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

Takayuki Warisawa; Christopher M. Cook; Yousif Ahmad; James P. Howard; Henry Seligman; Christopher Rajkumar; Takumi Toya; Shunichi Doi; Akihiro Nakajima; Masafumi Nakayama; Rafael Vera-Urquiza; Sonoka Yuasa; Takao Sato; Yuetsu Kikuta; Yoshiaki Kawase; Hidetaka Nishina; Rasha Al-Lamee; Sayan Sen; Amir Lerman; Hitoshi Matsuo; Yoshihiro J. Akashi; Javier Escaned; Justin E. Davies

doi:10.1161/CIRCINTERVENTIONS.122.012700

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

Takayuki Warisawa, Christopher M. Cook, Yousif Ahmad, James P. Howard, Henry Seligman, Christopher Rajkumar, Takumi Toya, Shunichi Doi, Akihiro Nakajima, Masafumi Nakayama, Rafael Vera-Urquiza, Sonoka Yuasa, Takao Sato, Yuetsu Kikuta, Yoshiaki Kawase, Hidetaka Nishina, Rasha Al-Lamee, Sayan Sen, Amir Lerman, Hitoshi MatsuoYoshihiro J. Akashi, Javier Escaned, Justin E. Davies

Research output: Contribution to journal › Article › peer-review

8 Scopus citations

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.

Original language	English
Pages (from-to)	E012700
Journal	Circulation: Cardiovascular Interventions
Volume	16
Issue number	6
DOIs	https://doi.org/10.1161/CIRCINTERVENTIONS.122.012700
State	Published - 1 Jun 2023
Externally published	Yes

Keywords

coronary physiology
deferral
instantaneous wave-free ratio
ischemia
left main coronary artery disease
revascularization

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10.1161/CIRCINTERVENTIONS.122.012700

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Warisawa, T., Cook, C. M., Ahmad, Y., Howard, J. P., Seligman, H., Rajkumar, C., Toya, T., Doi, S., Nakajima, A., Nakayama, M., Vera-Urquiza, R., Yuasa, S., Sato, T., Kikuta, Y., Kawase, Y., Nishina, H., Al-Lamee, R., Sen, S., Lerman, A., ... Davies, J. E. (2023). Deferred Versus Performed Revascularization for Left Main Coronary Disease with Hemodynamic Significance. Circulation: Cardiovascular Interventions, 16(6), E012700. https://doi.org/10.1161/CIRCINTERVENTIONS.122.012700

@article{56a447ca3b674feb93763d051893be8b,

title = "Deferred Versus Performed Revascularization for Left Main Coronary Disease with Hemodynamic Significance",

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.",

keywords = "coronary physiology, deferral, instantaneous wave-free ratio, ischemia, left main coronary artery disease, revascularization",

author = "Takayuki Warisawa and Cook, {Christopher M.} and Yousif Ahmad and Howard, {James P.} and Henry Seligman and Christopher Rajkumar and Takumi Toya and Shunichi Doi and Akihiro Nakajima and Masafumi Nakayama and Rafael Vera-Urquiza and Sonoka Yuasa and Takao Sato and Yuetsu Kikuta and Yoshiaki Kawase and Hidetaka Nishina and Rasha Al-Lamee and Sayan Sen and Amir Lerman and Hitoshi Matsuo and Akashi, {Yoshihiro J.} and Javier Escaned and Davies, {Justin E.}",

year = "2023",

month = jun,

day = "1",

doi = "10.1161/CIRCINTERVENTIONS.122.012700",

language = "English",

volume = "16",

pages = "E012700",

journal = "Circulation: Cardiovascular Interventions",

issn = "1941-7640",

publisher = "Lippincott Williams and Wilkins Ltd.",

number = "6",

}

Warisawa, T, Cook, CM, Ahmad, Y, Howard, JP, Seligman, H, Rajkumar, C, Toya, T, Doi, S, Nakajima, A, Nakayama, M, Vera-Urquiza, R, Yuasa, S, Sato, T, Kikuta, Y, Kawase, Y, Nishina, H, Al-Lamee, R, Sen, S, Lerman, A, Matsuo, H, Akashi, YJ, Escaned, J & Davies, JE 2023, 'Deferred Versus Performed Revascularization for Left Main Coronary Disease with Hemodynamic Significance', Circulation: Cardiovascular Interventions, vol. 16, no. 6, pp. E012700. https://doi.org/10.1161/CIRCINTERVENTIONS.122.012700

TY - JOUR

T1 - Deferred Versus Performed Revascularization for Left Main Coronary Disease with Hemodynamic Significance

AU - Warisawa, Takayuki

AU - Cook, Christopher M.

AU - Ahmad, Yousif

AU - Howard, James P.

AU - Seligman, Henry

AU - Rajkumar, Christopher

AU - Toya, Takumi

AU - Doi, Shunichi

AU - Nakajima, Akihiro

AU - Nakayama, Masafumi

AU - Vera-Urquiza, Rafael

AU - Yuasa, Sonoka

AU - Sato, Takao

AU - Kikuta, Yuetsu

AU - Kawase, Yoshiaki

AU - Nishina, Hidetaka

AU - Al-Lamee, Rasha

AU - Sen, Sayan

AU - Lerman, Amir

AU - Matsuo, Hitoshi

AU - Akashi, Yoshihiro J.

AU - Escaned, Javier

AU - Davies, Justin E.

PY - 2023/6/1

Y1 - 2023/6/1

N2 - 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.

AB - 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.

KW - coronary physiology

KW - deferral

KW - instantaneous wave-free ratio

KW - ischemia

KW - left main coronary artery disease

KW - revascularization

UR - http://www.scopus.com/inward/record.url?scp=85163392831&partnerID=8YFLogxK

U2 - 10.1161/CIRCINTERVENTIONS.122.012700

DO - 10.1161/CIRCINTERVENTIONS.122.012700

M3 - Article

C2 - 37339234

AN - SCOPUS:85163392831

SN - 1941-7640

VL - 16

SP - E012700

JO - Circulation: Cardiovascular Interventions

JF - Circulation: Cardiovascular Interventions

IS - 6

ER -

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

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