CCI: Unprotected left main PCI safe for low-risk patients

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Treating unprotected left main coronary artery (ULMCA) disease with drug-eluting stents (DES) is safe and effective, even for low-risk patients, researchers from the University of California, Los Angeles found in a study published June 22 in Catheterization and Cardiovascular Interventions. Elective unprotected left main PCI with DES in patients with normal left ventricular function could one day replace CABG as the standard of care; however, more trials comparing PCI and CABG will be necessary.

“Although the standard of care for patients with ULMCA disease is coronary artery bypass surgery, the current guidelines recommend PCI in clinical conditions that predict an increased risk of adverse surgical outcomes,” wrote Michael S. Lee, MD, of the University of California, Los Angeles Medical Center, and colleagues.

Because the long-term outcomes of patients at low-risk for adverse surgical outcomes who undergo PCI are unknown, Lee and colleagues set out to evaluate the early and long-term outcomes of patients with normal LV function who underwent elective PCI to treat ULMCA disease. The researchers used a multicenter international data registry that included 221 patients from four institutions who underwent elective ULMCA PCI with DES from 2002 to 2009.

Current guidelines only recommend PCI with DES for patients who are poor candidates for surgery; however, Lee said that this may change if additional studies can prove that this less invasive procedure is safe and effective in lower-risk patients.

The researchers reported that no incidences of cardiac death, Q-wave MI, target lesion revascularization (TLR), stent thrombosis or stroke occurred within the first 30 days of the study. Only seven patients experienced periprocedural MI.

Lee and colleagues reported that cardiac death and TLR event rates were 97.7 percent and 92.9 percent at one-year. Twenty-two patients needed to be retreated during the study—14 patients underwent repeat PCI and eight underwent bypass surgery.

"Our analysis found that the short-term outcomes were excellent," Lee said. "Patients who survived after the first year had very good long-term survival and a low incidence of retreatment."

Four-year follow-up showed that event-free rates for cardiac death and TLR were 95.5 percent and 88.9 percent, respectively. In addition, the authors reported that 22 patients died during the study and nine deaths were cardiac related.

"We found that this procedure had a low overall risk profile and may prove to be a viable alternative for this patient group," Lee said. A limitation of the study was the fact that this was a retrospective analysis without comparative analysis with patients who underwent CABG.

Lee and colleagues concluded that a randomized clinical trial should be undertaken to compare PCI with DES to CABG in lower-risk patient populations.