Published online before print July 15, 2002, doi: 10.1161/01.CIR.0000024983.34728.5D
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
(Circulation. 2002;106:698.)
© 2002 American Heart Association, Inc.
Clinical Investigation and Reports |
Results and Long-Term Predictors of Adverse Clinical Events After Elective Percutaneous Interventions on Unprotected Left Main Coronary Artery
From EMO Centro Cuore Columbus, Milan, Italy (T.T., G.S., L.F., K.T., N.C., R.A., G.S., R.P., C.D.M., A.C.), and San Raffaele Hospital, Milan, Italy (A.C., V.S., F.L., C.B., C.D.M., A.C.).
Correspondence to Antonio Colombo, MD, EMO Centro Cuore Columbus, 48 Via Buonarroti, 20145 Milan, Italy. E-mail columbus{at}micronet.it
 |
Abstract |
|---|
 Top Abstract IntroductionMethodsResultsDiscussionReferences |
|---|
Background— The safety and efficacy of percutaneous coronary intervention of de novo lesions in unprotected left main coronary arteries remains an unresolved issue.
Methods and Results— We analyzed 67 consecutive patients treated with the following devices: 39 with stents, 12 with rotational atherectomy plus stents, 13 with directional coronary atherectomy plus stents (a total of 64 patients were treated with stents), and 3 patients with directional coronary atherectomy only. The reference vessel size was 3.78±0.73 mm and lesion length was 6.6±3.0 mm. In-hospital complications were 2 coronary artery bypass grafts (CABGs) (3.0%), 2 Q-wave myocardial infarctions (MIs) (3.0%), and 3 non-Q-wave MIs (4.5%); there were no deaths. The estimated cardiac survival at 3 years was 91%. The cardiac mortality rate was higher in patients with Parsonnet score >15 versus 
15 (21.4% versus 4.2%, P=0.02) at 3 years. The independent covariate of cardiac death was preserved left ventricular ejection fraction; for combined cardiac events (cardiac death, MI, repeat revascularization) it was large reference vessel size. Follow-up angiography at 5±2 months in 85% of eligible patients revealed 31.4% restenosis. Extending the follow-up to 31±23 months (19 patients with follow-up beyond 3 years) the cumulative event rates were 11 deaths (16.4%), 8 of them cardiac (11.9%), 2 (3.0%) MI, and 16 (23.9%) repeat revascularizations (CABG in 5 patients).
Conclusions— Elective percutaneous coronary intervention of de novo lesions in left main coronary arteries is feasible, with low procedural risk. The long-term follow-up revealed a high rate of angiographic restenosis and repeat revascularization, with a relatively high incidence of cardiac death. Reference vessel size and left ventricular function are the most important predictors of favorable follow-up.
Key Words: angioplasty • coronary disease • revascularization • stents • survival
|
Introduction |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
The application of percutaneous coronary interventions (PCI) has expanded beyond standard indications in recent years as the result of the wide availability and use of stents.1,2 Lesions in the left main coronary artery (LM) are considered a standard indication for surgical revascularization, on the basis of the results of randomized studies.3 Several recent reports using coronary stenting for unprotected LM lesion showed encouraging follow-up clinical results with this technique. The first published multicenter experience in 107 patients (ULTIMA Registry: Unprotected Left Main Trunk Investigation Multicenter Assessment) including both elective and emergent treatment4 showed an in-hospital mortality rate of 12% and a cumulative 1-year mortality rate of 29%, whereas recent studies in patients with elective treatment reported very low hospital complications and a 1-year survival rate of 97% or higher.5 However, an updated report from the ULTIMA Registry continued to show a high in-hospital and follow-up mortality rates.6
One major problem is that many series include elective and emergency interventions, making the results difficult to use when recommending this procedure to a specific patient.
With the intent to provide further data in this controversial field, we examined and report our complete experience with elective percutaneous treatment of lesions involving unprotected LM.
|
Methods |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
Patients and PCI
From April 1993 to June 2001, 67 consecutive patients with de novo unprotected LM stenosis were electively treated in our institution. Every patient had
50% diameter stenosis by visual estimate. The decision to perform PCI versus surgery was considered when one of the two conditions was present: (1) suitable anatomy and lesion characteristics for stenting and preference by the patient and by the referring physician for a percutaneous approach, both of them being aware of the procedural risks; (2) suitable anatomy and lesion characteristics for stenting and contraindication to surgery on the basis of the presence of comorbidity evaluated by a cardiac surgeon. The Parsonnet surgical risk score7 8 was calculated for each patient, and patients were stratified in high- and low-surgical risk groups. Lesions underwent balloon predilation, rotational atherectomy, directional atherectomy, or intravascular ultrasound evaluation, according to the operator’s decision. Final stent implantation was encouraged in most of the lesions. Stents were deployed to achieve the best possible final lumen diameter.9,10 Preprocedural and postprocedural therapy consisted of ticlopidine and aspirin.11
A clinical and angiographic follow-up was scheduled for all patients. Clinical follow-up was performed at 1, 3, and 6 months and at the latest follow-up time by clinic visits or by telephone interview with the patient’s physician. Angiographic follow-up was scheduled at 6 months after successful procedure or earlier if noninvasive evaluation or clinical presentation suggested the presence of ischemia.
Definitions
Procedural success was defined as revascularization in the target lesion with 30% residual stenosis according to angiography and with the patient leaving hospital free from any of the following events: death, Q-wave or non-Q-wave myocardial infarction (MI), or coronary artery bypass graft (CABG). Non-Q wave MI was defined as elevation of total CK 2 times above the upper limit of normal with a positive MB fraction, in the absence of pathological Q waves.
The events analyzed for follow-up in this study were cardiac death, CABG, MI (Q-wave and non-Q-wave), restenosis, and target vessel revascularization (TVR), including ostium of left anterior descending artery (LAD) and circumflex artery (LCx). Deaths were classified as either cardiac or noncardiac. Deaths that could not be classified were considered to be cardiac related.
Restenosis was defined as 50% luminal narrowing at the target site or ostium of the LAD and/or LCx demonstrated at the follow-up angiography, irrespective of clinical symptoms of the patient.
Parsonnet score is a numeric scoring system used to stratify the risk of death at 30 days in patients undergoing open heart surgery.7,8 The score is calculated as the sum of predefined numerical values assigned to 15 different clinical risk factors (example: 1 for morbid obesity and 20 for a second or subsequent reoperation). A score value >15 was chosen to express a risk >4%.7,8
Quantitative Coronary Angiography
The reference diameter, the stenosis length, and the minimal luminal diameter were determined with the use of a validated edge-detection program (CMS version 4.0, MEDIS) at baseline, after procedure, and at follow-up. The luminal indexes (eg, acute gain, late loss, loss index, and so forth) were calculated according to the standard criteria.
Statistical Analysis
Data were analyzed with commercial statistical programs (StatView 5, SAS Institute Inc). Continuous data are expressed as mean±SD. For the analysis of continuous data, the Student’s t test was used to assess differences between groups with and without clinical events. Categorical data were compared with the use of 
2 or Fisher’s exact tests. Cox proportional hazards model with the use of the stepwise procedure was used to assess the correlates of events among multiple clinical, procedural, and angiographic variables. Event-free survival during follow-up at 3 years (72% of patients) was evaluated according to the Kaplan-Meier method. A comparison of cardiac survival between low- and high-surgical risk groups was performed by means of the log-rank test.
|
Results |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
Immediate Results
Baseline clinical, angiographic, and procedural characteristics are summarized in Tables 1 and 2. The mean age of patients was 65±12 years (range, 30 to 86); 40% of patients had unstable angina. Almost half of the patients (45%) had 3-vessel disease. The site of the lesion in the LM was the ostium in 22% of patients, the midportion of the artery in 18%, and the distal bifurcation in 60%. Angiographic success was obtained in 65 patients (97%) and procedural success in 61 patients (91%). All patients with angiographic success had complete revascularization. Stents were placed in 64 patients. In 39 patients, stents were deployed after balloon angioplasty, 16 patients underwent directional coronary atherectomy (stents were placed in 13 of them), and 12 patients had rotational atherectomy and stenting. Intra-aortic balloon pump was used in 58% of patients, intravascular ultrasound was performed in 46%, and GP IIb/IIIa antagonists were used in 15% of patients. Minimal lumen diameter increased from 1.48±0.55 mm before angioplasty to 3.77±0.70 mm after the procedure, whereas mean diameter stenosis decreased from 59±13% to 4±10%. Thirty-two patients (48%) also underwent PCIs in the other major coronary segment in the same procedure.
|
|
In-hospital complications occurred in 6 patients: There were no deaths; 2 patients required emergency CABG, 2 patients had Q-wave MI, and 3 patients had non-Q-wave MI (Table 3).
|
Follow-Up Cardiac Events
After hospital discharge, patients completed a mean clinical follow-up of 31±23 months (range, 5 to 94.7). Table 3 shows cardiac events during the follow-up period. A total of 11 patients died: 8 of these patients had cardiac death (8 of 67; 11.9%). The characteristics of these patients and the time of occurrence of death are presented in Table 4. The total event rate at the end of the follow-up period, comprising cardiac death, MI, and any revascularization, was 34.3%.
|
Angiographic follow-up was performed in 51 patients of 60 eligible (angiographic follow-up rate 85%) after 5±2 months. Angiographic restenosis was found in 16 patients (31%). The specific location of the restenotic lesions according to the LM segment originally involved are presented in Table 2.
TVR was performed in 16 patients (11 repeat PCI and 5 CABG). Among these patients, 3 late (average, 16.7 months) TVR were observed, all at the ostium of LAD or LCx. Figure 1 shows the Kaplan-Meier curve for freedom from major adverse cardiac events (death, Q-wave MI, and TVR) limited to 3 years. Event-free survival was 76% at 6 months, 71% at 1 year, and 62% at 3 years. By multivariate analysis, reference vessel diameter was the only covariate of all cardiac events at follow-up (hazard ratio, 0.36; P=0.02; 95% CI, 0.15 to 0.87).
|
Cardiac Deaths
In total, there were 11 deaths (16.4%), 8 of which were cardiac related. Six cardiac deaths occurred within 6 months after the procedure. The other two patients died >3 years after procedure, and both had low left ventricular ejection fraction (LVEF) (0.35). Three noncardiac deaths were due to cancer. The estimated cardiac survival rates at 1 and 3 years were 91% and 91%, respectively (Figure 2). By multivariate analysis, the covariate of cardiac death was LVEF 0.40 (hazard ratio, 8.6; P=0.003; 95% CI, 2.2 to 34.8).
|
Cardiac mortality rate was higher in the patients with high Parsonnet score (95.8% freedom from cardiac death at 3 years in the low-risk group versus 78.6% in the high-risk group, P=0.021) (Figure 3).
|
Directional Atherectomy and Stenting for Bifurcation Lesions
Forty patients had lesions involving the bifurcation of the left main. Debulking with atherectomy was performed in 15, and in 12 a stent was implanted. The angiographic restenosis rate in these patients was 35.7% (5 of 14) and was not different from patients who had stenting without debulking (47.1%, 8 of 17, P=0.7). When we consider only the branch of the bifurcation that underwent debulking, the restenosis rate was 23.5% (4 of 17).
|
Discussion |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
The major findings in this study are (1) PCI with stenting of lesions located in the LM is feasible in a variety of lesions with high immediate clinical success; (2) at an average follow-up time of 31 months there is an incidence of cardiac death of 11.9% and of a need of TVR of 24.6%; (3) patients with a high surgical risk by Parsonnet score have a 21.4% 3-year cardiac mortality rate compared with 4.2% in patients with a low surgical risk; and (4) the most important predictor of major adverse cardiac events during follow-up is the reference vessel size of the LM, whereas LVEF
0.40 is the only covariate of cardiac death. Results of clinical follow-up of PCI performed on the LM are inferior to the ones obtained after PCI in other locations. An analysis of 4 recently published studies5,12–14 addressing elective LM interventions with stenting in most of the lesions shows an incidence of in-hospital mortality rates ranging from 0% to 4% for elective procedures, but cardiac mortality rate increases to 13.7% when emergency PCIs are included.6
The long-term outcome in the same studies with a follow-up time ranging from 7.3 to 25.5 months shows a cardiac mortality rate between 0.7% to 5.7%, an incidence of MI between 0% to 2.6%, and a need for revascularization from 6.8% to 16.4%.
In these studies, the predictors of freedom from cardiac events, including the need for revascularization, were angiographic reference vessel size of the LM for the incidence of restenosis5 and final lumen diameter for death.14 Our results emphasize one important aspect of this type of procedure: The hospital outcome is favorable, but the follow-up is affected by a relatively high incidence of events such as cardiac death, MI, and the need for reintervention. The fact that 6 of 8 cardiac deaths occurred in the first 6 months highlights the dramatic way restenosis could manifest when PCI is performed on the LM and stresses that only a clear improvement in this area will justify a wider application of the PCI approach to LM disease. It could be argued that a surgical approach could have avoided some of these early deaths. Despite these valid concerns, we should consider that LM disease carried a 15% mortality rate 5 years after surgical revascularization in the Coronary Artery Surgery Study (CASS).3 On the other side, we cannot dismiss that there are improvements in surgical mortality rate, and it is difficult to exactly estimate the surgical risk of this small cohort.
Along with the other investigators, we found favorable outcome in patients with a low surgical risk. In our series, patients (72% of total population) with a Parsonnet score <15 had 3-year cardiac mortality rate of 4.2%.
Despite these encouraging results in the group with unprotected LM disease and low surgical risk, it is important to consider that only a prospective study with a predefined characterization of the low risk group will support this preliminary finding.
The fact that there were predictors of long-term success may help the selection of the most appropriate patient for this type of procedure. The size of the reference vessel, a low surgical risk, and a preserved left ventricular function5,14 are the most important parameters to be considered.
Unfortunately, the finding that patients with LM disease and a high Parsonnet score or a low LVEF have the worst prognosis undermines the value of PCI as an alternative to surgery in these patients.
Another way to look at the practice of PCI of unprotected LM is that in our series only 2 cardiac deaths occurred from 6 months to the end of follow-up (mean 31±23 months). This means that a solution to the problem of restenosis may favorably affect the long-term outcome of this condition.
With regard to the value of atherectomy debulking before stenting, we cannot draw any conclusion from our study, most probably because of the small number of patients treated with this approach, the tendency of the operator to use atherectomy in the most complex bifurcations, and some limitations in the ability to perform effective debulking in both branches, especially with the old devices used in the early time of this experience. It is interesting to notice that the lowest numeric restenosis (4 of 17, 23.5%) was found in the branch of a bifurcation in which debulking was performed before stenting.
On the basis of these data, we conclude that while awaiting a solution to the problem of restenosis, elective PCI on unprotected LM has good long-term results in patients with low surgical risk and large reference vessel diameter.
Limitations
The most important limitation of this study is that this series represents a selected group of patients with LM disease. The fact that the procedures were performed over a long time period introduces variables related to the evolution of devices (more friendly stents) and operator experience. With regard to the use of atherectomy, we need to take into account that this approach was mostly used in bifurcations, making a comparison with simple stenting difficult. The wide difference in cardiac mortality rates among patients with low versus high Parsonnet scores could be partially accounted for by chance, as the result of our small sample size.
The fact that this study was not randomized versus surgery is in our view a minor limitation because PCI of the LM is still an approach in evolution and not yet ready for randomization versus an established technique such as CABG.
Received March 20, 2002; revision received May 17, 2002; accepted May 21, 2002.
|
References |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
1. Finci L, Ferraro M, Nishida T, et al. Coronary stenting beyond standard indications: immediate and follow-up results. Ital Heart J. 2000; 1: 739–748.[Medline] [Order article via Infotrieve]
2. Colombo A. Innovations in stenting to treat diverse problems in interventional cardiology. J Invasive Cardiol. 2000; 12: 38–40.[Medline] [Order article via Infotrieve]
3. Caracciolo EA, Davis KB, Sopko G, et al. Comparison of surgical and medical group survival in patients with left main coronary artery disease: long-term CASS experience. Circulation. 1995; 91: 2325–2334.
4. Ellis SG, Tamai H, Nobuyoshi M, et al. Contemporary percutaneous treatment of unprotected left main coronary stenoses: initial results from a multicenter registry analysis 1994 to 1996. Circulation. 1997; 96: 3867–3872.
5. Park S, Hong M, 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.
6. Tan WA, Tamai H, Park SJ, et al. Long-term clinical outcomes after unprotected left main trunk percutaneous revascularization in 279 patients. Circulation. 2001; 104: 1609–1614.
7. Parsonnet V, Dean D, Bernstein AD. A method of uniform stratification of risk for evaluating the results of surgery in acquired adult heart disease. Circulation. 1989; 79 (suppl I): I-3–I-12.[Medline] [Order article via Infotrieve]
8. Bernstein AD, Parsonnet V. Bedside estimation of risk as an aid for decision-making in cardiac surgery. Ann Thorac Surg. 2000; 69: 823–828.
9. Nakamura S, Hall P, Gaglione A, et al. High pressure assisted coronary stent implantation accomplished without intravascular ultrasound guidance and subsequent anticoagulation. J Am Coll Cardiol. 1997; 29: 21–27.[Abstract]
10. Moussa I, Moses J, Di Mario C, et al. Stenting after optimal lesion debulking (sold) registry: angiographic and clinical outcome. Circulation. 1998; 98: 1604–1609.
11. Colombo A, Hall P, Nakamura S, et al. Intracoronary stenting without anticoagulation accomplished with intravascular ultrasound guidance. Circulation. 1995; 91: 1676–1688.
12. Wong P, Wong V, Tse KK, et al. A prospective study of elective stenting in unprotected left main coronary disease. Catheter Cardiovasc Interv. 1999; 46: 153–159.[CrossRef][Medline] [Order article via Infotrieve]
13. Silvestri M, Barragan P, Sainsous J, et al. Unprotected left main coronary artery stenting: immediate and medium- term outcomes of 140 elective procedures. J Am Coll Cardiol. 2000; 35: 1543–1550.
14. Black A, Cortina R, Bossi I, et al. Unprotected left main coronary stenting: correlates of midterm survival and impact of patient selection. J Am Coll Cardiol. 2001; 37: 832–838.
This article has been cited by other articles:
 |
|
 |
|
  F. G. Kushner, M. Hand, S. C. Smith Jr, S. B. King III, J. L. Anderson, E. M. Antman, S. R. Bailey, E. R. Bates, J. C. Blankenship, D. E. Casey Jr, et al. 2009 Focused Updates: ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction (Updating the 2004 Guideline and 2007 Focused Update) and ACC/AHA/SCAI Guidelines on Percutaneous Coronary Intervention (Updating the 2005 Guideline and 2007 Focused Update): A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines J. Am. Coll. Cardiol., December 1, 2009; 54(23): 2205 - 2241. [Full Text] [PDF]
|
|
|
|
 |
|
 F. G. Kushner, M. Hand, S. C. Smith Jr, S. B. King III, J. L. Anderson, E. M. Antman, S. R. Bailey, E. R. Bates, J. C. Blankenship, D. E. Casey Jr, et al. 2009 Focused Updates: ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction (Updating the 2004 Guideline and 2007 Focused Update) and ACC/AHA/SCAI Guidelines on Percutaneous Coronary Intervention (Updating the 2005 Guideline and 2007 Focused Update): A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Circulation, December 1, 2009; 120(22): 2271 - 2306. [Full Text] [PDF]
|
|
|
|
|
|
American College of Cardiology Foundation, American Heart Association Task Force on Practice, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interve, Society for Vascular Medicine, Society for Vascular Surgery, L. A. Fleisher, et al. 2009 ACCF/AHA Focused Update on Perioperative Beta Blockade Incorporated Into the ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery J. Am. Coll. Cardiol., November 24, 2009; 54(22): e13 - e118. [Full Text] [PDF]
|
|
|
|
|
|
2007 WRITING COMMITTEE MEMBERS, L. A. Fleisher, J. A. Beckman, K. A. Brown, H. Calkins, E. L. Chaikof, K. E. Fleischmann, W. K. Freeman, J. B. Froehlich, E. K. Kasper, et al. 2009 ACCF/AHA Focused Update on Perioperative Beta Blockade Incorporated Into the ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Circulation, November 24, 2009; 120(21): e169 - e276. [Full Text] [PDF]
|
|
|
|
|
|
I. Sheiban, D. Sillano, G. Biondi-Zoccai, A. Chieffo, A. Colombo, S. Vecchio, M. Margheri, J. P. Gunn, T. Raina, F. Liistro, et al. Incidence and management of restenosis after treatment of unprotected left main disease with drug-eluting stents 70 restenotic cases from a cohort of 718 patients: FAILS (Failure in Left Main Study). J. Am. Coll. Cardiol., September 22, 2009; 54(13): 1131 - 1136. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
Y.-H. Kim, D.-W. Park, S.-W. Lee, S.-C. Yun, C. W. Lee, M.-K. Hong, S.-W. Park, K. B. Seung, H.-C. Gwon, M.-H. Jeong, et al. Long-Term Safety and Effectiveness of Unprotected Left Main Coronary Stenting With Drug-Eluting Stents Compared With Bare-Metal Stents Circulation, August 4, 2009; 120(5): 400 - 407. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
B. Vaquerizo, T. Lefevre, O. Darremont, M. Silvestri, Y. Louvard, J. L. Leymarie, P. Garot, H. Routledge, F. de Marco, T. Unterseeh, et al. Unprotected Left Main Stenting in the Real World: Two-Year Outcomes of the French Left Main Taxus Registry Circulation, May 5, 2009; 119(17): 2349 - 2356. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 C. Tamburino, M. E. Di Salvo, D. Capodanno, A. Marzocchi, I. Sheiban, M. Margheri, A. Maresta, F. Barlocco, G. Sangiorgi, G. Piovaccari, et al. Are drug-eluting stents superior to bare-metal stents in patients with unprotected non-bifurcational left main disease? Insights from a multicentre registry Eur. Heart J., May 2, 2009; 30(10): 1171 - 1179. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
P. S. Teirstein Percutaneous Revascularization Is the Preferred Strategy for Patients With Significant Left Main Coronary Stenosis Circulation, February 24, 2009; 119(7): 1021 - 1033. [Full Text] [PDF]
|
|
|
|
 |
|
 S.-J. Park and D.-W. Park Percutaneous Coronary Intervention With Stent Implantation Versus Coronary Artery Bypass Surgery for Treatment of Left Main Coronary Artery Disease: Is It Time to Change Guidelines? Circ Cardiovasc Interv, February 1, 2009; 2(1): 59 - 68. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. J. Shemin Coronary Artery Bypass Grafting Versus Stenting for Unprotected Left Main Coronary Artery Disease: Where Lies the Body of Proof? Circulation, December 2, 2008; 118(23): 2326 - 2329. [Full Text] [PDF]
|
|
|
|
|
|
J. Rodes-Cabau, J. DeBlois, O. F. Bertrand, S. Mohammadi, J. Courtis, E. Larose, F. Dagenais, J.-P. Dery, P. Mathieu, M. Rousseau, et al. Nonrandomized Comparison of Coronary Artery Bypass Surgery and Percutaneous Coronary Intervention for the Treatment of Unprotected Left Main Coronary Artery Disease in Octogenarians Circulation, December 2, 2008; 118(23): 2374 - 2381. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 C. Wu, E. L. Hannan, G. Walford, and D. P. Faxon Utilization and Outcomes of Unprotected Left Main Coronary Artery Stenting and Coronary Artery Bypass Graft Surgery Ann. Thorac. Surg., October 1, 2008; 86(4): 1153 - 1159. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 W. Rademacher, A. Knape, J. Schumm, M. Ferrari, A. Lauten, H. Mudra, and H. R. Figulla Acute and long-term outcome of unprotected left main coronary angioplasty compared to the anticipated surgical risk Interactive CardioVascular and Thoracic Surgery, October 1, 2008; 7(5): 871 - 877. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 A. J. White, G. Kedia, J. M. Mirocha, M. S. Lee, J. S. Forrester, W. C. Morales, S. Dohad, S. Kar, L. S. Czer, G. P. Fontana, et al. Comparison of Coronary Artery Bypass Surgery and Percutaneous Drug-Eluting Stent Implantation for Treatment of Left Main Coronary Artery Stenosis J. Am. Coll. Cardiol. Intv., June 1, 2008; 1(3): 236 - 245. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
D. P. Taggart, S. Kaul, W. E. Boden, T. B. Ferguson Jr, R. A. Guyton, M. J. Mack, P. T. Sergeant, R. J. Shemin, P. K. Smith, and S. Yusuf Revascularization for unprotected left main stem coronary artery stenosis stenting or surgery. J. Am. Coll. Cardiol., March 4, 2008; 51(9): 885 - 892. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
P. E. Buszman, S. R. Kiesz, A. Bochenek, E. Peszek-Przybyla, I. Szkrobka, M. Debinski, B. Bialkowska, D. Dudek, A. Gruszka, A. Zurakowski, et al. Acute and late outcomes of unprotected left main stenting in comparison with surgical revascularization. J. Am. Coll. Cardiol., February 5, 2008; 51(5): 538 - 545. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
P. S. Teirstein Unprotected left main intervention patient selection, operator technique, and clinical outcomes. J. Am. Coll. Cardiol. Intv., February 1, 2008; 1(1): 5 - 13. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
L. A. Fleisher, J. A. Beckman, K. A. Brown, H. Calkins, E. L. Chaikof, K. E. Fleischmann, W. K. Freeman, J. B. Froehlich, E. K. Kasper, J. R. Kersten, et al. ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) Developed in Collaboration With the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery J. Am. Coll. Cardiol., October 23, 2007; 50(17): e159 - e242. [Full Text] [PDF]
|
|
|
|
|
|
L. A. Fleisher, J. A. Beckman, K. A. Brown, H. Calkins, E. L. Chaikof, K. E. Fleischmann, W. K. Freeman, J. B. Froehlich, E. K. Kasper, J. R. Kersten, et al. ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) Circulation, October 23, 2007; 116(17): e418 - e500. [Full Text] [PDF]
|
|
|
|
|
|
D. P. Taggart Coronary Artery Bypass Grafting is Still the Best Treatment for Multivessel and Left Main Disease, But Patients Need to Know Ann. Thorac. Surg., December 1, 2006; 82(6): 1966 - 1975. [Full Text] [PDF]
|
|
|
|
|
|
C. Kimmelstiel Multislice Computed Tomography After Left Main Drug-Eluting Stenting: Are We Putting the CarT Before the Horse? Circulation, August 15, 2006; 114(7): 616 - 619. [Full Text] [PDF]
|
|
|
|
|
|
C. A.G. Van Mieghem, F. Cademartiri, N. R. Mollet, P. Malagutti, M. Valgimigli, W. B. Meijboom, F. Pugliese, E. P. McFadden, J. Ligthart, G. Runza, et al. Multislice Spiral Computed Tomography for the Evaluation of Stent Patency After Left Main Coronary Artery Stenting: A Comparison With Conventional Coronary Angiography and Intravascular Ultrasound Circulation, August 15, 2006; 114(7): 645 - 653. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
D. J. Kereiakes and D. P. Faxon Left Main Coronary Revascularization at the Crossroads Circulation, May 30, 2006; 113(21): 2480 - 2484. [Full Text] [PDF]
|
|
|
|
|
|
A. Chieffo, N. Morici, F. Maisano, E. Bonizzoni, J. Cosgrave, M. Montorfano, F. Airoldi, M. Carlino, I. Michev, G. Melzi, et al. Percutaneous Treatment With Drug-Eluting Stent Implantation Versus Bypass Surgery for Unprotected Left Main Stenosis: A Single-Center Experience Circulation, May 30, 2006; 113(21): 2542 - 2547. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. Valgimigli, P. Malagutti, G. A. Rodriguez-Granillo, H. M. Garcia-Garcia, J. Polad, K. Tsuchida, E. Regar, W. J. Van der Giessen, P. de Jaegere, P. De Feyter, et al. Distal Left Main Coronary Disease Is a Major Predictor of Outcome in Patients Undergoing Percutaneous Intervention in the Drug-Eluting Stent Era: An Integrated Clinical and Angiographic Analysis Based on the Rapamycin-Eluting Stent Evaluated At Rotterdam Cardiology Hospital (RESEARCH) and Taxus-Stent Evaluated At Rotterdam Cardiology Hospital (T-SEARCH) Registries J. Am. Coll. Cardiol., April 18, 2006; 47(8): 1530 - 1537. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. J. Price, E. Cristea, N. Sawhney, J. A. Kao, J. W. Moses, M. B. Leon, R. A. Costa, A. J. Lansky, and P. S. Teirstein Serial Angiographic Follow-Up of Sirolimus-Eluting Stents for Unprotected Left Main Coronary Artery Revascularization J. Am. Coll. Cardiol., February 21, 2006; 47(4): 871 - 877. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
D. S. Baim, L. Mauri, and D. C. Cutlip Drug-Eluting Stenting for Unprotected Left Main Coronary Artery Disease: Are We Ready to Replace Bypass Surgery? J. Am. Coll. Cardiol., February 21, 2006; 47(4): 878 - 881. [Full Text] [PDF]
|
|
|
|
|
|
M. Valgimigli, P. Malagutti, J. Aoki, H. M. Garcia-Garcia, G. A. Rodriguez Granillo, C. A.G. van Mieghem, J. M. Ligthart, A. T.L. Ong, G. Sianos, E. Regar, et al. Sirolimus-Eluting Versus Paclitaxel-Eluting Stent Implantation for the Percutaneous Treatment of Left Main Coronary Artery Disease: A Combined RESEARCH and T-SEARCH Long-Term Analysis J. Am. Coll. Cardiol., February 7, 2006; 47(3): 507 - 514. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S. C. Smith Jr, T. E. Feldman, J. W. Hirshfeld Jr, A. K. Jacobs, M. J. Kern, S. B. King III, D. A. Morrison, W. W. O'Neill, H. V. Schaff, P. L. Whitlow, et al. ACC/AHA/SCAI 2005 Guideline Update for Percutaneous Coronary Intervention--Summary Article: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/SCAI Writing Committee to Update the 2001 Guidelines for Percutaneous Coronary Intervention) J. Am. Coll. Cardiol., January 3, 2006; 47(1): 216 - 235. [Full Text] [PDF]
|
|
|
|
|
|
S. C. Smith Jr, T. E. Feldman, J. W. Hirshfeld Jr, A. K. Jacobs, M. J. Kern, S. B. King III, D. A. Morrison, W. W. O'Neill, H. V. Schaff, P. L. Whitlow, et al. ACC/AHA/SCAI 2005 Guideline Update for Percutaneous Coronary Intervention--Summary Article: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/SCAI Writing Committee to Update the 2001 Guidelines for Percutaneous Coronary Intervention) Circulation, January 3, 2006; 113(1): 156 - 175. [Full Text] [PDF]
|
|
|
|
|
|
S.-J. Park Inflammatory Biomarkers for Prediction of Outcomes After Unprotected Left Main Coronary Intervention Circulation, October 11, 2005; 112(15): 2226 - 2227. [Full Text] [PDF]
|
|
|
|
|
|
T. Palmerini, A. Marzocchi, C. Marrozzini, P. Ortolani, F. Saia, L. Bacchi-Reggiani, S. Virzi, S. Gianstefani, and A. Branzi Preprocedural Levels of C-Reactive Protein and Leukocyte Counts Predict 9-Month Mortality After Coronary Angioplasty for the Treatment of Unprotected Left Main Coronary Artery Stenosis Circulation, October 11, 2005; 112(15): 2332 - 2338. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 N Curzen Percutaneous coronary intervention in unprotected left main stem disease: the state of play Heart, June 1, 2005; 91(suppl_3): iii39 - iii41. [Full Text] [PDF]
|
|
|
|
|
|
M. Valgimigli, C. A.G. van Mieghem, A. T.L. Ong, J. Aoki, G. A. R. Granillo, E. P. McFadden, A. P. Kappetein, P. J. de Feyter, P. C. Smits, E. Regar, et al. 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) Circulation, March 22, 2005; 111(11): 1383 - 1389. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. Chieffo, G. Stankovic, E. Bonizzoni, E. Tsagalou, I. Iakovou, M. Montorfano, F. Airoldi, I. Michev, M. G. Sangiorgi, M. Carlino, et al. Early and Mid-Term Results of Drug-Eluting Stent Implantation in Unprotected Left Main Circulation, February 15, 2005; 111(6): 791 - 795. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S.-J. Park, Y.-H. Kim, B.-K. Lee, S.-W. Lee, C. W. Lee, M.-K. Hong, J.-J. Kim, G. S. Mintz, and S.-W. Park Sirolimus-eluting stent implantation for unprotected left main coronary artery stenosis: Comparison with bare metal stent implantation J. Am. Coll. Cardiol., February 1, 2005; 45(3): 351 - 356. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J. P. Carrozza Jr and F. W. Sellke A 69-Year-Old Woman With Left Main Coronary Artery Disease JAMA, November 24, 2004; 292(20): 2506 - 2514. [Full Text] [PDF]
|
|
|
|
 |
|
 H. Griffiths, A. Bakhai, D. West, M. Petrou, T. De Souza, N. Moat, J. Pepper, and C. Di Mario Feasibility and cost of treatment with drug eluting stents of surgical candidates with multi-vessel coronary disease Eur. J. Cardiothorac. Surg., September 1, 2004; 26(3): 528 - 534. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. P. Kelley, B. D. Klugherz, S. M. Hashemi, N. F. Meneveau, J. M. Johnston, W. H. Matthai Jr, V. S. Banka, H. C. Herrmann, J. W. Hirshfeld Jr, S. E. Kimmel, et al. One-year clinical outcomes of protected and unprotected left main coronary artery stenting Eur. Heart J., September 1, 2003; 24(17): 1554 - 1559. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
K. Empen, T. Bollmann, J. B. Dahm, T. Takagi, G. Stankovic, L. Finci, K. Toutouzas, N. Corvaja, R. Albiero, G. Sivieri, et al. Beneficial Outcome After Angioplasty of Unprotected Left Main Stenosis in Patients During Resuscitation * Response Circulation, April 8, 2003; 107 (13): e91 - e91. [Full Text] [PDF]
|
|
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||