Percutaneous Coronary Intervention for Left Main Coronary Artery Disease: A Real Life Experience

Background:
Recent evidence from the EXCEL trial suggests that the clinical outcomes of selected patients with favorable anatomic features (SYNTAX score ≤ 32) undergoing PCI using DES for the treatment of Unprotected left main (UPLM) coronary artery disease (CAD) are favorable and non-inferior to CABG in terms of survival and major adverse cardiovascular outcomes (MACE). We aimed to evaluate the characteristics, outcomes, and predictors of adverse outcomes in a cohort of “real life” high risk patients undergoing UPLM PCI in our medical center.

Methods and Results:
We identified 181 consecutive patients who underwent UPLM PCI using DES. Mean age was 72.7 ± 12.5 years and 68.5% were males. The indication for intervention was stable CAD in 25% of patients, NSTEMI-ACS in 60% of patients and STEMI in 15%. Forty one patients (23%) presented with Killip class > 1, nine of which (5%) with cardiogenic shock. Two/three vessel involvement was present in 82% of patients. Within one year of the procedure, death occurred in 26 patients (14%), cardiovascular death in 7 patients (3.9%), Myocardial Infarct in 3 (2%), and ischemic driven target vessel revascularization in 10 (5.5%). In total, MACE occurred in 40 patients (22%). In a multivariable logistic regression, age > 75 years (OR 4.4, 95% CI 1.4-14, p=0.01), Killip class > 1 at presentation (OR 2.6, 95% CI 0.9-8, p=0.08) and CKD (OR 4.2, 95% CI 1.5-12, p=0.007) were identified as independent predictors of 1 year mortality. Notably, mortality reached 32% in patients with Killip class > 1.

Conclusions:
In our experience, high risk patients undergoing PCI for UPLM using DES experience higher rates of adverse events than reported in randomized prospective trials with selective inclusion criteria. Future efforts should focus on optimized care to improved ourtcomes among patients with unprotected LM stenting