Angioplastia del tronco de la arteria coronaria izquierda no protegido en pacientes con alto riesgo quirúrgico

Coronary artery by-pass graft surgery (CABGS) is the treatment of choice for lesions of the left main coronary artery. Nevertheless, there are a great number of patients with high risk at surgery due to concomitant diseases and/or clinical instability. ObjectivesTo assess the outcomes of percutaneous coronary intervention (PCI) in the unprotected left main coronary artery (LMCA) in high-risk patients for CABGS (EUROSCORE = 6). Material and methodsFifty nine patients who had undergone PCI in the unprotected LMCA were assessed; 8 patients in cardiogenic shock secondary to acute myocardial infarction (AMI) and 12 patients not considered to have high risk at surgery were excluded. This study was performed among the remaining 32 high-risk patients treated with conventional stents. In-hospital mortality predicted by logistic EUROSCORE was compared to observed mortality, and the incidence of major adverse events and late follow-up outcomes were assessed. ResultsMedian age was 76.5 years, 43% were 80 years old or older, 22% were women, 28% were diabetic, 56% had moderate to severe left ventricular dysfunction, 31% had chronic renal failure, 50% extracardiac arteriopathy, 53% had refractory angina, 22% recent AMI, 28% underwent emergency procedures, and median EUROSCORE was 10.5 points. Distal compromise of LMCA was present in 41% of patients. Angiographic success was achieved in 94% of the procedures. IIb/IIIa inhibitors were used in 47% of cases, cutting balloon in 28%, Rotablator® in 3% and counterpulsation balloon in 31%. A stent was implanted in all patients and other obstructions were treated in 50% of patients. In-hospital mortality rate was 3.1% (95% confidence interval, 0.2%-14.5%, p = 0.003), compared to a predicted mortality rate of 23.8%. Neurological deficits, transmural AMI or necessity for performing dialysis were not observed. The procedure failed in one patient who subsequently underwent elective CABGS surgery. Median follow-up was 15.5 months; during this period 6 deaths (2 due to cardiovascular causes) and 4 reinterventions were reported. Cumulative incidence of reintervention was 15.6% (95% CI, 6.0%-31.3%). ConclusionsPCI in the unprotected LMCA in patients with high risk at surgery should be considered an alternative to CABGS surgery.