Author + information
- Erion Xhepa1,
- Sebastian Kufner1,
- Salvatore Cassese1,
- Robert Byrne1,
- Michael Joner2,
- Tareq Ibrahim3,
- Gjin Ndrepepa4,
- Klaus Tiroch5,
- Marco Valgimigli6,
- Ralph Toelg7,
- Massimiliano Fusaro1,
- Heribert Schunkert2,
- Karl-Ludwig Laugwitz8 and
- Adnan Kastrati2
- 1Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
- 2Deutsches Herzzentrum München, Munich, Germany
- 3Klinikum Rechts der Isar, Munich, Germany
- 4DHZ, Munich, Germany
- 5Herz-Zentrum Bodensee, Konstanz, Germany
- 6Swiss Cardiovascular Center, Inselpsital, Bern, Switzerland
- 7Herzzentrum Segeberger Kliniken, Henstedt-Ulzburg, Germany
- 8Klinikum rechts der Isar TUM, Munich, Germany
Large randomized clinical trials as well as real world registries lend support to the use of percutaneous treatment of unprotected left main coronary artery (uLMCA) as a valid alternative to CABG in patients with low-intermediate SYNTAX scores. However, long-term clinical outcomes of patients presenting with in-stent-restenosis (ISR) after drug-eluting stent (DES) implantation for uLMCA have not been adequately investigated.
The present report is based on the pooled patient-level data of the ISAR-LEFT MAIN and ISAR-LEFT MAIN 2 randomized clinical trials. It aimed to specifically investigate the long-term clinical outcomes of the patient subgroup presenting with ISR after DES implantation for uLMCA. The clinical outcomes of this patient subgroup were studied with the follow-up (FU) being extended up to 5 years. The primary endpoint was the composite of death and target lesion revascularization (TLR) at 5-year FU. Survival analysis was made by applying the Kaplan-Meier method and differences were assessed for significance by means of the log-rank test.
Of the 1257 patients enrolled in the 2 randomized trials, 174 patients (13.8%), owing to symptoms and/or evidence of myocardial ischemia, underwent repeat catheterization with evidence of ISR. At 5-year FU, 122 patients survived while 52 patients (29.8%) didn't. As compared with non-survivors, patients surviving at 5-years FU were younger (72.9 (68.7-80.0) vs. 68.3 (63.0-75.9); p=0.004), less often diabetic (25 (48.1%) vs. 38 (31.1%); p=0.03), had lower creatinine serum levels (1.18 (0.99-1.76) vs. 0.90 (0.80-1.03); p<0.001) and higher left ventricular ejection fraction (49.0 (34.5-59.3) vs. 59.0 (50.0-61.8); p<0.001), presented less often with chronic obstructive pulmonary disease (4 (7.7%) vs. 1 (0.83%); p=0.01), acute coronary syndrome (23 (44.2%) vs. 20 (16.4%); p<0.001) and cardiogenic shock (3 (5.8%) vs. 1 (0.83%); p=0.04). The repeat revascularization strategy was represented by CABG in 17 patients (9.77%), PTCA in 88 patients (50.58%) and repeat stent implantation in 69 patients (39.66%). There were no significant differences in the occurrence of the composite endpoint of death and TLR when stratified for (i) revascularization strategy (CABG vs. PTCA vs. repeat stenting): p=0.8672; (ii) LM lesion localization (ostial vs. body vs. distal): p=0.7845; (iii) stenting technique (single stent vs. T-stenting technique vs. culotte stenting technique): p=0.2678.
The occurrence of the composite endpoint of death or TLR al 5 year follow-up in patients presenting with ISR after DES implantation for uLMCA is not negligible. We found no signficant interaction between the occurrence of this composite endpoint and revascularization strategy, left main lesion localization and stenting technique. Independently of anatomical complexity and interventional strategy, relevant clinical factors were unevenly distributed between the group of patients who survived the 5 year follow-up and those who didn't and could therefore play a relevant role in determining patient outcomes.
CORONARY: PCI Outcomes