Clinical outcomes of left main percutaneous coronary intervention with rotational atherectomy: results from the RA-BIA cohort

Background Severe coronary calcification remains a major challenge in percutaneous coronary intervention (PCI). Data on outcomes of rotational atherectomy (RA) in left main (LM) lesions are limited and inconsistent. Purpose To assess procedural and 2-year clinical outcomes after LM PCI with RA based on the largest published single-center European registry to date. Methods Among 1060 patients with severe coronary calcification treated with PCI using RA between 2008 and 2022, LM was target vessel in 178 cases. The primary endpoint was procedural success (lesion modification with RA with stent placement with ≤20% residual stenosis) and and clinical success (achievement of procedural success in the absence of major in-hospital complications). The secondary endpoints were major adverse cardiovascular and cerebrovascular events (MACCE: cardiovascular death, myocardial infarction, target vessel revascularization, stroke) and all-cause mortality at 24 months. Outcome rates were calculated for LM PCI alone and for comparison with non-LM patients. Results In final LM PCI cohort median age was 77 (69-82), 26% (46) were female, median SYNTAX score was 35 (28-43), EuroSCORE II 4.9% (2.02-9.8%) and ejection fraction (EF) 45% (30-52%). Majority of patients had true bifurcation lesion (defined as medina 1-1-1; 83 [47%]) and intravascular imaging (IVI) was used in 56 patients (32%). Technical and clinical success rates were 98% and 81%, respectively. Both uni- and multivariate analysis including age, IVI and EF revealed SYNTAX score as the only factor associated with higher risk of clinical failure (OR 1.41, 95% CI 1.01-1.97, P=0.043 per 10-point increase). In-hospital MACCE occurred in 19 patients (11%). In two-year observation there were 71 MACCE [cumulative incidence estimated by Kaplan-Meier method was 40.8% (95% CI 33.9-48.5%)]. Univariable Cox analysis recognized clinical success as the only factor significantly associated with reduction of MACCE (HR 0.22, 95% CI 0.14-0.37, P<0.001). In 2-year observation there were 42 all-cause deaths [mortality rate 23.2% (95% CI 17.6–30.1%)]. In multivariable analysis, EF remained the only independent predictor of all-cause mortality (HR 0.95, 95% CI 0.93-0.98, P<0.001 per 1% increase), whereas renal dysfunction, atrial fibrillation, anemia and age had no significant impact. Compared with non-LM PCI, LM PCI was associated with similar rate of procedural success (unadjusted OR 1.11, 95% CI 0.38-3.27) but lower clinical success (unadjusted OR 0.62, 95% CI 0.40–0.94; P=0.03). 2-year MACCE (unadjusted HR 1.11, 95% CI 0.86–1.43; P=0.45) and all-cause mortality (unadjusted HR 1.30, 95% CI 0.92–1.83; P=0.13) were similar between two groups. Conclusion LM PCI with RA achieved high clinical success despite complex anatomy. Worse clinical outcomes were driven by anatomical complexity, whereas mid-term prognosis was primarily determined by baseline myocardial function rather than lesion characteristics.