CORRESPONDENCE: LETTER TO THE EDITOR
Reply
Matthew J. Price, MD, FACC and
Paul S. Teirstein, MD, FACC*
* Scripps Clinic, Division of Cardiovascular Diseases, 10666 North Torrey Pines Road, Maildrop S1056, La Jolla, California 92037 (Email: teirstein.paul{at}scrippshealth.org).
We appreciate the comments by Dr. Bonvini et al. regarding our study (1). Their concerns appropriately highlight the difficulty in defining the best strategy for approaching stent implantation within the distal bifurcation of the unprotected left main coronary artery (ULMCA). The investigators believe our "elevated" rate of major adverse cardiac events (MACE) could be due to use of the "crush" technique. In our study, the majority of patients (68%) were treated with simultaneous kissing stents (SKS), whereas only a small minority of patients (16%) underwent "crush" stenting. Therefore, our higher than expected MACE rate (44% at 9 months) cannot be explained by the use of the "crush" technique alone. We believe our increased late revascularization rate, compared to other series, was likely due to our unusually high (98%) rate of angiographic follow-up and the presence of distal left main disease (DLMD) in nearly all (94%) of our patients.
Interestingly, a very recent report describing late follow-up after LMCA intervention with drug-eluting stents (DES) documented outcomes similar to our report. In that study (2), the cumulative incidence of MACE was 30% in patients with DLMD; in those at high surgical risk (similar to two-thirds of the patients in our study), the risk of MACE was >40%. Importantly, stenting technique (bifurcation versus main branch only) had no impact on outcomes. It is difficult, however, to draw conclusions about the appropriate stent technique from any of the published data about DES for ULMCA because the choice of technique in these studies is operator-driven, presumably in response to specific lesion characteristics (angulation of the distal bifurcation, diameter and degree of stenosis within the left circumflex, etc.).
We do agree with Dr. Bonvini et al. that a meticulous technical approach to ULMCA stenting is essential. We continue to use DES to treat many patients with ULMCA disease. We have now changed our technique (based on our reported experience) in the following manner: 1) we always preload patients with 300 to 600 mg of clopidogrel; 2) we always complete the stent implantation procedure with a high-pressure postdilation using noncompliant balloons; 3) we always employ postprocedure intravascular ultrasound to confirm stent expansion and apposition; and 4) we routinely use glycoprotein IIb/IIIa inhibitors in the absence of significant bleeding risk.
Finally, before percutaneous coronary intervention for unprotected LMCA disease becomes the "worldwide standard of care," it is imperative that further studies define the optimal stenting strategy based on specific lesion characteristics and also determine whether restenosis of the left circumflex ostium has a benign prognosis if left untreated. This truth is self-evident: all left main lesions are not alike, and they should not be treated as equals.
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References
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- 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]
- Valgimigli M, Malagutti P, Rodriguez-Granillo GA, et al. 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 J Am Coll Cardiol 2006;47:1530-1537.[Abstract/Free Full Text]
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