Caution when reading „A word of caution”

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Stefan Dan Cezar Mot1 *


1 1st Department of Cardiology, „N. Stancioiu” Heart Institute, Cluj-Napoca, Romania
* This editorial reflects the views and opinions of the authors and does not necessarily represent the views and official position of the Romanian Journal of Cardiology. The editorial board and the publisher disclaim any responsibility or liability for the materials. The authors are liable for the content of the articles.


I read the online published letter-to-editor by Dregoesc and Iancu1 and I must admit that I was disappoin-ted (not to say disgusted) by the unfriendly manner of presenting their point of view.
Firstly, I will begin with the particular emphasize of the two authors regarding the use of IVUS for the LM PCI: there is not yet any published randomized trial comparing the LM PCI with or without IVUS, all the results and recommended dimensions are the results of retrospective, pooled analyses, or registries2-7 as the 2018 ESC Guidelines on Myocardial Revasculari-zation are stating: of course the use of IVUS must be favoured (class IIA) but is still a long distance to a class I recommendation, this why we are maybe in the need of a large trial as the ongoing MAIN EBC8. I strongly agree with the important aspects of the role of IVUS in the assessment of intermediate lesions, but this is a domain of discussion, with different data coming from above cited studies; that’s why we are still having a „grey area” between the cutoff of >6 mm2 MLA (Mi-nimal Luminal Area) where there is a clear indication for conservative treatment5 and the <4.5 mm2 where is strong correlation with FFR, indicating the need for revascularization6. I agree also with the role of IVUS in Acute Coronary Syndromes, but this was not the sub-ject of our published article!!! Putting an accent only on IVUS, forgetting other aspects as: choosing the ri-ght patient, techniques for revascularization, alternati-ve imaging modalities as FFR or OCT, as the authors of the Letter to Editor are doing is clearly indicating that searching for the Internet Data Base is more important for them that having a professional backgro-und in treating that kind of patients and lesions.
Secondly, not citing the 2018 ESC Guideline for Myocardial Revascularization can be looked as a mista-ke; BUT: all the other references of the article where in fact the source of that document; this was in fact a proof of modesty, since the author of the article represented the Romanian Society of Cardiology, as a re-viewer, in elaborating those Guidelines9.
Thirdly, regarding some „minor inadequacies”: „lower quality of DES” means that there is a proof that Everolimus stent is now known the best in class10-11, „large non compliant balloons” are defi ned by Expert consensus as balloons with a diameter >4.5 mm2, and still images that were shown in the article are examples of different techniques used in the prac-tical experience of the author when treating patients with LM disease, but again, this is very well known by people working in cath-labs and less by those doing only research.
Finally, it looks to me that treating LM disease is po-larizing people involved in Myocardial Revascularizati-on techniques (Interventional Cardiologists, Surgeons, Researchers) more than the way it happened when TAVI procedures appeared! Certainly, seeing the af-ter-words resulted in the publication of the EXCEL data, that any study can compare, in a scientific way, the major clinical outcomes of the patients with LM disease is helpful, and the work of the authors has to be respected by the Cardiology Community.

Conflict of interest: none declared.

References
1. Dregoesc I.M, Iancu A. C. A word of caution Romanian Journal of Cardiology |-Vol. 29, No. 4, 2019)
2. De la Torre Hernandez JM, Hernández Hernandez F, Alfonso F, Ru-moroso JR, Lopez-Palop R, Sadaba M, Carrillo P, Rondan J, Lozano I, Ruiz Nodar JM, Baz JA, Fernandez Nofrerias E, Pajin F, Garcia Camarero T, Gutierrez H; LITRO Study Group (Spanish Working Group on Interventional Cardiology). Prospective application of pre-defined intravascular ultrasound criteria for assessment of interme-diate left main coronary artery lesions results from the multicenter LITRO study. J Am Coll Cardiol 2011;58:351–358.
3. Park S-J, Ahn J-M, Kang S-J, Yoon S-H, Koo B-K, Lee J-Y, Kim W-J, Park D-W, Lee S-W, Kim Y-H, Lee CW, Park S-W. Intravascular ultrasound-derived minimal lumen area criteria for functionally sig-nificant left main coronary artery stenosis. JACC Cardiovasc Interv 2014;7:868–874
4. Kang S-J, Ahn J-M, Song H, Kim W-J, Lee J-Y, Park D-W, Yun S-C, Lee S-W, KimY-H, Lee CW, Mintz GS, Park S-W, Park S-J. Com-prehensive intravascular management of left main disease using ul-trasound assessment of stent area and its impact on restenosis and adverse cardiac events in 403 patients with unprotected left main disease. Circ Cardiovasc Interv 2011;4:562–569.
5. De la Torre Hernandez JM, Baz Alonso JA, Gómez Hospital JA, Al-fonso Manterola F, Garcia Camarero T, Gimeno de Carlos F, Roura Ferrer G, Recalde AS, Martínez-Luengas IL, Gomez Lara J, Hernan-dez Hernandez F, Pérez-Vizcayno MJ, Cequier Fillat A, Perez de Pra-do A, Gonzalez-Trevilla AA, Jimenez Navarro MF, Mauri Ferre J, Fer-nandez Diaz JA, Pinar Bermudez E, Zueco Gil J; IVUS-TRONCO-ICP Spanish study. Clinical impact of intravascular ultrasound guidance in drug-eluting stent implantation for unprotected left main coronary disease: pooled analysis at the patient-level of 4 registries. JACC Cardiovasc Interv 2014;7:244–254.
6. Park S-J, Kim Y-H, Park D-W, Lee S-W, Kim W-J, Suh J, Yun S-C, Lee CW, Hong M-K, Lee J-H, Park S-W; MAIN-COMPARE Investigators. Impact of intravascular ultrasound guidance on long-term mortality in stenting for unprotected left main coronary artery ste-nosis. Circ Cardiovasc Interv 2009;2:167–177.
7. Andell P, Karlsson S, Mohammad MA, Götberg M, James S, Jensen J, Fröbert O, Angerås O, Nilsson J, Omerovic E, Lagerqvist B, Pers-son J, Koul S, Erlinge D. Intravascular ultrasound guidance is asso-ciated with better outcome in patientsundergoing unprotected left main coronary artery stenting compared with angiography guidance alone. Circ Cardiovasc Interv 2017; Chieffo A, Hildick-Smith D. The European Bifurcation Club Left Main Study (EBC MAIN): rationale and design of an international, multicentre, randomized comparison of two stent strategies for the treatment of left main coronary bifur-cation disease. EuroIntervention 2016;12:47–52.
8. Franz-Josef Neumann, Miguel Sousa-Uva, Anders Ahlsson, Fernan-do Alfonso, Adrian P Banning, Umberto Benedetto, Robert A By-rne, Jean-Philippe Collet, Volkmar Falk, Stuart J Head et all 2018 ESC/EACTS Guidelines on myocardial revascularization European Heart Journal, Volume 40, Issue 2, 07 January 2019, Page 157 https:// doi.org/10.1093/eurheartj/ehy394
9. Mehilli J, Richardt G, Valgimigli M, Schulz S, Singh A, Abdel-Wahab M, Tiroch K,Pache J, Hausleiter J, Byrne RA, Ott I, Ibrahim T, Fusaro M, Seyfarth M, LaugwitzK-L, Massberg S, Kastrati A; ISAR-LEFT-MAIN 2 Study Investigators. Zotarolimus- versus everolimus-eluting stents for unprotected left main coronary artery disease. J Am Coll Cardiol 2013;62:2075–2082.
10. Lee PH, Kwon O, Ahn J-M, Lee CH, Kang D-Y, Lee J-B, Kang S-J, Lee S-W, Kim Y-H, Lee CW, Park S-W, Park D-W, Park S-J. Safe-ty and effectiveness of second generation drug-eluting stents in patients with left main coronary artery disease.J Am Coll Cardiol 2018;71:832–841.
11. Lassen JF, Burzotta F, Banning AP, Lefèvre T, Darremont O, Hildick-Smith D, Chieffo A, Pan M, Holm NR, Louvard Y, Stankovic G. Per-cutaneous coronary intervention for the Left Main stem and other bifurcation lesions. The 12(th) consensus document from the Euro-pean Bifurcation Club. EuroIntervention 2018; 13:1540–1553.

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