In-hospital outcomes of left main coronary interventions in high-risk surgical patients:A 12-Year single-center analysis by procedural urgency

Background The coronary artery bypass grafting (CABG) operation has long been considered the gold standard for treating stenosis of the main stem of the left coronary artery (LM). With advancements in percutaneous coronary intervention (PCI), rising age of the patients with increasing prevalence of comorbidities, PCI has now become an equally viable alternative to CABG for cases with low to moderate anatomical complexity. This study aims to investigate patient profiles, interventional characteristics, and in-hospital outcomes following LM-PCI over a 12-year period, categorized by different urgencies of LM-PCI. Methods A single-center observational study with a retrospective analysis of a cohort (n=824) who underwent main stem PCI of the left coronary artery between 2012 and 2023. The entire cohort was divided into three groups depending on the urgency of LM-PCI (acute vs. subacute vs. elective). The primary endpoint was a composite of all-cause mortality, myocardial infarction, and stroke (MACE). Follow-up included all events until discharge. Results Median age in the entire cohort was 76 years, with patients exhibiting a high cardiovascular risk profile including dyslipidamia (81%), hypertension (85%) and diabetes mellitus (27%). LM-PCI was performed in 20% of cases acutely, 36% subacutely and 44% electively. Patients undergoing acute LM-PCI were more frequently anaemic (60% vs. 57% vs 41%), presented with acute kidney injury (52% vs. 49% vs. 34%) and had a severely impaired left ventricular ejection fraction <30 % (57% vs. 26%. vs. 10 %). The duration of procedure was longer in acute settings (136 vs 117 vs 105 minutes) and contrast agent dose consequently higher. Mechanic circulatory support via ECMO was more frequently required in acute cases (25% vs 2% vs 0.3%). Intraprocedural complications such as arrhythmias were more common (18%, 5%, 2%). Stenting technique (one stent vs. two stent approach) did not significantly differ across procedural urgencies. MACE was significantly higher in acute LM-PCIs (41.5% vs 13% vs 8%). Independent multivariate predictors of MACE in an acute LM-PCI include age> 75 years (OR 2.07; CI 1.01, 4.24) and cardiogenic shock (OR 4.6; CI 1.84, 11.52). In subacute and elective LM-PCIs multivariable predictors for MACE include a reduced LVEF<50% (OR 4.59, CI 1.67, 12.61 and OR 5.17, CI 1.03, 25.99, respectively). Conclusion In this single-center study, acute LM-PCI was associated with significantly higher rates of intrahospital mortality and complications compared to subacute and elective procedures. Independent predictors of adverse outcomes included cardiogenic shock and age>75 years in acute cases, while reduced left ventricular ejection fraction is a main predictor of adverse outcome in subacute and elective settings.