JACC: Left main PCI, particularly with DES, has good long-term outcomes

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Stenting unprotected left main coronary artery disease (CAD) is feasible, offering a good long-term outcome, and using drug-eluting stents (DES) improves outcomes, according to the LE MANS Registry in the Journal of the American College of Cardiology.

Pawel E. Buszman, MD, from the Medical University of Silesia, Upper-Silesian Heart Centre in Katowice, Poland, and colleagues sought to evaluate early and late outcomes after PCI of unprotected left main CAD, and to compare bare-metal stent and DES subgroups. They noted that PCI is an increasingly utilized method of revascularization in patients with unprotected left main CAD.

The multicenter, prospective LE MANS (Left Main Coronary Artery Stenting) Registry included 252 patients after unprotected left main CAD stenting enrolled between March 1997 and February 2008.

The researchers found non–ST-segment elevation acute coronary syndrome was diagnosed in 58 percent of patients; STEMI cases were excluded. DES was implanted in 36.2 percent of patients. Major adverse cardiovascular and cerebral events (MACCE) occurred in 4.8 percent of patients during the 30-day period, which included 1.5 percent deaths, according to the authors.

After 12 months, Buszman and colleagues found that there were 12.1 percent of angiographically confirmed cases of restenosis. During long-term follow-up (mean of 3.8 years) there were 25.4 percent MACCE and 13.9 percent deaths. Overall, they reported that the five- and 10-year survival rates were 78.1 percent and 68.9 percent, respectively.

Despite differences in demographical and clinical data in favor of BMS patients, unmatched analysis showed a significantly lower MACCE rate in DES patients (25.9 vs. 14.9 percent). The authors noted that the difference was strengthened after propensity score matching. Ejection fraction of less than 50 percent was the only independent risk factor influencing long-term survival.

Buszman and colleagues noted that DES lowered both mortality and MACCE for distal unprotected left main CAD lesions when compared with BMS. There was one case (0.4 percent of the whole study group, 1 percent of the DES subgroup) of definite very late in-stent thrombosis that occurred 2.5 years after DES implantation.

Based on their findings, the researchers said that the implantation of DES for unprotected left main CAD decreased the risk of long-term MACCE, and particularly improved survival in patients with distal unprotected left main CAD disease.

“Our 12-year experience with left main stenting reflects its continuous progress,” the authors wrote. “First, we showed significant reduction of angina, significant improvement of the left ventricular systolic function, and preservation of exercise capacity in long-term follow-up. Second, we provided evidence for the superiority of unprotected left main CAD stenting over CABG in terms of restoring left ventricular ejection fraction along with a trend for better survival.”