A Need For Long-Term Results of LMCA-CTO-PCI

Dear Editors:

With great interest, we read the article “Left Main Chronic Total Occlusion Percutaneous Coronary Intervention: A Case Series” by Xenogiannis, et al.¹ In fact, the authors are to be congratulated for providing more evidence of the feasibility and favorable procedural outcomes of left main coronary artery chronic total occlusion percutaneous coronary intervention (LMCA-CTO-PCI) in this special population.  

Their results support previous findings of smaller series, including the fact that LMCA-CTO-PCI is infrequently performed, but in daily practice, the high surgical risk profile of these patients resulting from multiple comorbidities and reintervention commonly leaves PCI as the only feasible option.² 

One important point to highlight is that 50% of the patients in this case series presented with acute coronary syndrome (ACS). These findings differed from preceding findings in which patients with LMCA-CTOs were known to present with stable angina,³ but are in line with the previous larger series of LMCA-CTO-PCI.² The mechanism for ACS presentation is well defined by the authors, taking into accounts factors such as coronary artery disease progression in other native vessels or bypass grafts, as it is known that patients with severe LMCA coronary artery disease typically have multivessel disease, a high burden of atherosclerotic disease, and high-risk plaques. 

In addition, the authors’ findings may support the clinical need to attempt LMCA-CTO-PCI when appropriate in this high-risk subset of patients where surgical revascularization may be contraindicated. The support of a left ventricular assist device may be considered in special situations, such as unprotected LMCA-CTO-PCI, as demonstrated by Xenogiannis et al,¹ who successfully used assist devices in 20% of their patients.

Currently, more follow-up data on the long-term results of CTO-PCI are desperately needed; unfortunately, the authors did not provide a long-term follow-up of their patients. Further studies with a long follow-up are needed to assess the association between LMCA-CTO-PCI and long-term survival benefit. 

Sincerely,

Pedro Cepas-Guillen, MD; Sara Vásquez, MD; Andrea Fernandez-Valledor, MD; Rodolfo San Antonio, MD; Eduardo Flores-Umanzor, MD; Victoria Martin-Yuste, MD, PhD

Address for correspondence: Eduardo Flores-Umanzor, MD, Cardiology Department, Cardiovascular Institute, Hospital Clínic de Barcelona, University of Barcelona, Spain. Email: ejfu0209@gmail.com

Authors’ Response:

We are grateful for the insightful comments of Dr Flores-Umanzor and colleagues on our study.¹ We could not agree more that long-term outcomes after LMCA-CTO-PCI are of critical importance and therefore we describe the available data from our cohort. 

Follow-up was available for 15 of the 20 LMCA-CTO-PCI patients in our series. Median follow-up time was 378 days (interquartile range, 152-736 days). One patient developed periprocedural myocardial infarction (MI) and died the day following his discharge. Another patient presented with stable angina and successfully underwent repeat target-vessel revascularization 533 days after the index procedure. Two patients presented with unstable angina and underwent PCI as well (one in the target vessel and the other in the non-target vessel 601 days and 324 days after the initial CTO-PCI, respectively). Finally, one patient presented with a non-ST segment elevation MI and underwent target-vessel PCI 807 days after the index procedure. In the case series by Flores-Umanzor, one of 5 patients (20%) who underwent LMCA-CTO-PCI died during 5 years of follow-up.² The follow-up period for our cases was much shorter, since all the interventions (except for 1 case performed in 2016) were performed between 2017 and 2018. 

The high incidence of subsequent events after PCI of LMCA-CTOs is likely related to high burden of atherosclerotic disease, multiple comorbidities, and high-risk plaques in patients with LMCA-CTO lesions and highlights the need for close follow-up of this high-risk patient group. 

Sincerely,

Iosif Xenogiannis, MD; Dimitri Karmpaliotis, MD; Khaldoon Alaswad, MD; Mir B. Basir, MD; Robert W. Yeh, MD; Hector Tamez, MD; Mitul Patel, MD; Ehtisham Mahmud, MD; James W. Choi, MD; M. Nicholas Burke, MD; Anthony H. Doing, MD; Phil Dattilo, MD; Jaikirshan J. Khatri, MD; Abdul M. Sheikh, MD; Bilal A. Malik, MD; Mary E. Greene, MD; Nidal Abi Rafeh, MD; Assaad Maalouf, MD; Fadi Abou Jaoudeh, MD; Jeffrey W. Moses, MD; Nicholas J. Lembo, MD; Manish Parikh, MD; Ajay J. Kirtane, MD; Ziad A. Ali, MD; Fotis Gkargkoulas, MD; Juan Russo, MD; Emad Hakemi, MD; Peter Tajti, MD; Allison B. Hall, MD; Evangelia Vemmou, MD; Ilias Nikolakopoulos, MD; Bavana V. Rangan, BDS, MPH; Shuaib Abdullah, MD; Subhash Banerjee, MD; Emmanouil S. Brilakis, MD, PhD

Address for correspondence: Emmanouil S. Brilakis, MD, PhD, Minneapolis Heart Institute, 920 East 28th Street #300, Minneapolis, MN 55407. Email: esbrilakis@gmail.com

References

1. Xenogiannis I, Karmpaliotis D, Alaswad K, et al. Left main chronic total occlusion percutaneous coronary intervention: a case series. J Invasive Cardiol. 2019;31:E220-E225.

2. Flores-Umanzor E, Martin-Yuste V, Caldentey G, et al. Percutaneous coronary intervention due to chronic total occlusion in the left main coronary artery after bypass grafting: a feasible option in selected cases. Rev Port Cardiol. 2018;37:865.e1-865.e4.

3. Koster NK, White M. Chronic effort-induced angina as presentation of a totally occluded left main coronary artery: a case report and review. Angiology. 2009;60:382-384.