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

• Published in: Postępy w kardiologii interwencyjnej 2018-01, Vol.14 (3), p.233-239
• Main Authors: Édes, István Ferenc, Ruzsa, Zoltán, Lux, Árpád, Gellér, László, Molnár, Levente, Nowotta, Fanni, Kerülő, Márta Csilla, Becker, Dávid, Merkely, Béla
• Format: Article
• Language: English
• Subjects: Acute coronary syndromes; acute myocardial infarction/STEMI; Cardiopulmonary resuscitation; Cardiovascular disease; coronary occlusion; CPR; left main coronary disease; Mortality; Original Paper; percutaneous coronary intervention
• ISSN: 1734-9338; 1897-4295
• DOI: 10.5114/aic.2018.78325

Acute, total occlusion of the unprotected left main stem (uLMo) in acute coronary syndrome (ACS) patients is a catastrophic event often accompanied by sudden cardiac death (SCD) and/or cardiogenic shock (CS) with high mortality rates and limited methods of successful treatment. Emergent, surgical and percutaneous revascularization has been reported before, yet comprehensive data remains scarce. To examine emergency percutaneous coronary intervention (PCI) outcomes in ACS cases presenting with uLMo. Data on 23 subjects undergoing primary PCI in uLMo cases were analyzed. The primary end-point was in-hospital death; secondary end-points were successful salvage of coronary anatomy and 90-day major cardiac adverse events (MACE). About 40% of LM occlusion cases presented following successful on-site cardio-pulmonary resuscitation (CPR). Of all patients arriving for treatment the occluded LM was successfully opened and stented in ~90% of cases. CS was present in > 85% of cases, and circulatory support in the form of intra-aortic balloon pump and/or extracorporeal membrane oxygenation systems was applied in every eligible case (~80%). The in-hospital death rate was 56%, mostly including individuals requiring prior CPR. At 6 months, additional MACE rates were low at 8.7%. We found that uLMo ACS cases often present with preceding CPR and mostly in manifest CS. Coronary salvage is generally successful, yet uLMo even with optimal present day complex treatment yields quite high mortality rates. This is especially true for patients receiving prior CPR. In surviving patients, however, 6-month MACE rates are acceptable.