Elsevier

American Heart Journal

Volume 155, Issue 2, February 2008, Pages 274-283
American Heart Journal

Clinical Investigation
Interventional Cardiology
A collaborative systematic review and meta-analysis on 1278 patients undergoing percutaneous drug-eluting stenting for unprotected left main coronary artery disease

https://doi.org/10.1016/j.ahj.2007.10.009Get rights and content

Background

Cardiac surgery is the standard treatment for unprotected left main disease (ULM). Drug-eluting stent (DES) implantation has been recently reported in patients with ULM but with unclear results. We systematically reviewed outcomes of percutaneous DES implantation in ULM.

Methods

Several databases were searched for clinical studies reporting on ≥20 patients and ≥6-month follow-up. The primary end point was major adverse cardiovascular events (MACEs; ie, death, myocardial infarction, or target vessel revascularization [TVR]) at the longest follow-up. Incidence and adjusted risk estimates were pooled with generic inverse variance random-effect methods (95% CIs).

Results

From 823 initial citations, 16 studies were included (1278 patients, median follow-up 10 months). Eight were uncontrolled registries, 5 nonrandomized comparisons between DES and bare-metal stents and 3 nonrandomized comparisons between DES and CABG, with no properly randomized trial. Meta-analysis for DES-based PCI showed, at the longest follow-up, rates of 16.5% (11.7%-21.3%) MACE, 5.5% (3.4%-7.7%) death, and 6.5% (3.7%-9.2%) TVR. Comparison of DES versus bare-metal stent disclosed adjusted odds ratios for MACE of 0.34 (0.16-0.71), and DES versus CABG showed adjusted odds ratios for MACE plus stroke of 0.46 (0.24-0.90). Meta-regression showed that disease location predicted MACE (P = .001) and TVR (P = .020), whereas high-risk features predicted death (P = .027).

Conclusions

Clinical studies report apparently favorable early and midterm results in selected patients with ULM. However, given their limitations in validity and the inherent risk for DES thrombosis, results from randomized trials are still needed to definitely establish the role of DES implantation instead of the reference treatment, surgery.

Section snippets

Methods

This review was reported according to established methods,4 minimizing duplication risks.5, 6 BioMedCentral, clinicaltrials.gov, Google Scholar, and PubMed were searched (January 2000-September 2006),6 without language restrictions. Citations were screened at title/abstract level and retrieved as full reports. Studies were included if the following criteria applied: (a) PCI with stent implantation, (b) for ULM disease, (c) using DES, and (d) in ≥20 patients. Exclusion criteria were as follows: (

Results

From 823 initial citations (Figure 1), we excluded 806 hits, leaving 17 studies,9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25 (Table I, Table II). The 17 included studies reported on a total of 16 nonduplicate cohorts, enrolling 1278 subjects undergoing PCI with DES for ULM disease. Eight studies were observational reports on 540 patients treated with DES,9, 15, 16, 18, 20, 21, 23, 25 6 studies were nonrandomized comparisons of PCI with DES (n = 576) versus BMS (n = 509),10,

Discussion

The present meta-analysis, reporting on DES implantation for ULM, has the following implications: published reports on DES use now include >1200 subjects, confirming that this treatment option has been already adopted into clinical practice despite the lack of a sound evidence base; although overall results suggest an apparently favorable risk of MACE in selected patients, most studies are fraught with validity threats; moreover, clinical follow-up is to date still limited at the midterm

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  • Cited by (0)

    Dr Biondi-Zoccai consulted for Boston Scientific, Boston, MA; Cordis, Miami, FL; and Mediolanum Cardio Research, Milan, Italy; and received lecture fees from Bristol-Myers-Squibb, New York, NY. Dr Agostoni has received lecture fees from Cordis.

    1

    Both authors equally contributed to this work.

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