Elsevier

American Heart Journal

Volume 135, Issue 2, February 1998, Pages 335-338
American Heart Journal

Spectrum of surgical risk for left main coronary stenoses: Benchmark for potentially competing percutaneous therapies,☆☆,

https://doi.org/10.1016/S0002-8703(98)70102-4Get rights and content

Abstract

Coronary artery bypass grafting is the preferred therapy for left main trunk coronary stenoses because of a demonstrated survival advantage compared with medical therapy. Recently, however, advocates of percutaneous intervention have suggested that stenting or atherectomy may provide acceptable results for these patients. To determine the spectrum of surgical outcome among patients with left main trunk coronary stenoses, we analyzed 14 potential covariates of in-hospital and 3-year mortality for a consecutive series of patients without prior coronary artery bypass grafting treated at our institution from January 1990 to December 1995. In-hospital mortality (2.3%) for 1585 consecutively treated patients correlated independently with renal dysfunction, age, and class III to IV heart failure. A model was constructed that allowed prediction of outcome (c-statistic = 0.77, p < 0.0001), and only the 9% of patients at highest risk were found to be at risk for death >5%. Mortality at 3 years (15.6% ± 2.2%) in a previously specified subgroup (n = 285) correlated independently with baseline age, renal dysfunction, and chronic pulmonary disease. A model was constructed that allowed prediction of outcome for the validation sample (four risk groups with 3-year mortality rates of 4.5% ± 2.5%, 6.5% ± 2.8%, 20.0% ± 4.2%, and 39.8% ± 8.5%; p < 0.0001. These data provide a contemporary benchmark of clinical outcome against which possible competing therapies may be compared. (Am Heart J 1998;135:335-8.)

Section snippets

Methods

Selected data on all patients with LMT stenosis of 50% or more undergoing CABG without valve repair or replacement at our institution from January 1, 1990, through December 31, 1995, were retrieved from a comprehensive relational database.2 Patients treated in the setting of acute myocardial infarction were excluded. The first 1000 patients who underwent CABG each year underwent prospective follow-up for clinical outcomes, and these data were retrieved. CABG was performed with accepted surgical

Results

Baseline characteristics of the 1585 patients are shown in Table I. The group is representative of patients from other recent CABG series,11, 12 except for the incidence of prior CABG. The 469 patients with long-term follow-up (0.9% not available for follow-up) did not differ from the entire group for any variable evaluated.

The overall in-hospital mortality rate was 2.3%, and median length of stay was 7 days. Independent correlates of in-hospital mortality rate are summarized in Table II, and

Discussion

Patients with left main coronary narrowing, especially narrowing of 70% or more,14 are recognized to be at high risk with medical therapy alone and to benefit from surgical revascularization.1 Generally excellent surgical results11, 12 and early reports of poor results with angioplasty4 for many years discouraged cardiologists from pursuing other means of revascularization for these patients. Recent advances, especially in stenting,15, 16 suggested to some groups that percutaneous

Acknowledgements

We thank the personnel from The Cleveland Clinic Foundation Cardiovascular Research Institute for their assistance in acquiring this information and Ms. Patti Durnwald for her expert preparation of this manuscript.

References (16)

There are more references available in the full text version of this article.

Cited by (78)

  • Invasive assessment modalities of unprotected left main stenosis

    2015, Journal of the Saudi Heart Association
  • Routine versus selective coronary artery bypass for left main coronary artery revascularization: The appraise a customized strategy for left main revascularization (CUSTOMIZE) study

    2011, International Journal of Cardiology
    Citation Excerpt :

    In patients with unprotected left main coronary artery (ULMCA) disease, bypass coronary artery graft (CABG) surgery has been widely proven to be more safe and effective compared to medical treatment [1–3]. Over the past decade the extensive experience reported in literature on surgical treatment of ULMCA covers thousands of patients, with consistent and satisfactory results in terms of clinical outcome [4–9]. Despite the high procedural success rates and satisfactory outcomes associated with percutaneous coronary intervention (PCI) in patients with ULMCA disease also eligible for CABG [10], all the series of patients undergoing revascularization with BMS report a high incidence of reintervention.

View all citing articles on Scopus

From The Cleveland Clinic Foundation.

☆☆

Reprint requests: Stephen G. Ellis, MD, The Cleveland Clinic Foundation, 9500 Euclid Ave., F-25, Cleveland, OH 44195.

4/1/86284

View full text