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Cabrol procedure is an alternative technique of anastomosing coronary arteries to the aortic root graft by an extra graft, if direct implantation of coronary arteries to the aortic root graft is not possible. The left main coronary artery stenosis is a rarely seen complication after aortic root operations. Treatment of large coronary arteries with renal stents is a challenging procedure. Herein, we, for the first time in the literature, present a case of left main coronary artery stenosis treated with renal stents after Cabrol operation.

The presence of critical coronary artery disease and concomitant critical limb ischemia represents a clinical challenge. Single-stage operations for cardiac and peripheral revascularization can be an option in such cases. The "Suzer technique" provides a more physiological extra-anatomical vascular reconstruction by using the descending thoracic aorta as the inflow source. This is an alternative to the more widely used technique of ascending aorta to bifemoral bypass and concomitant coronary revascularization. We report a case of critical limb ischemia with juxtrarenal aortic occlusion and left main coronary artery stenosis treated with concomitant coronary artery bypass grafting and descending thoracic aorto-bi-iliac bypass using a modification of the Suzer technique.

Background: Studies of the civilian population with left main coronary artery disease (LMCAD) who underwent coronary artery bypass grafting (CABG) have shown 2% to 4.2% 30-day mortality. However, there is a lack of reporting from the veteran population. Here we analyze the outcomes of veterans with LMCAD who underwent CABG by a single surgeon at a single Veterans Affairs Medical Center (VAMC). Methods: Veterans who underwent isolated CABG between 1998 to 2018 at a VAMC were further divided into a group with significant left main coronary artery disease (LMCAD) of stenosis greater than or equal to 50% and a group without left main coronary artery stenosis (non-LMCAD). The primary outcome was mortality. Secondary outcomes included postoperative complications. Multivariable regression analysis and Kaplan-Meier survival analysis were used to compare the two cohorts. Results: The demographics and comorbidities are similar between the two cohorts except for higher average age and percentage of stroke in the LMCAD group (n = 509) compared to non-LMCAD (n = 927). Perioperative complications are comparable between the two groups except for increased length of stay (LOS) in the LMCAD group (12.9 ± 15.9 days versus 10.9 ± 9.0 days in non-LMCAD, P < .001). 30-day mortality in the LMCAD group is 4.1% versus 1.4% in non-LMCAD. However, Kaplan-Meier curves show no significant difference in adjusted overall survival throughout 15 years between the groups (P = .560). Conclusion: Veterans with LMCAD who underwent CABG have similar postoperative complications compared to non-LMCAD group. The 30-day mortality is higher in the LMCAD group; however, there is no difference in long-term survival.

Background and objectives: Coronary artery bypass grafting (CABG) is the gold standard therapy for unprotected left main coronary artery (ULMCA) stenosis in coronary atherosclerosis. However, ULMCA stenosis has recently been successfully treated with drug-eluting stents. The present study aims to compare the safety and efficacy of CABG versus rapamycin-eluting stents for ULMCA stenosis in older adult patients with degenerative coronary atherosclerosis. Methods: The proposed prospective, non-randomized, controlled trial will include 224 older adult patients with degenerative coronary atherosclerosis with ULMCA stenosis being treated at Taihe Hospital (Affiliated Hospital of Hubei University of Medicine) and Renmin Hospital Affiliated to Hubei University of Medicine, China. Patients will be divided into two groups in accordance with each patient’s treatment choice and indications (n = 112/group): the stent group will receive rapamycin-eluting stents, while the CABG group will undergo CABG. All patients will be followed up at 9, 12, 24, and 36 months postoperatively. Outcome measures and preliminary results: The primary outcome measure will be the rate of repeat revascularizations in the target lesion at 36 months postoperatively. The secondary outcome measures will be the rates of repeat revascularizations in the target lesion at 9, 12, and 24 months postoperatively, the rate of restenosis, mortality, causes of death, and survival at 9, 12, 24, and 36 months postoperatively, and the angiographic appearance of the diseased vessels preoperatively and at 9, 12, 24, and 36 months postoperatively. The safety indicator will be the incidence of major adverse cardiac and cerebrovascular events at 9, 12, 24, and 36 months postoperatively. Pilot study results showed that the stent group (n = 48) had a significantly reduced waiting time for surgery, hospitalization time, and rate of complete revascularizations in the target lesion compared with the CABG group (n = 38) (P < 0.05). At 6 months postoperatively, there were no significant differences between the two groups in mortality, and incidences of myocardial infarction, repeat revascularizations in the target lesion, and cardiovascular events. Discussion: The results of this study will indicate the medium- and long-term efficacy and safety of rapamycin-eluting stents versus CABG in older adult patients with ULMCA stenosis. Ethics and dissemination: This study was approved by Medical Ethics Committee, Taihe Hospital (approval No. TH0058X), and Shiyan Renmin Hospital (approval No. RM011X), China in July 2017. This study protocol will be performed in strict accordance with the Declaration of Helsinki. Written informed consent will be obtained from each patient. The study protocol was designed in January 2018. Patient recruitment will begin in August 2018 and end in August 2019. Data analysis will begin in October 2022. The study will end in December 2022. Results will be disseminated through presentations at scientific meetings and/or by publication in a peer-reviewed journal. Trial registration: This trial was registered with the Chinese Clinical Trial Registry (registration number: ChiCTR1800016413). Protocol version: 1.0.

Background The optimal revascularization technique in patients with left main coronary artery disease (CAD) remains controversial. We aimed to compare the long-term performance of percutaneous coronary intervention (PCI) versus coronary artery bypass graft (CABG) surgery in treatment of left main CAD. Methods PubMed, EMBASE, and the Cochrane Library were searched until November 16, 2016. Results Six randomized controlled trials and 22 matched observational studies including 22,487 patients and 90,167 patient-years of follow-up were included. PCI was associated with an overall higher risk for the major adverse cardiac and cerebrovascular events (hazard ratio (HR), 1.42; 95% confidence interval (CI), 1.14–1.77), mainly driven by higher rates of myocardial infarction (HR, 1.69; 95% CI, 1.22–2.34) and revascularization (HR, 2.80; 95% CI, 1.86–4.22). The overall risks for all-cause death (HR, 1.05; 95% CI, 0.93–1.20), cardiac death (HR, 1.05; 95% CI, 0.69–1.59), stroke (HR, 0.64; 95% CI, 0.33–1.24), and the composite safety endpoint of death, myocardial infarction, or stroke (HR, 1.06; 95% CI, 0.97–1.16) were similar between PCI and CABG. Stratified analysis based on stent types showed that the increased risk for myocardial infarction associated with PCI was only evident in patients with bare-metal stents or early-generation drug-eluting stents (DES), but not newer-generation DES. Stratified analyses based on study designs showed largely similar findings with the overall analyses, except for a significantly higher incidence of myocardial infarction in adjusted studies (HR, 2.01; 95% CI, 1.64–2.45) but a trend toward higher incidence in randomized trials (HR, 1.39; 95% CI, 0.85–2.27) associated with PCI. Conclusions Compared with CABG, PCI with newer-generation DES might be a safe alternative revascularization strategy for treatment of left main CAD, but is associated with more repeat revascularization. Electronic supplementary material The online version of this article (doi:10.1186/s12916-017-0853-1) contains supplementary material, which is available to authorized users.

Objectives This study has reported 10-year clinical follow-up of patients enrolled in the prospective, randomized LE MANS (Left Main Stenting) trial. Background The very long-term outcome after left main stenting in comparison with surgical revascularization remains unknown. Methods In this prospective, multicenter trial, we randomly assigned 105 patients with unprotected left main coronary artery stenosis with low and medium complexity of coexisting coronary artery disease according to SYNTAX (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery) score to percutaneous coronary intervention (PCI) with stenting (n = 52) or coronary artery bypass grafting (CABG) (n = 53). Drug-eluting stents were implanted in 35%, whereas arterial grafts to the left anterior descending artery were utilized in 81%. Currently, the mean long-term follow-up was collected at 9.8 ± 1.0 years. Follow up for all-cause mortality is complete, whereas the incidence of major adverse cardiovascular and cerebral events (MACCE) was reported from 90% of patients. Ambulatory follow-up was completed in 46 (43.9%) patients. Results At 10 years, there was a trend toward higher ejection fraction in stenting when compared with surgery (54.9 ± 8.3% vs. 49.8 ± 10.3%; p = 0.07). The mortality (21.6% vs. 30.2%; p = 0.41) and MACCE (51.1% vs. 64.4%; p = 0.28) were statistically not different between groups; however, numerically the difference was in favor of stenting. Similarly, there was no difference in the occurrence of myocardial infarction (8.7 vs. 10.4%; p = 0.62), stroke (4.3 vs. 6.3%; p = 0.68), and repeated revascularization rates (26.1% vs. 31.3%; p = 0.64). The probability of very long-term survival up to 14 years was comparable between PCI and CABG (74.2% vs. 67.5%; p = 0.34; hazard ratio: 1.45, 95% confidence interval: 0.67 to 3.13); however, there was a trend toward higher MACCE-free survival in the PCI group (34.7% vs. 22.1%; p = 0.06; hazard ratio: 1.71, 95% confidence interval: 0.97 to 2.99). Conclusions In patients with unprotected left main coronary artery stenosis with low and medium complexity of coexisting coronary artery disease, stenting offers numerically, but statistically nonsignificant, favorable long-term outcome up to 10 years in terms of safety and efficacy outcome measures, therefore, constitutes an alternative therapy for CABG.

Background Major randomized clinical trials assessing clinical outcomes in patients who underwent a percutaneous coronary intervention (PCI) for left main coronary artery disease excluded some high-risk subsets. Whether the effectiveness and safety of a percutaneous approach in this group of patients are comparable with those observed in clinical trials is unclear. We aimed to explore the long-term outcomes of contemporary drug-eluting stent (DES)-based revascularization for left main coronary artery disease in patients presenting with one or more clinical or angiographic characteristics who would have precluded inclusion in randomized trials. Patients and methods Between April 2003 and December 2011, 340 consecutive patients with unprotected left main coronary artery stenosis of at least 50% who underwent successful PCI with DES at Sejong General Hospital (Bucheon, Republic of Korea) were included in this retrospective study. Patients were classified into the exclusion group (group E; n=120) and the inclusion group (group I; n=220) according to the prespecified inclusion and exclusion criteria utilized in clinical trials. Results During the median follow-up of 86 (52-114) months, major adverse cardiac or cerebrovascular events occurred in 69 (31.4%) patients in group I and 46 (38.3%) patients in group E (P=0.155). In the propensity score-matched population, group E was not associated with a higher incidence of major adverse cardiac or cerebrovascular events (hazard ratio: 1.42, 95% confidence interval: 0.76-2.65, P=0.758). Definite or probable stent thrombosis occurred in five patients of group I, with no cases in group E. Conclusion In our real-world registry, about a third of patients who underwent PCI for unprotected left main coronary artery stenosis had one or more high-risk characteristics or comorbid conditions that represent exclusion criteria of previous randomized trials. PCI using DES is feasible in these patients.

Background In a previous randomized trial, we found that percutaneous coronary intervention (PCI) was not inferior to coronary artery bypass grafting (CABG) for the treatment of unprotected left main coronary artery stenosis at 1 year. Objectives This study sought to determine the 5-year outcomes of PCI compared with CABG for the treatment of unprotected left main coronary artery stenosis. Methods We randomly assigned 600 patients with unprotected left main coronary artery stenosis to undergo PCI with a sirolimus-eluting stent (n = 300) or CABG (n = 300). The primary endpoint was a major adverse cardiac or cerebrovascular event (MACCE: a composite of death from any cause, myocardial infarction, stroke, or ischemia-driven target vessel revascularization) and compared on an intention-to-treat basis. Results At 5 years, MACCE occurred in 52 patients in the PCI group and 42 patients in the CABG group (cumulative event rates of 17.5% and 14.3%, respectively; hazard ratio [HR]: 1.27; 95% confidence interval [CI]: 0.84 to 1.90; p = 0.26). The 2 groups did not differ significantly in terms of death from any cause, myocardial infarction, or stroke as well as their composite (8.4% and 9.6%; HR, 0.89; 95% CI, 0.52 to 1.52; p = 0.66). Ischemia-driven target vessel revascularization occurred more frequently in the PCI group than in the CABG group (11.4% and 5.5%, respectively; HR: 2.11; 95% CI: 1.16 to 3.84; p = 0.012). Conclusions During 5 years of follow-up, our study did not show significant difference regarding the rate of MACCE between patients who underwent PCI with a sirolimus-eluting stent and those who underwent CABG. However, considering the limited power of our study, our results should be interpreted with caution. (Bypass Surgery Versus Angioplasty Using Sirolimus-Eluting Stent in Patients With Left Main Coronary Artery Disease [PRECOMBAT]; NCT00422968)

Congenital supravalvar aortic stenosis (SVAS) is an arteriopathy associated with Williams-Beuren syndrome (WBS) and other isolated elastin gene deletions. Cardiovascular manifestations associated with WBS are characterized by obstructive arterial lesions such as SVAS and pulmonary artery stenosis in addition to bicuspid aortic valve and mitral valve prolapse. However, coronary artery ostial stenosis may be associated with SVAS, and it increases the risk of sudden death and may complicate surgical management. In this report, we present our experience with two patients having SVAS and left coronary artery ostial stenosis with associated left ventricular dysfunction.

Objectives: To investigate whether intravascular ultrasound (IVUS) guided percutaneous coronary intervention (PCI) could improve clinical outcomes compared with angiography-guided PCI in the treatment of unprotected left main coronary artery stenosis (ULMCA) in the elderly. Methods: This controlled study was carried out between October 2009 and September 2012, in Qinhuangdao First Hospital, Hebei Province, China. One hundred and twenty-three consecutive patients with ULMCA, aged 70 or older, were randomized to an IVUS-guided group and a control group. The occurrence of major adverse cardiac events (MACE): death, non-fatal myocardial infarction, or target lesion revascularizations) were recorded after 2 years of follow-up. Results: The IVUS-guided group had a lower rate of 2-year MACE than the control group (13.1% versus 29.3%, p =0.031). The incidence of target lesion revascularization was lower in the IVUS-guided group than in the control group (9.1% versus 24%, p =0.045). However, there were no differences in death and myocardial infarction in the 2 groups. On Cox proportional hazard analysis, distal lesion was the independent predictor of MACE (hazard ratio [HR]: 1.99, confidence interval [CI]: 1.129-2.367; p =0.043); IVUS guidance was independent factor of survival free of MACE (HR: 0.414, CI: 0.129-0.867; p =0.033). Conclusion: The use of IVUS could reduce MACE in elderly patients undergoing ULMCA intervention. Saudi Med J 2015; Vol. 36 (5): 549-553 doi: 10.15537/smj.2015.5.11251

The patient presented with flash pulmonary edema related to severe left ventricular diastolic dysfunction several weeks after arterial switch operation (ASO) for D-transposition of the great arteries. Long segment, critical left main coronary artery stenosis in this 3.6 kilogram infant was successfully stented and resulted in resolution of the clinical findings. At 15-month follow-up, the patient remains asymptomatic and thriving.

In patients with left main coronary artery (LMCA) stenosis, coronary artery bypass grafting (CABG) has been the standard therapy for several decades. However, some studies suggest that percutaneous coronary intervention (PCI) with drug-eluting stents may be an acceptable alternative.To compare the long-term safety of PCI with drug-eluting stent vs CABG in patients with LMCA stenosis.PubMed, Scopus, EMBASE, Web of Knowledge, and ScienceDirect databases were searched from December 18, 2001, to February 1, 2017. Inclusion criteria were randomized clinical trial, patients with LMCA stenosis, PCI vs CABG, exclusive use of drug-eluting stents, and clinical follow-up of 3 or more years.Trial-level hazard ratios (HRs) and 95% CIs were pooled by fixed-effect and random-effects models with inverse variance weighting. Time-to-event individual patient data for the primary end point were reconstructed. Sensitivity analyses according to drug-eluting stent generation and coronary artery disease complexity were performed.The primary end point was a composite of all-cause death, myocardial infarction, or stroke at long-term follow-up. Secondary end points included repeat revascularization and a composite of all-cause death, myocardial infarction, stroke, or repeat revascularization at long-term follow-up.A total of 4 randomized clinical trials were pooled; 4394 patients were included in the analysis. Of these, 3371 (76.7%) were men; pooled mean age was 65.4 years. According to Grading of Recommendations, Assessment, Development and Evaluation, evidence quality with respect to the primary composite end point was high. Percutaneous coronary intervention and CABG were associated with a comparable risk of all-cause death, myocardial infarction, or stroke both by fixed-effect (HR, 1.06; 95% CI, 0.90-1.24; P = .48) and random-effects (HR, 1.06; 95% CI, 0.85-1.32; P = .60) analysis. Sensitivity analyses according to low to intermediate Synergy Between PCI With Taxus and Cardiac Surgery (SYNTAX) score (random-effects: HR, 1.02; 95% CI, 0.74-1.41; P = .89) and drug-eluting stent generation (first generation: HR, 0.90; 95% CI, 0.68-1.20; P = .49; second generation: HR, 1.19; 95% CI, 0.82-1.73; P = .36) were consistent. Kaplan-Meier curve reconstruction did not show significant variations over time between the techniques, with a 5-year incidence of all-cause death, myocardial infarction, or stroke of 18.3% (319 events) in patients treated with PCI and 16.9% (292 events) in patients treated with CABG. However, repeat revascularization after PCI was increased (HR, 1.70; 95% CI, 1.42-2.05; P .001). Other individual secondary end points did not differ significantly between groups. Finally, pooled estimates of trials with LMCA stenosis tended overall to differ significantly from those of trials with multivessel coronary artery disease without left main LMCA stenosis.Percutaneous coronary intervention and CABG show comparable safety in patients with LMCA stenosis and low to intermediate-complexity coronary artery disease. However, repeat revascularization is more common after PCI.

Percutaneous coronary intervention (PCI) of the left main coronary artery (LMCA) for revascularization after stenosis is still considered controversial therapy. Previous studies were performed with balloon-expandable drug-eluting stents (DES). Balloon-expandable stents presented a challenge because they were not able to adapt effectively to variation in the vessel lumen. There are limited data on LMCA therapy with self-expandable DES for treatment of medial and distal lesions. The advantages of a self-apposing stent are adaptation to vessel size, vessel tapering, stent sizing, and good apposition. This was a pilot study to determine safety and device success rate in patients with middle and distal LMCA stenosis treated with the STENTYS self-expanding coronary DES stent. The primary endpoints were device success, acute procedural success and in-hospital and 30-day MACE. Twenty-four patients were included. Median logistic EuroSCORE was 1.6% (1.1–2.6%). Median Syntax score was 20.0 (20.0–27.2) points. Significant stenosis according to the anatomical region was in the middle of the LMCA in 5 cases (21%) and the distal part in 19 (79%). Stent sizes used were: 3.0 × 3.5 mm in 9 (37.5%); 3.5 × 4.0 mm in 3 (12.5%); 3.5 × 4.5 mm in 12 (50%). Device success and acute procedural success were achieved in 23 patients (95.8%), with no edge dissection in any patient. In 1 patient the proximal end of the stent protruded into the aorta. In all patients during their hospitalization and 30-day follow-up there were no adverse events. The data compiled from this small, single-center pilot study suggest that the STENTYS self-expanding coronary stent may be a reasonable approach to treat lesions within the LMCA. These results warrant a larger future clinical trial.

During the recent years, since the start of coronary artery stent era not only coronary artery bypass graft surgery, but percutaneous transluminal angioplasty became common in patients with left main coronary artery stenosis. Mechanical complications of myocardial infarction, such as ventricular septal rupture, left ventricle free wall rupture and mitral regurgitation due to papillary muscle rupture, are straight indications for cardiac surgery. However, studies show that the age of over 70 years is a high-risk factor for cardiac surgery. In elderly patients, the duration of cardiopulmonary bypass and aortic cross-clamping time have a major impact on the surgery outcome. Therefore, strategies aimed at reducing the volume of cardiac surgery, should be more successful in elderly patients. On the other hand, elderly patients should be well prepared for surgery, and it should be performed when concomitant diseases are compensated. A case of 82-year patient admitted to the intensive care unit with acute myocardial infarction and chord papillary muscles partial rupture associated with severe mitral regurgitation, is presented. Due to the progression of pulmonary edema, mechanical ventilation was started and emergency percutaneous intervention was administered as a life-saving measure. Stents were placed in obtuse marginal branch, circumflex artery and anterior interventricular artery. Because of existing mitral regurgitation of 3-4 grade, after 2 weeks the patient was re-evaluated ex consilio. Considering relatively stable condition, mitral valve replacement with cardiopulmonary bypass was administered, which was successfully done. The successful treatment of this patient was possible because of the proper and timely staging of the patient’s management.

Background: Aim of the study was to evaluate the primary procedural success of percutaneous coronary intervention of unprotected left main coronary artery stenosis using either Bare-metal stents or drug eluting stent. Methods: Total 33 patients were enrolled in this very preliminary non-randomized prospective cohort study. Among them, Male: 25 and Female: 8. Total 35 stents were deployed. Mean age were for Male: 59 yrs, for Female: 62 yrs. Associated coronary artery diseases risk factors were dyslipidemia, High Blood pressure, Diabetes Mellitus, Positive family history for coronary artery diseases and smoking. Results: Among the study group; 26 (78%) were Dyslipidemic, 24(70%) were hypertensive; 17 (51.5%) patients were Diabetic, 11(33%) were smoker and 7(21%) patients had family history of Ischaemic heart disease. Female patients were more obese (BMI M 26: F 27) and developed coronary artery diseases in advance age. Common stented territory were left main: 20 (60%), Left main to left anterior descending artery 7 (22%) and Left main to left circumflex artery 6 (18%). Average length and diameter of stent was 3.5 and 18 mm respectively. Stent used: Bare Metal Stent 5 (15%), Drug Eluting Stent: 28 (85%). Among the different Drug Eluting Stents, Everolimus eluting stents were 11 (39.3%), Sirolimus eluting 10(35.7%), Paclitaxel eluting 3 (10.7%), Biolimus eluting 3 (10.7%) and Zotarolimus eluting1 (3.6%). In the present study, overall survival outcome was 94% (31 patient), mortality of cardiac cause 3% (1 patient) and 1 patient (3%) died of hepatocellular carcinoma. Conclusion: Our study has shown that percutaneous coronary intervention of the unprotected left main is a safe and effective alternative to Coronary Artery Bypass Graft (CABG). DOI: http://dx.doi.org/10.3329/cardio.v6i2.18349 Cardiovasc. j. 2014; 6(2): 107-111

In a recent issue of the Journal , Park et al. [(1)][1] published the 10-year follow-up results of the MAIN-COMPARE (Revascularization for Unprotected Left Main Coronary Artery Stenosis: Comparison of Percutaneous Coronary Angioplasty versus Surgical Revascularization) study in patients with

Concomitant aortic valve replacement (AVR) and coronary artery bypass graft surgery (CABG) is a common procedure. Whether the extent of coronary artery disease (CAD) influences outcomes of AVR plus CABG is unknown.All AVR plus CABG cases from 2008 to 2010 were extracted from the California CABG Outcomes Reporting Program database. Patients with left main coronary artery stenosis greater than 50% or at least three diseased vessels were defined as having extensive CAD, and patients with one or two diseased coronary vessels were defined as having less extensive CAD. Multivariable logistic regression models were developed for predicting major postoperative complications and 30-day mortality. A Cox proportional hazards model was developed to predict the risk of 1-year mortality.Between 2008 and 2010, 6,151 AVR plus CABG were performed in California. Compared with patients with one- or two-vessel CAD, patients with extensive CAD undergoing AVR plus CABG were on average older, more often male, had greater prevalence of multiple comorbidities, and underwent more urgent or emergent operations (all p0.05). After adjusting for baseline risk factors, AVR plus CABG with extensive CAD was associated with significantly increased risk of major postoperative complications (adjusted odds ratio, 1.24; 95% confidence interval, 1.10 to 1.40; p = 0.001) but not operative mortality (adjusted odds ratio, 1.00; 95% confidence interval, 0.77 to 1.29; p = 0.978). A Cox proportional hazards model showed that age and other medical comorbidities, but not extensive CAD, were significant risk factors for 1-year mortality.Compared with AVR plus CABG for one- or two-vessel CAD, AVR plus CABG for left main or three or more vessel CAD had higher observed and risk-adjusted rates of postoperative complications but not operative or 1-year mortality.

Objectives: The goal of this study was to provide a systematic review comparing the long-term outcomes of percutaneous coronary intervention (PCI) with drug-eluting stents (DES) versus coronary art...

An unexpected incident or rapid deterioration of a patient's condition may require optimal adaptation of the treatment to the current state of the patient. We present a case of a 74-year-old man with significant left main coronary artery stenosis and tight stenoses of both carotid arteries. The case was initially qualified for bypass grafting with accompanying carotid artery endarterectomy, but an unexpected accident changed our way of treatment. Three days after angiography the patient suffered an ischemic stroke. We held a multidisciplinary meeting of the “Neuro-Vascular-Heart Team” and decided to treat the patient percutaneously.

Acute coronary syndrome (ACS) as a result of iatrogenic coronary ostial stenosis (ICOS) is a rare but potentially life-threatening complication of aortic valve replacement (AVR). We present three cases of patients with ACS shortly after AVR, in whom ICOS were revealed. They refused an operation and thus they were treated with percutaneous coronary intervention. The potential pathomechanisms of ICOS and treatment options are discussed.

Williams-Beuren syndrome (WBS) is a multisystem genetic disorder comprising of craniofacial, developmental, and cardiac malformations. The most common cardiac defects found are supravalvar aortic stenosis and peripheral pulmonary stenosis. However, WBS should be regarded as a general arteriopathy consisting of stenoses of medium- and large-sized arteries including the coronary arteries. Cardiac manifestations are often the initial reason for referral and careful cardiovascular assessment is important as coronary artery involvement confers a significant anesthetic risk and may be associated with ischemia and resultant ventricular dysfunction. Here we review the literature and describe a 2-year-old boy with evolving clinical features of WBS. He presented to our pediatric cardiology department for a routine assessment of peripheral pulmonary branch stenosis. A 12-lead electrocardiogram showed changes consistent with left ventricular ischemia and a two-dimensional echocardiogram showed reduced left ventricular function and mild supravalvar aortic stenosis. Subsequent cardiac catheterization diagnosed severe left main coronary artery stenosis. Deteriorating ventricular function secondary to acute ischemia postcatheterization required intensive care treatment from which the patient did not recover. This case report highlights the necessity of careful cardiology assessment without delay in patients with a suspicion of WBS. Isolated coronary stenosis though rare in WBS should be considered in the presence of ischemia or reduced ventricular function. Larger case series are needed to further characterize the correlation between WBS and acute coronary events.

Few studies have examined differences in long-term mortality between coronary artery bypass graft surgery and stenting with drug-eluting stents (DES) for multivessel disease without left main coronary artery stenosis. This study compares the risks of long-term mortality between these 2 procedures during a follow-up of up to 5 years.Patients who underwent isolated bypass surgery (n=13,212) and stenting with DES (n=20,161) between October 2003 and December 2005 in New York State were followed for their vital status through 2008. To control for treatment selection bias, bypass and stenting patients were matched on age, number of diseased coronary vessels, presence of proximal or nonproximal left anterior descending (LAD) artery disease, and propensity of undergoing bypass surgery. Five-year survival rates for the 2 procedures were compared and hazard ratios for death of bypass surgery compared with stenting were obtained.The respective 5-year survival rates in the 8,121 pairs of matched bypass and stenting patients were 80.4% and 73.6% (p0.001), and the risk of death after bypass surgery was 29% lower than for stenting (hazard ratio = 0.71, 95% confidence interval: 0.67 to 0.77, p0.001). Significantly lower risks of death for bypass surgery were observed in patients with LAD artery disease but not in patients without LAD artery disease. Significantly lower risks of death for bypass surgery were also found in all patient subgroups defined by the presence of selected baseline risk factors.Bypass surgery is associated with lower risk of death than stenting with DES for multivessel disease without left main stenosis.

Background— Current guidelines suggest that coronary artery bypass grafting (CABG) should be the preferred revascularization method for unprotected left main coronary artery stenosis. In light of evidence from recent randomized trials, we assessed whether percutaneous coronary intervention (PCI) using drug-eluting stents is as safe and effective as CABG for the treatment of unprotected left main coronary artery disease. Methods and Results— Digital databases and manual searches were performed for randomized trials comparing PCI and CABG for unprotected left main coronary artery stenosis. Among 3887 potentially relevant studies, 5 met inclusion criteria. The primary safety end point was defined as the composite of all-cause death, myocardial infarction, or stroke. Secondary end points included a clinical effectiveness composite, which was defined as all-cause death, myocardial infarction, stroke, or repeat revascularization. Summary estimates were obtained using random-effects modeling. In total, 4594 patients were included in the analysis. There was no significant difference in the primary safety end point between the revascularization strategies (odds ratio [OR], 0.97; 95% confidence interval [CI], 0.79–1.17; P =0.73). However, when compared with CABG, PCI was less effective (OR, 1.36; 95% CI, 1.18–1.58; P P P =0.61), myocardial infarction (OR, 1.46; 95% CI, 0.88–2.45; P =0.08), and stroke (OR, 0.88; 95% CI, 0.39–1.97; P =0.53) did not differ between PCI and CABG. Conclusions— PCI using drug-eluting stents and CABG are equally safe methods of revascularization for patients at low surgical risk with significant unprotected left main coronary artery stenosis. However, CABG is associated with significantly lower rates of repeat revascularization.

High-risk candidates for percutaneous coronary intervention (PCI) may include patients with severe multi-vessel coronary artery disease, unprotected left main coronary artery stenosis, or last patent conduit with a stenosis, especially in patients with a left ventricular (LV) ejection fraction of ≤35% (1-4). In addition, the condition and co-morbidities of the patient should be taken into consideration. Traditionally, revascularization in these patients could be better accomplished with coronary artery bypass graft (CABG) surgery; however, sometimes these patients are high-risk surgical candidates, have advanced age and/or have poor distal targets for bypass surgery (5). PCI in these patients is a viable option, however, episodic interruption of blood flow to the target coronary artery in these high-risk patients during contrast dye injections, balloon inflation and stent implantation may result in a decrease in LV performance raising procedural morbidity and/or mortality (3,4,6). Currently, it is thought that hemodynamic support devices like the Impella (Abiomed, Danvers, Massachusetts) percutaneous left ventricular assist device (PLVAD) or intra-aortic balloon pump (IABP) may provide support during high-risk PCI (2,3,7-9).

Objectives This study sought to evaluate the safety and efficacy of second-generation drug-eluting stents (DES) for patients with unprotected left main coronary artery (ULMCA) stenosis. Background The clinical benefit of second-generation DES for ULMCA stenosis has not been determined. Methods The authors assessed 334 consecutive patients who received everolimus-eluting stents (EES) for ULMCA stenosis between 2009 and 2010. The 18-month incidence rates of major adverse cardiac or cerebrovascular events (MACCE), including death, myocardial infarction (MI), stroke, or ischemia-driven target vessel revascularization (TVR), were compared with those of a randomized study comparing patients who received sirolimus-eluting stents (SES) (n = 327) or coronary artery bypass grafts (CABG) (n = 272). Results EES (8.9%) showed a comparable incidence of MACCE as SES (10.8%; adjusted hazard ratio [aHR] of EES: 0.84; 95% confidence interval [CI]: 0.51 to 1.40; p = 0.51) and CABG (6.7%, aHR of EES: 1.40; 95% CI: 0.78 to 2.54; p = 0.26). The composite incidence of death, MI, or stroke also did not differ among patients receiving EES (3.3%), SES (3.7%; aHR of EES: 0.63; 95% CI: 0.27 to 1.47; p = 0.29), and CABG (4.8%; aHR of EES: 0.67; 95% CI: 0.29 to 1.54; p = 0.34). However, the incidence of ischemia-driven TVR in the EES group (6.5%) was higher than in the CABG group (2.6%, aHR of EES: 2.77; 95% CI: 1.17 to 6.58; p = 0.02), but comparable to SES (8.2%, aHR of EES: 1.14; 95% CI: 0.64 to 2.06; p = 0.65). Angiographic restenosis rates were similar in the SES and EES groups (13.8% vs. 9.2%, p = 0.16). Conclusions Second-generation EES had a similar 18-month risk of MACCE for ULMCA stenosis as first-generation SES or CABG. (Evaluation of Outcomes of EES Implantation for Unprotected Left Main Coronary Artery Stenosis [PRECOMBAT-2]; NCT01348022 )

OBJECTIVES: To compare the safety and efficacy of coronary artery bypass grafting (CABG) with percutaneous coronary intervention (PCI) using drug-eluting stents (DES) in patients with unprotected left main coronary artery (ULMCA) disease. METHODS: MEDLINE, EMBASE, CENTRAL/CCTR, SciELO, LILACS, Google Scholar and reference lists of relevant articles were searched for clinical studies that reported outcomes at the 1-year follow-up after PCI with DES and CABG for the treatment of ULMCA stenosis. Sixteen studies (three randomized controlled trials and 13 observational studies) were identified and included a total of 5674 patients (2331 for PCI with DES and 3343 for CABG). RESULTS: At the 1-year follow-up, there was no significant difference between the CABG and DES groups in the risk for death (odds ratio [OR] 0.691, P= 0.051) or the composite endpoint of death, myocardial infarction or stroke (OR 0.832, P = 0.258). The risk for target vessel revascularization (TVR) was significantly higher in the PCI group compared with the CABG group (OR 3.597, P < 0.001). The risk of major adverse cardiac and cerebrovascular events (MACCE) was significantly higher in the PCI group compared with the CABG group (OR 1.607, P< 0.001). A publication bias was observed regarding the outcome of death and also a considerable heterogeneity effect on the composite endpoint of death, myocardial infarction or stroke and MACCE. CONCLUSIONS: CABG surgery remains the best option of treatment for patients with ULMCA disease, with less need of TVR and lower MACCE rates.

Background: We previously demonstrated that squatting induces left ventricular (LV) wall motion abnormalities (WMA) in areas subtended by stenotic coronary arteries. In addition, it was observed that some subjects developed acute changes in LV shape (acute left ventricular remodeling [ALVRM]) during squatting. Objective: This study tested the hypothesis that patients with ALVRM during squatting echocardiography have higher incidences of severe coronary artery disease (CAD). Methods: Echocardiography was performed in all standard views during standing and squatting. End-systolic frames in the apical four-chamber view were analyzed. Results: The subjects were divided into three groups. Group 1 consisted of 12 subjects who developed squatting-induced ALVRM with apical and distal posterior septal akinesis, dilation of the apex and marked LV shape change at end-systole. Group 2 consisted of 20 subjects with distal posterior septal and apical akinesis without ALVRM, during squatting. Group 3 consisted of 64 subjects who developed WMA in areas other than the apex (n = 49), or normal wall motion (n = 15) during squatting. Coronary angiography in group 1 revealed that 6 subjects had left main coronary artery stenosis (LMCAS ≥ 50%), two had severe three vessel disease (≥90% stenosis), and one had 100% left anterior descending coronary artery occlusion. Severe CAD was defined for purpose of this study as the presence of LMCAS, or severe three vessel disease (≥90% stenosis). Six subjects in group 2 had LMCAS and none had severe three vessel disease (P < 0.05 vs. group 1 for LMCAS and/or three vessel disease). In group 3, eight had LMCAS and none had severe three vessel disease (P < 0.0001 vs. group 1). Conclusion: Patients with ALVRM have severe CAD. Therefore, patients who develop ALVRM during squatting require urgent evaluation for revascularization therapy. (Echocardiography 2012;29:700-705)

Objectives This study sought to assess percutaneous coronary intervention (PCI) for unprotected left main coronary artery (ULMCA) stenosis in routine U.S. clinical practice. Background Percutaneous coronary intervention for ULMCA stenosis is controversial; however, current use and outcomes of ULMCA PCI in routine U.S. clinical practice have not been described. Methods We evaluated 5,627 patients undergoing ULMCA PCI at 693 centers within the National Cardiovascular Data Registry Catheterization Percutaneous Coronary Intervention Registry for temporal trends in PCI use (2004 to 2008), patient characteristics, and in-hospital mortality. Thirty-month mortality and composite major adverse events (death, myocardial infarction, and revascularization) with drug-eluting versus bare-metal stents were compared using inverse probability weighted (IPW) hazard ratios (HRs) in a nonrandomized Medicare-linked (age ≥65 years) patient cohort (n = 2,765). Results ULMCA PCI was performed in 4.3% of patients with ULMCA stenosis. Unadjusted in-hospital mortality rates ranged from 2.9% for elective cases to 45.1% for emergent/salvage cases. By 30 months, 57.9% of the elderly ULMCA PCI population experienced death, myocardial infarction, or revascularization, and 42.7% died. Patients receiving drug-eluting stents (versus bare-metal stents) had a lower 30-month mortality (IPW HR: 0.84, 95% confidence interval [CI]: 0.73 to 0.96), but the composite of major adverse events were similar (IPW HR: 0.95, 95% CI: 0.84 to 1.06). Conclusions In the United States, ULMCA PCI is performed in

Coronary artery stenosis is a rare phenomenon in children. Coronary stent implantation is generally not considered a standard treatment option due to technical difficulties and potential complications in this group of patients. Nevertheless, several pediatric cases reporting successful implantation with acceptable short-term experiences have been described. The following case presents a successful stent implantation for left main coronary artery (LMCA) stenosis early after surgery for anomalous left coronary artery from pulmonary artery (ALCAPA) at the age of 6 months. The excellent mid-term results and notably the procedure's potential as a longterm treatment in small children are highlighted. A 6-month-old infant underwent surgery for ALCAPA. Due to sudden postoperative deterioration, cardiac catheterization was performed. Coronary angiography revealed severe (90%) ostial LMCA stenosis. A PROMUS drug-eluting stent (Promus Element AL3.0 × 8 mm, Boston Scientific, Natick, Massachusetts, USA) was implanted. The procedure was performed without complications. Antiplatelet therapy with acetylsalicylic acid and clopidogrel was initiated. Subsequently, cardiac function improved slowly. Cardiac catheterization 3 years 8 months after stent implantation showed no restenosis with a proximal LMCA diameter still at the 50(th) percentile for age. Neither were signs of heart failure reported at the last follow-up at 7 years of age. Presupposing normal growth, the implanted stent would thus provide sufficient myocardial perfusion with a LMCA lumen at the 40(th) percentile at the age of 16 years. In selected cases, coronary stent implantation may be an effective mid- to long-term treatment of coronary artery stenosis even in very young children.

Calcified nodules in human coronary arteries are usually focally distributed. Non-invasive imaging of coronary arteries by bedside emergency transthoracic echocardiography in adults is possible and may become a useful adjunct to other methods of coronary artery examination. Coronary artery stenosis can be identified as localized color aliasing and accelerated flow velocities. Complete visualization of individual ostial coronary segments might ease the demonstration of coronary stenosis by bedside transthoracic echocardiography. The left main coronary artery stenosis requires prompt emergency evaluation and treatment because emergency conditions have higher mortality rates. The authors wish to emphasize the usefulness of emergency bedside echo-Doppler for a prompt diagnosis and treatment of this life-threatening condition.

Background The feasibility of percutaneous coronary intervention (PCI) using drug-eluting stents and its comparability with bypass surgery in treatment of unprotected left main coronary artery (LMCA) stenosis has been shown previously. We compared the mid-to long-term outcome between sirolimus-(SES) vs. paclitaxel-eluting stents (PES) in an all-comer analysis that included all patients with unprotected LMCA stenosis who underwent PCI with SES or PES. Methods From March 2003 and June 2007, 196 patients underwent PCI with SES or PES for unprotected LMCA stenosis at Seoul National University Main or Bundang Hospital; SES was implanted in 141 patients and PES in 55 patients. The baseline clinical and procedural characteristics were mostly similar between the SES and PES group. Results After 2years of follow-up, there were no differences in the rate of cardiac death (9.1% vs. 8.5%) and nonfatal MI (5.5% vs. 2.8%) between the two groups. However, the risk of repeat revascularization tended to be lower in the SES group compared with the PES group [TLR, 9.9% vs. 20.0% ( P =0.06); TVR, 17.7% vs. 30.9% ( P =0.05)], which did not reach statistical significance. The rate of stent thrombosis (ST) was also similar between the two groups (3.6% vs. 2.1% for definite ST, 3.6% vs. 2.8% for definite+probable ST). Conclusions In all-comers undergoing first generation DES implantation for unprotected LMCA stenosis, PES and SES showed comparable 2-year clinical results regarding hard endpoints and major adverse cardiac events.

Background: Percutaneous coronary intervention (PCI) with stent implantation is now considered a safe and feasible treatment for stenosis of the unprotected left main coronary artery (ULMCA). Because few studies have focused on de novo distal ULMCA lesions, a propensity score-matched cohort study was conducted to compare bare metal stents (BMS) with drug-eluting stents (DES) for long-term outcomes following PCI. Methods and Results: This study reviewed the outcomes of patients undergoing PCI with DES (n=127) or BMS (n=51) for distal de novo ULMCA stenosis. The baseline demographic, angiographic and procedural characteristics differed between the 2 groups, indicating potential selection bias. The propensity score-matched cohort showed that the DES group had significantly less target lesion revascularization (TLR) and major adverse cardiovascular events (MACE) following PCI than the BMS group. Furthermore, heart failure (HF) of New York heart Association functional class III/IV was associated with an increased risk of TLR and MACE, whereas implantation of DES in patients with significant HF led to more favorable outcomes. Conclusions: Lower rates of TLR and MACE occurred in patients following PCI with DES implantation than with BMS implantation for distal ULMCA stenosis. Implantation of DES in patients with significant HF may improve the unfavorable outcome. When PCI is chosen to manage distal ULMCA stenosis, DES is the preferred stent type. (Circ J 2011; 75: 290-298)

Drug-eluting stents (DES) have markedly reduced the incidence of coronary in-stent restenosis. However, DES may be still vulnerable to coronary thrombus, and the long-term outcome remains unknown, especially in infancy. Here, we present a 9-month-old infant, who developed severe stenosis of the left main coronary artery after surgery for Brand-White-Garland syndrome, and was successfully treated with DES. He was healthy and his cardiac function had improved to the normal level at 6 years old. An angiographic examination and computed tomography showed the complete persistence of DES and no evidence of intimal thickening.

Objectives We performed the long-term follow-up of a large cohort of patients in a multicenter study receiving left main coronary artery (LMCA) revascularization. Background Limited information is available on long-term outcomes for patients with unprotected LMCA disease who underwent coronary stent procedure or coronary artery bypass grafting (CABG). Methods We evaluated 2,240 patients with unprotected LMCA disease who received coronary stents (n = 1,102; 318 with bare-metal stents and 784 with drug-eluting stents) or underwent CABG (n = 1,138) between 2000 and 2006 and for whom complete follow-up data were available for at least 3 to 9 years (median 5.2 years). The 5-year adverse outcomes (death; a composite outcome of death, Q-wave myocardial infarction [MI], or stroke; and target vessel revascularization [TVR]) were compared with the use of the inverse probability of treatment weighted method and propensity-score matching. Results After adjustment for differences in baseline risk factors with the inverse probability of treatment weighting, the 5-year risk of death (hazard ratio [HR]: 1.13; 95% confidence interval [CI]: 0.88 to 1.44, p = 0.35) and the combined risk of death, Q-wave MI, or stroke (HR: 1.07; 95% CI: 0.84 to 1.37, p = 0.59) were not significantly different for patients undergoing stenting versus CABG. The risk of TVR was significantly higher in the stenting group than in the CABG group (HR: 5.11; 95% CI: 3.52 to 7.42, p Conclusions During 5-year follow-up, stenting showed similar rates of mortality and of the composite of death, Q-wave MI, or stroke but higher rates of TVR as compared with CABG for patients with unprotected LMCA disease.

Objectives We sought to evaluate at 5 years the occurrence of cardiac death; cardiac death, and/or myocardial infarction (MI); cardiac death, MI, and/or stroke; target vessel revascularization; and major adverse cardiac and cerebrovascular events following percutaneous coronary intervention (PCI) with drug-eluting stent (DES) versus coronary artery bypass graft (CABG) in unprotected left main coronary artery lesions. Background Preliminary results at 1 year showed comparable occurrence of major adverse cardiac and cerebrovascular events in our center between PCI and CABG. Methods All consecutive patients with an unprotected left main coronary artery stenosis electively treated with DES implantation versus CABG in our center, between March 2002 and July 2004, were analyzed. A propensity analysis was performed to adjust for baseline differences between the 2 cohorts. Results We included 249 patients in the study: 107 were treated with PCI and DES implantation and 142 with CABG. At 5-year clinical follow-up, no difference was found between PCI and CABG in the occurrence of cardiac death (adjusted odds ratio [OR]: 0.502; 95% confidence interval [CI]: 0.162 to 1.461; p = 0.24). The PCI group showed a trend toward a lower occurrence of the composite end point of cardiac death and MI (adjusted OR: 0.408; 95% CI: 0.146 to 1.061; p = 0.06). Percutaneous coronary intervention was associated with a lower rate of the composite end point of death, MI, and/or stroke (OR: 0.399; 95% CI: 0.151 to 0.989; p = 0.04). Indeed, CABG was correlated with lower target vessel revascularization (adjusted OR: 4.411; 95% CI: 1.825 to 11.371; p = 0.0004). No difference was detected in the occurrence of major adverse cardiac and cerebrovascular events (adjusted OR: 1.578; 95% CI: 0.825 to 3.054; p = 0.18). Conclusions At 5-year clinical follow-up, there was still no difference in the occurrence of major adverse cardiac and cerebrovascular events between elective PCI with DES implantation and CABG in unprotected left main coronary artery lesions in this single-center experience. There was an advantage of PCI in the composite end point of death, MI, and/or stroke, whereas a benefit in the need for reintervention was still found in CABG.

The long-term safety and efficiency of sirolimus-eluting stent (SES) treatment in unprotected left main coronary artery (ULMCA) have not yet been ascertained.From 2003 to 2006, 126 consecutive patients with de novo lesions in ULMCA who underwent SES were retrospectively analyzed in a single center in China. During 4-year follow-up, major adverse cardiovascular event (MACE)-free survival was 74.6%. Cardiac death occurred in 5 (4.0%), and target lesion revascularization (TLR) and target vessel revascularization (TVR) occurred in 15 (11.9%) and 24 (19.0%) patients, respectively. One (0.8%) experienced probable stent thrombosis while 1 (0.8%) presented possible stent thrombosis. Impaired LVEF (40%) and high surgical risk (Euro score6) were the independent predictors of MACEs.PCI with SES for de novo lesions in ULMCA is feasible with a low procedural risk. However, SES was associated with a relatively higher rate of TLR and TVR. Impaired LVEF and high surgical risk were important predictors of MACEs.

Recently, drug-eluting stent (DES) has been recommended as the first choice in those patients who need stent implantation in unprotected left main coronary artery (ULMCA) stenosis. However, the long-term safety and efficacy of this procedure is still controversial. The objective of this study was to evaluate the safety and efficacy of bare metal stent (BMS) implantation in ULMCA stenting in the DES era. We implanted BMS (mainly 4 mm-diameter) in large-sized ULMCA after December 2004 when DES became available. The results of BMS implantation (n = 19) were compared with those of DES implantation (n = 39). There was no significant difference between the 2 groups regarding age, gender and coronary risk factors. Emergency procedures were more frequently performed in the BMS group than in the DES group (53% vs. 26%, p = 0.08). The initial mortality was 10.5% (n = 2) in the BMS group and 2.6% (n = 1) in the DES group (p = 0.25). There was no stent thrombosis, Q-wave myocardial infarction or emergent bypass surgery in either group during their hospital stay. The restenosis rate was 0% (n = 45) in both groups, and the target vessel revascularization rate was 5.9% in the BMS group (1/17) and 2.6% (1/38) in the DES group (p = 0.53). Therefore, there were no statistically significant differences in outcomes between the two study groups. These results indicate that BMS implantation in a large-sized ULMCA may be a safe and effective treatment even in the DES era.

Background— Limited information is available on long-term outcomes for patients with unprotected left main coronary artery disease who received drug-eluting stents (DES). Methods and Results— In the multicenter registry evaluating outcomes among patients with unprotected left main coronary artery stenosis undergoing stenting with either bare metal stents (BMS) or DES, 1217 consecutive patients were divided into 2 groups: 353 who received only BMS and 864 who received at least 1 DES. The 3-year outcomes were compared by use of the adjustment of inverse-probability-of-treatment-weighted method. Patients receiving DES were older and had a higher prevalence of diabetes mellitus, hypertension, hyperlipidemia, and multivessel disease. In the overall population, with the use of DES, the 3-year adjusted risk of death (8.0% versus 9.5%; hazard ratio, 0.71; 95% confidence interval, 0.36 to 1.40; P =0.976) or death or myocardial infarction (14.3% versus 14.9%; hazard ratio, 0.83; 95% confidence interval, 0.49 to 1.40; P =0.479) was similar compared with BMS. However, the risk of target lesion revascularization was significantly lower with the use of DES than BMS (5.4% versus 12.1%; hazard ratio, 0.40; 95% confidence interval, 0.22 to 0.73; P =0.003). When patients were classified according to lesion location, DES was still associated with lower risk of target lesion revascularization in patients with bifurcation (6.9% versus 16.3%; hazard ratio, 0.38; 95% confidence interval, 0.18 to 0.78; P =0.009) or nonbifurcation (3.4% versus 10.3%; hazard ratio, 0.39; 95% confidence interval, 0.17 to 0.88; P =0.024) lesions with a comparable risk of death or myocardial infarction. Conclusions— Compared with BMS, DES was associated with a reduction in the need for repeat revascularization without increasing the risk of death or myocardial infarction for patients with unprotected left main coronary artery stenosis.

Objectives The aim of this study was to evaluate long-term clinical outcomes after implantation of sirolimus-eluting stents (SES) or paclitaxel-eluting stents (PES) among patients with unprotected left main coronary artery (LMCA) disease. Background There have been few comparisons of long-term outcomes among currently available drug-eluting stents (DES) for the treatment of LMCA disease. Methods A total of 858 consecutive patients with unprotected LMCA stenosis were treated with SES (n = 669) or PES (n = 189) between May 2003 and June 2006. Primary outcome was the composite of death, myocardial infarction (MI), or target vessel revascularization (TVR). Results Baseline clinical and angiographic characteristics were similar in the 2 groups. During 3 years of follow-up, the adjusted risk of primary composite outcome was similar among the groups (SES vs. PES: 25.8% vs. 25.7%, hazard ratio [HR]: 0.95, 95% confidence interval [CI]: 0.64 to 1.41, p = 0.79). The 2 groups also showed a comparable adjusted rate of each component of outcome: death (9.1% vs. 11.0%, HR: 0.92, 95% CI: 0.47 to 1.80, p = 0.82), MI (8.1% vs. 8.0%, HR: 0.80, 95% CI: 0.43 to 1.48, p = 0.47), and TVR (12.1% vs. 10.6%, HR: 1.10, 95% CI: 0.53 to 2.29, p = 0.81). The 3-year rates of definite or probable stent thrombosis were 0.6% in the SES group and 1.6% in the PES group (adjusted p = 0.18). Conclusions In consecutive patients with unprotected LMCA disease undergoing DES implantation, SES and PES showed similar long-term clinical outcomes in terms of death, MI, repeat revascularization, and stent thrombosis.

Background: Although recent studies suggest that percutaneous coronary intervention (PCI) with drug-eluting stents (DES) achieves clinical outcomes comparable to coronary artery bypass graft surgery (CABG) for unprotected left main coronary artery (ULMCA) disease, long-term studies are rarely performed. Methods and Results: This study reviewed outcomes in 363 patients undergoing CABG (n=216), PCI with DES (n=94) or PCI with bare-metal stent (BMS) (n=53) for ULMCA stenosis between January 2000 and March 2007. The CABG group had more patients with diabetes (50.5%) and 3- or 4-vessel disease (77.3%) than the PCI group. Kaplan-Meier survival estimates showed higher TLR-free survival and revascularization-free survival in CABG group. Although cardiac-death-free survival did not significantly differ between the 3 groups, the DES group had the highest overall survival. Age (hazard ratio (HR): 1.060; 95% confidence interval (CI): 1.017-1.104) and diffuseness score (HR: 1.157; 95%CI: 1.019-1.313) were significant independent risk factors for cardiac death. Conclusions: There was higher TLR in the PCI group with either DES or BMS, but cardiac death did not significantly differ between the 3 groups. Advanced age and diffuse coronary atherosclerosis may increase the risk of cardiac death following revascularization. (Circ J 2009; 73: 705 - 712)

Experience of on- and off-pump coronary artery bypass in 379 patients with significant left main coronary artery stenosis was retrospectively reviewed. Beating-heart operations were performed on 219 patients between January 2001 and October 2007. Their results were compared with 160 who underwent revascularization under cardiopulmonary bypass during the same period. All patients had multivessel grafting via a median sternotomy. Both groups were comparable demographically. Off-pump patients received significantly fewer grafts per patient (3.21 ± 0.86 vs 3.74 ± 0.82). The use of moderate or high doses of inotropics (> 5 μ g · kg−1 · min−1) was more frequent in the on-pump group (44% vs 26%). Postoperative blood transfusion requirement was lower in off-pump patients, and fewer of them experienced worsening of preexisting renal insufficiency. There were 2 operative deaths in the on-pump group and 1 in the off-pump group. The off-pump procedure is safe and effective in patients with left main coronary artery disease.

Background Conventional coronary artery bypass grafting (CABG) is recognized as the treatment of choice for left main coronary artery stenosis (LMCA) with excellent results. Patch angioplasty is an alternative method in selected cases for ostial stenosis of the LMCA. However, the long-term outcome data of this surgical technique are lacking. Therefore, the aim of this study was to evaluate the long-term outcome of patients treated by patch angioplasty using saphenous vein for ostial stenosis of the LMCA. Methods Nineteen patients underwent vein patch angioplasty for ostial LMCA stenosis between 1995 and 2005 at our institution. On three of them simultaneous aortic valve replacement was carried out and on one patient concomitant coronary artery bypass grafting of the right coronary artery was performed. Patients were followed up clinically and by magnetic resonance imaging (MRI) at 5.11 +/- 3.34 years (range 0.6-10 years). Results The early postoperative course was uneventful in all patients. There were no in-hospital deaths. In the late course, three patients died from unrelated causes three and a half, four, and six years after surgery. Importantly, at the time of follow-up the MRI revealed no restenosis or aneurysmatic coronary formation. All patients were in excellent clinical condition at follow-up. Conclusions Surgical patch angioplasty with saphenous vein for isolated ostial LMCA stenosis is a safe operative technique with good long-term results. MRI is able to adequately depict the operative result of left main coronary ostium reconstruction.

The Coronary Artery Revascularization Prophylaxis (CARP) study showed no survival benefit with preoperative coronary artery revascularization before elective vascular surgery. The generalizability of the trial results to all patients with multivessel coronary artery disease (CAD) has been questioned. The objective of this study was to determine the impact of prophylactic coronary revascularization on long-term survival in patients with multivessel CAD. Over a 4-year period, 1,048 patients underwent coronary angiography before vascular surgery during screening into the CARP trial. The cohort was composed of registry (n = 586) and randomized (n = 462) patients, and their survival was determined at 2.5 years after vascular surgery. High-risk coronary anatomy without previous bypass surgery included 2-vessel disease (n = 204 [19.5%]), 3-vessel disease (n = 130 [12.4%]), and left main coronary artery stenosis > or = 50% (n = 48 [4.6%]). By log-rank test, preoperative revascularization was associated with improved survival in patients with a left main coronary artery stenoses (0.84 vs 0.52, p

Several studies have compared the treatment effects of coronary stenting and coronary-artery bypass grafting (CABG). However, there are limited data regarding the long-term outcomes of these two interventions for patients with unprotected left main coronary artery disease.We evaluated 1102 patients with unprotected left main coronary artery disease who underwent stent implantation and 1138 patients who underwent CABG in Korea between January 2000 and June 2006. We compared adverse outcomes (death; a composite outcome of death, Q-wave myocardial infarction, or stroke; and target-vessel revascularization) with the use of propensity-score matching in the overall cohort and in separate subgroups according to type of stent.In the overall matched cohort, there was no significant difference between the stenting and CABG groups in the risk of death (hazard ratio for the stenting group, 1.18; 95% confidence interval [CI], 0.77 to 1.80) or the risk of the composite outcome (hazard ratio for the stenting group, 1.10; 95% CI, 0.75 to 1.62). The rates of target-vessel revascularization were significantly higher in the group that received stents than in the group that underwent CABG (hazard ratio, 4.76; 95% CI, 2.80 to 8.11). Comparisons of the group that received bare-metal stents with the group that underwent CABG and of the group that received drug-eluting stents with the group that underwent CABG produced similar results, although there was a trend toward higher rates of death and the composite end point in the group that received drug-eluting stents.In a cohort of patients with unprotected left main coronary artery disease, we found no significant difference in rates of death or of the composite end point of death, Q-wave myocardial infarction, or stroke between patients receiving stents and those undergoing CABG. However, stenting, even with drug-eluting stents, was associated with higher rates of target-vessel revascularization than was CABG.

Objectives: To assess the safety and efficacy of percutaneous coronary intervention (PCI) with drug-eluting stents (DES) in orthotopic heart transplantation (OHT) patients with unprotected left main coronary artery (ULMCA) disease. Background: Accelerated transplant coronary artery disease occurs in 50% of patients at 5 years and is the major cause of death following OHT. The optimal treatment for ULMCA disease in OHT patients is unknown. Methods: From April 2003 to December 2006, five OHT patients with ULMCA disease underwent PCI with DES at the University of California, Los Angeles, Medical Center. Results: Technical success was achieved in all five patients. At a median follow-up of 518 days (range 124–990 days), all five patients were alive and free from death, myocardial infarction, and target vessel revascularization. No binary restenosis was present in four patients who underwent surveillance angiography. One patient underwent repeat OHT for progressive left ventricular dysfunction. Conclusions: In OHT patients, ULMCA PCI with DES is feasible with an excellent technical success rate and is a reasonably palliative treatment option for this difficult patient population. © 2008 Wiley-Liss, Inc.

ObjectivesThe purpose of this study was to compare the early and late results of percutaneous and surgical revascularization of left main coronary artery stenosis.BackgroundUnprotected left main coronary artery (ULMCA) stenting is being investigated as an alternative to bypass surgery.MethodsWe randomly assigned 105 patients with ULMCA stenosis to percutaneous coronary intervention (PCI; 52 patients) or coronary artery bypass grafting (CABG; 53 patients). The primary end point was the change in left ventricular ejection fraction (LVEF) 12 months after the intervention. Secondary end points included 30-day major adverse events (MAE), major adverse cardiac and cerebrovascular events (MACCE), length of hospitalization, target vessel failure (TVF), angina severity and exercise tolerance after 1 year, and total and MACCE-free survival.ResultsA significant increase in LVEF at the 12-month follow-up was noted only in the PCI group (3.3 ± 6.7% after PCI vs. 0.5 ± 0.8% after CABG; p = 0.047). Patients performed equally well on stress tests, and angina status improved similarly in the 2 groups. PCI was associated with a lower 30-day risk of MAE (p < 0.006) and MACCE (p = 0.03) and shorter hospitalizations (p = 0.0007). Total and MACCE-free 1-year survival was comparable. Left main TVF was similar in the 2 groups. During the 28.0 ± 9.9-month follow-up, there were 3 deaths in the PCI group and 7 deaths in the CABG group (p = 0.08).ConclusionsPatients with ULMCA disease treated with PCI had favorable early outcomes in comparison with the CABG group. At 1 year, LVEF had improved significantly only in the PCI group. After more than 2 years, MACCE-free survival was similar in both groups with a trend toward improved survival after PCI. (Study of Unprotected Left Main Stenting Versus Bypass Surgery [LE MANS study]; NCT00375063).