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Dokollari A, Gemelli M, Sicouri S, Gray WA, Shapiro TA, McGeehin F, Badri M, Coady P, Gnall E, Caroline M, Khan AA, Bonacchi M, Cabrucci F, Bacchi B, Chiarello B, Shah A, Spooner A, Ghorpade N, Hassanabad AF, Kjelstrom S, Montone G, Wertan MA, Ramlawi B, Sutter FP. Midterm Clinical Outcomes of Robotic-Assisted Reverse Hybrid Coronary Revascularization: A Single-Center Experience. Am J Cardiol 2024; 216:35-42. [PMID: 38185437 DOI: 10.1016/j.amjcard.2023.12.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 11/26/2023] [Accepted: 12/22/2023] [Indexed: 01/09/2024]
Abstract
Outcomes of robotic-assisted reverse hybrid coronary revascularization (HCR) remain hindered. We aimed to analyze midterm clinical outcomes of robotic-assisted reverse HCR. All consecutive 285 patients who underwent reverse robotic-assisted HCR between September 2005 and July 2021 were included. Reverse HCR comprises percutaneous coronary intervention with stent implantation in non-left anterior descending (LAD) coronary arteries was performed within 30 days before robotic-assisted left internal thoracic artery (LITA) harvesting and LITA-to-LAD manual anastomosis through a 4-cm left minithoracotomy. Dual antiplatelet therapy was not interrupted in any patient. Preoperatively, mean age was 70.2 years (±11.2). Before surgery, 168 patients received 1 stent, 112 patients 2 stents, and 5 patients 3 stents. Intraoperatively, mean operating room time was 5.9 hours (±1); no case was converted to full sternotomy, whereas 9 patients (3.1%) received intraoperative blood product transfusions. Postoperatively, a small incidence of stroke, 1 (0.3%), reoperation for bleeding, 7 (2.4%), blood product transfusions, 48 (16.8%), and hospital stay (4.8 days) was observed. At 30-day follow-up, 1 patient (0.3%) underwent percutaneous coronary intervention with stent on a surgical LITA-LAD anastomosis owing to graft failure. Mean follow-up was 4.2 years. Reported midterm outcomes included all-cause death in 31 patients (10.9%), major adverse cardiovascular and cerebrovascular events in 102 of 285 (35.9%), nonfatal stroke in 2 of 285 (0.7%), myocardial infarction in 17 of 285 (5.9%), and repeat intervention in 50 of 285 patients (17.5%). This single-center study reports effective and safe clinical outcomes at midterm follow-up of reverse HCR procedures for treating multivessel coronary artery disease.
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Affiliation(s)
- Aleksander Dokollari
- Departments of Cardiac Surgery, Lankenau Heart Institute, Lankenau Medical Center, Main Line Health, Wynnewood, Pennsylvania; Cardiac Surgery Department, St. Boniface Hospital, University of Manitoba, Winnipeg, Manitoba, Canada.
| | - Marco Gemelli
- Cardiac Surgery Department, University of Padua, Padua, Italy
| | - Serge Sicouri
- Department of Cardiac Surgery Research, Lankenau Institute for Medical Research, Main Line Health, Wynnewood, Pennsylvania
| | - William A Gray
- Interventional Cardiology, Lankenau Heart Institute, Lankenau Medical Center, Main Line Health, Wynnewood, Pennsylvania
| | - Timothy A Shapiro
- Interventional Cardiology, Lankenau Heart Institute, Lankenau Medical Center, Main Line Health, Wynnewood, Pennsylvania
| | - Frank McGeehin
- Interventional Cardiology, Lankenau Heart Institute, Lankenau Medical Center, Main Line Health, Wynnewood, Pennsylvania
| | - Marwan Badri
- Interventional Cardiology, Lankenau Heart Institute, Lankenau Medical Center, Main Line Health, Wynnewood, Pennsylvania
| | - Paul Coady
- Interventional Cardiology, Lankenau Heart Institute, Lankenau Medical Center, Main Line Health, Wynnewood, Pennsylvania
| | - Eric Gnall
- Interventional Cardiology, Lankenau Heart Institute, Lankenau Medical Center, Main Line Health, Wynnewood, Pennsylvania
| | - Mara Caroline
- Interventional Cardiology, Lankenau Heart Institute, Lankenau Medical Center, Main Line Health, Wynnewood, Pennsylvania
| | - Amid A Khan
- Interventional Cardiology, Lankenau Heart Institute, Lankenau Medical Center, Main Line Health, Wynnewood, Pennsylvania
| | - Massimo Bonacchi
- Department of Clinical and Experimental Medicine, University of Florence, Florence, Italy
| | - Francesco Cabrucci
- Department of Clinical and Experimental Medicine, University of Florence, Florence, Italy
| | - Beatrice Bacchi
- Department of Clinical and Experimental Medicine, University of Florence, Florence, Italy
| | - Bruno Chiarello
- Department of Clinical and Experimental Medicine, University of Florence, Florence, Italy
| | - Ashish Shah
- Cardiac Surgery Department, St. Boniface Hospital, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Aaron Spooner
- Cardiac Surgery Department, St. Boniface Hospital, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Nitin Ghorpade
- Cardiac Surgery Department, St. Boniface Hospital, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Ali Fatehi Hassanabad
- Cardiac Surgery Department, Libin Cardiovascular Institute of Medicine, University of Alberta, Calgary, Alberta, Canada
| | - Stephanie Kjelstrom
- Population Health, Lankenau Institute for Medical Research, Main Line Health, Wynnewood, Pennsylvania
| | - Georgia Montone
- Population Health, Lankenau Institute for Medical Research, Main Line Health, Wynnewood, Pennsylvania
| | - Mary Ann Wertan
- Departments of Cardiac Surgery, Lankenau Heart Institute, Lankenau Medical Center, Main Line Health, Wynnewood, Pennsylvania
| | - Basel Ramlawi
- Departments of Cardiac Surgery, Lankenau Heart Institute, Lankenau Medical Center, Main Line Health, Wynnewood, Pennsylvania; Department of Cardiac Surgery Research, Lankenau Institute for Medical Research, Main Line Health, Wynnewood, Pennsylvania
| | - Francis P Sutter
- Departments of Cardiac Surgery, Lankenau Heart Institute, Lankenau Medical Center, Main Line Health, Wynnewood, Pennsylvania
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2
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Taggart DP. PCI versus CABG in coronary artery disease. Vascul Pharmacol 2024; 155:107367. [PMID: 38508356 DOI: 10.1016/j.vph.2024.107367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Accepted: 03/15/2024] [Indexed: 03/22/2024]
Abstract
The evidence basis for percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in coronary artery disease (CAD) has become more firmly established over the last decade in view of new evidence from several large, randomized trials and propensity-matched registries. In comparison to PCI, CABG offers substantial survival benefits and significant reductions in myocardial infarction and need for repeat revascularization in multivessel disease in patients with intermediate and high severity disease, whereas for left main disease these benefits are largely observed in patients with the highest-severity disease. In general, the benefits of CABG are further enhanced in patients with diabetes and/or impaired ventricular function. In stable or urgent clinical situations most decisions for intervention should be agreed by a multidisciplinary group ('Heart Team'), incorporating the severity of CAD and the patient's overall clinical suitability and personal wishes for any proposed procedure.
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Affiliation(s)
- David P Taggart
- Cardiovascular Surgery, Nuffield Dept of Surgical Sciences, University of Oxford, John Radcliffe Hospital, United Kingdom.
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Lopez-Ayala P, De Caterina R, Mueller C. Challenges with the 4th Universal Definition of Myocardial Infarction - the unsolved issue of Type 2 and the arbitrariness of Type 4 and 5. Vascul Pharmacol 2024; 155:107365. [PMID: 38471618 DOI: 10.1016/j.vph.2024.107365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 02/02/2024] [Accepted: 02/27/2024] [Indexed: 03/14/2024]
Affiliation(s)
- Pedro Lopez-Ayala
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Raffaele De Caterina
- University of Pisa and University Cardiology Division, Pisa University Hospital, Pisa, Italy; Fondazione VillaSerena per la Ricerca, Città Sant'Angelo, Pescara, Italy
| | - Christian Mueller
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland.
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Hachiro K, Takashima N, Suzuki T. Off-pump bilateral internal thoracic artery grafting in patients with left main coronary artery disease. J Cardiothorac Surg 2024; 19:81. [PMID: 38336822 PMCID: PMC10858637 DOI: 10.1186/s13019-024-02582-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 01/30/2024] [Indexed: 02/12/2024] Open
Abstract
BACKGROUND To compare postoperative outcomes in patients with left main coronary artery disease who underwent off-pump isolated coronary artery bypass grafting for multivessel disease using either skeletonized bilateral or single internal thoracic artery (ITA). METHODS Among 1583 patients who underwent isolated coronary artery bypass grafting (CABG) in our hospital between 2002 and 2022, 604 patients with left main coronary artery disease underwent single (n = 169) or bilateral (n = 435) ITA grafting. We compared postoperative outcomes between the two groups after adjusting preoperative characteristics using inverse probability of treatment weighting. RESULTS After adjustment using inverse probability of treatment weighting method, the sum of weights was 599.74 in BITA group and 621.64 in SITA group. There was no significant difference in postoperative deep sternal wound infection (p = 0.227) and 30-day mortality (p = 0.612). Follow-up was completed in 98.7% (596/604) of the patients, and the mean follow-up duration was 6.7 years. At 10 years, the overall survival following bilateral versus single ITA grafting was 71.2% and 60.6%, respectively (log-rank test, p = 0.040), and freedom from major adverse cardiac and cerebrovascular events (MACCE) was 63.3% and 46.3%, respectively (log-rank test, p = 0.008). In multivariate Cox proportional hazard models, bilateral ITA grafting was significantly associated with a lower risk of all-cause death (hazard ratio [HR]: 0.706, 95% confidence interval [CI]: 0.504-0.987; p = 0.042) and MACCE (HR: 0.671, 95% CI: 0.499-0.902; p = 0.008). CONCLUSIONS Bilateral skeletonized ITA grafting is associated with lower rates of all-cause death and MACCE than single ITA grafting in patients with left main coronary artery disease undergoing off-pump CABG.
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Affiliation(s)
- Kohei Hachiro
- Division of Cardiovascular Surgery, Department of Surgery, Shiga University of Medical Science, Setatsukinowa-cho, Otsu, 520-2192, Shiga, Japan.
| | - Noriyuki Takashima
- Division of Cardiovascular Surgery, Department of Surgery, Shiga University of Medical Science, Setatsukinowa-cho, Otsu, 520-2192, Shiga, Japan
| | - Tomoaki Suzuki
- Division of Cardiovascular Surgery, Department of Surgery, Shiga University of Medical Science, Setatsukinowa-cho, Otsu, 520-2192, Shiga, Japan
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Onea HL, Lazar FL, Olinic DM, Homorodean C, Cortese B. The role of optical coherence tomography in guiding percutaneous coronary interventions: is left main the final challenge? Minerva Cardiol Angiol 2024; 72:41-55. [PMID: 36321887 DOI: 10.23736/s2724-5683.22.06181-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2024]
Abstract
Left main (LM) coronary artery disease is a high-risk lesion subset, with important prognostic implications for the patients. Recent advances in the field of interventional cardiology have narrowed the gap between surgical and percutaneous approach of this complex lesion setting. However, the rate of repeat revascularization remains higher in the case of percutaneous coronary intervention (PCI) on long-term follow-up. As such, the need for better stent optimization strategies has led to the development of intravascular imaging techniques, represented mainly by intravascular ultrasound (IVUS) and optical coherence tomography (OCT). These techniques are both able to provide excellent pre- and post-PCI guidance. While IVUS is an established modality in optimizing LM PCI, and is recommended by international revascularization guidelines, data and experience on the use of OCT are still limited. This review paper deeply analyzes the current role of OCT imaging in the setting of LM disease, particularly focusing on its utility in assessing plaque morphology and distribution, vessel dimensions and proper stent sizing, analyzing mechanisms of stent failure such as malapposition and underexpansion, guiding bifurcation stenting, as well as offering a direct comparison with IVUS in this critical clinical scenario, based on the most recent available data.
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Affiliation(s)
- Horea-Laurentiu Onea
- Department of Interventional Cardiology, Cluj County Emergency Hospital, Cluj-Napoca, Romania
- Medical Clinic Number1, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Florin-Leontin Lazar
- Department of Interventional Cardiology, Cluj County Emergency Hospital, Cluj-Napoca, Romania
| | - Dan-Mircea Olinic
- Department of Interventional Cardiology, Cluj County Emergency Hospital, Cluj-Napoca, Romania
- Medical Clinic Number1, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Calin Homorodean
- Department of Interventional Cardiology, Cluj County Emergency Hospital, Cluj-Napoca, Romania
- Medical Clinic Number1, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Bernardo Cortese
- Fondazione Ricerca e Innovazione Cardiovascolare, Milan, Italy -
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Vervoort D, Sud M, Zeis TM, Haouzi AA, An KR, Rocha R, Eikelboom R, Fremes SE, Tamis-Holland JE. Do the Few Dictate Care for the Many? Revascularisation Considerations That Go Beyond the Guidelines. Can J Cardiol 2024; 40:275-289. [PMID: 38181974 DOI: 10.1016/j.cjca.2023.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 10/31/2023] [Accepted: 11/07/2023] [Indexed: 01/07/2024] Open
Abstract
The burden of coronary artery disease (CAD) is large and growing, commonly presenting with comorbidities and older age. Patients may benefit from coronary revascularisation with percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG), yet half of patients with CAD who would benefit from revascularisation fall outside the eligibility criteria of trials to date. As such, the choice of revascularisation procedures varies depending on the CAD anatomy and complexity, surgical risk and comorbidities, the patient's preferences and values, and the treating team's expertise. The recent American guidelines on coronary revascularisation are comprehensive in describing recommendations for PCI, CABG, or conservative management in patients with CAD. However, individual challenging patient presentations cannot be fully captured in guidelines. The aim of this narrative review is to summarise common clinical scenarios that are not sufficiently described by contemporary clinical guidelines and trials in order to inform heart team members and trainees about the nuanced considerations and available evidence to manage such cases. We discuss clinical cases that fall beyond the current guidelines and summarise the relevant evidence evaluating coronary revascularisation for these patients. In addition, we highlight gaps in knowledge based on a lack of research (eg, ineligibility of certain patient populations), underrepresentation in research (eg, underenrollment of female and non-White patients), and the surge in newer minimally invasive and hybrid techniques. We argue that ultimately, evidence-based medicine, patient preference, shared decision making, and effective heart team communications are necessary to best manage complex CAD presentations potentially benefitting from revascularisation with CABG or PCI.
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Affiliation(s)
- Dominique Vervoort
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Maneesh Sud
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada; Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Tessa M Zeis
- Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Alice A Haouzi
- Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Kevin R An
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Rodolfo Rocha
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Rachel Eikelboom
- Division of Cardiac Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Stephen E Fremes
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada; Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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7
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Mrevlje B, McFadden E, de la Torre Hernández JM, Testa L, De Maria GL, Banning AP, Spitzer E. Intravascular ultrasound-guided versus angiography-guided percutaneous coronary intervention in unprotected left main coronary artery disease: A systematic review. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024; 59:99-108. [PMID: 37657950 DOI: 10.1016/j.carrev.2023.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 08/13/2023] [Accepted: 08/24/2023] [Indexed: 09/03/2023]
Abstract
BACKGROUND Significant unprotected left main coronary artery (ULMCA) disease is encountered in approximately 5 % of patients undergoing diagnostic coronary angiography. Intravascular ultrasound (IVUS) overcomes many of the known limitations of angiography and improves outcomes of patients undergoing percutaneous coronary interventions (PCI) in stable or complex coronary artery disease. The aim of this systematic review is to evaluate the evidence on IVUS-guidance versus angiography-guidance in ULMCA PCI, highlighting the chronological frequencies of event rates in line with the maturation of PCI technique and devices over time. METHODS A comprehensive systematic search in Medline was performed to identify all studies that had assessed the effect of IVUS-guided versus angiography-guided ULMCA PCI on various primary and secondary endpoints. RESULTS Seventeen studies (2 randomized, 10 non-randomized and 5 meta-analyses) were included in this systematic review. CONCLUSIONS This systematic review on IVUS-guided versus angiography-guided PCI in patients with significant ULMCA disease strongly supports the hypothesis that IVUS-guided PCI is associated with a significant reduction in major adverse cardiac events composites, all-cause death, cardiac death, myocardial infarction and stent thrombosis. Ongoing, adequately powered trials will contribute significantly to the level of evidence.
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Affiliation(s)
| | | | | | - Luca Testa
- Coronary Revascularisation Unit, IRCCS Policlinico S. Donato, San Donato Milanese, Milan, Italy.
| | - Giovanni Luigi De Maria
- Heart Centre, John Radcliffe Hospital, Oxford University Hospitals, NHS Foundation Trust, Oxford, United Kingdom.
| | - Adrian P Banning
- Heart Centre, John Radcliffe Hospital, Oxford University Hospitals, NHS Foundation Trust, Oxford, United Kingdom.
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8
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SUI YG, YANG C, GUAN CD, XU YL, WU NQ, YANG WX, WU YJ, DOU KF, YANG YJ, QIAO SB, YU W, XU B, TU SX, QIAN J. Diagnostic performance of intravascular ultrasound-based fractional flow reserve in evaluating of intermediate left main stenosis. J Geriatr Cardiol 2024; 21:34-43. [PMID: 38440337 PMCID: PMC10908580 DOI: 10.26599/1671-5411.2024.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2024] Open
Abstract
BACKGROUND The recently introduced ultrasonic flow ratio (UFR), is a novel fast computational method to derive fractional flow reserve (FFR) from intravascular ultrasound (IVUS) images. In the present study, we evaluate the diagnostic performance of UFR in patients with intermediate left main (LM) stenosis. METHODS This is a prospective, single center study enrolling consecutive patients with presence of intermediated LM lesions (diameter stenosis of 30%-80% by visual estimation) underwent IVUS and FFR measurement. An independent core laboratory assessed offline UFR and IVUS-derived minimal lumen area (MLA) in a blinded fashion. RESULTS Both UFR and FFR were successfully achieved in 41 LM patients (mean age, 62.0 ± 9.9 years, 46.3% diabetes). An acceptable correlation between UFR and FFR was identified (r = 0.688, P < 0.0001), with an absolute numerical difference of 0.03 (standard difference: 0.01). The area under the curve (AUC) in diagnosis of physiologically significant coronary stenosis for UFR was 0.94 (95% CI: 0.87-1.01), which was significantly higher than angiographic identified stenosis > 50% (AUC = 0.66, P < 0.001) and numerically higher than IVUS-derived MLA (AUC = 0.82; P = 0.09). Patient level diagnostic accuracy, sensitivity and specificity for UFR to identify FFR ≤ 0.80 was 82.9% (95% CI: 70.2-95.7), 93.1% (95% CI: 82.2-100.0), 58.3% (95% CI: 26.3-90.4), respectively. CONCLUSION In patients with intermediate LM diseases, UFR was proved to be associated with acceptable correlation and high accuracy with pressure wire-based FFR as standard reference. The present study supports the use of UFR for functional evaluation of intermediate LM stenosis.
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Affiliation(s)
- Yong-Gang SUI
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Cheng YANG
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Chang-Dong GUAN
- Catheterization Laboratories, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yan-Lu XU
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Na-Qiong WU
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wei-Xian YANG
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yong-Jian WU
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ke-Fei DOU
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yue-Jin YANG
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shu-Bin QIAO
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wei YU
- Biomedical Instrument Institute, School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Bo XU
- Catheterization Laboratories, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Sheng-Xian TU
- Biomedical Instrument Institute, School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Jie QIAN
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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9
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Dokollari A, Sicouri S, Erten O, Gray WA, Shapiro TA, McGeehin F, Badri M, Coady P, Gnall E, Caroline M, Khan AA, Kjelstrom S, Montone G, Ramlawi B, Wertan MA, Sutter FP, Torregrossa G. Long-term clinical outcomes of robotic-assisted surgical coronary artery revascularisation. EUROINTERVENTION 2024; 20:45-55. [PMID: 37994042 PMCID: PMC10756223 DOI: 10.4244/eij-d-23-00373] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 09/25/2023] [Indexed: 11/24/2023]
Abstract
BACKGROUND Patients who are not candidates for traditional coronary artery bypass grafting (CABG) and amenable only for percutaneous coronary intervention (PCI) with stents can receive the "gold standard" left internal thoracic artery (LITA) to left anterior descending artery (LAD) anastomosis through robotic-assisted CABG and PCI to non-LAD coronary targets. AIMS We aimed to analyse clinical outcomes of robotic-assisted CABG. METHODS A total of 2,280 consecutive patients who had undergone robotic-assisted CABG between May 2005 and June 2021 were included in our study. Robotic-assisted LITA harvest was followed by LITA-LAD manual anastomosis through a 4 cm left thoracotomy. Hybrid coronary intervention (HCR) consists of stent implantation in a non-LAD coronary artery performed within 7 days after robotic-assisted LITA-LAD. We performed a propensity-adjusted analysis comparison after dividing all robotic-assisted CABG patients into three time periods: 2005-2010, 615 patients; 2011-2016, 904 patients; and 2017-2021, 761 patients. RESULTS The mean age increased from 64.5 years in the first time period to 65.8 years in the second time period to 68.1 years in the third (p<0.0001). Operative time was progressively reduced in the three periods (6.4; 6.2; 5.5 hours; p<0.001). The incidence of conversion to sternotomy remained similar for each period (1.8%; 1.7%; 1.5%; p=0.53). Thirty-day mortality in the three periods included 9 (1.4%), 9 (1.0%), and 7 (0.9%) patients, respectively (p=0.91), while 8 (0.3%) patients had PCI with stents in the entire group. The mean follow-up for the entire population was 4.2 years. At follow-up, the rates of all-cause death, major adverse cardiac and cerebrovascular events, non-fatal stroke, and repeat revascularisation with stents were significantly decreased from the first to the last period (pË0.0001). CONCLUSIONS Robotic-assisted CABG and HCR provide good long-term outcomes in patients who are not candidates for conventional CABG.
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Affiliation(s)
- Aleksander Dokollari
- Department of Cardiac Surgery, Lankenau Heart Institute, Lankenau Medical Center, Main Line Health, Wynnewood, PA, USA
| | - Serge Sicouri
- Department of Cardiac Surgery Research, Lankenau Institute for Medical Research, Main Line Health, Wynnewood, PA, USA
| | - Ozgun Erten
- Department of Cardiac Surgery Research, Lankenau Institute for Medical Research, Main Line Health, Wynnewood, PA, USA
| | - William A Gray
- Department of Interventional Cardiology, Lankenau Heart Institute, Main Line Health, Wynnewood, PA, USA
| | - Timothy A Shapiro
- Department of Interventional Cardiology, Lankenau Heart Institute, Main Line Health, Wynnewood, PA, USA
| | - Frank McGeehin
- Department of Interventional Cardiology, Lankenau Heart Institute, Main Line Health, Wynnewood, PA, USA
| | - Marwan Badri
- Department of Interventional Cardiology, Lankenau Heart Institute, Main Line Health, Wynnewood, PA, USA
| | - Paul Coady
- Department of Interventional Cardiology, Lankenau Heart Institute, Main Line Health, Wynnewood, PA, USA
| | - Eric Gnall
- Department of Interventional Cardiology, Lankenau Heart Institute, Main Line Health, Wynnewood, PA, USA
| | - Mara Caroline
- Department of Interventional Cardiology, Lankenau Heart Institute, Main Line Health, Wynnewood, PA, USA
| | - Amid A Khan
- Department of Interventional Cardiology, Lankenau Heart Institute, Main Line Health, Wynnewood, PA, USA
| | - Stephanie Kjelstrom
- Population Health, Lankenau Institute for Medical Research, Main Line Health, Wynnewood, PA, USA
| | - Georgia Montone
- Population Health, Lankenau Institute for Medical Research, Main Line Health, Wynnewood, PA, USA
| | - Basel Ramlawi
- Department of Cardiac Surgery, Lankenau Heart Institute, Lankenau Medical Center, Main Line Health, Wynnewood, PA, USA
- Department of Cardiac Surgery Research, Lankenau Institute for Medical Research, Main Line Health, Wynnewood, PA, USA
| | - Mary Ann Wertan
- Department of Cardiac Surgery, Lankenau Heart Institute, Lankenau Medical Center, Main Line Health, Wynnewood, PA, USA
| | - Francis P Sutter
- Department of Cardiac Surgery, Lankenau Heart Institute, Lankenau Medical Center, Main Line Health, Wynnewood, PA, USA
| | - Gianluca Torregrossa
- Department of Cardiac Surgery, Lankenau Heart Institute, Lankenau Medical Center, Main Line Health, Wynnewood, PA, USA
- Department of Cardiac Surgery Research, Lankenau Institute for Medical Research, Main Line Health, Wynnewood, PA, USA
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10
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Torres-Ruiz G, Mallofré-Vila N, Rojas-Flores P, Carrión-Montaner P, Bosch-Peligero E, Valcárcel-Paz D, Cardiel-Perez A, Guindo-Soldevila J, Martínez-Rubio A. Evidence-based Management of Left Main Coronary Artery Disease. Eur Cardiol 2023; 18:e63. [PMID: 38213664 PMCID: PMC10782428 DOI: 10.15420/ecr.2023.36] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 10/16/2023] [Indexed: 01/13/2024] Open
Abstract
Left main coronary artery disease (LMCAD) is associated with high morbidity and mortality due to the large myocardial mass at risk. Although medical treatment may be an option in selected low-risk patients, revascularisation is recommended to improve survival in the majority of patients presenting with a significant left main stenosis. In the past decade, multiple randomised clinical trials and meta-analyses have compared coronary artery bypass grafting surgery (CABG) versus percutaneous coronary intervention (PCI), finding controversial results. The strategy for LMCAD revascularisation is still challenging. Coronary anatomy complexity, clinical features and patient preferences are key elements to be considered by the heart team. The current guidelines define CABG as standard therapy, but the continuous improvements in PCI techniques, the use of intracoronary imaging and functional assessment make PCI a feasible alternative in selected patients, particularly in those with comorbidities and contraindications to CABG. This review analyses the most important studies comparing CABG versus PCI in patients with LMCAD.
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Affiliation(s)
- Gabriel Torres-Ruiz
- Department of Cardiology, Parc Taulí Hospital UniversitariSabadell, Spain
- Department of Medicine, Universitat Autònoma de BarcelonaBarcelona, Spain
| | - Nuria Mallofré-Vila
- Department of Cardiology, Parc Taulí Hospital UniversitariSabadell, Spain
- Department of Medicine, Universitat Autònoma de BarcelonaBarcelona, Spain
| | - Paola Rojas-Flores
- Department of Cardiology, Parc Taulí Hospital UniversitariSabadell, Spain
- Department of Medicine, Universitat Autònoma de BarcelonaBarcelona, Spain
| | - Pablo Carrión-Montaner
- Department of Cardiology, Parc Taulí Hospital UniversitariSabadell, Spain
- Department of Medicine, Universitat Autònoma de BarcelonaBarcelona, Spain
| | - Eduard Bosch-Peligero
- Department of Cardiology, Parc Taulí Hospital UniversitariSabadell, Spain
- Department of Medicine, Universitat Autònoma de BarcelonaBarcelona, Spain
| | - Daniel Valcárcel-Paz
- Department of Cardiology, Parc Taulí Hospital UniversitariSabadell, Spain
- Department of Medicine, Universitat Autònoma de BarcelonaBarcelona, Spain
| | - Ada Cardiel-Perez
- Department of Gynaecology and Obstetrics, Hospital Clínic i ProvincialBarcelona, Spain
| | - Josep Guindo-Soldevila
- Department of Cardiology, Parc Taulí Hospital UniversitariSabadell, Spain
- Department of Medicine, Universitat Autònoma de BarcelonaBarcelona, Spain
| | - Antoni Martínez-Rubio
- Department of Cardiology, Parc Taulí Hospital UniversitariSabadell, Spain
- Department of Medicine, Universitat Autònoma de BarcelonaBarcelona, Spain
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11
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Hannan EL, Wu Y, Harik L, Tamis-Holland J, Jacobs AK, Chikwe J, Cozzens KS, Gaudino M. Coronary artery bypass surgery versus percutaneous interventions for women with multivessel coronary artery disease. J Thorac Cardiovasc Surg 2023:S0022-5223(23)01196-0. [PMID: 38101766 DOI: 10.1016/j.jtcvs.2023.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 12/05/2023] [Accepted: 12/06/2023] [Indexed: 12/17/2023]
Abstract
OBJECTIVE To compare outcomes in women undergoing percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) surgery. DESIGN This retrospective, propensity-score matched cohort study from the New York State cardiac registry (2012-2018) included all women with multivessel coronary artery disease undergoing PCI with everolimus-eluting stents (EES) and CABG surgery. The primary outcome was all-cause mortality. The key secondary outcome was major adverse cardiac events, defined as the composite of all-cause mortality, myocardial infarction, and stroke. RESULTS PCI with EES was associated with a higher 6-year risk of mortality (25.75% vs 23.57%; adjusted hazard ratio [AHR], 1.29; 95% confidence interval [CI], 1.14-1.45). PCI also was associated with a higher rate of the composite outcome of death, myocardial infarction, and stroke (36.58% vs 32.89%; AHR, 1.28; 95% CI, 1.17-1.41), as well as myocardial infarction (14.94% vs 9.12%; AHR, 1.84; 95% CI, 1.56-2.17), but not stroke (7.07% vs 7.62%; AHR, 0.83; 95% CI, 0.67-1.03). Repeat revascularization rates also were higher for women undergoing PCI (21.53% vs 11.57%; AHR, 1.88; 95% CI, 1.63-2.17). There was no difference in mortality between the 2 interventions when PCI patients received complete revascularization or had noncomplex lesions and for women without diabetes. CONCLUSIONS For women with multivessel coronary artery disease, CABG surgery is associated with lower 6-year mortality, myocardial infarction, and repeat revascularization rates compared to PCI with EES.
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Affiliation(s)
- Edward L Hannan
- University at Albany, State University of New York, Albany, NY
| | - Yifeng Wu
- University at Albany, State University of New York, Albany, NY
| | - Lamia Harik
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Jacqueline Tamis-Holland
- Cardiovascular Institute, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Alice K Jacobs
- Department of Medicine, Boston Medical Center, Boston, Mass
| | - Joanna Chikwe
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, Calif
| | | | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY.
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12
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Virani SS, Newby LK, Arnold SV, Bittner V, Brewer LC, Demeter SH, Dixon DL, Fearon WF, Hess B, Johnson HM, Kazi DS, Kolte D, Kumbhani DJ, LoFaso J, Mahtta D, Mark DB, Minissian M, Navar AM, Patel AR, Piano MR, Rodriguez F, Talbot AW, Taqueti VR, Thomas RJ, van Diepen S, Wiggins B, Williams MS. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2023; 82:833-955. [PMID: 37480922 DOI: 10.1016/j.jacc.2023.04.003] [Citation(s) in RCA: 35] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/24/2023]
Abstract
AIM The "2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease" provides an update to and consolidates new evidence since the "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease" and the corresponding "2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease." METHODS A comprehensive literature search was conducted from September 2021 to May 2022. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. STRUCTURE This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team-based care. Relevant topics include general approaches to treatment decisions, guideline-directed management and therapy to reduce symptoms and future cardiovascular events, decision-making pertaining to revascularization in patients with chronic coronary disease, recommendations for management in special populations, patient follow-up and monitoring, evidence gaps, and areas in need of future research. Where applicable, and based on availability of cost-effectiveness data, cost-value recommendations are also provided for clinicians. Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.
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13
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Virani SS, Newby LK, Arnold SV, Bittner V, Brewer LC, Demeter SH, Dixon DL, Fearon WF, Hess B, Johnson HM, Kazi DS, Kolte D, Kumbhani DJ, LoFaso J, Mahtta D, Mark DB, Minissian M, Navar AM, Patel AR, Piano MR, Rodriguez F, Talbot AW, Taqueti VR, Thomas RJ, van Diepen S, Wiggins B, Williams MS. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation 2023; 148:e9-e119. [PMID: 37471501 DOI: 10.1161/cir.0000000000001168] [Citation(s) in RCA: 91] [Impact Index Per Article: 91.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/22/2023]
Abstract
AIM The "2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease" provides an update to and consolidates new evidence since the "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease" and the corresponding "2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease." METHODS A comprehensive literature search was conducted from September 2021 to May 2022. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. STRUCTURE This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team-based care. Relevant topics include general approaches to treatment decisions, guideline-directed management and therapy to reduce symptoms and future cardiovascular events, decision-making pertaining to revascularization in patients with chronic coronary disease, recommendations for management in special populations, patient follow-up and monitoring, evidence gaps, and areas in need of future research. Where applicable, and based on availability of cost-effectiveness data, cost-value recommendations are also provided for clinicians. Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.
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Affiliation(s)
| | | | | | | | | | | | - Dave L Dixon
- Former Joint Committee on Clinical Practice Guideline member; current member during the writing effort
| | - William F Fearon
- Society for Cardiovascular Angiography and Interventions representative
| | | | | | | | - Dhaval Kolte
- AHA/ACC Joint Committee on Clinical Data Standards
| | | | | | | | - Daniel B Mark
- Former Joint Committee on Clinical Practice Guideline member; current member during the writing effort
| | | | | | | | - Mariann R Piano
- Former Joint Committee on Clinical Practice Guideline member; current member during the writing effort
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14
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Pellegrini D, Ielasi A, Tespili M, Guagliumi G, De Luca G. Percutaneous Treatment of Left Main Disease: A Review of Current Status. J Clin Med 2023; 12:4972. [PMID: 37568374 PMCID: PMC10419939 DOI: 10.3390/jcm12154972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 07/13/2023] [Accepted: 07/25/2023] [Indexed: 08/13/2023] Open
Abstract
Percutaneous treatment of the left main coronary artery is one of the most challenging scenarios in interventional cardiology, due to the large portion of myocardium at risk the technical complexity of treating a complex bifurcation with large branches. Our aim is to provide un updated overview of the current indications for percutaneous treatment of the left main, the different techniques and the rationale underlying the choice for provisional versus upfront two-stent strategies, intravascular imaging and physiology guidance in the management of left main disease, and the role of mechanical support devices in complex high-risk PCI.
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Affiliation(s)
- Dario Pellegrini
- Division of Cardiology, IRCCS Ospedale Galeazzi-Sant’Ambrogio, Via Cristina Belgioioso, 173, 20161 Milan, Italy; (D.P.)
| | - Alfonso Ielasi
- Division of Cardiology, IRCCS Ospedale Galeazzi-Sant’Ambrogio, Via Cristina Belgioioso, 173, 20161 Milan, Italy; (D.P.)
| | - Maurizio Tespili
- Division of Cardiology, IRCCS Ospedale Galeazzi-Sant’Ambrogio, Via Cristina Belgioioso, 173, 20161 Milan, Italy; (D.P.)
| | - Giulio Guagliumi
- Division of Cardiology, IRCCS Ospedale Galeazzi-Sant’Ambrogio, Via Cristina Belgioioso, 173, 20161 Milan, Italy; (D.P.)
| | - Giuseppe De Luca
- Division of Cardiology, IRCCS Ospedale Galeazzi-Sant’Ambrogio, Via Cristina Belgioioso, 173, 20161 Milan, Italy; (D.P.)
- Division of Cardiology, AOU “Policlinico G. Martino”, Via Consolare Valeria, 1, 98124 Messina, Italy
- Department of Clinical and Experimental Medicine, University of Messina, Piazza Pugliatti, 1, 98122 Messina, Italy
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15
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Hollman J, Johnson J. Left Main Revascularization in Perspective. Cardiology 2023; 148:293-295. [PMID: 37231789 DOI: 10.1159/000531068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 04/21/2023] [Indexed: 05/27/2023]
Affiliation(s)
- Jay Hollman
- Louisiana State Health Sciences Center Baton Rouge Branch Campus, Baton Rouge, Louisiana, USA
| | - John Johnson
- Louisiana State Health Sciences Center Baton Rouge Branch Campus, Baton Rouge, Louisiana, USA
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16
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Khalid U, Kayani W, Alam M, Denktas AE. Revascularization Options for Left Main Disease: What Clinicians Need to Know. Curr Atheroscler Rep 2023:10.1007/s11883-023-01105-2. [PMID: 37178417 DOI: 10.1007/s11883-023-01105-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/15/2023] [Indexed: 05/15/2023]
Abstract
PURPOSE OF REVIEW Left main disease represents the highest-risk lesion subset of coronary artery disease and is associated with adverse cardiovascular events. Accordingly, we aim to understand how the significance of left main disease is assessed by different modalities, followed by a review of management options in current era. RECENT FINDINGS Invasive coronary angiogram remains the gold standard for assessment of left main disease, but intracoronary imaging or physiological testing is indicated for angiographically equivocal disease. Revascularization by either coronary artery bypass surgery or percutaneous coronary intervention is strongly recommended, which have been compared by six randomized trials, as well as recent meta-analyses. Surgical revascularization remains the preferred mode of revascularization, especially in patients with high lesion complexity and left ventricular dysfunction. Randomized studies are needed to understand if current-generation stents with the use of intracoronary imaging and improved medical therapy could match outcomes with surgical revascularization.
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Affiliation(s)
- Umair Khalid
- Section of Cardiology, Medical Care Line, Michael E. DeBakey VA Medical Center, Houston, TX, USA.
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA.
| | - Waleed Kayani
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Mahboob Alam
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Ali E Denktas
- Section of Cardiology, Medical Care Line, Michael E. DeBakey VA Medical Center, Houston, TX, USA
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
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17
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Moroni A, Marin F, Venturi G, Scarsini R, Ribichini F, De Maria GL, Banning AP. Management of failed stenting of the unprotected left main coronary artery. Catheter Cardiovasc Interv 2023; 101:1001-1013. [PMID: 37002949 DOI: 10.1002/ccd.30636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 02/16/2023] [Accepted: 03/03/2023] [Indexed: 04/03/2023]
Abstract
Percutaneous coronary intervention (PCI) is increasingly accepted as treatment for unprotected left main coronary artery (ULMCA) disease especially in those patients who are unsuitable for cardiac surgery. Treatment of any stent failure is associated with increased complexity and worse clinical outcomes when compared with de novo lesion revascularization. Intracoronary imaging has provided new insight into mechanisms of stent failure and treatment options have developed considerably over the last decade. There is paucity of evidence on the management strategy for stent failure in the specific setting of ULMCA. Treating any left main with PCI requires careful consideration and consequently treatment of failed stents in ULMCA is complex and provides unique challenges. Consequently, we provide an overview of ULMCA stent failure, proposing a tailored algorithm to guide best management and decision in daily clinical practice, with a special focus on intracoronary imaging characterization of causal mechanisms and specific technical and procedural considerations.
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Affiliation(s)
- Alice Moroni
- Clinical and Interventional Cardiology Department, IRCCS Policlinico San Donato, University of Milan, San Donato Milanese, Italy
| | - Federico Marin
- Deparment of Cardiology, Oxford Heart Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Gabriele Venturi
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Roberto Scarsini
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Flavio Ribichini
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Giovanni Luigi De Maria
- Deparment of Cardiology, Oxford Heart Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Adrian P Banning
- Deparment of Cardiology, Oxford Heart Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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18
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Park S, Park SJ, Park DW. Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting for Revascularization of Left Main Coronary Artery Disease. Korean Circ J 2023; 53:113-133. [PMID: 36914602 PMCID: PMC10011221 DOI: 10.4070/kcj.2022.0333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Accepted: 01/24/2023] [Indexed: 03/03/2023] Open
Abstract
Owing to a large-jeopardized myocardium, left main coronary artery disease (LMCAD) represents the substantial high-risk anatomical subset of obstructive coronary artery disease. For several decades, coronary artery bypass grafting (CABG) has been the "gold standard" treatment for LMCAD. Along with advances in CABG, percutaneous coronary intervention (PCI) has also dramatically evolved over time in conjunction with advances in the stent or device technology, adjunct pharmacotherapy, accumulated experiences, and practice changes, establishing its position as a safe, reasonable treatment option for such a complex disease. Until recently, several randomized clinical trials, meta-analyses, and observational registries comparing PCI and CABG for LMCAD have shown comparable long-term survival with tradeoffs between early and late risk-benefit of each treatment. Despite this, there are still several unmet issues for revascularization strategy and management for LMCAD. This review article summarized updated knowledge on evolution and clinical evidence on the treatment of LMCAD, with a focus on the comparison of state-of-the-art PCI with CABG.
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Affiliation(s)
- Sangwoo Park
- Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Seung-Jung Park
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Duk-Woo Park
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
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19
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Milojevic M, Nikolic A. Management of Left Main Coronary Artery Disease in Nonemergent Settings: The Heart of Multidisciplinary Teamwork. JACC Cardiovasc Interv 2023; 16:289-291. [PMID: 36609039 DOI: 10.1016/j.jcin.2022.11.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 11/11/2022] [Accepted: 11/22/2022] [Indexed: 01/06/2023]
Affiliation(s)
- Milan Milojevic
- Departments of Cardiac Surgery and Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia; Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands.
| | - Aleksandar Nikolic
- Department of Cardiac Surgery, Acibadem Sistina Hospital, Skopje, North Macedonia
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20
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Tarantini G, Fovino LN, Varbella F, Trabattoni D, Caramanno G, Trani C, De Cesare N, Esposito G, Montorfano M, Musto C, Picchi A, Sheiban I, Gasparetto V, Ribichini FL, Cardaioli F, Saccà S, Cerrato E, Napodano M, Martinato M, Azzolina D, Andò G, Mugnolo A, Caruso M, Rossini R, Passamonti E, Teles RC, Rigattieri S, Gregori D, Tamburino C, Burzotta F. A large, prospective, multicentre study of left main PCI using a latest-generation zotarolimus-eluting stent: the ROLEX study. EUROINTERVENTION 2023; 18:e1108-e1119. [PMID: 36043326 PMCID: PMC9909455 DOI: 10.4244/eij-d-22-00454] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 07/11/2022] [Indexed: 02/09/2023]
Abstract
BACKGROUND Data on left main (LM) percutaneous coronary interventions (PCI) have mostly been obtained in studies using drug-eluting stent (DES) platforms without dedicated large-vessel devices and with limited expansion capability. AIMS Our study aimed to investigate the safety and efficacy of LM PCI with the latest-generation Resolute Onyx DES. METHODS ROLEX (Revascularization Of LEft main with resolute onyX) is a prospective, multicentre study (ClinicalTrials.gov: NCT03316833) enrolling patients with unprotected LM coronary artery disease and a SYNTAX score <33 undergoing PCI with the Resolute Onyx zotarolimus-eluting coronary stent, that includes dedicated extra-large vessel platforms. The primary endpoint (EP) was target lesion failure (TLF): a composite of cardiac death, target vessel myocardial infarction (TVMI) and ischaemia-driven target lesion revascularisation (ID-TLR), at 1 year. All events were adjudicated by an independent clinical event committee. An independent core lab analysed all procedural angiograms. RESULTS A total of 450 patients (mean age 71.8 years, SYNTAX score 24.5±7.2, acute coronary syndrome in 53%) were enrolled in 26 centres. Of these, 77% of subjects underwent PCI with a single-stent and 23% with a 2-stent technique (8% double kissing [DK] crush, 6% culotte, 9% T/T and small protrusion [TAP] stenting). Intravascular imaging guidance was used in 45% (42% intravascular ultrasound [IVUS], 3% optical coherence tomography [OCT]). At 1 year, the primary EP incidence was 5.1% (cardiac death 2.7%, TVMI 2.7%, ID-TLR 2.0%). The definite/probable stent thrombosis rate was 1.1%. In a prespecified adjusted subanalysis, the primary EP incidence was significantly lower in patients undergoing IVUS/OCT-guided versus angio-guided PCI (2.0 vs 7.6%; hazard ratio [HR] 0.28, 95% confidence interval [CI]: 0.13-0.58; p<0.001). CONCLUSIONS In this large, multicentre, prospective registry, LM PCI with the Resolute Onyx DES showed good safety and efficacy at 1 year, particularly when guided by intracoronary imaging.
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Affiliation(s)
- Giuseppe Tarantini
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Luca Nai Fovino
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | | | | | | | - Carlo Trani
- Fondazione Policlinico Universitario A. Gemelli ICCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | | | | | - Matteo Montorfano
- Interventional Cardiology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Carmine Musto
- Department of Cardiosciences, A.O. San Camillo-Forlanini Hospital, Rome, Italy
| | - Andrea Picchi
- Cardiovascular Department, Azienda USL Toscana SudEst, Misericordia Hospital, Grosseto, Italy
| | - Imad Sheiban
- Division of Cardiology, Peschiera del Garda Hospital, Verona, Italy
| | | | - Flavio L Ribichini
- Division of Cardiovascular Medicine, Department of Medicine, University of Verona, Verona, Italy
| | - Francesco Cardaioli
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | | | - Enrico Cerrato
- Interventional Cardiology Unit, San Luigi Gonzaga University Hospital, Orbassano, Italy
| | - Massimo Napodano
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Matteo Martinato
- Unit of Biostatistics, Epidemiology and Public Health, University of Padova, Padova, Italy
| | - Danila Azzolina
- Unit of Biostatistics, Epidemiology and Public Health, University of Padova, Padova, Italy
| | - Giuseppe Andò
- Division of Cardiology, University of Messina, Messina, Italy
| | | | - Marco Caruso
- Division of Cardiology, University of Palermo, Palermo, Italy
| | - Roberta Rossini
- Division of Cardiology, ASST Papa Giovanni XXIII Hospital, Cuneo, Italy
| | - Enrico Passamonti
- Division of Cardiology, Azienda Socio-Sanitaria Territoriale di Cremona, Cremona, Italy
| | - Rui Campante Teles
- Hospital de Santa Cruz, CHLO, Nova Medical School, CEDOC, Lisbon, Portugal
| | | | - Dario Gregori
- Unit of Biostatistics, Epidemiology and Public Health, University of Padova, Padova, Italy
| | - Corrado Tamburino
- Cardiology, CAST-Policlinico Hospital, Cardio-Thorax-Vascular and Transplant Department, University of Catania, Catania, Italy
| | - Francesco Burzotta
- Fondazione Policlinico Universitario A. Gemelli ICCS, Università Cattolica del Sacro Cuore, Rome, Italy
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21
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Jabbour RJ, Curzen N. National Institute for Health and Care Excellence guidelines on myocardial revascularisation. Heart 2023:heartjnl-2022-321397. [PMID: 36631143 DOI: 10.1136/heartjnl-2022-321397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 12/09/2022] [Indexed: 01/13/2023] Open
Abstract
Cardiologists in the UK predominantly use the National Institute for Health and Care Excellence (NICE) and European Society of Cardiology guidelines to help guide decision-making. This article will appraise the current recommendations from NICE regarding myocardial revascularisation and compare them with other major international guidelines. While there are many similarities, subtle differences exist. These differences arise in part due to the evidence base at time of publication, as well as from the different healthcare systems that they are designed for, and from the cost-effectiveness models that dominate the methodology used by NICE. The clinical implications of the differences between the international guidelines will be analysed.
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Affiliation(s)
- Richard J Jabbour
- Cardiology, University Hospital Southampton NHS Foundation Trust, Southampton, UK.,Faculty of Medicine, University of Southampton, Southampton, UK
| | - Nick Curzen
- Cardiology, University Hospital Southampton NHS Foundation Trust, Southampton, UK .,Faculty of Medicine, University of Southampton, Southampton, UK
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22
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Narayan P. The BEST trial is here - but is anyone listening? Indian J Thorac Cardiovasc Surg 2023; 39:95-97. [PMID: 36590038 PMCID: PMC9794644 DOI: 10.1007/s12055-022-01438-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Accepted: 10/27/2022] [Indexed: 11/16/2022] Open
Abstract
The long-term outcome of the Randomized Comparison of Coronary Artery Bypass Surgery and Everolimus-Eluting Stent Implantation in the Treatment of Patients with Multivessel Coronary Artery Disease trial has recently been published. This appraisal provides a critical evaluation of the main findings of the study.
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Affiliation(s)
- Pradeep Narayan
- Department of Cardiac Surgery, Rabindranath Tagore International Institute of Cardiac Sciences, Narayana Health, 124, EM Bypass, Mukundapur, Kolkata, 700099 India
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23
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Carvalho PEP, Veiga TMA, Machado FSL, Porto GV, Pirez J, Rivera M, Melo PC, Braghiroli J, Cardoso R. Long-term outcomes of percutaneous versus surgical revascularization in patients with diabetes and left main coronary artery disease: A meta-analysis of randomized controlled trials. J Card Surg 2022; 37:4646-4653. [PMID: 36259716 DOI: 10.1111/jocs.17046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Revised: 08/29/2022] [Accepted: 10/05/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND The efficacy and safety of percutaneous coronary interventions (PCI) relative to coronary artery bypass grafting (CABG) in patients with diabetes and unprotected left main coronary artery disease (LMCAD) are not well established. OBJECTIVES To perform a meta-analysis evaluating the long-term outcomes after PCI with drug-eluting stents (DES), as compared with CABG, in patients with diabetes and unprotected LMCAD. METHODS MEDLINE, Cochrane, and Embase were searched for randomized controlled trials (RCTs) that reported outcomes after PCI with DES versus CABG in unprotected LMCAD among patients with diabetes. To evaluate the long-term effects of these interventions, we restricted this analysis to studies with a minimum follow-up period of 3 years. Risk ratios (RRs) with 95% confidence intervals (CIs) were pooled with a random-effects model. Quality assessment and risk of bias were performed according to Cochrane recommendations. RESULTS Four RCTs with a total of 1080 patients were included, 553 (51.2%) of whom underwent PCI. There was no difference for individual outcomes of all-cause mortality (RR: 1.21; 95% CI: 0.86-1.71; p = .27; I2 = 28%), cardiovascular death (RR 1.29; 95% CI: 0.76-2.18; p = .34; I2 = 0%), or myocardial infarction (MI) (RR: 0.94; 95% CI: 0.61-1.45; p = .79; I2 = 0%). However, the risk of stroke was reduced with PCI relative to CABG (RR: 0.41; 95% CI: 0.18-0.94; p = .04; I2 = 0%), whereas the risk of any repeat revascularization was higher in the PCI group (RR: 1.99; 95% CI: 1.44-2.75; p < .001; I2 = 0%). The risk of the composite outcome of all-cause mortality, MI, stroke, or repeat revascularization was higher after PCI compared with CABG (RR: 1.30; 95% CI: 1.09-1.56; p = .004; I2 = 0%). CONCLUSION In this meta-analysis with more than 1000 patients with diabetes and unprotected LMCAD followed for a minimum of 3 years, the incidence of repeat revascularization was higher among those treated with PCI, whereas the risk of stroke was higher in patients treated with CABG.
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Affiliation(s)
- Pedro E P Carvalho
- Department of Medicine, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Thiago M A Veiga
- Department of Medicine, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Felipe S L Machado
- Department of Medicine, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Gabriel V Porto
- Department of Medicine, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | | | - Manuel Rivera
- Division of Cardiology, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Pedro C Melo
- Cardiovascular Research Foundation, New York, New York, USA
| | | | - Rhanderson Cardoso
- Heart and Vascular Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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24
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A Practical Approach to Left Main Coronary Artery Disease. J Am Coll Cardiol 2022; 80:2119-2134. [DOI: 10.1016/j.jacc.2022.09.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 09/07/2022] [Indexed: 11/22/2022]
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25
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Coronary Stenting: Reflections on a 35-Year Journey. Can J Cardiol 2022; 38:S17-S29. [PMID: 34375695 DOI: 10.1016/j.cjca.2021.07.224] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 07/12/2021] [Accepted: 07/14/2021] [Indexed: 01/09/2023] Open
Abstract
Stenting was introduced as a therapy for coronary artery disease 35 years ago, and is currently the most commonly performed minimally invasive procedure globally. Percutaneous coronary revascularization, initially with plain old balloon angioplasty and later with stenting, has dramatically affected the outcomes of acute myocardial infarction and acute coronary syndromes. Coronary stenting is probably the most intensively studied therapy in medicine on the basis of the number of randomized clinical trials for a broad range of indications. Continuous improvements in stent materials, design, and coatings concurrent with procedural innovations have truly been awe-inspiring. The story of stenting is replete with high points and some low points, such as the initial experience with stent thrombosis and restenosis, and the more recent disappointment with bioabsorbable scaffolds. History has shown rapid growth of stent use with expansion of indications followed by contraction of some uses in response to clinical trial evidence in support of bypass surgery or medical therapy. In this review we trace the constantly evolving story of the coronary stent from the earliest experience until the present time. Undoubtedly, future iterations of stent design and materials will continue to move the stent story forward.
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Abstract
Traditionally, the treatment of left main coronary artery disease is recommended coronary artery bypass grafting because of its superior long-term outcomes compared with medical treatment and plain old balloon angioplasty. However, improvement of percutaneous coronary intervention technique and introduction of drug-eluting stent led to change of treatment strategy of left main coronary artery disease through cumulative data for revascularization that based on clinical evidence.
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Affiliation(s)
- Jinho Lee
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea
| | - Duk-Woo Park
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea.
| | - Seung-Jung Park
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea.
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27
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Dąbrowski EJ, Kożuch M, Dobrzycki S. Left Main Coronary Artery Disease-Current Management and Future Perspectives. J Clin Med 2022; 11:jcm11195745. [PMID: 36233613 PMCID: PMC9573137 DOI: 10.3390/jcm11195745] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 09/22/2022] [Accepted: 09/26/2022] [Indexed: 02/05/2023] Open
Abstract
Due to its anatomical features, patients with an obstruction of the left main coronary artery (LMCA) have an increased risk of death. For years, coronary artery bypass grafting (CABG) has been considered as a gold standard for revascularization. However, notable advancements in the field of percutaneous coronary intervention (PCI) led to its acknowledgement as an important treatment alternative, especially in patients with low and intermediate anatomical complexity. Although recent years brought several random clinical trials that investigated the safety and efficacy of the percutaneous approach in LMCA, there are still uncertainties regarding optimal revascularization strategies. In this paper, we provide a comprehensive review of state-of-the-art diagnostic and treatment methods of LMCA disease, focusing on percutaneous methods.
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28
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Percutaneous coronary intervention versus coronary artery bypass grafting in left main coronary artery disease: A review. Rev Port Cardiol 2022. [DOI: 10.1016/j.repc.2021.06.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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29
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Bittl JA, Tamis-Holland JE, Lawton JS. Does Bypass Surgery or Percutaneous Coronary Intervention Improve Survival in Stable Ischemic Heart Disease? JACC Cardiovasc Interv 2022; 15:1243-1248. [PMID: 35583361 DOI: 10.1016/j.jcin.2022.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 05/05/2022] [Indexed: 11/18/2022]
Affiliation(s)
- John A Bittl
- Scientific Publishing Committee, American College of Cardiology, Washington, DC, USA.
| | | | - Jennifer S Lawton
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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30
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Meta-Analysis of Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting for Left Main Narrowing. Am J Cardiol 2022; 173:39-47. [PMID: 35393084 DOI: 10.1016/j.amjcard.2022.02.044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 02/11/2022] [Accepted: 02/18/2022] [Indexed: 12/12/2022]
Abstract
Randomized controlled trials (RCTs) comparing percutaneous coronary intervention (PCI) with drug-eluting stents and coronary artery bypass grafting (CABG) for patients with left main coronary artery disease (LMCAD) have reported conflicting results. We performed a systematic review up to May 23, 2021, and 1-stage reconstructed individual patient data meta-analysis (IPDMA) to compare outcomes between both groups. The primary outcome was 10-year all-cause mortality. Secondary outcomes included myocardial infarction (MI), stroke, and unplanned revascularization at 5 years. We performed individual patient data meta-analysis using published Kaplan-Meier curves to provide individual data points in coordinates and numbers at risk were used to increase the calibration accuracy of the reconstructed data. Shared frailty model or, when proportionality assumptions were not met, a restricted mean survival time model were fitted to compare outcomes between treatment groups. Of 583 articles retrieved, 5 RCTs were included. A total of 4,595 patients from these 5 RCTs were randomly assigned to PCI (n = 2,297) or CABG (n = 2,298). The cumulative 10-year all-cause mortality after PCI and CABG was 12.0% versus 10.6%, respectively (hazard ratio [HR] 1.093, 95% confidence interval [CI] 0.925 to 1.292; p = 0.296). PCI conferred similar time-to-MI (restricted mean survival time ratio 1.006, 95% CI 0.992 to 1.021, p=0.391) and stroke (restricted mean survival time ratio 1.005, 95% CI 0.998 to 1.013, p = 0.133) at 5 years. Unplanned revascularization was more frequent after PCI than CABG (HR 1.807, 95% CI 1.524 to 2.144, p <0.001) at 5 years. This meta-analysis using reconstructed participant-level time-to-event data showed no statistically significant difference in cumulative 10-year all-cause mortality between PCI versus CABG in the treatment of LMCAD.
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31
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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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32
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Laricchia A, Khokhar AA, Giannini F, Colomb A. PCI for Unprotected Left Main Disease. Interv Cardiol 2022. [DOI: 10.1002/9781119697367.ch15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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33
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Zhou JY, Tie EN, Liew D, Duffy SJ, Shaw J, Walton A, Chan W, Stub D. Sex-Specific Outcomes Following Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting for Left Main Disease: A Systematic Review and Meta-Analysis. Heart Lung Circ 2022; 31:658-665. [PMID: 35033432 DOI: 10.1016/j.hlc.2021.10.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 09/27/2021] [Accepted: 10/28/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To assess whether outcomes following percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG) for left main coronary artery (LMCA) disease differ between men and women. BACKGROUND Current guidelines recommend either PCI or CABG for patients with unprotected LMCA disease and low-to-intermediate anatomical complexity. However, it is unclear whether these guidelines apply to women, who are underrepresented in clinical trials. METHODS An electronic search was performed to identify studies reporting sex-specific outcomes after PCI versus CABG in patients with LMCA disease. Trial level hazard ratios (HRs) and 95% confidence intervals (CIs) were pooled by random-effects modelling. RESULTS Eight (8) studies met inclusion criteria, comprising 13,066 patients (24.3% women). In both sexes, there was no difference between PCI and CABG with respect to the primary composite endpoint of death, myocardial infarction or stroke (HR in women: 1.03, 95% CI 0.76-1.40; HR in men: 1.04, 95% CI 0.92-1.17). However, both sexes were more likely to require repeat revascularisation after PCI. There was no interaction between sex and treatment effect for the primary composite endpoint nor for the individual outcomes of death, stroke and repeat revascularisation. However, in women the risk of myocardial infarction was higher after PCI compared with CABG (HR 1.84, 95% CI 1.06-3.18), with a trend toward the opposite in men (HR 0.78, 95% CI 0.54-1.13; p-interaction=0.01). CONCLUSION Percutaneous coronary intervention and CABG have a comparable risk of the composite outcome of death, stroke or myocardial infarction in patients undergoing revascularisation for LMCA disease, with no significant interaction between sex and treatment effect.
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Affiliation(s)
- Jennifer Y Zhou
- Department of Cardiology, The Alfred Hospital, Melbourne, Vic, Australia
| | - Emilia Nan Tie
- Department of Cardiology, The Alfred Hospital, Melbourne, Vic, Australia
| | - Danny Liew
- Department of Cardiology, The Alfred Hospital, Melbourne, Vic, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic, Australia
| | - Stephen J Duffy
- Department of Cardiology, The Alfred Hospital, Melbourne, Vic, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic, Australia
| | - James Shaw
- Department of Cardiology, The Alfred Hospital, Melbourne, Vic, Australia
| | - Antony Walton
- Department of Cardiology, The Alfred Hospital, Melbourne, Vic, Australia
| | - William Chan
- Department of Cardiology, The Alfred Hospital, Melbourne, Vic, Australia; Western Health, Melbourne, Vic, Australia
| | - Dion Stub
- Department of Cardiology, The Alfred Hospital, Melbourne, Vic, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic, Australia; Western Health, Melbourne, Vic, Australia.
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Riku S, Suzuki S, Yokoi T, Sakaguchi T, Yamamoto T, Jinno Y, Tanaka A, Ishii H, Inden Y, Murohara T. <Editors' Choice> Very long-term clinical outcomes after percutaneous coronary intervention for complex vs non-complex lesions: 10-year outcomes following sirolimus-eluting stent implantation. NAGOYA JOURNAL OF MEDICAL SCIENCE 2022; 84:352-365. [PMID: 35967938 PMCID: PMC9350579 DOI: 10.18999/nagjms.84.2.352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 08/18/2021] [Indexed: 11/23/2022]
Abstract
Few studies have reported the long-term outcomes (>10 years) following first-generation drug-eluting stent implantation. In this single-center retrospective study, we investigated the very long-term clinical outcomes after first-generation sirolimus-eluting stent (SES) implantation in patients with complex lesions. The study included 383 consecutive patients who underwent initial SES implantation between July 2004 and January 2006; 84 and 299 of these patients reported a history of percutaneous coronary intervention (PCI) for complex and noncomplex lesions, respectively. Complex PCI was defined as having at least one of the following features: left main trunk PCI, implantation of ≥3 stents, bifurcation lesions with implantation of 2 stents, total stent length >60 mm, or chronic total occlusion. The target lesion revascularization (TLR) rate was significantly higher in the complex PCI than in the noncomplex PCI group (29.4% vs 13.0%, P=0.001), and we observed a significant intergroup difference in the late TLR (>1 year) rates (21.6% vs 9.5%, P=0.008). Late TLR continued over 10 years at a rate of 2.4%/year in the complex PCI and 1.1%/year in the noncomplex PCI group. Cox regression analysis revealed that complex PCI was related to TLR both over 10 years (hazard ratio 2.29, P=0.003) and beyond 1 year (hazard ratio 2.32, P=0.01). Cardiac death was more common in the complex PCI than in the noncomplex PCI group, particularly 4 years after PCI (15.8% vs 7.5%, P=0.031). Sudden death was the major cause of cardiac death beyond 4 years in the complex PCI group. These data indicate that long-term careful follow-up is essential for patients implanted with SES, especially those treated for complex lesions.
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Affiliation(s)
- Shuro Riku
- Department of Cardiology, Handa City Hospital, Handa, Japan
,Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Susumu Suzuki
- Department of Cardiology, Handa City Hospital, Handa, Japan
,Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tsuyoshi Yokoi
- Department of Cardiology, Handa City Hospital, Handa, Japan
| | | | | | - Yasushi Jinno
- Department of Cardiology, Handa City Hospital, Handa, Japan
| | - Akihito Tanaka
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hideki Ishii
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
,Department of Cardiology, Fujita Health University Bantane Hospital, Nagoya, Japan
| | - Yasuya Inden
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
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35
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Gaudino M, Farkouh ME, Stone GW. Left main revascularization: an evidence-based reconciliation. Eur Heart J 2022; 43:2421-2424. [PMID: 35452115 DOI: 10.1093/eurheartj/ehac216] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 02/17/2022] [Accepted: 04/11/2022] [Indexed: 12/26/2022] Open
Affiliation(s)
- Mario Gaudino
- Department of Cardiothoracic Surgery, Cornell Medicine, New York, NY 10065, USA
| | - Michael E Farkouh
- Peter Munk Cardiac Centre and Heart and Stroke Richard Lewar Centre, University of Toronto, Toronto, ON M5G 2N2, Canada
| | - Gregg W Stone
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, Mount Sinai Medical Center, 1 Gustave L. Levy Place, New York, NY 10029, USA
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36
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van Geuns RJ, Chun-Chin C, McEntegart MB, Merkulov E, Kretov E, Lesiak M, O’Kane P, Hanratty CG, Bressollette E, Silvestri M, Wlodarczak A, Barragan P, Anderson R, Protopopov A, Peace A, Menown I, Rocchiccioli P, Onuma Y, Oldroyd KG. Bioabsorbable polymer drug-eluting stents with 4-month dual antiplatelet therapy versus durable polymer drug-eluting stents with 12-month dual antiplatelet therapy in patients with left main coronary artery disease: the IDEAL-LM randomised trial. EUROINTERVENTION 2022; 17:1467-1476. [PMID: 35285803 PMCID: PMC9900447 DOI: 10.4244/eij-d-21-00514] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Improvements in drug-eluting stent design have led to a reduced frequency of repeat revascularisation and new biodegradable polymer coatings may allow a shorter duration of dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI). AIMS The Improved Drug-Eluting stent for All-comers Left Main (IDEAL-LM) study aims to investigate long-term clinical outcomes after implantation of a biodegradable polymer platinum-chromium everolimus-eluting stent (BP-PtCr-EES) followed by 4 months DAPT compared to a durable polymer cobalt-chromium everolimus-eluting stent (DP-CoCr-EES) followed by 12 months DAPT in patients undergoing PCI of unprotected left main coronary artery (LMCA) disease. METHODS This is a multicentre randomised clinical trial study in patients with an indication for coronary artery revascularisation who have been accepted for PCI for LMCA disease after Heart Team consultation. Patients were randomly assigned in a 1:1 ratio to receive either the BP-PtCr-EES or the DP-CoCr-EES. The primary endpoint was a non-inferiority comparison of the rate of major adverse cardiovascular events (MACE), defined as all-cause death, myocardial infarction, or ischaemia-driven target vessel revascularisation at 2 years. RESULTS Between December 2014 and October 2016, 818 patients (410 BP-PtCr-EES and 408 DP-CoCr-EES) were enrolled at 29 centres in Europe. At 2 years, the primary endpoint of MACE occurred in 59 patients (14.6%) in the BP-PtCr-EES group and 45 patients (11.4%) in the DP-CoCr-EES group; 1-sided upper 95% confidence interval (CI) 7.18%; p=0.04 for non-inferiority; p=0.17 for superiority. The secondary endpoint event of BARC 3 or 5 bleeding occurred in 11 patients (2.7%) in the BP-PtCr-EES group and 2 patients (0.5%) in the DP-CoCr-EES group (p=0.02). CONCLUSIONS In patients undergoing PCI of LMCA disease, after two years of follow-up, the use of a BP-PtCr-EES with 4 months of DAPT was non-inferior to a DP-CoCr-EES with 12 months of DAPT with respect to the composite endpoint of all-cause death, myocardial infarction or ischaemia-driven target vessel revascularisation.
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Affiliation(s)
- Robert-Jan van Geuns
- Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, the Netherlands
| | - Chang Chun-Chin
- Department of Cardiology, Thorax Center, Erasmus Medical Center, Rotterdam, the Netherlands,Division of Cardiology, Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | | | - Evgeny Merkulov
- Russian Cardiology Research Center, Moscow, Russian Federation
| | - Evgeny Kretov
- E.N. Meshalkin National Medical Research Center, Novosibirsk, Russian Federation
| | - Maciej Lesiak
- 1st Department of Cardiology, Poznan University of Medical Sciences, Poznan, Poland
| | - Peter O’Kane
- Department of Cardiology, Royal Bournemouth Hospital, Bournemouth, United Kingdom
| | | | | | | | - Adrian Wlodarczak
- Department of Cardiology, Miedziowe Centrum Zdrowia S.A., Lubin, Poland
| | - Paul Barragan
- Department of Cardiology, Polyclinique les Fleurs, Ollioules, France
| | | | | | - Aaron Peace
- Altnagelvin Hospital, Londonderry, United Kingdom
| | - Ian Menown
- Craigavon Area Hospital, Craigavon, United Kingdom
| | | | - Yoshinobu Onuma
- Department of Cardiology, Thorax Center, Erasmus Medical Center, Rotterdam, the Netherlands,Cardialysis, Rotterdam, the Netherlands
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37
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Outcomes of Left Main Revascularization after Percutaneous Intervention or Bypass Surgery. J Interv Cardiol 2022; 2022:6496777. [PMID: 35494423 PMCID: PMC9019449 DOI: 10.1155/2022/6496777] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Revised: 03/20/2022] [Accepted: 03/23/2022] [Indexed: 11/20/2022] Open
Abstract
Background This study is aimed at comparing the clinical outcomes of unprotected left main coronary artery disease (ULMCAD) treatment with contemporary percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) in a “real-world” population. Methods and Results Overall, 558 consecutive patients with ULMCAD (mean age 71 ± 9 years, male gender 81%) undergoing PCI or CABG were compared. The primary endpoint was the composite of death, nonfatal myocardial infarction, or stroke. Diabetes was present in 29% and acute coronary syndrome in 56%; mean EuroSCORE was 11 ± 8. High coronary complexity (SYNTAX score >32) was present in 50% of patients. The primary composite endpoint was similar after PCI and CABG up to 4 years (15.5 ± 3.1% vs. 17.1 ± 2.6%; p=0.585). The primary end point was also comparable in a two propensity score matched cohorts. Ischemia-driven revascularization was more frequently needed in PCI than in CABG (5.5% vs. 1.5%; p=0.010). By multivariate analysis, diabetes mellitus (HR 2.00; p=0.003) and EuroSCORE (HR 3.71; p < 0.001) were the only independent predictors associated with long-term outcome. Conclusions In a “real-world” population with ULMCAD, a contemporary revascularization strategy by PCI or CABG showed similar long-term clinical outcome regardless of the coronary complexity.
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d'Entremont MA, Yagi R, Salia SJS, Zhang S, Shaban L, Bene-Alhasan Y, Papatheodorou S, Couture ÉL, Huynh T, Nguyen M, Hamaya R. The effect of diabetes on surgical versus percutaneous left main revascularization outcomes: a systematic review and meta-analysis. J Cardiothorac Surg 2022; 17:61. [PMID: 35365159 PMCID: PMC8973812 DOI: 10.1186/s13019-022-01795-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 03/12/2022] [Indexed: 12/02/2022] Open
Abstract
Background The optimal method of coronary revascularization for diabetes mellitus (DM) patients with left main coronary artery disease (LMCAD) is controversial in the drug-eluting stent (DES) era. Methods We performed a systematic review and meta-analysis comparing DES-based percutaneous coronary intervention (PCI) to coronary artery bypass grafting (CABG) for LMCAD in DM patients and tested for effect measure modification (EMM) by diabetes for adverse events. We included all randomized controlled trials (RCTs) and observational studies comparing CABG to DES-based PCI including DM patients with LMCAD published up to March 1, 2021. We completed separate random-effects meta-analyses for four RCTs (4356 patients, mean follow-up of 4.9 years) and six observational studies (9360 patients, mean follow-up of 5.2 years). Results In RCTs among DM patients, DES-based PCI, compared to CABG, was associated with a 30% increased relative risk (RR) (RR 1.30, 95% CI 1.09–1.56, I2 = 0%), while among non-DM patients, there was a 25% increased relative risk (RR 1.25, 95% CI 1.07–1.44, I2 = 0%) for the composite endpoint of all-cause mortality, myocardial infarction, stroke, and unplanned revascularization (MACCE). There was no evidence of EMM (p-value for interaction = 0.70). The mean weighted SYNTAX score was 25.7. In observational studies, there was no difference between DES-based PCI and CABG for all-cause mortality in patients with DM (RR 1.13, 95% CI 0.91–1.40, I2 = 0%). Conclusions CABG was superior to PCI for LMCAD in RCTs in DM patients for MACCE. Heart teams may consider DM as one of the many components in the clinical decision-making process, but may not want to consider DM as a primary deciding factor between DES-based PCI and CABG for LMCAD with low to intermediate anatomical complexity in the other coronary arteries. Study registration CRD42021246931 (PROSPERO). Supplementary Information The online version contains supplementary material available at 10.1186/s13019-022-01795-w.
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Affiliation(s)
- Marc-André d'Entremont
- Division of Cardiology, Department of Medicine, Sherbrooke University Hospital Center (CHUS), 3001, 12e Avenue Nord, Sherbrooke, QC, J1H 5N4, Canada. .,Harvard T.H. Chan School of Public Health, Boston, MA, USA.
| | - Ryuichiro Yagi
- Harvard T.H. Chan School of Public Health, Boston, MA, USA.,Saiseikai Central Hospital, Tokyo, Japan
| | | | - Shuqi Zhang
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Lamyaa Shaban
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | | | | | - Étienne L Couture
- Division of Cardiology, Department of Medicine, Sherbrooke University Hospital Center (CHUS), 3001, 12e Avenue Nord, Sherbrooke, QC, J1H 5N4, Canada
| | - Thao Huynh
- McGill Health University Center, Montreal, QC, Canada
| | - Michel Nguyen
- Division of Cardiology, Department of Medicine, Sherbrooke University Hospital Center (CHUS), 3001, 12e Avenue Nord, Sherbrooke, QC, J1H 5N4, Canada
| | - Rikuta Hamaya
- Harvard T.H. Chan School of Public Health, Boston, MA, USA.,Brigham and Women's Hospital, Boston, MA, USA
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Park S, Park SJ, Park DW. Percutaneous Coronary Intervention for Left Main Coronary Artery Disease. JACC: ASIA 2022; 2:119-138. [PMID: 36339118 PMCID: PMC9627854 DOI: 10.1016/j.jacasi.2021.12.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 12/09/2021] [Accepted: 12/17/2021] [Indexed: 11/26/2022]
Abstract
For several decades, coronary artery bypass grafting has been regarded as the standard choice of revascularization for significant left main coronary artery (LMCA) disease. However, in conjunction with remarkable advancement of device technology and adjunctive pharmacology, percutaneous coronary intervention (PCI) offers a more expeditious approach with rapid recovery and is a safe and effective alternative in appropriately selected patients with LMCA disease. Several landmark randomized clinical trials showed that PCI with drug-eluting stents for LMCA disease is a safe option with similar long-term survival rates to coronary artery bypass grafting surgery, especially in those with low and intermediate anatomic risk. Although it is expected that the updated evidence from recent randomized clinical trials will determine the next guidelines for the foreseeable future, there are still unresolved and unmet issues of LMCA revascularization and PCI strategy. This paper provides a comprehensive review on the evolution and an update on the management of LMCA disease. With advancements in PCI, clinical outcomes after left main PCI have progressively improved. Unmet needs still exist between clinical practice and the current evidence for left main PCI. Better decision making of revascularization choice and PCI optimization should be emphasized to improve outcomes of LMCA disease. Further research will provide further evidence to resolve conflicting issues on left main PCI.
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Mukherjee D. Is Percutaneous Coronary Intervention Now the Default Revascularization Strategy for Unprotected Left Main Coronary Artery Stenosis? J Am Heart Assoc 2022; 11:e025748. [PMID: 35352567 PMCID: PMC9075449 DOI: 10.1161/jaha.122.025748] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Debabrata Mukherjee
- Division of Cardiovascular Medicine Texas Tech University Health Sciences Center El Paso TX
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Mohammad MA, Persson J, Buccheri S, Odenstedt J, Sarno G, Angerås O, Völz S, Tödt T, Götberg M, Isma N, Yndigegn T, Tydén P, Venetsanos D, Birgander M, Olivecrona GK. Trends in Clinical Practice and Outcomes After Percutaneous Coronary Intervention of Unprotected Left Main Coronary Artery. J Am Heart Assoc 2022; 11:e024040. [PMID: 35350870 PMCID: PMC9075483 DOI: 10.1161/jaha.121.024040] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Background The use of percutaneous coronary intervention (PCI) to treat unprotected left main coronary artery disease has expanded rapidly in the past decade. We aimed to describe nationwide trends in clinical practice and outcomes after PCI for left main coronary artery disease. Methods and Results Patients (n=4085) enrolled in the SCAAR (Swedish Coronary Angiography and Angioplasty Registry) as undergoing PCI for left main coronary artery disease from 2005 to 2017 were included. A count regression model was used to analyze time‐related differences in procedural characteristics. The 3‐year major adverse cardiovascular and cerebrovascular event rate defined as death, myocardial infarction, stroke, and repeat revascularization was calculated with the Kaplan‐Meier estimator and Cox proportional hazard model. The number of annual PCI procedures grew from 121 in 2005 to 589 in 2017 (389%). The increase was greater for men (479%) and individuals with diabetes (500%). Periprocedural complications occurred in 7.9%, decreasing from 10% to 6% during the study period. A major adverse cardiovascular and cerebrovascular event occurred in 35.7% of patients, falling from 45.6% to 23.9% (hazard ratio, 0.56; 95% CI, 0.41–0.78; P=0.001). Radial artery access rose from 21.5% to 74.2% and intracoronary diagnostic procedures from 14.0% to 53.3%. Use of bare‐metal stents and first‐generation drug‐eluting stents fell from 19.0% and 71.9%, respectively, to 0, with use of new‐generation drug‐eluting stents increasing to 95.2%. Conclusions Recent changes in clinical practice relating to PCI for left main coronary artery disease are characterized by a 4‐fold rise in procedures conducted, increased use of evidence‐based adjunctive treatment strategies, intracoronary diagnostics, newer stents, and more favorable outcomes.
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Affiliation(s)
- Moman A Mohammad
- Department of Cardiology Clinical Sciences Lund UniversitySkane University Hospital Lund Sweden
| | - Jonas Persson
- Division of Cardiovascular Medicine Department of Clinical Sciences Karolinska InstitutetDanderyd University Hospital Stockholm Sweden
| | - Sergio Buccheri
- Division of Cardiology Uppsala UniversityUppsala University hospital Uppsala Sweden
| | - Jacob Odenstedt
- Department of Cardiology Gothenburg UniversitySahlgrenska University Hospital Gothenburg Sweden
| | - Giovanna Sarno
- Division of Cardiology Uppsala UniversityUppsala University hospital Uppsala Sweden
| | - Oskar Angerås
- Department of Cardiology Gothenburg UniversitySahlgrenska University Hospital Gothenburg Sweden
| | - Sebastian Völz
- Department of Cardiology Gothenburg UniversitySahlgrenska University Hospital Gothenburg Sweden
| | - Tim Tödt
- Department of Cardiology Clinical Sciences Lund UniversitySkane University Hospital Lund Sweden
| | - Matthias Götberg
- Department of Cardiology Clinical Sciences Lund UniversitySkane University Hospital Lund Sweden
| | - Nazim Isma
- Department of Cardiology Clinical Sciences Lund UniversitySkane University Hospital Lund Sweden
| | - Troels Yndigegn
- Department of Cardiology Clinical Sciences Lund UniversitySkane University Hospital Lund Sweden
| | - Patrik Tydén
- Department of Cardiology Clinical Sciences Lund UniversitySkane University Hospital Lund Sweden
| | - Dimitrios Venetsanos
- Department of Cardiology Karolinska Institutet Solna and Karolinska University Hospital Stockholm Sweden
| | - Mats Birgander
- Department of Cardiology Clinical Sciences Lund UniversitySkane University Hospital Lund Sweden
| | - Göran K Olivecrona
- Department of Cardiology Clinical Sciences Lund UniversitySkane University Hospital Lund Sweden
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Yadava OP, Narayan P, Padmanabhan C, Sajja LR, Sarkar K, Varma PK, Jawali V. IACTS position statement on "2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization": section 7.1-a consensus document. Indian J Thorac Cardiovasc Surg 2022; 38:126-133. [PMID: 35221551 PMCID: PMC8857365 DOI: 10.1007/s12055-022-01329-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
American College of Cardiology (ACC), American Heart Association (AHA) and Society for Cardiovascular Angiography and Interventions (SCAI) recently released the Clinical Practice Guidelines for myocardial revascularization [1]. The guidelines were the felt need of the fraternity and this single all-encompassing document, relegating the previous six guidelines on the subject to archives, is indeed welcome. However, the downgrading of coronary artery bypass surgery for stable multivessel coronary artery disease and its bracketing with percutaneous coronary interventions has caused a lot of anguish in the surgical fraternity. This document presents the official viewpoint of the Indian Association of Cardiovascular and Thoracic Surgeons on the matter.
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Affiliation(s)
| | - Pradeep Narayan
- NH Rabindranath Tagore International Institute of Cardiac Sciences, Kolkata, India
| | | | | | | | - Praveen Kerala Varma
- Dept of Cardio-Thoracic and Vascular Surgery, Amrita Institute of Medical Sciences, Cochin, India
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Enfermedad del tronco coronario izquierdo en las guías clínicas del ACC/AHA/SCAI del 2021: un tema muy controvertido. CIRUGIA CARDIOVASCULAR 2022. [DOI: 10.1016/j.circv.2022.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Percutaneous Coronary Intervention versus Coronary Artery Bypass Grafting for Non-Protected Left Main Coronary Artery Disease: 1-Year Outcomes in a High Volume Single Center Study. Life (Basel) 2022; 12:life12030347. [PMID: 35330098 PMCID: PMC8953531 DOI: 10.3390/life12030347] [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: 01/27/2022] [Revised: 02/23/2022] [Accepted: 02/25/2022] [Indexed: 11/16/2022] Open
Abstract
Introduction: There is clear evidence of a significant reduction in all major cardiovascular adverse events (MACE) by coronary artery bypass grafting (CABG) in left main coronary artery stenosis (LMCS), but revascularization by percutaneous coronary artery intervention (PCI) shows an increasingly important role as an alternative to CABG. Several recent trials aiming to test the difference in mortality between the two types of revascularization found conflicting data. The aim of this study is to determine whether PCI is non-inferior to CABG with respect to the occurrence of MACE at 1 year in patients with significant LMCS. Material and methods: We prospectively enrolled 296 patients with chronic or acute coronary syndromes and significant LM stenosis. The angiography that recommended the revascularization procedure was used for the calculation of the Syntax II score, in order to classify the patients as low-, intermediate- or high-risk. Low- and high-risk patients were revascularized with either PCI or CABG, according to current guidelines, and were included in the subgroup S1. The second subgroup (S0) included intermediate-risk patients (Syntax II score 23–32), in whom the type of revascularization was chosen depending on the decision of the heart team or the patient preference. Patients were monitored according to the chosen mode of revascularization—PCI or CABG. LM revascularization was performed in all the patients. Clinical endpoints included cardiac death, myocardial infarction, need for revascularization and stroke. Patients were evaluated at 1 year after revascularization. Event rates were estimated using the Kaplan–Meier analysis in time to the first event. Results: At 1-year follow-up, a primary endpoint occurred in 35/95 patients in the CABG group and 37/201 in the PCI group. There were no significant differences between the 2 treatment strategies in the 1-year components of the end-point. However, a tendency to higher occurrence of cardiac death (HR = 1.48 CI (0.55–3.9), p = 0.43), necessity of repeat revascularization (HR = 1.7, CI (0.81–3.6), p = 0.16) and stroke (HR = 1.52, CI (1.15–2.93), p = 0.58) were present after CABG. Contrariwise, although without statistical significance, MI was more frequent after PCI (HR = 2, CI (0.78–5.2), p = 0.14). The Kaplan–Meier estimates in subgroups demonstrated the same tendency to higher rates for cardiac death, repeat revascularization and stroke after CABG, and higher rates of MI after PCI. Although without statistical significance, patients with an intermediate-risk showed a slightly lower risk of MACE after PCI than CABG. With the exception of dyslipidemia and gender, other cardiovascular risk factors were in favor of CABG (CKD, obesity). Conclusion: In patients with LMCS, PCI with drug-eluting stents was non-inferior to CABG with respect to the composite of cardiac death, myocardial infarction, repeat revascularization and stroke at 1 year, even in patients with intermediate Syntax II risk score.
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Skorupski WJ, Kałużna-Oleksy M, Lesiak M, Araszkiewicz A, Skorupski W, Grajek S, Mitkowski P, Pyda M, Grygier M. Short- and Long-Term Outcomes of Left Main Coronary Artery Stenting in Patients Disqualified from Coronary Artery Bypass Graft Surgery. J Pers Med 2022; 12:jpm12030348. [PMID: 35330348 PMCID: PMC8953089 DOI: 10.3390/jpm12030348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 02/17/2022] [Accepted: 02/22/2022] [Indexed: 12/10/2022] Open
Abstract
The study aims to evaluate the short- and long-term outcomes of left main percutaneous coronary interventions (LM PCI) in patients disqualified from coronary artery bypass graft surgery (CABG). We included 459 patients (mean age: 68.4 ± 9.4 years, 24.4% females), with at least 1-year follow-up; 396 patients in whom PCI was offered as an alternative to CABG (Group 1); and 63 patients who were disqualified from CABG by the Heart Team (Group 2). The SYNTAX score (29.1 ± 9.5 vs. 23.2 ± 9.7; p < 0.001) and Euroscore II value (2.72 ± 2.01 vs. 2.15 ± 2.16; p = 0.007) were significantly higher and ejection fraction was significantly lower (46% vs. 51.4%; p < 0.001) in Group 2. Patients in Group 2 more often required complex stenting techniques (33.3% vs. 16.2%; p = 0.001). The procedure success rates were very high and did not differ between groups (100% vs. 99.2%; p = 0.882). We observed no difference in periprocedural complication rates (12.7% vs. 7.8%; p = 0.198), but the long-term all-cause mortality rate was higher in Group 2 (26% vs. 21%; p = 0.031). LM PCI in patients disqualified from CABG is an effective and safe procedure with a low in-hospital complication rate. Long-term results are satisfactory.
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Malick WA, Soriano K, Stone GW. Sex-Based Differences in Revascularization Outcomes: Is It Time for a Dedicated Randomized Trial in Women? J Am Heart Assoc 2022; 11:e024281. [PMID: 35189696 PMCID: PMC9075096 DOI: 10.1161/jaha.121.024281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Waqas A Malick
- The Zena and Michael A. Wiener Cardiovascular Institute Icahn School of Medicine at Mount Sinai New York NY
| | - Kevin Soriano
- The Zena and Michael A. Wiener Cardiovascular Institute Icahn School of Medicine at Mount Sinai New York NY
| | - Gregg W Stone
- The Zena and Michael A. Wiener Cardiovascular Institute Icahn School of Medicine at Mount Sinai New York NY.,Clinical Trials Center Cardiovascular Research Foundation New York NY
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Nakamura M, Yaku H, Ako J, Arai H, Asai T, Chikamori T, Daida H, Doi K, Fukui T, Ito T, Kadota K, Kobayashi J, Komiya T, Kozuma K, Nakagawa Y, Nakao K, Niinami H, Ohno T, Ozaki Y, Sata M, Takanashi S, Takemura H, Ueno T, Yasuda S, Yokoyama H, Fujita T, Kasai T, Kohsaka S, Kubo T, Manabe S, Matsumoto N, Miyagawa S, Mizuno T, Motomura N, Numata S, Nakajima H, Oda H, Otake H, Otsuka F, Sasaki KI, Shimada K, Shimokawa T, Shinke T, Suzuki T, Takahashi M, Tanaka N, Tsuneyoshi H, Tojo T, Une D, Wakasa S, Yamaguchi K, Akasaka T, Hirayama A, Kimura K, Kimura T, Matsui Y, Miyazaki S, Okamura Y, Ono M, Shiomi H, Tanemoto K. JCS 2018 Guideline on Revascularization of Stable Coronary Artery Disease. Circ J 2022; 86:477-588. [DOI: 10.1253/circj.cj-20-1282] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Masato Nakamura
- Division of Cardiovascular Medicine, Toho University Ohashi Medical Center
| | - Hitoshi Yaku
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine
| | - Junya Ako
- Department of Cardiovascular Medicine, Kitasato University Graduate School of Medical Sciences
| | - Hirokuni Arai
- Department of Cardiovascular Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University
| | - Tohru Asai
- Department of Cardiovascular Surgery, Juntendo University Graduate School of Medicine
| | | | - Hiroyuki Daida
- Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine
| | - Kiyoshi Doi
- General and Cardiothoracic Surgery, Gifu University Graduate School of Medicine
| | - Toshihiro Fukui
- Department of Cardiovascular Surgery, Graduate School of Medical Sciences, Kumamoto University
| | - Toshiaki Ito
- Department of Cardiovascular Surgery, Japanese Red Cross Nagoya Daiichi Hospital
| | | | - Junjiro Kobayashi
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | - Tatsuhiko Komiya
- Department of Cardiovascular Surgery, Kurashiki Central Hospital
| | - Ken Kozuma
- Department of Internal Medicine, Teikyo University Faculty of Medicine
| | - Yoshihisa Nakagawa
- Department of Cardiovascular Medicine, Shiga University of Medical Science
| | - Koichi Nakao
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center
| | - Hiroshi Niinami
- Department of Cardiovascular Surgery, Tokyo Women’s Medical University
| | - Takayuki Ohno
- Department of Cardiovascular Surgery, Mitsui Memorial Hospital
| | - Yukio Ozaki
- Department of Cardiology, Fujita Health University Hospital
| | - Masataka Sata
- Department of Cardiovascular Medicine, Tokushima University Graduate School of Biomedical Sciences
| | | | - Hirofumi Takemura
- Department of Cardiovascular Surgery, Graduate School of Medical Sciences, Kanazawa University
| | | | - Satoshi Yasuda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Hitoshi Yokoyama
- Department of Cardiovascular Surgery, Fukushima Medical University
| | - Tomoyuki Fujita
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | - Tokuo Kasai
- Department of Cardiology, Uonuma Institute of Community Medicine, Niigata University Uonuma Kikan Hospital
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine
| | - Takashi Kubo
- Department of Cardiovascular Medicine, Wakayama Medical University
| | - Susumu Manabe
- Department of Cardiovascular Surgery, Tsuchiura Kyodo General Hospital
| | | | - Shigeru Miyagawa
- Frontier of Regenerative Medicine, Graduate School of Medicine, Osaka University
| | - Tomohiro Mizuno
- Department of Cardiovascular Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University
| | - Noboru Motomura
- Department of Cardiovascular Surgery, Graduate School of Medicine, Toho University
| | - Satoshi Numata
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine
| | - Hiroyuki Nakajima
- Department of Cardiovascular Surgery, Saitama Medical University International Medical Center
| | - Hirotaka Oda
- Department of Cardiology, Niigata City General Hospital
| | - Hiromasa Otake
- Department of Cardiovascular Medicine, Kobe University Graduate School of Medicine
| | - Fumiyuki Otsuka
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Ken-ichiro Sasaki
- Division of Cardiovascular Medicine, Kurume University School of Medicine
| | - Kazunori Shimada
- Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine
| | - Tomoki Shimokawa
- Department of Cardiovascular Surgery, Sakakibara Heart Institute
| | - Toshiro Shinke
- Division of Cardiology, Department of Medicine, Showa University School of Medicine
| | - Tomoaki Suzuki
- Department of Cardiovascular Surgery, Shiga University of Medical Science
| | - Masao Takahashi
- Department of Cardiovascular Surgery, Hiratsuka Kyosai Hospital
| | - Nobuhiro Tanaka
- Department of Cardiology, Tokyo Medical University Hachioji Medical Center
| | | | - Taiki Tojo
- Department of Cardiovascular Medicine, Kitasato University Graduate School of Medical Sciences
| | - Dai Une
- Department of Cardiovascular Surgery, Okayama Medical Center
| | - Satoru Wakasa
- Department of Cardiovascular and Thoracic Surgery, Hokkaido University Graduate School of Medicine
| | - Koji Yamaguchi
- Department of Cardiovascular Medicine, Tokushima University Graduate School of Biomedical Sciences
| | - Takashi Akasaka
- Department of Cardiovascular Medicine, Wakayama Medical University
| | | | - Kazuo Kimura
- Cardiovascular Center, Yokohama City University Medical Center
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Yoshiro Matsui
- Department of Cardiovascular and Thoracic Surgery, Graduate School of Medicine, Hokkaido University
| | - Shunichi Miyazaki
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, Kindai University
| | | | - Minoru Ono
- Department of Cardiac Surgery, Graduate School of Medicine, The University of Tokyo
| | - Hiroki Shiomi
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Kazuo Tanemoto
- Department of Cardiovascular Surgery, Kawasaki Medical School
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Rajachandran M, Makhija R. PCI or CABG for Left Main Disease: Does Disease Location Matter? Curr Cardiol Rep 2022; 24:93-101. [PMID: 35038131 DOI: 10.1007/s11886-021-01629-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/12/2021] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW This review attempts to specifically assess impact of disease location in left main artery on mortality and cardiovascular outcomes in patients treated with percutaneous coronary intervention versus coronary artery bypass surgery. RECENT FINDINGS The management of left main disease, once thought to be the sole province of cardiothoracic surgeon, has recently undergone a reappraisal by the cardiovascular medicine community. For many years, societal guideline recommendations advised bypass surgery as the "de rigeur" method of revascularization for unprotected left main disease. However, recent studies suggest that coronary intervention, especially with advances in drug-eluting stent technology, has mounted a serious challenge to surgical bypass in treatment of this disease. Although overall mortality rates are comparable for percutaneous coronary intervention and bypass surgery, left main disease location does influence long-term outcomes for percutaneous coronary intervention more than bypass surgery. A patient- and lesion-centered approach to treatment of this disease may provide optimal outcomes.
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Affiliation(s)
- Manu Rajachandran
- Division of Cardiology, Medicine/Cardiology, Department of Internal Medicine, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, Associate Professor, El Paso, TX, USA.
| | - Rakhee Makhija
- Division of Cardiovascular Medicine, Texas Tech University, El Paso, TX, USA
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Mailey JA, Spence MS. The Contemporary Management of Left Main Coronary Artery Disease. Curr Cardiol Rev 2022; 18:e170621194128. [PMID: 34139985 PMCID: PMC9241110 DOI: 10.2174/1573403x17666210617094735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 12/23/2020] [Accepted: 03/16/2021] [Indexed: 11/22/2022] Open
Abstract
The 'gold standard' in the management of left main coronary artery disease has historically been coronary artery bypass surgery. Recent innovations in drug-eluting stent technology coupled with the increasing utility of physiology and imaging guidance for procedures have led to an evolving role of percutaneous coronary intervention in left main disease of low and intermediate anatomical complexity. This revascularization modality carries the clear advantage of being less invasive and significantly reduced recovery times. This practice is currently supported by international guidelines, however, it remains a controversial topic in the field of interventional cardiology, and the long-term outcomes of a percutaneous strategy have been questioned. This review describes the current evidence base for the assessment and choice of intervention in left main coronary artery disease. The percutaneous revascularization techniques and use of imaging to optimize procedures and improve clinical outcomes have been discussed.
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Affiliation(s)
- Jonathan A Mailey
- Cardiology Department, Royal Victoria Hospital, Belfast, United Kingdom
| | - Mark S Spence
- Cardiology Department, Royal Victoria Hospital, Belfast, United Kingdom
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OUP accepted manuscript. Eur Heart J 2022; 43:1455-1456. [DOI: 10.1093/eurheartj/ehac081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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