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Temporal Trends in In-Hospital Outcomes Following Unprotected Left-Main Percutaneous Coronary Intervention: An Analysis of 14 522 Cases From British Cardiovascular Intervention Society Database 2009 to 2017

Originally publishedhttps://doi.org/10.1161/CIRCINTERVENTIONS.122.012350Circulation: Cardiovascular Interventions. 2023;16

    Abstract

    Background:

    Percutaneous coronary intervention (PCI) is increasingly used as a treatment option for unprotected left main stem artery (unprotected left main stem percutaneous intervention) disease. However, whether patient outcomes have improved over time is uncertain.

    Methods:

    Using the United Kingdom national PCI database, we studied all patients undergoing unprotected left main stem percutaneous intervention between 2009 and 2017. We excluded patients who presented with ST-segment–elevation, cardiogenic shock, and with an emergency indication for PCI.

    Results:

    Between 2009 and 2017, in the study-indicated population, 14 522 unprotected left main stem percutaneous intervention procedures were performed. Significant temporal changes in baseline demographics were observed with increasing patient age and comorbid burden. Procedural complexity increased over time, with the number of vessels treated, bifurcation PCI, number of stents used, and use of intravascular imaging and rotational atherectomy increased significantly through the study period. After adjustment for baseline differences, there were significant temporal reductions in the occurrence of peri-procedural myocardial infarction (P<0.001 for trend), in-hospital major adverse cardiac or cerebrovascular events (P<0.001 for trend), and acute procedural complications (P<0.001 for trend). In multivariable analysis examining the associates of in-hospital major adverse cardiac or cerebrovascular events, while age per year (odds ratio, 1.02 [95% CIs, 1.01–1.03]), female sex (odds ratio, 1.47 [1.19–1.82]), 3 or more stents (odds ratio, 1.67 [05% [1.02–2.67]), and patient comorbidity were associated with higher rates of in-hospital major adverse cardiac or cerebrovascular events, by contrast use of intravascular imaging (odds ratio, 0.56 [0.45–0.70]), and year of PCI (odds ratio, 0.63 [0.46–0.87]) were associated with lower rates of in-hospital major adverse cardiac or cerebrovascular events.

    Conclusions:

    Despite trends for increased patient and procedural complexity, in-hospital patient outcomes have improved after unprotected left main stem percutaneous intervention over time.

    What is Known

    • Percutaneous coronary intervention is considered a reasonable alternative to coronary artery bypass surgery for some variants of unprotected left main stem disease (unprotected left main stem percutaneous intervention).

    • Although it is recognized that unprotected left main stem percutaneous intervention is associated with higher complication rates, whether these rates have changed over time is unknown.

    What the Study Adds

    • Between 2009 and 2017, we observed a significant trend for reductions in the rate of acute procedural complications and in-hospital major adverse cardiac or cerebrovascular events in patients following unprotected left main stem percutaneous intervention.

    • These data imply that over time, improved technologies and techniques combined with greater operator experience have improved patient outcomes following unprotected left main stem percutaneous intervention.

    Percutaneous coronary intervention (PCI) is increasingly considered as a revascularisation strategy in certain anatomical and patient subsets of unprotected left main stem (uLMS) disease and is supported by the European Society of Cardiology 2018 Guidelines on myocardial revascularization and the AHA/ACC guidelines.1,2 In recent years, the landscape of PCI has changed significantly, with major advances in interventional technologies and techniques. A previous analysis of the United Kingdom National PCI Database demonstrated a temporal increase in use of intravascular imaging, and that imaging use was strongly associated with improved 12-month survival.3 Furthermore, several large randomized trials have informed interventional cardiologists as to optimal bifurcation strategies and side branch management.4–6 Finally, as uLMS-PCI procedural volumes have increased over time, the effects of operator experience may also be associated with improved patient outcomes.7 However, whether patient outcomes after uLMS-PCI have improved over time as a result of these changes is not well defined. Therefore, we used the United Kingdom National PCI Database to study temporal trends in in-hospital clinical outcomes following uLMS-PCI over a 9-year period.

    Methods

    Study Design and Participants

    We analyzed data from all patients undergoing uLMS-PCI in the United Kingdom between January 1, 2009 and December 31, 2017. We excluded patients who presented with ST-segment–elevation, cardiogenic shock, and with an emergency indication for PCI. Thus, only patients without an immediate clinical need for uLMS-PCI were included in the analysis.

    Study Setting and Sources of Data

    Data on PCI practice were obtained from the United Kingdom National PCI Audit dataset with the accuracy and quality of the British Cardiovascular Intervention Society (BCIS) dataset previously described.8,9 The study was approved by the BCIS data extraction group and by Healthcare Quality Improvement Partnership (HQIP) research ethics groups. Because of the sensitive nature of the data collected for this study, requests to access the dataset from qualified researchers trained in human subject confidentiality protocols may be sent to BCIS .

    Study Definitions

    Study definitions were used as in the BCIS National PCI Audit dataset10 (Appendix S1). Periprocedural myocardial infarction is defined in the BCIS dataset as “a rise of > 3 times the 99th percentile of the upper reference limit of a troponin biomarker. If the troponin is not stable in at least 2 samples at baseline for at least 2 samples 6 hours apart, there are insufficient data to recommend criteria for the diagnosis of reinfarction.”

    Data Analyses

    We examined the baseline characteristics of patients undergoing uLMS-PCI and tested for significance using Cochrane Armitage test for trends. Independent predictors of in-hospital major adverse cardiac or cerebrovascular events (MACCEs) after uLMS-PCI were evaluated using a multivariable logistic regression model to generate odds ratios, 95% CIs and corresponding P. To select predictors to enter into the final multivariable model, we used forward stepwise variable selection on the data and an inclusion criterion of P<0.1 (listed in Appendix S1). To correct for missing values, we imputed missing data on baseline covariates using multiple imputations with chained equations to adjust for missing data (Table S1). To evaluate if the temporal outcome trends were present after adjustment, we used a logistic regression and tested in the linear trend over time adjusted for the baseline covariates was significant or not.

    Results

    uLMS-PCI Crude Numbers and Trend in the United Kingdom 2009 to 2017

    Between 2009 and 2017, 14,522 uLMS-PCI procedures were performed in the study indicated population. During the study period, annual uLMS-PCI volumes increased (Figure 1) and represented an increasing percentage of each yearly total PCI, rising from 1.8% of total PCI in 2009 and 3.4% in 2017 (Figure 2, right panel).

    Figure 1.

    Figure 1. Trends of unprotected left main stem percutaneous intervention (uLMS-PCI) in the United Kingdom 2009 to 2017. Left, change in total numbers of percutaneous intervention (PCI) in the study population (ST-segment–elevation myocardial infarction, emergency non–ST-segment–elevation myocardial infarction, and cardiogenic shock excluded) in light blue bars and uLMS-PCI in dark over time. Right, percentage of total-PCI represented by uLMS-PCI over time.

    Figure 2.

    Figure 2. Acute procedural complications during unprotected left main stem percutaneous intervention (uLMS-PCI) in the United Kingdom 2009 to 2017. Panels indicate serial changes in coronary dissection (P<0.001 for trend), shock induction by percutaneous intervention (nonsignificant trend), occurrence of slow flow (P=0.02 for trend), loss of a major side branch (nonsignificant trend), and all acute coronary complications combined including coronary perforation, ventilation required, and direct current cardioversion required (P<0.001 for trend).

    Patient and Procedural Characteristics Undergoing uLMS-PCI in the United Kingdom 2009 to 2017

    Significant changes were observed in patient age, female sex, and other comorbidity including diabetes, concomitant valvular heart disease, and number of diseased vessels over time (Table 1). There were also changes in the complexity of the uLMS-PCI procedure over time (Table 2). The number of vessels treated, LMS-PCI involving the left anterior descending and circumflex, number of stents used, and use of tools such as intravascular imaging and rotational atherectomy all increased significantly through the study period. Use of glycoprotein inhibitors, left ventricle support, and femoral access decreased significantly over time (Table 2).

    Table 1. Baseline Characteristics of Patients Undergoing uLMS-PCI by Procedure Year in the United Kingdom 2009–2017

    Variable2009 (n=1089)2010 (n=1091)2011 (n=1259)2012 (n=1453)2013 (n=1474)2014 (n=1625)2015 (n=1757)2016 (n=2122)2017 (n=2652)P value
    Age, y; ±SD70.7±12.271.3±12.171.3±11.572.3±11.671.8±11.671.6±12.071.6±11.871.7±11.671.6±11.90.002
    Female sex, no. (%)361 (33.1)350 (32.1)373 (29.7)459 (31.6)428 (29.1)451 (27.8)502 (28.6)622 (29.3)780 (29.4)0.006
    Body mass index, ±SD27.6±5.728.0±5.628.5±5.628.0±5.627.9±5.628.0±5.528.0±5.528.0±5.328.1±5.70.685
    Hypertension, no. (%)701 (64.7)722 (66.5)818 (65.6)1007 (70.0)963 (66.8)1088 (67.8)1107 (66.2)1412 (67.1)1724 (67.3)0.389
    Diabetes, no. (%)237 (22.0)224 (21.0)293 (23.8)330 (23.4)376 (25.9)446 (27.7)451 (26.0)583 (27.9)737 (28.4)<0.001
    Previous MI, no. (%)339 (35.5)368 (37.2)461 (39.1)515 (37.8)531 (36.8)592 (37.2)618 (35.9)707 (34.0)901 (34.7)0.008
    Previous CVA/PVD, no. (%)179 (16.5)176 (16.2)240 (19.2)258 (17.9)233 (16.2)242 (15.1)254 (15.2)290 (13.8)418 (16.3)0.134
    Chronic kidney disease, no. (%)63 (5.9)78 (7.3)68 (5.5)108 (7.9)94 (6.6)108 (6.8)126 (7.3)104 (5.0)131 (5.1)0.019
    Valvular heart disease, no. (%)32 (2.9)42 (3.9)44 (3.5)60 (4.2)67 (4.6)69 (4.3)84 (5.0)130 (6.2)181 (7.1)<0.001
    Potent DAPT, no. (%)0 (0)7 (0.6)20 (1.6)73 (5.0)192 (13.1)309 (19.2)400 (22.8)575 (27.1)796 (30.1)<0.001
    Previous PCI, no. (%)274 (25.2)288 (26.6)355 (28.4)369 (25.6)460 (31.2)505 (31.3)572 (32.9)693 (32.9)842 (32.2)0.003
    ACS presentation, no. (%)544 (49.9)604 (55.3)681 (54.1)773 (53.2)792 (53.7)897 (55.2)1001 (57.0)1147 (54.1)1444 (54.5)<0.001
    Ejection fraction (%), ±SD48.0 (11.6)47.7 (11.8)47.3 (12.2)46.6 (12.5)46.5 (12.8)47.2 (12.1)47.2 (12.4)46.8 (12.7)47.8 (11.9)0.271
    Ejection fraction <30%, no. (%)70 (9.6)70 (9.9)97 (11.1)129 (13.2)139 (13.2)111 (10.2)133 (11.8)166 (12.1)18.3 (10.8)0.530
    No. of diseased vessels ±SD1.86±0.951.99±0.971.99±1.002.07±0.982.05±0.982.06±0.972.08±0.982.05±0.962.12±1.00<0.001

    ACS indicates acute coronary syndrome; CVA, cerebrovascular disease; DAPT, dual antiplatelet therapy; MI, myocardial infarction; PCI, percutaneous coronary intervention; PVD, peripheral vascular disease; and uLMS-PCI, unprotected left main stem percutaneous intervention.

    Table 2. Procedural Variables of Patients Undergoing uLMS-PCI by Procedure Year in the United Kingdom 2009–2017

    Variable2009 (n=1090)2010 (n=1091)2011 (n=1259)2012 (n=1453)2013 (n=1474)2014 (n=1625)2015 (n=1757)2016 (n=2122)2017 (n=2652)P value trend
    No. of vessels attempted, ±SD1.99±0.792.02±0.802.04±0.802.08±0.812.11±0.792.08±0.782.13±0.792.11±0.792.17±0.79<0.001
    Bifurcation intervention, no. (%)251 (23.0)252 (23.1)292 (23.2)359 (24.7)403 (27.3)412 (25.3)480 (27.3)564 (26.6)754 (28.4)<0.001
    CTO attempted, no. (%)60 (6.0)55 (5.3)63 (5.3)69 (5.0)88 (6.2)79 (5.0)102 (6.0)93 (4.6)141 (5.6)0.715
    Restenosis, no. (%)101 (9.9)68 (6.3)88 (7.2)90 (6.3)117 (8.2)115 (7.3)108 (6.3)161 (7.9)218 (8.7)0.253
    No. of stents used, ±SD2.06±1.452.11±1.392.15±1.422.20±1.442.21±1.522.16±1.422.20±1.382.18±1.392.30±1.40<0.001
    1 stent used, no. (%)369 (34.2)373 (34.5)425 (34.0)468 (32.5)464 (31.8)517 (32.1)552 (31.7)641 (30.5)750 (28.4)<0.001
    2+ stents used, no. (%).710 (65.8)701 (65.5)825 (66.0)972 (67.5)996 (68.2)1093 (67.9)1188 (68.3)1466 (69.5)1890 (71.6)<0.001
    GPI used, no. (%)239 (24.1)225 (21.9)204 (17.5)209 (15.0)163 (11.8)152 (9.9)138 (8.2)125 (6.3)152 (6.3)<0.001
    Intravascular imaging used, no. (%)417 (40.4)467 (44.6)573 (47.6)654 (46.5)698 (49.5)786 (48.3)920 (52.8)1088 (54.7)1403 (58.6)<0.001
    Rotational atherectomy, no. (%)81 (8.1)75 (7.3)115 (9.8)151 (11.0)170 (12.1)203 (12.8)184 (10.8)261 (12.7)310 (14.4)<0.001
    Laser, no. (%)2 (0.2)7 (0.7)7 (0.6)5 (0.3)10 (0.7)7 (0.4)4 (0.2)6 (0.3)4 (0.2)0.823
    Cutting balloon, no. (%)58 (5.8)62 (6.1)67 (5.7)75 (5.5)107 (7.7)105 (6.6)112 (6.6)173 (8.4)180 (8.3)<0.001
    Microcatheter, no. (%)1 (0.1)6 (0.6)19 (1.6)36 (2.6)51 (3.7)63 (4.0)109 (6.4)133 (6.5)173 (8.0)<0.001
    Mechanical LV support use, no. (%)58 (5.7)50 (4.8)57 (4.7)66 (4.7)54 (3.8)49 (3.1)53 (3.1)36 (1.8)56 (2.2)<0.001
    Femoral access, no. (%)691 (64.2)623 (58.1)699 (56.4)667 (46.3)654 (44.9)625 (38.8)560 (32.2)559 (26.8)629 (24.1)<0.0001
    Dual access, no. (%)78 (7.2)61 (5.7)85 (6.9)115 (8.0)67 (7.5)102 (6.3)137 (7.9)151 (7.2)226 (8.7)0.0216

    CTO indicates chronic total occlusion; GPI, glycoprotein inhibitor; LV, left ventricular; and uLMS-PCI, unprotected left main stem percutaneous intervention.

    Clinical and Procedural Outcomes After uLMS- in the United Kingdom 2009 to 2017

    The crude unadjusted outcomes after uLMS-PCI by procedure year are presented in Table 3 and Figure 2. The adjusted annual rate of clinical outcomes indexed to the first year of study (2009) are presented in Figure 3 and illustrate significant temporal reductions in the occurrence of periprocedural myocardial infarction (P<0.001 for trend), in-hospital MACCE (P<0.001 for trend), and acute procedural complication (P<0.001 for trend). The odds ratios for in-hospital major bleeding and in-hospital death did not change significantly over time. Subgroup analyses for in-hospital MACCE by sex (male versus female, P for interaction=0.735) and clinical presentation (acute coronary syndrome versus stable angina P for interaction=0.979) do not differ significantly from the main study findings (Tables S2 and S3).

    Table 3. Crude Unadjusted Outcomes After uLMS-PCI by Procedure Year in the United Kingdom 2009–2017

    Variable2009 (n=1090)2010 (n=1091)2011 (n=1259)2012 (n=1453)2013 (n=1474)2014 (n=1625)2015 (n=1757)2016 (n=2122)2017 (n=2652)P value trend
    Acute procedural outcomes
    No. successful lesions, ±SD2.03±1.161.94±1.041.98±1.062.00±1.042.03±1.092.00±1.062.07±1.092.02±1.042.13±1.10<0.001
    Major side branch loss, no. (%)13 (1.4)9 (0.9)13 (1.1)19 (1.4)15 (1.1)18 (1.1)21 (1.2)18 (0.9)27 (1.0)0.469
    Coronary dissection, no. (%)59 (6.2)59 (6.1)75 (6.5)66 (4.9)71 (5.1)52 (3.3)71 (4.2)63 (3.1)81 (3.1)<0.001
    Coronary perforation, no. (%)5 (0.5)14 (1.4)9 (0.8)15 (1.1)12 (0.9)8 (0.5)14 (0.8)20 (1.0)18 (0.7)0.469
    Slow flow, no. (%)5 (0.5)7 (0.7)11 (1.0)13 (1.0)14 (1.0)7 (0.5)10 (0.6)8 (0.4)10 (0.4)0.022
    Shock induction, no. (%)3 (0.3)7 (0.7)10 (0.9)8 (0.6)11 (0.8)11 (0.7)14 (0.8)11 (0.5)15 (0.6)0.948
    Any complication, no. (%)86 (9.0)83 (8.5)107 (9.3)107 (7.9)117 (8.5)83 (5.3)117 (6.9)111 (5.3)144 (5.4)<0.001
    Clinical outcomes
    Periprocedural MI, no. (%)34 (3.1)23 (2.1)15 (1.2)10 (0.6)18 (1.2)9 (0.6)11 (0.6)6 (0.3)9 (0.3)<0.001
    Periprocedural CVA, no. (%)1 (0.1)1 (0.1)1 (0.1)2 (0.1)1 (0.1)0 (0)0 (0)5 (0.2)5 (0.2)0.220
    Transfusion, no. (%)8 (0.7)8 (0.7)7 (0.6)9 (0.6)8 (0.5)10 (0.6)12 (0.7)11 (0.5)5 (0.2)0.036
    Access site complication, no. (%)21 (2.1)22 (2.1)23 (1.9)29 (2.0)27 (1.9)30 (1.9)51 (3.0)49 (2.4)25 (1.0)0.2631
    Emergency PCI/CABG, no. (%)2 (0.2)7 (0.6)8 (0.6)8 (0.6)4 (0.3)3 (0.2)10 (0.6)5 (0.2)7 (0.3)0.539
    Acute kidney injury, no. (%)5 (0.5)7 (0.6)5 (0.4)8 (0.6)4 (0.3)3 (0.2)5 (0.3)2 (0.1)2 (0.1)<0.001
    In-patient mortality, no. (%)22 (2.0)20 (1.8)28 (2.2)28 (1.9)29 (2.0)34 (2.1)40 (2.2)40 (1.9)43 (1.7)0.510
    In-patient MACCE, no. (%)55 (5.0)33 (3.0)38 (3.0)38 (2.6)47 (3.2)43 (2.6)49 (2.8)48 (2.3)56 (2.1)<0.001
    In-patient major bleed, no. (%)17 (2.0)18 (1.6)14 (1.1)25 (1.7)15 (1.0)24 (1.5)27 (1.5)25 (1.1)25 (0.9)0.095

    CABG indicates coronary artery bypass surgery; CVA, cerebrovascular accident; MACCE, major adverse cardiovascular event; MI, myocardial infarction; PCI, percutaneous coronary intervention; and uLMS-PCI, unprotected left main stem percutaneous intervention.

    Figure 3.

    Figure 3. Clinical outcomes following unprotected left main stem percutaneous intervention (uLMS-PCI) in the United Kingdom 2009 to 2017. Panels indicate annual odds ratios indexed to 2009 for clinical outcomes including periprocedural myocardial infarction (MI; P<0.001 for trend), in-hospital death (non-significant trend), in-hospital major adverse cardiovascular events (MACCEs; P<0.001 for trend), in-hospital major bleeding (non-significant trend), and acute coronary complications (P<0.001 for trend).

    In multivariable adjusted modeling examining the associates of in-hospital MACCE, age per year, female sex, peripheral vascular disease, 3 or more stents used, chronic kidney disease, ejection fraction and use of left ventricle support were associated with higher rates of in-hospital MACCE (Figure 4). Use of intravascular imaging and year of PCI were associated with lower rates of in-hospital MACCE. Although there was a trend for potent DAPT to be associated with lower MACCE, this did not reach statistical significance (OR, 0.82 [95% CI, 0.83–1.07]).

    Figure 4.

    Figure 4. Associates of in-hospital major adverse cardiovascular events (MACCEs). Multivariate-adjusted model for in-hospital outcomes following left main stem percutaneous intervention (LMS-PCI) in the United Kingdom 2009 to 2017 (significant factors highlighted in red, nonsignificant highlighted in black). CTO indicates chronic total occlusion; DAPT, dual antiplatelet therapy; MI, myocardial infarction; PCI, percutaneous coronary intervention; and PVD, peripheral vascular disease.

    Discussion

    Although there are many studies comparing uLMS-PCI and coronary artery bypass surgery, there are limited data on the temporal changes in patient outcomes after uLMS-PCI, and in particular, in the CHIP population. Previously published series of outcomes after uLMS-PCI have limitations including that they examine other aspects of the interventional procedure such as access site or imaging, are non-contemporary, do not provide data on temporal trends in patient outcomes, or study only relatively short historical time-frames.11–15 Two previously published larger scale studies have findings consistent with the current study. The IRIS-MAIN registry observed a reduction in MACCE rates after uLMS-PCI over time whilst.16 Similarly, in an analysis of 4085 uLMS-PCI cases from the Swedish Coronary Angiography and Angioplasty Registry (2005–2017), the 3-year major adverse cardiovascular and cerebrovascular event fell from 45.6% to 23.9% over the study period.17 However, the current study is much larger than any other previous study of uLMS-PCI outcome trends, reports procedures from a more contemporary time frame, and is the first analysis of uLMS-PCI outcomes in the “CHIP-indicated” population. The exclusion of patients with an emergency indication is important as a non-selected study population outcomes are likely to be heavily skewed by high event rates in the small subset of emergency patients.

    In considering the mechanisms of the observed improved patient outcomes, there may be several plausible explanations underpinning the improved in-hospital outcomes following uLMS-PCI over time. Previous studies have demonstrated that in the majority of cases, disease involving the left main artery extends into its distal bifurcation.18 Many of the technical issues, such as accessing the circumflex, have largely been overcome by the advent of technologies such as angled microcatheters and techniques including dual lumen catheter wiring.19 Emerging data on optimal interventional strategies to address bifurcation disease may also contribute to improved outcomes after uLMS-PCI over time. As with other studies of non-LMS PCI—including the Nordic Bifurcation Study and the British Bifurcation Coronary Study—data on uLMS-PCI suggest that where possible, a provisional stepwise stent strategy is at least as good as a planned 2-stent strategy in patients with bifurcation LMS disease.6,20 Where a 2-stent approach is considered necessary, a greater understanding of optimal planned bifurcation strategies derived from several randomized comparisons of bifurcation techniques such as the double kissing (DK)-crush technique and proximal stent optimization may also underpin some of the improved outcomes observed.21,22 Although in the current study, we observed an increase in the number of stents used over time, and an increased MACCE rate in cases where 3 or more stents were used, as this is observational data, the contribution of baseline disease likely confounds any association between the number of stents used and clinical outcomes. Additionally, an increase in the use of intravascular ultrasound imaging over time may improve outcomes driven by enhanced lesion coverage, optimal stent expansion, and appropriate stent sizing and apposition.3,23 Similarly, radial arterial access has previously been shown to be associated with improved outcomes after uLMS-PCI.12 The increase in operator volume and experience is likely to be a major factor in improving patient outcomes after uLMS-PCI. A previous study of the UK national PCI database demonstrated improved patient outcomes with higher operator uLMS-PCI volumes, a volume-outcome effect not seen with PCI in general.7 A similar association between higher uLMS-PCI operator volumes and improved patient outcomes was observed in a study of patients treated in a high-volume Chinese centre.24 Finally, increases in more potent DAPT may be another explanation for improvements in outcomes over time. Although we observed a trend for lower MACCE rates when potent DAPT was used, this did not reach statistical significance, perhaps because of a lack of statistical power given the relatively infrequent use of potent DAPT until latter study years.

    In considering the limitations of the present study, statistical methodology issues are discussed in the Appendix S1. The measurement of post-procedure troponin evaluation is left up to the discretion of the individual operator and center and thus there is likely to be variation in its measurement between centres. However, there has been no temporal change in the reporting of troponin values (97.7% field completion in 2009 versus 98.3% in 2017, P=NS) implying that the data are not confounded by reporting bias over time. Additionally, the observation of a reduced periprocedural myocardial infarction over the study period is consistent with a lower rate of acute procedural complications and thus appears to be underpinned by biological plausibility. In addition, the BCIS database does not capture details of anatomical data such as the location of disease with the LMS, complexity of lesions such as calcification or the presence, or type of distal LMS bifurcation disease. Therefore, we cannot provide detailed data on the relationship to the pattern of disease and outcomes over time, or indeed on the exact technical approach used to treat the LMS disease.

    Conclusions

    In patients undergoing uLMS-PCI, there were significant temporal changes in baseline demographics with increasing patient age and comorbid burden observed over time. Additionally, uLMS-PCI procedural complexity increased over time, with the number of vessels treated, LMS-PCI involving the left anterior descending and circumflex, number of stents used, use of intravascular imaging and rotational atherectomy all increasing significantly through the study period. Despite increases in patient and procedural complexity, the adjusted annual rates of peri-procedural myocardial infarction, in-hospital MACCE, and acute procedural complication declined significantly over time. These data help inform procedural planning, patient choice and consent, and Heart Team discussions.

    Article Information

    Supplemental Material

    Supplemental Methods

    Tables S1–S3

    Reference 25

    Nonstandard Abbreviations and Acronyms

    BCIS

    British Cardiovascular Intervention Society

    LMS

    left main stem

    MACCE

    major adverse cardiac or cerebrovascular event

    PCI

    percutaneous coronary intervention

    uLMS-PCI

    unprotected left main stem percutaneous intervention

    Disclosures None.

    Footnotes

    This manuscript was sent to Michael P. Savage, Guest Editor, for review by expert referees, editorial decision, and final disposition.

    Supplemental Material is available at https://www.ahajournals.org/doi/suppl/10.1161/CIRCINTERVENTIONS.122.012350.

    Correspondence to: Tim Kinnaird, MD, Department of Cardiology, University Hospital of Wales, Cardiff, United Kingdom. Email

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