Clinical Research in Cardiology

, Volume 106, Issue 12, pp 953–959 | Cite as

Impact of left main coronary artery disease on long-term mortality in patients undergoing drug-eluting stent implantation

  • Se Hun Kang
  • Cheol Whan LeeEmail author
  • Seunghee Baek
  • Pil Hyung Lee
  • Jung-Min Ahn
  • Duk-Woo Park
  • Soo-Jin Kang
  • Seung-Whan Lee
  • Young-Hak Kim
  • Seong-Wook Park
  • Seung-Jung Park
Original Paper



Limited data are available on long-term mortality according to the extent of coronary artery disease (CAD) in patients undergoing percutaneous coronary intervention (PCI) with drug-eluting stent (DES). We assessed long-term mortality DES implantation according to the extent of CAD and the impact of left main CAD alone on mortality among patients undergoing PCI with DES.

Methods and results

A total of 18,716 patients were pooled from real-world PCI registries. The primary outcome was death from any cause. The median follow-up duration was 47.1 (interquartile range 32.8–57.9) months. The presence of left main CAD [adjusted hazard ratio (HR) 1.24, 95% confidence interval (CI) 1.05–1.46, p = 0.012] and the extent of diseased vessels (adjusted HR 1.17, 95% CI 1.08–1.27, p < 0.001) significantly increased the risk of all-cause mortality. Left main CAD alone was associated with a risk of all-cause mortality similar to one- and two-vessel CAD, whereas it was associated with a significantly lower risk of mortality compared with three-vessel CAD (adjusted HR 0.42, 95% CI 0.18–0.98, p = 0.044). Among patients with left main CAD, the risk of mortality tended to increase in proportion with the number of concomitant vessel CAD, but it did not achieve statistical significance.


Among patients undergoing DES implantation, the risk of mortality increased in a stepwise manner according to the extent of coronary CAD. Left main CAD alone was associated with a risk of long-term mortality similar to one- and two-vessel CAD.


All-cause mortality Drug-eluting stents Left main coronary artery disease 


Compliance with ethical standards


This work was supported by the Cardiovascular Research Foundation.

Conflict of interest

The authors declare that they have no conflict of interest.


  1. 1.
    Silverman KJ, Grossman W (1984) Angina pectoris. Natural history and strategies for evaluation and management. N Engl J Med 310(26):1712–1717. doi: 10.1056/nejm198406283102606 CrossRefPubMedGoogle Scholar
  2. 2.
    Conley MJ, Ely RL, Kisslo J, Lee KL, McNeer JF, Rosati RA (1978) The prognostic spectrum of left main stenosis. Circulation 57(5):947–952CrossRefPubMedGoogle Scholar
  3. 3.
    Eagle KA, Guyton RA, Davidoff R, Edwards FH, Ewy GA, Gardner TJ, Hart JC, Herrmann HC, Hillis LD, Hutter AM Jr, Lytle BW, Marlow RA, Nugent WC, Orszulak TA (2004) ACC/AHA 2004 guideline update for coronary artery bypass graft surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1999 Guidelines for Coronary Artery Bypass Graft Surgery). Circulation 110(14):e340–e437PubMedGoogle Scholar
  4. 4.
    Caracciolo EA, Davis KB, Sopko G, Kaiser GC, Corley SD, Schaff H, Taylor HA, Chaitman BR (1995) Comparison of surgical and medical group survival in patients with left main coronary artery disease. Long-term CASS experience. Circulation 91(9):2325–2334CrossRefPubMedGoogle Scholar
  5. 5.
    Morice MC, Serruys PW, Kappetein AP, Feldman TE, Stahle E, Colombo A, Mack MJ, Holmes DR, Choi JW, Ruzyllo W, Religa G, Huang J, Roy K, Dawkins KD, Mohr F (2014) Five-year outcomes in patients with left main disease treated with either percutaneous coronary intervention or coronary artery bypass grafting in the synergy between percutaneous coronary intervention with taxus and cardiac surgery trial. Circulation 129(23):2388–2394. doi: 10.1161/circulationaha.113.006689 CrossRefPubMedGoogle Scholar
  6. 6.
    Ahn JM, Roh JH, Kim YH, Park DW, Yun SC, Lee PH, Chang M, Park HW, Lee SW, Lee CW, Park SW, Choo SJ, Chung C, Lee J, Lim DS, Rha SW, Lee SG, Gwon HC, Kim HS, Chae IH, Jang Y, Jeong MH, Tahk SJ, Seung KB, Park SJ (2015) Randomized trial of stents versus bypass surgery for left main coronary artery disease: 5-year outcomes of the PRECOMBAT study. J Am Coll Cardiol 65(20):2198–2206. doi: 10.1016/j.jacc.2015.03.033 CrossRefPubMedGoogle Scholar
  7. 7.
    Cavalcante R, Sotomi Y, Lee CW, Ahn JM, Farooq V, Tateishi H, Tenekecioglu E, Zeng Y, Suwannasom P, Collet C, Albuquerque FN, Onuma Y, Park SJ, Serruys PW (2016) Outcomes after percutaneous coronary intervention or bypass surgery in patients with unprotected left main disease. J Am Coll Cardiol 68(10):999–1009. doi: 10.1016/j.jacc.2016.06.024 CrossRefPubMedGoogle Scholar
  8. 8.
    Stone GW, Sabik JF, Serruys PW, Simonton CA, Genereux P, Puskas J, Kandzari DE, Morice MC, Lembo N, Brown WM 3rd, Taggart DP, Banning A, Merkely B, Horkay F, Boonstra PW, van Boven AJ, Ungi I, Bogats G, Mansour S, Noiseux N, Sabate M, Pomar J, Hickey M, Gershlick A, Buszman P, Bochenek A, Schampaert E, Page P, Dressler O, Kosmidou I, Mehran R, Pocock SJ, Kappetein AP (2016) Everolimus-eluting stents or bypass surgery for left main coronary artery disease. N Engl J Med 375(23):2223–2235. doi: 10.1056/NEJMoa1610227 CrossRefPubMedGoogle Scholar
  9. 9.
    Makikallio T, Holm NR, Lindsay M, Spence MS, Erglis A, Menown IB, Trovik T, Eskola M, Romppanen H, Kellerth T, Ravkilde J, Jensen LO, Kalinauskas G, Linder RB, Pentikainen M, Hervold A, Banning A, Zaman A, Cotton J, Eriksen E, Margus S, Sorensen HT, Nielsen PH, Niemela M, Kervinen K, Lassen JF, Maeng M, Oldroyd K, Berg G, Walsh SJ, Hanratty CG, Kumsars I, Stradins P, Steigen TK, Frobert O, Graham AN, Endresen PC, Corbascio M, Kajander O, Trivedi U, Hartikainen J, Anttila V, Hildick-Smith D, Thuesen L, Christiansen EH (2016) Percutaneous coronary angioplasty versus coronary artery bypass grafting in treatment of unprotected left main stenosis (NOBLE): a prospective, randomised, open-label, non-inferiority trial. Lancet 388(10061):2743–2752. doi: 10.1016/s0140-6736(16)32052-9 CrossRefPubMedGoogle Scholar
  10. 10.
    Lee CW, Ahn JM, Cavalcante R, Sotomi Y, Onuma Y, Suwannasom P, Tenekecioglu E, Yun SC, Park DW, Kang SJ, Lee SW, Kim YH, Park SW, Serruys PW, Park SJ (2016) Coronary artery bypass surgery versus drug-eluting stent implantation for left main or multivessel coronary artery disease: a meta-analysis of individual patient data. JACC Cardiovasc Interv 9(24):2481–2489. doi: 10.1016/j.jcin.2016.10.008 CrossRefPubMedGoogle Scholar
  11. 11.
    Trikalinos TA, Alsheikh-Ali AA, Tatsioni A, Nallamothu BK, Kent DM (2009) Percutaneous coronary interventions for non-acute coronary artery disease: a quantitative 20-year synopsis and a network meta-analysis. Lancet 373(9667):911–918. doi: 10.1016/s0140-6736(09)60319-6 CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Park DW, Kim YH, Song HG, Ahn JM, Kim WJ, Lee JY, Kang SJ, Lee SW, Lee CW, Park SW, Yun SC, Her SH, Hur SH, Park JS, Kim MK, Choi YS, Kim HS, Cho JH, Lee SG, Park YW, Jeong MH, Lee BK, Lee NH, Lim DS, Yoon J, Seung KB, Shin WY, Rha SW, Kim KS, Tahk SJ, Park BE, Ahn T, Yang JY, Jeong YS, Rhew JH, Park SJ, Investigators I-D (2012) Outcomes after unrestricted use of everolimus-eluting and sirolimus-eluting stents in routine clinical practice: a multicenter, prospective cohort study. Circ Cardiovasc Interv 5(3):365–371. doi: 10.1161/CIRCINTERVENTIONS.111.966549 CrossRefPubMedGoogle Scholar
  13. 13.
    Lee PH, Ahn JM, Chang M, Baek S, Yoon SH, Kang SJ, Lee SW, Kim YH, Lee CW, Park SW, Park DW, Park SJ (2016) Left main coronary artery disease: secular trends in patient characteristics, treatments, and outcomes. J Am Coll Cardiol 68(11):1233–1246. doi: 10.1016/j.jacc.2016.05.089 CrossRefPubMedGoogle Scholar
  14. 14.
    Park DW, Kim YH, Song HG, Ahn JM, Oh J, Kim WJ, Lee JY, Kang SJ, Lee SW, Lee CW, Park SW, Yun SC, Jung SH, Choo SJ, Chung CH, Lee JW, Park SJ (2011) Long-term comparison of drug-eluting stents and coronary artery bypass grafting for multivessel coronary revascularization: 5-year outcomes from the Asan Medical Center-Multivessel Revascularization Registry. J Am Coll Cardiol 57(2):128–137. doi: 10.1016/j.jacc.2010.09.022 CrossRefPubMedGoogle Scholar
  15. 15.
    Weintraub WS, Grau-Sepulveda MV, Weiss JM, Delong ER, Peterson ED, O’Brien SM, Kolm P, Klein LW, Shaw RE, McKay C, Ritzenthaler LL, Popma JJ, Messenger JC, Shahian DM, Grover FL, Mayer JE, Garratt KN, Moussa ID, Edwards FH, Dangas GD (2012) Prediction of long-term mortality after percutaneous coronary intervention in older adults: results from the National Cardiovascular Data Registry. Circulation 125(12):1501–1510. doi: 10.1161/circulationaha.111.066969 CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Park SJ, Lee CW (2012) Coronary artery disease: risk models for revascularization—the search continues. Nat Rev Cardiol 9(6):316–318. doi: 10.1038/nrcardio.2012.57 CrossRefPubMedGoogle Scholar
  17. 17.
    Wu C, Camacho FT, King SB 3rd, Walford G, Holmes DR Jr, Stamato NJ, Berger PB, Sharma S, Curtis JP, Venditti FJ, Jacobs AK, Hannan EL (2014) Risk stratification for long-term mortality after percutaneous coronary intervention. Circ Cardiovasc Interv 7(1):80–87. doi: 10.1161/circinterventions.113.000475 CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Roques F, Nashef SA, Michel P, Gauducheau E, de Vincentiis C, Baudet E, Cortina J, David M, Faichney A, Gabrielle F, Gams E, Harjula A, Jones MT, Pintor PP, Salamon R, Thulin L (1999) Risk factors and outcome in European cardiac surgery: analysis of the EuroSCORE multinational database of 19030 patients. Eur J Cardiothorac Surg 15(6):816–822 (discussion 822–823) CrossRefPubMedGoogle Scholar
  19. 19.
    Mohr FW, Morice MC, Kappetein AP, Feldman TE, Stahle E, Colombo A, Mack MJ, Holmes DR Jr, Morel MA, Van Dyck N, Houle VM, Dawkins KD, Serruys PW (2013) Coronary artery bypass graft surgery versus percutaneous coronary intervention in patients with three-vessel disease and left main coronary disease: 5-year follow-up of the randomised, clinical SYNTAX trial. Lancet 381(9867):629–638. doi: 10.1016/s0140-6736(13)60141-5 CrossRefPubMedGoogle Scholar
  20. 20.
    Garg S, Sarno G, Garcia-Garcia HM, Girasis C, Wykrzykowska J, Dawkins KD, Serruys PW (2010) A new tool for the risk stratification of patients with complex coronary artery disease: the Clinical SYNTAX Score. Circ Cardiovasc Interv 3(4):317–326. doi: 10.1161/circinterventions.109.914051 CrossRefPubMedGoogle Scholar
  21. 21.
    Park SJ, Ahn JM, Kim YH, Park DW, Yun SC, Yoon SH, Park HW, Chang M, Lee JY, Kang SJ, Lee SW, Lee CW, Park SW (2015) Temporal trends in revascularization strategy and outcomes in left main coronary artery stenosis: data from the ASAN Medical Center-Left MAIN Revascularization registry. Circ Cardiovasc Interv 8(3):e001846. doi: 10.1161/circinterventions.114.001846 CrossRefPubMedGoogle Scholar
  22. 22.
    Farkouh ME, Domanski M, Sleeper LA, Siami FS, Dangas G, Mack M, Yang M, Cohen DJ, Rosenberg Y, Solomon SD, Desai AS, Gersh BJ, Magnuson EA, Lansky A, Boineau R, Weinberger J, Ramanathan K, Sousa JE, Rankin J, Bhargava B, Buse J, Hueb W, Smith CR, Muratov V, Bansilal S, King S 3rd, Bertrand M, Fuster V (2012) Strategies for multivessel revascularization in patients with diabetes. N Engl J Med 367(25):2375–2384. doi: 10.1056/NEJMoa1211585 CrossRefPubMedGoogle Scholar
  23. 23.
    Sipahi I, Akay MH, Dagdelen S, Blitz A, Alhan C (2014) Coronary artery bypass grafting vs percutaneous coronary intervention and long-term mortality and morbidity in multivessel disease: meta-analysis of randomized clinical trials of the arterial grafting and stenting era. JAMA Intern Med 174(2):223–230. doi: 10.1001/jamainternmed.2013.12844 CrossRefPubMedGoogle Scholar
  24. 24.
    Chang M, Ahn JM, Lee CW, Cavalcante R, Sotomi Y, Onuma Y, Tenekecioglu E, Han M, Park DW, Kang SJ, Lee SW, Kim YH, Park SW, Serruys PW, Park SJ (2016) Long-term mortality after coronary revascularization in nondiabetic patients with multivessel disease. J Am Coll Cardiol 68(1):29–36. doi: 10.1016/j.jacc.2016.04.034 CrossRefPubMedGoogle Scholar
  25. 25.
    Weintraub WS, Grau-Sepulveda MV, Weiss JM, O’Brien SM, Peterson ED, Kolm P, Zhang Z, Klein LW, Shaw RE, McKay C, Ritzenthaler LL, Popma JJ, Messenger JC, Shahian DM, Grover FL, Mayer JE, Shewan CM, Garratt KN, Moussa ID, Dangas GD, Edwards FH (2012) Comparative effectiveness of revascularization strategies. N Engl J Med 366(16):1467–1476. doi: 10.1056/NEJMoa1110717 CrossRefPubMedPubMedCentralGoogle Scholar
  26. 26.
    Garcia S, Sandoval Y, Roukoz H, Adabag S, Canoniero M, Yannopoulos D, Brilakis ES (2013) Outcomes after complete versus incomplete revascularization of patients with multivessel coronary artery disease: a meta-analysis of 89,883 patients enrolled in randomized clinical trials and observational studies. J Am Coll Cardiol 62(16):1421–1431. doi: 10.1016/j.jacc.2013.05.033 CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany 2017

Authors and Affiliations

  • Se Hun Kang
    • 1
    return OK on get
  • Cheol Whan Lee
    • 2
    Email author
  • Seunghee Baek
    • 3
  • Pil Hyung Lee
    • 2
  • Jung-Min Ahn
    • 2
  • Duk-Woo Park
    • 2
  • Soo-Jin Kang
    • 2
  • Seung-Whan Lee
    • 2
  • Young-Hak Kim
    • 2
  • Seong-Wook Park
    • 2
  • Seung-Jung Park
    • 2
  1. 1.Department of Cardiology, CHA Bundang Medical CenterCHA UniversitySeongnamKorea
  2. 2.Division of Cardiology, Heart Institute, Asan Medical CenterUniversity of Ulsan College of MedicineSeoulKorea
  3. 3.Department of Clinical Epidemiology and Biostatistics, Asan Medical CenterUniversity of Ulsan College of MedicineSeoulKorea

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