LM Bifurcation: Is PCI Making a Comeback?

LM Bifurcation PCI remains a topic of great interest in our fraternity of Interventional Cardiology. Endless debate between PCI and CABG in patients with left main and multivessel disease fuels interest in evolving strategies to improve PCI outcomes. Two recent trial publications have shed further light on our understanding.

A recent subgroup analysis of EXCEL Trial reported outcomes of LM PCI vs CABG according to lesion site:  Either distal LM bifurcation or ostial/shaft lesion. Total of 1852 patients were evaluated in the study with 84.2% with distal bifurcation and 15.8% ostial/shaft left main disease. It is important to note that EXCEL enrolled patients with low to intermediate SYNTAX score of ≤ 32.

At three year follow up, patients with distal left main disease have similar death, MI or stoke whether treated with PCI or CABG (15.6% vs 14.9% or 1.07,95% CI 081-1.42, P=0.80). Similarly, patients with ostial/shaft left main disease also exhibited no difference between PCI or CABG. However, rate of ischemia driven revascularization at three years was twice as high in PCI arm compared to CABG in distal LM group (13.2% vs 7.2%, OR 2.00, 95% CI 1.41-2.85, P=0.0002). Conversely, patients with ostial and shaft left main disease did not exhibit higher rate of revascularization compared to CABG.  Not surprisingly, non LM disease extent had impact on outcomes. Patients with SYNTAX score > 32, composite of death, MI, stroke or ischemia revascularization was worse with PCI. (Distal LM and SYNTAX > 32: PCI 25.5% vs CABG 14.5% P=0.008)

Outside of US, especially in Asia, PCI is practiced as preferred strategy for ostial/shaft LM disease already and perhaps these findings may have impact on guideline writers in western hemisphere about expansion of indication. However, technique used for distal LM bifurcation PCI was not reported.

However, another study reporting from two multicenter real-world registries of 1353 patients evaluated impact of generation of DES and one vs two stent bifurcation techniques on long term outcomes of LMCA PCI. The primary endpoint was cardiac death or MI, stent thrombosis and TVR at three year follow up. As expected single stent strategy and current generation DES has better outcomes. Specifically, stent strategy one vs two (4.7% vs 18.6 %, HR 3.71, CI 2.55 to 5.39, P < 0.001); Current vs Early generation DES (4.6% vs 10.9%, HR 0.55, 95% CI 0.34 to 0.89, P = 0.014) Importantly, CKD and pre-PCI SB diameter stenosis > 50 % were independent predictors of MACE in current generation DES arm.

Moreover, the difference in outcome was mainly seen in patients with early generation DES. It is critical to note that number of patients treated with two stents in current generation DES arm was very small. Also, no finer techniques such as POT or FKB was taken into account. In summary, what we have learned from both studies is that we should always use current generation DES, with single stent strategy as preferred technique. The bigger question is how we can improve on this further?

This year at C3, in partnership with European Bifurcation Club, we explored finer techniques for LMCA PCI. Dr. Junya Shite from Kobe, Japan, presented data from 3DOCT registry demonstrating impressive impact on repeat revascularization in LMT distal bifurcation PCI.

For 2019, we will again we bring back the deep dive into LMT treatment, especially targeting critical issue of how we reduce TLR at long term in distal LM bifurcation. My opinion, after performing hundreds of distal LM PCI for almost two decades, is that multiple important steps impact long term outcome of these patients including precision techniques and best medical therapy.

In 2019 at C3, we will once again have world experts on bifurcation all together in one platform.  This includes; current president of EBC, Dr. Goran Stankovic, Dr. Junya Shite and Yoshinobu Murasato from Japan, Francesco Burzotta and Imad Sheiban from Italy, Yves Louvard from France along with North American experts.  We will debate the best techniques and review the expert opinions for LM PCI. Please mark your calendar for June 23-26, 2019 – you do not want to miss this event!

By, Rajesh Dave, MD, FACC, FSCAI

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