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Long-Term Clinical Results Following Stenting of the Left Main Stem

Insights From RESEARCH (Rapamycin-Eluting Stent Evaluated at Rotterdam Cardiology Hospital) and T-SEARCH (Taxus-Stent Evaluated at Rotterdam Cardiology Hospital) Registries

Yoshinobu Onuma, MD^_*, Chrysafios Girasis, MD^_*, Nicolo Piazza, MD^_*, Hector M. Garcia-Garcia, MD^_*, Neville Kukreja, MA^_*, Scot Garg, MD^_*, Jannet Eindhoven, MSc^_*, Jin-Ming Cheng, MSc^_*, Marco Valgimigli, MD, PhD, Ron van Domburg, PhD^_*, Patrick W. Serruys, MD, PhD^_*,_* on behalf of Interventional Cardiologists at Thoraxcenter 2000–2005

^_* Thoraxcenter, Erasmus Medical Center, Rotterdam, the Netherlands
The Cardiovascular Institute, University of Ferrara, Ferrara, Italy

^_* Reprint requests and correspondence: Prof. Patrick W. Serruys, Thoraxcenter, Ba-583, 's Gravendijkwal 230, Rotterdam 3015 CE, the Netherlands (Email: p.w.j.c.serruys{at}erasmusmc.nl).

Objectives: We investigated the long-term clinical outcomes and independent predictors of major cardiac events in unprotected left main coronary artery disease (ULMCA) patients treated by percutaneous coronary intervention with drug-eluting stent (DES).

Background: There is limited information on long-term (>3 years) outcomes after DES implantation for ULMCA. Furthermore, bifurcation angle and SYNTAX (Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery) score are emerging as parameters for patient risk stratification, and their prognostic implications have still to be elucidated.

Methods: One hundred forty-eight patients with ULMCA treated with DES were analyzed and compared with a historical cohort of 79 patients who received bare-metal stents for the treatment of ULMCA. Patient-oriented composite end point was defined as the occurrence of all-cause death, any myocardial infarction, or any revascularization.

Results: The 4-year cumulative incidence of all-cause death, any myocardial infarction, any revascularization, and patient-oriented composite were 35.6%, 3.8%, 25.2%, and 54.4%, respectively. These end points had relatively increased from 1 year to 4 years by 70%, 5%, 50%, and 68%, respectively. When compared with a historical cohort who received bare-metal stents for ULMCA treatment, landmark analysis performed after the first 2 years of follow-up demonstrated that the DES cohort had significantly higher patient-oriented composite end point over the last 2 years of follow-up (26% vs. 8%, p = 0.02). EuroSCORE (European System for Cardiac Operative Risk Evaluation), cardiogenic shock, and SYNTAX score were identified as independent predictors for the 4-year patient-oriented composite, whereas bifurcation angle was not.

Conclusions: Late increase in patient-oriented composite end points after DES implantation for ULMCA warrants careful and long-term follow-up. SYNTAX score and EuroSCORE appear to have a significant prognostic value in long-term patient risk.

Key Words: coronary disease • stents • atherosclerosis

Abbreviations and Acronyms   BMS = bare-metal stent(s)   CABG = coronary artery bypass graft   CI = confidence interval   DES = drug-eluting stent(s)   HR = hazard ratio   LM = left main   MACCE = major adverse cerebrovascular cardiac event   MACE = major adverse cardiac events   PCI = percutaneous coronary intervention   QCA = quantitative coronary angiography   STEMI = ST-segment elevation myocardial infarction   TVR = target vessel revascularization   ULMCA = unprotected left main coronary artery disease

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