Left main intervention revisited: early and late outcome of PTCA and stenting

Outcomes After Left Main Percutaneous Coronary Intervention in Patients With Acute Myocardial Infarction Complicated by Cardiogenic Shock (from the German ALKK PCI Registry)

Early revascularization therapy with percutaneous coronary intervention (PCI) has been shown to improve outcomes in patients with acute myocardial infarction (AMI) complicated by cardiogenic shock (CS). Data from consecutive patients with AMI and CS treated with PCI enrolled into the prospective Arbeitsgemeinschaft Leitende Kardiologische Krankenhausärzte-PCI registry were centrally collected and analyzed. Patients were divided into 4 groups with PCI for left main (LM), 1-vessel, 2-vessel, and 3-vessel diseases. Patients' characteristics, procedural features, antithrombotic therapies, and in-hospital complications were compared between the 4 groups. Between 2010 and 2015 a total of 2,348 consecutive patients with AMI and CS were treated by PCI in 51 hospitals, 295 for LM (15 for protected, 280 for unprotected) and single-vessel (n = 491), 2-vessel (n = 524), and 3-vessel disease (n = 1,038). Thrombolysis in myocardial infarction 3 patency of the culprit lesion after PCI was 84.3%, 84.0%, 80.8%, and 84.6% in single-vessel, 2-vessel, 3-vessel disease, and LM PCI, respectively, whereas in-hospital mortality was 27.9%, 33.9%, 46.5%, and 55.9%. Bleeding rates were low (2.0%-2.3 %) and not different between groups. In a multivariate analysis a higher age, thrombolysis in myocardial infarction flow <3 after PCI, 3-vessel disease, and LM PCI were independent predictors of mortality. In conclusion, PCI of the LM is performed in about 12.5% of patients with AMI and CS and was associated with a high procedural success rate, whereas mortality is increased with LM PCI.

Electrocardiographic changes in patients with acute myocardial infarction caused by left main trunk occlusion

BACKGROUND

Left main trunk (LMT) occlusion is a rare angiographic finding. The primary purpose was to investigate the ECG pattern of patients with angiographic confirmation of LMT as culprit lesion.

METHODS

Forty-eight patients (32 men; mean age 73 years) with angiographic total (21 patients; 44%) or subtotal (27 patients; 56%) occlusion of the LMT were analyzed. Twenty patients (42%) were found to have concomitant coronary lesions. Eighteen patients (38%) required intra-aortic balloon pump support.

RESULTS

A significant left axis deviation was observed in 26 cases (54%) and an intraventricular conduction delay in 32 patients (67%). The average QRS width and QTc interval were 122 and 433 ms, respectively. ST-segment elevation in lead aVR occurred in 32 patients (67%). ST-segment elevation in leads V2-5 and in leads I and aVL [classic left anterior descending (LAD) type] was frequently observed (18 cases; 35%). In six patients (13%), a partial LAD type was observed with ST-segment elevation in leads I and aVL, but not in peripheral leads. The remaining patients showed ST-segment elevation only in peripheral leads (12 cases), in inferior leads III + aVF (six cases), whereas six patients had no ST-segment elevation. Diffuse ST-segment depression only (>6 leads) was observed in 15 cases (31%). Eighteen patients (38%) died during hospitalization.

CONCLUSION

ST-segment elevation in lead aVR or a LAD-type pattern can be associated with LMT disease. Other relevant aspects are the presence of cardiogenic shock at admission, the left axis deviation and marked prolongation of QTc interval and QRS width.

Clinical outcomes after PCI for acute coronary syndrome in unprotected left main coronary artery disease: insights from the Swiss Acute Left Main Coronary Vessel Percutaneous Management (SALVage) study

AIMS

Unprotected left main (ULM) coronary artery disease is encountered in 3%-10% of coronary angiograms and is associated with high mortality. The survival of patients with ULM disease presenting with acute coronary syndromes (ACS) depends on different variables and is lowest in those with cardiogenic shock (CS). The aim of the present study was to estimate the impact of baseline characteristics on the subsequent clinical outcome in patients treated by percutaneous coronary intervention (PCI) of ULM for ACS.

METHODS AND RESULTS

One hundred and thirty-four patients were retrieved from our database and followed by phone or physician visit. Patients were classified into two groups according to their presentation (CS/STEMI group: patients presenting with CS or ST-elevation myocardial infarction; NSTEMI/UA group: patients with non-STEMI or unstable angina). Data collected were baseline characteristics, procedural information, and clinical outcome. The primary endpoint was all-cause mortality at 6-month follow-up. The secondary end point was a composite of cardiac death, myocardial infarction, and any repeat revascularisation, i.e., major adverse cardiac events (MACE). Kaplan-Meier curves were computed for survival. Logistic regression determined that hypercholesterolaemia (OR 6.22, p=0.03), high pre-procedural TIMI score (OR 3.89, p=0.01), preserved left ventricular ejection fraction (OR 1.07, p=0.01) and LM as culprit lesion (OR 8.57, p=0.01) protected against development of CS. Primary outcome occurred in 44% of patients in the CS/STEMI group compared to 6% in the NSTEMI/UA group (p<0.001). MACE were observed in 30 patients (48%) of the CS/STEMI group and in 12 patients (19%) of the NSTEMI/UA group (p=0.001).

CONCLUSIONS

Acute coronary syndrome due to critical ULM stenosis is associated with high mortality even after successful PCI. Patients presenting with CS or STEMI are at particular risk.

Outcomes of primary percutaneous coronary intervention for acute myocardial infarction with unprotected left main coronary artery occlusion

BACKGROUND

We determined the in-hospital and the long-term outcomes of primary percutaneous coronary intervention (PCI) for acute left main coronary artery (LMCA) occlusion.

METHODS

Between 1988 and 2009, 72 patients with acute myocardial infarction (AMI) underwent primary PCI for unprotected LMCA occlusion. The short- and the long-term outcomes of primary PCI in these patients were retrospectively evaluated.

RESULTS

Upon arrival, cardiogenic shock was observed in 33 (46%) patients and cardiopulmonary arrest (CPA) in 12 (17%). Twenty-three (32%) required extracorporeal life support and 64 (89%) intra-aortic balloon pumping. Although successful reperfusion was achieved in 60 (83%) patients, in-hospital death was observed in 32 (44%). Multivariate analysis revealed predictors of in-hospital death to be CPA on arrival (RR, 7.05; 95% CI: 1.28-39.0; P = 0.025). During 1.7 ± 2.9 years of follow-up, 10 of the 40 hospital survivors died. All presenting CPA on arrival died within 2 years. Although the estimated survival of the all study patients was only 26.2% at 8 years by the Kaplan-Meier methods, those without shock/CPA on arrival showed nearly flat survival curve after 4 years.

CONCLUSIONS

Despite performance of primary PCI, patients with AMI due to LMCA occlusion were associated with >50% in-hospital mortality. Hemodynamic deficit upon arrival was the major determinant of their poor hospital outcomes. The hospital survivors, however, were associated with favorable long-term outcomes.

[Acute non protected main left coronary artery occlusion: a report of six cases treated by angioplasty]

AIM

Acute main left coronary artery occlusion is rarely observed during primary angioplasty in myocardial infarction. This retrospective study reports the results of six patients treated by angioplasty in a hospital without cardiac surgery department.

PATIENTS AND METHODS

From 2002 to 2009, 746 patients were treated by primary angioplasty for acute coronary syndromes with ST elevation. Among those patients, six (0,7%) had acute non protected main left coronary occlusion. We report clinical, angiographical data and follow-up.

RESULTS

The population was composed of six patients (five males) with an average age of 64+/-7 years. Five patients were admitted with cardiogenic shock and four were mechanically ventilated. Distal occlusion of main left coronary artery and dominant right coronary artery were noted in all cases. Sub-occluded lesion of right coronary artery was noted in one case. Successful procedure with bare metal stent was achieved in five cases. Mortality rate was 66% (n=4): three patients died in hospital and another 1 or 2 months later of congestive heart failure. Coronary artery bypass grafting was performed at 4 and 12 months later for two patients. They are alive after 12 and 72 months of follow-up.

CONCLUSION

We demonstrate the feasibility of percutaneous coronary intervention of acute main left coronary occlusion. Inspite successful procedure, intrahospital mortality rate is still high and prognosis is related to cardiogenic shock.

Percutaneous revascularization in acute myocardial infarction due to left main stem occlusion

Following the encouraging results of trials testing the effect of primary percutaneous coronary intervention (PCI) more cases of left main arterial stenosis (LMS) as culprit lesions in acute myocardial infarction (AMI) are being handled. Not many cases of primary PCI on LMS have been published. We present 12 cases of primary PCI on LMS. Eighty-three percent of the patients presented with cardiogenic shock and only 42% were discharged alive. Due to the high rate of cardiogenic shock at presentation, PCI seems to be the treatment of choice, over coronary artery bypass grafting (CABG), although one might consider using PCI as a bridge over to CABG.

Left main coronary artery stenosis: state-of-the-art

Patients with stenosis of the left main coronary artery present difficult challenges. The risks associated with this lesion have been known since the early days of angiography when patients were found to have increased mortality during follow-up. This information led to the general guidelines that surgical revascularization should be considered the treatment of choice in patients with significant left main coronary artery stenosis. Current advances in invasive cardiology have brought important information to the field. Intravascular ultrasound is now used routinely to evaluate angiographically indeterminate lesions with criteria now set forward as to what constitutes an indication for revascularization. Stents have even further dramatically changed the landscape. There are substantial issues, however, that need to addressed. These include the following: (1) the effect of specific lesion location on outcome - it is known that patients with distal bifurcation left main disease have worse outcome; (2) the potential for subacute thrombosis of the left main coronary artery; (3) the impact of left ventricular function and patient comorbidities irrespective of the degree and location of left main coronary artery stenosis; and (4) the risk-benefit ratio of stenting versus coronary artery bypass graft surgery. These issues are currently being addressed in two seminally important trials including the SYNTAX trial, which randomizes patients with left main and/or three-vessel disease to either coronary artery bypass graft surgery or a TAXUS drug-eluting stent. This trial is in the final stages of patient recruitment and will have important implications for the field. The other trial is the COMBAT trial, which is focused exclusively on left main coronary artery stenosis and randomizes patients with left main coronary artery disease either to a Sirolimus-eluting stent (Cypher, Johnson and Johnson Cordis, USA) or to coronary artery bypass graft surgery. The field of left main coronary artery disease continues to expand in terms of the evidence available for optimal patient evaluation and selection of treatment modalities.

Five-year outcomes after stenting of unprotected left main coronary artery stenosis in patients with normal left ventricular function

BACKGROUND

We analyzed the long-term (5-year) outcome of patients treated with stenting for unprotected left main coronary artery (LMCA) stenosis.

METHODS

Between January 1995 and September 2001, 187 consecutive patients with unprotected LMCA stenosis and normal left ventricular function underwent elective stenting. Patients were examined or interviewed after 1, 3 and 6 months, and every 4 months thereafter for the occurrence of major adverse cardiac events (MACE), including death, myocardial infarction (MI) and target lesion revascularization (TLR).

RESULTS

The procedural success rate was 99.5%. During hospitalization, there were no deaths and only one stent thrombosis. Six-month angiography in 162 patients (follow-up rate, 86.6%) showed a restenosis rate of 33.3%. During 5-year follow-up, there were 13 deaths (6 cardiac, 7 noncardiac) and 2 nonfatal MI. TLRs were required in 36 (20.9%) patients and new lesion revascularizations were required in 13 (5.0%) patients. At 1, 3 and 5 years, the cumulative probabilities for freedom from MACE were 79.9+/-1.8%, 77.5+/-2.5% and 77.5+/-2.5%, respectively.

CONCLUSION

The initial favorable outcomes of patients with normal left ventricular function after stenting of unprotected LMCA stenosis were sustained for up to 5 years.

Recurrent myocardial ischemia due to riding left main coronary artery bifurcation thrombus--noninterventional therapy with glycoprotein blocker and thrombolysis

BACKGROUND

Acute coronary syndrome (ACS) comprises different manifestations of coronary artery disease. Angiograms performed at the time of an ACS may present different coronary morphologies; mostly there are acute vessel occlusions, ruptured atherosclerotic plaques, or thrombotic lesions that require reperfusion therapy. In the presence of intracoronary thrombi localized in the left main coronary artery, the clinical situation is challenging. Hemodynamic situation, symptoms, and rhythm status may change immediately and entail high mortality. Catheter-based therapy and surgical revascularization are associated with a high mortality rate. A noninterventional approach may be chosen in patients with stable hemodynamics and reestablished perfusion.

METHODS AND PATIENT

We describe a patient with acute ST-elevation myocardial infarction with chest pain and stable hemodynamics. Angiography revealed a large thrombus in the left main coronary artery bifurcation with ostial subtotal narrowing of the circumflex and left anterior descending artery. However, coronary perfusion was maintained. Immediate treatment with the glycoprotein IIb/IIIa inhibitor abciximab was performed. The patient became asymptomatic. Angiography the next day showed no change in thrombus formation, so abciximab infusion was prolonged. Initial elevated enzymes decreased to normal values. Three days later the patient developed a new unstable angina with newly elevated cardiac enzymes. At this time, a thrombolytic agent was administered. Angiography 2 days later demonstrated normal coronaries.

CONCLUSION

This case demonstrates the impact of intracoronary thrombi on repetitive myocardial ischemia and the effectiveness of a noninterventional pharmacological approach for the treatment of acute myocardial infarction due to intracoronary thrombus even in the left main coronary bifurcation.

Left main coronary artery thrombus: a case series with different outcomes

Left main coronary artery (LMCA) thrombosis with acute myocardial infarction is an uncommon condition with an extremely high mortality. The small number of reported cases prevents the development of an evidence-based approach. Hence there are no clear-cut guidelines describing the best management approach for this condition. We describe our experience with six patients who presented with LMCA thrombosis and discuss the epidemiology, etiology and management options available for this high-risk subgroup.

Early and late clinical outcomes after primary stenting of the unprotected left main coronary artery stenosis in the setting of acute myocardial infarction

BACKGROUND

Acute left main coronary artery occlusion is a dramatic condition with very high mortality. The study was aimed to evaluate the effect of primary stenting in patients with left main coronary artery (LMCA) disease in the setting of acute myocardial infarction (AMI).

METHODS

Between June 1997 and April 2002, primary stenting for left main coronary artery disease was performed in 18 patients with acute myocardial infarction. We evaluated early and late clinical outcomes, and prognostic determinants in this clinical setting.

RESULTS

Mean ages of patients were 59 +/- 12 years. Fourteen patients had cardiogenic shock on admission. Angiographic success (TIMI flow > or = 2 and diameter stenosis < 30% after stenting) was achieved in 17 patients (94%). In-hospital death occurred in eight patients (44%). Two patients (11%) received emergent bypass surgery because of hemodynamic instability after primary stenting. On univariate analysis, good pre-intervention TIMI flow (grade > or = 2) was identified as a good prognostic determinant of in-hospital survival. During mean follow-up of 39 +/- 22 months, there was no late death and one patient received bypass surgery. Probability of freedom from death at 3-year was 56 +/- 12%.

CONCLUSION

Primary stenting is a valuable therapeutic strategy for left main coronary disease in the setting of acute myocardial infarction, and it might save the life especially in patients with good pre-intervention TIMI flow (grade > or = 2). Long-term clinical outcome of patients surviving to hospital discharge is favorable.

Long term follow up after elective percutaneous coronary intervention for unprotected non-bifurcational left main stenosis: is it time to change the guidelines?

BACKGROUND

According to the American College of Cardiology/American Heart Association guidelines, percutaneous coronary intervention (PCI) for left main coronary artery (LMCA) stenosis is contraindicated and coronary artery bypass graft surgery (CABG) is preferred. However, PCI of the LMCA is performed under exceptional circumstances.

OBJECTIVE

To analyse the data of patients who underwent PCI of the unprotected LMCA in St Antonius Hospital, Nieuwegein, Netherlands.

RESULTS

In a database of 17 683 PCI procedures, 71 patients (0.4%) were found with non-bifurcational LMCA stenosis who underwent an elective PCI between 1991 and 2001. Ages ranged from 26.7-86.5 years. Severe concomitant disease was the most frequent argument in favour of PCI instead of CABG. PCI consisted of only balloon angioplasty in 23 cases (32.4%). A stent was used in 46 cases (64.4%). Average follow up was 43 months (range 0-121 months). One patient died one day after the procedure. The total one year survival rate was 98.6% (70/71). Seven patients died during the follow up period, mostly because of non-cardiac reasons. The annual mortality rate was 2.5%. Recurrent elective percutaneous transluminal coronary angioplasty for restenosis of the LMCA was performed in one patient (1.4%) six weeks after the initial procedure. CABG was required in 13 patients (18.3%) throughout the follow up period.

CONCLUSION

These results suggest that at highly experienced centres, elective PCI of the non-bifurcational LMCA can be performed safely where the anatomy is suitable.

Effectiveness of sirolimus-eluting stent for treatment of left main coronary artery disease

The present study reports on the clinical outcome of 31 consecutive patients with left main coronary artery disease treated with a sirolimus-eluting stent. The implantation of this stent was associated with abolition of post-discharge fatal events and percutaneous reintervention.

Percutaneous reperfusion of left main coronary disease complicated by acute myocardial infarction

Previous studies have shown a benefit of a strategy of direct angioplasty and stenting in patients with acute myocardial infarction (AMI) complicated by early cardiogenic shock. However, few data exist for the subset of patients with left main trunk disease complicated by AMI and cardiogenic shock. We performed an analysis of patients with AMI who underwent mechanical intervention between January 1995 and December 2000. Out of 1,433 patients with ST segment elevation AMI treated with primary coronary angioplasty (PTCA), 22 patients (1.5%) had left main disease (LMD) as the culprit lesion. Baseline characteristics were age, 66 +/- 11 years; female gender, 9%; diabetes, 14%; previous myocardial infarction, 14%; mean systolic blood pressure, 77 +/- 24 mm Hg; time to treatment, 4.8 +/- 2.2 hr; TIMI 0-1, 77%; collateral flow (Rentrop grade >or= 2) 9%. The primary success rate was 91%. Primary stenting was performed in 17 patients (77%). The in-hospital mortality rate was 50%. All deaths were due to refractory shock. The 6-month survival rate was 41% +/- 1%, while the event-free survival rate was 27% +/- 10%. At 6-month follow-up, the mortality rate increased to 59%; the target vessel revascularization rate was 14%. A percutaneous mechanical intervention strategy in patients with left main disease complicated by AMI is feasible and effective, and patients discharged alive have a good mid-term prognosis.

Short- and long-term results of emergency and elective percutaneous interventions on left main coronary artery stenoses

In this prospective study, we analyzed the short- and long-term outcomes of percutaneous interventions on significant left main coronary artery (LM) stenoses. Between January 1998 and June 2000, 18 patients underwent emergency interventions on unprotected LM stenoses (group 1), while 15 patients had elective interventions on protected LM stenoses (group 2). Despite a procedural success of 88.9% in group 1, event-free in-hospital and mortality rates were 50.0% and 38.9%. After 6.4 +/- 4.4 months of follow-up, late event-free survival and mortality rates were 33.3% and 38.9%. In group 2, procedural success was 100%, with 100% event-free in-hospital survival; late event-free survival and mortality rates were 93.3% and 0% after 6.7 +/- 4.1 months of follow-up. Emergency interventions on LM stenoses remain a procedure with high acute and mid-term mortality. In spite of the high rate of major adverse cardiac events, an acceptable long-term survival can be achieved.

Long-term clinical outcomes after unprotected left main trunk percutaneous revascularization in 279 patients

BACKGROUND

Percutaneous coronary revascularization (PCI) has been increasingly applied to unprotected left main trunk (LMT) lesions, with varied long-term success. This study attempts to define the predictors of outcome in this population.

METHODS AND RESULTS

Two hundred seventy-nine consecutive patients who had LMT PCI at 1 of 25 sites between 1993 and 1998 were studied. Forty-six percent of these patients were deemed inoperable or at high surgical risk. Thirty-eight patients (13.7%) died in hospital, and the rest were followed up for a mean of 19 months. The 1-year incidence was 24.2% for all-cause mortality, 20.2% for cardiac mortality, 9.8% for myocardial infarction, and 9.4% for CABG. Independent correlates of all-cause mortality were left ventricular ejection fraction </=30%, mitral regurgitation grade 3 or 4, presentation with myocardial infarction and shock, creatinine >/=2.0 mg/dL, and severe lesion calcification. For the 32% of patients <65 years old with left ventricular ejection fraction >30% and without shock, the prevalence of these adverse risk factors was low. No periprocedural deaths were observed in this low-risk subset, and the 1-year mortality was only 3.4%.

CONCLUSIONS

Patients undergoing unprotected LMT PCI have frequent serious comorbidities and consequently have high event rates. PCI may be an alternative to CABG for a select proportion of elective patients and may also be appropriate for highly symptomatic inoperable patients. Meticulous follow-up of hospital survivors is required because of the rather high mortality during the first few months after treatment.

Effect of primary angioplasty on total or subtotal left main occlusion: analysis of incidence, clinical features, outcomes, and prognostic determinants

BACKGROUND

Although acute left main coronary artery (LMCA) occlusion is a rare clinical entity, it carries a very high mortality rate. The purposes of this study were to evaluate the effect of primary angioplasty for a severely obstructed or totally occluded LMCA, and to determine the incidence, clinical features, outcome, and prognostic determinants in this clinical setting.

MATERIALS AND METHODS

Between May 1993 and July 2000, a total of 740 patients with acute myocardial infarction underwent primary angioplasty in our hospital. Eighteen of 740 patients (2.4%) with a severely obstructed or totally occluded LMCA constituted the population of this study.

RESULTS

Seventeen of 18 patients (94.4%) experienced pulmonary edema (including 14 patients in cardiogenic shock). Six patients (33.3%) sustained sudden death due to malignant ventricular tachyarrhythmias. Coronary angiography showed that there were variable grade flow of intercoronary collaterals in 12 patients (66.7%), a totally occluded LMCA in 8 patients (44.4%), an incompletely occluded LMCA in 10 patients (55.6%), and a dominant right coronary artery (RCA) in 16 patients (88.9%). Primary angioplasty of the LMCA was performed with a 72.2% procedural success rate. Four patients (22.2%) received coronary artery bypass surgery after angioplasty. Six patients (33.3%) died in the hospital. Two patients died after discharge. Ten of 18 patients (55.6%) survived in long-term follow-up (mean +/- SD, 44 +/- 14 months). Those patients who survived to be discharged had significantly higher combined coexisting incidence of intercoronary collaterals, dominant RCA, and incompletely occluded LMCA (100% vs 0.0%, p = 0.0006) than those patients who died in the hospital.

CONCLUSIONS

Acute obstructive LMCA disease generally presented as pulmonary edema, cardiogenic shock, or sudden death. Only those who had combined coexistence of intercoronary collaterals, a dominant RCA, and an incompletely occluded LMCA could survive to be discharged. Our experience suggests that primary LMCA angioplasty is a feasible and effective procedure, and it may save lives in this clinical setting.

Factors predicting mortality in patients after myocardial infarction caused by left main coronary artery occlusion: significance of ST segment elevation in both aVR and aVL leads

Acute left main coronary artery obstruction is rare and most patients in this clinical setting die of sudden death or cardiogenic shock. During the past 8 years, we encountered 13 patients with acute myocardial infarction caused by total occlusion of the left main coronary artery (LMCA-AMI). Thus, we surveyed these patients, and attempted to elucidate helpful predictors related to the prognosis. Six of 13 patients with LMCA-AMI survived. Successful left coronary artery dilatation was achieved in all survivors (group S), and in 5 (71%) non-survivors (group non-S). The age was not different between the two groups. A past history of angina was confirmed in 83% of group S. while only in 29% of group non-S. Clinical findings such as time of onset of AMI, interval from the AMI onset to admission, elapsed period from the AMI onset to recanalization of LMCA and the value of CK on admission were not different between the two groups. However, cardiogenic shock occurred in only 1 patient (17%) in group S compared with 5 patients (71%) in group non-S. As emphasized in the literature, good collateral circulation to the left anterior descending artery was observed in 5 patients (83%) in group S, while not observed in group non-S. Electro cardiographically, ST elevation in the aVR lead was very characteristic. This finding was confirmed in 69% of the total patients. Noticeably, 5 out of 6 non-survivors (83%) showed ST elevation not only in leads aVR but also in the aVL lead. In addition to the absence of collateral circulation, this electrocardiographic finding, which obviously indicates the presence of extensive myocardial ischemia in the diseased heart, is a simple and important predictor suggesting a poor prognosis in LMCA-AMI patients.

Catheter-based reperfusion of unprotected left main stenosis during an acute myocardial infarction (the ULTIMA experience). Unprotected Left Main Trunk Intervention Multi-center Assessment

The ULTIMA registry was a prospective, multicenter, international registry of 277 patients who underwent percutaneous coronary interventions of unprotected left main trunk stenosis. The 40 patients who underwent an emergency percutaneous left main intervention for acute myocardial infarction are the focus of this study. We compared the results of primary angioplasty with primary stenting, characterizing both the short-term (in-hospital) and long-term (12-month) outcomes. Of the 40 patients, 23 underwent primary angioplasty, whereas 17 underwent primary stenting. The angiographic success rate was an 88% for the cohort. The in-hospital death or coronary artery bypass grafting rate was 65% for the entire group, 74% for the percutaneous transluminal coronary angioplasty group (PTCA), and 53% for the stent group (p = 0.2). The in-hospital death rate was 55% for the entire cohort, 70% for the PTCA group, and 35% for the stent group (p = 0.1). The 12-month rate of death or bypass surgery was 83% and 58% for the PTCA and stent groups, respectively (p = 0.047). The 12-month survival rate was 35% and 53% for the PTCA and stent groups, respectively (p = 0.18). Bypass surgery was required in 6 patients in the PTCA group and 2 patients in the stent group (p = 0.07). Patients undergoing percutaneous interventions for unprotected left main myocardial stenosis during an acute myocardial infarction are critically ill; an initial percutaneous revascularization approach appears feasible and may be the preferred revascularization strategy. Primary stenting was associated with improved clinical outcomes.

Intravascular ultrasound predictors of target lesion revascularization after stenting of protected left main coronary artery stenoses

We evaluated the predictors of late clinical outcomes after stenting of protected left main coronary artery (LMCA) stenoses. Intravascular ultrasound (IVUS) guided stenting of protected LMCA stenoses was performed in 87 consecutive patients between January 1994 and December 1996. Results were evaluated using conventional (clinical, angiographic, and IVUS) methodology. Late (12 month) clinical follow-up information was obtained in all patients. Initial procedural success was achieved in 86 patients (99%). There was 1 in-hospital death (in the 1 patient with a procedural failure). There were no other in-hospital complications, including Q-wave myocardial infarction, emergency bypass surgery, or repeat coronary angioplasty. The overall target lesion revascularization (TLR) rate was 13%. Using multivariate logistic regression analysis, the only independent predictor of TLR was the postintervention lumen area by IVUS. A final lumen area > or =7.0 mm2 was obtained in 74 patients (86%); the TLR rate for these patients was 7%. This was compared with patients with a final lumen area <7.0 mm2 in whom the TLR rate was 50% (p = 0.0011). Stenting of protected LMCA stenoses is safe and effective with acceptable long-term clinical outcomes. The most important factor determining long-term success was the postintervention lumen area by IVUS.