Circulation journal : official journal of the Japanese Circulation Society
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Review Meta Analysis Comparative Study
Percutaneous coronary intervention vs. coronary artery bypass graft surgery for unprotected left main coronary artery disease in the drug-eluting stents era--an aggregate data meta-analysis of 11,148 patients.
Patients with unprotected left main coronary artery (LMCA) disease are increasingly treated with percutaneous coronary intervention (PCI) using drug-eluting stents (DES), but its benefits compared with coronary artery bypass grafting (CABG) remain controversial. We hypothesized that PCI with DES for unprotected LMCA disease is safe and effective compared with CABG. ⋯ In the DES era, PCI for unprotected LMCA disease is associated with equivalent mortality and MI, lower stroke rates and higher rates of repeat revascularization compared with CABG.
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Fractional flow reserve (FFR) has become an increasingly important index for decision making with respect to revascularization of coronary artery stenosis. It is the gold standard to indicate whether a particular stenosis is responsible for inducible ischemia and it is generally accepted that a stenosis with an ischemic value of FFR is responsible for angina pectoris and a worse outcome, and should be revascularized, whereas lesions with a non-ischemic FFR have a more favorable prognosis and can better be treated medically. ⋯ Finally, a word of caution is given with respect to using resting pressure indexes, which seem attractive because they avoid the need for hyperemia, but negatively affect the accuracy of the measurements. This review can be read as an overview of the state-of-the-art of FFR and as a guide to further reading.
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Cardiac resynchronization therapy (CRT) is an effective therapy for advanced heart failure (HF) patients. The indications are well defined in recent guidelines and broadly indicate that CRT is suitable for chronic HF patients with left ventricular ejection fraction (EF) ≤35% and in NYHA class III or IV (Class I), and those with prolonged QRS duration ≥120 ms with left bundle branch block (LBBB) QRS morphology, or QRS duration ≥150 ms irrespective of QRS morphology (Class IIa). ⋯ In this review, we summarize the role of CRT in some subgroups, including patients with mild and moderate HF, upgrading to CRT from right ventricular (RV) pacing, bradycardia patients with routine pacing indications, congenital heart disease and specific cardiomyopathies. It is possible that CRT can give symptomatic and mortality benefits in some of these subgroups in the future and further clinical trials are warranted.
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Chronic ischemic mitral regurgitation (IMR) is still a significant clinical problem. It is present in 10-20% of patients with coronary artery disease and is associated with a worse prognosis after myocardial infarction and subsequent revascularization. ⋯ In order to do so, the condition will be defined and the evolution of classic or traditional surgical approaches to repairing or replacing the mitral valve in the setting of IMR will be described. Finally, novel approaches to the repair of the ischemic mitral valve will be considered.