Trends in Clinical Practice and Outcomes After Percutaneous Coronary Intervention of Unprotected Left Main Coronary Artery

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.

Sex Differences in Outcomes After Percutaneous Coronary Intervention or Coronary Artery Bypass Graft for Left Main Disease: From the DELTA Registries

Background

Controversy exists over whether sex has significant interaction with revascularization strategy for unprotected left main coronary artery disease. Higher mortality has been reported among women treated with percutaneous coronary intervention compared with coronary artery bypass grafting.

Methods and Results

The DELTA (Drug‐Eluting Stents for Left Main Coronary Artery Disease) and DELTA‐2 registries are international, multicentric registries evaluating the outcomes of subjects undergoing coronary revascularization for unprotected left main coronary artery disease. The primary outcome was a composite of death, myocardial infarction, or cerebrovascular accidents. The population consisted of 6253 patients, including 1689 (27%) women. Women were older and more likely to have diabetes and chronic kidney disease than men (P<0.05). At a median follow‐up of 29 months (interquartile range 12–49), a significant interaction between sex and revascularization strategy was observed for the primary end point (p_int=0.012) and all‐cause death (p_int=0.037). Among women, compared with percutaneous coronary intervention, coronary artery bypass grafting was associated with lower risk of the primary end point (event rate 9.5% versus 15.3%; adjusted hazard ratio [AHR], 0.53; 95% CI, 0.35–0.79, P<0.001) and all‐cause death (event rate 5.6% versus 11.7% AHR, 0.50; 95% CI, 0.30–0.82) and no significant differences were observed in men.

Conclusions

In women undergoing coronary revascularization for unprotected left main coronary artery disease, coronary artery bypass grafting was associated with lower risk of death, myocardial infarction, or cerebrovascular accidents whereas no significant differences between coronary artery bypass grafting and percutaneous coronary intervention were observed in men. Further dedicated studies are needed to determine the optimal revascularization strategy in women with unprotected left main coronary artery disease.

Four-year outcomes after percutaneous coronary intervention of unprotected left main coronary artery disease in patients with stable angina and acute coronary syndrome

Background. Percutaneous coronary intervention (PCI) of unprotected left main coronary artery disease (ULMCAD) have become a feasible and efficient alternative to coronary artery bypass surgery, especially in patients with acute coronary syndrome (ACS). There are limited data regarding early and late outcomes after ULMCAD PCI in patients with ACS and stable angina.The aim of this study was to compare early and four-year clinical outcomes in patients with ULMCAD PCI presenting as ACS or stable angina in a high-volume PCI center.Methods. We conducted a single center retrospective observational study, which included 146 patients with ULMCAD undergoing PCI between 2014 and 2018. Patients were divided in two groups: Group A included patients with stable angina (n = 70, 47.9%) and Group B patients with ACS (n = 76, 52.1%).Results. 30-day mortality was 8.22% overall, lower in Group A (1.43% vs 14.47%, p = 0.02). Mortality and major adverse cardiac events (MACE) rates at 4 years were significantly lower in Group A (9.64% vs 33.25%, p = 0.001, and 24.06% vs 40.11%, p = 0.012, respectively). Target lesion revascularization (TLR) at 4 year did not differ between groups (15% in Group A vs 12.76% in Group B, p = 0.5).Conclusions. In our study patients with ULMCAD and ACS undergoing PCI had higher early and long-term mortality and MACE rates compared to patients with stable angina, with similar TLR rate at 4-year follow-up.

Long-term outcomes of single stenting compared with double stenting strategy for unprotected left main coronary artery disease: A protocol for systematic review and meta-analysis

BACKGROUND

The optimal interventions for unprotected left main coronary artery (ULMCA) disease have long been debated, and long-term clinical studies comparing single stenting to double stenting strategies for ULMCA are currently lacking.

METHODS

We plan to perform a systematic review and meta-analysis of clinical trials comparing single stenting with double stents strategy for ULMCA disease. We will search PubMed, EMBASE, Web of science and Cochrane Library using a comprehensive strategy. The related conference proceedings and reference lists of the included studies will also be checked to identify additional studies. Two reviewers will screen retrieved records, extract information and assess the risk of bias independently. STATA software will be used to conduct data synthesis. There is no requirement of ethical approval and informed consent.

RESULTS

This study will be submitted to a peer-reviewed journal for publication.

CONCLUSION

We hope it will provide a relatively comprehensive reference for clinical practice and future relevant clinical trials.

ETHICS AND DISSEMINATION

Ethics approval and patient consent are not required, as this study is a systematic review and meta-analysis.

INPLASY REGISTRATION NUMBER

INPLASY2020110030.

Procedural Volume and Outcomes After Percutaneous Coronary Intervention for Unprotected Left Main Coronary Artery Disease-Report From the National Clinical Data (J-PCI Registry)

Background There is a limited evidence base to support the volume-outcome relationship in patients undergoing percutaneous coronary intervention (PCI) for unprotected left main coronary artery disease (UPLMD). This study aimed to evaluate the relationship between institutional and operator volume and in-hospital outcomes in patients undergoing PCI for unprotected left main coronary artery disease. Methods and Results We analyzed characteristics and clinical outcomes of 24 320 patients undergoing PCI for unprotected left main coronary artery disease at 1102 hospitals by 7244 operators using data from the Japanese nationwide J-PCI Registry (National PCI Data Registry) between January 2014 and December 2017. We classified institutions and operators into quartiles based on the mean annual volume of PCI. A generalized linear mixed-effects model was used to evaluate the association between institutional and operator PCI volume and in-hospital outcomes. Among the 24 320 patients, 4027 (16.6%), 6147 (25.3%), and 14 146 (58.2%) presented with ST-segment-elevation myocardial infarction, non-ST-segment-elevation acute coronary syndrome, and stable ischemic heart disease; their crude in-hospital mortality was 15%, 3.1%, and 0.3%, respectively. Compared with patients in the lowest quartile of institutional volume (1-216 PCIs/y), the adjusted odds ratio of in-hospital death in patients in the second (217-323 PCIs/y), third (324-487 PCIs/y), and fourth (488-3015 PCIs/y) quartile of institutional volume was 0.75 (95% CI, 0.51-1.10; P=0.14), 0.87 (95% CI, 0.57-1.34; P=0.54), and 0.51 (95% CI, 0.30-0.86; P=0.01), respectively. These findings were consistent in rates of in-hospital death or any complication. Conversely, operator PCI volume was not significantly associated with in-hospital outcomes. Conclusions Institutional rather than operator-based PCI volume was associated with better in-hospital outcomes in patients undergoing PCI for unprotected left main coronary artery disease.

Long noncoding RNA NEAT1/microRNA-125a axis predicts increased major adverse cardiac and cerebrovascular event risk independently in patients with unprotected left main coronary artery disease underwent coronary artery bypass grafting

Background

The study aimed to investigate the long noncoding RNA nuclear‐enriched abundant transcript 1 (lnc‐NEAT1) and microRNA‐125a (miR‐125a) expressions, and further explore the role of lnc‐NEAT1/miR‐125a axis in predicting major adverse cardiac and cerebrovascular event (MACCE) risk in patients with unprotected left main coronary artery disease (ULMCAD) underwent coronary artery bypass grafting (CABG).

Methods

A total of 280 patients with ULMCAD underwent CABG were consecutively enrolled in our prospective study, and their plasma samples were collected before CABG for the detection of lnc‐NEAT1 and miR‐125a expressions by reverse transcription quantitative polymerase chain reaction. Lnc‐NEAT1/miR‐125a axis was calculated via dividing lnc‐NEAT1 by miR‐125a. After CABG, regular follow‐up was continued until MACCE occurrence or 36 months.

Results

Lnc‐NEAT1 expression, miR‐125a expression, and lnc‐NEAT1/miR‐125a axis were 0.998 (IQR: 0.440‐1.720, range: 0.116‐5.771), 0.997 (IQR: 0.461‐1.650, range: 0.055‐3.621), and 1.018 (IQR: 0.384‐2.782, range: 0.041‐52.832), respectively. And lnc‐NEAT1 was negatively associated with miR‐125a. The 1‐, 2‐, and 3‐year MACCE occurrence was 19 (6.8%), 29 (10.4%), and 38 (13.6%), respectively. Lnc‐NEAT1/miR‐125a axis (χ² = 11.207, P = .001) and lnc‐NEAT1 expression (χ² = 5.345, P = .021) positively associated with accumulating MACCE occurrence, while miR‐125a expression (χ² = 5.869, P = .015) negatively correlated with accumulating MACCE occurrence. Notably, lnc‐NEAT1/miR‐125a axis presented numerically better predictive value compared with lnc‐NEAT1 or miR‐125a alone for MACCE risk. Furthermore, lnc‐NEAT1/miR‐125a axis high, elderly age, increased BMI, diabetes, previous stroke, LVEF, and higher disease extent (all P < .05) were independent predictive factors for increased accumulating MACCE occurrence.

Conclusion

Lnc‐NEAT1/miR‐125a axis, as a combined index, presents potential value to be a prognostic biomarker for MACCE risk in ULMCAD management.

Orbital Atherectomy of Severely Calcified Unprotected Left Main Coronary Artery Disease: One-Year Outcomes

OBJECTIVE

We assessed the 1-year outcomes of patients who underwent orbital atherectomy for severely calcified unprotected left main coronary artery (ULMCA) disease.

BACKGROUND

The standard of care for ULMCA is coronary artery bypass graft surgery. Percutaneous coronary intervention (PCI) is a reasonable option for the treatment for ULMCA disease, especially in patients who are not good candidates for surgical revascularization. Coronary artery calcification is associated with worse clinical outcomes in patients who undergo PCI. Modification of severely calcified plaque with orbital atherectomy facilitates stent delivery and expansion. Data on intermediate outcomes of patients with ULMCA disease who undergo orbital atherectomy are unknown.

METHODS

We retrospectively evaluated 62 patients who underwent PCI with orbital atherectomy for ULMCA disease. The primary endpoint was the major cardiac and cerebrovascular event (MACCE) rate, which was the composite of cardiac death, myocardial infarction, target-lesion revascularization, and stroke at 1 year.

RESULTS

Distal bifurcation disease was present in 71.0%, and a single-stent strategy was used in 90.5%. No patients experienced coronary perforation or no-reflow. Two patients experienced coronary dissection (3.2%). One patient experienced BARC-2 bleeding (1.6%). At 1 year, the MACCE rate was 11.3%, with cardiac death occurring in 1.6%, myocardial infarction in 8.1%, and target-lesion revascularization in 4.8%. Non-cardiac death occurred in 4.8%. No patient experienced stroke or stent thrombosis.

CONCLUSION

Orbital atherectomy is an acceptable treatment option for patients with severely calcified ULMCA disease, especially if patients are deemed too high risk for surgical revascularization.

Meta-analysis study comparing percutaneous coronary intervention/drug eluting stent versus coronary artery bypass surgery of unprotected left main coronary artery disease: Clinical outcomes during short-term versus long-term (> 1 year) follow-up

BACKGROUND

Results on the safety and long-term efficacy of drug-eluting stent placement in unprotected left main coronary artery disease (ULMCAD) compared with those of coronary artery bypass surgery (CABG) remain inconsistent across randomized clinical trials and recent meta-analysis studies. We aimed to compare the clinical outcomes and safety over short- and long-term follow-ups by conducting a meta-analysis of large pooled data from randomized controlled trials and up-to-date observational studies.

METHODS

A systematic review of PubMed, Google Scholar, Medline, and reference lists of related articles was performed for studies conducted in the drug-eluting stent era, to compare percutaneous coronary intervention (PCI) with CABG in ULMCAD. The primary outcome was major adverse cardiovascular and cerebrovascular events (MACCE), myocardial infarction (MI), stroke, all-cause mortality, and revascularization after at least 1-year follow-up. In-hospital and 30-day clinical outcomes were considered secondary outcomes. Furthermore, a subgroup analysis of studies with ≥5 years follow-up was performed to test the sustainability of clinical outcomes.

RESULTS

A total of 29 studies were extracted with 21,832 patients (10,424 in PCI vs 11,408 in CABG). Pooled analysis demonstrated remarkable differences in long-term follow-up (≥1 year) MACCE (odds ratio [OR] 1.42, 95% CI 1.27-1.59), P < .00001), repeat revascularization (OR 3.00, 95% CI 2.41-3.73, P < .00001), and MI (OR 1.32, 95% CI 1.14-1.53, P = .0002), favoring CABG over PCI. However, stroke risk was significantly lower in the PCI group. Subgroup analysis of studies with ≥5 years follow-up showed similar outcomes except for the noninferiority outcome of MACCE in the PCI arm. However, the PCI group proved good safety profile after a minimum of 30-day follow-up with lower MACCE outcome.

CONCLUSION

PCI for ULMCAD can be applied with attentiveness in carefully selected patients. MI and the need for revascularization remain drawbacks and areas of concern among previous studies. Nonetheless, it has been proven safe during short-term follow-up.

Drug-eluting stents in unprotected left main coronary artery disease

Though coronary bypass graft surgery (CABG) has traditionally been the cornerstone of therapy in patients with unprotected left main coronary artery (ULMCA) disease, recent evidence supports the use of percutaneous coronary intervention in appropriate patients. Indeed in patients with ULMCA disease, drug-eluting stents (DES) have shown similar incidence of hard end points, fewer periprocedural complications and lower stroke rates compared with CABG, though at the cost of increased revascularization with time. Furthermore, the availability of newer efficacious and safer DES as well as improvements in diagnostic tools, percutaneous techniques and, importantly, a better patient selection, allowed percutaneous coronary intervention a viable alternative to CABG of left main-patients with low disease complexity; however, even in this interventional era characterized by efficacious DES, patients with ULMCA disease remain a challenging high-risk population where outcomes strongly depend on clinical characteristics, anatomical disease complexity and extension and operator's experience. This review summarizes the role of DES in ULMCA disease patients.