Left main and multivessel coronary artery stenting for patients deemed inoperable—A real need for a tandem approach

While the occurrence of serious adverse events with percutaneous coronary intervention (PCI) is generally low, there is a spectrum of risk, and some patientrelated and anatomy-related factors are clearly predictive of higher event rates. Many angiographic features are well recognized to be predictive of worse outcome and include: ostial location, total occlusion, bifurcation, long lesions, heavy calcification, tortuosity, angulation, and location and extent of disease. The Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery (SYNTAX) score [1] is a cumulative assessment of the coronary anatomic features for all lesions to be treated, and it is based upon an amalgamation of several modified risk scores including the ACC/AHA Classification System [2]. Likewise, scoring systems for estimating the perioperative risk associated with coronary artery bypass surgery (CABG) are also established, such as the European System for Cardiac Operative Risk Evaluation (EuroSCORE) [3], and have been weighted mainly with patient-related factors including: advanced age, severe ventricular dysfunction, significant concomitant valvular heart disease, renal insufficiency, and recent myocardial infarction. Many components of the EuroSCORE also impact outcome associated with PCI. Taken together, patients with left main and extensive coronary artery disease (ie, a high SYNTAX score) and who have been separately deemed unattractive for bypass surgery or frankly inoperable (ie, due in part to a high EuroSCORE) represent the end of the spectrum of patients at very high risk for adverse events with PCI. In this issue of Catheterization and Cardiovascular Interventions, Vranckx et al [4] consider such a group of patients, those with unprotected left main coronary artery stenoses and also considered inoperable or at an unacceptably high risk for adverse events with CABG. What is unique about this particular case-series report is the use of the TandemHeartVR mechanical circulatory support device during PCI. During a 6-year interval, these investigators performed very high-risk PCI for nine such patients using the TandemHeartVR with a median SYNTAX Score of 43 and a median EuroSCORE of 13.6. For perspective, the average SYNTAX and EuroSCORE values in the SYNTAX trial of 1,800 patients with left main and multivessel CAD were markedly lower at 29 and 3.8, respectively [5]. Among the PCI-treated patients in the SYNTAX trial, the 12-month mortality was 4.4%. Impressively, in the current case series of ultra-high-risk patients, there was no in-hospital death, and the morality rate at 6 months was 11.1%. These outcomes are noteworthy considering the EuroSCORE in the present case series is roughly 10 points higher than in the SYNTAX trial. The real-world French Left Main Taxus Registry [6] investigators recently reported that the relative risk of mortality increased by 15% for every 1-point increase in EuroSCORE, which perfectly relates the current case-series report to the SYNTAX trial observations (152% higher mortality rate and 9.8-point higher EuroSCORE). What is not surprising and a recognized challenge in such ill patients, is the risk of vascular compromise or injury from large-bore vascular cannulae. Vranckx et al. [4] reported that access site complications occurred in four of their nine patients, three of whom required vascular surgical intervention. Among the patients requiring vascular surgery, two had established peripheral arterial disease and had been treated with