JACC WHITE PAPER
Revascularization for Unprotected Left Main DiseaseEvolution of the Evidence Basis to Redefine Treatment Standards
David E. Kandzari, MD*,
Antonio Colombo, MD ,
Seung-Jung Park, MD, PhD ,
Carl L. Tommaso, MD||,
Stephen G. Ellis, MD¶,
Luis A. Guzman, MD ,
Paul S. Teirstein, MD*,
Corrado Tamburino, MD,
John Ormiston, MD#,
Gregg W. Stone, MD**,
George D. Dangas, MD**,
Jeffrey J. Popma, MD,
Theodore A. Bass, MD,* on behalf of the American College of Cardiology Interventional Scientific Council
* Scripps Clinic, Division of Cardiovascular Diseases, La Jolla, California
EMO Centro Cuore Columbus, San Raffaele Scientific Institute, Milan, Italy
Division of Cardiology, University of Catania, Catania, Italy
Division of Cardiology, Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
|| North Shore University Health System, Skokie, Illinois
¶ Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
# Auckland City Hospital, Auckland, New Zealand
** Columbia University Medical Center and Cardiovascular Research Foundation, New York, New York
Beth Israel Deaconess Medical Center, Boston, Massachusetts
Division of Cardiology, University of Florida College of Medicine-Shands Jacksonville, Jacksonville, Florida
Manuscript received June 12, 2009;
revised manuscript received July 13, 2009,
accepted July 21, 2009.
* Reprint requests and correspondence: Dr. Theodore A. Bass, Shands Cardiovascular Center, ACC 5th Floor, 655 West 8th Street, Jacksonville, Florida 32209 (Email: ted.bass{at}jax.ufl.edu).
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Abstract
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Determining the most appropriate revascularization strategy for patients presenting with unprotected left main coronary (UPLM) disease has been a topic of great recent interest. During this current decade, there have been multiple clinical trials and registries addressing this subject. Previously, UPLM disease has almost exclusively resulted in utilizing a surgical revascularization treatment strategy. However, recent improvements in percutaneous coronary intervention (PCI) techniques in parallel with the benefits of drug-eluting stents (DES) to reduce clinical restenosis have enabled further investigation in catheterization-based treatment strategies as possible alternative therapeutic options. These advances as well as an increased understanding of both the procedural and anatomical challenges involved with complex coronary interventions have allowed further advancements in the field. Better adjunctive antithrombotic pharmacological therapy in the PCI setting has favored such progress. American College of Cardiology/American Heart Association/Society for Coronary Angiography and Interventions guidelines do not currently endorse the performance of PCI as an appropriate alternative to surgical revascularization for patients with UPLM disease. This paper is a review of the current evidence on UPLM PCI and proposes future directions in this evolving field.
Key Words: left main coronary • percutaneous coronary intervention • revascularization
Since its introduction over 3 decades ago, percutaneous revascularization of "unprotected" (nonrevascularized) left main coronary artery disease has been considered as a possibly less invasive alternative to surgical bypass. However, except for patients with high surgical risk that might preclude coronary artery bypass grafting (CABG), historical studies evaluating percutaneous coronary intervention (PCI) with balloon angioplasty or conventional bare-metal stents have reported at best inconsistent intermediate-term success and at worst unacceptably high rates of restenosis-related complications manifested as repeat revascularization or even sudden cardiac death. In many instances, these early discouraging reports were confounded by poor patient selection and still-evolving procedural technique.
Acknowledging a prior historical background of generally unfavorable clinical outcomes and the absence of direct, comparative trials with CABG, only modest evidence has been available to support the indication for unprotected left main (UPLM) percutaneous revascularization in patients ineligible for bypass surgery with even less evidence to endorse PCI as an otherwise routine therapy in this indication. Accordingly, intersociety guidelines have recommended against UPLM percutaneous revascularization as an optional therapy in individuals eligible for CABG (Class III) and support the indication with a still uncertain benefit (Class IIb) only in circumstances of excessive surgical risk (1). Similarly, a multidisciplinary committee evaluating general appropriateness criteria for PCI based on practice guidelines determined the evidence basis for UPLM percutaneous revascularization also did not merit its performance as a standard treatment (2). However, in light of data provided by more recent clinical trials, the evidence used as the basis to form these recommendations is now dated.
More recently, along with advances in technique, and the realized reduction in restenosis provided by the use of drug-eluting stents (DES), renewed enthusiasm for catheter-based revascularization of UPLM disease has paralleled the clinical achievements observed with DES in less complex coronary anatomy. In a lesion subset once routinely and systematically excluded from interventional cardiology trials, recent successes principally limited to observational and nonrandomized comparative trials of DES in ULPM revascularization also support a rationale to revisit established conventions for treatment (3). Specifically, these studies have demonstrated clinical equipoise between the 2 previously contested (4–6) revascularization strategies of PCI and bypass surgery, consistently reporting similar rates of combined safety outcomes including death, myocardial infarction, and stroke. New insights have also arisen from recent studies that have identified selected characteristics among patients with left main disease in whom PCI is suggested to be an acceptable or even preferable alternative to CABG (7–9).
Contemporary results involving revascularization with DES demonstrate significant advances compared with earlier experiences. The results from these individual studies—though varied in trial design, methods, and sample size—are remarkably concordant and challenge current standards for appropriateness of PCI in this specific lesion subset (3,6). Yet some questions remain that need to be addressed in order to establish UPLM PCI as an alternative revascularization strategy to the existing standard of CABG: - 1 Beyond the issue of relevant trial design and end points, what outstanding information must be obtained before treatment guidelines may be advanced and UPLM PCI should be recommended?
- 2 Are there current, existing data that permit us to move forward with accepting UPLM PCI as an alternative therapy in broad patient populations or more narrowly defined subgroups of patients?
- 3 What nontechnical issues need to be resolved to move this process forward, for example, long-term pharmacological therapy and other aspects of patient management?
Although not all uncertainties must be satisfied before advancing the indication, considering the potential clinical implications of UPLM restenosis or stent thrombosis, prioritizing these details is warranted to reassure clinical decision-making. The purpose of this statement is to critically examine the available data with DES in contemporary UPLM revascularization, identifying existing strengths and deficiencies in the current evidence, as well as to determine outstanding concerns that must be satisfied before redefining standards for left main coronary revascularization.
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Contemporary Evidence in UPLM Percutaneous Revascularization
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Successes and shortcomings with DES.
Considering the potential significant clinical implications of left main restenosis following angioplasty and stent placement, the UPLM indication best represents the convergence of efficacy and safety outcomes. Aside from 1 modest-sized randomized trial comparing DES with bare-metal stents (10), DES performance in left main PCI has been evaluated in nonrandomized, observational surveys with abbreviated longitudinal follow-up (11–31) (Table 1). Compared with conventional bare-metal stents, DES revascularization in UPLM disease is associated with statistically significant and clinically meaningful reductions in angiographic restenosis and the need for repeat revascularization with a relative reduction in clinical restenosis similar to that reported in other lesion complexities (10). These findings are consistent throughout all studies involving this comparison, and in most instances, DES-related safety outcomes of death, myocardial infarction, and stent thrombosis do not statistically vary by direct (or more often indirect) comparison with bare-metal stents. Conclusions regarding late-term safety and efficacy are limited, not only by variability in trial design and lack of statistical power, but also according to patient selection and technique.
Encouraged by small, randomized trial experience and an array of observational dedicated UPLM or subgroup reports, more recent clinical trials examining UPLM DES revascularization versus CABG and comparative DES studies with longer-term follow-up have provided an important perspective regarding safety and efficacy outcomes with DES treatment (32–44) (Table 2). The nonrandomized MAIN-COMPARE (Revascularization for Unprotected Left Main Coronary Artery Stenosis: Comparison of Percutaneous Coronary Angioplasty versus Surgical Revascularization) trial involving 2,240 patients with UPLM disease compared outcomes according to treatment with percutaneous revascularization (DES 71%/bare-metal stent 29%) or CABG (43). Expectedly, population differences existed, most notably patients in the PCI cohort were less likely to have diabetes or multivessel coronary disease. Patients were followed for approximately 3 years, and a propensity scoring model found treatment with DES was associated with a significantly lower rate of freedom from repeat revascularization versus CABG (90.7% vs. 98.4%, p < 0.001). Importantly, no significant differences in safety end points including freedom from death (DES 91.0% vs. CABG 93.1%, p = 0.26) or the composite end point of death, myocardial infarction, or stroke were identified. In the randomized SYNTAX (Synergy Between Percutaneous Coronary Intervention With TAXUS and Cardiac Surgery) trial comparing CABG with PCI for left main/multivessel disease, patient treatment assignment was stratified according to the presence of significant UPLM disease, representing a patient cohort (n = 705) with approximately 60% bifurcation disease and 13% isolated left main disease (i.e., no additional target lesions) (8). For the overall left main subgroup, there were no differences in 1-year individual outcomes of death or myocardial infarction, despite significantly higher rates of stroke in the CABG group (2.7% CABG vs. 0.3% PCI, p = 0.009). Repeat revascularization was more common with PCI (6.7% CABG vs. 12.0% PCI, p = 0.02) and was particularly driven by higher rates among patients with left main disease treated for additional 2-vessel (15.3% vs. 7.7%, p = 0.08) or 3-vessel (14.8% vs. 6.0%, p = 0.02) disease. These findings paralleled the overall SYNTAX trial results demonstrating no difference between PCI and CABG for outcomes of death and myocardial infarction despite the association of CABG with significantly higher rates of stroke and lower rates of repeat revascularization (45).
Implicit in recent favorable outcomes reported with percutaneous UPLM treatment is the consideration whether clinical safety and efficacy are equivalent for different DES. Given that (1) the principal benefit of DES is to reduce clinical restenosis; (2) DES vary considerably in angiographic outcomes (e.g., late lumen loss) but less in clinical outcome; and (3) safety differences in direct comparative DES trials have been inconsistent, demonstration of DES-specific performance seems preferred over assumption of class effect. At present, most DES-related UPLM trials are limited to sirolimus- and paclitaxel-eluting stents, and only 1 randomized trial examining a clinical primary end point exists. In the ISAR-LEFT MAIN (Intracoronary Stenting and Angiographic Results: Drug-Eluting Stents for Unprotected Coronary Left Main Lesions) trial (30), 607 patients ( 60% bifurcation involvement, 75% multivessel disease) were evenly assigned to UPLM revascularization with sirolimus- or paclitaxel-eluting stents to compare by noninferiority design the 1-year composite outcome of death, myocardial infarction, or target lesion revascularization. In addition to demonstrating no significant differences in the 1-year primary end point (paclitaxel 13.6% vs. sirolimus 15.8%; relative risk: 0.85, 95% confidence interval: 0.56 to 1.29), angiographic restenosis (6- to 9-month follow-up; paclitaxel 16.0% vs. sirolimus 19.4%, p = 0.30) and 2-year left main-specific target lesion revascularization (paclitaxel 9.2% vs. sirolimus 10.7%, p = 0.47) also did not statistically vary. For both stent types, the 2-year rate of definite stent thrombosis was <0.5%, with no new events occurring beyond the initial 30 days following revascularization. The ISAR-LEFT MAIN trial, therefore, not only demonstrated outcomes of death and myocardial infarction consistent with other DES-related trials, but also confirmed the comparative effectiveness in the UPLM indication among 2 commonly used DES designs. In particular, similar to the findings reported in the MAIN-COMPARE and SYNTAX trials, no signal suggesting an increased safety risk with DES UPLM PCI strategy was detected.
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Considerations for UPLM Percutaneous Revascularization
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Anatomic lesion complexity and technique.
Similar to categorical PCI qualifiers such as diabetes or acute myocardial infarction, not all left main revascularization is alike, and yet clinical outcomes may vary more according to left main complexity than any other lesion type or clinical characteristic. In particular, lesion location appears to be of paramount importance. Left main lesions not involving the distal bifurcation (representing <40% of patients undergoing revascularization) are associated with high procedural success rates and favorable late-term outcomes of death, myocardial infarction, and repeat revascularization. In a multicenter study of 147 patients undergoing ostial or shaft UPLM percutaneous revascularization with DES, the rates of cardiac death and repeat target lesion revascularization were 2.7% and 0.7%, respectively, during an average follow-up period of approximately 2.5 years (7). In comparison, outcomes following DES revascularization of the more common left main bifurcation lesions are technically more challenging, and optimal PCI strategies (e.g., bare-metal stents vs. DES, 1 vs. 2 stents) are yet to be clearly defined. A meta-analysis of 17 trials involving UPLM PCI identified the presence of bifurcation disease as the most significant predictor of repeat revascularization and overall major adverse cardiac events (46). Furthermore, these strategies may vary depending on different anatomical features of the entire coronary anatomy and lesion morphology (e.g., bifurcation angles, differences in vessel size, and mismatch). It is not surprising then that clinical outcomes, including both safety and efficacy end points, have been less encouraging when compared with results from DES PCI of nonbifurcation left main lesions (24,47). In many instances, anatomic disease complexity and limitations of currently available device technologies may not lend treatment of bifurcation disease to fair comparisons regarding stent technique. However, it is encouraging that several recent observational studies have consistently demonstrated nearly equivalent clinical outcomes comparing single-stent bifurcation revascularization to left main stenting for ostial or shaft disease (15,21,47–49). Notably, 1 large study reported comparatively higher rates of cardiovascular death and target lesion revascularization with 2-stent treatment of bifurcation disease, including instances of unsuccessful provisional approaches that required additional stent placement (50).
Consistent with published results involving bifurcation stenting in non-left main disease, preliminary results in UPLM bifurcation PCI favor a single-stent provisional approach compared with intentional 2-stent techniques. However, historically, it has not been uncommon to use more than 1 stent to treat the UPLM bifurcation as this strategy has been employed in approximately 40% of cases (30,50). In such instances, the optimal 2-stent technique (e.g., crush, Culotte, V- or T-stenting) has not been determined, since any existing comparisons are challenged by operator and institutional preference. Although novel dedicated bifurcation stent designs are in early clinical development (51,52), there is insufficient evidence to support their procedural and clinical superiority over existing standards. Alternatively, treatment of left main coronary diameters that exceed current stent designs might otherwise necessitate treatment with bare-metal stents and may instead favor bypass surgery in certain circumstances; whereas restenosis risk associated with bare-metal stent placement may be reduced by their use in larger caliber vessels, multiple (bare-metal) stent treatment of bifurcation disease may be less preferred.
Left main coronary lesion complexity has clear procedural and clinical implications, underscoring the need for proper evaluation of both the distribution and severity of disease. In the latter instance, hemodynamic and intravascular ultrasound (IVUS) assessment of left main coronary atherosclerotic disease has associated the functional and/or anatomic relevance of stenosis with the need for treatment and clinical outcome (53,54). In many circumstances, the application of IVUS may also be invaluable to optimally assess plaque distribution, bifurcation involvement, and vessel calcification, which are often poorly defined by angiography alone. Presence of deep concentric vessel calcification, for example, may represent a significant challenge to achieve optimal stent expansion and apposition. These findings may influence decisions regarding optimal revascularization strategy (i.e., PCI vs. CABG) or stent technique. IVUS may also provide important information regarding stent sizing, post-deployment stent expansion, and stent-wall apposition. Although more established in non-left main PCI studies, the impact of these functional or anatomical assessments on clinical outcomes appears to be intuitively beneficial when applied to the left main stent group (12,55). Nevertheless, the application of IVUS in UPLM PCI trials has been inconsistent, with some studies reporting favorable outcomes despite negligible use of IVUS (30).
Finally, there are no standardized recommendations addressing adjunctive procedural technical decisions such as when and in whom to use hemodynamic support during percutaneous UPLM revascularization, although elective use of intra-aortic balloon counterpulsation may prevent procedural-related complications in higher-risk patients (56).
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Stent Thrombosis and Antiplatelet Therapy
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The importance of compliance with dual antiplatelet medication in DES-treated patients is underscored by the demonstrated increased stent thrombosis rates occurring in the setting of premature drug withdrawal (57–59). In a recent observational survey of patients treated for UPLM stenosis with PCI, most adverse events occurred among patients treated with <6 months dual antiplatelet therapy, and the risk of cardiovascular death or myocardial infarction was more than 4-fold greater within 90 days of clopidogrel cessation compared with later time periods (60). DES placement in UPLM revascularization thus represents a narrow margin between the need for a potent antirestenotic effect balanced by the risk of stent thrombosis related to delayed healing. Since stent thrombosis at any time is nearly uniformly associated with myocardial infarction, and mortality rates may exceed 30% (57), its occurrence in the left main location could have devastating consequences. In that regard, any measure to reduce its occurrence following UPLM PCI would be clinically meaningful and must be considered when moving forward with a UPLM PCI strategy recommendation.
Several recent multicenter registries evaluating the occurrence of late and very late stent thrombosis provide some reassuring and remarkably consistent evidence to support DES treatment in UPLM disease. In the DELFT (Drug Eluting stent for LeFT main) registry, the 3-year rate of definite/probable stent thrombosis was 1.7%, with only 2 events occurring after the initial 30 days (1 definite, 1 probable) (27). Similarly, a recent analysis of 731 patients undergoing DES revascularization for UPLM stenosis identified an overall 0.5% definite stent thrombosis rate with only 1 late event and no very late (>1 year) events (61). Notably, all patients were on dual antiplatelet therapy at the time of the event. Two additional randomized trials have also compared stent thrombosis rates between DES types and versus symptomatic bypass graft occlusion following CABG. In the ISAR-LEFT MAIN trial (N = 607) evaluating outcomes with sirolimus- and paclitaxel-eluting stents, the 2-year occurrence of definite stent thrombosis was 0.5% and did not significantly vary according to stent type (30). Recently, the frequency of left main stent thrombosis following DES revascularization has also been examined against the perspective of clinically relevant bypass graft occlusion. In the left main subset of the randomized SYNTAX trial (8), the 1-year rate of stent thrombosis with paclitaxel-eluting stents was 2.7% compared with a 3.7% rate of clinically manifest bypass graft occlusion (p = 0.49), suggesting that the frequency of acute, thrombotic events may be more similar than previously recognized. Notably, in the PCI cohort of the SYNTAX trial, stent thrombosis outcomes are reported as any event and were not specified to the left main target lesion.
The optimal duration of dual antiplatelet therapy in patients with UPLM disease treated with DES remains to be defined. Recent observational studies have inconsistently demonstrated a benefit of combination antiplatelet therapy continued beyond 6 to 12 months to reduce late-term outcomes of death, myocardial infarction, or stent thrombosis in non-UPLM cohorts (58,59,62–66). Current American College of Cardiology/American Heart Association/Society for Coronary Angiography and Interventions guidelines offer limited assistance regarding this very practical issue (1). Although current guidelines support long-term aspirin treatment and at least 1 year of thienopyridine therapy in post-PCI patients (Class I, Level of Evidence: B), this is not specific for UPLM coronary stenting. The support for longer-term (>1 year) dual antiplatelet therapy following DES revascularization is even less robust (Class IIb, Level of Evidence: C). Improved strategies to ensure patient medication compliance will also need to be developed, and it appears especially relevant following UPLM PCI to identify a minimum duration after which at least temporary interruption of antiplatelet therapy for intervening medical need may be considered safe. The utility of functional assays to guide most appropriate antiplatelet treatment is similarly not clearly defined; present guidelines suggest performance of platelet aggregation studies in patients undergoing UPLM PCI (or its clinical equivalent) and empirically advocate increasing the clopidogrel dose to 150 mg daily if <50% platelet aggregation is demonstrated (1). The importance of better understanding and resolving some of these issues will become increasingly apparent if performance of UPLM PCI is expected to increase in broad populations.
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Post-Revascularization Surveillance
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Restenosis may still occur with DES treatment of UPLM disease, and a surveillance strategy to optimally and efficiently detect this problem has not been established. Issues related to patient selection, purpose, and timing of follow-up functional stress testing, invasive angiography (Class IIa recommendation [1]), intravascular ultrasound, and/or noninvasive computed tomographic angiography (67) are less characterized regarding comparative effectiveness and based more on individual clinical practice. When clinical restenosis following UPLM stenting is identified, appropriate treatment is also uncertain, namely whether patients should be treated with repeat DES placement, balloon angioplasty alone for focal disease, or CABG. Recurrent adverse events may be more common following repeat revascularization for UPLM in-stent restenosis; however, outcomes following CABG for this indication may be similar to surgery for de novo left main disease. However, it is important to recognize that failure to have complete resolution of these particular issues does not in itself prohibit the advancement of UPLM PCI as an important therapeutic alternative to bypass surgery for selected patients.
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Application of Risk Score Models
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Although predictive models based on risk assessment are commonplace for varied clinical and angiographic subgroups in interventional cardiology, their routine application is often less practical. Specific to UPLM PCI, the lack of consensus regarding a comparable surgical benchmark limits any method for informed risk and benefit. Nevertheless, for UPLM revascularization in which: 1) a surgical standard of care has been historically established; and 2) both PCI and surgical alternatives may result in divergent clinical outcomes favoring either therapy depending upon risk, the development and widespread adoption of a predictive model based on clinical and angiographic characteristics seems essential to clinical decision-making and educated, informed consent for patients.
Until recently, estimation of procedural and clinical outcome following percutaneous UPLM revascularization has been limited by extrapolation of risk models from bypass surgery for complex left main and multivessel coronary disease (e.g., EuroSCORE, Parsonnet score [68,69]) and/or retrospective assessment within individual trials. In most instances, these risk scores have more often been applied for descriptive purposes as a reference to surgical patients with left main and multivessel disease rather than to prospectively determine clinical treatment or predict outcome. In limited examples, a higher EuroSCORE and presentation with acute coronary syndromes have been associated with increased risk of death, myocardial infarction, and stent thrombosis (33,41,70–72). Although advanced age as an independent variable has been inconsistently predictive of adverse outcome (and may more closely reflect comorbidity) (41), elderly patients may especially benefit from a strategy of percutaneous revascularization given increased perioperative risks such as stroke. Inflammatory biomarkers, for example C-reactive protein, have also been associated with an increased likelihood for adverse outcome following UPLM PCI (73,74), although this finding may simply represent those individuals with high-risk clinical presentation.
Expectedly, an emerging predictor of clinical outcome following UPLM revascularization relates to both non-left main disease extent and severity. Although anatomic location of disease within the left main segment has been identified as an important predictor of clinical outcome following PCI, the extent, severity, and complexity of non-left main disease may be an even greater determinant of risk. Increasing disease burden may also indicate a higher likelihood for incomplete revascularization, which was significantly more common among PCI compared with CABG patients within the left main subgroup of the SYNTAX trial (8).
Recent application of a coronary anatomic risk score based on lesion severity and extent (SYNTAX score [75]) has provided insight into both patient selection and safety and efficacy outcomes but must be cautiously interpreted, given limitations of sample size and subgroup analysis. Among 705 patients with significant UPLM disease in the SYNTAX trial, isolated left main stenosis was identified in only 13% of individuals, and the increasing number of additional vessels treated was identified as the single independent procedural determinant of 1-year combined adverse events (8). For UPLM patients identified in the upper tercile of lesion complexity represented by a SYNTAX score  33, compared with bypass surgery, PCI was associated with numerically higher death, myocardial infarction, and stroke (10.9% PCI vs. 14.2% CABG, p = 0.40) and significantly greater repeat revascularization (17.2% vs. 4.8%, p = 0.0008). Conversely, no significant differences in clinical restenosis or the composite end point of death, myocardial infarction, and stroke were observed between treatment strategies in patients with low (0 to 22) and intermediate (23 to 32) SYNTAX scores. Validation of the SYNTAX score in association with clinical risk factors, in addition to proposed UPLM-specific models, are evolving for UPLM PCI (76) and may possibly expand their clinical utility.
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Percutaneous UPLM Revascularization: Is it Time? Are We Ready?
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Ultimately, demonstration of at least clinical equivalence in a randomized trial comparing DES and surgical revascularization for UPLM disease is essential before UPLM PCI can be uniformly adopted as a routine alternative (Class I) to bypass surgery, although like many large, ambitious studies, the proposal alone seems likely to be an oversimplification. Especially important is the identification of a suitable trial population in addition to selection and timing of study end points. A clinical trial end point is implied (vs. angiographic outcomes), and a composite end point representing safety metrics is essential. As previously suggested for the left main indication, the delineation between efficacy and safety relative to PCI is less distinct. Although nonrandomized in design, current comparative studies of UPLM PCI versus CABG are nevertheless consistent in reporting similar hard clinical end point event rates following risk adjustment. The data obtained from patients receiving DES in 2 recent large-scale randomized trials, SYNTAX and ISAR-LEFT MAIN, is encouraging and concordant with previously reported experiences involving DES PCI in an UPLM population. Accordingly, we must consider whether the primary end point of subsequent investigations should compare only clinical outcomes restricted to death, myocardial infarction, and stroke (favoring PCI) versus the inclusion of target lesion revascularization (favoring CABG). The relative weight and clinical relevance of such heterogeneous end points may not be shared equally. Nevertheless, when revascularization is considered, the timing of end point ascertainment is pertinent since clinically driven repeat revascularization following PCI may occur earlier than later bypass graft failure. A future challenge will involve the identification of the most appropriate length for optimal clinical follow-up when comparing these treatment strategies. Further, as advancing patient and lesion complexity favors CABG, future trial designs must also consider exclusion of highest risk patients or, alternatively, pre-specified comparisons according to risk score. Pre-specified analyses according to lesion characteristics (vessel caliber, bifurcation involvement) and technique (provisional vs. 2-stent methods) are also mandatory.
What are the existing data permitting us to accept UPLM PCI as a treatment alternative either in broad patient populations or more narrowly defined subgroups, and what outstanding information must be obtained before treatment guidelines may be advanced and UPLM PCI be recommended? Presently, available evidence is substantive enough to advance guideline recommendations for nonbifurcation UPLM PCI to Class IIa status. We also believe that there is sufficient data to advance the indication for more complex UPLM PCI beyond the present Class III to a Class IIb recommendation in the absence of complex coexisting multivessel disease. An additional consideration is that such procedures are performed at centers and by operators skilled in left main intervention, and after the patient has had a full consultation with both a cardiac surgeon and interventionalist. Finally, there are outstanding issues whose resolution would assist in moving this process forward, such as further defining optimal adjunctive pharmacology, examining cost-effectiveness, and better standardization of post-procedural surveillance.
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Conclusions
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For selected patient and lesion groups, our present and evolving understanding of UPLM revascularization with DES supports revisiting PCI as an alternative to bypass surgery beyond existing guidelines that recommend against its performance. This represents an opportunity for a reappraisal of current treatment standards. The implementation of advances in catheter-based technology will help better address remaining technical challenges. The issue is not whether UPLM PCI can be technically performed, but rather what treatment should be performed, and how the relative merits and risks of revascularization strategies can be responsibly translated to patients as part of informed consent.
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Footnotes
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Dr. Kandzari receives research/grant support and consulting honoraria from Medtronic Vascular, Inc. and Cordis Corporation. Dr. Colombo is a minor shareholder in Cappella, Inc. Dr. Ellis receives consulting honoraria from Boston Scientific, Cordis Corporation, and Abbott Vascular. Dr. Teirstein receives research/grant support and consulting honoraria from Boston Scientific, Medtronic Vascular, and Abbott Vascular. Dr. Ormiston receives consulting honoraria from Abbott Vascular and Boston Scientific. Dr. Stone serves on advisory boards for Boston Scientific and Abbott Vascular. Dr. Dangas receives consulting honoraria and/or lecture fees from Abbott Vascular, Medtronic Vascular, Cordis Corporation, and Boston Scientific. Dr. Popma receives research/grant support from and serves on advisory boards for Medtronic Vascular, Cordis Corporation, Boston Scientific, and Abbott Vascular. Dr. Bass is on the Speakers' Bureau for Eli-Lilly and Daiichi Sankyo.
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References
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1. Smith Jr. SC, Feldman TE, Hirschfeld Jr. JW, et al. ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/SCAI Writing Committee to Update the 2001 Guidelines for Percutaneous Coronary Intervention) J Am Coll Cardiol 2006;47:e1-e121.[Free Full Text]2. Patel MR, Dehmer GJ, Hirshfeld JW, et al. ACCF/SCAI/STS/AATS/AHA/ASNC 2009 appropriateness criteria for coronary revascularization: a report of the American College of Cardiology Foundation Appropriateness Criteria Task Force, Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, American Association for Thoracic Surgery, American Heart Association, and the American Society of Nuclear Cardiology J Am Coll Cardiol 2009;53:530-553.[Free Full Text] 3. Park SJ, Park DW. Percutaneous coronary intervention with stent implantation versus coronary artery bypass surgery for treatment of left main coronary artery disease. Is it time to change guidelines?. Circ Cardiovasc Interv 2009;2:59-68. 4. Taggart DP, Kaul S, Boden WE, et al. Revascularization for unprotected left main stent coronary artery stenosis. Stenting or surgery. J Am Coll Cardiol 2008;51:885-892.[Abstract/Free Full Text] 5. Smith CR. Surgery, not percutaneous revascularization, is the preferred strategy for patients with significant left main coronary stenosis Circulation 2009;119:1013-1020.[Free Full Text] 6. Teirstein PS. Percutaneous revascularization is the preferred strategy for patients with significant left main coronary stenosis Circulation 2009;119:1021-1033.[Free Full Text] 7. Chieffo A, Park SJ, Valgimigli M, et al. Favorable long-term outcome after drug-eluting stent implantation in nonbifurcation lesions that involve unprotected left main coronary artery: a multicenter registry Circulation 2007;116:158-162.[Abstract/Free Full Text] 8. Serruys P. The synergy between percutaneous coronary intervention with Taxus and cardiac surgery: the SYNTAX trial. Primary endpoint results at 1 year in subset of patients with left main disease. Paper presented at: Transcatheter Cardiovascular Therapeutics (TCT) Meeting; October 14, 2008; Washington, DC. 9. Alfonso F. Left main coronary artery stenting: crossing the rubicon J Am Coll Cardiol 2009;53:1769-1772.[Free Full Text] 10. Erglis A, Narbute I, Kumsars I, et al. A randomized comparison of paclitaxel-eluting stents versus bare-metal stents for treatment of unprotected left main coronary artery stenosis J Am Coll Cardiol 2007;50:491-497.[Abstract/Free Full Text] 11. de Lezo JS, Medina A, Pan M, et al. Rapamycin-eluting stents for the treatment of unprotected left main coronary disease Am Heart J 2004;148:481-485.[CrossRef][Web of Science][Medline] 12. Agostoni P, Valgimigli M, Van Mieghem CAG, et al. Comparison of early outcome of percutaneous coronary intervention for unprotected left main coronary artery disease in the drug-eluting stent era with versus without intravascular ultrasonic guidance Am J Cardiol 2005;95:644-647.[CrossRef][Web of Science][Medline] 13. 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] 14. Lee SH, Ko YG, Jang Y, et al. Sirolimus-versus paclitaxel-eluting stent implantation for unprotected left main coronary artery stenosis Cardiology 2005;104:181-185.[CrossRef][Web of Science][Medline] 15. 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] 16. 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] 17. Wood F, Bazemore E, Schneider JE, Jobe RL, Mann T. Technique of left main stenting is dependent on lesion location and distal branch protection Catheter Cardiovasc Interv 2005;65:499-503.[CrossRef][Web of Science][Medline] 18. Carrie D, Lhermusier T, Hmem M, Maupas E, Elbaz M, Puel J. Clinical and angiographic outcome of paclitaxel-eluting stent implantation for unprotected left main coronary artery bifurcation narrowing EuroIntervention 2006;1:396-402.[Medline] 19. Christiansen EH, Lassen JF, Andersen HR, et al. Outcome of unprotected left main percutaneous coronary intervention in surgical low-risk, surgical high-risk, and acute myocardial infarction patients EuroIntervention 2006;1:403-408.[Medline] 20. Han YL, Wang SL, Jin QM, et al. Efficacy of stenting for unprotected left main coronary artery disease in 297 patients Chin Med J 2006;119:544-550.[Web of Science][Medline] 21. Kim YH, Park SW, Hong MK, et al. Comparison of simple and complex stenting techniques in the treatment of unprotected left main coronary artery bifurcation stenosis Am J Cardiol 2006;97:1597-1601.[CrossRef][Medline] 22. Migliorini A, Moschi G, Giurlani L, et al. Drug-eluting stent supported percutaneous coronary intervention for unprotected left main disease Catheter Cardiovasc Interv 2006;68:225-230.[CrossRef][Web of Science][Medline] 23. 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] 24. Sheiban I, Meliga E, Moretti C, et al. Sirolimus-eluting stents versus bare metal stents for the treatment of unprotected left main coronary artery stenosis EuroIntervention 2006;2:356-362.[Medline] 25. Gao RL, Bo X, Chen JL, et al. Immediate and long-term outcomes of drug-eluting stent implantation for unprotected left main coronary artery disease: comparison with bare-metal stent implantation Am Heart J 2008;155:553-561.[Web of Science][Medline] 26. Kim YH, Dangas GD, Solinas E, et al. Effectiveness of drug-eluting stent implantation for patients with unprotected left main coronary artery stenosis Am J Cardiol 2008;101:801-806.[CrossRef][Web of Science][Medline] 27. Meliga E, Garcia-Garcia HM, Valgimigli M, et al. Longest available clinical outcomes after drug-eluting stent implantation for unprotected left main coronary artery disease: the DELFT (Drug Eluting stent for LeFT main) registry J Am Coll Cardiol 2008;51:2212-2219.[Abstract/Free Full Text] 28. Palmerini T, Marzocchi A, Tamburino C, et al. Two-year clinical outcome with drug-eluting stents versus bare metal stents in a real world registry of unprotected left main coronary artery stenosis from the Italian Society of Invasive Cardiology Am J Cardiol 2008;102:1463-1468.[CrossRef][Web of Science][Medline] 29. Carrie D, Eltchaninoff H, Lefevre T, et al. Twelve month clinical and angiographic outcome after stenting of unprotected left main coronary artery stenosis with paclitaxel-eluting stents: results of the multicentre FRIEND registry EuroIntervention 2009;4:449-456.[Medline] 30. Mehilli J, Kastrati A, Byrne RA, et al. ISAR-LEFT MAIN (Intracoronary Stenting and Angiographic Results: Drug-Eluting Stents for Unprotected Coronary Left Main Lesions) Study Investigators Paclitaxel- versus sirolimus-eluting stents for unprotected left main coronary artery disease J Am Coll Cardiol 2009;53:1760-1768.[Abstract/Free Full Text] 31. Tamburino C, Di Salvo ME, Capodonno D, et al. Are drug-eluting stents superior to bare metal stents in patients with unprotected non-bifurcational left main disease?. Insights from a multicentre registry. Eur Heart J 2009;30:1171-1179.[Abstract/Free Full Text] 32. Chieffo A, Morici N, Maisano F, et al. Percutaneous treatment with drug-eluting stent implantation versus bypass surgery for unprotected left main stenosis: a single-center experience Circulation 2006;113:2542-2547.[Abstract/Free Full Text] 33. Lee MS, Kapoor N, Jamal F, et al. Comparison of coronary artery bypass surgery with percutaneous coronary intervention with drug-eluting stents for unprotected left main coronary artery disease J Am Coll Cardiol 2006;47:864-870.[Abstract/Free Full Text] 34. Palmerini T, Marzocchi A, Marrozzini C, et al. Comparison between coronary angioplasty and coronary artery bypass surgery for the treatment of unprotected left main coronary artery stenosis (the Bologna Registry) Am J Cardiol 2006;98:54-59.[CrossRef][Web of Science][Medline] 35. Palmerini T, Barlocco F, Santarelli A, et al. A comparison between coronary artery bypass grafting surgery and drug eluting stent for the treatment of unprotected left main coronary artery disease in elderly patients (aged 75 years) Eur Heart J 2007;38:2714-2719. 36. Sanmartin M, Baz JA, Claro R, et al. Comparison of drug-eluting stents versus surgery for unprotected left main coronary artery disease Am J Cardiol 2007;100:970-973.[CrossRef][Medline] 37. Brener SJ, Galla JM, Bryant R, Sabik JF, Ellis SG. Comparison of percutaneous versus surgical revascularization of severe unprotected left main coronary stenosis in matched patients Am J Cardiol 2008;101:169-172.[CrossRef][Web of Science][Medline] 38. Buszman PE, Kiesz SR, Bochenek A, et al. Acute and late outcomes of unprotected left main stenting in comparison with surgical revascularization J Am Coll Cardiol 2008;51:538-545.[Abstract/Free Full Text] 39. Hsu JT, Chu CM, Chang ST, Kao CL, Chung CM. Percutaneous coronary intervention versus coronary artery bypass graft surgery for the treatment of unprotected left main coronary stenosis. In-hospital and one year outcome after emergent and elective treatments. Int Heart J 2008;49:355-370.[CrossRef][Web of Science][Medline] 40. Makikallio TH, Niemela M, Kervinen K, et al. Coronary angioplasty in drug eluting stent era for the treatment of unprotected left main stenosis compared to coronary artery bypass grafting Ann Med 2008;40:437-443.[CrossRef][Web of Science][Medline] 41. Rodes-Cabau J, DeBlois J, Bertrand OF, et al. Nonrandomized comparison of coronary artery bypass surgery and percutaneous coronary intervention for the treatment of unprotected left main coronary artery disease in octagenarians Circulation 2008;118:2374-2381.[Abstract/Free Full Text] 42. Wu C, Hannan EL, Walford G, Faxon D. Utilization and outcomes of unprotected left main coronary artery stenting and coronary artery bypass graft surgery Ann Thoracic Surg 2008;86:1153-1159.[Abstract/Free Full Text] 43. Seung KB, Park DW, Kim YH, et al. Stents versus coronary-artery bypass grafting for left main coronary artery disease N Engl J Med 2008;358:1781-1792.[CrossRef][Medline] 44. Boudriot E. Randomised, multicentre trial between PCI with Sirolimus-eluting stent versus CABG for unprotected left main coronary disease. Paper presented at: EuroPCR 2009 Scientific Programme; May 19, 2009; Barcelona, Spain. 45. Serruys PW, Morice MC, Kappetein AP, et al. Percutaneous coronary interventions versus coronary-artery bypass grafting for severe coronary artery disease N Engl J Med 2009;360:961-972.[CrossRef][Medline] 46. Biondi-Zoccai GG, Lotrionte M, Moretti C, et al. A collaborative systematic review and meta-analysis on 1278 patients undergoing percutaneous drug-eluting stenting for unprotected left main coronary artery disease Am Heart J 2008;155:274-283.[CrossRef][Medline] 47. 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] 48. Valgimigli M, Malagutti P, Rodriguez Granillo GA, et al. Single-vessel versus bifurcation stenting for the treatment of distal left main coronary artery disease in the drug-eluting stenting era: clinical and angiographic insights into the Rapamycin-Eluting Stent Evaluated at Rotterdam Cardiology Hospital (RESEARCH) and Taxus-Stent Evaluated at Rotterdam Cardiology Hospital (T-SEARCH) registries Am Heart J 2006;152:896-902.[CrossRef][Web of Science][Medline] 49. Park SJ, Lee CW, Kim YH, et al. Technical feasibility, safety, and clinical outcome of stenting of unprotected left main coronary artery bifurcation narrowing Am J Cardiol 2002;90:374-378.[CrossRef][Web of Science][Medline] 50. Palmerini T, Marzocchi A, Tamburino C, et al. Impact of bifurcation technique on 2-year clinical outcomes in 773 patients with distal unprotected left main coronary artery stenosis treated with drug-eluting stents Circ Cardiovasc Interv 2008;1:185-192.[CrossRef] 51. Verheye S, Agostoni P, Dubois CL, et al. 9-month clinical, angiographic, and intravascular ultrasound results of a prospective evaluation of the Axxess self-expanding biolimus A9-eluting stent in coronary bifurcation lesions: the DIVERGE (Drug-Eluting Stent Intervention for Treating Side Branches Effectively) study J Am Coll Cardiol 2009;53:1031-1039.[Abstract/Free Full Text] 52. Lefèvre T, Ormiston J, Guagliumi G, et al. The FRONTIER stent registry: safety and feasibility of a novel dedicated stent for the treatment of bifurcation coronary artery lesions J Am Coll Cardiol 2005;46:592-598.[Abstract/Free Full Text] 53. Bech GJW, Droste H, Pijls NH, et al. Value of fractional flow reserve in making decisions about bypass surgery for equivocal left main coronary artery disease Heart 2001;86:547-552.[Abstract/Free Full Text] 54. Jasti V, Ivan E, Yalamanchili V, Wongpraparut N, Leesar MA. Correlations between fractional flow reserve and intravascular ultrasound in patients with an ambiguous left main coronary artery stenosis Circulation 2004;110:2831-2836.[Abstract/Free Full Text] 55. Park SJ, Kim YH, Park DW, et al. 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. 56. Briguori C, Airoldi F, Chieffo A, et al. Elective versus provisional intraaortic balloon pumping in unprotected left main stenting Am Heart J 2006;152:565-572.[CrossRef][Web of Science][Medline] 57. Iakovou I, Schmidt T, Bonizzoni E, et al. Incidence, predictors, and outcome of thrombosis after successful implantation of drug-eluting stents JAMA 2005;293:2126-2130.[Abstract/Free Full Text] 58. Airoldi F, Colombo A, Morici N, et al. Incidence and predictors of drug-eluting stent thrombosis during and after discontinuation of thienopyridine treatment Circulation 2007;116:745-754.[Abstract/Free Full Text] 59. Park DW, Yun SC, Lee SW, et al. Stent thrombosis, clinical events, and influence of prolonged clopidogrel use after placement of drug-eluting stent: data from an observational cohort study of drug-eluting versus bare-metal stents J Am Coll Cardiol Intv 2008;1494–03. 60. Palmerini T, Marzocchi A, Tamburino C, et al. Temporal pattern of ischemic events in relation to dual antiplatelet therapy in patients with unprotected left main coronary artery stenosis undergoing percutaneous coronary intervention J Am Coll Cardiol 2009;53:1176-1181.[Abstract/Free Full Text] 61. Chieffo A, Park SJ, Meliga E, et al. Late and very late stent thrombosis following drug-eluting stent implantation in unprotected left main coronary artery stenosis in a large multicentre registry Eur Heart J 2008;29:2108-2115.[Abstract/Free Full Text] 62. Eisenstein EL, Anstrom KJ, Kong DF, et al. Clopidogrel use and long-term clinical outcomes after drug-eluting stent implantation JAMA 2007;297:159-168.[Abstract/Free Full Text] 63. Brar SS, Kim J, Brar SK, et al. Long-term outcomes by clopidogrel duration and stent type on a diabetic population with de novo coronary artery lesions J Am Coll Cardiol 2008;51:2220-2227.[Abstract/Free Full Text] 64. Kimura T, Morimoto T, Nakagawa Y, et al. j-Cypher Registry Investigators Antiplatelet therapy and stent thrombosis following sirolimus-eluting stent implantation Circulation 2009;119:987-995.[Abstract/Free Full Text] 65. Schulz S, Schuster T, Mehilli J, et al. Stent thrombosis after drug-eluting stent implantation: incidence, timing and relation to discontinuation of clopidogrel therapy over a 4-year period Eur Heart J 2009Jul 11 [E-pub ahead of print]. 66. van Werkum JW, Heestermans AA, Zomer AC, et al. Predictors of coronary stent thrombosis: the Dutch Stent Thrombosis Registry J Am Coll Cardiol 2009;53:1399-1409.[Abstract/Free Full Text] 67. Van Mieghem CAG, Cademartiri F, Mollet NR, et al. Multislice spiral computed tomography for the evaluation of stent patency after left main coronary artery stenting: a comparison with conventional coronary angiography and intravascular ultrasound Circulation 2006;114:645-653.[Abstract/Free Full Text] 68. Nashef SA, Roques F, Michel P, Gauducheau E, Lemeshow S, Salamon R. European system for cardiac operative risk evaluation (EuroSCORE) Eur J Cardiothorac Surg 1999;16:9-13.[Abstract/Free Full Text] 69. Parsonnet V, Dean D, Bernstein AD. A method of uniform stratification of risk for evaluating the results of surgery in acquired adult heart disease Circulation 1989;79:I3-I12.[Medline] 70. Tamburino C, Di Salvo ME, Capodonno D, et al. Comparison of drug-eluting stents and bare metal stents for the treatment of unprotected left main coronary artery disease in acute coronary syndromes Am J Cardiol 2009;103:187-193.[CrossRef][Web of Science][Medline] 71. Kim YH, Ahn JM, Park DW, et al. EuroSCORE as a predictor of death and myocardial infarction after unprotected left main stenting Am J Cardiol 2006;98:1567-1570.[CrossRef][Web of Science][Medline] 72. Tamburino C, Angiolillo DJ, Capranzano P, et al. Long-term clinical outcomes after drug-eluting stent implantation in unprotected left main coronary disease Catheter Cardiovasc Interv 2009;73:291-298.[Web of Science][Medline] 73. Palmerini T, Marzocchi A, Marrozzini C, et al. Preprocedural levels of C-reactive protein and leukocyte counts predict 9-month mortality after coronary angioplasty for the treatment of unprotected left main coronary artery stenosis Circulation 2005;112:2332-2338.[Abstract/Free Full Text] 74. Park SJ. Inflammatory biomarkers for prediction of outcomes after unprotected left main coronary intervention Circulation 2005;112:2226-2227.[Free Full Text] 75. Sianos G, Morel MA, Kappetein AP, et al. The SYNTAX score: an angiographic tool grading the complexity of coronary artery disease EuroIntervention 2005;1219–7. 76. Capodanno D, Di Salvo ME, Cincotta G, Miano M, Tamburino C, Tamburino C. Usefulness of the SYNTAX score for predicting clinical outcome after percutaneous coronary intervention of unprotected left main coronary artery disease Circ Intervasc Interv 2009 Jun 30[E-pub ahead of print].
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