There is modest data on long-term impact of diabetes on left main coronary artery (LMCA) percutaneous coronary intervention (PCI). This observational study, based on the largest single-center registry of LMCA PCI in Poland, evaluated the impact of diabetes on long-term survival following PCI in a real-world setting.

We retrospectively analyzed 998 patients who underwent LMCA PCI between December 27, 2007, and February 21, 2022. Diabetes and insulin dependence were defined based on medical history, prior records, and prescribed treatment. The endpoint was all-cause mortality at the longest available follow-up (mean 4.2 years). Survival analysis was conducted in the overall cohort and a one-to-one propensity score-matched (PSM) population. Moderation effects and differences between subgroups were analysed in predefined groups of PSM cohort.

The median age was 71 (63-79) years; 212 (28.2%) were women, and 250 (33.2%) had diabetes. In the overall cohort, diabetes was associated with a worse prognosis (HR 1.35, 95% CI 1.03-1.76, P = 0.03). PSM resulted in 214 well-balanced pairs (median age 73 years (66-79)), with no significant difference in all-cause mortality between groups (adjusted HR 1.27, 95% CI 0.91-1.77, P = 0.16). After PSM subgroup analysis showed worse outcomes for patients with diabetes undergoing two-stent angioplasty (HR 3.70, 95% CI 1.64-8.34, P = 0.002) and elective PCI (HR 2.07, 95% CI 1.29-3.31, P = 0.003). Conversely, among patients presenting with myocardial infarction (MI), people with diabetes had better survival than the control group (HR 0.56, 95% CI 0.35-0.90, P = 0.02). No significant differences in outcomes were observed in patients with heart failure (HR 1.29, 95% CI 0.88-1.89, P = 0.19), chronic kidney disease (HR 1.08, 95% CI 0.69-1.71, P = 0.19), intravascular imaging use (HR 1.38, 95% CI 0.70-2.71, P = 0.35), or concomitant multivessel disease (HR 1.14, 95% CI 0.75-1.73, P = 0.53).

No significant association was observed between diabetes and overall mortality following LMCA PCI. Sensitivity analyses showed worse survival outcomes in diabetic patients treated with two-stent techniques and undergoing non-emergency PCI. These findings suggest the overall safety of PCI for LMCA in people with diabetes and highlight the need for randomized trials, especially investigating indicated high-risk subgroups.

There is a paucity of data regarding drug-coated balloon (DCB) treatment in the context of left main (LM) true bifurcation lesions.

The aim of this study was to evaluate the safety and efficacy of DCB-based treatment for unprotected LM true bifurcation lesions.

A total of 39 patients with LM true bifurcation lesion (Medina: 1,1,1/0,1,1/1,0,1) who were successfully treated with DCB alone or in combination with drug-eluting stent (DES) were retrospectively enrolled into the DCB-based group. They were compared with 39 propensity-matched patients who were treated with second-generation DES from the COBIS III registry (n = 2648). Major adverse cardiovascular events (MACE) were defined as cardiac death, myocardial infarction, stent or target lesion thrombosis, and target lesion revascularization at the 2-year follow-up.

Baseline clinical characteristics were similar between the groups, except for the prevalence of in-stent restenosis (ISR) lesions (41.0% in DCB-based group vs. 17.9% in DES-only group, p = 0.047). In the DCB-based group, 59.0% of the patients (n = 23) underwent DCB-only treatment. There were no cases of abrupt vessel closure requiring treatment following DCB application. The MACE were comparable between both groups (12.8% in DCB-based group vs. 17.9% in DES-only group, p = 0.861) after 2 years.

In patients with unprotected LM true bifurcation lesions, DCB-based treatment demonstrated comparable clinical outcomes at the 2-year follow-up when compared to DES-only treatment. DCB-based treatment could be considered a safe and effective alternative to DES for carefully selected patients who have achieved satisfactory predilation results (Impact of DCB Treatment in De Novo Coronary Lesion; NCT04619277).

Despite significant reductions in in-stent restenosis (ISR) incidence with the adoption of drug-eluting stents (DES) over bare metal stents (BMS), ISR remains an unresolved issue in the DES era. The risk factors associated with DES-ISR have not been thoroughly analyzed. This meta-analysis aims to identify the key factors and quantify their impact on DES-ISR.

We conducted comprehensive literature searches in PubMed, EMBASE, Cochrane, and Web of Science up to 28 February 2023, to identify studies reporting risk factors for DES-ISR. Meta-analysis was performed on risk factors reported in two or more studies to determine their overall effect sizes.

From 4357 articles screened, 17 studies were included in our analysis, evaluating twenty-four risk factors for DES-ISR through meta-analysis. The pooled incidence of DES-ISR was approximately 13%, and significant associations were found with seven risk factors. Ranked risk factors included diabetes mellitus (odds ratio [OR]: 1.46; 95% confidence interval [CI]: 1.14-1.87), stent length (OR: 1.026; 95% CI: 1.003-1.050), number of stents (OR: 1.62; 95% CI: 1.11-2.37), involvement of the left anterior descending artery (OR: 1.56; 95% CI: 1.25-1.94), lesion length (OR: 1.016; 95% CI: 1.008-1.024), medical history of myocardial infarction (OR: 1.79; 95% CI: 1.12-2.86) and previous percutaneous coronary intervention (OR: 1.97; 95% CI: 1.53-2.55). Conversely, a higher left ventricular ejection fraction was identified as a protective factor (OR: 0.985; 95% CI: 0.972-0.997).

Despite advancements in stent technology, the incidence of ISR remains a significant clinical challenge. Our findings indicate that patient characteristics, lesion specifics, stent types, and procedural factors all contribute to DES-ISR development. Proactive strategies for early identification and management of these risk factors are essential to minimize the risk of ISR following DES interventions.

CRD42023427398, https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=427398.

Provisional single stenting strategy (PSS) is a default strategy for percutaneous coronary intervention (PCI) of unprotected left main distal bifurcation lesions (ULMD). Previous study reported that a bifurcation angle change (BAC) between end diastole and systole was associated with outcomes after PCI with double stent strategy (DSS) for ULMD. However, there are no data comparing outcomes after PCI with PSS versus DSS according the degree of BAC.

We evaluated outcomes after PCI with PSS versus DSS for true ULMD with small and large BAC.

We identified 566 patients with true ULMD underwent PCI in three high-volume centers. We calculated the BAC in ULMD between end-diastole and systole before stenting with 2-dimensional quantitative coronary angiographic assessment. We defined small (BAC < 7.0°) and large BAC (≥7.0°) group. We compared clinical outcomes after PCI with PSS versus DSS in each cohort after propensity score adjustment. The primary endpoint was target-lesion failure (TLF), which was defined as a composite of cardiac death, target lesion revascularization, and myocardial infarction.

In small BAC cohort, TLF rate was significantly lower in DSS group than in PSS group (12.5% vs. 20.1%, adjusted HR 0.45; 95% CI, 0.26-0.79; p = 0.006). In contrast, in large BAC cohort, TLF rate was significantly higher in DSS group than in PSS group (54.9% vs. 29.0%, adjusted HR 2.25; 95% CI, 1.50-3.38; p < 0.001).

The TLF rate after PCI with DSS was significantly lower in true ULMD with small BAC compared to PSS even after propensity score adjustment. In contrast, it was significantly higher in those with large BAC.

Percutaneous coronary intervention (PCI) of the left main coronary artery (LMCA) for stable angina has steadily increased. Outcomes stratified by sex are inconclusive and limited. We assessed sex-based trends and differences in clinical outcomes among patients with stable angina who received LMCA PCI.

We retrospectively collected data on patients with stable angina who underwent LMCA PCI (2006-2022) from the UK national PCI registry. The primary outcome of interest was inpatient mortality. Secondary outcomes were major bleeding and major cardiovascular and cerebral events. Multivariate logistic regression was used to assess adjusted odds ratio for outcome of interest. Of the 24 271 LMCA PCI performed, 5497 (22.7%) were in women. Women were older than men (median 72.7 versus 70.4) and less likely to have their PCI via radial access (50.3% versus 58.9%). More women had PCI guided by intravascular ultrasound (43.4% versus 41.2%). Women had significantly lower comorbid burden than men. Higher prevalence of chronic renal failure (6.72% versus 4.77%), smoking history (61.47% versus 45.68%), diabetes (27.36% versus 25.74%), prior myocardial infarction (45.36% versus 35.89%), and prior coronary artery bypass grafting (42.13% versus 30.34%) was observed in men than in women, respectively; P value <0.005 for all. Women had higher adjusted mortality (adjusted odds ratio, 1.63 [95% CI, 1.1-2.3]) and major bleeding events (adjusted odds ratio, 2.07 [95% CI, 1.19-3.59]). Although odds of major cardiovascular and cerebral events (adjusted odds ratio, 1.27[95% CI, 0.9-1.6]) were higher in women, it was not statistically significant.

Despite being less comorbid, women had a significant increase in their mortality and major bleeding events following LMCA PCI. A sex-tailored approach considering age, intravascular imaging, and vascular access may improve outcomes.

The left main coronary artery (LMCA) supplies over 70% of the myocardium, and significant LMCA disease is associated with high morbidity and mortality. With remarkable advances in percutaneous coronary intervention (PCI), including stent technology, antithrombotic agents, and evolving procedural techniques, PCI has become an important treatment option in clinical practice guidelines for the revascularization of LMCA disease. In contemporary clinical practice, a heart-team approach to shared decision-making, considering clinical/anatomic factors along with patient preferences, is emphasized for patients with significant LMCA disease requiring myocardial revascularization. Furthermore, recent progress in PCI procedures combined with intravascular imaging or functional guidance has resulted in significant improvements in PCI outcomes, especially for complex lesions, including LMCA disease. Nevertheless, owing to inherent anatomic complexities and frequent multivessel involvement, several unmet issues remain regarding the determination of the appropriate treatment approach for significant LMCA disease, for which further clinical research is required. This contemporary review article provides a comprehensive overview of left main PCI based on current guidelines and underlying trial data, addresses important unresolved diagnostic and therapeutic issues, and identifies future perspectives likely to advance progress in this field.

Many patients with premature ventricular complexes (PVCs) do not experience symptoms. However, for those with frequent or symptomatic PVCs, medical interventions are available. If medications fail, radiofrequency catheter ablation may be performed. Despite careful attention to avoiding the coronary arteries during ablation, injuries may still occur. Here, we present the case of a 66-year-old Caucasian female with frequent PVCs causing worsening palpitations, chest pain, fatigue, and lightheadedness, who underwent elective PVC ablation and suffered catheter-induced left main coronary artery stenosis, necessitating subsequent coronary artery bypass grafting (CABG). This case highlights a rare complication of cardiac ablation in the setting of PVCs and the rationale for clinical decisions made throughout the patient's hospital course.

Percutaneous coronary intervention for left main coronary artery disease (LM-PCI) represents a high-risk yet life-saving procedure that has evolved significantly over the years. This review outlines the current state-of-the-art practices for LM-PCI in Japan in detail, emphasizing the integration of coronary physiology and intracoronary imaging alongside with evidence-based standardized technique using latest drug-eluting stents. These advancements enable precise lesion assessment, stent sizing, and optimal deployment, thereby enhancing procedural safety and efficacy. Despite discrepancies between current guidelines favoring coronary artery bypass grafting and real-world practice trends towards increased LM-PCI adoption, particularly in elderly populations with multiple comorbidities, careful patient selection and procedural planning are critical. Future perspectives include further refining LM-PCI through conducting randomized controlled trials integrating advanced techniques and addressing the issue of ostial left circumflex lesions and nationwide standardization of medical care for LM disease.

Despite recent advancements, challenges persist in determining the optimal stenting strategy for LM bifurcation disease. Hence, this systematic review aims to compare single provisional and systematic dual stenting for managing LM bifurcation disease. A systematic search was performed until January 14, 2024. For the effect measure, risk ratios (RRs) was calculated. This study included 22 studies with 10776 participants. The all-cause mortality and cardiovascular mortality revealed comparable outcomes between provisional and dual-systematic stenting (RR 1.13, CI95 %: 0.87-1.47, p 0.36, I2 59 %; RR 1.16, CI95 %: 0.73-1.84, p 0.63, I2 80 %). In addition, MACE, MI, TLR, TVR, and in stent thrombosis also showed similar findings. Subgroup analysis revealed that cohort studies was the source of heterogeneity in all-cause mortality, stent thrombosis, and TLR. This meta-analysis suggests comparable outcomes between provisional and dual-systematic stenting in managing LM bifurcation disease. Further study is needed to validate the outcomes of novel techniques.

Significant unprotected left main (ULM) disease is the highest-risk coronary artery lesion, carries high morbidity and mortality related to a large amount of myocardium supplied, and should undergo prompt revascularization. Among recent randomized controlled trials (RCTs), NOBLE failed to demonstrate non-inferiority of percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG). However, all the other RCTs have shown comparable outcomes. While CABG is associated with higher stroke rates at 30 days and 1 year, PCI is associated with increased spontaneous myocardial infarction (MI) events and the need for repeat revascularization. Furthermore, the benefit of CABG is more evident with the increased complexity of coronary artery disease. In current European and American guidelines, CABG is the standard of care for ULM disease. PCI is considered a reasonable alternative in selected patients (2a B-NR). There is still a great need for carefully designed RCTs with longer follow-up times to validate the role of recent technological and pharmacological regimens.

We systematically reviewed and meta-analyzed the predictors of major adverse cardiac and cerebrovascular events (MACE/MACCE) in older adults who underwent PCI.

Three databases, PubMed, Embase, and Scopus, were searched for observational studies considering the out-of-hospital MACE/MACCE in adults ≥ 60 years old with coronary artery disease (acute or chronic) who underwent PCI. Studies were eligible if they had determined at least two statistically significant predictors of MACE/MACCE by multivariable analysis. We used the QUIPS tool to evaluate the risk of bias in the studies. Random-effects meta-analysis was utilized to pool the hazard ratios (HRs) of the most reported predictors.

A total of 34 studies were included in the review. Older age (HR = 1.04, 95% Confidence Interval (CI): 1.03-1.06, P-value < 0.001), diabetes (HR = 1.36, 95% CI: 1.22-1.53, P < 0.001), history of myocardial infarction (MI) (HR = 1.88, 95% CI: 1.37-2.57, P < 0.001), ST-elevation MI (STEMI) at presentation (HR = 1.72, 95% CI: 1.37-2.18, P < 0.001), reduced left ventricular ejection fraction (LVEF) (HR = 2.01, 95% CI: 1.52-2.65, P < 0.001), successful PCI (HR = 0.35, 95% CI: 0.27-0.47, P < 0.001), eGFR (HR = 0.99, 95% CI: 0.97-1.00; P-value = 0.04) and left main coronary artery (LMCA) disease (HR = 2.07, 95% CI: 1.52-2.84, P < 0.001) were identified as predictors of MACE.

We identified older age, diabetes, history of MI, STEMI presentation, lower LVEF, and LMCA disease increased the risk of MACE/MACCE after PCI in older adults. Meanwhile, higher eGFR and successful PCI predicted lower adverse events risk. Future studies should focus on a more robust methodology and a precise definition of MACE.

PROSPERO (CRD42023480332).

The optimal surveillance strategy after percutaneous coronary intervention (PCI) for high-risk patients with multivessel or left main coronary artery disease (CAD) remains uncertain.

This study aims to determine the prognostic role of routine functional testing in patients with multivessel or left main CAD who underwent PCI.

The POST-PCI (Pragmatic Trial Comparing Symptom-Oriented Versus Routine Stress Testing in High-Risk Patients Undergoing Percutaneous Coronary Intervention) trial randomized high-risk PCI patients to routine functional testing at 1 year or standard care alone during follow-up. This analysis focused on participants with multivessel or left main CAD. The primary outcome was a composite of death from any cause, myocardial infarction, or hospitalization for unstable angina at 2 years.

Among 1,706 initially randomized patients, 1,192 patients with multivessel (n = 833) or left main (n = 359) were identified, with 589 in the functional testing group and 603 in the standard care group. Two-year incidences of primary outcome were similar between the functional testing group and the standard care group (6.2% vs 5.7%, respectively; HR: 1.09; 95% CI: 0.68-1.74; P = 0.73). This trend persisted in both groups of multivessel (6.2% vs 5.7%; HR: 1.09; 95% CI: 0.62-1.89; P = 0.78) and left main disease (6.2% vs 5.7%; HR: 1.09; 95% CI: 0.46-2.56; P = 0.85) (P for interaction = 0.90). Routine surveillance functional testing was associated with increased rates of invasive angiography and repeat revascularization beyond 1 year.

In high-risk patients with multivessel or left main CAD who underwent PCI, there was no incremental clinical benefit from routine surveillance functional-testing compared with standard care alone during follow-up. (Pragmatic Trial Comparing Symptom-Oriented Versus Routine Stress Testing in High-Risk Patients Undergoing Percutaneous Coronary Intervention [POST-PCI]; NCT03217877).

Information related to research culture in the busy catheterisation (cath) labs across the Asia-Pacific (APAC) region is sparse.

The aims of this study were to examine the variability in research culture in busy cath labs in the APAC region and to propose a roadmap for hospitals to develop in-house research capabilities in conjunction with industry and academia.

Data related to research practices in the APAC region were collected from busy cath labs (at least 250 angioplasty/year) and analysed. Results were shared with research experts to understand the challenges in institutional research and create a roadmap for hospitals to develop research capabilities.

A total of 220 respondents from 62 cath labs (88.6%) across 13 APAC countries participated in the survey. A wide variation was noted in research culture across APAC countries. Well-established infrastructure was reported in Australia, New Zealand, South Korea, Singapore, and Japan. Large multicentre trials were common in South Korea, while routine follow-ups were common in Japan. Linking medical records across hospitals/states was considered challenging. Research exposure and training were limited in the APAC region. The experts suggested a roadmap, including creating a conducive regulatory environment, forming synergistic goals, training programs for the professionals involved in research, and leveraging best practices, for improving the research culture in APAC.

Clinical research in cardiology has grown significantly in the APAC region, with a huge research potential in China and India. Implementing measures to improve research training and involvement of the industry will boost the research culture in the APAC region.

The debate on percutaneous coronary intervention (PCI) of the unprotected left main coronary artery (LMCA) has been constant over time.

To investigate the clinical and procedural characteristics and cardiovascular outcomes of PCI of unprotected LMCA.

Observational study which included patients with unprotected LMCA disease undergoing PCI; patients with cardiogenic shock prior to the procedure were excluded. We describe the clinical and angiographic characteristics, as well as the major adverse cardiac and cerebrovascular events (MACCE) according to the year of the procedure.

We included 73 patients, with a SYNTAX I score of 31.2 ± 9.1, mostly with ST-elevation acute coronary syndrome (35%). There was a higher frequency of triple vessel coronary disease (63%) and distal LMCA lesions (35%). The provisional stent technique was the most used for distal lesions (58%) and the 2-stent technique for bifurcation lesions (78%), supported by intravascular ultrasound (IVUS) in 38%. During follow-up, 19 presented MACCE (26%), out of which cardiac death occurred in 13%, non-cardiovascular death in 5%, non-fatal acute myocardial infarction in 1%, cerebrovascular event in 2%, and revascularization of the treated vessel in 4%.

It was observed a similar frequency to the one appearing in other studies of cardiovascular events, mainly in patients with intermediate risk, which supports the increasing use of percutaneous intervention in this population.

Intravascular imaging (IVI) during percutaneous coronary intervention (PCI) has been shown to improve clinical outcomes. However, data is limited in complex PCI and the adoption remains low. We aimed to conduct a meta-analysis of all available randomized controlled trials comparing IVI with conventional angiography in patients who underwent complex PCI. The primary outcomes of interest were major adverse cardiovascular events, all-cause death, cardiovascular death, myocardial infarction, stent thrombosis, target lesion revascularization and target vessel revascularization. Random-effects model was used to calculate pooled risk ratios (RRs) and 95% confidence intervals (CIs). A total of 10 randomized controlled trials comprising 6,368 patients with 3,452 in the IVI group and 2,916 in the angiography group were included. The mean duration of follow up was 2 years, mean age was 65 years and 73% of patients were men. As compared with PCI with routine angiography, the IVI-guided PCI group had significantly lower risks of major adverse cardiovascular events (RR 0.65, 95% CI 0.56 to 0.75, p <0.00001), stent thrombosis (RR 0.57, 95% CI 0.36 to 0.92, p = 0.02), cardiovascular deaths (RR 0.46, 95% CI 0.31 to 0.68, p = 0.0001), target lesion revascularization (RR 0.61, 95% CI 0.48 to 0.78, p <0.0001) and target vessel revascularization (RR 0.62, 95% CI 0.48 to 0.80, p = 0.0003). All-cause deaths and MI were similar in the 2 groups. In conclusion, among patients who underwent complex PCI, IVI reduces adverse events, importantly stent thrombosis and repeat revascularizations, compared with angiography alone guided PCI.

The present study sought to determine the rate and prognostic implications of post-procedural physiologically significant residual ischemia according to Murray law-based quantitative flow ratio (μQFR) after left main (LM) bifurcation percutaneous coronary intervention (PCI).

Consecutive patients undergoing LM bifurcation stenting at a large tertiary care center between January 2014 and December 2016 with available post-PCI μQFR were included. Physiologically significant residual ischemia was defined by post-PCI μQFR values ≤0.80 in the left anterior descending (LAD) or left circumflex artery (LCX). The primary outcome was 3-year cardiovascular death. The major secondary outcome was 3-year bifurcation-oriented composite endpoint (BOCE). Among 1170 included patients with analyzable post-PCI μQFR, 155 (13.2%) had residual ischemia in either LAD or LCX. Patients with vs. those without residual ischemia had a higher risk of 3-year cardiovascular mortality [5.4% vs. 1.3%; adjusted hazard ratio (HR) 3.20, 95% confidence interval (CI): 1.16-8.80]. The 3-year risk of BOCE was significantly higher in the residual ischemia group (17.8% vs. 5.8%; adjusted HR 2.79, 95% CI: 1.68-4.64), driven by higher incidence of the composite of cardiovascular death and target bifurcation-related myocardial infarction (14.0% vs. 3.3%; adjusted HR 4.06, 95% CI: 2.22-7.42). A significant, inverse association was observed between continuous post-PCI μQFR and the risk of clinical outcomes (per 0.1 μQFR decrease, HR of cardiovascular death 1.27, 95% CI: 1.00-1.62; HR of BOCE 1.29, 95% CI: 1.14-1.47).

After angiographically successful LM bifurcation PCI, residual ischemia assessed by μQFR was identified in 13.2% of patients and was associated with higher risk of 3-year cardiovascular death, indicating the superior prognostic value of post-PCI physiological assessment.

Stent enhancement techniques allow adequate visualization of stent deformation or incomplete stent expansion at the ostium of the side branch. Measuring the stent enhancement side branch length (SESBL) could reflect procedural success in terms of optimal stent expansion and apposition with better long-term outcomes. A longer SESBL may reflect a better stent apposition at the polygon of confluence and at the side branch (SB) ostium.

We evaluated 162 patients receiving the left main (LM) provisional one-stent technique and measured the SESBL, dividing them into two groups: SESBL≤ 2.0 mm and SESBL > 2.0 mm.

The mean SESBL was 2.0 ± 1.2 mm. More than half of the bifurcations had both main and side branch lesions (Medina 1-1-1) (84 patients, 51.9%) and the length of the SB disease was 5.2 ±1.8 mm. Kissing balloon inflation (KBI) was performed in 49 patients (30.2%). During follow-up (12 months), there was a significantly higher rate of cardiac death in the SESBL ≤ 2.0 mm group (p = 0.02) but no significant difference in all major adverse cardiovascular events (MACEs) (p = 0.7). KBI did not influence the outcomes (p = 0.3).

Suboptimal SESBL is positively correlated with worse outcomes and SB compromise. This novel sign could aid the LM operator to assess the level of stent expansion at the ostium of the SB in the absence of intracoronary imaging.

Background and Objectives: Available data with regard to the outcomes of patients with severely calcified left main (LM) lesions after revascularization by percutaneous coronary intervention (PCI) when compared to non-calcified LM lesions is unclear. Materials and Methods: The present study sought to retrospectively investigate in hospital and 1 year post-intervention outcomes of patients with extremely calcified LM lesions after PCI facilitated by calcium-dedicated devices (CdD). Seventy consecutive patients with LM PCI were included. CdD requirement was based on suboptimal results after balloon angioplasty. Results: Twenty-two patients (31.4%) required at least one CdD, while nine patients (12.8%) required at least two. Intravascular lithotripsy and rotational atherectomy were the predominantly used methods(59.1% and 40.9% respectively, for in-group ratios), while ultra-high pressure and scoring balloons contributed the least to lesion preparation (9%). In 20 patients (28.5%), severe or moderate calcifications were angiographically identified, but non-compliant balloon predilation was adequate and CdD were not necessary. Total procedural time was significantly higher in CdD group (p-value 0.02). Procedural and clinical success were obtained in 100% of cases. There were no major adverse cardiac and cerebrovascular events (MACCE) recorded during hospitalization. MACCE at 1 year post-procedure were recorded in three patients (4.2% overall). All three events were documented in the control group (6.2%), and no events were recorded in CdD group (p-value 0.23). There was one cardiac death at 10 months and two target lesion revascularizations for side-branch restenosis. Conclusions: Patients with extremely calcified LM lesions treated by PCI present a favorable prognosis if angioplasty is facilitated by more aggressive lesion debulking using calcium-dedicated devices.

Percutaneous coronary intervention (PCI) is increasingly accepted as treatment for unprotected left main coronary artery (ULMCA) disease especially in those patients who are unsuitable for cardiac surgery. Treatment of any stent failure is associated with increased complexity and worse clinical outcomes when compared with de novo lesion revascularization. Intracoronary imaging has provided new insight into mechanisms of stent failure and treatment options have developed considerably over the last decade. There is paucity of evidence on the management strategy for stent failure in the specific setting of ULMCA. Treating any left main with PCI requires careful consideration and consequently treatment of failed stents in ULMCA is complex and provides unique challenges. Consequently, we provide an overview of ULMCA stent failure, proposing a tailored algorithm to guide best management and decision in daily clinical practice, with a special focus on intracoronary imaging characterization of causal mechanisms and specific technical and procedural considerations.

Owing to a large-jeopardized myocardium, left main coronary artery disease (LMCAD) represents the substantial high-risk anatomical subset of obstructive coronary artery disease. For several decades, coronary artery bypass grafting (CABG) has been the "gold standard" treatment for LMCAD. Along with advances in CABG, percutaneous coronary intervention (PCI) has also dramatically evolved over time in conjunction with advances in the stent or device technology, adjunct pharmacotherapy, accumulated experiences, and practice changes, establishing its position as a safe, reasonable treatment option for such a complex disease. Until recently, several randomized clinical trials, meta-analyses, and observational registries comparing PCI and CABG for LMCAD have shown comparable long-term survival with tradeoffs between early and late risk-benefit of each treatment. Despite this, there are still several unmet issues for revascularization strategy and management for LMCAD. This review article summarized updated knowledge on evolution and clinical evidence on the treatment of LMCAD, with a focus on the comparison of state-of-the-art PCI with CABG.