J Am Coll Cardiol 2008;51:538–45 Acute and Late Outcomes of Unprotected Left Main Stenting in Comparison With Surgical Revascularization Pawel E. Buszman, Stefan R. Kiesz, Andrzej Bochenek, Ewa Peszek-Przybyla, Iwona Szkrobka, Marcin Debinski, Bozena Bialkowska, Dariusz Dudek, Agata Gruszka, Aleksander Zurakowski, Krzysztof Milewski, Miroslaw Wilczynski, Lukasz Rzeszutko, Piotr Buszman, Jan Szymszal, Jack L. Martin, Michal Tendera Oxford, United Kingdom; Los Angeles, California; Buffalo, New York Greenville and Durham, North Carolina; Atlanta, Georgia; Dallas, Texas Leuven, Belgium; and Hamilton, Ontario, Canada

Introduction Drug-eluting stents do not improve survival reduce myocardial infarction lack of cost-effectiveness increased risk of stent thrombosis ACC/AHA guidelines for LMS stenosis PCI is a class III indication (i.e., that the procedure is generally not effective and may even be harmful) in those who are otherwise eligible for CABG European Society of Cardiology stenting for unprotected left main disease should only be considered in the absence of other revascularization options In comparison with BMS

Introduction in a 2004 survey of interventions for LMS stenosis 29% of European and 18% of U.S. patients The advent of coronary stents lowered the incidence of abrupt vessel closure DES decreased the risk of ULMCA in-stent restenosis compare acute and late clinical end points, functional status, and LV function at 1 year following stent-supported PCI or CABG for ULMCA disease in a prospective randomized trial

Figure 1 Experimental Design of the Study

Materials and Methods Exclusion criteria acute myocardial infarction total occlusion of left main comorbid conditions coronary anatomic considerations that increased the surgical risk to a Euroscore of 8 or more stroke or transient ischemic attack within 3 months Renal dysfunction contraindication to antiplatelet therapy LV function evaluation Before and 12 months after the index procedure Treadmill stress tests; 1, 3, 6, 12 months after procedure

Materials and Methods Percutaneous revascularization “culotte” technique with kissing balloon angioplasty ( no crush stent technique) 3.8 mm BMS glycoprotein IIb/IIIa blockers Surgical revascularization All but 1 operation; standard cardiopulmonary bypass One patient underwent off-pump CABG Left internal mammary artery grafts; 72% radial artery grafts; 9% Primary end point The change in LVEF assessed by 2D echocardiography 12 months after the index intervention Secondary end points 30-day and 1-year MAE and MACCE

Table 1 Baseline Characteristics of the Study Groups

Table 2 Detailed List of MAE in CABG and PCI Group During the First Year After the Procedure

Figure 2 LVEF in PCI and CABG Groups at Baseline and After 12 Months

Figure 3 CCS Functional Class at Baseline and Follow-Up

Figure 4 Results of Treadmill Stress Tests After PCI and CABG

Figure 5 Survival After PCI and CABG

Figure 6 MACCE-Free Survival After PCI and CABG

Discussion 3 important anatomical features of LM Left main stem stenosis occurs as an isolated lesion in only 6% to 9% of patients, whereas over 70% to 80% of patients also have multivessel CAD thereby potentially enabling more complete coronary revascularization with CABG than with stenting Most LMS stenoses (40% to 94%) occur in the distal segment of the artery and extend into the proximal coronary arteries; such bifurcated or trifurcated lesions have a high risk of restenosis while acute occlusion at this site can have catastrophic consequences Morphologically, around one-half of LMS lesions have significant calcification

Current Results of CABG for LMS Stenosis

Eight Studies of PCI Using BMS in LMS

DES in LMS

Conclusions stent-supported PCI have favorable early outcomes in comparison with CABG At 1 year, LVEF improved only in the PCI group Freedom from MACCE was comparable after more than 2 years of follow-up, and there was a trend for better survival in the PCI group.