Nirat Beohar1, Shmuel Chen2,3, Nicholas J Lembo2,3, Adrian P Banning4, Patrick W Serruys5,6, Martin B Leon2,3, Marie-Claude Morice7, Philippe Généreux2,8,9, David E Kandzari10, Arie Pieter Kappetein11, Joseph F Sabik12, Ovidiu Dressler2, Thomas McAndrew2, Zixuan Zhang2, Gregg W Stone2,13. 1. Columbia University Division of Cardiology at the Mount Sinai Medical Center, Miami Beach, Florida, USA. 2. Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA. 3. New York-Presbyterian/Columbia University Irving Medical Center, New York, New York, USA. 4. John Radcliffe Hospital, Oxford, UK. 5. Department of Cardiology, NUIG, National University of Ireland, Galway, Ireland. 6. Imperial College of Science Technology and Medicine, London, UK. 7. Ramsay Générale de Santé, Institut Cardiovasculaire Paris Sud, Paris, France. 8. Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, New Jersey, USA. 9. Hôpital du Sacré-Coeur de Montréal, Montreal, Quebec, Canada. 10. Piedmont Heart Institute, Atlanta, Georgia, USA. 11. Thoraxcenter, Erasmus MC, Rotterdam, The Netherlands. 12. Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA. 13. The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
Abstract
OBJECTIVES: We examined outcomes according to lesion preparation strategy (LPS) in patients with left main coronary artery (LMCA) percutaneous coronary intervention (PCI) in the EXCEL trial. BACKGROUND: The optimal LPS for LMCA PCI is unclear. METHODS: We categorized LPS hierarchically (high to low) as: (a) rotational atherectomy (RA); (b) cutting or scoring balloon (CSB); (c) balloon angioplasty (BAL); and d) direct stenting (DIR). The primary endpoint was 3-year MACE; all-cause death, stroke, or myocardial infarction. RESULTS: Among 938 patients undergoing LMCA PCI, RA was performed in 6.0%, CSB 9.5%, BAL 71.3%, and DIR 13.2%. In patients treated with DIR, BAL, CSB, and RA, respectively, there was a progressive increase in SYNTAX score, LMCA complex bifurcation, trifurcation or calcification, number of stents, and total stent length. Any procedural complication occurred in 10.4% of cases overall, with the lowest rate in the DIR (7.4%) and highest in the RA group (16.1%) (ptrend = .22). There were no significant differences in the 3-year rates of MACE (from RA to DIR: 17.9%, 20.2%, 14.5%, 14.7%; p = .50) or ischemia-driven revascularization (from RA to DIR: 16.8%, 10.8%, 12.3%, 14.2%; p = .65). The adjusted 3-year rates of MACE did not differ according to LPS. CONCLUSIONS: The comparable 3-year outcomes suggest that appropriate lesion preparation may be able to overcome the increased risks of complex LMCA lesion morphology.
OBJECTIVES: We examined outcomes according to lesion preparation strategy (LPS) in patients with left main coronary artery (LMCA) percutaneous coronary intervention (PCI) in the EXCEL trial. BACKGROUND: The optimal LPS for LMCA PCI is unclear. METHODS: We categorized LPS hierarchically (high to low) as: (a) rotational atherectomy (RA); (b) cutting or scoring balloon (CSB); (c) balloon angioplasty (BAL); and d) direct stenting (DIR). The primary endpoint was 3-year MACE; all-cause death, stroke, or myocardial infarction. RESULTS: Among 938 patients undergoing LMCA PCI, RA was performed in 6.0%, CSB 9.5%, BAL 71.3%, and DIR 13.2%. In patients treated with DIR, BAL, CSB, and RA, respectively, there was a progressive increase in SYNTAX score, LMCA complex bifurcation, trifurcation or calcification, number of stents, and total stent length. Any procedural complication occurred in 10.4% of cases overall, with the lowest rate in the DIR (7.4%) and highest in the RA group (16.1%) (ptrend = .22). There were no significant differences in the 3-year rates of MACE (from RA to DIR: 17.9%, 20.2%, 14.5%, 14.7%; p = .50) or ischemia-driven revascularization (from RA to DIR: 16.8%, 10.8%, 12.3%, 14.2%; p = .65). The adjusted 3-year rates of MACE did not differ according to LPS. CONCLUSIONS: The comparable 3-year outcomes suggest that appropriate lesion preparation may be able to overcome the increased risks of complex LMCA lesion morphology.