Author + information
- Saqib Ghani1,
- Grigoris Karamasis1,
- Firas Al Janabi1,
- Edney Boston Griffiths1,
- Thomas Keeble1,
- John Davies1,
- Kare Tang1 and
- Paul Kelly1
Left main stem (LMS) disease has major prognostic significance due to the proportion of myocardium at risk. Revascularization of unprotected LMS by percutaneous coronary intervention (PCI) can be technically challenging due to factors like vessel size, aorto-ostial location, calcification, bifurcation and risk of hemodynamic compromise. Recent randomized control studies support LMS PCI in a selected cohort of patients.
The purpose of this study was to assess outcomes of unprotected LMS PCI in a high volume tertiary centre.
We conducted a retrospective observational study on all patients undergoing PCI for unprotected LMS in a single tertiary cardiac centre from 2012 to 2016. Data was collected from a dedicated electronic PCI database and hospital patient administration system.
For the study period, 245 patients underwent PCI to unprotected LMS. The mean age was 71.6 (range 31 to 94) and 72 % were male; 24% were diabetic and 36% had previous myocardial infarction. 35% were elective procedures and 65% emergency cases (17.5% STEMI, 47.5% NSTEMI / ACS); 6.5% were ventilated pre-procedure; 13.4% had cardiogenic shock. Radial arterial access was used in 51% cases, intra-vascular ultrasound (IVUS) was used in 41% (61% of electives), 6% underwent rotablation, and intra-aortic balloon pump (IABP) was inserted in 1.6% cases. Isolated LMS PCI was performed in 15% and another 4% underwent PCI to RCA at the same time; 51% cases underwent LMS + LAD/LCX PCI; 30% had PCI to LMS+LAD+LCX. Average length of hospital stay was 3.2 days for all cases; 88% of elective cases were discharged within 48 hours; 25% of emergency cases had >10day hospital stay. In-hospital mortality was 4% (all elective cases survived to hospital discharge); overall 30-day and 1 year mortality were 7% and 16% (0% and 0.3% for electives; 10% and 23% for emergencies respectively). Other complications included embolic stroke 1.2%; vascular complications 1.6%; pericardial effusion 1.2%; stent thrombosis 0.4%, emergency bypass graft 0.4%, contrast nephropathy 0.8% and gastro-intestinal bleed requiring blood transfusion 0.4%.
Unprotected LMS PCI in selected group of patients is safe and effective with good survival outcomes when performed by experienced operators. In particular, the 1-year survival rate of 99.7% for elective cases is impressive and highlights the importance of appropriate case selection. Further long term follow-up of these patients is needed.