Temporal Trends in Revascularization Strategy and Outcomes in Left Main Coronary Artery Stenosis: Data From the Asan Medical Center-Left Main Revascularization Registry

Background—Changes over time in revascularization strategies and outcomes among patients with unprotected left main coronary artery stenosis remain largely unknown. Methods and Results—A total of 2618 consecutive patients with unprotected left main coronary artery stenosis who underwent revascularization were identified from the ASAN Medical Center-Left MAIN Revascularization registry and classified by time periods: bare metal stent (wave 1, 1995–1998), early drug-eluting stents (wave 2, 2003–2006), and late drug-eluting stents (wave 3, 2007–2010). Primary end point was major adverse cerebrocardiovascular events (the composite of death, myocardial infarction, repeat revascularization, and stroke). During the study period, 1124 patients underwent percutaneous coronary intervention (PCI) and 1494 patients underwent coronary artery bypass grafting. The proportion of PCI significantly increased from 35% to 52% between waves 1 and 3. In patients receiving PCI, the risk-adjusted incidence rate of major adverse cerebro-cardiovascular events decreased from 20.18 cases per 100 person-years in wave 1 to 6.77 cases per 100 person-years in wave 3 (P<0.001 for trend). Death, the composite of death, myocardial infarction, stroke, and repeat revascularization were also significantly decreased by 40%, 35%, and 46%, respectively. The risk-adjusted incidence rate of major adverse cerebrocardiovascular events did not change in patients receiving coronary artery bypass grafting. The difference major adverse cerebrocardiovascular events risk between PCI and coronary artery bypass grafting progressively reduced (adjusted hazard ratio [95% confidence interval], 0.33 [0.23–0.47]; 0.53 [0.35–0.80]; and 1.01 [0.68–1.49] from wave 1 to wave 3. Conclusions—The outcomes of unprotected left main coronary artery PCI have significantly improved over time. In addition, more patients received PCI for unprotected left main coronary artery stenosis in recent years.

[1]  Si‐Hyuck Kang,et al.  Everolimus- versus sirolimus-eluting stents for the treatment of unprotected left main coronary artery stenosis (results from the EXCELLENT registry). , 2013, International journal of cardiology.

[2]  S. Yusuf,et al.  Effects of off-pump and on-pump coronary-artery bypass grafting at 1 year. , 2013, The New England journal of medicine.

[3]  Deepak L. Bhatt,et al.  Response to letter regarding article, “Short- and long-term outcomes with drug-eluting and bare-metal coronary stents: a mixed-treatment comparison Analysis of 117,762 patient-years of follow-up from randomized trials”. , 2013, Circulation.

[4]  Sankey V. Williams,et al.  2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American College of Physicians, American Ass , 2012, Journal of the American College of Cardiology.

[5]  Sankey V. Williams,et al.  2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: executive summary: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physi , 2012, Circulation.

[6]  Deepak L. Bhatt,et al.  Short- and Long-Term Outcomes With Drug-Eluting and Bare-Metal Coronary Stents: A Mixed-Treatment Comparison Analysis of 117 762 Patient-Years of Follow-Up From Randomized Trials , 2012, Circulation.

[7]  K. Anstrom,et al.  Characteristics and long-term outcomes of percutaneous revascularization of unprotected left main coronary artery stenosis in the United States: a report from the National Cardiovascular Data Registry, 2004 to 2008. , 2011, Journal of the American College of Cardiology.

[8]  Douglas Weaver,et al.  Third universal definition of myocardial infarction. , 2012, Circulation.

[9]  Maarten L. Simoons,et al.  The third universal definition of myocardial infarction , 2013 .

[10]  Gary S. Mintz,et al.  Comprehensive Intravascular Ultrasound Assessment of Stent Area and Its Impact on Restenosis and Adverse Cardiac Events in 403 Patients With Unprotected Left Main Disease , 2011, Circulation. Cardiovascular interventions.

[11]  M. Jeong,et al.  Randomized trial of stents versus bypass surgery for left main coronary artery disease. , 2011, The New England journal of medicine.

[12]  Seung‐Jung Park,et al.  Comparison of single‐ versus two‐stent techniques in treatment of unprotected left main coronary bifurcation disease , 2011, Catheterization and cardiovascular interventions : official journal of the Society for Cardiac Angiography & Interventions.

[13]  Seung‐Jung Park,et al.  Long-term outcomes after stenting versus coronary artery bypass grafting for unprotected left main coronary artery disease: 10-year results of bare-metal stents and 5-year results of drug-eluting stents from the ASAN-MAIN (ASAN Medical Center-Left MAIN Revascularization) Registry. , 2010, Journal of the American College of Cardiology.

[14]  Volkmar Falk,et al.  Guidelines on Myocardial Revascularization the Task Force on Myocardial Revascularization of the European Society of Cardiology (esc) and the European Association for Cardio-thoracic Surgery (eacts) Developed with the Special Contribution of the European Association for Percutaneous Cardiovascular I , 2022 .

[15]  M. Mack,et al.  Outcomes in Patients With De Novo Left Main Disease Treated With Either Percutaneous Coronary Intervention Using Paclitaxel-Eluting Stents or Coronary Artery Bypass Graft Treatment in the Synergy Between Percutaneous Coronary Intervention With TAXUS and Cardiac Surgery (SYNTAX) Trial , 2010, Circulation.

[16]  Young-Hak Kim,et al.  Drug-eluting versus bare-metal stents in unprotected left main coronary artery stenosis a meta-analysis. , 2010, JACC. Cardiovascular interventions.

[17]  M. Tendera,et al.  Early and long-term results of unprotected left main coronary artery stenting: the LE MANS (Left Main Coronary Artery Stenting) registry. , 2009, Journal of the American College of Cardiology.

[18]  Á. Avezum,et al.  Unprotected left main revascularization in patients with acute coronary syndromes. , 2009, European heart journal.

[19]  Joon-Won Kang,et al.  Comparison of radial artery patency according to proximal anastomosis site: direct aorta to radial artery anastomosis is superior to radial artery composite grafting. , 2009, The Journal of thoracic and cardiovascular surgery.

[20]  S. de Servi,et al.  Impact of Bifurcation Technique on 2-Year Clinical Outcomes in 773 Patients With Distal Unprotected Left Main Coronary Artery Stenosis Treated With Drug-Eluting Stents , 2008, Circulation. Cardiovascular interventions.

[21]  Young-Hak Kim,et al.  Stents versus coronary-artery bypass grafting for left main coronary artery disease. , 2008, The New England journal of medicine.

[22]  J. Alpert,et al.  Joint ESC/ACCF/AHA/WHF Task Force for the Redefinition of Myocardial Infarction , 2008 .

[23]  Yiannis S Chatzizisis,et al.  Prevalence of narrowing >or=50% of the left main coronary artery among 17,300 patients having coronary angiography. , 2006, The American journal of cardiology.

[24]  Feroze U. Mahmood,et al.  Radial artery grafts vs . saphenous vein grafts in coronary artery bypass surgery : A randomized trial , 2022 .