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Hindawi Journal of Interventional Cardiology Volume 2021, Article ID 8829686, 10 pages https://doi.org/10.1155/2021/8829686 Research Article Long-Term Clinical Outcomes of Unprotected Left Main Percutaneous Coronary Intervention: A Large Single-Centre Experience 1 1 1 2 2 1 1 Lijian Gao , Zhan Gao, Ying Song, Changdong Guan, Bo Xu, Jue Chen, Haibo Liu, 1 1 1 1 1 1 Xuewen Qin, Min Yao, Jinqing Yuan, Yongjian Wu, Fenghuan Hu, Jie Qian, 1 1 1 1 1 1 1 Yida Tang, Kefei Dou, Weixian Yang, Hong Qiu, Chaowei Mu, Jun Dai, Shubin Qiao, 1 1 1 Jilin Chen, Runlin Gao, and Yuejin Yang Department of Cardiology, Coronary Heart Disease Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China Catheterization Laboratories, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Beijing, China Correspondence should be addressed to Yuejin Yang; yangyjfw@126.com Received 26 July 2020; Revised 16 December 2020; Accepted 30 December 2020; Published 12 January 2021 Academic Editor: Seif S. El-Jack Copyright © 2021 Lijian Gao et al. -is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Aims. -is study sought to report the 10-year clinical outcomes of patients who underwent unprotected left main (LM) per- cutaneous coronary intervention (PCI) in a large centre. Methods and Results. A total of 913 consecutive patients who underwent unprotected LM PCI from January 2004 to December 2008 at Fu Wai Hospital were retrospectively analysed; the mean age was 60.0± 10.9 years, females accounted for 22% of patients, diabetes was present in 27.7% of patients, and an LM bifurcation lesion occurred in 82.9% of patients. During the median follow-up of 9.7 years, major adverse cardiac or cerebrovascular events (MACCEs) occurred in 25.6% (234) of patients, and the rates of all-cause death, myocardial infarction, and stroke were 14.9%, 11.0%, and 7.1%, respectively. Cardiac death occurred in only 7.9% of patients. -e estimated event rate was 41.9% for death/ myocardial infarction/any revascularization and 45.9% for death/MI/stroke/any revascularization. Definite/probable stent thrombosis occurred in 4.3% (39) of patients. According to the subgroup analysis, IVUS-guided PCI was associated with less long- term MACCEs. Further multivariate analysis identified that age and LVEF<40% were the only independent predictors for 10-year death. Age, LVEF<40%, creatinine clearance, and incomplete revascularization were independent predictors for death/MI, while a two-stent strategy, diabetes, a transradial approach, and the use of bare metal stents (BMSs) or first-generation drug-eluting stents (DESs) were not. Conclusions. Unprotected LM PCI in a large cohort of consecutive patients in a single large centre demonstrated favourable long-term outcomes up to 10 years even with the use of BMSs and first-generation of DESs. in daily practice, except in bifurcated lesion and the two- 1. Introduction stent strategy [5]. Although randomized controlled trials comparing the effect During the last 2 decades, therapeutic advancements of percutaneous coronary interventions (PCIs) and coronary including drug-eluting stents (DESs) [6–11] and invasive artery bypass graft (CABG) still have not reached consistent imaging tools such as intravascular ultrasound (IVUS) results in patients with unprotected left main (LM) coronary [12–17] have largely improved PCI outcomes in patients artery disease (CAD) [1, 2], PCI has always been recom- with unprotected LM disease. In addition, increased expe- mended as an effective treatment for patients with unpro- rience in complex LM stenting [18] has further improved tected LM CAD by guidelines [3, 4] and has been performed interventional device-oriented outcomes [19]. However, the 2 Journal of Interventional Cardiology long-term outcomes of patients undergoing LM PCI have always been a concern due to suboptimal results, such as 916 patients with unprotected le main lesions were treated with PCI at Fu Wai Hospital stent underexpansion or malapposition at this particular between 2004 and 2008 part, which make patients prone to stent thrombosis and in- stent restenosis, leading to devastating consequences, in- cluding death [20–22]. Previous reports have revealed more Exclude: favourable outcomes in LM patients who underwent PCI (i) 1 patient < 18 years of age than in those who underwent CABG or medical therapy (ii) 2 patients missing baseline alone; however, the long-term follow-up results showed information conflicting reversed findings [23, 24]. On the other hand, clinical or technique factors that influence long-term out- 913 LM-PCI patients were included in this analysis comes following LM are still controversial. In this cir- cumstance, we retrospectively collected over 900 consecutive LM patients with detailed patient demographics, lesion, and Median follow-up duration was 9.7 years procedural information who underwent LM PCI at a large (Min, Max: 8.9, 13.7) cardiac centre with as long as a 10-year follow-up duration. -e study sought to analyse the very long-term performance Figure 1: Patient flow. PCI � percutaneous coronary intervention; of PCI for LM disease and investigate potential factors that LM � left main. influence long-term outcomes. operators decided the strategy of a 1- or 2-stent technique. 2. Methods When the 2-stent strategy was applied, the proximal optimization technique and postdilatation with kissing 2.1. Study Population. Between January 2004 and December balloon angioplasty was mandatory to achieve complete 2008, 19,600 patients underwent PCI at Fu Wai Hospital; apposition of the LM stent. -e use of intravascular ul- among them, a total of 916 consecutive patients diagnosed trasound (IVUS) or optical coherence tomography (OCT) with LM diseases were retrospectively collected. -e ex- was at the operator’s discretion, and an intra-aortic clusion criteria were age <18 years and missing major balloon bump (IABP) was used as mechanical support in baseline information. After excluding 3 patients who met the patients with a very low LVEF or other complications. -e exclusion criteria, 913 LM PCI patients were finally analysed use of dual antiplatelet therapy with aspirin and clopi- (Figure 1). Unprotected LM disease was defined as docu- dogrel was recommended for, at least, 12 months after mented myocardial ischaemia with ≥50% LM stenosis and stent implantation. no patent bypass graft to the left anterior descending or left circumflex arteries. -e population of patients who were rejected by surgeons from surgery included those who met 2.3. Endpoints and Definitions. -e present study evaluated any 1 of the following criteria: chronic obstructive pulmo- the long-term safety and efficacy following LM PCI. -e nary disease, left ventricular ejection fraction <35% with primary safety endpoint was the composite endpoint of minimal or without viable myocardium, age>70 years, acute death, MI, and stroke. -e primary efficacy endpoint was myocardial infarction with haemodynamic instability, cre- target-vessel revascularization (TVR). -e secondary atinine clearance <50 ml/min, or bleeding history within 6 endpoints included individual components of the com- months. Clinical, procedural, and outcomes data were posite outcome, cardiac death, any revascularization, target recorded in a dedicated database. -e baseline and residual lesion revascularization (TLR), and stent thrombosis as SYNTAX Score (SS) were assessed using standard quanti- defined according to definite or probable Academic Re- tative coronary analysis methodology by an independent search Consortium (ARC) criteria [22]. Cardiac death was angiographic core laboratory. Follow-up was performed via defined as any death that could not be attributed to a an office visit or telephone contact at 30 days and annually noncardiac cause. Periprocedural MI was defined as a thereafter. creatine kinase concentration >2 times the upper limit of normal within 48 hours after the procedure, and TVR was defined as any revascularization within the entire major 2.2. Procedures. All patients undergoing PCI were pre- coronary vessels proximal or distal to a target lesion, in- scribed aspirin plus clopidogrel (loading dose, 300 or cluding upstream and downstream side branches and the 600 mg) before the coronary intervention unless they had target lesion itself. previously received regular antiplatelet medications. Procedures were performed with standard interventional techniques. Lesions in the ostium or body of the LM 2.4. Statistical Analysis. Continuous variables are presented usually received a single stent with the postdilation as the mean± SD and were compared by Student’s t-test. technique; if the single stent crossed over the LM bifur- Categorical variables are presented as percentages and cation to the LAD, postdilatation with kissing balloon counts; between-group differences were compared by the chi-square test or Fisher’s exact test. Subgroup analyses were angioplasty was used at the operator’s discretion to finish the procedure. When treating distal LM bifurcation, the performed to identify long-term outcome predictors after Journal of Interventional Cardiology 3 Table 1: Baseline patient characteristics. LM PCI among different populations including patients who were suitable for surgery versus the regular population, the N � 913 transradial versus the transfemoral approach, bifurcation Age, years 60.0± 10.9 versus nonbifurcation lesions, one- versus two-stent strat- Female 22.0% (201) egy, BMS versus DES treatments, and treatment with or 2 Body mass index, kg/m 25.6± 3.1 without IVUS guidance. -e ten-year outcomes in the Diabetes 27.7% (253) overall population and subgroups are presented as Insulin requiring 0.4% (4) Kaplan–Meier estimates and were compared using the log- Current smoking 33.4% (305) rank test. Multivariable Cox proportional hazards models Hypertension 59.6% (544) Hyperlipidaemia 49.8% (455) were constructed to identify independent predictors of 10- Family history of coronary artery disease 14.5% (132) year all-cause death, cardiac death, and death/MI. All sta- Previous percutaneous coronary intervention 24.1% (220) tistical analyses were performed using SAS version 9.1.3 Prior myocardial infarction 30.9% (282) (SAS Institute, Cary, North Carolina). Prior stroke 6.9% (63) Peripheral arterial disease 3.3% (30) Unstable angina 60.4% (551) 3. Results LVEF, % 62.5± 7.9 3.1. Clinical and Procedural Characteristics. Baseline char- LVEF<40% 1.3% (12) acteristics are presented in Table 1. A total of 913 LM PCI LVEF 40%–50% 5.8% (53) LVEF> 50% 92.9% (848) patients with the mean age of 60.0± 10.9 years were enrolled; females accounted for 22.0% of patients, diabetes was Values are reported as the mean± SD or % (n). LVEF � left ventricular ejection fraction. present in 27.7% of patients, and unstable angina was present in 60.4% of patients. An LM bifurcation lesion was present in 82.9% of patients, LM plus 3-vessel disease was 3.3. Multivariate Analysis. In the multivariate analysis, we present in 36.1% of patients, and the mean LVEF was found that age and a left ventricular eject fraction (LVEF) 62.5± 7.9%. Patients with a SYNTAX score ≤32 and>32 < 40% were independent predictors for 10-year death (all accounted for 86.3% and 13.7%, respectively. LM PCI was p< 0.01). In addition, age, LVEF<40%, creatinine clearance, performed with a transradial approach in 45.7% of the and incomplete revascularization were independent pre- patients, the 2-stent strategy in 26.5%, and IVUS guidance in dictors for 10-year death/MI (all p< 0.01) (Table 4). 39.5%, as shown in Table 2. -e median follow-up duration of these patients was 9.7 years (min, max: 8.9, 13.7 years). -e composite endpoint of 4. Discussion death/MI/stroke occurred in 234 (25.6%, 95% confidence In this study, the long-term outcomes of patients after interval [CI]: 22.7–28.5%) patients, the rate of all-cause unprotected LM PCI were assessed in a large cohort of real- death was 14.9% (136), and 11.0% (100) and 7.1% (65) of world patients in a large Chinese cardiovascular centre. -e patients suffered MI and stroke, respectively (Table 3 and major findings of this study were as follows: (1) even with the Figure 2). -e 10-year estimated incidence of any revas- use of a BMS or first-generation DES, PCI for unprotected cularization was 25.0%, and the TVR and target lesion re- LM disease showed favourable long-term results for up to 10 vascularization (TLR) were 16.1% and 9.9%, respectively, years; (2) compared with BMSs, DESs significantly reduced with increase rates 1.4% (TVR) and 0.9% (TLR) annually long-term adverse events, and IVUS-guided PCI was as- (Figure 3). Up to 10 years, 136 (14.9%) patients died; among sociated with a lower incidence of the composite death, them, 72 (7.9%) patients died due to cardiac events (Ap- stroke, or MI events; and (3) age and an LVEF< 40% are pendix). Definite/probable stent thrombosis occurred in 39 independent predictors for 10-year death, while age, (4.3%) patients. LVEF< 40%, creatinine clearance, and incomplete revas- cularization are independent predictors for 10-year death/ 3.2.SubgroupAnalyses. A total of 197 (21.6%) patients in the MI. present study were rejected by surgeons due to patient LM PCI outcomes after a 10-year follow-up duration are comorbidities or surgical ineligibility. Kaplan–Meier curves scarcely reported. Patients in the MAINCOMPARE (Re- showed that there were no differences between patients who vascularization for Unprotected Left Main Coronary Artery underwent the transradial or transfemoral approach (log- Stenosis: Comparison of Percutaneous Coronary Angio- rank p � 0.69), those with LM bifurcation or nonbifurcation plasty Versus Surgical Revascularization) registry [25] who lesions (log-rank p � 0.97), or those treated with the two- received BMSs for LM with less complex CAD showed a 10- stent or one-stent strategy (log-rank p � 0.28), while the 10- year survival probability of 83.1%. In the LE MANS (Left year death/MI/stroke rate was significantly higher in patients Main Coronary Artery Stenting) registry, which included a who were rejected by surgeons (log-rank p< 0.0001) and in wide spectrum of patients with CAD, as well as acute patients with implantation of BMS (32.7% vs. 23.9%, log- coronary syndromes, the 10-year survival after LM stenting rank p � 0.04). On the other hand, an LM PCI procedure was nearly 70% [11]. In the LE MANS prospective trial, guided by IVUS significantly reduced long-term death/MI/ which randomly evaluated LM stenting and CABG for stroke (20.8% vs. 27.7%, log-rank p � 0.03) (Figure 4). unprotected LM stenosis with low and medium SYNTAX 4 Journal of Interventional Cardiology Table 2: Baseline lesion and procedure characteristics. cohort of 913 LM PCI patients with 10-year follow-up re- sults. In this study, the 10-year estimated rate of all-cause N � 913 death was 14.9% with cardiac death accounting for only Coronary artery disease extent 7.9%, which was even lower than the results of the above- Isolated LM 8.0% (73) mentioned studies. Overall, the results of this study together LM + 1VD 19.9% (182) with those of the others mentioned above suggest that the LM + 2VD 35.9% (328) very long-term outcomes of PCI for LM were acceptable. LM + 3VD 36.1% (330) Furthermore, a recent study demonstrated that LM PCI Total occluded lesion 4.4% (40) using DESs in those patients with high-risk features that LM lesion location represent exclusion criteria of previous randomized trials Ostium 11.4% (104) Shaft 5.7% (52) (e.g., AMI within 1 week, LVEF< 30%, and cardiogenic Bifurcation 82.9% (757) shock) achieved the same long-term outcomes compared with low-risk patients [29]. Our latest study analysed all PCI Main vessel Reference vessel diameter, mm 3.66± 0.46 patients in 2013 in our centre, and during a 2-year follow-up Lesion length, mm 20.7± 15.3 period, we found that LM PCI was not an independent risk Diameter stenosis, % 83.0± 10.7 factor for any clinical adverse events [30]. -us, it seems that Side branch interventionists should not consider LM lesions per se as a Reference vessel diameter, mm 2.96± 0.38 particular high-risk subgroup any more with contemporary Lesion length, mm 20.3± 13.7 PCI treatment. On the other hand, in this retrospective Diameter stenosis, % 79.8± 13.2 study, a large portion of the patients (21.6%) evaluated for Medina type for bifurcation lesion LM PCI was rejected by surgeons due to patient comor- 0,1,1 4.1% (37) bidities or surgical ineligibility, and those patients were 1,0,0 3.8% (29) proven to have a worse long-term prognosis. 1,0,1 7.9% (60) After the introduction of DESs, with a remarkable re- 1,1,0 46.8% (354) duction in restenosis and repeat revascularization, LM PCI 1,1,1 36.6% (277) with DESs has been confirmed to have more favourable Lesion type clinical outcomes than that with BMSs [6–11]. However, it De novo 96.4% (880) could be associated with increased risk of very late stent SYNTAX score 24.5± 7.4 thrombosis. Due to inaccuracy of angiography in LM cor- SYNTAX score≤ 32 86.3% (788) onary stenosis assessment [31], IVUS guidance has been SYNTAX score> 32 13.7% (125) proven to be more important than for non-LM lesions and Procedure access improve the long-term prognosis in patients with unpro- Transradial approach 45.7% (417) tected LM CAD undergoing PCI [18, 32–34]. Our study had Transfemoral approach 54.3% (496) same findings: compared with BMSs, first-generation DESs Stent type significantly reduced long-term adverse events. -e majority Bare metal stent 12.0% (110) of definite/probable stent thrombosis was very late throm- Drug-eluting stent 88.0% (803) bosis, and it may be partly explained by the predominant use 1st generation drug-eluting stent 15.0% (137) 2nd generation drug-eluting stent 72.9% (666) of DESs in this population; IVUS-guided PCI was associated Number of stents per patient 2.15± 1.18 with a lower incidence of the composite death, stroke, or MI Total stent length, mm 32.1± 19.3 events. -is retrospective study revealed no difference in the 2-stent strategy 26.5% (242) long-term prognosis with the 1- or 2-stent strategy. Most Crush 16.3% (149) patients with LM bifurcations received the 1-stent strategy, T-stent 3.3% (30) while the 2-stent strategy was mainly chosen for LM bi- V or kissing stent 5.4% (49) furcation lesions with more complex anatomy or true bi- Culotte 1.5% (14) furcations and was performed by high-volume operators Residual SYNTAX score 4.86± 6.26 [19]. -e techniques used in this series were similar to Guidance with IVUS 39.5% (361) European Bifurcation Club recommendations [32]. In this Performed by an experienced operator∗ 83.2% (760) observational study, DM status was not seen to be signifi- ∗Experienced operator defined as those performed, at least, 15 LM PCIs per cantly associated with worse long-term adverse events, and year for, at least, 3 consecutive years. this finding was inconsistent with previous reports [35–38]. -is study demonstrated that age and an LVEF < 40% scores, the patients in the PCI arm reached nearly 80% 10- were independent predictors of 10-year death. On the other year survival [26]. In the ASAN-MAIN (ASAN Medical hand, age, LVEF<40%, creatinine clearance, and incomplete Center-Left MAIN Revascularization) registry, the 10-year revascularization were independent predictors for 10-year survival was 84.1% in patients with LM bare metal stenting death and MI. -is finding was consistent with our previous [27]. In a recent report comparing provisional stenting vs. short-term (15-month follow-up) small cohort (220 LM PCI the two-stent strategy in patients with LM bifurcation le- patients) study from 2003 to 2006 in our centre, which also found that an LVEF< 40% and incomplete revascularization sions, the 10-year survival of the overall patients was over 70% [28]. To our knowledge, this study included the largest (residual SS≥ 8) were independent predictors for death and Journal of Interventional Cardiology 5 Table 3: 10-year clinical outcomes. Estimated event rates N � 913 95% confidence interval All-cause death 14.9% (136) 12.5%–17.3% Cardiac death 7.9% (72) 6.1%–9.7% MI 11.0% (100) 8.9%–13.0% Periprocedural MI∗ 3.3% (30/913) 3.0%–3.6% Target-vessel-related MI 9.7% (89) 7.8%–11.7% Stroke 7.1% (65) 5.4%–8.8% Any revascularization 25.0% (228) 22.1%–27.8% TVR 16.1% (147) 13.7%–18.5% TLR 9.9% (90) 7.9%–11.8% Definite/probable ST 4.3% (39) 2.9%–5.6% Definite ST 1.2% (11) 0.4%–2.0% Probable ST 3.1% (28) 1.9%–4.2% Acute 0.2% (2) 0%–0.6% Subacute 0.4% (4) 0%–0.9% Late 0.3% (3) 0%–0.8% Very late 3.3% (30) 2.1%–4.5% Death + stroke + MI 25.6% (234) 22.7%–28.5% Cardiac death + target-vessel MI + TLR 23.1% (211) 20.3%–25.9% Death + MI + any revascularization 41.9% (383) 38.7%–45.2% Death + MI + stroke + any revascularization 45.9% (419) 42.6%–49.2% Values are reported as % (n); ∗periprocedural MI was defined as a creatine kinase concentration> 2 times the upper limit of normal within 48 hours after the procedure; TVR � target-vessel revascularization; TLR � target lesion revascularization; ST �stent thrombosis; and MI � myocardial infarction. 30 30 25.0% 24 24 20.2% 18 18 14.3% 14.0% 12 12 10.8% 7.9% 6.9% 6 6 0 0 02468 10 02468 10 Time since index procedure (Years) Time since index procedure (Years) Number at risk: Number at risk: Death 913 877 857 831 801 785 Cardiac 913 839 826 810 789 782 Death/MI MI 913 847 840 827 816 814 Death/MI 913 831 809 778 744 729 Stroke 913 912 903 883 862 850 Death/MI/ 913 830 801 757 709 685 Cardiac 913 877 857 831 801 785 Stroke death Death Cardiac death Cardiac death/MI MI Stroke Death/MI Death/MI/Stroke (a) (b) Figure 2: Long-term efficiency and safety after LM PCI. (a) Kaplan–Meier curves for death, cardiac death, MI, and stroke events; (b) Kaplan–Meier curves for composite events including death/MI and death/MI/stroke. MI � myocardial infarction. MI after multivariate analysis [39]. -ese results were also PCI cases from 2004 to 2008 only accounted for 4.67% of the consistent with two recently published long-term studies total PCI cases at the same time; a large proportion of [40, 41]. patients with LM disease were recommended to undergo Our study has potential clinical implications. It seems CABG treatment. Second, just as our previous study dem- that interventionists should be more optimistic for the very onstrated that operator experience affected prognosis after long-term outcomes of LM PCI, but there still are some LM PCI [17], whether the conclusions of this study achieved issues that need to be noted. First, these consecutive 916 LM in a large cardiac centre where most LM PCIs were Cumulative incidence of events (%) Cumulative incidence of events (%) 6 Journal of Interventional Cardiology Target lesion revascularization Target vessel revascularization 20 20 y = 1.4238x + 2.3222 y = 0.8573x + 1.4665 16.1 2 2 R = 0.99094 R = 0.99545 15.2 15 15 14.2 12.6 10.8 9.9 9.3 10 10 9.2 8.8 7.8 7.4 6.5 6.4 5.6 5.1 4.8 5 5 3.9 3.8 3.1 2.7 0 0 1y 2y 3y 4y 5y 6y 7y 8y 9y 10y 1y 2y 3y 4y 5y 6y 7y 8y 9y 10y (a) (b) Figure 3: 10-year target lesion revascularization and target-vessel revascularization. Annual target lesion revascularization (a) and target- vessel revascularization (b) event rates. 50 50 44.2% 40 40 P < 0.0001 P = 0.03 log-rank log-rank 30 30 27.7% 20.8% 20 20 19.7% 10 10 0 0 02468 10 02468 10 Time since index procedure (Years) Time since index procedure (Years) Number at risk: Number at risk: Surgical turn Angiography- 197 164 152 133 117 110 552 496 474 447 416 399 down guidance IVUS- Regular 716 666 649 624 592 575 361 334 327 310 293 286 guidance Surgical exclusion population Angiography guidance Regular population IVUS guidance (a) (b) Figure 4: Continued. Cumulative incidence of events (%) Cumulative incidence of events (%) Journal of Interventional Cardiology 7 50 50 40 40 P = 0.04 P = 0.17 log-rank log-rank 32.7% 30.8% 30 30 25.0% 23.9% 20 20 10 10 0 0 02468 10 02468 10 Time since index procedure (Years) Time since index procedure (Years) Number at risk: Number at risk: BMS 110 96 91 84 75 74 DM 253 235 227 200 174 100 DES 803 734 710 673 634 611 Non-DM 660 594 572 541 485 308 BMS Diabetes mellitus DES Non-diabetes mellitus (c) (d) 50 50 40 40 P = 0.28 P = 0.69 log-rank log-rank 30 30 25.6% 27.7% 24.2% 23.5% 20 20 10 10 0 0 02468 10 02468 10 Time since index procedure (Years) Time since index procedure (Years) Number at risk: Number at risk: Two-stent 242 211 201 194 180 175 Transradial 417 376 363 341 327 316 One-stent 515 474 457 433 409 394 Transfemoral 496 454 438 416 382 369 Two stents Transfemoral One stents Transradial (e) (f ) Figure 4: Continued. Cumulative incidence of events (%) Cumulative incidence of events (%) Cumulative incidence of events (%) Cumulative incidence of events (%) 8 Journal of Interventional Cardiology P = 0.97 log-rank 25.6% 24.8% 02468 10 Time since index procedure (Years) Number at risk: bifurcation 757 685 658 627 589 569 Non- 156 145 143 130 120 116 bifurcation Bifurcation Nonbifurcation (g) Figure 4: Survival curves of 10-year death/MI/stroke events among subgroups. -e surgical exclusion population included patients meeting any one of the following criteria: chronic obstructive pulmonary disease, left ventricular ejection fraction <35%, age >70, acute myocardial infarction with haemodynamic instability, creatinine clearance <50, or bleeding history within 6 months. BMS � bare metal stent; DES � drug-eluting stent; and IVUS � intravascular ultrasound. Other abbreviations are as in Figure 2. Table 4: Predictors of long-term adverse events after LM PCI. Hazard ratio (95% confidence interval) p value Death Bifurcation lesion 1.11 (0.70, 1.77) 0.66 EF<40% 4.51 (1.98, 10.28) <0.001 Incomplete revascularization 1.06 (0.73, 1.55) 0.76 Diabetes 0.98 (0.67, 1.44) 0.92 Age 1.71 (1.37, 2.12) <0.001 CCr 0.10 (0.92, 1.07) 0.89 Death/MI Bifurcation lesion 0.87 (0.73, 1.04) 0.66 EF<40% 1.89 (1.09, 3.28) 0.02 Incomplete revascularization 1.16 (1.01, 1.33) 0.03 Diabetes 1.05 (0.98, 1.22) 0.49 Age 1..15 (1.07, 1.24) <0.001 CCr 1.04 (1.02, 1.06) 0.001 Incomplete revascularization was defined as a SYNTAX revascularization index< 100%. Abbreviations are as in Tables 1 and 2. performed by experienced operators [19] could be expanded which is an old definition that might overestimate MI rates. to other centres needs to be further confirmed. Finally, these data are from 2004 to 2008, which cannot reveal the latest advances in the PCI era. Including patients with now-historical stents, this report does not include 5. Study Limitations physiologic assessment (FFR/iFR, etc) and has limited use of imaging. However, with utility of these modern as- -is report has some limitations that should be ac- sessment modalities, one would expect even more knowledged. First, the major limitation of this study is its favourable results of PCI for LM disease in contemporary observational design, which introduces latent, unrecog- practice. nized, or unmeasured variables that could result in hidden bias. Second, this study only included patients who un- derwent LM PCI; therefore, the very long-term outcomes of 6. Conclusions LM PCI in comparison with those of LM-CABG cannot be evaluated by this study. -ird, the study used a creatine -e current report, drawn from a large cohort of con- kinase concentration >2 times to define periprocedural MI, secutive patients who underwent LM PCI, indicated that Cumulative incidence of events (%) Journal of Interventional Cardiology 9 guidelines, and the American association for thoracic surgery, even with the use of BMSs or first-generation DESs, PCI for preventive cardiovascular nurses association, society for unprotected LM disease showed favourable long-term cardiovascular angiography and interventions, and society of results for up to 10 years. In addition, age and the LVEF are thoracic surgeons,” Journal of the American College of Car- key factors for long-term prognosis following LM PCI. diology, vol. 64, pp. 1929–1949, 2014. Further study should focus on the long-term outcomes of [5] F. Burzotta, J. F. Lassen, A. P. Banning et al., “Percutaneous LM PCI in comparison with LM-CABG to provide more coronary intervention in left main coronary artery disease: the evidence. 13th consensus document from the European Bifurcation Club,” EuroIntervention, vol. 14, no. 1, pp. 112–120, 2018. Data Availability [6] S.-J. Lef` evre, Y.-H. Kim, B.-K. Lee et al., “Sirolimus-eluting stent implantation for unprotected left main coronary artery -e clinical and procedural data used to support the findings stenosis,” Journal of the American College of Cardiology, of this study are included within the article. vol. 45, no. 3, pp. 351–356, 2005. [7] M. Valgimigi, C. A. G. van Mieghem, A. T. L. Ong et al., Ethical Approval “Short- and long-term clinical outcome after drug-eluting stent implantation for the percutaneous treatment of left main Data collection for this study was approved by the insti- coronary artery disease,” Circulation, vol. 111, no. 11, tutional review board central committee at Fuwai Hospital pp. 1383–1389, 2005. and National Center for Cardiovascular Diseases of China. [8] A. Cheiffo, G. Stankovic, E. Bonizzoni et al., “Early and mid- term results of drug-eluting stent implantation in unprotected left main,” Circulation, vol. 111, no. 6, pp. 791–795, 2005. Consent [9] A. Erglis, I. Narbute, I. Kumsars et al., “A randomized comparison of paclitaxel-eluting stents versus bare-metal All human patients provided written, informed consent. stents for treatment of unprotected left main coronary artery stenosis,” Journal of the American College of Cardiology, Conflicts of Interest vol. 50, no. 6, pp. 491–497, 2007. [10] Y. H. Kim, D. W. Park, and S. W. Lee, “For the revascular- -e authors report no conflicts of interest in regards to this ization for unprotected left main coronary artery stenosis: manuscript. comparison of percutaneous coronary angioplasty versus surgical revascularization investigators. Long-term safety and Acknowledgments effectiveness of unprotected left main coronary stenting with drug-eluting stents compared with bare-metal stents,” Cir- -e authors are grateful to the Department of Cardiology, culation, vol. 120, pp. 400–407, 2009. Cardiovascular Institute of Fu Wai Hospital, for its help in [11] P. E. Buszman, P. P. Buszman, R. S. Kiesz et al., “Early and recruiting patients. -e authors thank all members who long-term results of unprotected left main coronary artery contributed to the study. -is work was supported by CAMS stenting,” Journal of the American College of Cardiology, Innovation Fund for Medical Sciences (CIFMS) (2016-I2M- vol. 54, no. 16, pp. 1500–1511, 2009. 1-009). [12] J. Mallidi, A. R. 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Journal of Interventional Cardiology – Hindawi Publishing Corporation
Published: Jan 12, 2021
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