Deferred Versus Performed Revascularization for Left Main Coronary Disease With Hemodynamic Significance

Author:

Warisawa Takayuki123ORCID,Cook Christopher M.45ORCID,Ahmad Yousif6ORCID,Howard James P.37ORCID,Seligman Henry37ORCID,Rajkumar Christopher37ORCID,Toya Takumi89ORCID,Doi Shunichi1,Nakajima Akihiro10,Nakayama Masafumi1112ORCID,Vera-Urquiza Rafael13ORCID,Yuasa Sonoka13,Sato Takao14ORCID,Kikuta Yuetsu31115,Kawase Yoshiaki,Nishina Hidetaka16ORCID,Al-Lamee Rasha37ORCID,Sen Sayan37,Lerman Amir9ORCID,Matsuo Hitoshi11ORCID,Akashi Yoshihiro J.1ORCID,Escaned Javier13ORCID,Davies Justin E.

Affiliation:

1. Division of Cardiology, Department of Internal Medicine, St Marianna University School of Medicine, Kawasaki, Japan (T.W., S.D., Y.J.A.).

2. Department of Cardiology, NTT Medical Center Tokyo, Japan (T.W.).

3. National Heart and Lung Institute, Imperial College London, UK (T.W., J.P.H., H.S., C.R., Y.K., R.A.-L., S.S., J.E.D.).

4. The Essex Cardiothroacic Centre, UK (C.M.K.).

5. Anglia Ruskin University, Essex, UK (C.M.K.).

6. Cardiovascular Medicine, Yale School of Medicine, New Haven, CT (Y.A.).

7. Cardiovascular Science, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK (J.P.H., H.S., C.R., R.A.-L., S.S.).

8. Department of Cardiology, National Defense Medical College, Tokorozawa, Japan (T.T.).

9. Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (T.T., A.L.).

10. Department of Cardiovascular Medicine, New Tokyo Hospital, Matsudo, Japan (A.N.).

11. Department of Cardiovascular Medicine, Gifu Heart Center, Japan (M.N., Y.K., H.M.).

12. Cardiovascular Center, Toda Central General Hospital, Japan (M.N.).

13. Hospital Clinico San Carlos IDISSC, Complutense University of Madrid, Spain (R.V.-U., S.Y., J.E.).

14. Department of Cardiology, Tachikawa General Hospital, Nagaoka, Japan (T.S.).

15. Division of Cardiology, Fukuyama Cardiovascular Hospital, Japan (Y.K.).

16. Department of Cardiology, Tsukuba Medical Center Hospital, Japan (H.N.).

Abstract

Background: The majority of randomized controlled trials of revascularization decision-making excludes left main coronary artery disease (LMD). Therefore, contemporary clinical outcomes of patients with stable coronary artery disease and LMD with proven ischemia remain poorly understood. The aim of this study was to assess the long-term clinical outcomes of physiologically significant LMD according to the treatment strategies of revascularization versus revascularization deferral. Methods: In this international multicenter registry of stable LMD interrogated with the instantaneous wave-free ratio, patients with physiologically significant ischemia (instantaneous wave-free ratio ≤0.89) were analyzed according to the coronary revascularization (n=151) versus revascularization deferral (n=74). Propensity score matching was performed to adjust for baseline clinical characteristics. The primary end point was a composite of death, nonfatal myocardial infarction, and ischemia-driven target lesion revascularization of left main stem. The secondary end points were as follows: cardiac death or spontaneous LMD-related myocardial infarction; and ischemia-driven target lesion revascularization of left main stem. Results: At a median follow-up period of 2.8 years, the primary end point occurred in 11 patients (14.9%) in the revascularized group and 21 patients (28.4%) in the deferred group (hazard ratio, 0.42 [95% CI, 0.20–0.89]; P =0.023). For the secondary end points, cardiac death or LMD-related myocardial infarction occurred significantly less frequently in the revascularized group (0.0% versus 8.1%; P =0.004). The rate of ischemia-driven target lesion revascularization of left main stem was also significantly lower in the revascularized group (5.4% versus 17.6%; hazard ratio, 0.20 [95% CI, 0.056–0.70]; P =0.012). Conclusions: In patients who underwent revascularization for stable coronary artery disease and physiologically significant LMD determined by instantaneous wave-free ratio, the long-term clinical outcomes were significantly improved as compared with those in whom revascularization was deferred.

Publisher

Ovid Technologies (Wolters Kluwer Health)

Subject

Cardiology and Cardiovascular Medicine

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