| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
|
Interact CardioVasc Thorac Surg 2008;7:306-314. doi:10.1510/icvts.2007.169938 © 2008 European Association of Cardio-Thoracic Surgery
For which patients with left main stem disease is percutaneous intervention rather than coronary artery bypass grafting the better option?
a Department of Cardiac Surgery, Policlinico Hospital, University of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy Received 12 October 2007; received in revised form 21 December 2007; accepted 23 December 2007
*Corresponding author. Tel.: +39-080-5592392; fax: +39-080-5595087.
A best evidence topic in cardiac surgery was written according to a structured protocol. The topic addressed was to identify the patients with left main stem disease for which percutaneous intervention would be a better option than coronary artery bypass grafting. Altogether 665 papers were found using the reported search, of which 15 presented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers were tabulated. We conclude that if a bare metal stent is used for left main stenting the mortality at one year may be from 3% to over 28% in reported series. The restenosis rate of the bare metal stent in the left main position is around 20% at one year. There are some early series and randomized studies of drug eluting stents for left main stem lesions and the restenosis rate is reported to be around 10%. The European Society of Cardiology in their 2005 percutaneous intervention guidelines state that coronary bypass grafting is the procedure of choice for left main stem disease and only patients with a prohibitively high surgical risk should be considered. We consider that with such high restenosis rates, and with short-term follow-up in such low numbers and short periods compared to coronary artery bypass grafting, left main stenting should only be used as a last resort in patients turned down for coronary artery bypass grafting after full assessment by a cardiac surgeon due to prohibitive co-morbidities.
Key Words: Evidence-based medicine; Left main coronary disease; Coronary artery bypass; Percutaneous coronary intervention; Coronary stent
A best evidence topic was constructed according to a structured protocol. This protocol is fully described in the ICVTS [1].
You are asked by the interventional cardiologist on-call to discuss a 73-year-old gentleman still on the table in the angiography lab. He was admitted with a non-ST myocardial infarction with a small troponin rise, has had clopidogrel, aspirin and reopro and is currently stable. The coronary angiogram shows a tight proximal left main stem lesion of about 70%. The patient is mildly obese and diabetic with some varicosities of the left leg and has prostate carcinoma, which is currently well controlled. The cardiologist would like to stent this lesion if you thought that he was not a good surgical candidate and asks for your opinion.
In a [patient with left main stem coronary disease] does [percutaneous stenting or CABG] result in the best [long-term survival].
Medline 1995 to Aug 2007 using Ovid Interface. [LMS.mp or left main.mp] AND [exp Angioplasty/OR angioplasty.mp]
Using the reported search, 665 papers were identified from which 15 papers provided the best evidence to answer the question. These are summarized in Table 1.
In 2005 the ACC/AHA Task Force on Practice Guidelines updated their guidelines for percutaneous intervention [2]. They provided extensive guidance for patients with left main stem disease. They reiterate that CABG remains the gold standard for the treatment of the unprotected left main coronary artery. PCI should only be considered for patients with or without angina if the patient is a candidate for revascularization but who is not eligible for CABG. They further state that patients with unstable angina or NSTEMI with cardiogenic shock and left main stem disease should still undergo CABG. The European Society of Cardiology Task Force for percutaneous interventions also published practice guidelines in 2005 [3]. They recommended that patients with left main stem disease or diabetics with multivessel disease undergo CABG rather than PCI. They additionally state that PCI could be contemplated in patients with a prohibitively high risk and cited a EuroSCORE risk of over 10% as a guide figure. Of note, in the UK we now perform at around half the EuroSCORE and thus a risk of 10% for CABG would equate to a EuroSCORE of approaching 20. The most recent study is by Erglis et al. [4] published in August 2007. They performed an RCT of Paclitaxel-eluting stent vs. bare-metal stent in 103 patients who were also good candidates for CABG with mean EF 54%. There were no immediate procedural complications. The 6-month mortality was 2% in both groups. MI rate at 6 months was 14% for BMS and 9% for PES. MACE at 6 months was 30% for BMS and 13% for PES. Ellis et al. [5] reported the results of 107 patients not eligible for CABG who had LMS disease prior to 1997. Survival was 70% at 12 months and of those who survived to 4 months for an angiogram, 20% had restenosis >50%. Fifty per cent of these patients had BMS, with the remainder having angioplasty or atherectomy. Palmerini et al. [6] reported a contemporary cohort study of patients with LMS disease. One hundred and fifty-four patients underwent CABG and 157 patients PCI. On mean follow-up of just over a year, 25% of patients undergoing PCI required target vessel revascularization compared to 2.6% in the CABG group (P=0.0001), and 8.3% had an MI compared to 4.5% (P=0.17). One-year PCI mortality was 13%. Chieffo et al. [7] reported a similar cohort of LMS patients. One hundred and forty-two patients were treated with CABG and 107 a DES during PCI. Of note the PCI patients were younger, had less diabetes, hypertension and smoking than CABG patients. Also the perioperative-MI rate of the CABG patients was reported as 26% at 30 days which seems extraordinary. At one year there was a 20% revascularization rate with PCI vs. 3.6% for CABG. There was no mortality or MI difference at one year. Mortality in the PCI group was 2.8% at 1 year in this group of patients with a mean EuroSCORE of 4.4. Lee et al. [8] published results of patients with LMS disease followed up for 6 months. The only significant differences between the 123 patients CABG group and the 50 patients DES-PCI group was for target vessel revascularization (CABG 3.6%; DES 19.6%; P=0.0001). Mortality and MI rates were similar. Mortality from PCI was 4% at six months in this group with mean Parsonnet score of 18. Tan et al. [9] reported their results of BMS-PCI in 279 patients deemed too high risk for CABG from 25 centres. The 1-year mortality/MI/CABG rate in the PCI group was 24% and death was 12%. Their risk scores were not given but 20% were in cardiogenic shock at PCI and 50% had an IABP. Kelley et al. [10] evaluated clinical outcomes of protected and unprotected left main coronary bare-metal stenting in patients unsuitable for CABG. At 1 year 43 ULMS stents had a 28% mortality and 48% MACE. Valgimigli et al. [11, 12] assessed clinical outcomes of left main stem stenting with 86 DES and 95 BMS patients over a mean of nearly two years. There were significant higher rates of myocardial infarction (DES 4%; BMS 12%; P=0.006) and target vessel revascularization (DES 6%; BMS 23%, P=0.004) for BMS. Mortality at a mean two years was DES 14% and BMS 16%. Mean Parsonnet in the DES group was 19. Agostoni et al. [13] achieved a 2-year mortality of only 5% in 58 patients undergoing PCI for LMS disease. Price et al. [17] reported the angiographic findings of LMS stenting with a serolimus stent in 50 patients. At nine months, 38% required revascularization and there was a 44% MACE. LMS stenting is also not being commonly performed. In a registry of current practice of 7752 patients undergoing PCI treated in 140 centres over 6 months in 2005, 90% received drug-eluting stents but only 110 patients had LMS stenting (2%) [18]. The results of surgery of left main stenosis were reviewed by Jonsson et al. [19]. They compared 1888 patients who underwent CABG for left-main stenosis with 8759 patients who had CABG for coronary disease without left-main disease. During 1970–1984 early mortality was 5.8% in patients with left-main stenosis vs. 1.5% in patients without left-main stenosis. The corresponding rates during 1995–1999 were 2.0% vs. 2.2%. Five-year survival in males with left-main stenosis was 88% after operations performed during 1994–1999. The continuous decline of mortality during three decades most likely reflects improvement of the peri- and postoperative management of patients undergoing CABG during this period.
If a bare-metal stent is used for left main stenting the mortality at 1 year may be from 3% to over 28% in reported series. The restenosis rate of the bare-metal stent in the left main position is around 20% at one year. There are some early series and RCTs of drug eluting stents for LMS lesions and the restenosis rate is reported to be around 10%. The European Society of Cardiology in their 2005 PCI guidelines state that CABG is the procedure of choice for left main stem disease and only patients with a prohibitively high surgical risk should be considered. We consider that with such prohibitively high restenosis rates, and with short-term follow-up in such low numbers and short periods compared to coronary artery bypass grafting, left main stenting should only be used as a last resort in patients turned down for coronary artery bypass grafting after full assessment by a cardiac surgeon due to prohibitive co-morbidities.
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| ANN THORAC SURG | ASIAN CARDIOVASC THORAC ANN | EUR J CARDIOTHORAC SURG |
| J THORAC CARDIOVASC SURG | ICVTS | ALL CTSNet JOURNALS |
Top
Abstract
1. Introduction