Original Article

Outcomes of Primary Percutaneous Intervention of the Unprotected Left Main Coronary Artery Stenosis in Myocardial Infarction

Authors: Yousef Hadi Darrat, MD, Hany Guirgis, MD, Mehiar O. El-Hamdani, MD, Silvestre Cansino, MD, Todd W. Gress, MD, MPH, Mark Studeny, MD

Abstract

Objective: The aim of our study was to examine the 30-day and 1-year survival rate for patients undergoing percutaneous coronary artery intervention (PCI) of unprotected left main (ULM) stenosis by the presence (acute myocardial infarction [AMI] group) or absence (non-AMI group) of AMI at the time of hospital admission.


Methods: We retrospectively reviewed 64 patients undergoing PCI of ULM stenosis at our regional heart institute between 2000 and 2008. Patients had no history of coronary artery bypass grafting.


Results: Thirty-six men and 28 women underwent PCI for ULM stenosis. Overall Kaplan-Meier survival at 30 days and 1 year was 71.5% and 57.8%, respectively. Thirty-three patients (51.6%) presented with AMI. Those with AMI had lower survival at both 30 days (59.2 vs 83.9%; P = 0.04) and 1 year (45.2 vs 70.2%; P = 0.04) compared with those without AMI. Compared with a lesion involving only the ostial/mid LM, diffuse disease (N = 11) was associated with an increased mortality at 1 year (hazard ratio 0.27; 95% confidence interval 0.09–0.79). A stent size >3 mm was associated with lower mortality at 1 year (hazard ratio 0.42; 95% confidence interval 0.19–0.93).


Conclusions: We found that AMI at presentation was significantly associated with higher mortality in patients undergoing ULM stenting. LM lesion location and stent size were both significantly associated with mortality. ULM stenting is an option in patients who are unable to undergo coronary artery bypass grafting, but patients should understand the overall high risk of mortality, particularly if they present with AMI.

This content is limited to qualifying members.

Existing members, please login first

If you have an existing account please login now to access this article or view purchase options.

Purchase only this article ($25)

Create a free account, then purchase this article to download or access it online for 24 hours.

Purchase an SMJ online subscription ($75)

Create a free account, then purchase a subscription to get complete access to all articles for a full year.

Purchase a membership plan (fees vary)

Premium members can access all articles plus recieve many more benefits. View all membership plans and benefit packages.

References

1. Buszman PE, Buszman PP, Kiesz RS, et al. Early and long-term results of unprotected left main coronary artery stenting: the LE MANS (Left Main Coronary Artery Stenting) Registry. J Am Coll Cardiol 2009; 54: 1500–1511.
 
2. Coronary Artery Surgery Study (CASS): a randomized trial of coronary artery bypass surgery. Survival data. Circulation 1983; 68: 939–950.
 
3. Varnauskas E. Twelve-year follow-up of survival in the randomized European Coronary Surgery Study. N Engl J Med 1988; 319: 332–337.
 
4. Serruys PW, Morice MC, Kappetein AP, et al. Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease. N Engl J Med 2009; 360: 961–972.
 
5. White HD, Assmann SF, Sanborn TA, et al. Comparison of percutaneous coronary intervention and coronary artery bypass grafting after acute myocardial infarction complicated by cardiogenic shock: results from the Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock (SHOCK) trial. Circulation 2005; 112: 1992–2001.
 
6. Kushner FG, Hand M, Smith SC Jr, et al. 2009 focused updates: STEMI and PCI guidelines. J Am Coll Cardiol 2009; 54: 2205–2241.
 
7. Ng MK, Yeung AC. Left main coronary artery disease: is CABG still the gold standard? Rev Cardiovasc Med 2005; 6: 187–193.
 
8. CHANCE Study Group. The immediate and long term prognosis following unprotected left main coronary artery stenting in Chinese. Chinese Registry of Unprotected Left Main Coronary Artery Stenting (CHANCE Study). Zhonghua Xin Xue Guan Bing Za Zhi 2005; 33: 210–215. [in Chinese].
 
9. Park SJ, Kim YH, Park DW, et al. Randomized trial of stents versus bypass surgery for left main coronary artery disease. N Engl J Med 2011; 364: 1718–1727.
 
10. Seung KB, Park DW, Kim YH, et al. Stents versus coronary-artery bypass grafting for left main coronary artery disease. N Engl J Med 2008; 358: 1781–1792.
 
11. Thompson CA, Sidhu MS, Brown JR, et al. Classification and atherosclerosis distribution in patients with left main coronary disease. J Interv Cardiol 2009; 22: 431–436.
 
12. Palmerini T, Sangiorgi D, Marzocchi A, et al. Ostial and midshaft lesions vs. bifurcation lesions in 1111 patients with unprotected left main coronary artery stenosis treated with drug-eluting stents: results of the survey from the Italian Society of Invasive Cardiology. Eur Heart J 2009; 30: 2087–2094.
 
13. Park SJ, Hong MK, Lee CW, et al. Elective stenting of unprotected left main coronary artery stenosis: effect of debulking before stenting and intravascular ultrasound guidance. J Am Coll Cardiol 2001; 38: 1054–1060.
 
14. Chieffo A, Park SJ, Valgimigli M, et al. Favorable long-term outcome after drug-eluting stent implantation in non-bifurcation lesions that involve unprotected left main coronary artery: a multicenter registry. Circulation 2007; 116: 158–162.
 
15. Hu WS, Lee SH, Chiu CZ, et al. Long-term clinical outcomes following elective stent implantation for unprotected left main coronary artery disease. J Formos Med Assoc 2011; 110: 19–26.
 
16. Hurtado J, Pinar Bermúdez E, Redondo B, et al. Emergency percutaneous coronary intervention in unprotected left main coronary arteries. Predictors of mortality and impact of cardiogenic shock. Rev Esp Cardiol 2009; 62: 1118–1124.
 
17. Silber S, Albertsson P, Aviles FF, et al. Guidelines for percutaneous coronary interventions. The Task Force for Percutaneous Coronary Interventions of the European Society of Cardiology. Eur Heart J 2005; 26: 804–847.
 
18. Hendler A, Kaluski E, Blatt A, et al. Percutaneous coronary intervention of unprotected left main coronary artery in the emergent/urgent setting. J Invas Cardiol 2007; 19: 202–206.