LEFT MAIN INTERVENTIOIN IN A STANDALONE PCI CENTRE - A RECENT 5 YEAR EXPERIENCE

BackgroundLeft main (LM) PCI is high risk and remains controversial despite the latest ACCF/AHA/SCAI 2011 PCI guidelines that endorsed LM PCI in favorable anatomy, in poor CABG candidates, and in STEMI with LM culprit and reduced flow if access to PCI is faster than CABG (Class IIa). There are no recommendations on non-emergeny LM PCI in standalone centres.MethodsWe report our LM PCI results from an experienced standalone PCI centre, where weekly case conference was held in collaboration with the regional cardiac surgery program.ResultsOf 9,568 PCIs performed 2008-12, 99 (1.0%) were LM PCIs. Of these 42 (42.4%) had previous CABG (protected LM PCIs) and the remaining 57 (57.6%) were unprotected LM PCIs. Mean age was 69±11yrs and 29.3% were diabetic. There were 60 (60.6%) CCS Class 4 patients, of which 25 (25.2%) were Class 4C and 12 (12.1%) on intra-aortic balloon pump (IABP). All except emergency cases were peer reviewed.LM lesion was ostial in 18 (18.2%), shaft in 15 (15.2%) and distal in 66 (66.7%) cases. Stents were deployed within LM lumen in 28 (28.3%), LM into LAD in 40 (41.4%), into LCx in 17 (17.2%), into ramus in 3 (3%) and bifurcating into LAD/LCx in 9 (9.1%) of patients. Balloon only was used in 2(2%) patients.Procedural success was achieved in all patients. No patient required emergency CABG because of PCI complications. Death and revascularization rates at 30 days were 8.1% and 1%, and at 1 year 11.1% and 4%. There was no difference in outcomes between protected and unprotected LM PCI patients at 1 year (death 9.5 vs 12.3%, revascularization 4.8 vs 3.5%, P=NS). One-year death rates were significantly higher in CCS Class 4 vs Class 1-3 patients (18.3 vs 2.5%, P=.02). All but 1 of 11 patients who died were CCS Class 4 patients. Mortality rate was especially high in Class 4C patients at 29.2 & 33.3% at 30-day & 1-year vs 1.3 & 4% in the remaining patients. Neither the location of LM lesion nor the site of stent deployment alone affected death and revascularization rates. However, patients with distal LM stenosis and CCS Class 4 angina had much higher mortality rates than the remaining patients at 30 days (15.4 vs 3.3%, P=.03) and 1-year (20.5 vs 5%, P=0.02).ConclusionOur results showed that LM PCI can be performed with very high success rate in a standalone PCI centre. However, despite recent technological advances, LM PCI patients remain at high risk for major adverse events and warrant close cardiologic follow up. BackgroundLeft main (LM) PCI is high risk and remains controversial despite the latest ACCF/AHA/SCAI 2011 PCI guidelines that endorsed LM PCI in favorable anatomy, in poor CABG candidates, and in STEMI with LM culprit and reduced flow if access to PCI is faster than CABG (Class IIa). There are no recommendations on non-emergeny LM PCI in standalone centres. Left main (LM) PCI is high risk and remains controversial despite the latest ACCF/AHA/SCAI 2011 PCI guidelines that endorsed LM PCI in favorable anatomy, in poor CABG candidates, and in STEMI with LM culprit and reduced flow if access to PCI is faster than CABG (Class IIa). There are no recommendations on non-emergeny LM PCI in standalone centres. MethodsWe report our LM PCI results from an experienced standalone PCI centre, where weekly case conference was held in collaboration with the regional cardiac surgery program. We report our LM PCI results from an experienced standalone PCI centre, where weekly case conference was held in collaboration with the regional cardiac surgery program. ResultsOf 9,568 PCIs performed 2008-12, 99 (1.0%) were LM PCIs. Of these 42 (42.4%) had previous CABG (protected LM PCIs) and the remaining 57 (57.6%) were unprotected LM PCIs. Mean age was 69±11yrs and 29.3% were diabetic. There were 60 (60.6%) CCS Class 4 patients, of which 25 (25.2%) were Class 4C and 12 (12.1%) on intra-aortic balloon pump (IABP). All except emergency cases were peer reviewed.LM lesion was ostial in 18 (18.2%), shaft in 15 (15.2%) and distal in 66 (66.7%) cases. Stents were deployed within LM lumen in 28 (28.3%), LM into LAD in 40 (41.4%), into LCx in 17 (17.2%), into ramus in 3 (3%) and bifurcating into LAD/LCx in 9 (9.1%) of patients. Balloon only was used in 2(2%) patients.Procedural success was achieved in all patients. No patient required emergency CABG because of PCI complications. Death and revascularization rates at 30 days were 8.1% and 1%, and at 1 year 11.1% and 4%. There was no difference in outcomes between protected and unprotected LM PCI patients at 1 year (death 9.5 vs 12.3%, revascularization 4.8 vs 3.5%, P=NS). One-year death rates were significantly higher in CCS Class 4 vs Class 1-3 patients (18.3 vs 2.5%, P=.02). All but 1 of 11 patients who died were CCS Class 4 patients. Mortality rate was especially high in Class 4C patients at 29.2 & 33.3% at 30-day & 1-year vs 1.3 & 4% in the remaining patients. Neither the location of LM lesion nor the site of stent deployment alone affected death and revascularization rates. However, patients with distal LM stenosis and CCS Class 4 angina had much higher mortality rates than the remaining patients at 30 days (15.4 vs 3.3%, P=.03) and 1-year (20.5 vs 5%, P=0.02). Of 9,568 PCIs performed 2008-12, 99 (1.0%) were LM PCIs. Of these 42 (42.4%) had previous CABG (protected LM PCIs) and the remaining 57 (57.6%) were unprotected LM PCIs. Mean age was 69±11yrs and 29.3% were diabetic. There were 60 (60.6%) CCS Class 4 patients, of which 25 (25.2%) were Class 4C and 12 (12.1%) on intra-aortic balloon pump (IABP). All except emergency cases were peer reviewed. LM lesion was ostial in 18 (18.2%), shaft in 15 (15.2%) and distal in 66 (66.7%) cases. Stents were deployed within LM lumen in 28 (28.3%), LM into LAD in 40 (41.4%), into LCx in 17 (17.2%), into ramus in 3 (3%) and bifurcating into LAD/LCx in 9 (9.1%) of patients. Balloon only was used in 2(2%) patients. Procedural success was achieved in all patients. No patient required emergency CABG because of PCI complications. Death and revascularization rates at 30 days were 8.1% and 1%, and at 1 year 11.1% and 4%. There was no difference in outcomes between protected and unprotected LM PCI patients at 1 year (death 9.5 vs 12.3%, revascularization 4.8 vs 3.5%, P=NS). One-year death rates were significantly higher in CCS Class 4 vs Class 1-3 patients (18.3 vs 2.5%, P=.02). All but 1 of 11 patients who died were CCS Class 4 patients. Mortality rate was especially high in Class 4C patients at 29.2 & 33.3% at 30-day & 1-year vs 1.3 & 4% in the remaining patients. Neither the location of LM lesion nor the site of stent deployment alone affected death and revascularization rates. However, patients with distal LM stenosis and CCS Class 4 angina had much higher mortality rates than the remaining patients at 30 days (15.4 vs 3.3%, P=.03) and 1-year (20.5 vs 5%, P=0.02). ConclusionOur results showed that LM PCI can be performed with very high success rate in a standalone PCI centre. However, despite recent technological advances, LM PCI patients remain at high risk for major adverse events and warrant close cardiologic follow up. Our results showed that LM PCI can be performed with very high success rate in a standalone PCI centre. However, despite recent technological advances, LM PCI patients remain at high risk for major adverse events and warrant close cardiologic follow up.