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

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.

Clinical Outcomes Following Emergent Percutaneous Coronary Intervention for Acute Total/Subtotal Occlusion of the Left Main Coronary Artery

BACKGROUND

Data regarding the clinical features, outcomes and prognostic factors in patients presenting with acute total/subtotal occlusion of the unprotected left main coronary artery (LMCA) remain limited.Methods and Results:From a multi-center registry, 134 patients due to acute total/subtotal occlusion of the unprotected LMCA were reviewed. Emergency room (ER) status classification was defined according to the presence of cardiogenic shock and cardiopulmonary arrest (CPA) in the ER (class 1=no cardiogenic shock; class 2= cardiogenic shock but not CPA; and class 3=CPA). In-hospital mortality and cerebral performance category (CPC) as the endpoints were evaluated. One-half (67/134) of the enrolled patients presented with total occlusion of the unprotected LMCA. Regarding ER status classification, class 1, 2, and 3 were observed in 30.6%, 45.5%, and 23.9% of the patients, respectively. In-hospital mortality occurred in 73 (54.5%) patients; of the remaining patients, 52 (85.3%) could be discharged with a CPC 1 or 2. ER status classification (odds ratio 4.4 [95% confidence interval: 2.33-10.67]; P<0.001) and total occlusion of the unprotected LMCA (odds ratio 8.29 [95% confidence interval 2.93-23.46]; P<0.001) were strong predictors of in-hospital mortality.

CONCLUSIONS

Acute total/subtotal occlusion involving the unprotected LMCA appeared to be associated with high in-hospital mortality. ER status classification and initial flow in the unprotected LMCA were significant predictive factors of in-hospital mortality.

Impact of Percutaneous Coronary Intervention and Implantation of Intra-Aortic Balloon Pump on the Outcome of an Acute Total Obstruction of the Left Main Coronary Artery

Background

Acute total occlusion of the left main coronary artery (LMCA) is a fatal event; most patients die before reaching hospitals. Few of them reach the hospital alive. Revascularization of the LMCA can be achieved by surgical intervention or percutaneous coronary intervention with unknown optimal modality. However, mortality of those patients is very high even with either; few cases reported successful management of acute total occlusion of the LMCA including our patient. Case Presentation. A 56-year-old male patient who is a smoker presented with typical chest pain worsened 2 hours prior to admission. He was hemodynamically stable, but he had respiratory failure due to pulmonary edema. An electrocardiogram showed anterior ST-elevation myocardial infarction. He was given loading doses of dual antiplatelet agents, in addition to respiratory support, then transferred immediately to the cardiac catheterization laboratory. Urgent cardiac catheterization showed total occlusion of the LMCA. Recanalization was done successfully, and a stent was inserted in the LMCA and left anterior descending artery. The patient developed cardiogenic shock during the procedure. An intra-aortic balloon pump (IABP) was applied which improved his hemodynamic status and enhanced his coronary flow. He is clinically improved, there was resolution of ST elevation, and cardiogenic shock gradually resolved. IABP was removed, and the patient was discharged in good general condition.

Conclusions

Survival after acute total occlusion of the LMCA is very rare. The good outcome in this patient is attributed to early recognition and timely successful intervention, with good respiratory and hemodynamic support. The surgical and anaesthesia team should be on stand-by until complete revascularization and stabilization of the patient are achieved.

Electrocardiographic findings in true acute left main coronary total occlusion a subanalisys from ATOLMA registry

INTRODUCTION

Acute total occlusion of the left main coronary artery (ATOLMA) usually leads to a catastrophic presentation. Prediction of ATOLMA by electrocardiogram (ECG) may contribute to early detection and reperfusion. Limited data have been reported previously. This study aims to identify the admission 12‑leads ECG features that can predict the presence of ATOLMA and in-Hospital mortality in these patients.

METHODS

The admission ECGs findings in 24 patients from the previously reported ATOLMA multicenter registry were compared to the ECGs findings in 15 patients with an acute subtotal occlusion of the left main (ASOLMA) and to 15 patients with anterior ST-elevation myocardial infarction of the proximal left anterior descending (LADp-STEMI).

RESULTS

Some ECG features at presentation can predict an ATOLMA: QRS left axis deviation (-61.17 ± 9 degrees); ST-segment elevation in aVL (1.9 ± 0.65 mm); absence of ST-segment elevation in V1 (0.0 ± 0.6 mm); bifascicular block (58%); fragmented QRS (62.5%); prolongation of QTc interval (465 ± 19 ms) and of QRS interval (136 ± 12 mm). The multivariate analysis found that the independent predictors to distinguish ATOLMA from ASOLMA were aVL ST-segment deviation (OR 5.6(95% CI 1.5-21), p = 0.01) and absence of V1 ST-segment elevation (OR 27(95% CI 1.4-52), p = 0.01); and from LADp-STEMI was QRS width (OR 1.1(95% CI 1.02-1.2), p = 0.02). Fragmented QRS was the only independent predictor of in-hospital mortality in ATOLMA (OR 0.125(95% CI 0.01-0.81), p = 0.03).

CONCLUSIONS

aVL ST-segment elevation, the absence of V1 ST-segment elevation, left axis deviation, the presence of bifascicular block, and prolongation of QRS and QTc interval are predictors of ATOLMA. Fragmented QRS predicts in-hospital mortality in ATOLMA.

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

Introduction

Thrombus occlusion of the left main coronary artery (LMCA) is a poorly prognostic condition that is commonly associated with mortality especially when complicated with cardiogenic shock.

Presentation of case

In this report, we presented a case for 44 years-old male patient who is not known to have ischemic heart disease. He was transferred from a peripheral hospital for emergency percutaneous coronary intervention (PCI) after presenting with anterior ST-elevation myocardial infarction (STEMI) complicated with cardiogenic shock.

Discussion

The PCI revealed complete occlusion of the LMCA with a thrombus which was stented and the patient regain his cardiovascular stability. The patient survived this complete occlusion that was complicated with cardiogenic shock giving the quick intervention with the PCI and the use of the circulatory support devices.

Conclusion

The PCI procedure with the intra-aortic balloon pump should be available and offered early for patients with STEMI complicated with cardiogenic shock. This could be very critical in increasing the survival rates for those patients.

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A case of a patient who survived a complete LMCA occlusion.

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Total LM occlusion often associated with lifethretining arrhythmia.

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A Primary Percutaneous Coronary Intervention with intra-aortic balloon pump should be available and offered early for patients with cardiogenic shock.

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.

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

Acute myocardial infarction (AMI) caused by total occlusion of the left main coronary artery (LMCA) is a catastrophic event. However, the clinical features and appropriate treatment of patients with this condition remain unclear. We report a man with total occlusion of the LMCA presenting with AMI combined with cardiogenic shock. He was successfully treated with angioplasty and drug-eluting stent implantation assisted by an intra-aortic balloon pump (IABP). This case suggests that percutaneous coronary intervention may be an optional therapeutic strategy in these patients, and that IABP implantation could improve clinical outcomes. A dominant right coronary artery and enhanced collateral circulation were considered to be key features related to the patient’s survival.