Revascularization For Unprotected Left Main Coronary Artery Disease

Background:For coronary artery disease with unprotected left main coronary artery (ULMCA) stenosis, coronary artery bypass grafting (CABG) is traditionally regarded as the gold-standard treatment because of its well-documented and durable survival advantage. Improved outcomes of percutaneous coronary interventions (PCI) with drug-eluting stents (DES) have resulted in their expanded use for left main coronary artery stenosis. The use of DES for treatment of ULMCA stenosis was safe and effective and provided similar outcomes when compared to CABG. Unprotected left main coronary artery stenting is being investigated as an alternative to bypass surgery.Objective:To investigate the clinical outcomes of unprotected left main coronary artery disease treated with coronary artery bypass graft surgery or percutaneous coronary interventions with drug-eluting stents,and confirm the safety and efficacy of stenting in ULMCA.Methods:This study was a retrospective cohort study. We evaluated 43 patients with unprotected left main coronary artery disease who underwent stents implantation (DES group) and 29 patients who underwent CABG (CABG group) in the first affiliated hospital of soochow university between December 2006 and December 2010. The clinical and CAG information were collected and studied. The incidences of major adverse cardiac and cerebrovascular events (MACCE) were recorded, including death of all causes, myocardial infarction, stroke and target vessel revascularization. All analysis was performed using the SPSS 16.0. Survival curves were computed by the Kaplan-Meier method and compared with the Log-rank test. Cox regression was evaluated for multivariate analysis of prognostic factors. Results:1. The clinical characteristics were comparable between the two groups. The average EuroSCORE of the DES group was higher than that of the CABG group(P=0.07). The average SYNTAXSCORE of the CABG group was higher than that of the DES group(P=0.02). Patients with high-risk in the CABG group were more than that of the DES group.2. With (24.59±11.16) months follow up, the short-outcome in the DES was superior to CABG(P<0.01). The MACCE-free at 2 years in the DES group and the CABG group was 86.4% and 80.5% respectively (P=0.85). There were no significant differences of death rate, TLR, cerebrovascular events at 2 years.3. The MACCE-free rate of the high-risk patients(SYNTAXSCORE≥32 or EuroSCORE≥4)at 2 years did not differ between groups.4. The estimated MACCE-free survival at 2 years was 95.2% in the left main only and left main plus single-vessel disease versus 70.8% in the left main plus double-vessel and triple-vessel disease. Compared with non-bifurcation, patient with the distal-bifurcation stenosis were more likely to have higher MACCE-free rate.Conclusion:1. Patients with ULMCA disease treated with PCI or CABG had favorable early and longtime outcomes.2. To left main coronary artery bifurcation stenosis, stenting may be the similar outcome to CABG because of the advantage of PCI.3. SYNTAXSCORE and EuroSCORE were useful tool to predict the outcomes of treatments together.4. The anti-platelet therapy helped to reduce cerebrovascular events.