AN INTERNATIONAL COLLABORATIVE META-ANALYSIS ON 1,274 PATIENTS UNDERGOING PERCUTANEOUS DRUG-ELUTING STENTING FOR UNPROTECTED LEFT MAIN CORONARY ARTERY DISEASE G. BIONDI-ZOCCAI1, C. MORETTI1, E. MELIGA1, P. AGOSTONI2, M. VALGIMIGLI3, A. ABBATE4, G. SANGIORGI5, G. TREVI1 AND I. SHEIBAN1 1University of Turin, Turin, Italy (gbiondizoccai@gmail.com); 2AZ Middelheim, Antwerp, Belgium; 3University of Ferrara, Ferrara, Italy; 4Virginia Commonwealth University, Virginia, USA; 5Emo Centro Cuore Columbus, Milano,Italy

BACKGROUND Cardiac surgery is the gold standard revascularization means for unprotected left main disease (ULM) Percutaneous drug-eluting stent (DES) implantation has been recently reported in patients with ULM, but with unclear results. We thus sought to systematically review the outcomes of DES implantation in patients with ULM coronary disease

OBJECTIVES To perform a systematic review of the outcomes of DES implantation in patients with ULM coronary disease To pool major outcomes with meta-analytic techniques

METHODS Several databases (BioMedCentral, clinicaltrials.gov, Google Scholar, and PubMed) were systematically searched for pertinent clinical studies published up to November 2006 Major selection criteria were: enrolment of at least 20 patients follow-up for at least 6 months full text publication (thus excluding abstracts)

METHODS Pre-specified subgroup analyses were performed according to ostial ULM, and non-high-risk features (defined by means of Parsonnet or EuroSCORE systems) Generic-inverse-variance random-effect methods were used to pool incidence rates and adjusted risk estimates (odds ratios [OR], with 95% confidence intervals) of death, myocardial infarction (MI), target vessel revascularization (TVR), or their composite, ie major adverse cardiovascular events (MACE)

REVIEW PROFILE

RESULTS After excluding 806 non-pertinent citations, we finally included 16 original studies (1274 patients, median follow-up 9 months [range 6-24]) There were 8 uncontrolled reports on DES, 5 non-randomized comparison between DES and bare-metal stents (BMS), and 3 between DES and CABG, with a median follow-up of 10 months

INCLUDED STUDIES

PATIENT AND PROCEDURAL CHARACTERISTICS

DESIGN AND QUALITY

RISK OF IN-HOSPITAL DEATH

RISK OF IN-HOSPITAL MI

RISK OF MACE AT FOLLOW-UP

RISK OF DEATH AT FOLLOW-UP

RISK OF TVR AT FOLLOW-UP

NON-RANDOMIZED COMPARISONS Multivariable adjusted estimates for the DES vs BMS comparison were reported only by a handful of studies, for a total of 206 patients treated with DES vs 190 with bare-metal stents (BMS). Pooled analysis showed the superiority of DES both in terms of follow-up MACE and TVR (respectively OR=0.34 [0.16-0.71], p=0.004, and OR=0.34 [0.12-0.94], p=0.04) Adjusted estimates for the DES-based PCI vs CABG were reported only by Chieffo et al and Lee et al for a total of 157 patients treated with DES and 265 with CABG. Meta-analysis for the occurrence of MACCE (ie MACE plus stroke) at follow-up, suggested the superiority of DES vs CABG (OR=0.46 [0.24-0.90], p=0.02), even if this estimate should be viewed with caution

CONCLUSIONS The largest cohort reported to date of patients with ULM treated with DES provides encouraging mid-term follow-up data, at least in selected patients Whether long-term outlook is also favourable needs to be established by longer clinical follow-up of currently available registries and ongoing randomized trials of DES vs CABG

For further slides on these topics please feel free to visit the metcardio.org website: http://www.metcardio.org/slides.html