Left main coronary artery stenosis: Clinical spectrum, pathophysiology, and management

Conti, C. Richard; Selby, John H.; Christie, Leonard G.; Pepine, Carl J.; Curry, R. Charles; Nichols, Wilmer W.; Conetta, Donald G.; Feldman, Robert L.; Mehta, Jawahar L.; Alexander, James A.

doi:10.1016/0033-0620(79)90016-1

Cited by 60 publications

(1 citation statement)

References 120 publications

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“…Left main coronary artery (LMCA) disease is a life-shortening disease with significant morbidity and mortality. LMCA stenosis present in about 15% of patients with symptomatic ischemic heart disease 1 . Surgical revascularization with coronary artery bypass grafting (CABG) remain the gold slandered treatment in left main and triple vessels disease.…”

Section: Introductionmentioning

confidence: 99%

NOBLE and EXCEL: The debate for excellence in dealing with left main stenosis

Kindi

Samaan

Hosny

2018

gcsp

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Left main coronary artery (LMCA) disease is associated with increased morbidity and mortality. Coronary artery bypass grafting surgery (CABG) has always been the standard revascularization strategy for this group of patients. However, with the recent developments in stents design and medical therapy over the past decade, several trials have been designed to evaluate the safety and efficacy of percutaneous coronary intervention (PCI) as an alternative to CABG surgery in patients with LMCA disease. Recently, the results of two major trials, EXCEL and NOBLE, comparing CABG versus PCI in this patient population have been released. In fact, the results of both trials might appear contradictory at first glance. While the EXCEL trial showed that PCI was non-inferior to CABG surgery, the NOBLE trial suggested that CABG surgery is a better option. In the following review, we will discuss some of the similarities and contrasts between these two trials and conclude with lessons to be learned to our daily practice.

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Section: Introductionmentioning

confidence: 99%

NOBLE and EXCEL: The debate for excellence in dealing with left main stenosis

Kindi

Samaan

Hosny

2018

gcsp

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Left main coronary artery disease in adults younger than 50 years: A comparison with older patients

Stouffer

Mott

Brizolara

et al. 2000

Cathet. Cardiovasc. Intervent.

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Left main coronary artery (LMCA) disease is a potentially lethal disease that can be effectively treated if it is recognized expeditiously. To determine whether clinical signs and symptoms vary with age, we examined data from 100 patients with angiographically significant LMCA disease (> or =50% stenosis). The majority of patients had myocardial infarction (32%) or Braunwald class I unstable angina (46%). There were no differences in initial symptoms, electrocardiographic findings (normal or only nonspecific changes in 52% of patients), or left ventricular function (normal or only mildly impaired in 76% of patients) between younger patients (< 50 yr; n = 29) and older patients (n = 71). Severe atherosclerosis was common in both groups. Risk factor profiles were different, however, in that diabetes mellitus (10% vs. 34%; P = 0.028) and hypertension (38% vs. 73%; P = 0.002) were less common and tobacco use was more common (79% vs. 39%; P <0.001) in younger patients. In summary, age influenced the risk factors associated with but not the clinical signs and symptoms of LMCAD.

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Mortality related to cardiac catheterization and angiography

Kennedy¹,

Baxley²,

Bunnel³

et al. 1982

Cathet. Cardiovasc. Diagn.

101

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During a 14-month period, 75 deaths occurring in relation to 53,581 cardiac catheterizations were consecutively and prospectively reported to the Registry Committee of the Society for Cardiac Angiography. Three of the patients died several days after their catheterization from an unrelated cause and are excluded from this analysis. There were 21 patients (group I) who arrived at the laboratory in extremis and whose deaths were expected irrespective of the catheterization. Most of these patients suffered from recent myocardial infarctions and cardiogenic shock, or had complex congenital malformations. In 35 patients (group II), a cardiovascular complication occurring during the catheterization resulted in death. In 16 patients (group III) catheterization seemed uneventful, but death occurred suddenly 10 min to 10 h after the procedure. Of these 16 patients, eight had left main coronary artery obstruction greater than or equal to 90%, five had three-vessel disease all with 90% obstructions, one had 2-vessel disease both with 90% obstructions, and who had critical aortic stenosis. The 51 unexpected deaths (groups II and III) were considered to be causally related to the procedure, a mortality rate of 0.10%. Subsets with an increased mortality rate (M), were patients with: a) left main disease greater than 50% (M = 0.94%); b) ejection fraction less than 30% (M = 0.54%); c) NYHA class III or IV (m = 0.24%); d) age over 60 years (M = 0.23%); or e) three-vessel disease (M = 0.13%). In conclusion, catheterization related mortality occurs mostly in patients with far advanced cardiac disease. Nearly 1/3 of the unexpected deaths occurred suddenly after a seemingly uneventful procedure. Close monitoring after catheterization of patients with similar characteristics (left main disease greater than or equal to 90%, or three-vessel disease all greater than or equal to 90%) might disclose avenues for reducing mortality occurring after catheterization.

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Left main coronary artery stenosis: Clinical spectrum, pathophysiology, and management

Cited by 60 publications

References 120 publications

NOBLE and EXCEL: The debate for excellence in dealing with left main stenosis

NOBLE and EXCEL: The debate for excellence in dealing with left main stenosis

Left main coronary artery disease in adults younger than 50 years: A comparison with older patients

Mortality related to cardiac catheterization and angiography

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