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Stenting a Good Option for Left Main Heart Artery

As effective as standard of bypass surgery, Polish study finds

WEDNESDAY, Aug. 19 (HealthDay News) -- Twelve-year data on treatment of blockage of the left main heart artery indicate that using a drug-coated stent is an effective alternative to bypass surgery, doctors report.

The study of 314 people who underwent the procedure between 1997 and 2008 in Poland supports the findings of a large European trial, which found no difference in the death rate between bypass surgery and angioplasty for the condition, according to a report published online Aug. 19 and in an upcoming print issue of the Journal of the American College of Cardiology by a group of physicians from Poland and the United States.

While no more than 5 percent of cases of coronary artery disease involve the left main artery, there has been controversy about the best treatment, in part because the vessel supplies blood to two-thirds of the heart muscle.

"In the earliest days, it was found that surgical revascularization [restoration of blood flow] prolonged survival," said Dr. David R. Holmes, the Scripps professor of medicine at the Mayo Graduate School of Medicine, and a participant in the earlier European trial.

While the left main vessel is an easy target for insertion of a balloon that is expanded to widen the artery, concerns that the procedure would not prevent the artery from closing again limited its use, Holmes said. But the arrival of stents -- thin metal tubes that help keep the artery open -- and then of stents coated with drugs to prevent clotting, made the procedure more feasible, he said.

The SYNTAX study, sponsored by stent maker Boston Scientific Inc. and reported last year, found no difference in the mortality rate between people who had angioplasty and stent implants, and those who had bypass surgery.

"It showed that selected patients with left main disease could be treated with drug-eluting stents," Holmes said.

The newly reported study helps show that "in some patients, not a majority, angioplasty is a very satisfactory alternative to bypass surgery," Holmes added.

"Long-term mortality of 13.9 percent at four years and the five- and 10-year survival of 78.1 percent and 68.9 percent are very satisfactory and compare favorably with survival presented in long-term outcomes of coronary artery bypass surgery," the report said.

At this time, the treatment of choice for left main artery disease depends largely on the country in which it is treated, Holmes said.

"In Japan or Korea, the treatment of choice is stenting," he said. "In the United States, the predominant treatment is coronary artery bypass surgery."

The results of the study in Poland might tip the scales slightly toward stenting, since it is a study "looking at real-life results," Holmes said. "The quality of evidence is not as good as in a randomized trial, but still is good."

But there is no hard-and-fast rule for making the choice, Holmes said. In some cases, "there is no good surgical option," he said. In other cases, the choice may be made by an individual's preference, since "some patients like to avoid open-heart surgery," Holmes said.

The study could influence medical practice in the United States, said Dr. Jeffrey W. Moses, a professor of medicine at Columbia University Medical Center, and co-author of an accompanying editorial.

"It gives a very long time perspective, now going out for multiple years, really indicating that the overall outcomes are pretty stable, especially if you look at mortality rates over time," Moses said.

A number of other studies have "said the same thing, that if the thing is done properly, in the right hands, it can be done safely with a good long-term outcome," Moses said. "This, along with the other studies, is going to move the consensus over a bit, at least widening the group of patients eligible to have stenting as a reasonable alternative to bypass surgery."

More information

You can learn about stenting from the American Heart Association.

SOURCES: David R. Holmes, M.D., Scripps professor of medicine, Mayo Graduate School of Medicine, Rochester, Minn.; Jeffrey W. Moses, professor, medicine, Columbia University Medical Center, New York City; Aug. 19, 2009, Journal of the American College of Cardiology, online

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