Percutaneous coronary intervention for unprotected left main coronary artery stenosis

Table 1 Outcomes of drug-eluting stents for unprotected left main coronary artery stenosis

	Chieffo et al[4]		Valgimigli et al[6]		Park et al[5]		de Lezo et al[28]	Price et al[11]	Kim et al[20]	Meliga et al[29]	Mehilli et al[48]
Stent type	SES, PES	BMS	SES, PES	BMS	SES	BMS	SES	SES	SES, PES	SES, PES	PES	SES
Design	Single center study		Single center study		Single center study		Single center study	Single center study	Single center study	Multicenter DELFT study	Multicenter randomized study
No. of patient	85	64	95	86	102	121	52	50	63	358	302	305
Age (yr)	63	66	64	66	60	58	63	69	67	66	69	69
Ejection fraction (%)	51a	57	41	42	60	62	57	NA	50	49	53	54
Acute myocardial infarction (%)	NA	NA	17	20a	9.8	6.6	NA	NA	5	8.4	NA	NA
Bifurcation involvement (%)	81a	58	65	66	71a	43	42	94	54	74	63	63
Two-stent technique (%)	74	NA	40a	15	41a	18	18	89	17	43	51	49
Initial clinical outcomes	In-hospital		30 d		In-hospital		In-hospital	In-hospital	In-hospital	In-hospital	30 d
Death (%)	0	0	11	7	0	0	0	0	0	3	1	2
Myocardial infarction (%)	6	8	4	9	7	8	4	8	10	7	4	4
Stent thrombosis (%)	0.0	0.0	0.0	0.0	0.0	0.0	0.0	4.0	0.0	NA	0.3	0.7
TVR (%)	0.0	2.0	0.0	2.0	0.0	0.0	0.0	6.0	0.0	0.8	0.3 (TLR)	0.7 (TLR)
Any events, %	NA	NA	15.0	19.0	7.0	8.0	4.0	10.0	10.0	11.0	5.0	4.6
Long-term outcomes (%)	Cumulative		Cumulative		Cumulative		Cumulative	After discharge	Cumulative	3 yr	2 yr
Mean follow-up (mo)	6	6	17	12	12	12	12	9	11	NA	NA	NA
Death (%)	4	14	14	16	0	0	0	10	5	9	10	9
Myocardial infarction (%)	NA	NA	4a	12	7	8	4	2	11	9	5	5
Stent thrombosis (%)	0.1	0.0	NA	NA	0.0	0.0	0.0	0.0	0.2	0.6	0.3	0.7
TVR (%)	19	31	6a	12	2a	17	2	38	19	14	9 (TLR)	11 (TLR)
Any MACE (%)	NA	NA	24a	45	8a	26	NA	44	29	32	21	21

^aP < 0.05 between drug-eluting stent (SES and/or PES) vs BMS. BMS: Bare metal stent; NA: Not available; MACE: Major adverse cardiac events including death, myocardial infarction, and TVR; PES: Paclitaxel-eluting stent; SES: Sirolimus-eluting stent; TVR: Target vessel revascularization; DELFT: Drug Eluting stent for left main.

Table 2 Features favoring PCI or CABG

	Indications in favor of PCI	Indications in favor of CABG
Absolute	Suitable coronary anatomy for stenting with preserved left ventricular function (≥ 40%)	Patient who refuses PCI
	Patient who refuses surgery	Contraindication to antiplatelet therapy including aspirin, heparin, and thienopyridine (ticlopidine or clopidogrel)
		History of serious allergic reaction to stainless steel, drugs on drug-eluting stents, and contrast agent
		History of known coagulopathy or bleeding diathesis
		Pregnant women
Relative	Lesion restricted to the LMCA ostium or shaft	Complex coronary anatomies at LMCA, unsuitable for stenting (e.g. severe calcification, severe tortuosity, etc.)
	Isolated LMCA lesion	Total occlusions at other major epicardial coronary arteries (≥ 2)
	Bail-out procedure (e.g. dissection at the LMCA complicated during angiography or PCI)	Multivessel stenosis except LMCA
	Acute myocardial infarction at the LMCA, in which emergent revascularization is necessary	Decreased left ventricular dysfunction (< 40%)
	Cardiogenic shock due to LMCA stenosis, in which emergent revascularization is necessary	Extensive peripheral vascular disease, in which placement of guiding catheter or intra-aortic balloon pump is not likely to be performed
	Age ≥ 80 yr	In-stent restenosis at the LMCA, in which repeat PCI is not likely to be performed
	Serious co-morbid disease (e.g. chronic lung disease, poor general performance, etc.)
	Limited life expectancy of less than 1 yr
	Prior CABG
	Coronary anatomy, unsuitable for CABG (e.g. poor distal run-off)

CABG: Coronary artery bypass graft surgery; LMCA: Left main coronary artery; PCI: Percutaneous coronary intervention.

Table 3 Comparison of drug-eluting stents to coronary artery bypass surgery for unprotected left main coronary artery stenosis

	Chieffo et al[7]		Lee et al[9]		Palmerini et al[15]		Buszman et al[17]		Seung et al[21]
Study design	Registry		Registry		Registry		Randomized study		Registry
Treatment type	PCI with SES, PES	CABG	PCI with SES	CABG	PCI with SES	CABG	PCI with BMS, DES	CABG	PCI with BMS, DES	CABG
No. of patient	107	142	50	123	157	154	52	53	1102	1138
Age (yr)	64	68	72	70	73a	69	61	61	62	64
Ejection fraction (%)	52	52	51	52	52	55	54	54	62	60
EuroSCORE or Parsonnet score (Lee)	4.4	4.3	18.0a	13.0	6.0a	5.0	3.3	3.5	NA	NA
Initial clinical outcomes	In-hospital		30 d		30 d		30 d		NA
Death (%)	0.0	2.0	2.0	5.0	3.2	4.5	0.0	0.0	NA	NA
Myocardial infarction (%)	9.0	26.0	0.0	2.0	4.5	1.9	1.9	3.8	NA	NA
TVR (%)	0.0	2.0	0.0	1.0	0.6	0.6	1.9	0.0	NA	NA
Any MACE (%)	NA	NA	0.0	8.0	NA	NA	NA	NA	NA	NA
Cerebrovascular accident	0.0	1.4	2.0a	17.0	NA	NA	0.0	2.0	NA	NA
Long-term clinical outcomes	Cumulative after discharge		Kaplan-Meier		Cumulative		At 1 yr		Kaplan-Meier at 3 yr for propensity-matched cohort
Mean follow-up (mo)	12.0	12.0	6.0	6.0	14.0	14.0	NA	NA	33.9	38.4
Death (%)	2.8	6.4	4.0	13.0	13.4	12.3	1.9	7.5	7.9	7.8
Myocardial infarction (%)	0.9	1.4	NA	NA	8.3	4.5	1.9	5.7	NA	NA
TVR (%)	19.6a	3.6	7.0	1.0	25.5a	2.6	28.8a	9.4	12.6	2.6
Cerebrovascular accident (%)	0.9	0.7	NA	NA	NA	NA	0.0	3.8	NA	NA
Any events (%)	NA	NA	11.0	17.0	NA	NA	NA	NA	NA	NA

^aP < 0.05 between PCI vs CABG.