stroke and in-hospital events following major surgery). For the future, ongoing large clinical trials might also boost interventional cardiologists to select PCI with stenting as an alternative revascularization strategy for unprotected LMCA disease. This evidence will most likely change the current clinical practice and guidelines of optimal revascularization strategy for unprotected LMCA disease.
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Affiliation(s)
- Seung-Jung Park
- Division of Cardiology, University of Ulsan College of Medicine, Asan Medical Center, 388-1 Poongnap-dong, Songpa-gu, Seoul, 138-736, Korea,
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