Unprotected left main (LM) percutaneous coronary intervention (PCI) at centers without
onsite cardiac surgery remains controversial. We aimed to evaluate the effect of onsite
cardiac surgery on short-term and long-term outcomes in patients who had unprotected
LM PCI. We analyzed Victorian Cardiac Outcomes Registry data on consecutive patients
who had unprotected LM PCI at cardiac surgical centers (SCs) and non-SCs (NSCs) between
January 2014 to December 2018. Compared with the SC group (n = 594, 81%), the NSC
group (n = 136) were younger (69 vs 72 years) and presented with more ST-elevation
myocardial infarction (35% vs 16%) and cardiogenic shock (25% vs 15%), with higher
rates of preprocedural intubation (17% vs 11%) and mechanical circulatory support
(20% vs 9.3%), all p <0.01. Unadjusted in-hospital mortality (23% vs 11.4%), and 30-day
major adverse cardiac events (composite of mortality, myocardial infarction, stent
thrombosis, or unplanned revascularization) (26% vs 16%) were higher in NSC patients,
all p <0.01. However, following multivariable adjustment, SC was neither a predictor
of in-hospital mortality (odds ratio 0.68, 95% confidence interval [CI] 0.32 to 1.43,
p = 0.31), 30-day mortality (odds ratio 0.70, 95% CI 0.33 to 1.48, p = 0.35) nor long-term
survival at 60 months (hazard ratio 0.88, 95% CI 0.62 to 1.27, p = 0.51). Propensity
score analysis confirmed the neutral effect of onsite cardiac surgery on long-term
survival (hazard ratio 0.99, 95% CI 0.66 to 1.50, p = 0.97). In conclusion, patients
who underwent unprotected LM PCI at NSCs presented with greater acuity of illness.
Despite this, the availability of onsite cardiac surgical support was not associated
with in-hospital, 30-day, or long-term outcomes underscoring the safety of LM PCI
in NSCs.
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References
- Five-year outcomes after PCI or CABG for left main coronary disease [published correction appears in N Engl J Med 2020;382:1078].N Engl J Med. 2019; 381: 1820-1830
- Management of left main coronary artery disease.J Am Heart Assoc. 2018; 7e008151
- Left main coronary artery stenosis: the influence of aortocoronary bypass surgery on survival.Circulation. 1978; 57: 1111-1115
- Asymptomatic left main coronary artery disease in the Coronary Artery Surgery Study (CASS) registry.Circulation. 1989; 79: 1171-1179
- Long-term survival of medically treated patients in the Coronary Artery Surgery Study (CASS) Registry.Circulation. 1994; 90: 2645-2657
- Early and long-term results of unprotected left main coronary artery stenting: the LE MANS (Left Main Coronary Artery Stenting) registry.J Am Coll Cardiol. 2009; 54: 1500-1511
- Percutaneous coronary angioplasty versus coronary artery bypass grafting in the treatment of unprotected left main stenosis: updated 5-year outcomes from the randomised, non-inferiority NOBLE trial.Lancet. 2020; 395: 191-199
- Double kissing crush versus provisional stenting for left main distal bifurcation lesions: DKCRUSH-V Randomized Trial.J Am Coll Cardiol. 2017; 70: 2605-2617
- 3-year outcomes of the DKCRUSH-V trial comparing DK crush with provisional stenting for left main bifurcation lesions.JACC Cardiovasc Interv. 2019; 12: 1927-1937
- Impact of intravascular ultrasound guidance on long-term mortality in stenting for unprotected left main coronary artery stenosis.Circ Cardiovasc Interv. 2009; 2: 167-177
- Advances in coronary angioplasty.N Engl J Med. 1996; 335: 1290-1302
- SCAI/ACC/AHA Expert consensus document: 2014 update on percutaneous coronary intervention without on-site surgical backup.Circulation. 2014; 129: 2610-2626
- Emergency coronary artery bypass surgery for percutaneous coronary interventions: changes in the incidence, clinical characteristics, and indications from 1979 to 2003.J Am Coll Cardiol. 2005; 46: 2004-2009
- Left main stenting in comparison with surgical revascularization: 10-year outcomes of the (left main coronary artery stenting) LE MANS trial.JACC Cardiovasc Interv. 2016; 9: 318-327
- Nonemergency PCI at hospitals with or without on-site cardiac surgery.N Engl J Med. 2013; 368: 1498-1508
- Outcomes of PCI at hospitals with or without on-site cardiac surgery.N Engl J Med. 2012; 366: 1792-1802
- 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.J Am Coll Cardiol. 2012; 59: 648-654
- The establishment of the Victorian cardiac outcomes registry (VCOR): monitoring and optimising outcomes for cardiac patients in Victoria.Heart Lung Circ. 2018; 27: 451-463
- Comparison of short-term clinical outcomes of proximal versus nonproximal lesion location in patients treated with primary percutaneous coronary intervention for ST-elevation myocardial infarction: the PROXIMITI study.Catheter Cardiovasc Interv. 2019; 93: 32-40
- Validation of the Bleeding Academic Research Consortium definition of bleeding in patients with coronary artery disease undergoing percutaneous coronary intervention.Circulation. 2012; 125: 1424-1431
- Contemporary use and trends in unprotected left main coronary artery percutaneous coronary intervention in the United States: an analysis of the national cardiovascular data registry research to practice initiative.JAMA Cardiol. 2019; 4: 100-109
- Long-term outcome of unprotected left main stenting: a Canadian tertiary care experience.Can J Cardiol. 2014; 30: 1407-1414
- Percutaneous coronary angioplasty versus coronary artery bypass grafting in treatment of unprotected left main stenosis (NOBLE): a prospective, randomised, open-label, non-inferiority trial.Lancet. 2016; 388: 2743-2752
- Percutaneous left main coronary disease treatment without on-site surgery back-up in patients with acute coronary syndromes: immediate and 2-year outcomes.Catheter Cardiovasc Interv. 2012; 79: 979-987
- Percutaneous coronary intervention for left main coronary artery disease – a single hospital experience without on-site cardiac surgery.Acta Cardiol Sin. 2015; 31: 267-279
- Left main coronary artery disease: secular trends in patient characteristics, treatments, and outcomes.J Am Coll Cardiol. 2016; 68: 1233-1246
- Public reporting of percutaneous coronary intervention mortality in New York state: are we helping our patients?.Circ Cardiovasc Qual Outcomes. 2017; 10e004027
- Emergency coronary artery bypass surgery in the contemporary percutaneous coronary intervention era.Circulation. 2002; 106: 2346-2350
- Clinical impact of intravascular ultrasound guidance in drug-eluting stent implantation for unprotected left main coronary disease: pooled analysis at the patient-level of 4 registries.JACC Cardiovasc Interv. 2014; 7: 244-254
- Use of intravascular ultrasound imaging in percutaneous coronary intervention to treat left main coronary artery disease.Interv Cardiol. 2017; 12: 8-12
Article Info
Publication History
Published online: January 31, 2022
Received in revised form:
December 10,
2021
Received:
September 29,
2021
Footnotes
A/Prof Stub's work is supported by National Heart foundation fellowship, GNT 101908. Prof. Duffy's work is supported by a National Health and Medical Research Council of Australia (Canberra, Australia) ], GNT 1111170. Prof. Reid's work is supported by mixed National Health and Medical Research Council (Canberra, Australia) Principal Research Fellowship, GNT 1136372.
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