Coronary Artery Dominance and Long-term Prognosis in Patients With ST-segment Elevation Myocardial Infarction Treated With Primary Angioplasty

A Case Report of High-Risk Percutaneous Coronary Intervention of Left Main Coronary Artery With Cardiogenic Shock

Acute total occlusion of the left main artery is a fatal event and is often accompanied by cardiogenic shock. Patients who experience this event have high mortality rates. Early percutaneous coronary intervention (PCI) with hemodynamic support has proven to improve clinical outcomes for these patients. Here we report a case of a 60-year-old man, who came into our emergency room with an acute anterior wall myocardial infarction accompanied by cardiogenic shock. He had a totally occluded left main artery on coronary angiography, necessitating cardiopulmonary resuscitation, followed by PCI with implantation of a drug-eluting stent along with hemodynamic support. Identification of typical ECG changes is crucial in patients with acute coronary syndrome caused by the occlusion of the left main coronary artery. A quick decision to perform a PCI procedure using early circulatory mechanical devices (intra-aortic balloon pump) is critical to patient survival.

Association of coronary artery dominance and mortality rate and complications in patients with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention

Background

Percutaneous coronary intervention (PCI) is the treatment of choice for patients with ST-segment elevation myocardial infarction (STEMI). Effect of coronary artery dominance on the patients' outcome following primary PCI (PPCI) is not fully investigated. We investigated the association of coronary artery dominance with complications and 1-year mortality rate of PPCI.

Materials and Methods

In this retrospective study, patients with STEMI treated with PPCI from March 2016 to February 2018 were divided into three groups based on their coronary dominancy: left dominance (LD), right dominance (RD), and codominant. Demographic characteristics, medical history, results of physical examination, electrocardiography, angiography, and echocardiography were compared between the groups.

Results

Of 491 patients included in this study, 34 patients (7%) were LD and 22 patients (4.5%) were codominant. Accordingly, 54 propensity-matched RD patients were included in the analysis. The demographics and comorbidities of the three groups were not different (P > 0.05); however, all patients in the RD group had thrombolysis in myocardial infarction (TIMI) 3, while five patients in the LD and five patients in the codominant group had a TIMI ≤2 (P = 0.006). At admission, the median left ventricular ejection fraction (LVEF) was highest in RD patients and lowest in LD and codominant patients (34%, P = 0.009). There was no difference in terms of success or complications of PCI, in-hospital, and 1-year mortality rate (P > 0.05).

Conclusion

Patients with left coronary artery dominance had a higher value of indicators of worse outcomes, such as lower LVEF and TIMI ≤ 2, compared with RD patients, but not different rates of success or complications of PCI, in-hospital, and 1-year mortality. This finding may suggest that interventionists should prepare themselves with protective measures for no-reflow and slow-flow phenomenon and also mechanical circulatory support before performing PPCI in LD patients.

Primary Angioplasty in a Catastrophic Presentation: Acute Left Main Coronary Total Occlusion-The ATOLMA Registry

OBJECTIVES

To determine the outcome predictors of in-hospital mortality in acute total occlusion of the left main coronary artery (ATOLMA) patients referred to emergent angioplasty and to describe the clinical presentation and the long-term outcome of these patients.

BACKGROUND

ATOLMA is an uncommon angiographic finding that usually leads to a catastrophic presentation. Limited and inconsistent data have been previously reported regarding true ATOLMA, yet comprehensive knowledge remains scarce.

METHODS

This is a multicenter retrospective cohort that includes patients presenting with myocardial infarction due to a confirmed ATOLMA who underwent emergency percutaneous coronary intervention (PCI).

RESULTS

In the period of the study, 7930 emergent PCI were performed in the five participating centers, and 46 of them had a true ATOLMA (0.58%). At admission, cardiogenic shock was present in 89% of patients, and cardiopulmonary resuscitation was required in 67.4%. All the patients had right dominance. Angiographic success was achieved in 80.4% of the procedures, 13 patients (28.2%) died during the catheterization, and the in-hospital mortality rate was 58.6% (27/46). At one-year and at the final follow-up, 18 patients (39%) were alive, including four cases successfully transplanted. Multivariate analysis showed that postprocedural TIMI flow was the only independent predictor of in-hospital mortality (OR 0.23, (95% CI 0.1-0.36), p < 0.001).

CONCLUSIONS

Our study confirms that the clinical presentation of ATOLMA is catastrophic, presenting a high in-hospital mortality rate; nevertheless, primary angioplasty in this setting is feasible. Postprocedural TIMI flow resulted as the only independent predictor of in-hospital mortality. In-hospital survivors presented an encouraging outcome. ATOLMA and left dominance could be incompatible with life.

Association of coronary dominance with the severity of coronary artery disease: a cross-sectional study in Shaanxi Province, China

OBJECTIVE

To investigate whether coronary artery dominance is associated with the severity of coronary artery disease (CAD).

DESIGN

Cross-sectional study.

SETTING

Single-centre.

PARTICIPANTS

Between July 2015 and February 2017, 1654 patients who underwent coronary angiography (CAG) were recruited into this cross-sectional study.

MEASUREMENT AND METHODS

According to coronary dominance, patients were classified into left dominance (LD), right dominance (RD) and codominance (CD) based on the CAG results. Multiple linear regression analysis was performed to test the association between severity of CAD and coronary dominance.

RESULTS

The total Gensini score was significantly higher in the RD group than in the left-CD group (42.3±33.6 vs 36.3±29.8; p=0.033). After adjusting for potential confounding factors, the results of multivariate linear regression showed that RD was associated with the severity of CAD (β=6.699, 95% CI 1.193 to 12.205, p=0.017).

CONCLUSIONS

The results suggest that right coronary dominance was associated with the severity of CAD.

Value of three-dimensional echocardiography study of left ventricle function correlated to coronary arterial dominance in predicting the outcome of primary percutaneous coronary intervention

Background

Limited information is available regarding the relationship between coronary vessel dominance and outcome after ST-segment elevation myocardial infarction (STEMI).

Objectives

The study was designed to evaluate the prognostic value of coronary arterial dominance after primary percutaneous coronary intervention (PCI) during hospital stay and at 3 months follow-up regarding cardiac mortality, heart failure, nonfatal myocardial infarction, revascularization, and stroke.

Patients and methods

The study population consisted of 300 consecutive patients (mean age, 57.35 ± 13.41 years; 91% men) with STEMI who were admitted to Dallah Hospital (Riyadh, Saudi Arabia) from January 2015 to December 2016. These patients underwent successful primary PCI with thrombolysis in myocardial infarction (TIMI) III flow. They were divided into three groups according to angiographic coronary dominance: 227 (75.7%) in the right coronary dominant group, 40 (13.3%) in the left coronary dominant group, and 33 (11%) in the balanced coronary dominant group. They were evaluated with two- (2D) and three-dimensional (3D) echocardiography within 48 hours of admission and at 3 months follow-up after STEMI.

Results

Right dominance was present in 75.6%, left dominance in 13.3%, and balanced dominance was present in 11% of patients. The main finding of this study was that a left dominant system was associated with increased risk of cardiac mortality, heart failure, nonfatal myocardial infarction, revascularization, and stroke shortly after primary PCI, during hospital stay, and at 3 months follow-up after STEMI. Moreover, a significantly lower left ventricular ejection fraction at admission was observed by both 2D and 3D echocardiography in patients with a left dominant system.

Conclusion

In patients with STEMI treated with primary PCI, left coronary artery dominance confers a higher risk of various adverse clinical events after primary PCI, during hospital stay, and at 3 months follow-up compared to right and balanced coronary artery dominance.

Automatic identification of coronary tree anatomy in coronary computed tomography angiography

An automatic coronary artery tree labeling algorithm is described to identify the anatomical segments of the extracted centerlines from coronary computed tomography angiography (CCTA) images. This method will facilitate the automatic lesion reporting and risk stratification of cardiovascular disease. Three-dimensional (3D) models for both right dominant (RD) and left dominant (LD) coronary circulations were built. All labels in the model were matched with their possible candidates in the extracted tree to find the optimal labeling result. In total, 83 CCTA datasets with 1149 segments were included in the testing of the algorithm. The results of the automatic labeling were compared with those by two experts. In all cases, the proximal parts of main branches including LM were labeled correctly. The automatic labeling algorithm was able to identify and assign labels to 89.2% RD and 83.6% LD coronary tree segments in comparison with the agreements of the two experts (97.6% RD, 87.6% LD). The average precision of start and end points of segments was 92.0% for RD and 90.7% for LD in comparison with the manual identification by two experts while average differences in experts is 1.0% in RD and 2.2% in LD cases. All cases got similar clinical risk scores as the two experts. The presented fully automatic labeling algorithm can identify and assign labels to the extracted coronary centerlines for both RD and LD circulations.