|Sperker W et al.|
Percutaneous Treatment of Left Main Coronary Artery Stenoses
Journal of Clinical and Basic Cardiology 2002; 5 (2): 163-169
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Keywords: Angioplastie, Koronare Herzkrankheit, linke Koronararterie, Stent, angioplasty, coronary artery disease, left main coronary artery, Stent
The poor prognosis of patients with symptomatic left main coronary artery (LM) atherosclerosis treated medically could be improved considerably by coronary artery bypass graft (CABG) surgery. The first percutaneous transluminal interventions of LM stenosis revealed that such procedures were quite difficult to perform and that early mortality was too high to be accepted as a standard treatment. As a consequence, in 1984, the National Heart, Lung, and Blood Institute published a consensus that stenoses of the LM were a contraindication to percutaneous transluminal coronary angioplasty. However, percutaneous interventions on the LM remained in scope, as some patients with high risk for CABG, with contraindications to CABG or with very limited life expectancy still had no other option than a percutaneous intervention of the LM. Furthermore, in the last years, new percutaneous techniques have been developed for interventional cardiology: the use of stents or atherectomy, the use of assist devices like intraaortic balloon pumps or cardio-pulmonary support devices improved the acute and long-term outcome of percutaneous coronary interventions even in patients with high risk or unstable haemodynamic conditions. On the basis of the haemodynamic situation, the outcomes of percutaneous interventions on protected and unprotected LM stenosis differ considerably: an unprotected LM stenosis paired with ischaemic syndromes always means a highly critical situation that has to be resolved in a very short time. Both protected and unprotected LM stenoses can be the reason for stable and unstable coronary syndromes; however, myocardial ischaemia caused by an unprotected LM stenosis is generally more severe as it more often results in haemodynamic instability requiring emergency bypass surgery, or if an operation is not possible, an emergency percutaneous treatment. The results from percutaneous interventions of protected LM stenoses showed that this kind of treatment is technically easily feasible and associated with a low incidence of short-, mid- and long-term death, myocardial infarction or repeat revascularization (MACE). Elective interventions of unprotected LM stenoses also seem to be safe: short-, mid- and long-term follow-ups demonstrate an acceptably low rate of MACE. Although emergency percutaneous interventions of both protected and unprotected LM disease lead to fairly good acute procedural success rates, a high in-hospital mortality with a further decrease in long-term event-free survival rate, but an acceptable mortality rate can be expected.