Survival after Acute and Complete Occlusion of Left Main Stem

Emmert, MY; Salzberg, SP; Felix, Cordula; Grüenenfelder, Jürg; Falk, Volkmar

doi:10.1177/0218492310368438

Cited by 3 publications

(5 citation statements)

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“…Even in study populations considering ACS and LM lesions, however, RCTs have never included subjects with the gravest of coronary pathology circumstances: complete unprotected LM occlusion (uLMo). Only limited data has been published regarding true uLMo, in which the authors reported mostly fair results following either surgical or percutaneous emergency revascularization in such cases [ 5 – 7 ].…”

Section: Introductionmentioning

confidence: 99%

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

Édes

Ruzsa

Lux

et al. 2018

pwki

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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.

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Section: Introductionmentioning

confidence: 99%

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

Édes

Ruzsa

Lux

et al. 2018

pwki

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“…Results. L eft main coronary artery disease (LMD) is a wellestablished risk factor for cardiac-related adverse events [1][2][3][4][5] and is generally associated with a higher calcific load of the aorta and other peripheral arteries [6,7]. As implemented in the commonly accepted guidelines of the American Heart Association (with a level of evidence: A), coronary artery bypass graft surgery (CABG) remains the method of choice for patients with LMD [8].…”

Section: Methods From 2002 To 2007 983 Patients Underwent Myocardial Revascularization At Our Institution We Compared 343 Opcabg Patientsmentioning

confidence: 99%

Despite modern off-pump coronary artery bypass grafting women fare worse than men☆

Emmert

Salzberg

Seifert

et al. 2010

Interactive CardioVascular and Thoracic Surgery

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Female gender is an established risk factor for worse outcomes after cardiac surgery. Avoiding cardiopulmonary bypass (CPB) for coronary bypass grafting has an unknown effect on gender differences. Herein, we evaluate if gender has an impact on outcomes after modern off-pump coronary artery bypass grafting (OPCAB). From 2002 to 2007, we analyzed 983 patients (male: n=807/female: n=176) who underwent OPCAB with symptomatic multi-vessel disease at our institution. The link between gender and outcome was assessed by multivariate analysis and logistic regression. A composite endpoint was constructed from: 30-day-mortality, renal failure, prolonged intensive care unit (ICU) stay, neurological complications, use of intra-aortic balloon pump (IABP) and conversion to CPB. Mortality was 3.2% in women vs.1.8% in men (P=0.15) and the EuroSCORE was significantly correlated to gender (6.8 vs. 5.2; P<0.001), even after correction (P=0.036). Significant more occurrence of the composite endpoint was noted in women (39.8% vs. 29.0%; P=0.007) whereas for men the risk was much lower [odds ratio (OR) 0.65; 95% confidence interval (CI) 0.46-0.92; P=0.015]. For both genders the logistic regression revealed a risk increase of 15% per one-point-increase of EuroSCORE (corrected) (OR 1.15; 95% CI: 1.10-1.19; P<0.0001). Women had more frequently a prolonged stay at ICU (P=0.006) and had a higher stroke rate (2.3% vs. 1.2%; P=0.29). Complete revascularization was achieved similarly (95% vs. 94%; P=0.93). OPCAB offers low mortality and excellent clinical outcome. Women are more likely to experience postoperative complications. Even if partially neutralized by avoiding CPB, gender differences remain present with modern OPCAB strategies.

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“…3 The left main artery lesions are classified into 4 morphological types: ostial, body, distal, and diffuse. 2 Figure 1A provided by Emmert and colleagues 1 does not show total occlusion of the LMCA because the stem of the LMCA is clearly opacified. Figure 1A demonstrates a distal type III left main lesion or total distal occlusion of the LMCA.…”

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confidence: 96%

“…I read with interest the paper of Emmert and colleagues 1 with the provided images. I would like to make the following remarks.…”

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confidence: 99%

“…5 The mortality rate of patients with left main shock syndrome undergoing emergency CABG is particularly high. 2 –4 Whether on-pump beating-heart CABG as performed by Emmert and colleagues 1 is appropriate in high-risk patients with left main shock syndrome has yet to be determined. Their delayed decision to insert an intraaortic balloon just prior to induction of anesthesia is, in my opinion, erroneous, and led to circulatory decompensation and cardiopulmonary resuscitation with internal direct cardiac massage, which exposed their critically ill patient to further risks before CABG.…”

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confidence: 99%

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