Acute and Mid-Term Outcomes of Coronary Stent Implantation for the Treatment of Unprotected Left Main Coronary Artery Disease Dr mahmoud ebrahimi Dr hosein saghi 14/7/90 Javad-al-aemmeh Hosp

Background Based on clinical trials, showing survival benefit of coronary-artery bypass grafting (CABG) over medial therapy, CABG has been regarded as the standard therapy for patients with unprotected LMCA disease. Coronary stenting for LMCA disease suggested the favorable mid-term safety and feasibility. Current availability of DES has reduced the rates of restenosis and revascularization, and had led to a re-evaluation of the role of PCI for LMCA disease.

Reason for PCI Patients with unprotected left main disease (defined as stenosis of more than 50%) Without suitable bypass conduits Concurrent severe medical illness Current malignancy Limited life expectancy Age ≥ 75 years and poor performance status “good candidate for stenting” Patient’s preference/ Patient refused surgery Bailout UPLM stenting Physician refused surgery -“poor candidates for CABG” Exclusion Criteria Prior CABG Concomitant valvular or aortic surgery

Procedures Ostial or shaft lesions were attempted with a single stent placement. For bifurcation lesions, a single-stent technique was preferred in patients with normal-appearing side branches, and two-stent techniques were considered in patients with diseased side branches. After the procedure, aspirin was continued indefinitely and clopidogrel or ticlopidine for at least 9-12 months.

Databases and Follow-up Clinical follow-up was recommended regularly. Angiographic follow-up was routinely recommended for all PCI patients between 6 and 10 months. However, patients without ischemic symptoms or signs, as well as patients who refused, did not undergo routine follow-up angiography.

Primary Outcome Measures Death Composite of death, Q-wave myocardial infarction, or stroke Target-vessel revascularization

Results

Procedural Characteristics Variable PCI (n = 40) Bare-metal stents(%) Drug-eluting stents (%) 2 (5%) 38 (95%) Number of stents at LMCA lesions 1 Total length of stents at LMCA (mm) 16.38±7.73 stent diameter at LM site 3.54±0.33 Number of stents per patients (LMCA and other vessels) 2.43±1.17

Baseline Characteristics Variable Demographic characteristics Age (yr) 63.67±9.97 Median 65 Male sex (%) 65% Cardiac or Coexisting conditions (%) Diabetes mellitus Any diabetes 16(40%) Requiring insulin 3(7.5%) Hypertension 21(52%) Hyperlipidemia Current smoker 2(5%)

Baseline Characteristics Variable Previous coronary angioplasty 10(25%) Previous myocardial infarction 12(30%) Chronic obstructive pulmonary disease 2(5%) Cerebrovascular disease Peripheral vascular disease Renal failure Ejection fraction (%) 45±13 Median 50%

Baseline Characteristics Variable Electrocardiographic findings Sinus rhythm 37(70%) Atrial fibrillation 3(7.5%) Clinical indication (%) Chronic stable angina 13(32.5%) Unstable angina 16(40%) NSTEMI 4(10%) STEMI 5(12.5%) Cardiogenic shock 2(%5)

Angiographic Characteristics Variable Involved location Ostium and/or mid-shaft 9(22.5%) Distal bifurcation 31(57%) Extent of diseased vessel Left main only 3(7.5%) Left main plus single-vessel disease 13(32.5%) Left main plus double-vessel disease 16(39.5%) Left main plus triple-vessel disease 8(20%) Right coronary artery disease

Clinical Outcomes Overall Patients (N=40) Outcome Death 2 Composite outcome (death, Q-wave myocardial infarction, or stroke) Target-vessel revascularization

zarvandi 55 yrs man Ahangar U/A FC:4 No MI EF: 57% RF; C/S,DM,HTN SCA: sever distal LMCT disease+ sever 3VD LAD: SEVER ostioproximal and medial& multiple lesion thereafter LCX:ostial and distal with diffuse stenosis of Oms. RCA: diffuse lesions & cutted at midportion

ALI mousavi A 55yold man presented to ED with resting typical CP from 12 hours ago He had exertional CP since few months ago BP:95/70 PR:90 RR:19 T:36.8

PH/E JVP:NL Lungs: fine crackle in the baseHeart:S1,S2:NL there was an early systolic murmur 2/6 in apex EXT:NL

PMH: HTN(+) HLP(+) SMOKING(+) DM(-) IHD:MI(?)4 years ago DH(-) FH(-)

ECG: NSR HR:70 NL axis ST elevation and inverted T in V1-V4-Q in V1-V3 TPI(+)

Echocardiography: EF:35%,akinesia in apex and hypokinesia in anterior,septal and lateral wall Mild MR

“Medical treatment, PCI, and CABG should not be seen as competing strategies but rather as complementary approaches with overlapping roles. All three have their limitations and no single one will suffice. Each approach will continue to improve with time, and coronary artery disease will become a relatively benign disease.”

Thank You !!