Left main coronary artery disease

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Significant, defined as a greater than 50 percent narrowing, left main coronary artery disease is found in 4 to 6 percent of all patients who undergo coronary arteriography. When present, it is associated with multivessel coronary artery disease about 70 percent of the time

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  • Coronary Intervention with TAXUS and Cardiac Surgery (SYNTAX) score of 32 or lower, the indication is class IIb (level of evidence B); however, when the SYNTAX score is 33 or higher, this becomes
    class IIIb.The American Heart Association (AHA)/American College of Cardiology (ACC)/Society for Cardiovascular and Angiographic Interventions (SCAI) recently modified their recommendation for PCI of the ULMCA from a class IIb to a class IIa (level of evidence B) indication in those with favorable anatomy for PCI (SYNTAX ≤ 22) and clinical conditions that confer an increased risk of adverse events with CABG. Furthermore, the guidelines state that in the setting of acute coronary syndrome, ULMCA PCI is a class IIa (level of evidence B) indication, and in ST elevation myocardial infarction when PCI can be performed more promptly than CABG, a class IIa (level of evidence C) indication
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  • Significant unprotected left main coronary artery (ULMCA) disease remains a class I indication for coronary artery bypass grafting (CABG).• Registries and randomized studies have shown a higher rate of repeat revascularization after percutaneous coronary intervention (PCI) compared with CABG, but a lower incidence of cerebrovascular events; no differences were reported in overall major adverse cardiovascular events.• It is important to use adjunctive techniques to evaluate the significance of ULMCA lesions (e.g., intravascular ultrasound and fractional flow reserve).
    • The location of the ULMCA lesion affects the optimal stent technique; factors that also need to be considered include plaque distribution, side branch size, severity and distribution of the side branch lesion, and bifurcation angle.• Drug-eluting stents (DES) should be the stent of choice, unless there are contraindications to or anticipated poor compliance with prolonged dual antiplatelet therapy. Hemodynamic support should be considered when there is evidence of severe left ventricular systolic dysfunction or hemodynamic instability or patients with acute presentations. Future randomized studies are awaited to definitively assess the long-term outcomes of patients undergoing PCI of the ULMCA compared with CABG.
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Left main coronary artery disease

  1. 1. 1912:Herrick reported first LMCA disease Left main coronary artery disease RAMACHANDRA
  2. 2. 4 Issues Distal bifurcation : worse outcome Sub acute thrombosis (Fatal) LVEF/Comorbidities(distal LMCA) CABG vs. PCI
  3. 3. Key trials ▪ COMBAT ▪ SYNTAX
  4. 4. Anatomy  Ramus intermedius-30%  Length = 4 to 6 cm  Diameter= 4.5 0.5 mm  Aortic wall in continuity=2-4mm(ostio/prox)  Ostium lacks adventitia  considerable smooth muscle/ elastic tissue/SMC arranged perpendicular to and surrounding the ostium  Has the most elastic tissue of all the coronary vessels  The most common site of stenosis: midportion or at the bifurcation  significant LMCA stenosis have, in addition, significant narrowing of at least one of the other major coronary vessels  In isolation LMCA is rare and ostial  Sometime from RC/NC sinus(acute angle)  Disease is shared with aorta
  5. 5. Aetiology Atherosclerosis(significant shear stress) Nonatherosclerotic Syphilitic  Giant cell arteritis  Takayasu disease Calcific diseases Valve replacement coronary angiography  Mediastinal irradiation, High angulated takeoff Compression
  6. 6. Define ≥ 50% percent narrowing and <7.5 mm( IVUS) 80% of LMCA disease has one more coronary disease
  7. 7. Left main equivalent >70% Proximal LAD and LCX stenosis
  8. 8. Indeterminate left main Just 50% stenosis FFR/IVUS is useful
  9. 9. Impact Stenosis of 50 to 70% : 3-year survival of 66% Stenosis of 70% : 3-year survival of 41% Conley MJ, Ely RL, Kisslo J, et al. The prognostic spectrum of left main stenosis.Circulation 1978;57:947-52
  10. 10. Incidence  4 to 6% of all CAG 70% of times when associated with TVD 7% of AMI 9% of CABG 5% of CSA Isolated significant in 0.5 to 1%(female more) RCA in 50% Atherosclerotic is majority
  11. 11. Contribution Occlusion of this vessel compromises flow to at least 75 percent of the left ventricle, unless it is protected by collateral flow or a patent bypass graft to either the left anterior descending or circumflex artery
  12. 12. Types Protected Unprotected
  13. 13. Diagnosis ▪ USA-43%(Most common presentation) ▪ NSTEMI-20%-ST depression in laterals ▪ STEMI –rare(STE in avR≥≥STE in V1) ▪ Positive stress test-28%
  14. 14. Contd...... TMT 1.ECG changes in stage I/II Bruce protocol 2.At HR< than 120 beats/min:Positive 3.Duke treadmill score :HIGH SPECT(+stress) 1.Reduced uptake in the septum/anterior/lateral wall 2. generalized ischemia 3.increased lung uptake 4. decline in ejection fraction
  15. 15. CAG If left main disease is suspected, a sinus injection prior to entering the left main should always be done to avoid occlusion or dissection of the lesion.
  16. 16. IVUS:intermediate stenosis  correlation between CAG and IVUS is poor  IVUS may be clinically useful after PCI to provide independent prognostic information Borderline disease
  17. 17. MSCT ▪ “blooming” effect(stent artifact) ▪ Better for calcified lesion assessment
  18. 18. MEDICAL THERAPY ▪ Smoking cessation ▪ Target blood pressure ▪ Lipid lowering therapy ▪ Statin ▪ Diabetes control
  19. 19. PCI VERSUS CABG PCI if CABG is a contraindication Left main only: HR 0.39, 95% CI 0.04-3.72  Left main with SVD: 0.70, 95% CI 0.11-4.16 Left main with DVD: 1.04, 95% CI 0.47-2.32 Left main with TVD: 3.05, 95% CI 1.29-7.21 Ischemia driven TVR more in PCI PRECOMBAT Trial
  20. 20. Lee et al. J Am Coll Cardiol 2006;47:864.)
  21. 21. DES(UPLMCA) vs. CABG ▪ LE MANS study is the first RCT ▪ Non inferiority
  22. 22. CABG Gold standard Veterans Administration Cooperative Study CASS registry
  23. 23. SYNTAX <23 Score vs. r intermediate (23-32) scores did not differ >32 scores had a significantly higher rate of the primary outcome with PCI (25.3 versus 12.9 percent)
  24. 24. TVR is more PCI>>>>>>>>CABG DELTA multicenter registry MAIN-COMPARE registry SYNTAX(score based) PRECOMBAT Jang JS et al. Meta-analysis of 3 RCT and nine observational studies comparing DES versus CABG for UPLMCA( Am J Cardiol 2012) Bittl JA et al. Bayesian methods affirm the use of PCI to improve survival in patients with UPLMCA. (Circulation 2013)
  25. 25. DES versus BMS DES is preferred(DAP compliance is assured)
  26. 26. Mortality
  27. 27. Gradient across DES Serolimus is better to Paclitaxel
  28. 28. Prox vs. Mid vs. Distal Distal is dangerous The j-Cypher registry SEARCH T-SEARCH The Left Main Taxus registry
  29. 29. Skilling distal LMCA PCI Be simple and remain safe The DKCRUSH-III study
  30. 30. LMCA stenting style
  31. 31. Bifurcation stenting
  32. 32. LogBook DELFT registry: Cardiac death (9.2) and reinfarction (8.6) with DES at 3 yrs. Primary PCI has more cardiac death (21.4 versus 6.2 percent).  The J-Cypher registry: AD [42]: Mortality with and without LMCAD (hazard ratio 1.23, 95% CI 0.951.60) LE MANS registry: MACCE (25 %-death in 14 and TVR 8%) The 5- and 10-year survival rates were 78 and 69 %. Korean registry: Angiographic ISR was 17.6 percent at 3 yrs with DES
  33. 33. Adjust ▪ IABP ▪ DAP ▪ Start with protected one ▪ Rotational artheroctomy(Debulking) ▪ IVUS ▪ FFR ▪ Cutting Balloon ▪ FU angiograghy
  34. 34. PRIMARY PCI Hemodynamicaly Unstable
  35. 35. Tips ▪ Lesion significant(Clinical Hx/CAG/FFR/IVUS)? ▪ CABG vs. PCI(multiple /complex lesion,EF%,ES) ▪ Is it distal? ▪ Stent (Expert/stent type/implant style) ▪ Reference ▪ Where is the ostium?
  36. 36. Choose First: Surgery 2nd:DES Before is best
  37. 37. It is only appetizer...........navigate .....

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