Three-Year Outcomes of Contemporary Left Main Coronary Intervention in Patients With and Without Acute Coronary
Yoshinobu Murasato1, Kensaku Higashi2, Hiroshi Sugino3
1Department of Cardiology, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan.
Insights
Patients with acute coronary syndrome (ACS) undergoing left main percutaneous coronary intervention (LM-PCI) face higher early mortality but similar long-term outcomes compared to those without ACS. Intracoronary imaging use was routine in this real-world study.
Area of Science:
- Cardiology
- Interventional Cardiology
- Clinical Outcomes Research
Background:
- Left main percutaneous coronary intervention (LM-PCI) is a common treatment for left main coronary artery disease.
- Real-world data on long-term outcomes after LM-PCI, particularly comparing patients with and without acute coronary syndrome (ACS), are crucial.
- Intracoronary imaging guidance is increasingly utilized in LM-PCI procedures.
Purpose of the Study:
- To evaluate three-year clinical outcomes after contemporary LM-PCI in patients with and without ACS.
- To identify predictors of major adverse cardiac and cerebrovascular events (MACCEs) in both patient groups.
- To assess the impact of routine intracoronary imaging guidance on LM-PCI outcomes.
Main Methods:
- A real-world cohort of 758 consecutive patients undergoing LM-PCI for unprotected de novo lesions was analyzed.
- Patients were categorized into ACS (n=241) and non-ACS (n=516) groups.
- Three-year MACCEs (all-cause mortality, revascularization, myocardial infarction, cerebrovascular events) were compared, with routine intracoronary imaging guidance used in 97.6% of cases.
Main Results:
- Patients with ACS had higher rates of bifurcation lesions, cardiogenic shock, and mechanical circulatory support (MCS) use.
- Three-year MACCE (40.7% vs. 28.5%) and mortality (25.8% vs. 10.2%) were significantly higher in the ACS group, primarily due to early mortality.
- After the initial 30 days, revascularization rates were similar between groups (13.4% vs. 15.8%). Predictors for MACCE varied between ACS and non-ACS groups.
Conclusions:
- Contemporary LM-PCI in patients presenting with ACS is associated with worse three-year outcomes, mainly driven by early mortality.
- Beyond the early phase, longer-term outcomes, including the need for revascularization, appear comparable between ACS and non-ACS presentations.
- The study highlights the importance of intracoronary imaging in achieving low rates of adverse events like stent thrombosis and target lesion revascularization.
Abstract:
We evaluated 3-year clinical outcomes after contemporary left main percutaneous coronary intervention in patients with and without acute coronary syndrome (ACS) in a real-world cohort, in which intracoronary imaging guidance was routinely used. Among 758 consecutive patients undergoing left main percutaneous coronary intervention for unprotected de novo lesions, 97.6% received imaging guidance. Patients were categorized by presenting ACS (n = 241) or without ACS (n = 516). Three-year major adverse cardiovascular and cerebrovascular events (MACCEs), including all-cause mortality, clinically driven revascularization, myocardial infarction, and cerebrovascular events were analyzed. Patients with ACS presented more true bifurcation lesions (31.9% vs 24.2%), cardiogenic shock (18.3% vs 0.2%), and increased mechanical circulatory support use (40.2% vs 5.6%). They had significantly higher MACCE (40.7% vs 28.5%; hazard ratio [HR] 1.81) and mortality rates (25.8% vs 10.2%; HR 3.09), primarily due to higher mortality within 30 days (HR 9.05), while revascularization rates were similar (13.4% vs 15.8%). MACCE predictors in ACS included male (HR 2.62), mechanical circulatory support (HR 2.44), and radial access (HR 0.42). In patients without ACS, left ventricular ejection fraction <40% (HR 2.27), severe calcification requiring coronary atherectomy (HR 1.86), two-stent implantation (HR 1.99), and radial access (HR 0.59) were predictive. In this cohort with extensive use of intracoronary imaging, rates of two-stent implantation (8.9%), target lesion revascularization (4.0%), myocardial infarction (3.0%), and stent thrombosis (0.3%) were low. In conclusion, in contemporary left main percutaneous coronary intervention practice, patients presenting with ACS experienced worse 3-year outcomes, largely attributable to early mortality. After the early phase, longer-term outcomes, including revascularization, were comparable between ACS and non-ACS presentations.
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