Comparative Outcomes of Left Main and Nonleft Main Percutaneous Coronary Intervention from the Excellence in Coronary
Robert C Stoler1, Minseob Jeong2, Talha Akram3
1Baylor Heart and Vascular Hospital, Dallas, Texas; Baylor University Medical Center, Dallas, Texas.
Insights
Left main (LM) percutaneous coronary intervention (PCI) patients have more comorbidities and higher 1-year major adverse cardiovascular events (MACE) compared to non-LM PCI. Repeat revascularization significantly drives MACE in the LM PCI group.
Area of Science:
- Cardiology
- Interventional Cardiology
- Health Outcomes Research
Background:
- Limited comparative data exists on real-world outcomes for left main (LM) versus non-LM coronary artery percutaneous coronary intervention (PCI).
- Understanding these differences is crucial for optimizing patient care and treatment strategies in complex coronary artery disease.
Purpose of the Study:
- To compare the real-world clinical outcomes of patients undergoing LM PCI versus non-LM PCI.
- To identify factors contributing to adverse events in LM PCI patients.
Main Methods:
- A prospective study of 873 consecutive patients (256 LM PCI, 617 non-LM PCI) from the Excellence in Coronary Artery Disease (XLCAD) Registry (Sept 2019-Mar 2023).
- Primary outcome: 1-year incidence of major adverse cardiovascular events (MACE) including death, myocardial infarction, repeat revascularization, and stroke.
- Secondary outcome: Periprocedural events (≤30 days).
Main Results:
- LM PCI patients were older and had significantly greater comorbidities than non-LM PCI patients.
- While procedural success was high, 1-year MACE was significantly higher in the LM PCI group (12.9% vs. 8.4%, p=0.043), primarily driven by increased repeat revascularization (12.1% vs. 6.2%, p=0.003).
- Thirty-day mortality and MACE were numerically higher in the LM PCI group, though not statistically significant.
Conclusions:
- Real-world LM PCI is performed in patients with higher comorbidity burden, achieving high procedural success.
- LM PCI is associated with significantly higher 1-year MACE, largely due to increased need for repeat revascularization.
- These findings highlight the need for careful patient selection and management strategies for LM PCI.
Background:
There are limited comparative data on real-world outcomes of patients undergoing percutaneous coronary intervention (PCI) of the left main (LM) and non-LM coronary arteries.
Methods:
Total 873 consecutive patients undergoing LM PCI (n = 256) and non-LM PCI (n = 617) were enrolled between September 2019-March 2023 in the Excellence in Coronary Artery Disease (XLCAD) Registry. Primary outcome was 1-year incidence of major adverse cardiovascular events (MACE), a composite of all-cause death, nonfatal myocardial infarction, clinically driven repeat revascularization and ischemic stroke. The secondary outcome was periprocedural (≤30 days) events.
Results:
Study cohort included 68% men, mean age 71.9 ± 10.3 in LM and 67.2 ± 11.1 years in non-LM PCI groups (p <0.001). LM PCI patients had significantly greater co-morbidities (diabetes mellitus, hyperlipidemia, prior stroke, prior myocardial infarction, prior coronary revascularization, peripheral artery disease, chronic lung and kidney disease and heart failure) compared with non-LM. Acute coronary syndrome indication was the most prevalent (69%). Mechanical circulatory support was employed in 3.1% LM vs 1% non-LM PCI patients (p = 0.026). Mean number of lesions treated were 2.2 ± 1.0 in LM and 1.4 ± 0.6 in non-LM PCI groups (p <0.001). Multivessel PCI was performed in 68.8% LM and 21% non-LM PCI patients (p <0.001). Overall, drug-eluting stent use (96.7%), bifurcation PCI (24.7%) and atherectomy (2.4%) were similar across groups. Technical and procedural success rates were high across groups, however significantly higher in non-LM group. Periprocedural (≤30 days postprocedure) events included mortality in 3.5% LM and 1.5% non-LM PCI (p = 0.334) and MACE 4.7% LM vs 2.4% non-LM PCI (p = 0.080) groups. One-year MACE was significantly higher in LM versus non-LM PCI (12.9% vs 8.4%, respectively; p = 0.043), driven mainly by higher repeat percutaneous revascularization in LM group (12.1% vs 6.2%; p = 0.003). Mortality at 1-year in LM vs non-LM PCI were 10.2% vs 5.8% (p = 0.074).
Conclusion:
In a real-world experience, LM PCI is performed in patients with significantly greater comorbidities compared with non-LM PCI, with high procedural success. Thirty-day mortality and 1-year MACE are significantly higher in LM group.
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