Corti, Roberto

Toggweiler, Stefan

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ESC HOT LINE COMMENTARYPCI in acute left main disease: a paradigm shiftor a new reality?Roberto Corti* and Stefan ToggweilerDepartment of Cardiology, Cardiovascular Center, University Hospital Zurich, Zurich 8000, SwitzerlandOnline publish-ahead-of-print 30 August 2009This commentary refers to ‘Unprotected left main revas-cularization in patients with acute coronary syndromes’†,by G. Montalescot et al., on page 2308In the last decade, percutaneous coronary intervention (PCI) hasbecome the treatment of choice for patients with acute coronarysyndrome (ACS) in most industrialized countries. As the benefit ofacute PCI increases with decreasing delay to vessel revasculariza-tion, major efforts have been focused in optimizing each step inpatient care. This includes raised awareness in the general popu-lation, well-organized alarm systems, rapid and safe patient trans-portation, pre-hospital patient care, and centralization of acutePCI facilities in high-volume centres.1 These optimized strategieshave resulted in a continuous decrease in mortality over the lastfew years (Figure 1). In fact, in-hospital mortality after acute PCIin ACS today is as low as ,5%.2–4 The introduction of newanti-thrombotics and the increasing use of drug-eluting stents5have the potential to improve the outcome of ACS patientsfurther. In addition, elective revascularization of left main diseaseexhibited very promising results in recent trials. In the subgroupof patients with relevant left main disease of the recently publishedSYNTAX trial, rates for major adverse cardiac or cerebrovascularevents were similar in patients treated with PCI and coronaryartery bypass graft (CABG) (15.9 and 13.7%, respectively).6However, left main stenting has been carried out with increasingfrequency during the last years. Nevertheless, patients with unpro-tected left main disease still represent a challenge for the interven-tionalist, especially in the setting of an ACS.Montalescot et al. have reported the results of patients withACS and left main disease included in the Global Registry ofAcute Coronary Events (GRACE) between 2000 and 2007.7From a total of 43 018 patients, 1799 patients (4%) with relevantleft main disease were treated by either PCI alone (n ¼ 514),CABG alone (n ¼ 612), or no revascularization (n ¼ 673). Overtime, a trend towards more PCI and less CABG was observed.Several pieces of important information can be derived from thisstudy. First of all, unprotected left main disease in patients withACS is associated with a high mortality, especially in patientspresenting with ST-segment elevation myocardial infarction(STEMI) and/or haemodynamic instability. Overall in-hospital mor-tality was 7.7%, but reached 11% in patients who presented withSTEMI or new left bundle branch block (LBBB), and was as highas 34% in patients with cardiogenic shock or cardiac arrest. Forcomparison, in the recently published Expanded GRACE registry,4in-hospital mortality was 3.7%. The second important piece ofinformation is that in patients not requiring immediate revascular-ization, a postponed surgical revascularization (during the samehospitalization) provides the best short- and long-term outcome.Patients treated with CABG had an in-hospital mortality of 5.4%,which favourably compared with patients treated conservatively(7.6%) or by PCI (11%). As this is a register and not a randomizedtrial, we cannot conclude that one or the other revascularizationstrategies provides better outcome. Patients treated with acutePCI did indeed present more often as STEMI, new LBBB, or cardio-genic shock. Thus, patients treated with PCI had the highest risk athospital admission. This explains the high in-hospital mortality inthis group, but also the incremental mortality of 5.4% during thenext months (i.e. between hospital discharge and 6-monthsfollow-up). The good results seen with CABG are at least in partdue to a lower risk for this patient group at admission and apatient selection bias. In fact, median time from admission to oper-ation was 4.5 days. Hence, patients who were initially scheduled forCABG, but died before the operation were assigned to the ‘con-servative treatment group’. This selection bias is also importantin patients with previous cardiac arrest where the neurologicalcondition often only becomes evident after 1 or 2 days. Neverthe-less, the outcome of patients treated with CABG was excellent,with incremental mortality of only 1.6% at 6 months. Patientswith initial conservative treatment, on the other hand, exhibitedan in-hospital mortality of 7.6%. Although 39% of these patientswere scheduled for elective CABG, the mortality rate betweenhospital discharge and 6-month follow-up was as high as 10%. Infact, it appears that the third and probably most relevantmessage from this registry is that patients that were revascularizedduring the event hospitalization showed a better long-termoutcome compared with the initial conservative therapy. ThisThe opinions expressed in this article are not necessarily those of the Editors of the European Heart Journal or of the European Society of Cardiology.* Corresponding author. Tel: þ41 1255 11 11, Fax: þ41 44 2554401, Email: roberto.corti@usz.ch† doi:10.1093/eurheartj/ehp353Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2009. For permissions please email: journals.permissions@oxfordjournals.org.European Heart Journal (2009) 30, 2295–2296doi:10.1093/eurheartj/ehp354highlights the importance of early revascularization in the presenceof symptomatic left main disease.As mentioned above, it is important to keep in mind that thesedata were derived from a registry and not a randomized study.Thus, the presence of selection bias is evident and is reflectedby the differences in clinical presentation. In addition, left maindisease is a very heterogenous disease in terms of clinical presen-tation and anatomy, and each factor can potentially influence thedecision-making process in the setting of ACS. A complete occlu-sion of the left main, for instance, is usually associated with cardio-genic shock and therefore represents a very high-risk situationrequiring immediate life support strategies and urgent revasculari-zation, often in conjunction with the use of left ventricle assistdevices, whereas a subtotal stenosis may present as unstableangina with subendocardial ischaemia associated with a muchlower risk. For the interventionalist, an ostial or midshaft leftmain lesion is easier to treat than distal lesions (which normallyrepresent a real technical challenge because of the involvementof a major vessel bifurcation). In addition to lesion morphology,several clinical features might influence decision-making strategies.Indeed, the presence of three-vessel disease or a total occlusion ofthe right coronary artery may shift the treatment preference of thephysician in charge towards surgical revascularization. In contrast,patients presenting with haemodynamic or rhythm instabilityrequire immediate decision making, resulting most commonly inan urgent percutaneous revascularization. Even though theoptimal treatment strategy for an individual patient can bereached in a case-based discussion between interventionalist andcardiac surgeon, such an approach is not applicable in an emer-gency situation. This explains why it is indeed very difficult toconduct a randomized trial in patients with ACS and left maindisease. Nevertheless, as demonstrated by the SYNTAX trial,such studies are possible under certain conditions. In patients pre-senting with ACS, however, only those in haemodynamically stableconditions may be eligible for future trials. Such a study would beimportant, as suggested by the registry data of Montalescot et al.7Finally, a concern of this study may be the short follow-up (6months). Unplanned revascularization due to instent-restenosis andlate/very late stent thrombosis may affect the long-term outcome ofPCI patients and favour surgical revascularization in the long term.Currently, rates of target lesion revascularization in patients with leftmain disease receiving a drug-eluting stent range from 0 to 14%.8In our opinion, this observational study provides new importantdata that stress the importance of prompt and complete revascu-larization of patients presenting with ACS and left main coronaryartery disease. Further research is required to characterizebetter those patients which benefit the most from percutaneousor surgical revascularization.Conflict of interest: none declared.References1. Spaulding C, Morice MC, Lancelin B, Haddad SE, Lepage E, Bataille S, Tresca JP,Mouranche X, Fosse S, Monchi M, Vernejoul N for the CARDIO-ARIF registryInvestigators. Is the volume–outcome relation still an issue in the era of PCIwith systematic stenting? Results of the greater Paris area PCI registry. Eur HeartJ 2006;27:1054–1060.2. Stone GW, Lansky AJ, Pocock SJ, Gersh BJ, Dangas G, Wong SC, Witzenbichler B,Guagliumi G, Peruga JZ, Brodie BR, Dudek D, Mo¨ckel M, Ochala A, Kellock A,Parise H, Mehran R, for the HORIZONS-AMI Trial Investigators. Paclitaxel-elutingstents versus bare-metal stents in acute myocardial infarction. N Engl J Med 2009;360:1946–1959.3. Steg PG, Goldberg RJ, Gore JM, Fox KA, Eagle KA, Flather MD, Sadiq I, Kasper R,Rushton-Mellor SK, Anderson FA; GRACE Investigators. Baseline characteristics,management practices, and in-hospital outcomes of patients hospitalized withacute coronary syndromes in the Global Registry of Acute Coronary Events(GRACE). Am J Cardiol 2002;90:358–363.4. Goodman SG, Huang W, Yan AT, Budaj A, Kennelly BM, Gore JM, Fox KAA,Goldberg RJ, Anderson FA, for the Expanded Global Registry of Acute CoronaryEventsn (GRACE2) Investigators. The expanded Global Registry of Acute Coron-ary Events: baseline characteristics, management practices, and hospital outcomesof patients with acute coronary syndromes. Am J Cardiol 2009;158:193–201.5. Mauri L, Silbaugh TS, Garg P, Wolf RE, Zelevinsky K, Lovett A, Varma MR, Zhou Z,Normand S-LT. Drug-eluting or bare-metal stents for acute myocardial infarction.N Engl J Med 2008;359:1330–1352.6. Serruys PW, Morice MC, Kappetein P, Colombo A, Holmes DR, Mack MJ, Sta¨hle E,Feldman TE, van den Brand M, Bass EJ, Dyck NV, Leadley K, Dawkins K, Mohr FW,for the SYNTAX Investigators. Percutaneous coronary intervention versuscoronary-artery bypass grafting for severe coronary artery disease. N Engl J Med2009;360:961–972.7. Montalescot G, Brieger D, Eagle KA, Anderson FA Jr, FitzGerald G, Lee MS, StegPh G, Avezum A´, Goodman SG, Gore JM for the GRACE Investigators. Unpro-tected left main revascularization in patients with acute coronary syndromes. EurHeart J 2009;30:2308–2317. First published on 30 August 2009. doi:10.1093/eurheartj/ehp353.8. Colombo A, Chieffo A. Drug-eluting stent update 2007: part III: technique andunapproved/unsettled indications (left main, bifurcations, chronic total occlusions,small vessels and long lesions, saphenous vein grafts, acute myocardial infarctions,and multivessel disease). Circulation 2007;116:1424–1432.Figure 1 Mortality of acute coronary syndrome. The mortalityof patients with acute coronary syndrome decreased during thelast decades. In the pre-ICU/CCU era, mortality was as high as30%. The ability to treat arrhythmias with ICD and b-blockersled to a significant decrease in mortality. The next step forwardwas the introduction of intravenous thrombolysis. Finally, percu-taneous coronary revascularization led to the low mortality ratesof ACS we face today. 1. Braunwald E, Zipes DP, Libby P. Heartdisease: a textbook of cardiovascular medicine, 6th edn. WBSaunders and Co., 2001. 2. ISIS-2 (Second International Studyof Infarct Survival) Collaborative Group. Randomized trial ofintravenous streptokinase, oral aspirin, both, or neither among17187 cases of suspected acute myocardial infarction: ISIS-2.J Am Coll Cardiol 1988;12 (6 Suppl A):3A–13A. 3. Steg PG,Goldberg RJ, Gore JM, et al. Baseline characteristics, managementpractices, and in-hospital outcomes of patients hospitalizedwith acute coronary syndromes in the Global Registry ofAcute Coronary Events (GRACE). Am J Cardiol 2002;90:358–363. 4. Goodman SG, Huang W, Yan AT, et al. The expandedGlobal Registry of Acute Coronary Events: baseline character-istics, management practices, and hospital outcomes of patientswith acute coronary syndromes. Am J Cardiol. 2009;158:193–201.Commentary2296

PCI in acute left main disease: a paradigm shift or a new reality?

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