Original title: Comparative Outcomes After Unprotected Left Main Stem Percutaneous Coronary Intervention: A National Linked Cohort Study of 5,065 Acute and Elective Cases From the BCIS Registry (British Cardiovascular Intervention Society). Reference: Sami S. Almudarra, et al. JACC Cardiovasc Interv 2014;7:717-30

Although myocardial revascularization surgery has long been the gold standard treatment for left main lesions, PCI has become a common practice these days. Yet, it has not been thoroughly described.

This study analyzed 5065 patients undergoing PCI to the unprotected left main stem (UPLMS) between 2005 and 2010, included in the prospective registry of the British Cardiovascular Intervention Society. 784 (15.5%) presented with STEMI, 2381 (47%) with NSTEACS, and 1900 (37.5%) with CSA. In addition, 76.2% of STEMI patients, 72.6% of NSTEACS and 69.8% of CSA patients received multiple vessel PCI. DES were used in 59.4%, 71.1% and 77.8%, respectively. 

IVUS and FFR were more frequently used in programmed patients with CSA. Mortality at 30 days and at 12 months was 28.3% and 37.6% respectively, in the context of STEMI, 8.9% and 19.5% respectively in the context of NSTEACS and 1.4% and 7% respectively in the context of CSA. Radial access presented lower mortality at 30 days and at 12 months in the three groups.

Mortality predictors for acute coronary syndromes were ≥80 years, cardiogenic shock, severe left ventricular dysfunction, mechanical ventilation, renal failure and femoral access. 

Conclusion

More than half of unprotected left main PCI procedures are performed in the context of acute coronary syndromes. Cardiogenic shock is frequent in STEMI and left main lesions, and has a mortality rate higher than 50% at 30 days. Radial Access was associated to a lower mortality rate.

Commentary

This analysis shows the evolution of left main PCI in the different scenarios and, as expected, shows that the combination of STEMI and cardiogenic shock increases 30 day mortality rate by 9 times, and 12 month mortality by 5. It also contributes to the already established notion that the radial access is beneficial to all groups of patients. 

Courtesy of Dr. Carlos Fava
Interventional Cardiologist
Favaloro Foundation
Buenos Aires – Argentina

Carlos Fava