The acutely occluded left main coronary artery culprit in cardiogenic shock and initial percutaneous coronary intervention: a substudy of the Manitoba “no option” left main PCI registry
Department of Cardiology, Saint Boniface General Hospital, University of Manitoba, Winnipeg, Canada.Canadian Journal of Physiology and Pharmacology (Impact Factor: 1.77). 08/2012; 90(9):1325-31. DOI: 10.1139/y2012-111
We aim to describe the in-hospital outcomes of the first reported Canadian cohort of patients with cardiogenic shock and acute myocardial infarction (MI) due to acute and total occlusion of the left main coronary artery, treated with initial percutaneous coronary intervention (PCI). Acute left main thromboses with cardiogenic shock were identified (N = 8) from a retrospective consecutive cohort of high risk left main PCI (N = 56) performed at our institution from 2004-2009. The mean age was 62.3 ± 13.2 years, with 6 (75%) male patients. Successful PCI was performed in all patients, with thrombectomy utilized in 4 patients (50%), stenting in 7 patients (88%), and intra-aortic balloon pump augmentation in 7 patients (88%). Two patients (25%) required extracorporeal membrane oxygenation (ECMO) and 2 other patients required ventricular assist devices. Post-PCI coronary artery bypass grafting (CABG) was performed for 2 patients (25%). The mean SYNTAX score was 26.6 ± 10.5. The mean logistic EuroSCORE was 30.4 ± 12.6%. In-hospital mortality occurred in 3 patients (38%). Acute left main occlusion is a rare but devastating presentation of myocardial infarction, invariably with cardiogenic shock. Emergent PCI may be an effective method to acutely revascularize this subset of patients; however, aggressive post-PCI care including ECMO, CABG, and ventricular support may be required to improve patient survival.
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ABSTRACT: Background Coronary stenting is increasingly utilized to treat unprotected left main disease in selected patients. However, there is a paucity of data on the long-term outcome of these patients in a Canadian context outside of clinical trials. Methods We retrospectively reviewed all provincially-insured patients undergoing left main coronary stenting at a large tertiary referral centre from 2000-2011. Pre-procedural angiograms were reviewed to identify location of left main disease, and extent of concomitant coronary disease quantified by calculating SYNTAX (Synergy between PCI with TAXUS drug-eluting stent and Cardiac Surgery) scores for each patient. In-hospital death and major adverse cardiac events (MACE) were evaluated as well as long-term death and MACE obtained by linkage of our institutional registry with the Ontario health claims database. Results Two hundred and twenty one patients underwent unprotected left main stenting with 29 (13.1%) in-hospital death and 34 (15.4%) MACE. At an average follow-up of 3.1±2.8 years, 109 (49.3%) of patients died and 151 (68.3%) experienced MACE. Higher SYNTAX tertile and use of bare metal rather than drug eluting stents was associated with increased rates of in-hospital and long-term death. Conclusions This study reports the largest Canadian cohort of unprotected left main stenting over more than a decade. Coronary stenting was associated with acceptable in-hospital event rates, but poor long term outcomes, reflecting the higher risk population traditionally selected for this procedure.
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