Contemporary percutaneous treatment of unprotected left main coronary stenoses: initial results from a multicenter
S G Ellis1, H Tamai, M Nobuyoshi
1The Cleveland Clinic Foundation, Ohio 44195, USA. elliss@cesmtp.ccf.org
Insights
Percutaneous treatment of unprotected left main (ULMT) coronary stenoses shows promising results in selected patients but requires further investigation to minimize early cardiac death. Coronary artery bypass surgery remains the preferred option for most patients.
Area of Science:
- Interventional Cardiology
- Cardiovascular Surgery
- Medical Device Technology
Background:
- Coronary artery bypass surgery (CABG) is the standard treatment for unprotected left main (ULMT) coronary stenoses.
- Emerging data suggests percutaneous interventions may offer comparable outcomes in select cases.
Purpose of the Study:
- To evaluate the outcomes of percutaneous ULMT revascularization across multiple experienced centers.
- To compare the efficacy and safety of percutaneous interventions versus CABG for ULMT disease.
Main Methods:
- Data collected from 25 centers on 107 consecutive patients treated for ULMT stenosis (elective or acute myocardial infarction) after January 1, 1994.
- Primary interventions included stenting, directional atherectomy, and balloon angioplasty.
- Follow-up was 98.8% complete at an average of 15 months.
Main Results:
- For elective procedures, technical success was 98.9%, with in-hospital survival correlated with left ventricular ejection fraction (LVEF).
- Patients with LVEF ≥ 40% had 98% in-hospital survival and 86% event-free survival at 9 months.
- Patients with LVEF < 40% had significantly lower survival rates (67% in-hospital, 22% event-free at 9 months).
- Early post-discharge cardiac death occurred in 10.6% of survivors within 6 months.
Conclusions:
- Percutaneous revascularization of ULMT stenosis is not yet a universal alternative to CABG due to risks of early post-discharge cardiac death.
- Directional atherectomy and stenting are preferred percutaneous techniques for ULMT.
- Routine follow-up angiography 6-8 weeks post-procedure is recommended.
Background:
Coronary artery bypass surgery (CABG) has been considered the therapy of choice for patients with unprotected left main (ULMT) coronary stenoses. Selected single-center reports suggest that the results of percutaneous intervention may now approach those of CABG.
Methods And Results:
To assess the results of percutaneous ULMT treatment from a wide variety of experienced interventional centers, we requested data on consecutive patients treated after January 1, 1994, from 25 centers. One hundred seven patients were identified who were treated either electively (n=91) or for acute myocardial infarction (n=16). Of patients treated electively, 25% were considered inoperable, and 27% were considered high risk for bypass surgery. Primary treatment included stents (50%), directional atherectomy (24%), and balloon angioplasty (20%). Follow-up was 98.8% complete at 15+/-8 months. Results varied considerably, depending on presentation and treatment. For patients with acute myocardial infarction, technical success was achieved in 75%, and survival to hospital discharge was 31%. For elective patients, technical success was achieved in 98.9%, and in-hospital survival was strongly correlated with left ventricular ejection fraction (P=.003). Longer-term event (death, infarction, or bypass surgery) -free survival was correlated with ejection fraction (P<.001) and was inversely related to presentation with progressive or rest angina (P<.001). Surgical candidates with ejection fractions > or = 40% had an in-hospital survival of 98% and a 9-month event-free survival of 86+/-5%, whereas patients with ejection fractions < 40% had 67% and 22+/-12% in-hospital and 9-month event-free survivals, respectively. Nine hospital survivors (10.6%) experienced cardiac death within 6 months of hospital discharge.
Conclusions:
While results for selected patients appear promising, until early post-hospital discharge cardiac death can be better understood and minimized, percutaneous revascularization of ULMT stenosis should not be considered an alternative to bypass surgery for most patients. When percutaneous revascularization of ULMT is required, directional atherectomy and stenting appear to be the preferred techniques, and follow-up angiography 6 to 8 weeks after treatment is probably advisable.
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