Impact of Target Lesion Revascularization on Long-Term Mortality After Percutaneous Coronary Intervention for Left
Tae Oh Kim1, Do-Yoon Kang1, Jung-Min Ahn1
1Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
Insights
Target lesion revascularization (TLR) after left main coronary artery percutaneous coronary intervention (PCI) with drug-eluting stents (DES) is common, mostly occurring within two years. However, TLR did not significantly impact long-term mortality in this 10-year study.
Area of Science:
- Cardiology
- Interventional Cardiology
- Vascular Medicine
Background:
- Target lesion revascularization (TLR) following percutaneous coronary intervention (PCI) for unprotected left main coronary artery (LMCA) disease is a known complication.
- The precise timing and long-term prognostic implications of TLR after LMCA PCI remain uncertain.
Purpose of the Study:
- To investigate the incidence of TLR over time after PCI with drug-eluting stents (DES) for LMCA disease.
- To assess the impact of TLR on long-term mortality in this patient population.
Main Methods:
- Pooled data from four multicenter observational registries (IRIS-DES, IRIS-MAIN, MAIN-COMPARE, PRECOMBAT) were analyzed.
- 1,397 patients with LMCA disease treated with DES and available long-term mortality data were included.
- A time-varying multivariable Cox proportional hazards regression model was used to examine the association between TLR and 10-year mortality risk.
Main Results:
- The 10-year cumulative incidence of TLR was 10.8%, with most events (61.9%) occurring within the first two years post-PCI.
- TLR occurred steadily throughout the 10-year follow-up period.
- The presence of TLR was not significantly associated with an increased risk of 10-year mortality (adjusted Hazard Ratio: 0.90; 95% Confidence Interval: 0.50-1.63).
Conclusions:
- While ischemia-driven TLR is most frequent within two years after left main PCI, it continues to occur over a decade.
- Optimal revascularization strategies appear to mitigate the substantial prognostic impact of TLR on long-term mortality.
- These findings suggest that TLR, while requiring monitoring, may not be a major driver of mortality when patients with LMCA disease are appropriately managed.
Background:
Although target lesion revascularization (TLR) after percutaneous coronary intervention (PCI) for unprotected left main coronary artery (LMCA) disease is not rare, its timing of occurrence and prognostic impact on long-term mortality is uncertain.
Objectives:
This study sought to investigate TLR incidence over time and its impact on mortality after PCI with drug-eluting stents (DES) for LMCA disease.
Methods:
Using a pooled data from 4 multicenter observational registries (IRIS-DES [Interventional Cardiology Research Incorporation Society-Drug-Eluting Stents], IRIS-MAIN [Interventional Cardiology Research Incorporation Society-Left MAIN Revascularization], MAIN-COMPARE [Revascularization for Unprotected Left Main Coronary Artery Stenosis: Comparison of Percutaneous Coronary Angioplasty Versus Surgical Revascularization], and PRECOMBAT [PREmier of Randomized COMparison of Bypass Surgery versus AngioplasTy Using Drug-Eluting Stent in Patients with Left Main Coronary Artery Disease]), we evaluated 1,397 patients with LMCA disease treated with DES and available long-term mortality data. The association between TLR and the 10-year risk of mortality was examined by multivariable Cox proportional hazards regression, with TLR as a time-varying covariate.
Results:
During maximum follow-up of 10 years (median 6.8 years), TLR occurred in 118 patients and its 10-year cumulative incidence was 10.8%. TLR mostly occurred within 2 years after initial PCI and decreased over time: early-stage TLR (within 2 years) in 73 (61.9%) patients and late-stage TLR (beyond 2 years) in 45 (38.1%) patients. Among all TLR patients, 23 patients underwent coronary artery bypass grafting and 95 underwent repeat PCI. In the time-varying multivariable Cox model, the presence of TLR was not significantly associated with an increased risk of mortality (adjusted HR: 0.90; 95% CI: 0.50-1.63; P = 0.73).
Conclusions:
Although the incidence of ischemia-driven TLR was mostly common within 2 years after left main PCI, TLR occurred steadily during the 10-year follow-up period. However, given that such patients were optimally revascularized, the prognostic impact of TLR on mortality was not substantial. (Evaluation of the First, Second, and New Drug-Eluting Stents in Routine Clinical Practice [IRIS-DES]; NCT01186133; Observational Study for Left Main Disease Treatment [IRIS-MAIN]; NCT01341327; Ten-Year Outcomes of Stents Versus Coronary-Artery Bypass Grafting for Left Main Coronary Artery Disease [MAIN COMPARE]; NCT02791412; Bypass Surgery Versus Angioplasty Using Sirolimus-Eluting Stent in Patients With Left Main Coronary Artery Disease [PRECOMBAT]; NCT00422968).
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