World Journal of Cardiovascular Diseases, 2013, 3, 419-427 WJCD Published Online October 2013 (
Percutaneous treatment of de novo unprotected left main
stenosis in unselected consecutive patients: Experience of a
high volume center
Elisabetta Varani, Sabine Vecchio, Matteo Aquilina, Giuseppe Vecchi, Marco Balducelli,
Valeria Frassineti, Massimo Margheri
Department of Cardiology, S. Maria delle Croci Hospital, Ravenna, Italy
Received 25 July 2013; revised 25 August 2013; accepted 12 September 2013
Copyright © 2013 Elisabetta Varani et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Background: Percutaneous coronary intervention
(PCI) has been increasingly employed to treat unpro-
tected left main (ULM) stenosis, with hard endpoints
similar to by-pass surgery, in patients selected by a
Heart Team. Methods: From January 2008 to De-
cember 2011, 317 unselected and consecutive patients
with de novo ULM stenosis underwent PCI with both
bare metal (BMS) and drug-eluting (DES) stents.
Major adverse cardiovascular events, target lesion
(TLR) and vessel (TVR) revascularization were eva-
luated over a mean period of 590 ± 371 days. Results:
Our population was characterized by a mean age 72 ±
10 years, high rate of acute coronar y syndrome (ACS )
(either with ST or non-ST elevation myocardial in-
farction, 15.5% and 35% respectively), severe co-
morbidity 16%, mean Euroscore 7 ± 3, mean Syntax
Score 25 ± 9. In-hospital mortality was 6%. During
the follow-up period, all-cause mortality was 16.7%,
falling to 7% at the end of the follow-up, excluding
patien ts pr esent ing with ACS . TLR wa s obser ved a nd
treated in 15% of patients. BMS utilization, age >75
years, ACS indication, Syntax Score >32 and associ-
ated peripheral artery disease were independent pre-
dictors of mortality at multivariate analysis. Conclu-
sions: Stenting of ULM stenosis appears to be associ-
ated with a favorable mid-term outcome, even in an
unselected population.
Keywords: Unprotected Left Main; Percutaneous
Coronary Intervention
Unprotected left main (ULM) percutaneous coronary
intervention (PCI) has recently become a valid alterna-
tive to coronary artery bypass graft (CABG) showing
similar mid-term results for hard endpoints (death and
myocardial infarction) even if still penalized by a higher
rate of repeated revascularization in the drug-eluting
stent (DES) era.
Four randomized studies [1-4], 1 metanalysis [5], and
several mono and multicentre registries [6-15] support
these conclusions and 2010 ESC/EACT guidelines on
myocardial revascularization have recognized a class IIa
or IIb level of indication for ULM PCI [16] and probably
they will be updated to a level of evidence A. In the
metanalysis of Capodanno [5], where 1611 patients from
4 randomized clinical trials were evaluated, there were
no significant differences between PCI and CABG in 1-
year death (PCI 3.0% vs CABG 4.1%, p = 0.29) or myo-
cardial infarction (2.8% vs 2.9%, p = 0.95), with in-
creased target vessel revascularization (11.4% vs 5.4%, p
< 0.001) and less frequent stroke (0.1% vs 1.7%, p =
0.013) in PCI group.
A potentially higher procedural risk due to the fre-
quent involvement of the bifurcation with the majority of
myocardium being jeopardized has been balanced by the
relative easiness of ULM PCI due to the vessel shortness
and big dimensions. DES development and diffusion, the
experience gained by intravascular ultrasound (IVUS)
use, the benefits of post-dilation and kissing techniques
and the protection given by a prolonged dual antiplatelet
therapy have all led to the growth and diffusion of this
The purpose of the present paper is to report the ULM
PCI results of a single centre without on-site cardiac
surgery, in consecutive “all comers” patients from 2008
until 2011. In all patients with de novo ULM lesions, PCI
option was evaluated by clinical and interventional car-
E. Varani et al. / World Journal of Cardiovascular Diseases 3 (2013) 419-427
diologists, and preferred over CABG, whenever a com-
plete or at least a functionally complete revascularization
was feasible or in presence of a high surgical risk deter-
mined by comorbidities.
2.1. Clinical Procedure
All consecutive unselected patients treated with PCI for
de novo lesions of ULM from 1.1.2008 to 31.12.2011 in
our catheterization laboratory (CL) were collected in this
Our laboratory is a province based CL in a region with
almost 400.000 inhabitants and 3 hospitals (1 hub and 2
spoke centres), with a yearly volume of more than 2000
total procedures and 1300 - 1400 PCI, resulting the high-
est volume CL in the Emilia-Romagna Region and one
of the most productive in Italy.
All clinical, angiographic and procedural data, hospital
discharge and clinical follow-up data were recorded in a
retrospective/prospective database. Data relative to the
clinical conditions of the last available follow-up were
collected by means of clinical examinations, telephone
interviews or from civil registries.
All patients gave written informed consent to the pro-
cedure after full discussion of the risk/benefit profile of
PCI and of the surgical alternative.
Indication and timing of the procedure (one stage or
subsequent steps in case of multivessel coronary disease)
were evaluated by an expert team (at least 2 expert
interventional and one clinical cardiologists), while all
procedural techniques (arterial access, provisional/in-
tended two stents, type of stent, intra-aortic balloon
pump (IABP), IVUS, etc.) were left to the discretion of
the first operator with a strong recommendation for sec-
ond generation DES utilization.
All patients were pre-treated with aspirin and clopido-
grel (at least 300 mg in the previous 24 hours and 75 mg
the morning of the procedure). They also received aspirin
100 mg daily indefinitely and clopidogrel 75 mg daily
for at least 12 months post-procedure.
Angiographic follow-up 7 ± 1 months after PCI was
strongly recommended and it was performed whenever
2.2. Definitions
Cardiac death: all deaths due to cardiac causes (ischemic
and non ischemic), or all deaths without a known cause.
Vascular death: all deaths due to cerebral or peripheral
artery disease.
Post procedural non Q myocardial infarction (MI):
CKMB elevation >3 times upper normal level (UNL),
without clinical or electrocardiographic (ECG) signs of
Spontaneous MI: every post-discharge elevation of
CKMB or troponin above UNL associated with clinical
or ECG signs of ischemia.
Target Lesion Revascularization (TLR): every new
target lesion (left main) revascularization comprehensive
of the 5 mm pre and post target (also left anterior de-
scendent artery and circumflex artery ostia).
Target Vessel Revascularization (TVR): every new in-
dex target vessel/s revascularization also outside the tar-
get lesion.
Major vascular complications: every ischemic or he-
morrhagic in-hospital complications requiring surgery or
Euroscore: 30 days death risk was stratified according
to the additive Euroscore, evaluating clinical, cardiac and
surgical parameters [17].
Syntax Score: anatomic complexity of the patients was
evaluated with the Syntax Score algorithm, which is
available on the SYNTAX Score Website
(www.syn [18].
Complete revascularization: left main (LM) PCI and
of every >70% stenosis of major epicardial coronary
Functionally complete revascularization: LM PCI and
of every >70% stenosis of major epicardial vessels with a
vital/ischemic bed.
Stent thrombosis (ST): defined on the basis of Aca-
demic Research Consortium criteria [19], as definite in
case of angiographic or pathologic confirmation of ST,
probable in case of any unexplained death within 30 days
or target vessel myocardial infarction without angiogra-
phic confirmation, and possible ST defined as unex-
plained death after 30 days.
2.3. Statistical Analysis
Statistical analysis was performed with SAS statistical
package. All continuous variables were expressed as
mean ± SD and categorical variables as percentages.
Comparison between groups was performed using
chi-square test for categorical variables and the unpaired
Student’s T test for continuous data. A two-side p value <
0.05 was considered statistically significant.
Logistic regression analysis was performed to identify
independent predictors of mortality, adjusted for baseline
confounding characteristics that were identified on the
basis of univariate analysis.
The odds ratios (OR) and 95% confidence intervals
(CI) were reported with two tailed probability values.
From the beginning of 2008 until the end of 2011, 383
LM PCI were performed in our CL; excluding 35 proce-
dures of protected LM and 31 procedures for in-stent LM
Copyright © 2013 SciRes. OPEN ACCESS
E. Varani et al. / World Journal of Cardiovascular Diseases 3 (2013) 419-427
Copyright © 2013 SciRes.
238 (75%)
restenosis, 317 were procedures on de novo ULM and
were considered for this analysis.
3.1. Clinical Characteristics
Clinical characteristics of treated patients are described
in Table 1.
Mean age was 72.6 years, with 49.5% of patients aged
75 years and 27% aged 80 years.
The unselected and consecutive population is com-
posed by 201 patients with acute coronary symdrome
(ACS) (63%); 49 of whom (15.5% of total) with ST ele-
vation myocardial infarction (STEMI) and 22 (7%) pre-
senting with cardiogenic shock.
Fifty patients (16%) presented severe comorbidity (39
neoplasia, 7 severe valvular disease, 2 dialysis, 2 severe
cognitive deterioration), various degrees of associated
peripheral artery disease (PAD) (cerebral or at the legs
level) was seen in 56% of patients, mean left ventricle
ejection fraction (LVEF) was 50% ± 11% and 40% in
20% of patients; mean additive Euroscore was 7 ± 3
(range 0 - 17).
3.2. Angiographic Characteristics
Angiographic characteristics of the population are sum-
marized in Table 2.
LM disease was associated with multivessel coronary
artery disease in more than 87% of patients, and in 28%
of cases there was a chronic total occlusion (CTO), in 54
patients (17%) of the right coronary artery.
Syntax Score was calculated in 311 patients; it was
22 in 125, between 23 and 32 in 120, and >32 in 66
patients. LM stenosis was distal in 75% of cases, with
bifurcation involvement in 227 patients (72%).
Procedural characteristics are summarized in Tab le 3.
LM PCI was “ad hoc” in 54% of cases, with femoral
access in 81% and with stent implantation in 99%, bare
metal stents (BMS) 16%, DES 84%, first generation in
15 patients and second generation (mainly Xience and
Biomatrix) in 249 patients. Isolated LM PCI was per-
formed in 80 patients, LM and other vessel/s PCI in 237
in a unique or staged procedure; in 21 patients also an
associated CTO was tempted. Mean number of implanted
stents was 2.6 ± 1.5 per patient (range 0 - 10). Revascu-
larization was complete in 177 patients (56%).
Bifurcation LM lesions were treated as follows: provi-
sional stenting strategy was adopted in 183 patients, a
two stent strategy in 41 (18%), with a minicrush tech-
nique in 20, T-stenting in 15, and V-stenting in 6 patients.
Final kissing-balloon was performed in 92% of cases.
Table 1. Clinical characteristics of 317 patients treated with PCI for de novo unprotected left main lesions.
Age 72 ± 10 (39 - 92); 157 (49.5%) 75 y; 86 (27%) 80 y
Indication to PCI STEMI 49 (15.5%)
NSTEMI 111 (35%)
Unstable angina 41 (14%)
Stable ischemic heart disease 116 (37%)
Hypertension 229 (72%)
Diabetes mellitus 89 (28%)
Hypercholesterolemia 234 (74%)
Smoking 161 (51%)
Chronic obstructive pulmonary disease 31 (10%)
Peripheral artery disease 178 (56%)
Previous myocardial infarction 77 (24%)
Chronic kidney disease (creatinine >2 mg/dl) 22 (7%)
Severe comorbidity 50 (16%)
Cardiogenic shock 22 (7%)
Left ventricle ejection fraction 50 ± 11; 35% 42 (13%)
Euroscore 7 ± 3
STEMI = non-ST elevation myocardial infarction; PCI = percutaneous coronary intervention; STEMI = ST elevation myocardial infarction.
E. Varani et al. / World Journal of Cardiovascular Diseases 3 (2013) 419-427
Table 2. Angiographic characteristics of the studied population.
Coronary disease
LM alone 39 (12%)
LM + 1 vessel 83 (26%)
LM + 2 vessels 102 (32%)
LM + 3 vessels 93 (29%)
Associated CTO 89 (28%)
RCA CTO 54 (17%)
Syntax score 25 ± 9
< 22 125 (40%)
22-32 120 (38.5%)
>32 66 (21%)
Left main
Ostial 61 (19.2%)
Body 17 (5.4%)
Distal 239 (75.4%)
Calcium 79 (25%)
Thrombus 15 (5%)
CTO = chronic total occlusion; LM = left main; RCA = right coronary
3.3. In-Hospital Events
There were 20 in-hospital deaths (6%), of which 16 (5%)
were cardiac deaths, 24 (7.5%) post-procedural non Q
MI, 7 urgent repeated PCI (2.2%); 5 of these were per-
formed for residual dissection (1 of LM, 3 of circumflex
artery, and 1 of left anterior descendent artery) and 2 for
sub-acute ST of left anterior descendent artery (LAD) (in
a patient after urgent intestinal resection). Furthermore, 1
patient presented a hemorrhagic stroke, and 10 (3%)
major ischemic or hemorrhagic vascular complications.
3.4. Follow-Up
Two hundred ninety seven patients were discharged alive;
they were given statin therapy in 77%, beta-blocker in
67.5%, and ACE-inhibitor in 59% of cases; moreover 23
(7%) of them were on oral anticoagulant therapy (war-
farin) together with aspirin 100 mg and clopidogrel 75
mg daily.
Mean duration of clinical follow-up was 590 ± 371
days (range 23 - 1516) median of 525 days (i.q. 25 - 75:
281 - 881 days).
One hundred and ninety patients (64%) had an an-
giographic follow-up, routinely performed in 138 and
clinically driven in 52 patients.
Table 4 depicts clinical events at follow-up.
Total mortality was 16.7%, cardiac mortality was 10%
(7.9% at 1 year); excluding patients with ACS (either
Table 3. Procedural characteristics.
Ad hoc PCI 172 (54%)
Femoral vascular access 257 (81%)
Debulking 17 (5%)
IVUS 44 (14%)
IABP 61 (19%)
GP IIb/IIIa inhibitors 33 (10%)
Stent 314 (99%)
BMS 50 (16%)
DES 264 (84%)
Biforcation technic
Provisional stenting 183
2 stents 41 (18%)
Final kissing 209/227 (92%)
Stent postdilatation 254 (80%)
Treated lesions
LM alone 80 (25%)
LM + 1 vessel 120 (38%)
LM + 2 vessels 90 (28%)
LM + 3 vessels 27 (8.5%)
CTO 21
Total stents/patient 2.6 ± 1.5 (0 - 10)
Complete revascularization 177 (56%)
BMS = bare metal stent; CTO = chronic total occlusion; DES = drug eluting
stent; GP = glicoprotein; IABP = intra-aortic balloon pump; IVUS =
intravascular ultrasound; LM = left main; PCI = percutaneous coronary
intervention; POBA = plein old balloon angioplasty.
with ST or non ST elevation myocardial infarction) as
indication for the index procedure, total mortality falls to
3.8% at 1 year and 7% at the end of follow-up.
Among cardiac deaths, 4 were undetermined possibly
due to ST: 1 at 185 days in a patient with moderate to
severe mitral regurgitation, 1 at 417 days, 1 at 487 days
after a red blood cells transfusion for acute anemia and 1
at 231 days for a documented ventricular fibrillation,
while no cases of definite ST were documented an-
giographically or anatomically.
A repeated revascularization procedure for a LM le-
sion was necessary in 15% of cases (47/48 cases were
treated with a repeated PCI and only one case with
CABG), in 13 patients this was due to a LM edge
restenosis, in 16 to a distal LM or LAD and circumflex
artery ostial lesion, in 17 to an isolated circumflex ostial
Copyright © 2013 SciRes. OPEN ACCESS
E. Varani et al. / World Journal of Cardiovascular Diseases 3 (2013) 419-427 423
Table 4. Clinical events at follow up.
12 months At follow-up (median 525 days)
Total death 41 (12.9%) 53 (16.7%)
Cardiac death 25 (7.9%) 31 (10%)
Vascular death 7 (2.2%) 8 (2.5%)
Other causes death 9 (2.8%) 14 (4.4%)
Total death excluding patients with STEMI 30/268 (11%) 40/268 (14.9%)
Total death excluding patients with STEMI/NSTEMI 6/157 (3.8%) 11/157 (7%)
Myocardial infarction (all NSTEMI) 18 (5.7%) 20 (6.3%)
LM TLR 43 (13.6%) 48 (15%)
Other vessel TVR 35 (11%) 42 (13.2%)
De novo lesion PCI 29 (9.1%) 41 (12.9%)
Stroke 2 (0.6%) 3 (0.9%)
Definite stent thrombosis 0 0
Possible stent thrombosi 2 (0.6%) 4 (1.2%)
LM = left main; NSTEMI = Non ST elevation myocardial infarction; PCI = percutaneous coronary intervention; STEMI = ST elevation myocardial infarction;
TLR = target lesion revascularization; TVR = target vessel revascularization.
lesion and in 2 to an isolated LAD ostial lesion.
TLR was clinically driven only in 25 patients, with an
angiographic follow-up due to symptoms or inducible
ischemia. Clinically driven TLR was performed at a
mean time of 208 days from the index procedure, a mean
of 30 days before TLR performed during a routine an-
giographic follow-up (233 days).
Forty-two patients (13.2%) had a repeated procedure
on an already treated vessel and 41 (12.9%) had a PCI of
another vessel/de nov o lesion.
At univariate analysis, variables correlated to total
mortality were age, ACS as indication for coronary an-
giography, ad hoc PCI, serum creatinine, presence of
chronic obstructive pulmonary disease and PAD, LVEF,
Killip class 3-4, associated 1 - 3 vessel disease, Syntax
Score, presence of thrombus, IABP utilization, BMS
implantation, pre-PCI TIMI flow <3, an incomplete re-
vascularization. Independent predictors of mortality at
multivariate analysis were: BMS utilization (<0.001),
age >75 years (p = 0.006), ACS indication (either
STEMI and non ST elevation MI-NSTEMI) (p = 0.017),
Syntax Score >32 (p = 0.010), and associated PAD (p =
0.042) (Table 5).
Comparisons between patients treated with DES or
BMS and between the three Syntax Score groups are
shown in Table 6 and 7.
The population studied represents a real world scenario,
being composed by unselected, consecutive patients ad-
mitted to a high volume hub centre without on-site car-
diac surgery. Most of the patients were admitted with an
ACS, who had frequent comorbidities and a complex
anatomic situation frequently associated with multivessel
disease (Tables 1 and 2).
The peculiarity of our LM PCI experience lies in the
absence of a proper “heart team” and in the presence of
experienced operators leading to the preferred choice of
the percutaneous revascularization option if possible (at
least a functionally complete revascularization) without
employing more than 4 - 5 stents, and in the absence of
absolute contraindications to DES. The main intent was
to avoid adverse events related to CABG, even those less
known or not routinely reported (i.e., sequelae of surgical
wounds, psycho-intellective deterioration) that signifi-
cantly impact on morbidity and on the quality of life and
costs [20].
Our results show a satisfactory short-term outcome,
with an acceptable in-hospital mortality considering the
type of patients (15% STEMI, comorbidity, age, mean
Euroscore 7 ± 3); moreover, also at 12 months, excluding
patients with acute MI (STEMI and NSTEMI) total mor-
tality results 3.8% (Table 4), similar to the 12-month
mortality of the LM subgroup of the Syntax trial that did
not enroll patients with acute MI (2). Our results also do
well in comparison with the experience of the large
DELTA Registry (6), with cardiac mortality of 10% ver-
sus 6.8%, if we considered that our patients were older
(mean age 72 ± 10 vs 65.8 ± 1.1 years), and presented
more frequently an ACS (STEMI 15% vs 2.9%, NSTEMI
Copyright © 2013 SciRes. OPEN ACCESS
E. Varani et al. / World Journal of Cardiovascular Diseases 3 (2013) 419-427
Table 5. Independent predictors of total mortality at multivariate analysis.
OR 95% CI p value
BMS utilization 5.15 2.28 - 11.66 <0.001
Age >75 years 3.12 1.39 - 6.99 0.006
Syntax score >32 3.53 1.25 - 9.96 0.010
ACS indication (STEMI and NSTEMI) 2.69 1.19 - 6.08 0.017
Associated PAD 2.31 1.03 - 5.18 0.042
ACS = acute coronary symdrome; BMS = bare metal stent; PAD = peripheral artery disease.
Table 6. Clinical characteristics of patients treated with BMS or DES.
BMS (n = 50) DES (n = 264) p value
Age 78.6 ± 10 71.5 ± 10 <0.001
STEMI inidication 15 (30%) 34 (13%) 0.001
Ad hoc PCI 36 (72%) 133 (50%) 0.005
Hypertension 37 (74%) 190 (72%) 0.768
Diabetes mellitus 14 (28%) 74 (28%) 0.996
Hypercholesterolemia 30 (60%) 203 (76%) 0.012
Creatinine, mg/dl 1.42 ± 0.6 1.17 ± 0.7 0.042
Left ventricle ejection fraction, % 43 ± 12 51 ± 11 <0.001
COPD 9 (18%) 22 (8%) 0.035
PAD 30 (60%) 145 (55%) 0.507
Previous MI 12 (24%) 64 (24%) 0.97
Severe comorbidity 18 (36%) 31 (11%) <0.001
Atrial fibrillation 13 (26%) 20 (7.8%) <0.001
Killip class 3-4 12 (24%) 22 (8.3%) 0.001
Syntax score 26.5 ± 10 24.5 ± 9 0.443
In-hospital death 6 (12%) 12 (4.5%) 0.048
Total death at follow up 21(42%) 30 (11.4%) <0.001
LM TLR 8 (16%) 39 (14.8%) 0.823
BMS = bare metal stent; COPD = chronic obstructive pulmonary disease; DES = drug-eluting stent; LM = left main; MI = myocardial infarction; PAD= periph-
eral artery disease; PCI = percutaneous coronary intervention; TLR = target lesion revascularization; STEMI = St elevation myocardial infarction.
35% vs 11.6%) and a higher Euroscore (7 ± 3 vs 4.9 ±
Medium term TLR rate is comparable to that reported
by another study with clinical and/or angiographic fol-
low-up [21] and seems to be linked to the routine an-
giographic follow-up, more often with a significant in-
volvement of circumflex artery ostium. Almost half of
(23/48) TLR were not clinically driven. Although an-
giographic follow-up is largely used to monitor the re-
sults of LM PCI, there are many doubts about its appro-
priateness [22]. All but one case of LM in-stent resteno-
sis were treated percutaneously in our experience.
In this population of anatomically complex patients,
mostly with multivessel disease, the need for a repeated
revascularization of already treated segments of other
vessels, or of de novo lesions or progression of disease
has all the same importances of total TLR (13.2% of
TVR and 12.9% of PCI of de novo lesions, Table 4);
progression of atherosclerosis is the main cause of the
PCI inferiority versus CABG as long as the long term
need for new revascularizations is concerned.
Although IVUS was rarely used, a post-dilatation with
Copyright © 2013 SciRes. OPEN ACCESS
E. Varani et al. / World Journal of Cardiovascular Diseases 3 (2013) 419-427 425
Table 7. Clinical characteristics and events in the three Syntax score groups.
<22 22 - 33 >33 p
N˚ patients 125 120 66
Age 71 ± 10 74 ± 10 73 ± 10 0.086
LVEF, % 53 ± 11 49 ± 11 47 ± 12 0.005
Creatinine, mg/dl 1.04 ± 0.4 1.4 ± 1 1.17 ± 0.46 0.001
Killip class 3-4 10 (8%) 12 (10%) 13 (19%) 0.044
Previous MI 22 (17.6%) 34 (28%) 20 (30%) 0.067
Euroscore 6.4 ± 3.6 7.4 ± 3.2 7.5 ± 3.9 0.038
Associated CTO 6 (4.8%) 35 (29%) 35 (53%) <0.001
Other vessel treated 61 (49%) 100 (83%) 60 (91%) <0.001
Complete revascularization 101 (81%) 55 (46%) 20 (30%) <0.001
In-hospital death 6 (4.8%) 6 (5%) 7 (10.6%) 0.227
Total death at follow up 13 (10.4%) 20 (16.6%) 18 (27.3%) 0.011
LM TLR 19 (15%) 18 (15%) 11 (16.5%) 0.951
Other vessel TVR 14 (11%) 20 (16.5%) 8 (12%) 0.426
CTO = chronic total occlusion, LM = left main; LVEF = left ventricle ejection fraction, MI = myocardial infarction, TLR = target lesion revascularization, TVR
= target vessel revascularization.
a non-compliant balloon (254/317, 80%) and final kiss-
ing-balloon in almost all bifurcation lesions were fre-
quently performed (Ta b l e 3). This technical feature, de-
rived from the results of IVUS-guided stenting studies
[23], may account for the low prevalence of ST (no case
of definite ST, 4 unknown cause death cases, possibly
due to ST).
Multivariate analysis shows a strong correlation of
BMS utilization with total mortality. This result deserves
a comment because it is likely due to the presence of a
higher risk profile (older age, more often STEMI presen-
tation, severe comorbidities, necessity for oral antico-
agulation, lower LVEF and compromised hemodynamic
status, Ta b le 6 ), which leads to the choice of BMS uti-
lization in order to avoid prolonged dual antiplatelet
therapy or is based on the supposedly worse cost/efficacy
ratio in very compromised clinical conditions. Probably
BMS utilization alone is not really an independent pre-
dictor of mortality but rather an indicator of a worse
clinical setting. This hypothesis is supported by the very
high acute in-hospital mortality of this subset of patients
(6/50, 12% vs 13/264, 4.5% in the BMS and DES group
respectively), without a concomitant higher TVR versus
DES group in patients who survived the in-hospital
phase (Table 6).
We cannot derive a difference between the first and sec-
ond generations DES from our data, even if recent stud-
ies showed no significant advantage of the latter one [24].
The presence of a Syntax Score >32 is also a predictor
of mortality and this result is in line with the increased
major adverse event rate at 3rd and 5th years in higher
Syntax Score subgroup in Syntax trial [25,26]. Notably,
our patients with Syntax Score >32 had lower LVEF,
higher Euroscore, more frequent Killip class 3-4 (Table
6). All these features made us to prefer percutaneous
coronary treatment over a surgical approach.
In our experience, besides anatomical situation, clini-
cal features (age, ACS presentation, PAD) are important
determinants of prognosis. An integrated clinical judg-
ment may be represented by the new risk scores (global
and clinical Syntax Score) [27,28], and is mandatory to
choose the right revascularization strategy for each indi-
vidual patient in order to guarantee the best benefit-to-
risk ratio and quality of life.
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