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Long-Term Outcome of Unprotected Left Main Percutaneous Coronary Interventions-An 8-Year Single-Tertiary-Care-Center
Orsolya Nemeth1,2, Tamas Ferenci3,4, Tibor Szonyi1
1Gottsegen National Cardiovascular Center, 1096 Budapest, Hungary.
Insights
Patients undergoing unprotected left main coronary artery percutaneous coronary intervention (PCI) have varying prognoses. Acute ULMCA PCI patients face higher event rates early on, influenced by clinical factors beyond anatomy.
Area of Science:
- Interventional Cardiology
- Cardiovascular Medicine
- Clinical Outcomes Research
Background:
- Randomized trials for unprotected left main coronary artery (ULMCA) disease often use highly selected patient cohorts.
- Real-world data on consecutive ULMCA percutaneous coronary intervention (PCI) outcomes are crucial for understanding broader patient populations.
- Identifying robust risk stratification tools and independent predictors is essential for managing ULMCA disease.
Purpose of the Study:
- To evaluate the 60-month event-free survival in consecutive patients undergoing ULMCA PCI.
- To compare the predictive performance of different risk score systems for ULMCA PCI outcomes.
- To identify independent predictors of long-term event-free survival after ULMCA PCI.
Main Methods:
- Retrospective analysis of 513 consecutive patients who underwent ULMCA PCI between January 2007 and December 2014.
- Primary endpoint: composite of cardiac death, target lesion myocardial infarction, or target lesion revascularization at 60 months.
- Assessment of risk score performance (ACEF, SYNTAX II, SYNTAX) and identification of independent predictors using survival analysis.
Main Results:
- The 60-month event-free survival rates were 16.8% for elective and 38.0% for acute ULMCA PCI patients.
- Acute ULMCA PCI patients experienced significantly more events within the first 6.5 months.
- ACEF and SYNTAX II scores demonstrated the best predictive power in elective and acute groups, respectively; SYNTAX score was least predictive.
- Independent predictors included left ventricular function, access site (femoral vs. radial), hyperlipidemia, and renal function (GFR).
Conclusions:
- Patients undergoing acute ULMCA PCI have a poorer prognosis compared to elective cases, with a higher early event burden.
- Risk stratification should consider anatomical complexity alongside clinical (e.g., left ventricular function, hyperlipidemia, renal function) and procedural (e.g., access site) factors.
- The ACEF and SYNTAX II scores show utility in predicting outcomes in elective and acute ULMCA PCI, respectively.
Abstract:
Background/Objectives: Randomized studies of patients with unprotected left main coronary artery (ULMCA) disease involve highly selected populations. Therefore, we sought to investigate the 60-month event-free survival of consecutive patients undergoing ULMCA percutaneous coronary intervention (PCI) and determine the best risk score system and independent predictors of event-free survival. Methods: All patients who underwent ULMCA PCI at our center between 1 January 2007 and 31 December 2014 were included. The primary endpoint was the time to cardiac death, target lesion myocardial infarction, or target lesion revascularization (whichever came first) with a follow-up of 60 months. Results: A total of 513 patients (mean age 68 ± 12 years, 64% male, 157 elective, 356 acute) underwent ULMCA PCI. The 60-month incidence of events was 16.8% and 38.0% in elective and acute patients, respectively. There were significantly more events in the acute group during the first 6.5 months. Of the risk scores, the ACEF (AUC = 0.786) and SYNTAX II (AUC = 0.716) scores had the best predictive power in elective and acute patients, respectively. The SYNTAX score proved to be the least predictive in both groups (AUC = 0.638 and 0.614 in the elective and acute groups, respectively). Left ventricular function (hazard ratio (HR) for +10% 0.53 [95% CI, 0.38-0.75] and 0.81 [95% CI, 0.71-0.92] in elective and acute patients, respectively) and, in acute patients, access site (femoral vs. radial HR 1.76 [95% CI, 1.11-2.80]), hyperlipidemia (HR 0.58 [95% CI, 0.39-0.86]), and renal function (HR for +10 mL/min/1.73 m2 higher GFR: 0.87 [95% CI, 0.78-0.97]) were independent predictors of event-free survival. Conclusions: Acute ULMCA PCI patients have worse prognosis than elective patients, having more events during the first 6.5 months. Besides anatomical complexity, clinical and procedural parameters determine the prognosis.
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