Acute, total occlusion of the left main stem: coronary intervention options, outcomes, and recommendations

Abstract

IntroductionAcute, total occlusion of the unprotected left main stem (uLMo) in acute coronary syndrome (ACS) patients is a catastrophic event often accompanied by sudden cardiac death (SCD) and/or cardiogenic shock (CS) with high mortality rates and limited methods of successful treatment. Emergent, surgical and percutaneous revascularization has been reported before, yet comprehensive data remains scarce.AimTo examine emergency percutaneous coronary intervention (PCI) outcomes in ACS cases presenting with uLMo.Material and methodsData on 23 subjects undergoing primary PCI in uLMo cases were analyzed. The primary end-point was in-hospital death; secondary end-points were successful salvage of coronary anatomy and 90-day major cardiac adverse events (MACE).ResultsAbout 40% of LM occlusion cases presented following successful on-site cardio-pulmonary resuscitation (CPR). Of all patients arriving for treatment the occluded LM was successfully opened and stented in ~90% of cases. CS was present in > 85% of cases, and circulatory support in the form of intra-aortic balloon pump and/or extracorporeal membrane oxygenation systems was applied in every eligible case (~80%). The in-hospital death rate was 56%, mostly including individuals requiring prior CPR. At 6 months, additional MACE rates were low at 8.7%.ConclusionsWe found that uLMo ACS cases often present with preceding CPR and mostly in manifest CS. Coronary salvage is generally successful, yet uLMo even with optimal present day complex treatment yields quite high mortality rates. This is especially true for patients receiving prior CPR. In surviving patients, however, 6-month MACE rates are acceptable.

A 44 years-old male patient surviving total occlusion of the left main coronary artery (STEMI) accompanied with cardiogenic shock

“…ST-segment elevation in aVR and/or V1 and widespread ST-segment depression usually raises the suspicion of LMCA occlusion [ 8 ]. Cardiogenic shock is the most common complication of LMCA occlusion, it may present in more than 85% of cases [ 9 ], and therefore, it also indicates LMCA occlusion. The mortality rate is high with LMCA occlusion compared to lesions in other vessels and >50% of patients require CPR at some point [ 9 ].…”

Successful treatment of left main coronary artery total occlusion combined with cardiogenic shock

“…The incidence of cardiogenic shock in such patients can be as high as 50%, and is a significant independent predictor of mortality. 5,6 Patients with myocardial infarction complicated with cardiogenic shock are commonly treated with IABP. However, previous studies have suggested that placement of an IABP in AMI patients with cardiogenic shock under coronary angiography does not reduce the incidence of major adverse cardiovascular events, and is significantly associated with increased mortality.…”

Electrocardiographic signs of the left main coronary artery disease in acute coronary syndrome

“…Паттерн ИМпST -это подъем ST в прекордиальных отведениях в сочетании с элевацией в aVR [4,26] или без нее [9] при окклюзии СтЛКА в отсутствие коллатерального кровотока. Данная ЭКГ-картина встречается в 37,5% всех случаев верифицированной тромботической окклюзии СтЛКА [10].…”

“…СтЛКА обеспечивает кровоснабжение 75% массы левого желудочка (ЛЖ) у пациентов с "правым" или "сбалансированным" типом кровоснабжения и 100% в случае "левого" типа. В связи с этим тяжёлые поражения СтЛКА приводят к нарушению кровоснабжения большей части миокарда ЛЖ с высоким риском угрожающих жизни событий, связанных с дисфункцией ЛЖ, фатальными аритмиями [1][2][3][4][5].…”

“…Острая полная окклюзия СтЛКА встречается нечасто и заканчивается внезапной смертью или кардиогенным шоком (КШ) с высокой, до 80%, госпитальной летальностью [9]. Частота КШ при поражении СтЛКА cоставляет 74-87% и почти в 3 раза выше при тотальной окклюзии СтЛКА по сравнению с субтотальной (85% и 29%, соответственно) [4,8,10]. В многоцентровом исследовании IABP-SHOCK II 8,9% больных с КШ имели поражение СтЛКА в качестве инфарктсвязанной артерии [11].…”