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J Am Coll Cardiol, 2006; 47:1530-1537, doi:10.1016/j.jacc.2005.11.066 (Published online 23 March 2006).
© 2006 by the American College of Cardiology Foundation
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CLINICAL RESEARCH: INTERVENTIONAL CARDIOLOGY

Distal Left Main Coronary Disease Is a Major Predictor of Outcome in Patients Undergoing Percutaneous Intervention in the Drug-Eluting Stent Era

An Integrated Clinical and Angiographic Analysis Based on the Rapamycin-Eluting Stent Evaluated At Rotterdam Cardiology Hospital (RESEARCH) and Taxus-Stent Evaluated At Rotterdam Cardiology Hospital (T-SEARCH) Registries

Marco Valgimigli, MD, Patrizia Malagutti, MD, Gaston A. Rodriguez-Granillo, MD, Héctor M. Garcia-Garcia, MD, Jawed Polad, MBChB, MRCP, Keiichi Tsuchida, MD, PhD, Evelyn Regar, MD, PhD, Willem J. Van der Giessen, MD, PhD, Peter de Jaegere, MD, PhD, Pim De Feyter, MD, PhD and Patrick W. Serruys, MD, PhD*

Erasmus Medical Center, Thoraxcenter, Rotterdam, the Netherlands.

Manuscript received October 2, 2005; revised manuscript received October 28, 2005, accepted November 8, 2005.

* Reprint requests and correspondence: Dr. Patrick W. Serruys, Thoraxcenter, Bd-406, Dr Molewaterplein 40, 3015-GD Rotterdam, the Netherlands. (Email: p.w.j.c.serruys{at}erasmusmc.nl).

OBJECTIVES: This study sought to investigate whether the anatomical location of the disease carries prognostic implications in patients undergoing drug-eluting stent (DES) implantation for the left main coronary artery (LMCA) stenosis.

BACKGROUND: Liberal use of DES, compared with a bare metal stent (BMS), has resulted in an improved outcome in patients undergoing LMCA intervention. However, the overall event rate in this subset of patients remains high, and alternative tools to risk-stratify this population beyond conventional surgical risk status would be desirable.

METHODS: From April 2002 to June 2004, 130 patients received DES as part of the percutaneous intervention for LMCA stenoses in our institution. Distal LMCA disease (DLMD) was present in 94 patients. They were at higher surgical risk and presented with a greater coronary disease extent compared with patients without DLMD.

RESULTS: After a median of 587 days (range 368 to 1,179 days), the cumulative incidence of major adverse cardiac events (MACE) was significantly higher in patients with DLMD at 30% versus 11% in those without DLMD (hazard ratio [HR] 3.42, 95% confidence interval [CI] 1.34 to 9.7; p = 0.007), mainly driven by the different rate of target vessel revascularization (13% and 3%; HR 6, 95% CI 1.2 to 29; p = 0.02). After adjustment for confounders, DLMD (HR 2.79,95% CI 1.17 to 8.9; p = 0.032) and surgical risk status (HR 2.18,95% CI 1.06 to 4.5; p = 0.038) remained independent and complementary predictors of MACE.

CONCLUSIONS: Distal LMCA disease carries independent prognostic implications, and it may help in selecting the most appropriate patient subset for LMCA intervention beyond the conventional surgical risk status in the DES era.

Abbreviations and Acronyms
  BMS = bare-metal stent
  DES = drug-eluting stent
  DLMD = distal left main disease
  LMCA = left main coronary artery
  MACE = major adverse cardiac events
  MI = myocardial infarction
  MLD = minimal luminal diameter
  SES = sirolimus-eluting stent
  TIMI = Thrombolysis In Myocardial Infarction
  TVR = target vessel revascularization




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