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| __NOTOC__
| | #Redirect [[Left main coronary artery#PCI in the left main patient]] |
| {{PCI}}
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| '''Editor(s)-in-Chief:''' [[C. Michael Gibson, M.S., M.D.]] [mailto:charlesmichaelgibson@gmail.com] Phone:617-632-7753; Joanna J. Wykrzykowska, M.D.; Thomas Tu, M.D.; Brian Bigelow, M.D.; Roger J. Laham, M.D.
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| ==Overview==
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| In carefully selected patients, percutaneous [[LMCA|left main]] intervention can safely and effectively treat patients in whom [[coronary artery bypass graft]] [[surgery]] is a suboptimal option. Data from the [[SYNTAX]] trial supports such an approach.
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| ==Patient Selection==
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| * Careful selection of patients for PCI is critical.
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| * [[Fractional Flow Reserve|Fractional Flow Reserve (FFR)]] may be helpful in determining if a [[lesion]] is critical
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| * [[Mortality]] and procedural results vary depending upon whether the [[lesion]] is [[ostium|ostial]] and/or in the shaft versus [[distal]] and involves the bifurcation. Thus, careful and meticulous [[angiography]] in multiple views is critical to fully assess the [[LMCA|left main]] at it's [[ostium]] and bifurcation. Optimal views include but are not limited to the AP caudal and the LAO Caudal.
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| * [[CABG|Coronary Artery Bypass Grafting (CABG)]] is currently the standard of care for patients with [[LMCA|left main disease]]. However, this recommendation may be modified as data emerge regarding:
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| # Very low in-hospital [[mortality]] among patients treated with [[LMCA|left main]] [[stent]]ing
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| # Comparable or better MACE-free survival rates vs [[CABG]] in some registries
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| # Low [[restenosis]] rate with [[drug eluting stent]] use
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| ===Appropriate Candidate for Left Main PCI===
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| #Nonoperative candidates
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| #Low-risk patients who decline [[CABG]]
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| #A patient who is both able and willing to take life long [[aspirin]] and [[clopidogrel]] ([[dual antiplatelet therapy]]) | |
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| ===High Risk Candidate for Left Main PCI===
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| :High-risk features in patients undergoing [[LMCA|left main]] disease PCI include:
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| #Absence of [[saphenous vein]] or [[internal mammary artery]] [[graft]]s [[distal]]ly
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| #Concomitant [[RCA]] disease
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| #Lack of [[collateral]]s from [[RCA]]
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| #[[Distal]] bifurcation involvement
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| #[[LV dysfunction]]
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| #Presence of [[clot]]
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| #Extensive [[calcification]]
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| == Technique ==
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| ===Pre-interventional Preparation===
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| # The [[anatomy]] should be well characterized before the PCI
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| # Evaluation of the potential to occlude or 'snowplow' a ramus is critical
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| ===Hemodynamic Monitoring and Support===
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| #[[Hemodynamic]] support with [[IABP|intra aortic balloon pump (IABP)]] placement is not mandatory, but should be considered for high-risk patients
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| #If an [[IABP|Intra aortic balloon pump]] is not placed, consideration should be given to placement of a 4 or 5 French sheath in the [[contralateral]] [[groin]] in case one needs to be placed urgently
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| #[[Percutaneous]] [[cardiopulmonary]] support (CPS) is an option for very-high-risk patient
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| #[[Pulmonary artery line]] monitoring may be helpful
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| ===IVUS Use===
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| #Characterizes extent of [[plaque]]
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| #Characterizes extent of [[calcification]]
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| # Can be used to calculate the MLD/MLA (minimal [[lumen]] diameter/area) accurately and ascertain the significance of [[stenosis]]
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| # [[QCA]] alone may not be adequate to determine the [[physiologic]] significance of an often eccentric [[LMCA|LM]] [[stenosis]]
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| # [[IVUS]] may assist in sizing the [[stent]] appropriately to avoid [[stent]] malaposition and consequent higher risk of [[stent thrombosis]] and [[restenosis]]
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| # In the presence of bifurcation disease you can use [[IVUS]] to determine the degree of [[plaque]] extent in the [[circumflex]] and use Murray's Law to calculate the [[stent]] size (diameter of the [[proximal]] main branch (diameter of [[distal]] main branch + diameter of [[distal]] side branch) X 0.67
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| ===Guiding Catheter Selection===
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| # Use larger guiding catheters (i.e.: 7 or 8 French) in case [[distal]] bifurcation intervention becomes necessary
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| # Select a guide that provides good support, but which can be backed out of the [[ostium]] if you are dealing with an [[ostium|ostial]] [[stenosis]]
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| # Do not occlude [[ostium]] with the guide
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| # Make side holes with an 18 gauge needle if necessary
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| ===Balloon Technique===
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| # Short [[occlusion]]/inflation times are critical to reduce [[ischemic]] time
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| # Consideration should be given to a [[perfusion]] [[balloon]] in a very high risk patient and the [[distal]] tip should be placed in the [[LAD]].
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| # Select equipment in advance
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| # Use a rapid exchange system
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| # Dilute [[contrast]] in the indeflator to allow faster deflation
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| ===Stent Technique===
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| * Adequate [[stent]] sizing and post-[[dilation]] cannot be understated
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| * [[Stent]] selection:
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| ** Consider using a [[drug eluting stent]] especially if the [[vessel]] is less than 4.5 mm
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| ** Good radial strength (larger Taxus [[stent]]s tend to recoil)
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| ** High visibility for [[ostium|ostial]] or bifurcation placement
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| ** Assure that [[aorta|aorto]]-[[ostium|ostial]] region covered by [[stent]] if there is [[ostium|ostial]] [[lesion]] ([[stent]] positioning in two orthogonal views is particularly important)
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| ===New Device Approaches to High Risk Lesion Morphologies===
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| * [[calcification|Calcified]] [[lesion]]s:
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| ** [[Rotational atherectomy]]
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| ** [[Stent]]ing
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| * Bulky [[plaque]]:
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| ** Directional [[atherectomy]] + [[stent]]ing
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| ** [[Stent]]ing alone
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| * [[Distal]] bifurcation involvement:
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| ** Similar to other bifurcation [[therapy|therapies]] but higher risk
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| ** DCA alone
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| ** DCA + [[stent]]ing of principal [[vessel]]
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| ** [[Stent]]ing of principal [[vessel]] (usually [[LAD]]) & rescuing [[circumflex]]
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| ** Bifurcation [[stent]]ing (V [[stent]]ing with kissing [[balloon]]s, crush or reverse crush, T [[stent]]ing, or Y, Culotte; in double barrel V or crush [[stent]]ing [[Left circumflex coronary artery|LCX]] limb is often the site of [[restenosis]] and re-crossing into the barrel is often challenging )
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| ==Pharmacotherapy==
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| * [[Antiplatelet]] regimen:
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| # [[aspirin|ASA]] 325 mg PO prior to the procedure, use non-[[enteric coating|enteric coated]] to assure rapid [[absorption]]
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| # [[Clopidogrel]] at a [[loading dose]] of 600 mg at least 2 hours prior to the intervention
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| # [[Glycoprotein IIb/IIIa inhibitor]] administration is typical for this high risk [[lesion]] [[morphology]] | |
| * If [[UFH|unfractionated heparin]] ([[UFH]]) is used as an [[antithrombin]], then [[UFH]] should be dosed to achieve an [[activated clotting time|activated clotting time (ACT)]] of 250 seconds in the presence of a [[Glycoprotein IIb/IIIa inhibitor]] or 300 seconds in the absence of a [[Glycoprotein IIb/IIIa inhibitor]]
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| ==Sheath Removal==
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| * A bad [[vagal reaction]] in a freshly implanted [[stent]] or in a patient awaiting PCI who has a significant [[LMCA|LM]] [[lesion]] can be very hazardous (risk of [[thrombosis]], or a downward spiral of poor [[perfusion]] leading to [[subendocardial]] [[ischemia]] leading to poorer [[LV function]], leading to poorer forward output).
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| * Some operators will preemptively administer an [[ampule]] of [[atropine]] prior to the sheath pull or will have a low threshold to administer a full [[ampule]] of [[atropine]].
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| ==Data Regarding The Efficacy and Safety of Left Main Stenting with Drug Eluting Stents<ref name="pmid17576862">Chieffo A, Park SJ, Valgimigli M, Kim YH, Daemen J, Sheiban I et al. (2007) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=17576862 Favorable long-term outcome after drug-eluting stent implantation in nonbifurcation lesions that involve unprotected left main coronary artery: a multicenter registry.] ''Circulation'' 116 (2):158-62. [http://dx.doi.org/10.1161/CIRCULATIONAHA.107.692178 DOI:10.1161/CIRCULATIONAHA.107.692178] PMID: [http://pubmed.gov/17576862 17576862]</ref>==
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| A [[retrospective]] multicenter registry study has demonstrated favorable long-term outcomes after the implantation of [[DES|drug eluting stents (DES)]] in non-bifurcation [[lesion]]s involving unprotected [[left main coronary artery|left main coronary arteries]]<ref name="pmid17576862">Chieffo A, Park SJ, Valgimigli M, Kim YH, Daemen J, Sheiban I et al. (2007) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=17576862 Favorable long-term outcome after drug-eluting stent implantation in nonbifurcation lesions that involve unprotected left main coronary artery: a multicenter registry.] ''Circulation'' 116 (2):158-62. [http://dx.doi.org/10.1161/CIRCULATIONAHA.107.692178 DOI:10.1161/CIRCULATIONAHA.107.692178] PMID: [http://pubmed.gov/17576862 17576862]</ref>.
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| The study, which was published in the online edition of [http://circ.ahajournals.org/ Circulation], examined registry data among 147 patients who were electively treated with percutaneous coronary intervention (PCI) with [[DES]] in unprotected [[left main coronary artery]] [[lesion]]s.
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| At a median follow-up of 886 days, the major adverse [[cardiac]] event rate was 7.4% with a cumulative [[cardiac]] [[mortality]] of 2.7%. Only seven patients required target [[vessel]] [[revascularization]]. The [[restenosis]] rate at six-month [[angiographic]] follow-up was 0.9% with a late loss of -0.01 mm. Additionally, there were no [[angiographic]]ally proven cases of [[stent thrombosis]], although [[stent thrombosis]] could not be excluded in the four patients who died of unknown causes.
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| While the results of the study suggest that the use of [[drug eluting stent]]s in nonbifurcation unprotected [[left main coronary artery]] [[stenosis]] is both safe and effective, Dr. Alaide Chieffo and colleagues note that the results are from a [[retrospective]] registry with a relatively small number of patients due to the low occurrence of this [[anatomy|anatomical]] subset. Currently there is no [[randomized control trial|randomized data]] comparing PCI with [[DES]] implantation versus [[coronary artery bypass graft]] [[surgery]]. The ongoing [[SYNTAX]] trial will evaluate 710 patients with [[LMCA|left main]] disease who have been randomized to either a [[DES]] or [[CABG]].
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| ==Follow-up of the Patient with a DES in the Left Main==
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| * [[LMCA|Left main]] [[restenosis]] may present as [[sudden death]] rather than recurrent [[angina]]
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| * Screen aggressively for [[restenosis]] (with either [[angiography]] or Multi Detector CT for [[ostium|ostial]] disease)
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| * Some operators perform [[platelet]] inhibition testing to confirm that the patient is not a [[clopidogrel]] non-responder.
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| * Some operators dose the patient with 150 mg of [[clopidogrel]] per day in case the patient is a [[clopidogrel]] non-responder
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| * Relook [[angiography]] recommended even in absence of sx at 2-3 months post-procedure to catch early [[restenosis]] and some operators recommend additional [[angiography]] at 6 months to identify late [[restenosis]]
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| * [[coronary angioscopy|Angioscopy]] may aid in determining if [[clot]] is present at the end of the procedure, and if clot is present on repeat evaluation.
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| ==View General References and Subscribe to an RSS Feed of New References==
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| [http://eutils.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=0TKZrqCxlMfSEG0HTIITBSEuJfZfvIsAdHaWfOUNRML PubMed References and RSS Feed of New References]
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| ==References==
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| {{reflist|2}}
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| [[Category:Up-To-Date]]
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| [[Category:Up-To-Date cardiology]]
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| [[Category:Cardiology]]
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