Background Despite data showing excellent results for revascularisation of patients with LMS disease by PCI in a randomised trial vs CABG, there is still a need for PCI outcome data in ‘real world’ patients, many of whom are not suitable for CABG.
Objective We assessed the results of left main stem (LMS) PCI in a ‘real world’ cohort of 302 consecutive patients.
Methods A retrospective analysis was made of prospectively collected data on every patient undergoing PCI to the LMS performed by a single operator between 2000 and 2009 including patients who were not candidates for coronary artery bypass surgery, those treated as an emergency and those in cardiogenic shock. Clinical and angiographic data and logistic New York PCI Risk Scores (NYRSs) and EuroSCOREs were recorded. The endpoint was long-term mortality and repeat revascularisation, short term mortality was modelled on risk adjusted funnel plots.
Results We treated 302 consecutive, unselected, patients with LMS disease±multi-vessel disease. The mean age was 67±10, 72% were male, 41% were non-elective, 10% were in cardiogenic shock, 21.5% required IABP and 46% were not surgical candidates. The NYRS was median 0.6% (IQR 0.32–4.2) and EuroSCORE 3.9 (1.82–11.4). Apart from the LMS, 2.1±0.9 vessels were diseased, 69% of the LMS lesions involved the bifurcation. Technical success was achieved in 99% LMS lesions, 1.7±0.8 other vessels were successfully treated and 57% LMS lesions were treated with drug-eluting stents; single stent being used in 44% and simultaneous kissing stents in 50%. The in-hospital, 30 day, 1 year and 3 year mortality rates of the whole group were 5%, 7.6%, 13.9% and 20.8%. For elective vs non-elective patients, the equivalent figures were 1% vs 4%, 1.3% vs 6.3%, 4% vs 10% and 8% vs 12.8%. The ischaemia-driven target lesion revascularisation rate at 1, 2 and 3 y was 12% (3%LMS), 15% (3.5% LMS) and 15.5% (4%LMS). There was 1% emergency CABG. The 30-day mortality rate was 7.6%, as compared with 6.2% predicted by NYRS (abstract 101 figure 1) and 10.1% predicted by EuroSCORE. Incomplete revascularisation was associated with an increased mortality at follow-up (1 yr 20.2% vs 10.3%, 3 yr 29.3% vs 16%; p<0.02) after adjustment for age, number vessels diseased, LV systolic function, diabetes, extra-cardiac arteriopathy, renal failure, and type of presentation.
Conclusions PCI is applicable to a wide variety of patients with CHD involving the LMS, with very few patients being unsuitable. Excellent results can be achieved for a typical, mixed population of patients requiring revascularisation over a wide range of risk profiles, in terms of both mortality and repeat revascularisation, to 3 years. Mortality risk is strongly influenced by clinical factors rather than disease pattern or procedural details.
- Left main stem