Safety and Efficacy of Unprotected Left Main Coronary Artery Stenting
To the Editor:
We read with interest the report by Tan et al1 of long-term clinical outcomes after unprotected left main coronary artery (LMCA) revascularization in a series of 279 patients from 25 contributing centers in the ULTIMA Registry. Forty-six percent of these patients were deemed high surgical risk.
The Veterans Administration Cooperative Study confirmed the benefit of coronary artery bypass graft (CABG) surgery for the treatment of LMCA disease compared with medical therapy.2 Since then, there have been an increasing number of reports of the potentially useful role of percutaneous coronary intervention (PCI) as an alternative to surgery when the latter option is deemed neither safe nor feasible.3,4⇓
We have had experience of 46 patients (mean age 73±11.7 years), the majority of whom were considered to be high risk surgical candidates and have consequently undergone unprotected LMCA stenting.5 Twenty-one (45.7%) of our patients had unstable or post-myocardial infarct angina and 6 (13%) patients had poor left ventricular (LV) function (ejection fraction (EF) <30%) and required periprocedural intraaortic balloon pump support. Abciximab was administered in 22 (47.8%) patients. Primary procedural success was achieved in 44 (95.7%) patients. Our in-hospital major adverse event (MACE) rate was 6.5%, with no in-hospital deaths, 2 (4.3%) patients undergoing emergency CABG surgery, and 1 (2.2%) patient undergoing repeat PCI after acute stent thrombosis.
Our overall MACE rate at a mean follow-up period of 32±12.5 weeks (range 10 to 63 weeks) was 30.4%: 7 (15.2%) patients died (one-year mortality), all of whom were considered high surgical risk cases, 2 (4.3%) patients underwent repeat PCI, and 5 (10.9%) patients had CABG surgery. All deaths occurred in patients >72 years of age (mean age 82 years; range, 72 to 92 years), 3 (43%) patients had LVEF <30%, 3 (43%) patients had LVEF <45%, and 1 patient had LVEF >50% but was 83 years old with severe obstructive airways disease.
We agree with the conclusions of the ULTIMA Investigators that unprotected LMCA stenting, with the continued technical improvements and developments in interventional devices available to us, provides a feasible and effective alternative to CABG surgery in high volume institutions and in surgically high risk patients. The question remains whether PCI should be offered as an alternative treatment option for those patients who would otherwise be ideal surgical candidates, and this can only be answered by a randomized, controlled trial.
- ↵Tan WA, Tamai H, Park S-J, et al, for the ULTIMA Investigators. Long-term clinical outcome after unprotected left main trunk percutaneous revascularization in 279 patients. Circulation. 2001; 104: 1609–1614.
- ↵Takaro T, Peduzzi P, Detre KM, et al. Survival in subgroups of patients with left main coronary artery disease: Veterans Administration Cooperative Study of Surgery for Coronary Arterial Occlusive Disease. Circulation. 1982; 66: 14–22.
- ↵Nageh T, McClean DR, Gunning MG, et al. Unprotected left main coronary artery stenting: a single centre experience. Eur Heart J. 2001; 22: 661.Abstract.