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Clinical Briefing: Left Main Coronary Stenting in High-Risk Patients

May / June 2006

Traditionally, left main coronary artery disease has been optimally treated with surgical revascularization with low mortality rates and high long-term success. However, patients with advanced age and/or co-morbidities including left ventricular dysfunction and renal disease are at significantly higher risk.

Recent advances in stent technology, namely drug-eluting stents, have improved the outcome of left main percutaneous coronary intervention. In addition, the development of percutaneous left ventricular assist devices, such as the TandemHeart® have allowed safe interventions in patients previously deemed ineligible for treatment.

“Penn interventionalists were among the first in the nation to have access to drug-eluting stents and ventricular assist devices as part of clinical trials. We continue to offer new therapies for high-risk patients with coronary artery disease, including the novel Conor stent and mesenchymal stem cell therapy to potentially regenerate myocardium.” – Howard C. Herrmann, MD

Case Study
Mr. K is an 80 year-old man with severe COPD and chronic renal insufficiency, who presented with unstable angina. Echocardiography showed severe left ventricular dysfunction (ejection fraction 10%), anterolateral wall akinesis and moderate mitral regurgitation. Cardiac catheterization revealed a 95% distal left main stenosis that involved the ostia of both the left circumflex and left anterior descending (LAD) arteries. The LAD was subtotally occluded with TIMI 1 flow.

His cardiologist referred him to the Hospital of the University of Pennsylvania (HUP) for treatment. Positron emission tomography (PET) revealed lateral wall ischemia and high anterolateral region viability. The patient was felt to be at high risk for surgical revascularization due to his multiple co-morbid conditions.

A TandemHeart® percutaneous left ventricular assist device was inserted transseptally to provide hemodynamic support during PCI. Left atrial to distal aorta bypass with a non-pulsatile flow rate of 3.0 liters/min was achieved.

Two sirolimus-eluting stents were simultaneously deployed with a “kissing” technique with an excellent result and stable hemodynamics. The patient was discharged two days later and remains angina-free at one year.

Clinical Trials

• COSTAR II Stent Trial - This trial is comparing a unique drug-eluting stent system (Conor Medsystems Inc.) that does not require a polymer to be loaded with paclitaxel with the Taxus polymer-based stent for prevention of restenosis.
• Provacel Trial - Uses adult mesenchymal stem cells made by Osiris Therapeutics Inc. to treat and potentially regenerate myocardium in patients after large myocardial infarctions.
• EVEREST II - A randomized trial comparing Evalve's percutaneous edge-to-edge mitral clip repair system to surgery for patients with mitral regurgitation.
• MIST 2 - A randomized trial comparing percutaneous PFO closure with NMT Medical Inc.'s STARFlex device to sham treatment in the prevention of migraine headaches.
• TOPSPIN - An early phase trial examining the utility of a novel magnetic resonance catheter for the identification of vulnerable plaques.
• CHAMPION PCI - A randomized trial comparing a new platelet ADP antagonist, intravenous cangrelor, with clopidogrel in patients undergoing PCI.

About Our Team
Our board-certified interventional cardiologists are dedicated exclusively to performing percutaneous coronary and non-coronary interventions. Over the past 5 years, our team has been involved in more than a dozen clinical trials providing access to novel drugs and devices for improving patient care before these treatments were generally available.

Several members of our staff serve on editorial boards of prestigious journals, including Circulation, Journal of the American College of Cardiology, American Journal of Cardiology, Catheterization and Cardiovascular Interventions, Journal of Invasive Cardiology and are recognized in Best Doctors in America® and Philadelphia magazine’s “Top Docs” issue.

Catheterization Laboratories
Hospital of the University of Pennsylvania

Howard C. Herrmann, MD
Professor of Medicine
Director, Interventional Cardiology and Cardiac Catheterization Laboratories

Ruchira Glaser, MD
Assistant Professor of Medicine

John W. Hirshfeld, Jr., MD
Professor of Medicine
Director, Interventional Training

Daniel M. Kolansky, MD
Associate Professor of Medicine
Director, Cardiac Care Unit

Robert L. Wilensky, MD
Associate Professor of Medicine
Director, Interventional Cardiology Research

Areas of Expertise

• Complex Coronary Intervention
• Valvular Heart Disease
• Structural and Congenital Heart Disease
• Intravascular and Intracardiac Echocardiography
• Coronary MRI

Access
Patient appointments are available at:

Hospital of the University of Pennsylvania
Ground Rhoads
3400 Spruce Street
Philadelphia, PA

Penn Medicine at Radnor
250 King of Prussia Road
Radnor, PA

To refer a patient and/or consult with a doctor:

• Call PENNHealth: 1-800-789-PENN, or
• Penn Cardiac Care web site

Please contact your UPHS physician liaison with any concerns or problems you may experience when referring your patient.

Locations

• Hospital of the University of Pennsylvania
• Penn Medicine at Radnor

	Referring Physicians: To speak with a Penn physician or refer a patient, contact PennHealth through the secure online referral form or by calling 1-800-789-PENN (7366).