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Left Main Stem Percutaneous Coronary Intervention - Data and Ongoing Trials.

ABSTRACT: Left main stem (LMS) disease is associated with significant morbidity and mortality. Traditionally coronary artery bypass grafting (CABG) has been the gold standard for treatment of these lesions. However over the past decade, percutaneous coronary intervention (PCI) has assumed a more prominent role in the treatment of LMS disease. With the advent of newer drug-eluting stents (DES) with an improved risk factor profile, better intravascular imaging modalities and careful patient selection, the use of PCI in this cohort is expanding. We review the current data to support this and discuss the on-going trials that will hopefully shed more light into the management of this complex disease.

SUBMITTER: Rampat R

PROVIDER: S-EPMC5808470 | biostudies-literature | 2015 Sep

REPOSITORIES: biostudies-literature

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Left Main Stem Percutaneous Coronary Intervention - Data and Ongoing Trials.

Rampat Rajiv R Hildick-Smith David D

Interventional cardiology (London, England) 20150901 3

Left main stem (LMS) disease is associated with significant morbidity and mortality. Traditionally coronary artery bypass grafting (CABG) has been the gold standard for treatment of these lesions. However over the past decade, percutaneous coronary intervention (PCI) has assumed a more prominent role in the treatment of LMS disease. With the advent of newer drug-eluting stents (DES) with an improved risk factor profile, better intravascular imaging modalities and careful patient selection, the u ...[more]

PMID: 29588688

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Adoption of same day discharge following elective left main stem percutaneous coronary intervention.

Project description:BackgroundThis study sought to investigate the safety and feasibility of same day discharge (SDD) practice and compare clinical outcomes to patients admitted for overnight stay (ON) undergoing elective left main stem (LMS) percutaneous coronary intervention (PCI). ON observation is still widely practiced in highly complex PCI as the standard of care, with no previous data comparing clinical outcomes in patients undergoing LMS PCI.MethodsWe analysed 6452 patients undergoing elective LMS PCI between 2007 and 2014 in England and Wales. Multiple logistic regressions and the BCIS risk model were used to study association between SDD and 30 day mortality.ResultsSDD rates almost doubled from 19.9% in 2007 to 39.8% in 2014 for all LMS procedures and increased from 20.7% to 41.4% for unprotected LMS cases during the same study period. There was a significant increase in procedural complexity with higher use of rotational atherectomy, longer stents and multivessel PCI. SDD was not associated with increased 30 day mortality (OR 0.70 95%CI 0.30-1.65) in the overall LMS PCI cohort and the results were similar in unprotected LMS (OR 0.48 95%CI 0.17-1.41) and those requiring ON stay (OR 0.58 95%CI 0.25-1.34).ConclusionsWe did not find evidence that SDD is not safe or feasible in highly complex LMS PCI procedures despite increasing procedural complexity with no significant increase in 30 day mortality rates.

| S-EPMC7392050 | biostudies-literature

Percutaneous coronary intervention for left main stem disease: Impact of diabetes mellitus on mortality.

Project description:ObjectivesWe assessed the impact of diabetes mellitus (DM) on mortality after percutaneous coronary intervention (PCI) for left main stem (LMS) disease. Second, we compared mortality outcomes between non-insulin treated (NITDM) and insulin treated diabetes (ITDM) in different clinical settings.BackgroundThere is a paucity of "real world" outcomes data in diabetic patients undergoing LMS PCI.MethodsWe undertook a retrospective analysis of consecutive patients undergoing unprotected LMS PCI at 2 high volume tertiary centers. Diabetic status and clinical setting for PCI were recorded. The primary outcome measure was all-cause 30-day and long-term mortality (up to 36 months) post index PCI.ResultsBetween 2003 and 2017, 2,675 patients undergoing index LMS PCI were analyzed. Of those, 77.1% were non-DM, 15.8% NITDM, and 7.1% ITDM. Overall, DM status was not associated with higher 30-day mortality (OR 1.39, 95% CI 0.89-2.16, p = .15). During a median follow-up of 36 months, there was a borderline statistical association of DM with long-term mortality in all PCI settings (HR 1.31, 95% CI 1.00-1.71, p = .05). Compared to non-DM, ITDM but not NITDM was associated with short- and long-term mortality in all clinical presentations.ConclusionsOverall, DM did not impact on 30-day mortality and had only a borderline statistical association with long-term mortality. It did not have an influence on mortality in non-emergency LMS PCI. The impact of DM on mortality outcomes following LMS PCI was only significant in the insulin treated patients.

| S-EPMC7687181 | biostudies-literature

Percutaneous Coronary Intervention for Left Main Coronary Artery Disease: Present Status and Future Perspectives.

Project description:For several decades, coronary artery bypass grafting has been regarded as the standard choice of revascularization for significant left main coronary artery (LMCA) disease. However, in conjunction with remarkable advancement of device technology and adjunctive pharmacology, percutaneous coronary intervention (PCI) offers a more expeditious approach with rapid recovery and is a safe and effective alternative in appropriately selected patients with LMCA disease. Several landmark randomized clinical trials showed that PCI with drug-eluting stents for LMCA disease is a safe option with similar long-term survival rates to coronary artery bypass grafting surgery, especially in those with low and intermediate anatomic risk. Although it is expected that the updated evidence from recent randomized clinical trials will determine the next guidelines for the foreseeable future, there are still unresolved and unmet issues of LMCA revascularization and PCI strategy. This paper provides a comprehensive review on the evolution and an update on the management of LMCA disease.

| S-EPMC9627854 | biostudies-literature

Contemporary Left Main Percutaneous Coronary Intervention: A State-of-the-art Review.

Project description:The majority of the left ventricular myocardium is supplied by the left main coronary artery. Atherosclerotic obstruction of the left main coronary artery therefore leads to significant myocardial jeopardy. Coronary artery bypass surgery (CABG) has been the gold standard for left main coronary artery disease in the past. However, advancements in technology have established percutaneous coronary intervention (PCI) as a standard, safe and reasonable alternative to CABG, with comparable outcomes. Contemporary PCI of left main coronary artery disease comprises careful patient selection, accurate technique guided by either intravascular ultrasound or optical coherence tomography and - if necessary - physiological assessment using fractional flow reserve. This review focuses on current evidence from registries and randomised trials comparing PCI with CABG, procedural tips and tricks, adjuvant technologies and the triumph of PCI.

| S-EPMC10331562 | biostudies-literature

Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting for Revascularization of Left Main Coronary Artery Disease.

Project description:Owing to a large-jeopardized myocardium, left main coronary artery disease (LMCAD) represents the substantial high-risk anatomical subset of obstructive coronary artery disease. For several decades, coronary artery bypass grafting (CABG) has been the "gold standard" treatment for LMCAD. Along with advances in CABG, percutaneous coronary intervention (PCI) has also dramatically evolved over time in conjunction with advances in the stent or device technology, adjunct pharmacotherapy, accumulated experiences, and practice changes, establishing its position as a safe, reasonable treatment option for such a complex disease. Until recently, several randomized clinical trials, meta-analyses, and observational registries comparing PCI and CABG for LMCAD have shown comparable long-term survival with tradeoffs between early and late risk-benefit of each treatment. Despite this, there are still several unmet issues for revascularization strategy and management for LMCAD. This review article summarized updated knowledge on evolution and clinical evidence on the treatment of LMCAD, with a focus on the comparison of state-of-the-art PCI with CABG.

| S-EPMC10011221 | biostudies-literature

Unprotected left main revascularization: Percutaneous coronary intervention versus coronary artery bypass. An updated systematic review and meta-analysis of randomised controlled trials.

Project description:BackgroundThe optimal treatment of unprotected left main (UPLM) with either PCI or CABG remains uncertain.AimThe purpose of this study was to determine the comparative safety and efficacy of PCI versus CABG in patients with UPLM disease.MethodsSearch of BioMedCentral, CENTRAL, mRCT, PubMed, major cardiological congresses proceedings and references cross-check (updated November 2016). Outcomes were the rate of MACE [all cause death, MI, stroke], the rates of the individual components of MACE and the rate of target vessel revascularisation (TVR).ResultsWe identified 6 Randomised Controlled Trials totalling 4717 patients allocated to PCI or CABG. At 1 year follow up, PCI and CABG were substantially equivalent with respect to the rates of MACE [PCI 8.5% vs CABG 8.9%, OR 1.02,(0.76-1.36), p = 0.9], death [PCI 5.4% vs CABG 6.6%, OR 0.81,(0.63-1.03),p = 0.08] and MI [PCI 3.4% vs CABG 4.3%, OR 0.80(0.59-1.07), p = 0.14]. Notably, PCI was associated with a significantly lower rate of stroke [PCI 0.6% vs CABG 1.8%, OR 0.36,(0.17-0.79), p = 0.01] and with a significantly higher rate of TVR [PCI 8.7% vs CABG 4.5%, OR 2.00(1.46-2.75), p<0.01]. At a median follow up of 5years, the rates of MACE were similar between the two strategies: PCI 14.6% vs CABG 13.8%, OR 1.02(0.76-1.38), p = 0.89. Likewise, the rates of death [PCI 8% and CABG 7.7%, OR 1(0.77-1.31), P = 0.9], MI [PCI 6.1% vs CABG 5%, OR 1.41(0.85-2.34), P = 0.19, I2 59%], and stroke [PCI 2% vs CABG 2.2%, OR 0.85(0.42-1.81), p = 0.65,] were similar while PCI was associated with a significantly higher rate of TVR [14.5% vs CABG 8.9%, OR 1.73(1.41-2.13), p<0.01].ConclusionIn patients with UPLM disease, PCI and CABG are associated with similar rates of MACE and mortality at 1 year as well as after 5 years. Differences can be detected for individual end points at both short and long term FU.

| S-EPMC5489169 | biostudies-literature

Emergency percutaneous coronary intervention for left main trunk thrombus following orthotopic heart transplantation.

Project description:Heart transplantation (HTx) is the gold standard therapy to improve quality and quantity of life in end-stage heart failure patients. However, recipients are at risk of experiencing allograft rejection and post-transplant complications, in the acute as well as chronic phase. A 43-year-old man with a history of left ventricular non-compaction underwent orthotopic HTx. On Day 7, transthoracic echocardiography showed a sudden decrease in cardiac function with hypokinesis in a left ventricular anterior wall distribution. Coronary angiography revealed a large thrombus in the left main trunk. With intra-aortic balloon pump support, emergency percutaneous coronary intervention was performed. Endomyocardial biopsy showed no rejection. A left main trunk thrombus is rare in the early phase after HTx, but it can be a life-threatening complication. Transthoracic echocardiography is well known to be important in the management of heart transplant recipients, and coronary angiography as well as myocardial biopsy should be considered when left ventricular wall motion is impaired.

| S-EPMC6487697 | biostudies-literature

Percutaneous intervention of left main coronary artery chronic total occlusion: A case report.

Project description: Not available

| S-EPMC5998863 | biostudies-literature

Percutaneous coronary intervention vs. coronary artery bypass grafting for left main revascularization: an updated meta-analysis.

Project description:AimsThe optimal revascularization strategy for left main coronary artery disease (LMD) remains controversial, especially with two recent randomized controlled trials showing conflicting results. We sought to address this controversy with our analysis.Methods and resultsComprehensive literature search was performed. We compared percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) for LMD revascularization using standard meta-analytic techniques. A 21% higher risk of long-term major adverse cardiac and cerebrovascular event [MACCE; composite of death, myocardial infarction (MI), stroke, and repeat revascularization] was observed in patients undergoing PCI in comparison with CABG [risk ratio (RR) 1.21, 95% confidence interval (CI) 1.05-1.40]. This risk was driven by higher rate of repeat revascularization in those undergoing PCI (RR 1.61, 95% CI 1.34-1.95). On the contrary, MACCE rates at 30 days were lower in PCI when compared with CABG (RR 0.55, 95% CI 0.39-0.76), which was driven by lower rates of stroke in the PCI arm (RR 0.41, 95% CI 0.17-0.98). At 1 year, lower stroke rates (RR 0.21, 95% CI 0.08-0.59) in the PCI arm were balanced by higher repeat revascularization rates in those undergoing PCI (RR 1.78, 95% CI 1.33-2.37), resulting in a clinical equipoise in MACCE rates between the two revascularization strategies. There was no difference in death or MI between PCI when compared with CABG at any time point.ConclusionOutcomes of CABG vs. PCI for LMD revascularization vary over time. Therefore, individualized decisions need to be made for LMD revascularization using the heart team approach.

| S-EPMC5730452 | biostudies-literature

Trends in Clinical Practice and Outcomes After Percutaneous Coronary Intervention of Unprotected Left Main Coronary Artery.

Project description:Background The use of percutaneous coronary intervention (PCI) to treat unprotected left main coronary artery disease has expanded rapidly in the past decade. We aimed to describe nationwide trends in clinical practice and outcomes after PCI for left main coronary artery disease. Methods and Results Patients (n=4085) enrolled in the SCAAR (Swedish Coronary Angiography and Angioplasty Registry) as undergoing PCI for left main coronary artery disease from 2005 to 2017 were included. A count regression model was used to analyze time-related differences in procedural characteristics. The 3-year major adverse cardiovascular and cerebrovascular event rate defined as death, myocardial infarction, stroke, and repeat revascularization was calculated with the Kaplan-Meier estimator and Cox proportional hazard model. The number of annual PCI procedures grew from 121 in 2005 to 589 in 2017 (389%). The increase was greater for men (479%) and individuals with diabetes (500%). Periprocedural complications occurred in 7.9%, decreasing from 10% to 6% during the study period. A major adverse cardiovascular and cerebrovascular event occurred in 35.7% of patients, falling from 45.6% to 23.9% (hazard ratio, 0.56; 95% CI, 0.41-0.78; P=0.001). Radial artery access rose from 21.5% to 74.2% and intracoronary diagnostic procedures from 14.0% to 53.3%. Use of bare-metal stents and first-generation drug-eluting stents fell from 19.0% and 71.9%, respectively, to 0, with use of new-generation drug-eluting stents increasing to 95.2%. Conclusions Recent changes in clinical practice relating to PCI for left main coronary artery disease are characterized by a 4-fold rise in procedures conducted, increased use of evidence-based adjunctive treatment strategies, intracoronary diagnostics, newer stents, and more favorable outcomes.

| S-EPMC9075483 | biostudies-literature

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