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The approach to left main coronary artery disease (CAD) in diabetic patients has been extensively debated. Diabetic patients have an elevated risk of left main disease in addition to multivessel disease. Previous trials have shown increased revascularization rates in percutaneous coronary intervention compared with coronary artery bypass grafting (CABG) but overall comparable outcomes, although many of these studies were not using the latest stent technology or CABG with arterial revascularization. Our aim is to review the most recent trials that have recently published long-term follow-up, as well as other literature pertaining to left main disease in diabetic patients. Furthermore, we will be discussing some future treatment strategies that could likely create a paradigm shift in how left main CAD is managed.

It is of critical importance to correctly assess the significance of a left main lesion. Underestimation of significance beholds the risk of inappropriate deferral of revascularization, whereas overestimation may trigger major but unnecessary interventions. This article addresses the invasive physiological assessment of left main disease and its role in deciding upon revascularization. It mainly focuses on the available evidence for fractional flow reserve and instantaneous wave-free ratio, their interpretation, and limitations. We also discuss alternative invasive physiological indices and imaging, as well as the link between physiology, ischemia, and prognosis.

Although coronary artery bypass graft (CABG) surgery traditionally has been considered the gold standard for left main revascularization, percutaneous coronary intervention has evolved in the past decades so that it now represents a valid alternative to CABG in a large proportion of cases. The landmark Evaluation of XIENCE versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization (EXCEL) trial is the largest contemporary randomized comparison assessing the impact of revascularization strategies for left main disease. This review discusses the background, rationale, design, results, and implications of the EXCEL trial.

Objectives: We aimed to evaluate the feasibility of using three dimensional-quantitative coronary angiography (3D-QCA) based fractional flow reserve (FFR) (vessel fractional flow reserve [vFFR], CAAS8.1, Pie Medical Imaging) and to correlate vFFR values with intravascular ultrasound (IVUS) for the evaluation of intermediate left main coronary artery (LMCA) stenosis. Background: 3D-QCA derived FFR indices have been recently developed for less invasive functional lesion assessment. However, LMCA lesions were vastly under-represented in first validation studies. Methods: This observational single-center cohort study enrolled consecutive patients with stable angina, unstable angina, or non-ST-segment elevation myocardial infarction and nonostial, intermediate grade LMCA stenoses who underwent IVUS evaluation. vFFR was computed based on two angiograms with optimal LMCA stenosis projection and correlated with IVUS-derived minimal lumen area (MLA). Results: A total of 256 patients with intermediate grade LMCA stenosis evaluated with IVUS were screened for eligibility; 147 patients met the clinical inclusion criteria and had a complete IVUS LMCA footage available, of them, 63 patients (63 lesions) underwent 3D-QCA and vFFR analyses. The main reason for screening failure was insufficient quality of the angiogram (51 patients,60.7%). Mean age was 65 ± 11 years, 75% were male. Overall, mean MLA within LMCA was 8.77 ± 3.17 mm2, while mean vFFR was 0.87 ± 0.09. A correlation was observed between vFFR and LMCA MLA (r =.792, p =.001). The diagnostic accuracy of vFFR ≤0.8 in identifying lesions with MLA < 6.0 mm2 (sensitivity 98%, specificity 71.4%, area under the curve (AUC) 0.95, 95% confidence interval (CI) 0.89–1.00, p =.001) was good. Conclusions: In patients with good quality angiographic visualization of LMCA and available complete LMCA IVUS footage, 3D-QCA based vFFR assessment of LMCA disease correlates well to LMCA MLA as assessed by IVUS.

Background Optimal strategy for treating bifurcation lesions or lesions with large thrombus in left main disease remains elusive. Excimer laser coronary angioplasty (ELCA) is a therapeutic option for thrombotic lesions in acute coronary syndrome. Case summary A 68-year-old man with chest pain was transferred to our emergency department, and subsequently diagnosed as inferior ST-segment elevation myocardial infarction (STEMI). Emergent coronary angiography revealed a 75% stenosis in the left main trunk (LMT). Optical coherence tomography (OCT) showed massive thrombus at the distal LMT to the ostial left anterior descending artery (LAD) and left circumflex artery (LCx). ELCA was performed in the three directions from LMT to proximal LAD, proximal LCx, and obtuse marginal branch. OCT after ELCA showed reduction of thrombus and no apparent plaque rupture or calcification, implying that coronary thrombosis was caused by OCT-defined plaque erosion. Intracoronary electrocardiogram of the LCx showed ST-segment elevation which corresponded to inferior ST-segment elevation, whereas no intracoronary electrocardiogram ST-segment elevation was detected for LAD. Taking all of the data including angiographic appearance, OCT-derived residual lumen size and residual thrombus volume, and strategic options into consideration, we completed percutaneous coronary intervention without stent deployment. He has been free from any cardiac events thereafter for 8 months. Discussion Optimal strategy of coronary intervention for bifurcation lesions, especially LMT bifurcations, remains elusive. ELCA may have a potential to safely reduce intracoronary thrombus in patients presenting with acute coronary syndrome with OCT guidance.

Background New‐generation drug‐eluting stents (DES) reduce target‐vessel revascularization compared with bare‐metal stents (BMS), and recent data suggest that DES have the potential to decrease the risk of myocardial infarction and cardiovascular mortality. We evaluated the treatment effect of DES versus BMS according to the target artery (left anterior descending [LAD] and/or left main [LM] versus other territories [no‐LAD/LM]). Methods and Results The Coronary Stent Trialist (CST) Collaboration gathered individual patient data of randomized trials of DES versus BMS for the treatment of coronary artery disease. The primary outcome was the composite of cardiac death or myocardial infarction. Hazard ratios (HRs) with 95% CIs were derived from a 1‐stage individual patient data meta‐analysis. We included 26 024 patients across 19 trials: 13 650 (52.4%) in the LAD/LM and 12 373 (47.6%) in the no‐LAD/LM group. At 6‐year follow‐up, there was strong evidence that the treatment effect of DES versus BMS depended on the target vessel ( P ‐interaction=0.024). Compared with BMS, DES reduced the risk of cardiac death or myocardial infarction to a greater extent in the LAD/LM (HR, 0.76; 95% CI, 0.68–0.85) than in the no‐LAD/LM territories (HR, 0.93; 95% CI, 0.83–1.05). This benefit was driven by a lower risk of cardiac death (HR, 0.83; 95% CI, 0.70–0.98) and myocardial infarction (HR, 0.74; 95% CI, 0.65–0.85) in patients with LAD/LM disease randomized to DES. An interaction ( P =0.004) was also found for all‐cause mortality with patients with LAD/LM disease deriving benefit from DES (HR, 0.86; 95% CI, 0.76–0.97). Conclusions As compared with BMS, new‐generation DES were associated with sustained reduction in the composite of cardiac death or myocardial infarction if used for the treatment of LAD or left main coronary stenoses. Registration URL: https://www.crd.york.ac.uk/PROSPERO ; Unique identifier: CRD42017060520.

Revascularization of both left main and bifurcation lesions is currently considered an important feature of complex percutaneous coronary intervention (PCI), whereas stenting distal left main bifurcation is fairly challenging. Recent evidence shows that such lesions are associated with an increased risk of ischemic events. There is no universal consensus on the optimal PCI strategy or the appropriate type and duration of antithrombotic therapy to mitigate the thrombotic risk. Prolonged dual antiplatelet therapy or use of more potent P2Y12 inhibitors have been investigated in the context of this high-risk subset of the population undergoing PCI. Thus, while complex PCI is a growing field in interventional cardiology, left main and bifurcation PCI constitutes a fair amount of the total complex procedures performed recently, and there is cumulative interest regarding antithrombotic therapy type and duration in this subset of patients, with decision-making mostly based on clinical presentation, baseline bleeding, and ischemic risk, as well as the performed stenting strategy.

Guideline‐based medical therapy is the foundation of treatment for individuals with coronary artery disease. However, revascularization with either percutaneous coronary intervention or coronary artery bypass grafting may be beneficial in patients with acute coronary syndromes, refractory symptoms, or in other specific scenarios (eg, left main disease and heart failure). While the goal of percutaneous coronary intervention and coronary artery bypass grafting is to achieve complete revascularization, anatomical and ischemic definitions of complete revascularization and their methodology for assessment remain highly variable. Such lack of consensus invariably contributes to the absence of standardized approaches for invasive treatment of coronary artery disease. Herein, we propose a novel, comprehensive, yet pragmatic algorithm with both anatomical and ischemic parameters that aims to provide a systematic method to assess complete revascularization after percutaneous coronary intervention or coronary artery bypass grafting in both clinical practice and clinical trials.

Background There are limited data on the impact of the COVID‐19 pandemic on left main (LM) coronary revascularisation activity, choice of revascularisation strategy, and post‐procedural outcomes. Methods All patients with LM disease (≥50% stenosis) undergoing coronary revascularisation in England between January 1, 2017 and August 19, 2020 were included (n = 22,235), stratified by time‐period (pre‐COVID: 01/01/2017–29/2/2020; COVID: 1/3/2020–19/8/2020) and revascularisation strategy (percutaneous coronary intervention (PCI) vs. coronary artery bypass grafting (CABG). Logistic regression models were performed to examine odds ratio (OR) of 1) receipt of CABG (vs. PCI) and 2) in‐hospital and 30‐day postprocedural mortality, in the COVID‐19 period (vs. pre‐COVID). Results There was a decline of 1,354 LM revascularisation procedures between March 1, 2020 and July 31, 2020 compared with previous years' (2017–2019) averages (−48.8%). An increased utilization of PCI over CABG was observed in the COVID period (receipt of CABG vs. PCI: OR 0.46 [0.39, 0.53] compared with 2017), consistent across all age groups. No difference in adjusted in‐hospital or 30‐day mortality was observed between pre‐COVID and COVID periods for both PCI (odds ratio (OR): 0.72 [0.51. 1.02] and 0.83 [0.62, 1.11], respectively) and CABG (OR 0.98 [0.45, 2.14] and 1.51 [0.77, 2.98], respectively) groups. Conclusion LM revascularisation activity has significantly declined during the COVID period, with a shift towards PCI as the preferred strategy. Postprocedural mortality within each revascularisation group was similar in the pre‐COVID and COVID periods, reflecting maintenance in quality of outcomes during the pandemic. Future measures are required to safely restore LM revascularisation activity to pre‐COVID levels.

Introduction: The optimal revascularization strategy for left main disease in very elderly patients is unclear given under-representation in randomized trials. Therefore, we sought to compare percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG) for left main disease in very elderly patients presenting with acute myocardial infarction (AMI). Methods: Retrospective study of patients aged ≥ 80 years undergoing invasive coronary angiography (ICA) for AMI at Kaiser Permanente Los Angeles Medical Center between June 2009 and February 2019. Patients were grouped by treatment decision: PCI, CABG, or medical therapy. Inverse Probability Treatment of Weighting (IPTW) was used to balance baseline characteristics. All-cause mortality and non-fatal myocardial infarction (MI) was evaluated. Results: A total of 172 patients (average age 84.4 ± 3.6 years, 37% female) were analyzed. Of these 54 (31.4%) underwent PCI, 67 (39%) underwent CABG, and 51 (29.7%) were treated with medical therapy. Compared to CABG, the PCI group was significantly older, with more history of CAD, COPD, previous CABG, and previous PCI. Median follow-up was 22.4 months (interquartile range 5.1-46.8 months). After IPTW adjustment, there were no differences in mortality between PCI vs CABG (Hazard Ratio [HR] 1.40, 95% Confidence Interval [CI] 0.97-2.01), but an increase in non-fatal MI with PCI (HR 2.6, 95% CI 1.02-6.69). Both PCI and CABG reduced mortality (PCI: HR 0.46, 95% CI 0.32-0.66; CABG: HR 0.71, 95% CI 0.52-0.96) and non-fatal MI (PCI: HR 0.22, 95% CI 0.11-0.41; CABG: HR 0.09, 95% CI 0.4-0.23) compared to medical therapy. Conclusion: In very elderly patients with left main disease presenting with AMI, there was no difference in mortality between PCI and CABG, but an increased risk for non-fatal MI with PCI. However, both PCI and CABG were superior to medical therapy. Either revascularization strategy may be reasonable in this population.

Background: The optimum revascularization modality in multi-vessel and left main disease patients presenting with non-ST elevation acute coronary syndrome (non-STE-ACS) is not well studied. The current recommendations are based on studies that primarily included patients with stable angina. Patients with non-STE-ACS were under-represented in clinical trials. We performed a meta-analysis of studies comparing coronary artery bypass grafting (CABG) vs. percutaneous coronary intervention (PCI) in non-STE-ACS, and reporting 30 days major adverse cardiac events (MACE). Methods: We searched Medline, EmCare, CINAHL, Cochrane database, and Google Scholar for relevant articles. We excluded studies that included patients with stable coronary artery disease and ST elevation myocardial infarction. Our primary outcome was 30 days MACE defined as all-cause death, stroke, repeat revascularization and re-infarction. We used the Paule-Mandel method with the Hartung-Knapp-Sidik-Jonkman adjustment to estimate risk ratio (RR) with a 95% confidence interval (CI). Heterogeneity was assessed using Higgin’s I 2 statistics. To account for heterogeneity, a meta-regression analysis was performed. Results: Five observational studies met our inclusion criteria summing to a total number of 7161 patients. At 30 days, there was no difference between CABG vs. PCI in terms of MACE, RR: 0.96, 95% CI 0.38 to 2.39, I 2 = 81% (Panel A). A meta-regression analysis reported that a history of PCI was associated with a lower risk of MACE with CABG compared to PCI (Panel B). Conclusion: At 30 days, there was no difference in MACE between the CABG and PCI groups. However, a history of PCI was associated with a lower risk of MACE in patients who underwent CABG.

Background Women have worse outcomes than men after PCI, with some studies suggesting a lower mortality of CABG vs PCI in females. Purpose To assess the outcomes of CABG and PCI according to sex in a large registry population of patients with unprotected left main coronary artery (ULMCA) disease. Methods The DELTA and DELTA 2 registries are two multicentric, prospective registries evaluating the outcomes of subjects undergoing coronary revascularization for ULMCA disease. Results Total population was 6253 patients, 27% women. Table 1 shows baseline clinical characteristics. Median follow up was of 880 days. Women undergoing CABG had lower incidence of death, myocardial infarction (MI) or cerebrovascular accidentc (CVA) (HR 0.53, 95% CI 0.35–0.79) and a lower risk of death (HR 0.40, 95% CI 0.24–0.67). No significant differences were observed in men (Figure 1A). SIgnificant interaction was observed between sex and revascularization strategy for both outcomes (p Conclusions In women undergoing coronary revascularization for ULMCA disease, CABG is associated to lower risk of death, MI or CVA. Further dedicated studies are needed to determine the optimal revascularization strategy in women with ULMCA disease. Figure 1 Funding Acknowledgement Type of funding source: None

Background Limited data exist on the optimal revascularization strategy for patients with left main coronary artery disease (LMCAD) and chronic kidney disease (CKD). We conducted a meta-analysis to compare the outcomes of coronary artery bypass grafting (CABG) versus percutaneous coronary intervention (PCI) in this population. Methods Multiple electronic databases were queried for studies comparing CABG and PCI in CKD patients undergoing LMCAD (>50% diameter stenosis) revascularization. CKD was defined as estimated glomerular filtration rate of Results Six studies (4 observational, 2 randomized controlled trials) met inclusion criteria with a total of 2051 patients (CABG: 977, PCI: 1074). Patients undergoing CABG had a higher incidence of multi-vessel disease (74.7% vs 65.7%, p=0.01). At a mean follow-up of 3.4±1.1 years, MACCE was significantly lower in the CABG group (OR = 0.70, 95% CI 0.57–0.87; p=0.001) (Figure 1). The odds of MI or repeat revascularization were lower with CABG, whereas the odds of stroke were higher; no statistically-significant difference was seen in all-cause mortality. Conclusion This meta-analysis shows that CABG is associated with lower rates of MACCE and MI but with a higher rate of stroke compared to PCI in LMCAD patients with CKD. Funding Acknowledgement Type of funding source: None

Varying definitions of procedural myocardial infarction (PMI) are in widespread use.This study sought to determine the rates and clinical relevance of PMI using different definitions in patients with left main coronary artery disease randomized to percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG) surgery in the EXCEL (Evaluation of XIENCE versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) trial.The pre-specified protocol definition of PMI (PMIPMIThe rates of PMI after PCI and CABG vary greatly with different definitions. In the EXCEL trial, the pre-specified PMI

Background Preventive intra-aortic balloon pump (IABP) for high-risk patients with stable hemodynamics is controversial, and its definition of high-risk is still unclear. This study aimed to investigate the effect of prophylactic IABP on the early outcome of left main disease (LMD) patients receiving off-pump coronary artery bypass grafting (OPCABG) with stable hemodynamics. Methods From January 2013 to April 2020, 257 consecutive patients who underwent OPCABG through sternotomy were enrolled in this study. All LMD patients (greater than 70%) had stable hemodynamics (BP>100 mmHg without vasoconstrictor substance infusion). Early outcomes of 125 patients with prophylactic IABP (IABP group) and 132 patients without IABP (Control group) were compared in this study. Results IABP did not show favorable effect on the conversion to CPB (RR 0.63, 95%CI 0.05–7.89, P = 0.7211), perioperative MI (RR 0.69, 95%CI 0.22–2.12, P = 0.5163), mortality (RR 0.65, 95%CI 0.04–10.25, P = 0.7608) or the composite end of the conversion, MI and mortality (RR 0.63, 95%CI 0.23–1.74, P = 0.3747). There was greater incidence of prolonged ventilation in IABP after adjustment (RR2.16, 95%CI 1.12–4.18, P = 0.0221). There was no IABP-related mortality or limb ischemia. Conclusion No significant difference in early outcomes was observed in hemodynamically stable patients with LMD between prophylactic IABP group and control group. Prophylactic IABP may be unnecessary in patients with LMD undergoing OPCABG.

PCI to improve survival is currently recommended as a reasonable alternative to CABG in patients with unprotected left main disease. However, RCTs to support this recommendation has generated mixed results and recently published EXCEL trial has sparked debate about differences in late mortality. To address this point, we performed landmark meta-analysis of 4 RCTs with 5 year follow up data — EXCEL, NOBLE, PRECOMBAT and SYNTAX LEFT MAIN. Overall, there was no significant difference in all-cause mortality between PCI and CABG at 5 years (RR = 1.03 [95% CI = 0.79–1.33]). However, there was apparent change in the direction of association before and after the 1 year landmark that underscores the need for long term follow up in these trials. In addition, we found that PCI was associated with significantly lower rate of intermediate stroke at 1 year (RR = 0.44 [0.24–0.82]) but higher rate of late MI after 1 year (3.31 [2.11–5.18]) compared to CABG.

Background Data are still limited regarding whether there are differential long‐term outcomes after percutaneous coronary intervention versus coronary artery bypass grafting ( CABG ) for left main coronary artery disease with or without diabetes mellitus ( DM ). Methods and Results Using the 10‐year data from the MAIN ‐ COMPARE (Revascularization for Unprotected Left Main Coronary Artery Stenosis: Comparison of Percutaneous Coronary Angioplasty Versus Surgical Revascularization) registry, we sought to examine the effect of DM on comparative outcomes after percutaneous coronary intervention or CABG in patients with unprotected left main coronary artery disease. The outcomes of interest were all‐cause mortality; a composite of death, Q‐wave myocardial infarction, or stroke; and target‐vessel revascularization. The primary adjusted analyses were performed with the use of propensity scores and inverse‐probability weighting. Of 2240 patients with left main coronary artery revascularization, 722 (32%) had DM . In the overall population, the adjusted 10‐year risks of death and composite outcome were similar between percutaneous coronary intervention and CABG , irrespective of DM status ( P interaction : 0.41, mortality; 0.40, composite outcome). However, in the cohort of bare‐metal stents and concurrent CABG , we observed differential outcomes after stenting and CABG by DM status ( P interaction : 0.09, mortality; 0.04, composite outcome), favoring CABG in patients with DM. In the cohort of drug‐eluting stents and concurrent CABG , the better effect of CABG over stenting was narrowed in patients with DM without a significant interaction ( P interaction : 0.63, mortality; 0.47, composite outcome). Conclusions In this cohort of patients with longest follow‐up who underwent left main coronary artery revascularization, the clinical impact of DM favoring CABG over percutaneous coronary intervention has diminished over time from the bare‐metal stent to the drug‐eluting stent era. Registration URL : http://www.clini​caltr​ials.gov . Unique identifier: NCT 02791412.

Background Data are still limited regarding whether there are differential long-term outcomes after percutaneous coronary intervention versus coronary artery bypass grafting (CABG) for left main coronary artery disease with or without diabetes mellitus (DM). Methods and Results Using the 10-year data from the MAIN-COMPARE (Revascularization for Unprotected Left Main Coronary Artery Stenosis: Comparison of Percutaneous Coronary Angioplasty Versus Surgical Revascularization) registry, we sought to examine the effect of DM on comparative outcomes after percutaneous coronary intervention or CABG in patients with unprotected left main coronary artery disease. The outcomes of interest were all-cause mortality; a composite of death, Q-wave myocardial infarction, or stroke; and target-vessel revascularization. The primary adjusted analyses were performed with the use of propensity scores and inverse-probability weighting. Of 2240 patients with left main coronary artery revascularization, 722 (32%) had DM. In the overall population, the adjusted 10-year risks of death and composite outcome were similar between percutaneous coronary intervention and CABG, irrespective of DM status (

Objectives The existence of a “weekend effect” for onset of acute myocardial infarction (AMI) has been suggested in the past, but the relation with the culprit vessel has not been investigated. MI due to left main coronary artery lesion represents a particularly serious life-threatening condition. Our study was aimed to assess the chronobiology of admission to the emergency department for AMI considered to be induced by a left main culprit lesion. Methods We retrospectively reviewed patients who experienced an AMI due to a left main culprit lesion between January 1, 2008 and January 1, 2018 stratifying them according to the day of admission, on the basis of the symptom onset time; the 30-day cardiovascular mortality was also analyzed on the basis of the time of symptom onset. Results Out of 1789 patients with AMI, 130 (7.2%, 104 males and 26 females, mean age 74.5 ± 8.1 years) had left main disease as the culprit lesion. Tuesday was significantly over-represented as the admission day (p Conclusion The relation between AMI onset and the day of the week is confirmed by our study, which also suggests that in case of a left main lesion, some delay of the weekend effect might be expected.

Although coronary-artery bypass grafting (CABG) is the standard choice of revascularization for significant left main coronary artery (LMCA) disease, percutaneous coronary intervention (PCI) for LMCA disease has been widely expanded with adoption of drug-eluting stents (DES). Several small- and moderate-sized trials of CABG and first-generation DES showed that PCI might be a good alternative for selected patients with LMCA disease. However, these early trials were relatively underpowered and comparative results of contemporary DES and CABG were clearly required. Subsequently, two large-sized trials comparing CABG and contemporary DES (EXCEL and NOBLE) were conducted, but these trials showed conflicting results with regards to the effects of PCI and CABG on clinical outcomes, which raises further uncertainty on the optimal revascularization for LMCA disease. This article serves to summarize the key findings of landmark clinical trials, to share our knowledge and experience and to express personal opinions on current controversies in the treatment of LMCA disease.

Background Although several meta-analyses have demonstrated the utility of intravascular ultrasound (IVUS) in guiding drug-eluting stent (DES) implantation compared to angiography-guidance, there has been a dearth of evidence in the left main coronary artery (LMCA) lesion subset. Methods We performed a meta-analysis to compare clinical outcomes of IVUS versus conventional angiography guidance during implantation of DES for patients with LMCA disease. Pubmed, Cochrane Library, Embase were searched. Results A total of 1002 publications were reviewed; and finally, seven clinical studies - one prospective randomized controlled trial and six observational studies with 4592 patients (1907 IVUS-guided and 2685 angiography-guided) - were included in the meta-analysis. IVUS guidance was associated with a significant reduction in major adverse cardiac events (relative ratio [RR] 95% CI 0.61; 95% confidence interval [CI] 0.53 to 0.70; P

We present a case of a 74-year old woman with a history of diabetes, hypertension, carotid endarterectomy and stenting of iliac arteries because of peripheral artery disease (PAD), admitted with the recognition of non ST-segment elevation myocardial infarction. Immediate coronary angiography revealed multivessel disease with critical calcified left main (LM) stenosis (Figure 1 A). Additionally, tight aortic stenosis (AS) with reduced left ventricle ejection fraction (LVEF 40%) was diagnosed. Unfortunately, after transfer to the intensive care unit pulmonary oedema occurred, successfully treated with pharmacotherapy. An urgent heart team meeting was held and the patient was disqualified from open-heart surgery because of comorbidities and high risk (EuroSCORE II – 17%). We decided to perform a hybrid procedure, including one stage balloon aortic valvuloplasty (BAV), percutaneous coronary intervention (PCI) and finally transcatheter aortic valve implantation (TAVI). Moreover, computed tomography revealed highly calcified aortic annulus and due to PAD only an alternative approach for TAVI was possible (Figure 1 B corner).

Extensive left main (LM) coronary artery thrombus is a rare and life-threatening angiographic finding with usual dramatic clinical presentation including hemodynamic instability and sudden cardiac death. The proper management of a big LM thrombus extending into aorta remains a challenging issue with no clear guidelines. In the following case report we present a 45-year-old patient with no apparent risk factors for coronary artery disease who presented with acute infero-lateral ST-elevation myocardial infarction (STEMI). The examination was performed using a right transfemoral approach and it revealed the presence of a large mobile, hazy mass within the left main coronary artery (LMCA) extending into the aorta. To confirm the extension of that structure we performed intravascular ultrasound (IVUS) which revealed a circumferential mass in the LMCA extending with its two-thirds into the aorta with no evidence of atherosclerotic plaques. After a long discussion within our Heart team we decided to transfer the patient for urgent surgical removal. Such decision was made with regard to the large size of the mass and in order to avoid systemic or distal embolization into coronary arteries. Perioperative transesophageal echocardiography (TEE) confirmed diagnosis and excluded presence of patent foramen ovale (PFO). Surgical removal was done successfully with complete resolution of ST-segment elevation and rapid fall of cardiac enzymes to normal levels. Postoperative course was uneventful. The mass was defined as a thrombus by pathophysiology examination. Patient was discharged well from our hospital after 1 week. Cardiol Res. 2017;8(6):331-335 doi: https://doi.org/10.14740/cr598e

Background: The EXCEL (Evaluation of Xience Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) trial compared outcomes in patients with unprotected left...

Coronary artery bypass grafting (CABG) is the standard of care for patients with multivessel disease (MVD) or left main disease (LMD) and high anatomic complexity (SYNTAX score >32). Percutaneous coronary intervention (PCI) has become a mainstay of treatment in less complex patients, with the most

After the impressive results of the DKCRUSH-V trial (Double Kissing Crush versus Provisional Stenting for Left Main Distal Bifurcation Lesions: The DKCRUSH-V Randomized Trial) in left main disease ([1][1]), this technique has definitely gained scientific support and has been demonstrated to be a

Background Percutaneous coronary intervention (PCI) of unprotected left main coronary artery disease is currently recommended as an alternative to coronary artery bypass grafting (CABG) in patients with low and intermediate SYNTAX score. Purpose We sought to compare clinical outcomes of unprotected left main coronary artery disease by PCI or CABG in a “real world” population referred to high volume center. Methods All consecutive patients with unprotected left main coronary artery disease treated by PCI with second-generation drug-eluting stent were compared to those treated by CABG. The primary endpoint was the composite of death, non-fatal myocardial infarction (MI) or stroke at 2 years follow-up. Results A total of 558 patients were included. The mean age was 71±9 years, diabetes was present in 29%, and 56% of the patients presented with acute coronary syndrome. The distal left main coronary artery was involved in 84.6% of the lesions, the rate of Syntax score >32 was 50%. At 2 years, the primary end-point occurred in 10% of the patients in the PCI group and in 9.6% in the CABG group (p=0.862). The rates of death, non-fatal MI or stroke at 2 years were comparable; conversely the rate of ischemia driven revascularization at 2 years was higher in PCI group than CABG (5.5% and 1.5% p=0.010, respectively in PCI and CABG group). Kaplan-Meier curves of MACCE Conclusions In a “real world” population with unprotected left main coronary artery disease, PCI with second generation stent, as compared to CABG, showed similar rates of the composite end point of death, non-fatal MI or stroke at 2 years, irrespective of coronary anatomy complexity.

Background Troponin elevation occurs commonly in the setting of transcatheter aortic valve replacement (TAVR). There is a lack of information on the extent of troponin elevation post TAVR that is prognostically significant. We assessed the optimal cutoff for post‐TAVR troponin T elevation that correlates with long‐term mortality. We also examined the relationship between coronary artery disease (CAD) and prognostically significant myocardial injury in TAVR. Methods and Results This is a retrospective, observational single‐center study involving patients who underwent TAVR at Cleveland Clinic between 2010 and 2015. Five hundred ten patients were included (mean follow‐up of 2.6±1.3 years). Receiver operating characteristic analysis showed that troponin T elevation ≥3× upper limit of normal was the best predictor of long‐term mortality post TAVR with area under the curve of 0.57, with transapical TAVR patients excluded. Multivariate analyses confirmed that troponin T elevation ≥3× upper limit of normal was significantly associated with increased long‐term mortality post TAVR (hazard ratio 1.57, CI 1.04–2.38, P =0.03). The most common causes for the presence of unrevascularized CAD included the presence of chronic total occlusion in the native/graft vessels (49.7%) and diffuse/complex CAD unsuitable for PCI (24.6%). The presence of unrevascularized CAD and significant left main disease correlated with increased mortality, but not with the presence of prognostically significant myocardial injury. Conclusions Troponin T elevation of ≥ 3× upper limit of normal is associated with increased long‐term mortality after TAVR, except for the transapical approach. This prognostically significant myocardial injury does not appear to be secondary to severe CAD/unrevascularized CAD or left main disease, but rather is associated with other factors such as post‐TAVR complications.

Little is known on the role of indirect clamp releasing in coronary artery bypass grafting (CABG). Loop isolation-based uploading preconditioning (LiuPhD) was modified to protect the heart from damage and the question of whether this can attenuate reperfusion injury after global myocardial ischemia was examined.A post-hoc comparative analysis was conducted of a prospective single-arm trial on the use of the LiuPhD strategy for 60 multivessel-disease patients undergoing isolated first-time elective on-pump CABG versus 1:1 propensity score-matched patients from the historical database of the same center.A total of 120 matched patients had a median age of 62.0 (interquartile range [IQR] 55.8-69.0) years, 27 (22.5%) women, 35 (29.2%) with left main disease, and median follow-up of 18.5 (10.9-35.4) months. The LiuPhD group had shorter post-bypass times than conventional controls (10 [6-13] vs 14 [10-19] mins; p = 0.003). The LiuPhD group had similar needs in terms of composite cardiac-specific interventions (38/60 vs 44/60; p = 0.29). At follow-up of safety, the risk for composite major adverse cardiac and cerebrovascular events was similar between groups (event-free survival: 82.3% vs 73.8%; hazard ratio 1.00 [0.39, 2.54], p log-rank test = 0.99).The LiuPhD strategy is associated with short post-bypass times, comparable risk of myocardial injury, and similar safety compared with conventional direct clamp releasing.HINTERGRUND: Es gibt nur wenige Daten zur Bedeutung der indirekten Klemmenentfernung in der koronaren Bypassoperation („coronary artery bypass grafting“ [CABG]). Eine Loop-Isolations-basierte Beladungsvorbereitung („loop isolation-based uploading preconditioning“ [LiuPhD]) wurde modifiziert, um das Herz vor einer Schädigung zu schützen. Es wurde untersucht, ob dadurch der Reperfusionsschaden nach globaler Myokardischämie eingedämmt werden kann.Es erfolgte eine vergleichende Post-hoc-Analyse einer prospektiven, einarmigen Studie zur Anwendung der LiuPhD-Strategie bei 60 Patienten mit Mehrgefäßerkrankung, die einer isolierten erstmaligen elektiven On-pump-CABG unterzogen wurden, gegenüber 1:1 Propensity-Score-gematchten Patienten aus der Datenbank desselben Zentrums.Das mediane Alter der insgesamt 120 gematchten Patienten lag bei 62,0 Jahren (Interquartilsabstand [IQR] 55,8–69,0 Jahre), 27 (22,5 %) waren Frauen, 35 (29,2 %) hatten eine linke Hauptstammstenose und das mediane Follow-up betrug 18,5 Monate (10,9–35,4 Monate). Die LiuPhD-Gruppe wies eine kürzere Post-Bypass-Zeit als die konventionell behandelten Kontrollen auf (10 min [6–13 min] vs. 14 min [10–19 min]; p = 0,003). In der LiuPhD-Gruppe war die Notwendigkeit von kombinierten kardialen Interventionen vergleichbar (38/60 vs. 44/60; p = 0,29). Im Sicherheits-Follow-up war das Risiko kombinierter schwerer unerwünschter kardialer und zerebrovaskulärer Ereignisse in den beiden Gruppen ähnlich (ereignisfreies Überleben: 82,3 % vs. 73,8 %; Hazard Ratio 1,00 [0,39; 2,54], p log-Rang-Test = 0,99).Die LiuPhD-Strategie ist im Vergleich zur konventionellen direkten Klemmenentfernung mit kürzeren Post-Bypass-Zeiten, einem vergleichbaren Risiko der Myokardschädigung und einem ähnlichen Sicherheitsniveau assoziiert.

Non-ST-elevation myocardial infarction (NSTEMI) is an urgent medical condition that requires prompt application of simultaneous pharmacologic and non-pharmacologic therapies. The variation in patient clinical characteristics coupled with the multitude of treatment modalities makes optimal and timely management challenging. This review summarizes risk stratification of patients, the role and timing of revascularization, and highlights important considerations in the revascularization approach with attention to individual patient characteristics. The early invasive management of NSTEMI has fostered a reduction in future ischemic events. Risk calculators are helpful in determining which patients should receive early invasive management. As many patients have multivessel disease, identifying the true culprit lesion can be challenging. Special attention should be given to those at the highest risk, such as diabetics, patients with renal failure, and those with left main disease. In patients with acute coronary syndrome, the decision and mode of revascularization should carefully integrate the patient’s clinical characteristics as well as the complexity of the coronary anatomy.

The BiOSS LIM stent is a dedicated device for the treatment of bifurcation lesions that present a proximal and distal part with two different diameters and a middle zone with two connecting struts facilitating side branch rewiring. In this study, after implanting the BiOSS LIM stent in the left main, rewiring to the side branch was easier compared to standard metallic stent. The device may be very useful in the treatment of bifurcation lesions for provisional stenting strategies or for two-stent strategies such as T-stenting or T-and-Protruding (TAP).