Mechanical emergency recanalization of the left main coronary artery

Qualitative Interviews to Better Understand the Patient Experience and Evaluate Patient-Reported Outcomes (PRO) in RLBP1 Retinitis Pigmentosa (RLBP1 RP)

INTRODUCTION

RLBP1 RP is an autosomal recessive form of retinitis pigmentosa (RP), characterized by night blindness, prolonged dark adaptation, constricted visual fields and impaired macular function. This study aimed to better understand the patient experience of RLBP1 RP and evaluate the content validity of existing patient reported outcome (PRO) instruments in this condition.

METHODS

Semi-structured concept elicitation and cognitive debriefing interviews were conducted with RLBP1 RP patients in Canada and Sweden. Interviews started with open-ended concept elicitation questioning, and then patients were cognitively debriefed on The National Eye Institute Visual Functioning Questionnaire (NEI VFQ-25), the Low Luminance Questionnaire (LLQ) and four light/dark adaptation items of the Visual Activities Questionnaire (VAQ). Qualitative interviews were also conducted with three expert clinicians. Anonymized, verbatim transcripts were analyzed using thematic analysis.

RESULTS

Twenty-one patients were interviewed (Canada n = 10; Sweden n = 11). Symptoms reported included night blindness (n = 21), difficulty adapting to changes in lighting (n = 21) and difficulties seeing in bright lighting (n = 18). Patients experienced substantial impacts on daily activities (n = 21) and physical functioning (n = 17). Patients had difficulty interpreting and selecting a response for some items in the NEI VFQ-25 and LLQ. Some items were not relevant to patients' disease experience. There were both gaps and overlaps in the conceptual coverage of the instruments.

CONCLUSIONS

Visual impairment due to RLBP1 RP has a substantial impact on physical functioning and daily activities. To adequately assess all important symptoms and associated functional impacts in RLBP1 RP, it is recommended to either modify one or more existing instruments or to develop a new non-syndromic RP specific instrument.

Prediction of acute left main coronary artery obstruction by 12-lead electrocardiography. ST segment elevation in lead aVR with less ST segment elevation in lead V(1)

OBJECTIVES

We sought to determine the electrocardiographic (ECG) features associated with acute left main coronary artery (LMCA) obstruction.

BACKGROUND

Prediction of LMCA obstruction is important with regard to selecting the appropriate treatment strategy, because acute LMCA obstruction usually causes severe hemodynamic deterioration, resulting in a less favorable prognosis.

METHODS

We studied the admission 12-lead ECGs in 16 consecutive patients with acute LMCA obstruction (LMCA group), 46 patients with acute left anterior descending coronary artery (LAD) obstruction (LAD group) and 24 patients with acute right coronary artery (RCA) obstruction (RCA group).

RESULTS

Lead aVR ST segment elevation (>0.05 mV) occurred with a significantly higher incidence in the LMCA group (88% [14/16]) than in the LAD (43% [20/46]) or RCA (8% [2/24]) groups. Lead aVR ST segment elevation was significantly higher in the LMCA group (0.16 +/- 0.13 mV) than in the LAD group (0.04 +/- 0.10 mV). Lead V(1) ST segment elevation was lower in the LMCA group (0.00 +/- 0.21 mV) than in the LAD group (0.14 +/- 0.11 mV). The finding of lead aVR ST segment elevation greater than or equal to lead V(1) ST segment elevation distinguished the LMCA group from the LAD group, with 81% sensitivity, 80% specificity and 81% accuracy. A ST segment shift in lead aVR and the inferior leads distinguished the LMCA group from the RCA group. In acute LMCA obstruction, death occurred more frequently in patients with higher ST segment elevation in lead aVR than in those with less severe elevation.

CONCLUSIONS

Lead aVR ST segment elevation with less ST segment elevation in lead V(1) is an important predictor of acute LMCA obstruction. In acute LMCA obstruction, lead aVR ST segment elevation also contributes to predicting a patient's clinical outcome.

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.

[Occlusion of the left main coronary artery with silent ischemia and syncope]

Mortality in the total occlusion of the left main coronary artery is very high, and the few cases who lived reported were very ill and symptomatic patients. We present a case with angiographic documentation of total occlusion of the left main coronary artery in a patient without angina and with a normal rest electrocardiogram in which a syncope was the only symptom. Severe isolated silent ischemia was induced during an exercise test. Total occlusion of the left main coronary artery associated to silent myocardial ischemia without cardiac failure has never been previously reported.

[Direct dilatation and emergency bypass operation of main branch occlusion in acute anterior wall infarct and cardiogenic shock]

Occlusion of the left main coronary artery (LMCA) is the cause of myocardial infarction in about 0.04%. Those patients who do not die during the acute phase often do have a dominant right coronary artery with extensive collaterals to the left coronary artery. Because this is a very rare situation there are only some cases reports dealing with the management of these patients. A 60 years old woman was admitted to our hospital with the signs of an acute Q-wave anterior myocardial infarction. Within a few minutes after the arrival she developed a cardiogenic shock. Coronary angiography was performed immediately. The left main coronary artery was occluded and a big right coronary artery showed a significant stenosis. There were many collaterals from the right coronary artery supplying the left coronary artery. After information of the cardiac surgeons, primary angioplasty of the LMCA was performed in order to achieve hemodynamic stabilisation and to relieve symptoms. Reperfusion of the left anterior descendent coronary artery (LAD) could be achieved within 30 minutes. This led to hemodynamic stabilisation of the patient. But a significant residual stenosis of the LMCA remained and the circumflex artery was still occluded. In the meanwhile cardiac surgery was able to be performed and so the patient was transferred to surgery without further dilatation or stent implantation. Four venous grafts (LAD, first diagonal branch, circumflex artery and right coronary artery) were inserted. After 4 weeks the patient was in a good shape and could be discharged at home. Primary angioplasty seems to be an effective treatment in patients with acute myocardial infarction and an occlusion of the LMCA. But coronary bypass surgery is nearly almost necessary during the following period in order to achieve complete revascularisation and to improve survival.

Survival following cardiogenic shock caused by acute left main coronary artery total occlusion. A case report and review of the literature

The authors describe a fifty-five-year-old Japanese man with an acute extensive anterior myocardial infarction associated with a total occlusion of the left main coronary artery. The patient suffered cardiogenic shock and was treated successfully with rescue percutaneous transluminal coronary angioplasty and an intraaortic balloon pump (IABP) after unsuccessful intracoronary thrombolysis. Ten days after admission, he was weaned from IABP, and recovery-phase coronary angiography revealed no significant coronary artery stenosis and an ejection fraction of 32% by left ventriculography. The patient was discharged from the hospital without any ischemic findings.

Total occlusion of the left main and proximal right coronary artery: case report and review of the literature

Chronic total left main coronary artery occlusion at angiography is very rare, and there are only four cases reported with concomitant total right coronary artery occlusion. We describe a case of total left main and proximal right coronary artery occlusion and review the clinical and angiographic characteristics of this condition which represents the most severe from of coronary artery disease compatible with life.

Survival from acute occlusion of the left main coronary artery with preexisting collateral vessels--a case report

A thirty-two-year-old man suffered from evolving acute myocardial infarction caused by total occlusion of the left main coronary artery, which was 95% stenosed before the onset. Nevertheless, he had a good clinical course. The myocardium may have been protected by well-developed preexisting collateral vessels as evidenced by serial coronary angiograms.

Nondiagnosed left main ostial stenosis partly due to the use of 5 French coronary angiographic catheters

Two cases have been reported in which the use of 5 F angiographic catheters is associated with a failure to diagnose an ostial stenosis of the left main coronary artery (LMCA). In both cases, the erroneous diagnosis led to an inappropriate indication for percutaneous transluminal coronary angioplasty (PTCA) on other stenosed vessels, and the ostial left main lesion was unexpectedly discovered when using 8F guiding catheters. It is supposed that the ability of performed 5F catheters to pass easily through an ostial lesion makes detection of such proximal stenosis much more difficult. We suggest that the choice of 5F catheters must be approached with caution when left main disease is potentially expected from the clinical features.

Acute occlusion of left main coronary artery without ventricular damage

We report a patient with acute occlusion of left main coronary artery with only a small increase of cardiac enzymes but without electrocardiographic signs of acute myocardial infarction. Normal global and regional left ventricular function could be documented angiographically. Damage of myocardium was prevented by extensive collateral circulation from a large dominant right coronary artery.

Left main percutaneous transluminal coronary angioplasty with the autoperfusion catheter in an animal model

Left main coronary angioplasty is associated with high risk because of interruption of blood flow to much of the left ventricle during balloon inflation. An "autoperfusion" balloon angioplasty catheter that allows blood to flow passively distal to an inflated balloon was tested in dogs and compared with inflations with standard balloon catheters. During 3 min occlusions of the left main coronary artery with the autoperfusion catheter, regional myocardial blood flow was preserved at 0.60 +/- 0.14 ml/min/g, compared with 0.07 +/- 0.03 ml/min/g during inflation with standard balloon catheters (P less than 0.01). Similarly, at the end of 3 min of inflation, left ventricular systolic pressure and dP/dt were maintained with autoperfusion catheter inflation, but they were severely depressed after standard angioplasty balloon inflation. All seven dogs survived autoperfusion balloon inflation, whereas five of seven developed sustained ventricular tachycardia and/or ventricular fibrillation during or after standard balloon inflation. Thus, distal blood flow, hemodynamics, and survival were preserved during autoperfusion balloon inflation in the left main coronary artery.

Left main coronary angioplasty: early and late results of 127 acute and elective procedures

The results of 127 left main (LM) coronary angioplasties were reviewed to assess short- and long-term effectiveness. Three major subgroups were considered: (1) elective "protected" (defined as the presence of a patent bypass graft to the left coronary circulation) patients (n = 84); (2) elective "unprotected" patients (n = 33); and (3) acute patients, in whom LM coronary angioplasty was performed in the setting of an acute myocardial infarction (n = 10). Successful LM dilation was achieved in 94% of elective patients and 90% of acute patients. Procedural mortality was 4.3% in elective patients (2.4 and 9.1% in protected and unprotected patients, respectively, p = 0.14) and 50% in the acute subgroup. Long-term follow-up data, available for 98% of patients, revealed actuarial 3-year survival rates of 90 and 36% in elective protected and unprotected subgroups, respectively (p less than 0.0005). In the acute subgroup, 3 patients (30%) were alive at the time of follow-up; all had undergone coronary artery bypass surgery. Thus, although elective angioplasty of an unprotected LM coronary artery is technically feasible, the long-term prognosis of such patients is very poor. LM angioplasty in this subgroup should be reserved for patients in whom surgical revascularization is not an option. In contrast, elective angioplasty of a protected LM coronary artery can be accomplished safely with good long-term results. LM coronary angioplasty for acute myocardial infarction can be effective as a salvage procedure; however, adjunctive coronary bypass surgery is important for long-term survival.

Survival after myocardial infarction caused by acute left main coronary artery occlusion: case report and review of the literature

We report a 44-year-old white male presenting with an acute anterior myocardial infarction. Cardiac catheterization at 2 weeks postinfarction revealed total occlusion of the left main coronary artery. There was a normal dominant right coronary artery supplying moderate collaterals to the left coronary system. The patient was managed with conservative therapy and was N.Y.H.A. functional class II on followup 2 years later. A review of the literature relative to myocardial infarction caused by acute left main coronary artery occlusion is presented, and unique features of these cases are described.

Complete occlusion of the left main coronary artery: clinical and angiographic observations in five cases

Involvement of the left main coronary artery is observed in approximately 5 to 8% of patients with coronary artery lesions detected by coronary angiography, but occlusion of the left main artery is a very infrequent finding. Out of approximately 4000 patients undergoing coronary angiography, four men and one woman, 37 to 60 years old, showed total occlusion of this vessel. Four of them had angina pectoris and three had had a myocardial infarction. All five showed deep ST depression in V 2(or 3)-6 during bicycle exercise testing. Apart from the left main artery occlusion, all had significant obstructive lesions in other coronary vessels, including the right coronary artery or its major branches. There was collateral circulation from the right coronary artery in all patients. Left ventricular function was well preserved in three patients and markedly impaired in two. Four patients underwent bypass surgery and they have been followed for 10 to 28 months. Three are free of angina and one has only minimal angina. One patient refused surgery and he continued to have severe angina despite intense medical treatment. He died suddenly after 30 months follow-up. In patients with complete occlusion of the left main coronary artery, development of adequate collateral flow seems important in preserving left ventricular function, but collaterals are usually insufficient to prevent angina. Moreover, associated obstructive lesions in other coronary arteries constitute a potential threat to the collateral circulation. Effective symptomatic relief is obtained by coronary bypass grafting, and revascularization may also improve prognosis in this subset of patients with coronary heart disease.