1
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Iwama M, Noda T, Takagi K, Tanaka A, Uemura Y, Umemoto N, Shibata N, Negishi Y, Ohashi T, Tanaka M, Yoshida R, Shimizu K, Tashiro H, Yoshioka N, Morishima I, Watarai M, Tanaka T, Tatami Y, Takada Y, Ishii H, Murohara T. Impact of right coronary artery dominance on the long-term mortality in the patients with acute total/subtotal occlusion of unprotected left main coronary artery. J Cardiol 2023; 82:165-171. [PMID: 37028507 DOI: 10.1016/j.jjcc.2023.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Revised: 02/21/2023] [Accepted: 03/11/2023] [Indexed: 04/09/2023]
Abstract
BACKGROUND Patients with a right dominant coronary artery anatomy account for a significant proportion of acute myocardial infarction cases, and this condition is associated with a better prognosis. However, there are limited data on the impact of coronary dominance on patients with acute total/subtotal occlusion of unprotected left main coronary artery (ULMCA). METHODS This study aimed to assess the impact of right coronary artery (RCA) dominance on long-term mortality in patients with acute total/subtotal occlusion of the ULMCA. From a multicenter registry, 132 cases of consecutive patients who had undergone emergent percutaneous coronary intervention (PCI) due to acute total/subtotal occlusion of the ULMCA were reviewed. RESULTS Patients were classified into two groups according to the size of their RCA (dominant RCA group, n = 29; non-dominant RCA group, n = 103). Long-term outcomes were examined according to the presence of dominant RCA. Cardiopulmonary arrest (CPA) occurred in 52.3 % of patients before revascularization. All-cause death was significantly lower in the dominant RCA group than in the non-dominant RCA group. In the Cox regression model, dominant RCA was an independent predictor of all-cause death, as well as total occlusion of ULMCA, collateral from RCA, chronic kidney disease, and CPA. Patients were further analyzed according to the degree of stenosis of the ULMCA; patients with non-dominant RCA and total occlusive ULMCA had the worst outcome compared with the other groups. CONCLUSIONS A dominant RCA might improve long-term mortality in patients with acute total/subtotal occlusion of the ULMCA who were treated with PCI.
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Affiliation(s)
- Makoto Iwama
- Department of Cardiology, Gifu Prefectural General Medical Center, Gifu, Japan.
| | - Toshiyuki Noda
- Department of Cardiology, Gifu Prefectural General Medical Center, Gifu, Japan
| | - Kensuke Takagi
- Department of Cardiology, Ogaki Municipal Hospital, Ogaki, Japan
| | - Akihito Tanaka
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yusuke Uemura
- Cardiovascular Center, Anjo Kosei Hospital, Anjo, Japan
| | - Norio Umemoto
- Department of Cardiology, Ichinomiya Municipal Hospital, Ichinomiya, Japan
| | - Naoki Shibata
- Department of Cardiology, Ogaki Municipal Hospital, Ogaki, Japan; Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan; Department of Cardiology, Ichinomiya Municipal Hospital, Ichinomiya, Japan
| | - Yosuke Negishi
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan; Department of Cardiology, Okazaki City Hospital, Okazaki, Japan
| | - Taiki Ohashi
- Department of Cardiology, Toyota Kosei Hospital, Toyota, Japan
| | - Miho Tanaka
- Department of Cardiology, Konan Kosei Hospital, Konan, Japan
| | - Ruka Yoshida
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan; Department of Cardiology, Japanese Red Cross Society Nagoya Daini Hospital, Nagoya, Japan
| | - Kiyokazu Shimizu
- Department of Cardiology, Ichinomiya Municipal Hospital, Ichinomiya, Japan
| | - Hiroshi Tashiro
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan; Department of Cardiology, Ichinomiya Municipal Hospital, Ichinomiya, Japan
| | - Naoki Yoshioka
- Department of Cardiology, Ogaki Municipal Hospital, Ogaki, Japan; Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Itsuro Morishima
- Department of Cardiology, Ogaki Municipal Hospital, Ogaki, Japan
| | | | | | - Yosuke Tatami
- Department of Cardiology, Toyota Kosei Hospital, Toyota, Japan
| | - Yasunobu Takada
- Department of Cardiology, Konan Kosei Hospital, Konan, Japan
| | - Hideki Ishii
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan; Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
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2
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Gaba P, Christiansen EH, Nielsen PH, Murphy SA, O’Gara PT, Smith PK, Serruys PW, Kappetein AP, Park SJ, Park DW, Stone GW, Sabik JF, Sabatine MS, Holm NR, Bergmark BA. Percutaneous Coronary Intervention vs Coronary Artery Bypass Graft Surgery for Left Main Disease in Patients With and Without Acute Coronary Syndromes: A Pooled Analysis of 4 Randomized Clinical Trials. JAMA Cardiol 2023; 8:631-639. [PMID: 37256598 PMCID: PMC10233454 DOI: 10.1001/jamacardio.2023.1177] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 03/27/2023] [Indexed: 06/01/2023]
Abstract
Importance Patients with left main coronary artery disease presenting with an acute coronary syndrome (ACS) represent a high-risk and understudied subgroup of patients with atherosclerosis. Objective To assess clinical outcomes after PCI vs CABG in patients with left main disease with vs without ACS. Design, Setting, and Participants Data were pooled from 4 trials comparing PCI with drug-eluting stents vs CABG in patients with left main disease who were considered equally suitable candidates for either strategy (SYNTAX, PRECOMBAT, NOBLE, and EXCEL). Patients were categorized as presenting with or without ACS. Kaplan-Meier event rates through 5 years and Cox model hazard ratios were generated, and interactions were tested. Patients were enrolled in the individual trials from 2004 through 2015. Individual patient data from the trials were pooled and reconciled from 2020 to 2021, and the analyses pertaining to the ACS subgroup were performed from March 2022 through February 2023. Main Outcomes and Measures The primary outcome was death through 5 years. Secondary outcomes included cardiovascular death, spontaneous myocardial infarction (MI), procedural MI, stroke, and repeat revascularization. Results Among 4394 patients (median [IQR] age, 66 [59-73] years; 3371 [76.7%] male and 1022 [23.3%] female) randomized to receive PCI or CABG, 1466 (33%) had ACS. Patients with ACS were more likely to have diabetes, prior MI, left ventricular ejection fraction less than 50%, and higher SYNTAX scores. At 30 days, patients with ACS had higher all-cause death (hazard ratio [HR], 3.40; 95% CI, 1.81-6.37; P < .001) and cardiovascular death (HR, 3.21; 95% CI, 1.69-6.08; P < .001) compared with those without ACS. Patients with ACS also had higher rates of spontaneous MI (HR, 1.70; 95% CI, 1.25-2.31; P < .001) through 5 years. The rates of all-cause mortality through 5 years with PCI vs CABG were 10.9% vs 11.5% (HR, 0.93; 95% CI, 0.68-1.27) in patients with ACS and 11.3% vs 9.6% (HR, 1.19; 95% CI, 0.95-1.50) in patients without ACS (P = .22 for interaction). The risk of early stroke was lower with PCI vs CABG (ACS: HR, 0.39; 95% CI, 0.12-1.25; no ACS: HR, 0.35; 95% CI, 0.16-0.75), whereas the 5-year risks of spontaneous MI and repeat revascularization were higher with PCI vs CABG (spontaneous MI: ACS: HR, 1.74; 95% CI, 1.09-2.77; no ACS: HR, 3.03; 95% CI, 1.94-4.72; repeat revascularization: ACS: HR, 1.57; 95% CI, 1.19-2.09; no ACS: HR, 1.90; 95% CI, 1.54-2.33), regardless of ACS status. Conclusion and Relevance Among largely stable patients undergoing left main revascularization and with predominantly low to intermediate coronary anatomical complexity, those with ACS had higher rates of early death. Nonetheless, rates of all-cause mortality through 5 years were similar with PCI vs CABG in this high-risk subgroup. The relative advantages and disadvantages of PCI vs CABG in terms of early stroke and long-term spontaneous MI and repeat revascularization were consistent regardless of ACS status. Trial Registration ClinicalTrials.gov Identifiers: NCT00114972, NCT00422968, NCT01496651, NCT01205776.
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Affiliation(s)
- Prakriti Gaba
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Per H. Nielsen
- Department of Cardiology, Aarhus, Aarhus University Hospital, Aarhus, Denmark
| | - Sabina A. Murphy
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Patrick T. O’Gara
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Deputy Editor, JAMA Cardiology
| | - Peter K. Smith
- Duke University School of Medicine, Duke Clinical Research Institute, Durham, North Carolina
| | - Patrick W. Serruys
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - A. Pieter Kappetein
- Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Seung-Jung Park
- Department of Cardiology, Asan Medical Center, Seoul, South Korea
| | - Duk-Woo Park
- Department of Cardiology, Asan Medical Center, Seoul, South Korea
| | - Gregg W. Stone
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Joseph F. Sabik
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Marc S. Sabatine
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Deputy Editor, JAMA Cardiology
| | - Niels R. Holm
- Department of Cardiology, Aarhus, Aarhus University Hospital, Aarhus, Denmark
| | - Brian A. Bergmark
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
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3
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Beijk MAM, Palacios-Rubio J, Grundeken MJD, Kalkman DN, De Winter RJ. Clinical Outcomes after Percutaneous Coronary Intervention for Cardiogenic Shock Secondary to Total Occlusive Unprotected Left Main Coronary Artery Lesion-Related Acute Myocardial Infarction. J Clin Med 2023; 12:jcm12041311. [PMID: 36835846 PMCID: PMC9959397 DOI: 10.3390/jcm12041311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 01/30/2023] [Accepted: 02/06/2023] [Indexed: 02/10/2023] Open
Abstract
BACKGROUND Acute myocardial infarction (AMI) with occlusion of an unprotected left main coronary artery (ULMCA) is a rare condition with a high mortality. The literature on clinical outcomes after percutaneous coronary intervention (PCI) for cardiogenic shock secondary to ULMCA-related AMI is scarce. METHODS In this retrospective analysis, all consecutive patients undergoing PCI for cardiogenic shock secondary to total occlusive ULMCA-related AMI were included between January 1998 and January 2017. The primary endpoint was 30-day mortality. The secondary endpoints were long-term mortality and 30-day and long-term major adverse cardiovascular and cerebrovascular events. The differences in clinical and procedural variables were assessed. A multivariable model was created to search for independent predictors of survival. RESULTS Forty-nine patients were included, and the mean age was 62 ± 11 years. The majority of patients suffered cardiac arrest prior or during PCI (51%). Thirty-day mortality was 78%, of which 55% died within 24 h. The median follow-up of patients who survived 30 days (n = 11) was 9.9 years (interquartile range 4.7-13.6), and long-term mortality was 84%. Long-term all-cause mortality was independently associated with cardiac arrest prior or during PCI (hazard ratio [HR] 2.02, 95% confidence interval 1.02-4.01, p = 0.043). Patients who survived to the 30-day follow-up with severe left ventricular dysfunction had a significantly higher risk of mortality compared to patients with moderate to mild dysfunction (p = 0.007). CONCLUSIONS Cardiogenic shock secondary to total occlusive ULMCA-related AMI carries a very high 30-day all-cause mortality. Thirty-day survivors with a severe left ventricular dysfunction have a poor long-term prognosis.
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Affiliation(s)
- Marcel A. M. Beijk
- Department of Cardiology, Amsterdam University Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
- Correspondence: ; Tel.: +31-20-566-9111
| | - Julián Palacios-Rubio
- Cardiology Department, Hospital Universitario Son Espases, Health Research Institute of the Balearic Islands (IdISBa), 07120 Palma, Spain
| | - Maik J. D. Grundeken
- Department of Cardiology, Amsterdam University Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Debbie N. Kalkman
- Department of Cardiology, Amsterdam University Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Robbert J. De Winter
- Department of Cardiology, Amsterdam University Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
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4
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Elkaryoni A, Elgendy IY, Qarajeh R, Allen S, Abdelkarim I, Mallas W, Leya FS, Lewis BE, Steen LH, Lopez JJ, Darki A. Outcomes of ST-elevation myocardial infarction due to left main coronary artery: a nationwide cohort sample. Coron Artery Dis 2022; 33:245-246. [PMID: 34010195 DOI: 10.1097/mca.0000000000001068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Ahmed Elkaryoni
- Division of Cardiovascular Disease, Loyola University Medical Center, Loyola Stritch School of Medicine, Maywood, Illinois, USA
| | - Islam Y Elgendy
- Department of Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Raed Qarajeh
- Department of Internal Medicine, University of Missouri-Kansas City, Kansas City, Missouri
| | - Sorcha Allen
- Division of Cardiovascular Disease, Loyola University Medical Center, Loyola Stritch School of Medicine, Maywood, Illinois, USA
| | - Islam Abdelkarim
- Department of Internal Medicine, University of Missouri-Kansas City, Kansas City, Missouri
| | - Waddah Mallas
- Department of Internal Medicine, Loyola University Medical Center, Loyola Stritch School of Medicine, Maywood, Illinois, USA
| | - Ferdinand S Leya
- Division of Cardiovascular Disease, Loyola University Medical Center, Loyola Stritch School of Medicine, Maywood, Illinois, USA
| | - Bruce E Lewis
- Division of Cardiovascular Disease, Loyola University Medical Center, Loyola Stritch School of Medicine, Maywood, Illinois, USA
| | - Lowell H Steen
- Division of Cardiovascular Disease, Loyola University Medical Center, Loyola Stritch School of Medicine, Maywood, Illinois, USA
| | - John J Lopez
- Division of Cardiovascular Disease, Loyola University Medical Center, Loyola Stritch School of Medicine, Maywood, Illinois, USA
| | - Amir Darki
- Division of Cardiovascular Disease, Loyola University Medical Center, Loyola Stritch School of Medicine, Maywood, Illinois, USA
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5
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Shibata N, Umemoto N, Tanaka A, Takagi K, Iwama M, Uemura Y, Inoue Y, Negishi Y, Ohashi T, Tanaka M, Yoshida R, Shimizu K, Tashiro H, Yoshioka N, Morishima I, Noda T, Watarai M, Asano H, Tanaka T, Tatami Y, Takada Y, Ishii H, Murohara T. Clinical Outcomes Following Emergent Percutaneous Coronary Intervention for Acute Total/Subtotal Occlusion of the Left Main Coronary Artery. Circ J 2021; 85:1789-1796. [PMID: 33746154 DOI: 10.1253/circj.cj-20-0545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
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.
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Affiliation(s)
- Naoki Shibata
- Department of Cardiology, Ichinomiya Municipal Hospital.,Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Norio Umemoto
- Department of Cardiology, Ichinomiya Municipal Hospital
| | - Akihito Tanaka
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | | | - Makoto Iwama
- Department of Cardiology, Gifu Prefectural General Medical Center
| | | | - Yosuke Inoue
- Department of Cardiology, Tosei General Hospital
| | | | | | - Miho Tanaka
- Department of Cardiology, Konan Kosei Hospital
| | - Ruka Yoshida
- Department of Cardiology, Nagoya University Graduate School of Medicine.,Department of Cardiology, Japanese Red Cross Society Nagoya Daini Hospital
| | | | - Hiroshi Tashiro
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | | | | | - Toshiyuki Noda
- Department of Cardiology, Gifu Prefectural General Medical Center
| | | | | | | | | | | | - Hideki Ishii
- Department of Cardiology, Nagoya University Graduate School of Medicine.,Department of Cardiology, Fujita Health University Bantane Hospital
| | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine
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6
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Omer MA, Exaire JE, Jentzer JC, Sandoval YB, Singh M, Cagin CR, Elgendy IY, Tak T. Management of ST-Elevation Myocardial Infarction in High-Risk Settings. Int J Angiol 2021; 30:53-66. [PMID: 34025096 DOI: 10.1055/s-0041-1723941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
Despite the widespread adoption of primary percutaneous intervention and modern antithrombotic therapy, ST-segment elevation myocardial infarction (STEMI) remains the leading cause of death in the United States and remains one of the most important causes of morbidity and mortality worldwide. Certain high-risk patients present a challenge for diagnosis and treatment. The widespread adoption of primary percutaneous intervention in addition to modern antithrombotic therapy has resulted in substantial improvement in the short- and long-term prognosis following STEMI. In this review, we aim to provide a brief analysis of the state-of-the-art treatment for patients presenting with STEMI, focusing on cardiogenic shock, current treatment and controversies, cardiac arrest, and diagnosis and treatment of mechanical complications, as well as multivessel and left main-related STEMI.
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Affiliation(s)
- Mohamed A Omer
- Cardiovascular Services, Mayo Clinic Health System, La Crosse, Wisconsin.,Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Jose E Exaire
- Cardiovascular Services, Mayo Clinic Health System, La Crosse, Wisconsin.,Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | | | | | | | - Charles R Cagin
- Cardiovascular Services, Mayo Clinic Health System, La Crosse, Wisconsin.,Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Islam Y Elgendy
- Division of Cardiology, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Tahir Tak
- Cardiovascular Services, Mayo Clinic Health System, La Crosse, Wisconsin.,Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
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7
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Farhan S, Vogel B, Montalescot G, Barthelemy O, Zeymer U, Desch S, de Waha-Thiele S, Maier LS, Sandri M, Akin I, Fuernau G, Ouarrak T, Hauguel-Moreau M, Schneider S, Thiele H, Huber K. Association of Culprit Lesion Location With Outcomes of Culprit-Lesion-Only vs Immediate Multivessel Percutaneous Coronary Intervention in Cardiogenic Shock: A Post Hoc Analysis of a Randomized Clinical Trial. JAMA Cardiol 2020; 5:1329-1337. [PMID: 32845312 DOI: 10.1001/jamacardio.2020.3377] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Importance Myocardial infarction with a culprit lesion located in the left main or proximal left anterior descending artery compared with other coronary segments is associated with more myocardium at risk and worse clinical outcomes. Objective To evaluate the association of culprit lesion location with outcomes of culprit-lesion-only percutaneous coronary intervention with optional staged revascularization vs immediate multivessel percutaneous coronary intervention in patients with multivessel disease, myocardial infarction, and cardiogenic shock. Design, Setting, and Participants Post hoc analysis of the Culprit Lesion Only Coronary Intervention vs Multivessel Coronary Intervention in Cardiogenic Shock (CULPRIT-SHOCK), an investigator-initiated randomized, open-label clinical trial. Patients with multivessel disease, acute myocardial infarction, and cardiogenic shock were enrolled at 83 European centers from April 2013 through April 2017. Interventions Patients were randomized to culprit-lesion-only percutaneous coronary intervention with optional staged revascularization or immediate multivessel percutaneous coronary intervention (1:1). For this analysis, patients were stratified by culprit lesion location in the left main or proximal left anterior descending artery group and other-culprit-lesion location group. Main Outcomes and Measures End points included a composite of death or kidney replacement therapy at 30 days and death at 1 year. Results The median age of the study population was 70 (interquartile range, 60-78 years) and 524 of the study participants were men (76.4%). Of the 685 patients, 33.4% constituted the left main or proximal left anterior descending artery group and 66.6% the other-culprit-lesion location group. The left main or proximal left anterior descending artery group had worse outcomes compared with the other-culprit-lesion location group (56.8% vs 47.5%; P = .02 for the composite end point at 30 days and 59.8% vs 50.1%; P = .02 for death at 1 year). In both groups, culprit-lesion-only vs immediate multivessel percutaneous coronary intervention was associated with a reduced risk of the composite end point at 30 days (49.1% vs 64.3% and 44.1% vs 50.9%; P for interaction = .27). At 1 year, culprit-lesion-only vs immediate multivessel percutaneous coronary intervention was associated with a significantly reduced risk of death in the left main or proximal left anterior descending artery but not the other-culprit-lesion location group (50.0% vs 69.6%; P = .003 and 49.8% vs 50.4%; P = .89; P for interaction = 0.02). Conclusions and Relevance In patients with multivessel disease with myocardial infarction and cardiogenic shock, a culprit lesion located in the left main or proximal left anterior descending artery vs other coronary segments was associated with worse outcomes. These patients may especially benefit from culprit-lesion-only percutaneous coronary intervention with optional staged revascularization, although further investigation is needed to confirm this finding. Trial Registration ClinicalTrials.gov Identifier: NCT01927549.
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Affiliation(s)
- Serdar Farhan
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York.,Wilhelminenspital, Department of Cardiology, Vienna, Austria
| | - Birgit Vogel
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York.,Wilhelminenspital, Department of Cardiology, Vienna, Austria
| | - Gilles Montalescot
- ACTION Study Group, Centre Hospitalier Universitaire Pitié-Salpêtrière, Sorbonne Université Paris 6, Paris, France
| | - Olivier Barthelemy
- ACTION Study Group, Centre Hospitalier Universitaire Pitié-Salpêtrière, Sorbonne Université Paris 6, Paris, France
| | - Uwe Zeymer
- Institut für Herzinfarktforschung, Ludwigshafen, Germany
| | - Steffen Desch
- Heart Center Leipzig at University of Leipzig and Leipzig Heart Institute, Leipzig, Germany
| | - Suzanne de Waha-Thiele
- Department of Internal Medicine/Cardiology/Angiology/Intensive Care Medicine, University Heart Center Luebeck, Luebeck, Germany
| | - Lars S Maier
- Department of Cardiology, Pneumology, and Intensive Care, University Hospital Regensburg, Regensburg, Germany
| | - Marcus Sandri
- Heart Center Leipzig at University of Leipzig and Leipzig Heart Institute, Leipzig, Germany
| | - Ibrahim Akin
- University Medical Centre Mannheim, First Department of Medicine, Faculty of Medicine, University of Heidelberg, Mannheim, Germany
| | - Georg Fuernau
- Department of Internal Medicine/Cardiology/Angiology/Intensive Care Medicine, University Heart Center Luebeck, Luebeck, Germany
| | | | - Marie Hauguel-Moreau
- ACTION Study Group, Centre Hospitalier Universitaire Pitié-Salpêtrière, Sorbonne Université Paris 6, Paris, France
| | | | - Holger Thiele
- Heart Center Leipzig at University of Leipzig and Leipzig Heart Institute, Leipzig, Germany
| | - Kurt Huber
- Wilhelminenspital, Department of Cardiology, Vienna, Austria.,Medical School, Sigmund Freud University, Vienna, Austria
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8
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Yeoh J, Andrianopoulos N, Reid CM, Yudi MB, Hamilton G, Freeman M, Noaman S, Oqueli E, Picardo S, Brennan A, Chan W, Stub D, Duffy S, Farouque O, Ajani A, Clark DJ. Long-term outcomes following percutaneous coronary intervention to an unprotected left main coronary artery in cardiogenic shock. Int J Cardiol 2020; 308:20-25. [PMID: 32192748 DOI: 10.1016/j.ijcard.2020.03.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 01/27/2020] [Accepted: 03/02/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND In cardiogenic shock with severe left main coronary artery stenosis (LM), limited information exists on short and longer-term outcomes. We sought to determine the outcomes of unprotected LM PCI in cardiogenic shock. METHODS Excluding patients with previous CABG, consecutive patients undergoing PCI in cardiogenic shock from the Melbourne Intervention Group registry between 2005 and 2013 were analysed. Those post LM PCI were compared to those post non-LM PCI. Patient and procedural data were collected with 30-day and 12-month follow-up. Australian National Death Index linkage was performed for long-term mortality analysis. RESULTS After excluding previous CABG, 18,069 procedures were performed during 1st January 2005 to 30th November 2013, 601 procedures in the setting of cardiogenic shock. Of these, 45 were performed to an isolated LM and 556 to a non-LM. Those with LM PCI were older and more likely to have a baseline left ventricular ejection fraction (LVEF) of <45%. The in-hospital, 30-day, 12-month and long-term mortality to 9 years in cardiogenic shock after LM PCI was 64.4%, 66.7%, 73.3% and 80.0% compared to 36.5%, 36.9%, 40.5% and 46.0%, after non-LM PCI (p < 0.001). On multivariate analysis, LM PCI was a significant independent predictor of long-term mortality (HR1.59, 95%CI 1.00-2.53, p = 0.048). Landmark analysis of survivors to discharge found the long-term mortality of LM PCI approaches 60% compared to 27% for those with non-LM PCI (p = 0.003). CONCLUSION Long-term outcomes after PCI to LM in cardiogenic shock are poor, with much of the excess in mortality occurring early. However, reasonable long-term survival was found beyond the initial high-risk period.
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Affiliation(s)
- Julian Yeoh
- Department of Cardiology, Austin Health, Melbourne, Australia
| | - Nick Andrianopoulos
- Centre of Cardiovascular Research and Education in Therapeutics (CCRET), Monash University, Melbourne, Australia
| | - Christopher M Reid
- Centre of Cardiovascular Research and Education in Therapeutics (CCRET), Monash University, Melbourne, Australia; School of Public Health, Curtin University, Perth, Western Australia, Australia
| | - Matias B Yudi
- Department of Cardiology, Austin Health, Melbourne, Australia; Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Garry Hamilton
- Department of Cardiology, Austin Health, Melbourne, Australia
| | - Melaine Freeman
- Department of Cardiology, Box Hill Hospital, Melbourne, Australia
| | - Samer Noaman
- Department of Cardiovascular Medicine, Alfred Hospital, Melbourne, Australia
| | - Ernesto Oqueli
- Department of Cardiology, Ballarat Base Hospital, Ballarat, Australia
| | - Sandra Picardo
- Department of Cardiology, Austin Health, Melbourne, Australia
| | - Angela Brennan
- Centre of Cardiovascular Research and Education in Therapeutics (CCRET), Monash University, Melbourne, Australia
| | - William Chan
- Department of Cardiovascular Medicine, Alfred Hospital, Melbourne, Australia
| | - Dion Stub
- Department of Cardiovascular Medicine, Alfred Hospital, Melbourne, Australia
| | - Stephen Duffy
- Department of Cardiovascular Medicine, Alfred Hospital, Melbourne, Australia
| | - Omar Farouque
- Department of Cardiology, Austin Health, Melbourne, Australia
| | - Andrew Ajani
- Centre of Cardiovascular Research and Education in Therapeutics (CCRET), Monash University, Melbourne, Australia; Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia
| | - David J Clark
- Department of Cardiology, Austin Health, Melbourne, Australia; Centre of Cardiovascular Research and Education in Therapeutics (CCRET), Monash University, Melbourne, Australia.
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9
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Two-Year Outcomes after Left Main Coronary Artery Percutaneous Coronary Intervention in Patients Presenting with Acute Coronary Syndrome. J Interv Cardiol 2020; 2020:6980324. [PMID: 32327944 PMCID: PMC7166269 DOI: 10.1155/2020/6980324] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Accepted: 03/10/2020] [Indexed: 11/17/2022] Open
Abstract
Objectives We aim to evaluate long-term outcomes after left main coronary artery (LMCA) percutaneous coronary intervention (PCI) in patients presenting with acute coronary syndrome (ACS). Background PCI of the LMCA has been an acceptable revascularization strategy in stable coronary artery disease. However, limited studies on long-term clinical outcomes of LMCA PCI in ACS patients are available. Methods A total of 6429 consecutive patients with ACS undergoing PCI in Fuwai Hospital in 2013 were enrolled. Patients are divided into LMCA group and Non-LMCA group according to whether the target lesion was located in LMCA. Prognosis impact on 2-year major adverse cardiovascular and cerebrovascular events (MACCE) is analyzed. Results 155 (2.4%) patients had target lesion in LMCA, while 6274 (97.6%) patients belong to the non-LMCA group. Compared with non-LMCA patients, LMCA patients have generally more comorbidities and worse baseline conditions. Two-year follow-up reveals that LMCA patients have significantly higher rate of cardiac death (2.6% vs. 0.7%, p = 0.034), myocardial infarction (7.1% vs. 1.8%, p < 0.001), in-stent thrombosis (4.5% vs. 0.8%, p < 0.001), and stroke (7.1% vs. 6.4%, p = 0.025). After adjusting for confounding factors, LMCA remains independently associated with higher 2-year myocardial infarction rate (HR = 2.585, 95% CI = 1.243-5.347, p = 0.011). Conclusion LMCA-targeted PCI is an independent risk factor for 2-year myocardial infarction in ACS patients.
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10
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Chiarito M, Mehilli J. Left main coronary artery disease: when and how to perform PCI? Minerva Cardioangiol 2020; 68:405-414. [PMID: 32107900 DOI: 10.23736/s0026-4725.20.05198-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Left main coronary artery (LMCA) disease has been reported in up to 10% of all patients with coronary artery disease (CAD) and in the majority of cases are associated with severe three-vessel CAD. Among patients with chronic coronary syndrome revascularization of significant LMCA disease improves prognosis, while there is a debate about which revascularization strategy, CABG surgery or percutaneous coronary interventions to use. We do a review of the available evidence about the impact of LMCA lesions on patient prognosis according to CAD extension and clinical presentation, the outcome after percutaneous or surgical revascularization, the procedural challenges of LMCA PCI and the available armamentarium to optimally treat this relevant population.
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Affiliation(s)
- Mauro Chiarito
- Cardio Center, Humanitas Research Hospital, Rozzano, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Julinda Mehilli
- Department of Cardiology, Munich University Hospital, Ludwig-Maximilians University, Munich, Germany - .,German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany
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11
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Staudacher DL, Schmitt C, Zirlik A, Zehender M, Stachon P, Bothe W, Zotzmann V, Bode C, von Zur Muehlen C. Predictors of survival in patients with acute coronary syndrome undergoing percutaneous coronary intervention of unprotected left main coronary artery stenosis. Catheter Cardiovasc Interv 2019; 96:E27-E33. [PMID: 31512392 DOI: 10.1002/ccd.28495] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 07/30/2019] [Accepted: 08/28/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Aim of this study was to investigate predictors of survival in unstable patients with high SYNTAX-1-score. BACKGROUND In significant unprotected left main coronary artery (ULMCA) stenosis, treatment options include percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG). While CABG is recommended for stable patients with ULMCA stenosis and a SYNTAX-1-score > 32, PCI may be preferable in unstable or high operative risk patients. METHODS Retrospective single-center all-comers registry study. RESULTS A total of 142 patients underwent ULMCA-PCI (~72.9 years, 23.2% females, 54.2% survival in 2-year follow-up), 84 of whom had a SYNTAX-1 > 32 (37.4 ± 12.8). Patients in the high-SYNTAX-1-group (score > 32) were more often in an acute condition compared to low-SYNTAX-2-group (score ≤ 32) including acute myocardial infarction (76.2% vs. 57.4%, p = .024), cardiogenic shock (48.2% vs. 14.8%, p = .001), or need for mechanical support (36.1% vs. 11.1%, p = .001). Survival was predicted by the acute condition including cardiogenic shock (OR 0.06 and 0.05) and myocardial infarction (OR 0.03 and 0.34) in both groups. Performance of the SYNTAX-1-score was limited in our patient collective in both groups (c-index 0.65 vs. 0.63) while SYNTAX-2-PCI-score performed better (c-index 0.67 vs. 0.67). EuroScore II had the best discriminative ability (c-index 0.87 vs. 0.78). CONCLUSIONS The majority of patients undergoing ULMCA-PCI presented in acute conditions with high SYNTAX-1-score, and is therefore underrepresented in clinical trials. Prognosis was best predicted by the acute condition and the EuroScore II. These data suggest that therapy in unstable patients should be guided by clinical condition over the anatomical SYNTAX-1-score.
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Affiliation(s)
- Dawid L Staudacher
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Charlotte Schmitt
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Andreas Zirlik
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Cardiology, LKH-University Hospital of the Medical University Graz, Graz, Austria
| | - Manfred Zehender
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Peter Stachon
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Wolfgang Bothe
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Viviane Zotzmann
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Christoph Bode
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Constantin von Zur Muehlen
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Tam DY, Bakaeen F, Feldman DN, Kolh P, Lanza GA, Ruel M, Piccolo R, Fremes SE, Gaudino M. Modality Selection for the Revascularization of Left Main Disease. Can J Cardiol 2019; 35:983-992. [DOI: 10.1016/j.cjca.2018.12.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 12/10/2018] [Accepted: 12/10/2018] [Indexed: 01/30/2023] Open
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13
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Rigatelli G, Zuin M, Dinh H, Giatti S, Nguyen VT, Maddali N, Dell'Avvocata F, Daggubati R. Long-Term Outcomes of Left Main Bifurcation Double Stenting in Patients with STEMI and Cardiogenic Shock. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2019; 20:663-668. [DOI: 10.1016/j.carrev.2018.09.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 09/17/2018] [Accepted: 09/27/2018] [Indexed: 11/26/2022]
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