Current management of left main coronary artery disease

Clinique Pasteur, Toulouse, France.
European Heart Journal (Impact Factor: 15.2). 01/2012; 33(1):36-50b. DOI: 10.1093/eurheartj/ehr426
Source: PubMed


Coronary artery bypass surgery is considered as the gold standard treatment of unprotected left main coronary artery (ULMCA) disease. Over the last 20 years, improvement in stent technology and operators experience explained the increased number of reports on the results of percutaneous coronary interventions (PCIs) for the treatment of left main (LM) coronary artery lesion. The recent data comparing efficacy and safety of PCIs using drug-eluting stent and coronary artery bypass surgery showed comparable results in terms of safety and a lower need for repeat revascularization for coronary artery bypass surgery. Patient selection for both techniques is fundamental and directly impacts the clinical outcome. Further randomized trials must be conducted to precise the indications of both techniques of revascularization in the treatment of LM disease.

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    • "This vessel is responsible for more than 75% of the blood supply to the left ventricular cardiac mass in patients with right dominant or balanced type cardiac circulation and 100% in those with left dominant type. Therefore, in the case of a lesion to the LMCA, the left ventricle (LV) will receive less blood supply and present impaired function, leading to a sharply increased risk of life-threatening events caused by LV dysfunction and arrhythmias in patients [2, page 36–50b] "
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    ABSTRACT: Coronary artery disease is the leading cause of mortality and morbidity in the world. Left main coronary artery disease (LMCAD) is a particularly severe phenotypic form of CAD and has a genetic basis. We hypothesized that some inflammation- and hyperhomocysteinemia-related gene polymorphisms may contribute to LMCAD susceptibility in a Chinese population. We studied the association between polymorphisms in the genes hepatocyte nuclear factor 1 alpha (HNF1A; rs7310409, G/A), C-reactive protein (rs1800947 and rs3093059 T/C), methylenetetrahydrofolate reductase (rs1801133, C/T), and methylenetetrahydrofolate dehydrogenase (rs1076991, A/G) in 402 LMCAD and 804 more peripheral CAD patients in a Chinese population. Genotyping was performed using the matrix-assisted laser desorption/ionization time-of-flight mass spectrometry method. When the HNF1A rs7310409 GG homozygote genotype was used as the reference group, both the individual, GA and AA, and combined GA/AA genotypes were associated with an increased risk of LMCAD. This single nucleotide polymorphism (rs7310409) is strongly associated with plasma CRP levels. In conclusion, the present study provides evidence that the HNF1A rs7310409 G/A functional polymorphism may contribute to the risk of LMCAD.
    Full-text · Article · Aug 2014 · Biochemistry Research International
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    • "Nonetheless, current improvements in interventional techniques and adjunctive pharmacology have challenged the orthodox wisdom that significant LMCA stenosis11-13 should be cured surgically. The introduction of coronary stenting has led to a reassessment of the role of PCI as a practical treatment option for LMCA disease,14-17 and the widespread availability of drug-eluting stents (DES), together with enhanced stenting techniques, has lowered the threshold for use of PCI, instead of CABG, in patients with LMCA disease.18 "
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    ABSTRACT: Objective: Critical stenosis of left main coronary artery (LMCA) has always remained a challenge for interventional cardiologists. Conventionally Coronary Artery Bypass Grafting (CABG) is done for these patients but recently Percutaneous Coronary Intervention (PCI) is also being tried more frequently, but data of PCI is scarce in this regard. Our objective was to determine the safety and technical success rate of percutaneous left main coronary artery stenting. Methods: This was 12 month follow up study conducted at Pakistan Institute of Medical Sciences (PIMS), Islamabad from 11th Jan 2012 to 11th Jan 2013. All symptomatic patients who underwent coronary angiogram at PIMS and were found to have either isolated LMCA disease or coexisting osteal Left Anterior Descending (LAD) artery disease were potentially eligible for the study. Patients who had previous surgical treatment for coronary artery disease and those with renal dysfunction requiring dialysis were excluded. Patients were counselled in detail regarding the pros and cons of PCI versus CABG.Those who opted for PCI were included in the study. All these patients were treated with percutaneous left main coronary artery stenting with or without osteal LAD stenting. Results: Seventy two patients had LMCA disease during angiogram. Fifteen patients opted for CABG. Four patients did not meet the inclusion criteria, whereas 53 patients were finally enrolled. Mean age of patients were 55.45±10.275 years. Twenty nine patients were with acute coronary syndrome and 22 presented with unstable angina.PCI with stenting was technically successful in all patients. One patient died three months after PCI, there was no other mortality. Conclusion: Our study showed that Percutaneous Coronary Intervention (PCI) to LMS has good technical success rate; the safety of the procedure is also acceptable.
    Full-text · Article · Jul 2014 · Pakistan Journal of Medical Sciences Online
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    • "Another issue is LMCA disease. CABG surgery is considered as the gold standard for the treatment of unprotected LMCA lesions; however, recent data comparing the efficacy and safety of PCIs using DES and CABG showed comparable results in terms of safety and a lower need for repeat revascularization for CABG.15)16) In a meta-analysis of 4 randomized controlled trials,17) and a recently published 5-year follow-up study of the SYNTAX trial,18) PCI was associated with a higher frequency of MACCE, and a higher risk of target vessel revascularization compared with CABG. "
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    ABSTRACT: With the increase in life expectancy, the proportion of very elderly people is increasing. Coronary artery disease (CAD) is an important cause of mortality and morbidity in this age group, for which myocardial revascularization is often indicated. Percutaneous coronary intervention (PCI) in the very elderly bears the inherent risks of complications and mortality, but the potential benefits may outweigh these risks. A number of observational studies, registries, and few randomized controlled trials have shown the safety and feasibility of PCI in octogenarians and nonagenarians. However, PCI is only rarely done in centenarians; so, the outcome of percutaneous coronary revascularization in this age group is largely unknown. PCI in a centenarian with complex CAD is described here; the patient presented with unstable angina despite optimum medical therapy, and surgery was declined. Good angiographic success was followed by non-cardiac complications, which were managed with a multidisciplinary approach.
    Full-text · Article · Mar 2014 · Korean Circulation Journal
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