Trends in percutaneous versus surgical revascularization of unprotected left main coronary stenosis in the drug-eluting stent era: a report from the American College of Cardiology-National Cardiovascular Data Registry (ACC-NCDR).

OBJECTIVES: We sought to determine how practice patterns for unprotected left main stenosis have changed with the advent of drug-eluting stents (DES).
BACKGROUND: Percutaneous coronary intervention (PCI) of unprotected left main coronary stenosis has been controversial.
METHODS: We analyzed data submitted to the American College of Cardiology-National Cardiovascular Data Registry (ACC-NCDR) between January 1, 2002 and December 31, 2004 from 1,276,582 cardiac catheterizations at 417 institutions. Of these, 53,548 (4.2%) had left main stenosis >50% and no prior CABG. After excluding the unrevascularized, the patient sample (N = 32,562) was analyzed for PCI vs. CABG. Data was stratified by year/quarter, bare metal stent vs. DES, elective vs. urgent/emergent situations, LVEF < or > or =40%, and %left main and RCA stenosis.
RESULTS: Of unprotected left main revascularizations from 2002 to 2004, PCI increased from 17.0% to 21.9%, while CABG decreased from 83.0% to 78.1% (P < 0.0001). In 2002, bare metal stents were used for all PCIs; in 2004, bare metal stent use was only 25.5%, while DES use was 74.5% (P < 0.0001). Of elective procedures, PCI rose from 19.1% to 27.5% while CABG fell from 80.9% to 72.5% (P < 0.0001). Similar trends, all significant, were seen in every clinical situation.
CONCLUSIONS: In the era of DES, the rate of PCI for unprotected left main stenosis has risen, while CABG has declined. These findings are seen across varying clinical situations, including elective procedures. DES have rapidly and largely replaced bare metal stents for PCI of unprotected left mains. However, PCI is still chosen less frequently than CABG for unprotected left main revascularization.