Short- and long-term clinical outcome after drug-eluting stent implantation for the percutaneous treatment of left main coronary artery disease: Insights from the Rapamycin-Eluting and Taxus Stent Evaluated at Rotterdam Cardiology Hospital Registries (RESEARCH and T-SEARCH)

Erasmus Medical Center, Rotterdam, The Netherlands.
Circulation (Impact Factor: 14.43). 04/2005; 111(11):1383-9. DOI: 10.1161/01.CIR.0000158486.20865.8B
Source: PubMed


The impact of drug-eluting stent (DES) implantation on the incidence of major adverse cardiovascular events in patients undergoing percutaneous intervention for left main (LM) coronary disease is largely unknown.
From April 2001 to December 2003, 181 patients underwent percutaneous coronary intervention for LM stenosis at our institution. The first cohort consisted of 86 patients (19 protected LM) treated with bare metal stents (pre-DES group); the second cohort comprised 95 patients (15 protected LM) treated exclusively with DES. The 2 cohorts were well balanced for all baseline characteristics. At a median follow-up of 503 days (range, 331 to 873 days), the cumulative incidence of major adverse cardiovascular events was lower in the DES cohort than in patients in the pre-DES group (24% versus 45%, respectively; hazard ratio [HR], 0.52 [95% CI, 0.31 to 0.88]; P=0.01). Total mortality did not differ between cohorts; however, there were significantly lower rates of both myocardial infarction (4% versus 12%, respectively; HR, 0.22 [95% CI, 0.07 to 0.65]; P=0.006) and target vessel revascularization (6% versus 23%, respectively; HR, 0.26 [95% CI, 0.10 to 0.65]; P=0.004) in the DES group. On multivariate analysis, use of DES, Parsonnet classification, troponin elevation at entry, distal LM location, and reference vessel diameter were independent predictors of major adverse cardiovascular events.
When percutaneous coronary intervention is undertaken at LM lesions, routine DES implantation, which reduces the cumulative incidence of myocardial infarction and the need for target vessel revascularization compared with bare metal stents, should currently be the preferred strategy.

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    • "Furthermore, the predilection of LMCAD for locations in the distal bifurcation makes PCI a challenge for interventional cardiologists, regardless of the type of device and the technique used. Moreover, 70-80% of patients have concomitant 3-VD5-7,19,29-32 and, combined with the relative frequency of distal bifurcation lesions (53-90% of patients) extending into the proximal coronary arteries (Cx, LAD),7,30,31,33 may favor CABG over PCI for LM stenosis to enable more complete surgical revascularization. In the present study, 50% of the patients with LMCAD suffered from 3-VD (39% in the PCI group vs. 60% in the CABG group, p=0.002), and, in 75% of cases, the lesion was located in the distal LM (59% in PCI group vs. 87% in CABG group, p<0.001). "
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    • "Coronary stenting, particularly the introduction of drug-eluting stents has been increasingly used to treat coronary artery disease [19] [20] [21]. The relatively low rates of in-stent restenosis have enabled the coronary stenting as an effective alternative to angioplasty with stenting of the left main coronary artery [22]. The description of the progression of atherosclerosis in the left coronary artery and at the bifurcation is therefore of paramount importance in the planning of stent deployment so that precise information about the type of stent to be used can be provided to ensure the success rate. "
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    • "Bifurcation LMCA lesions were, however, considered inappropriate for PCI due to technical difficulties in stent implantation and relative higher rates of restenosis. Valgimigli et al (2005) 9 reported short and long term outcome after DES implantation for PCI of ULMCA from Rotterdam (Netherlands), Cardiology Hospital Registries (Research and T ăSearch). From April 2001 to Dec. 2003, 181 patients underwent PCI for LMCA. "
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