Impact of Nonobstructive Left Main Coronary Artery Atherosclerosis on Long-Term Mortality.

BACKGROUND: Although the presence of severe stenosis in the left main coronary artery (LMCA) is a well-established predictor of mortality, whether this extends to nonobstructive atherosclerosis in the LMCA is unknown. OBJECTIVES: The aim of this study was to evaluate the association between LMCA disease by intravascular ultrasound (IVUS) and long-term mortality. METHODS: Between 2005 and 2013, 3,239 patients with LMCA IVUS imaging without LMCA revascularization (either before angiography or scheduled based on index angiography or IVUS) were included. The primary and secondary endpoints were all-cause and cardiac mortality at a minimum of 5 years obtained from the National Death Index. RESULTS: The IVUS-measured LMCA minimum lumen area (MLA) and plaque burden were 13.1 ± 5.0 mm2 and 41.7% ± 15.6%, respectively. The median follow-up was 8.2 years. The Kaplan-Meier estimated 12-year all-cause and cardiac death rates were 37.5% and 17.0%, respectively. Greater plaque burden (unadjusted HR per 10%: 1.17; 95% CI: 1.12-1.22; P < 0.0001) and smaller IVUS MLA (unadjusted HR per 1 mm2: 0.98; 95% CI: 0.96-0.99; P = 0.0008) were associated with all-cause death. After adjusting for clinical, angiographic, and IVUS factors, plaque burden (adjusted HR per 10%: 1.12; 95% CI: 1.04-1.21; P = 0.003) but not MLA (adjusted HR per 1 mm2: 1.02; 95% CI: 0.99-1.04; P = 0.18) was associated with long-term all-cause death. These findings were also consistent for long-term cardiac mortality. CONCLUSIONS: In the present large-scale study with a 12-year follow-up, increasing LMCA plaque burden was associated with long-term all-cause and cardiac mortality in patients not undergoing LMCA revascularization, even when the lumen area was preserved.

Robotic-Enhanced PCI Compared to the Traditional Manual Approach.

Remote-controlled robotic-enhanced percutaneous coronary intervention (PCI) was developed to improve procedural outcomes, reduce operator radiation exposure, and improve ergonomics. Critics questioned whether protection of the operator might result in increased radiation exposure to the patient and increase contrast media use. We studied this in a single-center comparison of robotic-enhanced versus traditional PCIs. A total of 40 patients who enrolled in the PRECISE study and had PCI with the CorPath 200 robotic system (Corindus Vascular Robotics) were compared to 80 consecutive patients who underwent conventional PCI. All patients had obstructive coronary artery disease, evidence of myocardial ischemia, and clinical indications for single-vessel PCI. Baseline demographics of the 40 robotic and 80 traditional PCIs were similar. Only 2 robotic-assisted cases required conversion to manual PCI. All patients had a final residual stenosis <30%. Robotic-enhanced PCI was associated with trends toward lower duration of fluoroscopy (10.1 ± 4.7 min vs 12.3 ± 7.6 min; P=.05), radiation dose (1389 ± 599 mGy vs 1665 ± 1026 mGy; P=.07), and contrast volume (121 ± 47 mL vs 137 ± 62 mL; P=.11). In conclusion, the initial experience with robotic-enhanced PCI was not associated with increased fluoroscopy duration, radiation, or contrast media exposure to patients, and compared favorably to the traditional approach.