Introduction The ESC/EACTS 2018 guidelines on myocardial revascularisation supported the use of percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) for left main stem (LMS) disease of low complexity, and recommended CABG over PCI in disease of intermediate or high complexity. Following revelations of EXCEL study data, the guidance is being reviewed. Meanwhile, patients with LMS disease continue to present in both elective and acute settings, and clinicians face complex decision-making, which can be particularly challenging in non-surgical centres.
Methods The aim of this study was to investigate the safety and efficacy of LMS PCI in our non-surgical, 24/7 primary PCI centre. We have performed a retrospective analysis of 136 patients who underwent LMS PCI between 2015-2019 in both elective and acute (Non ST elevation-ACS and ST elevation MI) settings. The median follow up time was 19 months (range 12-59 months). Inpatient mortality and complication rates and all-cause mortality over the follow up period were assessed. We also examined use of the MDT and intracoronary imaging rates.
Results The number of PCI for LMS in both elective and acute settings steadily increased over the study period (figure 1). The patient and procedural characteristics are presented in tables 1 and 2, demonstrating appropriate patient selection (low risk anatomy, low percentage diabetes, predominant single stent strategy) and significantly increasing use of intracoronary imaging over time (figure 2). There was documented evidence of formal MDT discussion, or informal discussion with colleagues and the patient, in 82.1% of elective cases. In elective patients there were no in-hospital complications. In the acute cohort, we observed 2 post-procedural acute renal failure episodes, 1 embolic stroke and 1 episode of anaemia requiring blood transfusion. Overall, all-cause mortality at a median 19 months was 15.5% (21 of 136 patients). There were 4 deaths among elective patients and 17 in ACS patients. Higher death rate in the acute cohort was partly driven by cardiogenic shock in STEMI patients. 8 patients required further PCI for in-stent restenosis.
Conclusions In an all-comer population, including those with cardiogenic shock, LMS PCI seems to be effective with acceptable mortality risk. In the elective setting, shared decision making via MDT is commonplace, appropriate patients are selected, acute complications are rare, and long-term outcomes are favourable with low in-stent restenosis rates. The acute setting, by default associated with a more adverse prognosis, presents more challenge – opportunity for MDT discussion is limited and patient/procedural factors can reduce intracoronary imaging rates. Procedural outcomes are favourable but all-cause mortality in LMS STEMI patients is predictably high. Finally, shared decision making is of paramount importance in this uncertain area and a further update to the guidelines will be welcomed.
Conflict of Interest none
Statistics from Altmetric.com
If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.