For which patients with left main stem disease is percutaneous intervention rather than coronary artery bypass
Pietro Giorgio Malvindi1, Joel Dunning, Nicola Vitale
1Department of Cardiac Surgery, Policlinico Hospital, University of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy.
Insights
Percutaneous intervention for left main stem disease shows high restenosis and mortality rates with bare metal stents. Drug-eluting stents offer improvement, but coronary artery bypass grafting remains the preferred treatment for most patients.
Area of Science:
- Cardiovascular Surgery
- Interventional Cardiology
- Evidence-Based Medicine
Background:
- Left main stem disease is a critical condition requiring revascularization.
- Coronary artery bypass grafting (CABG) has traditionally been the gold standard treatment.
- Percutaneous coronary intervention (PCI) is an alternative, but its efficacy in left main stem disease is debated.
Purpose of the Study:
- To evaluate the evidence comparing PCI with CABG for left main stem disease.
- To identify patient subgroups that may benefit from PCI.
- To assess the safety and efficacy of PCI in left main stem lesions.
Main Methods:
- A systematic literature search was conducted to identify relevant studies.
- A best evidence topic protocol was followed.
- 15 high-quality papers were selected from 665 initial results for detailed analysis.
Main Results:
- Bare metal stent (BMS) left main stenting shows 1-year mortality rates from 3% to over 28% and restenosis rates around 20%.
- Drug-eluting stents (DES) demonstrate improved outcomes with 1-year restenosis rates around 10%.
- Current guidelines recommend CABG as the primary treatment, reserving PCI for high-risk surgical patients.
Conclusions:
- PCI for left main stem disease, especially with BMS, is associated with significant risks.
- DES show promise but require further long-term data compared to CABG.
- Left main stenting should be considered a last resort for patients unsuitable for CABG due to prohibitive comorbidities.
Abstract:
A best evidence topic in cardiac surgery was written according to a structured protocol. The topic addressed was to identify the patients with left main stem disease for which percutaneous intervention would be a better option than coronary artery bypass grafting. Altogether 665 papers were found using the reported search, of which 15 presented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers were tabulated. We conclude that if a bare metal stent is used for left main stenting the mortality at one year may be from 3% to over 28% in reported series. The restenosis rate of the bare metal stent in the left main position is around 20% at one year. There are some early series and randomized studies of drug eluting stents for left main stem lesions and the restenosis rate is reported to be around 10%. The European Society of Cardiology in their 2005 percutaneous intervention guidelines state that coronary bypass grafting is the procedure of choice for left main stem disease and only patients with a prohibitively high surgical risk should be considered. We consider that with such high restenosis rates, and with short-term follow-up in such low numbers and short periods compared to coronary artery bypass grafting, left main stenting should only be used as a last resort in patients turned down for coronary artery bypass grafting after full assessment by a cardiac surgeon due to prohibitive co-morbidities.
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