CORRESPONDENCE: LETTER TO THE EDITOR
Unprotected Left Main Disease: Stent or Surgery?
Robert Francis Bonvini, MD*,
Vitali Verin, MD and
Ulrich Sigwart, MD, FRCP
* Cardiology Center, University Hospital of Géneva, Rue Micheli du Crest 24, 1211 Geneva 14, Switzerland (Email: Robert.Bonvini{at}hcuge.ch).
In a recent issue of the Journal, Price et al. (1) reported the clinical and angiographic follow-up of 50 consecutive patients undergoing sirolimus-eluting stent implantation for unprotected left main coronary-artery (ULMCA) stenosis. This carefully performed study (i.e., 98% of angiographic follow-up) shows a surprisingly high rate of major adverse cardiac events (MACE) (10% in-hospital, 44% at 1 year). The study, however, presented several important limitations, as already outlined by the investigators themselves (1), and in the accompanying editorial (2). We would like to comment on several other important issues.
In recent years interventional cardiologists have been trying to define the best strategy for bifurcation coronary stenting (provisional-T, V-stenting, or simultaneous kissing stent [SKS], crush, culotte). Contemporary published data suggest that in case of a small diameter side branch (SB), stenting of the main vessel with simple balloon angioplasty of the SB with provisional stenting ("only if needed") seems to be associated with the best overall long-term outcome (3). The crush technique seems to have a number of disadvantages in cases of true bifurcation lesions with small SB, because the resulting 3 metal layers in the SB-ostium tend to increase the risk of restenosis (ISR) (4). It is therefore possible that the excess of ISR of the left circumflex ostium observed in the Price et al. (1) series was mainly related to the particular adopted stenting strategy.
In our view, this high target lesion revascularization (TLR) rate should be interpreted cautiously. The majority of other investigators recently reported similar series showing encouraging TLR and MACE rates at 6 and 12 months, clearly contrasting with the results of the Price et al. study (5–8).
In addition, we would propose not to be overly concerned by the elevated 1-year MACE rate (TLR: 38%) reported by Price et al. (1), but to pay more attention to some pharmacological and anatomical aspects enumerated below:
- 1 The importance of the clopidogrel loading dose in such a delicate procedure (the same patient without the loading dose experienced 3 of the 5 in-hospital MACE).
- 2 The ULMCA stenting strategy should be tailored to the specific coronary anatomy (SKS or V-stenting in case of ostial involvement of both major vessels; provisional-T stenting if one of the ostia remains disease free).
Finally, in our opinion, percutaneous coronary intervention for ULMCA disease is progressively becoming a worldwide standard of care; therefore, interventional cardiologists should make an effort to generate strong evidence supporting safety and long-term efficacy of this very promising technique, utilizing data generated from tailored stented ULMCA with carefully performed clinical and angiographic follow-up protocols (1,5–8).
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1. Price MJ, Cristea E, Sawhney N, et al. Serial angiographic follow-up of sirolimus-eluting stents for unprotected left main coronary artery revascularization J Am Coll Cardiol 2006;47:871-877.[Abstract/Free Full Text]2. Baim DS, Mauri L, Cutlip DC. Drug-eluting stenting for unprotected left main coronary artery disease: are we ready to replace bypass surgery? J Am Coll Cardiol 2006;47:878-881.[Free Full Text] 3. Louvard Y, Lefevre T, Morice MC. Percutaneous coronary intervention for bifurcation coronary disease Heart 2004;90:713-722.[Free Full Text] 4. Ormiston JA, Currie E, Webster MW, et al. Drug-eluting stents for coronary bifurcations: insights into the crush technique Catheter Cardiovasc Interv 2004;63:332-336.[CrossRef][Web of Science][Medline] 5. Chieffo A, Stankovic G, Bonizzoni E, et al. Early and mid-term results of drug-eluting stent implantation in unprotected left main Circulation 2005;111:791-795.[Abstract/Free Full Text] 6. Valgimigli M, van Mieghem CA, Ong AT, et al. Short- and long-term clinical outcome after drug-eluting stent implantation for the percutaneous treatment of left main coronary artery disease: insights from the Rapamycin-Eluting and Taxus Stent Evaluated At Rotterdam Cardiology Hospital registries (RESEARCH and T-SEARCH) Circulation 2005;111:1383-1389.[Abstract/Free Full Text] 7. Park SJ, Kim YH, Lee BK, et al. Sirolimus-eluting stent implantation for unprotected left main coronary artery stenosis: comparison with bare metal stent implantation J Am Coll Cardiol 2005;45:351-356.[Abstract/Free Full Text] 8. Carrie D, Maupas E, Hmem M, Lhermusier T, Elbaz M, Puel J. Clinical and angiographic outcome of stenting of unprotected left main coronary artery bifurcation narrowing Int J Cardiovasc Interv 2005;7:97-100.[CrossRef][Medline]
Related Article
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Reply
- Matthew J. Price and Paul S. Teirstein
J. Am. Coll. Cardiol. 2006 48: 1728-1729.
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