(Circulation. 1997;96:3867-3872.)
© 1997 American Heart Association, Inc.
Articles |
Contemporary Percutaneous Treatment of Unprotected Left Main Coronary Stenoses
Initial Results From a Multicenter Registry Analysis 1994–1996
From The Cleveland (Ohio) Clinic Foundation.
Correspondence to Stephen G. Ellis, MD, The Cleveland Clinic Foundation, 9500 Euclid Ave, F-25, Cleveland, OH 44195. E-mail elliss{at}cesmtp.ccf.org
Background Coronary artery bypass surgery (CABG) has been considered the therapy of choice for patients with unprotected left main (ULMT) coronary stenoses. Selected single-center reports suggest that the results of percutaneous intervention may now approach those of CABG.
Methods and Results To assess the results of
percutaneous ULMT treatment from a wide variety of
experienced interventional centers, we requested data on consecutive
patients treated after January 1, 1994, from 25 centers. One hundred
seven patients were identified who were treated either electively
(n=91) or for acute myocardial infarction (n=16). Of patients treated
electively, 25% were considered inoperable, and 27% were considered
high risk for bypass surgery. Primary treatment included stents (50%),
directional atherectomy (24%), and balloon angioplasty (20%).
Follow-up was 98.8% complete at 15±8 months. Results varied
considerably, depending on presentation and treatment. For
patients with acute myocardial infarction, technical success was
achieved in 75%, and survival to hospital discharge was 31%. For
elective patients, technical success was achieved in 98.9%, and
in-hospital survival was strongly correlated with left
ventricular ejection fraction (P=.003).
Longer-term event (death, infarction, or bypass surgery) -free survival
was correlated with ejection fraction (P<.001) and was
inversely related to presentation with progressive or rest
angina (P<.001). Surgical candidates with ejection
fractions 
40% had an in-hospital survival of 98% and a 9-month
event-free survival of 86±5%, whereas patients with ejection
fractions <40% had 67% and 22±12% in-hospital and 9-month
event-free survivals, respectively. Nine hospital survivors (10.6%)
experienced cardiac death within 6 months of hospital discharge.
Conclusions While results for selected patients appear promising, until early post–hospital discharge cardiac death can be better understood and minimized, percutaneous revascularization of ULMT stenosis should not be considered an alternative to bypass surgery for most patients. When percutaneous revascularization of ULMT is required, directional atherectomy and stenting appear to be the preferred techniques, and follow-up angiography 6 to 8 weeks after treatment is probably advisable.
Key Words: angioplasty • bypass • coronary disease • arteries • stents
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