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We report the case of a 62-year-old male with multiple cardiovascular risk factors and comorbidities who presented to our institution due to unstable angina. One year earlier, he underwent percutaneous coronary intervention (PCI) to unprotected left main trifurcation lesion involving the ostial left anterior descending artery (LAD) (Medina classification 0-0-1-0) with provisional stenting technique with single drug-eluting stent (DES) implantation from left main to LAD and PCI to LAD with single DES implantation from LAD in crossover with D1 for the treatment of LAD-D1 bifurcation lesion (Medina 1-1-0). Coronary angiography by radial approach found sub-occlusive restenosis of both jailed ostial ramus intermediate (RI) and left circumflex (LCX), with patency of DES to left main LAD and a significant in-stent restenosis (ISR) of DES to LAD at the bifurcation with D1. LAD ISR was treated with PCI with single DES implantation with optimal angiographic results. The left main trifurcation restenosis was treated by radial approach PCI with simultaneous trissing balloon inflation to left main, RI, and LCX, followed by kissing balloon with drug-coated balloons with sirolimus elution to RI and LCX, subsequent trissing balloon inflation, and final proximal optimization technique to the left main achieving an optimal angiographic result. Planned follow-up angiography at 1 year showed persistence of optimal angiographic results.

Intravascular ultrasound (IVUS) has been increasingly used as an adjunctive tool for complex percutaneous interventions (PCIs); however, comparative randomized evidence with conventional angiography in unprotected left main coronary artery (ULMCA) disease remains scarce and fragmented. Therefore, this systematic review and meta-analysis aimed to assess and synthesize evidence regarding its use in ULMCA disease. We performed a systematic literature search across PubMed, Scopus, Web of Science, and Cochrane until April 2026 to identify relevant RCTs comparing IVUS-guided PCI with conventional angiography-guided PCI in ULMCA disease. Risk of bias of studies was assessed using the Cochrane RoB-2 tool. A random-effects model meta-analysis was performed in R, with an exploratory univariate meta-regression of covariates. Four randomized trials involving 2278 patients with ULMCA disease were included. Compared with angiography-guided PCI, IVUS guidance was associated with numerically lower risks of all-cause death, cardiac death, target lesion revascularization, and target vessel revascularization, while myocardial infarction and stent thrombosis were similar between groups. In patients undergoing PCI for ULMCA disease, IVUS guidance was associated with numerically favorable but statistically nonsignificant reductions in mortality and repeat revascularization, without clear differences in myocardial infarction or stent thrombosis. Although randomized evidence is still lacking to determine clinical superiority, these results justify powered future trials to determine whether the effects of IVUS guidance vary according to prior myocardial infarction status and left ventricular ejection fraction.

PurposeThe objective of this research was to analyze and correlate the length of the left main coronary artery (LMCA) with significant clinical parameters using multi-slice CT (MSCT).Materials and Methods1500 patients (851 males and 649 females; mean age 57.38 ± 11.03 [SD]; age range: 5–85 years) who underwent MSCT scans from September 2020 to March 2022 were retrospectively included. The data were applied to generate three-dimensional (3D) simulations of a coronary tree using the syngo.via post-processing workstation. The reconstructed images were then interpreted, and the collected data were subjected to statistical analysis.ResultsThe results showed 1206 (80.4%) cases with medium LMCA, 133 (8.9%) with long LMCA, and 161 (10.7%) with short LMCA. The average diameter of LMCA at its midpoint was 4.69 ± 0.74 mm. The most frequent type of division of LMCA was bifurcation in 1076 (71.7%) cases; in 424 (28.3%) cases, the LMCA was divided into three or more branches. The dominance was right in 1339 (89.3%), left in 78 (5.2%), and co-dominant in 83 (5.5%) cases. There was a positive correlation between the length and branching patterns of LMCA, χ2 = 113.993, P = 0.000 (< 0.05). Other variables like age, sex, diameter of LMCA, and coronary dominance did not show any significant correlation.ConclusionThis study has demonstrated a significant association between the length and the branching pattern of LMCA, which may be essential in diagnosing and treating coronary artery patients.

Left Main Coronary Artery (LMCA) disease is considered a standout manifestation of coronary artery disease (CAD), because it is accompanied by the highest mortality. Increased mortality is expected, because LMCA is responsible for supplying up to 80% of total blood flow to the left ventricle in a right-dominant coronary system. Due to the significant progress of biomedical technology, the modern drug-eluting stents have remarkably improved the prognosis of patients with LMCA disease treated invasively. In fact, numerous randomized trials provided similar results in one- and five-year survival of patients treated with percutaneous coronary interventions (PCI) -guided with optimal imaging and coronary artery bypass surgery (CABG). However, interventional treatment requires optimal imaging of the LMCA disease, such as intravascular ultrasound (IVUS) and optical coherence tomography (OCT). The aim of this manuscript is to review the main pathophysiological characteristics, to present the imaging techniques of LMCA, and, last, to discuss the future directions in the depiction of LMCA disease.

Purpose of ReviewThis review attempts to specifically assess impact of disease location in left main artery on mortality and cardiovascular outcomes in patients treated with percutaneous coronary intervention versus coronary artery bypass surgery.Recent FindingsThe management of left main disease, once thought to be the sole province of cardiothoracic surgeon, has recently undergone a reappraisal by the cardiovascular medicine community. For many years, societal guideline recommendations advised bypass surgery as the “de rigeur” method of revascularization for unprotected left main disease. However, recent studies suggest that coronary intervention, especially with advances in drug-eluting stent technology, has mounted a serious challenge to surgical bypass in treatment of this disease.SummaryAlthough overall mortality rates are comparable for percutaneous coronary intervention and bypass surgery, left main disease location does influence long-term outcomes for percutaneous coronary intervention more than bypass surgery. A patient- and lesion-centered approach to treatment of this disease may provide optimal outcomes.

ObjectivePulmonary arterial hypertension (PAH) can lead to left main coronary artery compression (LMCo), but data on the impact, screening and treatment are limited. A meta-analysis of LMCo cases could fill the knowledge gaps in this topic.MethodsElectronic databases were searched for all LMCo/PAH studies, abstracts and case reports including pulmonary artery (PA) size. Restricted maximum likelihood meta-analysis was used to evaluate LMCo-associated factors. Specificity, sensitivity and accuracy of PA size thresholds for diagnosis of LMCo were calculated. Treatment options and outcomes were summarized.ResultsA total of five case–control cohorts and 64 case reports/series (196 LMCo and 438 controls) were included. LMCo cases had higher PA diameter (Hedge’s g 1.46 [1.09; 1.82]), PA/aorta ratio (Hedge’s g 1.1 [0.64; 1.55]) and probability of CHD (log odds-ratio 1.22 [0.54; 1.9]) compared to non-LMCo, but not PA pressure or vascular resistance. A 40 mm cut-off for the PA diameter had balanced sensitivity (80.5%), specificity (79%) and accuracy (79.7%) for LMCo diagnosis, while a value of 44 mm had higher accuracy (81.7%), higher specificity (91.5%) but lower sensitivity (71.9%). Pooled mortality after non-conservative treatment (n = 150, predominantly stenting) was 2.7% at up to 22 months of mean follow-up, with 83% survivors having no angina at follow-up.ConclusionPA diameter, PA/aorta ratio and CHD are associated with LMCo, while hemodynamic parameters are not. Data from this study support that a PA diameter cut-off between 40 and 44 mm can offer optimal accuracy for LMCo screening. Preferred treatment was coronary stenting, associated with low mid-term mortality and symptom relief.Diagnosis and management of left main coronary artery compression (LMCo) in patients with pulmonary arterial hypertension (PAH).

Background Early detection of patients concomitant with left main and/or three‐vessel disease (LM/3VD) and high SYNTAX score (SS) is crucial for determining the most effective revascularization options regarding the use of antiplatelet medications and prognosis risk stratification. However, there is a lack of study for predictors of LM/3VD with SS in patients with non‐ST‐segment elevation myocardial infarction (NSTEMI). We aimed to identify potential factors that could predict LM/3VD with high SS (SS > 22) in patients with NSTEMI. Methods This dual‐center retrospective study included a total of 481 patients diagnosed with NSTEMI who performed coronary angiography procedures. Clinical factors on admission were collected. The patients were divided into non‐LM/3VD, Nonsevere LM/3VD (SS ≤ 22), and Severe LM/3VD (SS > 22) groups. To identify independent predictors, Univariate and logistic regression analyses were conducted on the clinical parameters. Results A total of 481 patients were included, with an average age of 60.9 years and 75.9% being male. Among these patients, 108 individuals had severe LM/3VD. Based on the findings of a multivariate logistic regression analysis, the extent of ST‐segment elevation observed in lead aVR (OR: 7.431, 95% CI: 3.862–14.301, p < .001) and age (OR: 1.050, 95% CI: 1.029–1.071, p < .001) were identified as independent predictors of severe LM/3VD. Conclusion This study indicated that the age of patients and the extent of ST‐segment elevation observed in lead aVR on initial electrocardiogram were the independent predictive factors of LM/3VD with high SS in patients with NSTEMI. The degree of ST‐segment elevation observed in lead aVR and the age of patients were the independent predictive factors of LM/3VD with high SS in patients with non‐ST‐segment elevation myocardial infarction.

The aim of this study was to investigate the quantitative flow ratio (QFR) outcomes in the left circumflex artery (LCX) following the placement of a crossover stent from the left main coronary artery (LM) to the left anterior descending artery (LAD) in LM bifurcation lesions. In addition, we sought to assess the relationship between these QFR results and clinical prognoses. The treatment approach for LM bifurcation lesions remains a topic of debate, with the LM-LAD single-stent technique being one possible option. QFR, a fractional flow reserve calculation method derived from angiography that does not require pressure guide wires, could serve as an alternative functional assessment of the LCX. This study aims to evaluate the clinical outcomes of postoperative LCX by utilizing QFR measurements, addressing a current gap in the relevant literature on this topic. This study was a retrospective, single-center analysis of patients with LM bifurcation lesions who underwent percutaneous coronary intervention (PCI) guided by intravascular ultrasound. QFR values were derived from angiographies. The primary endpoint was the 1-year rate of major adverse cardiac events, defined as a composite of cardiovascular death, target bifurcation-related myocardial infarction (MI), or target bifurcation revascularization. The secondary clinical endpoint was defined as the persistence or recurrence of angina pectoris after PCI. We analyzed 91 patients from a total of 180 who were screened for LM bifurcation lesions. All patients completed the 1-year follow-up. The pre- and post-PCI QFR values were 0.89 ± 0.09 and 0.86 ± 0.11, respectively. Subgroup analysis showed that 74 patients were in the postoperative QFR ≥0.80 group, whereas 17 patients were in the QFR <0.80 group. In addition, 32 patients had a ΔQFR ≥0, and 58 patients had a ΔQFR <0. Nine patients (9.9%) achieved the primary endpoint, including one patient with non-ST elevation myocardial infarction who received revascularization in both the LM-LAD and LCX arteries. In addition, nine patients (9.9%) reported no substantial improvement in their chest pain symptoms. Post-LCX-QFR <0.8 was associated with a higher 1-year incidence of cardiovascular death or MI (  = 0.036). ΔQFR proved to be a robust predictor of the 1-year incidence of the primary endpoint, with an incidence of 15.3% in the ΔQFR ≥0 group compared to 0% in the ΔQFR <0 group (area under the curve: 0.822; 95% CI: 0.728-0.895,  < 0.001), especially when ΔQFR ≤-0.03. After the LM-LAD single-stent strategy for LM bifurcation lesions, a ΔQFR of LCX ≤-0.03 was associated with a higher risk of 1-year main adverse cardiac events, indicating the superior prognostic value of the post-PCI physiological assessment.

We report the case of a 47-year-old woman who was admitted to the cardiac department for worsening dyspnea. The last chest computed tomography (CT) showed a rapid increase in pulmory artery dimension (65 mm in 2019, 76 mm in 2021). The symptoms reported by the patient were due to important extrinsic compression of the left main corory artery (LMCA). In this case, it is very difficult to choose the best therapeutic strategy. In the end, we decided to treat the left main corory for prevention. After 3 months no new clinical symptoms have developed.

The prevalence of congenital left main coronary artery atresia is very low. We report the characteristics and long-term outcomes of four children with left main coronary artery atresia. Three patients had heart murmurs due to mitral regurgitation at less than 1 year old. Their myocardial ischaemia worsened on exercise with aging. In the fourth patient, hypertrophic cardiomyopathy and Noonan syndrome were suspected at 1 year old. The development of communicating arteries between the conus branch and the left anterior descending artery was detected at 7 years old. The left main coronary artery atresia was confirmed by a selective coronary angiogram at 15 years old. Congenital left main coronary artery atresia could not be diagnosed by two-dimensional echocardiography; however, the left coronary arteries were small. Two patients underwent coronary artery bypass grafting of the left anterior descending artery using the left internal thoracic artery at 3 years and 6 years old, respectively. Two patients had an angioplasty with a cut back at the orifice of the left coronary artery at 2 years old and 17 years old, respectively. Two patients had no cardiac events without medication for more than 30 years after the operation. We must differentiate the diagnosis of left main coronary artery atresia in the small left coronary arteries with mitral regurgitation during the first year. Coronary artery revascularisation and mitral annuloplasty are needed. The long-term outcome of both coronary artery bypass grafting and angioplasty were good. The degree of mitral regurgitation after surgery may affect the prognosis.