Left Main Target Lesion Revascularization: When is it Necessary?

Courtesy of Dr. Agustín Vecchia.

Incidence, predictors and impact of target lesion revascularization (TLR) on unprotected left main stenosis initially treated with second generation DES have not yet been clearly defined and this is the main goal of the present study.

This is a multicenter observational retrospective study of patients with unprotected left main stenosis undergoing second generation DES stenting between 2007 and 2015; final end point was TLR.

The study assessed 1,270 consecutive patients. After a mean follow up of 650 days (230 to 1170) 47 patients (3.7%) required left main reintervention, 22 as a result of planned angiographic follow up. The remaining 16 patients were hospitalized for unstable angina, 4 with non ST elevation AMI and one with ST elevation AMI. 56% of restenosis cases were focal, 33% diffuse and 10% proliferative. 

In multivariable analyzis, diabetes mellitus (DM) increased the risk of TLR (HR 2.0: 1.1 to 2.6, p=0.04) while intravascular ultrasound (IVUS) guided PCI, reduced it (HR 0.5: 0.3 to 0.9 p=0.02).

Cardiovascular mortality was similar between patients who needed TLR vs. those who didn’t (4% vs. 4% p=0.95), and multivariable analyzis showed the need of TLR did not increase the risk of global mortality (HR 0.4: 0.1 a 1.6, p=0.22), while cardiogenic shock and III score syntax did.

The authors concluded that the need of repeat revascularization after left main second generation DES stenting

•  is low
• is higher in patients with DM and lower in patients with IVUS guided PCI
• has no significant impact on global mortality.

Editorial Comment

This is an observational retrospective study about a multicenter registry of patients admitted for left main intervention, treated with techniques and post PCI drug prescription protocols left to participant centers criteria, which were not disclosed for publication purposes.

Clinical restenosis rate is low and similar to the already reported for this procedure with second generation DES and lower to the one observed with first generation DES; positive association with DM and negative association to IVUS use confirm previously published findings.

However, TLR impact on global mortality, which appears neutral, should be regarded with caution, considering the retrospective character of this study and the lack of an events assigning committee.

Courtesy of Dr. Agustín Vecchia. Buenos Aires German Hospital, Buenos Aires, Argentina

Original Title:  Incidence and Management of Restenosis after Treatment of Unprotected Left Main Disease with Second-Generation Drug-Eluting Stents (from Failure in Left Main Study with 2nd Generation Stents – Cardiogroup III Study).

Reference: D´Ascenzo F, Chieffo A, Cerrato E, et al Am J Cardiol 2017 Apr 1;119(7):978-982.

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