title: Impact of coronary anatomy and stenting technique on long-term outcome after drug-eluting stent implantation for unprotected left main coronary artery disease.
abstract: OBJECTIVE
  This study sought to evaluate the impact of anatomic and procedural variables on the outcome of the unprotected left main coronary artery (uLMCA) itself after drug-eluting stent (DES) implantation.
  
  
  BACKGROUND
  There is a controversial debate regarding when and how to perform percutaneous coronary intervention (PCI) for an uLMCA stenosis.
  
  
  METHODS
  This analysis is based on a randomized study of 607 patients undergoing PCI for uLMCA, randomized 1:1 to receive paclitaxel- or sirolimus-eluting stents. We evaluated the impact of the SYNTAX score, uLMCA anatomy, and stenting technique on in-stent restenosis (ISR), target lesion revascularization (TLR), and the 3-year outcomes.
  
  
  RESULTS
  The 3-year cardiac mortality rate was 5.8%; 235 (39%) patients had a true bifurcation lesion (TBL), and the median SYNTAX score was 27. TBL was associated with a higher need for multiple stents (72% vs. 37%, p < 0.001). TBL was a significant predictor of ISR (23% vs. 14%, p = 0.008) and for TLR (18% vs. 9%, p < 0.001). The need for multiple stents was a predictor of ISR (22% vs. 13%, p = 0.005) and for TLR (16% vs. 9%, p = 0.005). Culotte stenting showed better results compared with T-stenting for ISR (21% vs. 56%, p = 0.02) and for TLR (15% vs. 56%, p < 0.001). We observed a significant association between uLMCA-TLR and SYNTAX scores (9.2% for scores ≤ 22, 14.9% for scores 23 to 32, and 13.0% for scores ≥ 33, p = 0.008).
  
  
  CONCLUSIONS
  PCI of uLMCA lesions with DES is safe and effective out to 3 years. TBL and multiple stents were independent predictors for ISR. In the multivariate analysis, independent predictors for TLR were TBL, age, and EuroSCORE (European System for Cardiac Operative Risk Evaluation). (Drug-Eluting-Stents for Unprotected Left Main Stem Disease [ISAR-LEFT-MAIN]; NCT00133237).
authors: Department of Cardiology, Helios Klinikum Wuppertal, Universität Witten/Herdecke, Wuppertal, Germany. Electronic address: klaus.tiroch@helios-kliniken.de.
authors: Klaus
authors: K
authors: Tiroch
authors: Department of Cardiology, Klinikum Großhadern, Ludwig-Maximilian Universität, Munich, Germany; Department of Cardiology, DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany.
authors: Julinda
authors: J
authors: Mehilli
authors: Department of Cardiology, Deutsches Herzzentrum, Technische Universitat, Munich, Germany.
authors: Robert A
authors: RA
authors: Byrne
authors: Department of Cardiology, Deutsches Herzzentrum, Technische Universitat, Munich, Germany.
authors: Stefanie
authors: S
authors: Schulz
authors: Department of Cardiology, Klinikum Großhadern, Ludwig-Maximilian Universität, Munich, Germany; Department of Cardiology, DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany.
authors: Steffen
authors: S
authors: Massberg
authors: Department of Cardiology, DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany; 1. Department of Cardiology, Medizinisches Klinik Rechts der Isar, Technische Universitat, Munich, Germany.
authors: Karl-Ludwig
authors: KL
authors: Laugwitz
authors: Department of Cardiology, Helios Klinikum Wuppertal, Universität Witten/Herdecke, Wuppertal, Germany.
authors: Marc
authors: M
authors: Vorpahl
authors: Department of Cardiology, Helios Klinikum Wuppertal, Universität Witten/Herdecke, Wuppertal, Germany.
authors: Melchior
authors: M
authors: Seyfarth
authors: Department of Cardiology, DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany; Department of Cardiology, Deutsches Herzzentrum, Technische Universitat, Munich, Germany.
authors: Adnan
authors: A
authors: Kastrati
mesh_terms: D000368:Aged; D002317:Cardiovascular Agents / Q000008:administration & dosage; D017023:Coronary Angiography; D003324:Coronary Artery Disease / Q000000981:diagnostic imaging / Q000401:mortality / Q000628:therapy*; D023903:Coronary Restenosis / Q000209:etiology; D023921:Coronary Stenosis / Q000000981:diagnostic imaging / Q000401:mortality / Q000628:therapy*; D003328:Coronary Thrombosis / Q000209:etiology; D003331:Coronary Vessels / Q000000981:diagnostic imaging*; D054855:Drug-Eluting Stents; D005260:Female; D005858:Germany; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D017239:Paclitaxel / Q000008:administration & dosage; D062645:Percutaneous Coronary Intervention / Q000009:adverse effects / Q000295:instrumentation* / Q000379:methods / Q000401:mortality; D011237:Predictive Value of Tests; D016016:Proportional Hazards Models; D011474:Prosthesis Design; D012307:Risk Factors; D020123:Sirolimus / Q000008:administration & dosage; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D002317:Cardiovascular Agents; D017239:Paclitaxel; D020123:Sirolimus
keywords: CABG; DES; ISR; LCX; LMCA; MACE; MI; PCI; SYNTAX score; TBL; TLR; coronary artery bypass graft surgery; drug-eluting stent(s); in-stent restenosis; left circumflex coronary artery; left main; left main coronary artery; major adverse cardiac event(s); myocardial infarction; percutaneous coronary intervention; stenting technique; target lesion revascularization; true bifurcation lesion; uLMCA; unprotected left main coronary artery