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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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Atkinson TM, Ohman EM, O’Neill WW, Rab T, Cigarroa JE. A Practical Approach to Mechanical Circulatory Support in Patients Undergoing Percutaneous Coronary Intervention. JACC Cardiovasc Interv 2016; 9:871-83. [DOI: 10.1016/j.jcin.2016.02.046] [Citation(s) in RCA: 85] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Revised: 01/29/2016] [Accepted: 02/01/2016] [Indexed: 10/21/2022]
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Ergenoglu MU, Yerebakan H, Demirsoy E. Extrinsic Compression of the Left Main Coronary Artery: A Case of Atrial Septal Defect with Enlarged Pulmonary Artery. Heart Surg Forum 2012; 15:E158-60. [DOI: 10.1532/hsf98.20111144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
We report the case of an adult referred to our center with an initial diagnosis of stenosis of the left main coronary artery (LMCA). A preoperative investigation disclosed an atrial septal defect (ASD) with pulmonary artery hypertension. The angiographic studies confirmed the diagnosis and showed external compression of the LMCA by an enlarged pulmonary artery. Surgical closure of the ASD and tricuspid valve ring annuloplasty with coronary artery bypass surgery (left internal mammary artery to left anterior descending artery) were undertaken. Six months after the surgery, the patient is doing well.
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Ellis SG. Percutaneous left main invention an evolving perspective. JACC Cardiovasc Interv 2010; 3:642-7. [PMID: 20630457 DOI: 10.1016/j.jcin.2010.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2010] [Accepted: 04/17/2010] [Indexed: 10/19/2022]
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Hu FB, Tamai H, Kosuga K, Kyo E, Hata T, Okada M, Nakamura T, Fujita S, Tsuji T, Takeda S, Motohara S, Uehata H. Predictors of improvement in left ventricular function after initially successful angioplasty of unprotected left main coronary artery stenoses. ACTA ACUST UNITED AC 2009; 6:119-27. [PMID: 16146904 DOI: 10.1080/14628840410030423] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Percutaneous coronary intervention (PCI) has been increasingly applied to unprotected left main coronary artery (LMCA) lesions, with varied procedural success and clinical outcomes. However, the effect of PCI on left ventricular performance is still unclear, and there are no clinical studies assessing factors that influence left ventricular ejection fraction (LVEF) in these cases. METHODS Between April 1986 and August 2002, de novo PCI was performed for unprotected LMCA stenoses in 199 patients. Close clinical and angiographic follow-up were conducted after the procedure. RESULTS One hundred eighty patients survived over six months and analysis of paired left ventriculography was possible in 175 patients. Improvement in LVEF was observed in the entire population (52.9 +/- 15.7% to 56.1 +/- 14.3%, p = 0.048). The LVEF change was 6.7 +/- 9.5% (p < 0.01) in group with baseline LVEF < or = 50% and 0.7 +/- 6.7 % (p = NS) in group with LVEF > 50%. There was significant intergroup difference (p < 0.001). Patients with baseline diameter stenosis > or = 60% had an improvement of 5.3 +/- 8.3% (p < 0.05) whereas those with stenosis < 60% had no improvement (2.0 +/- 8.4%, p = NS). CK-MB elevation > or = 3 times normal after PCI had a significant inverse association with improvement in LVEF (p < 0.05). Multivariate analysis revealed baseline LVEF < or = 50% was the only independent predictor of improvement in LVEF (standard estimate = 3.509, 95% CI: 2.164-4.854, p < 0.001). CONCLUSIONS Successful PCI procedure is associated with significant improvement in LVEF, especially in patients with depressed left ventricular function.
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Affiliation(s)
- Fang-Bin Hu
- Department of Cardiology, Shiga Medical Center for Adults, Moriyama, Shiga, Japan
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Abstract
Patients with stenosis of the left main coronary artery present difficult challenges. The risks associated with this lesion have been known since the early days of angiography when patients were found to have increased mortality during follow-up. This information led to the general guidelines that surgical revascularization should be considered the treatment of choice in patients with significant left main coronary artery stenosis. Current advances in invasive cardiology have brought important information to the field. Intravascular ultrasound is now used routinely to evaluate angiographically indeterminate lesions with criteria now set forward as to what constitutes an indication for revascularization. Stents have even further dramatically changed the landscape. There are substantial issues, however, that need to addressed. These include the following: (1) the effect of specific lesion location on outcome - it is known that patients with distal bifurcation left main disease have worse outcome; (2) the potential for subacute thrombosis of the left main coronary artery; (3) the impact of left ventricular function and patient comorbidities irrespective of the degree and location of left main coronary artery stenosis; and (4) the risk-benefit ratio of stenting versus coronary artery bypass graft surgery. These issues are currently being addressed in two seminally important trials including the SYNTAX trial, which randomizes patients with left main and/or three-vessel disease to either coronary artery bypass graft surgery or a TAXUS drug-eluting stent. This trial is in the final stages of patient recruitment and will have important implications for the field. The other trial is the COMBAT trial, which is focused exclusively on left main coronary artery stenosis and randomizes patients with left main coronary artery disease either to a Sirolimus-eluting stent (Cypher, Johnson and Johnson Cordis, USA) or to coronary artery bypass graft surgery. The field of left main coronary artery disease continues to expand in terms of the evidence available for optimal patient evaluation and selection of treatment modalities.
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Brunner S, Kopp R, Franz WM. Endovascular repair of symptomatic abdominal aortic aneurysm complicated by postoperative acute myocardial infarction with cardiogenic shock. Clin Res Cardiol 2007; 96:236-9. [PMID: 17323012 DOI: 10.1007/s00392-007-0498-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2006] [Accepted: 01/03/2007] [Indexed: 10/23/2022]
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Abstract
Patients undergoing percutaneous coronary intervention (PCI) who have severely compromised left ventricular systolic function and complex coronary lesions including multivessel disease, left main disease, or bypass graft disease are at higher risk of adverse outcomes from hemodynamic collapse. The TandemHeart percutaneous left ventricular assist device and the Impella Recover LP 2.5 System may provide rapid circulatory support in high-risk PCI patients and in those who have cardiogenic shock. Identification of patients who are at high risk for severe hemodynamic compromise and most likely to benefit from mechanical circulatory support is crucial to derive the most benefit from this therapy. Multicenter randomized clinical trials are needed to clearly define the role of these two devices in providing circulatory support in a variety of clinical settings.
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Affiliation(s)
- Michael S Lee
- Cardiovascular Intervention Center, Cedars-Sinai Medical Center, School of Medicine, University of California-Los Angeles, 8631 West Third Street, Los Angeles, CA 90048, USA
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Aoki J, Hoye A, Staferov AV, Alekyan BG, Serruys PW. Sirolimus-eluting stent implantation for chronic total occlusion of the left main coronary artery. J Interv Cardiol 2005; 18:65-9; discussion 69. [PMID: 15788057 DOI: 10.1111/j.1540-8183.2005.04069.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Chronic total occlusion of the left main coronary artery (LMCA) is rare. Recently, percutaneous coronary intervention has been increasingly applied to unprotected LMCA lesions. We describe a patient with chronic total occlusion of the LMCA who was successfully treated with bifurcation stenting with sirolimus-eluting stents.
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Affiliation(s)
- Jiro Aoki
- Department of Interventional Cardiology, Erasmus MC, Rotterdam, The Netherlands
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Matos G, Steen L, Leya F. Treatment of unprotected left main coronary artery stenosis with a drug eluting stent in a heart transplant patient with allograft vasculopathy. Heart 2005; 91:e11. [PMID: 15657201 PMCID: PMC1768724 DOI: 10.1136/hrt.2004.045096] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/11/2004] [Indexed: 01/15/2023] Open
Abstract
High risk angioplasty with drug eluting stent placement into an unprotected left main coronary artery in a heart transplant recipient with allograft vasculopathy is reported. Ten month angiographic follow up is reported. The literature is reviewed and current methods of revascularisation are described in detail. This is the first report of drug eluting stent use in this clinical situation.
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Affiliation(s)
- G Matos
- Department of Cardiology, Loyola University Medical Center, 2130 South First Avenue, Maywood, IL 60153, USA.
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Lozano Í, Herrera C, Morís C, Gómez-Hospital JA, Rondán J, Iráculis E, Martín M, Cequier Á, Suáreza E, Esplugas E. Stent liberador de fármacos en lesiones de tronco coronario izquierdo en pacientes no candidatos a revascularización quirúrgica. Rev Esp Cardiol 2005. [DOI: 10.1157/13071888] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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López-Palop R, Pinar E, Saura D, Pérez-Lorente F, Lozano Í, Teruel F, Hurtado J, Lacunza J, Picó F, Valdés M. Short- and Medium-Term Outcomes of Percutaneous Coronary Intervention for Unprotected Left Main Coronary Artery Disease in Patients Who Are Poor Candidates for Surgical Revascularization. ACTA ACUST UNITED AC 2004. [DOI: 10.1016/s1885-5857(06)60189-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Costa MA, Gigliotti OS, Zenni MM, Gilmore PS, Bass TA. Synergistic use of sirolimus-eluting stents and intravascular ultrasound for the treatment of unprotected left main and vein graft disease. Catheter Cardiovasc Interv 2004; 61:368-75. [PMID: 14988898 DOI: 10.1002/ccd.10782] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Treating unprotected left main disease and degenerated saphenous vein grafts by percutaneous intervention remains one of the more challenging situations facing interventional cardiologists. We present two cases showing how the use of sirolimus-eluting stents in combination with other novel techniques might alter treatment paradigms in the future.
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Affiliation(s)
- Marco A Costa
- Division of Cardiology, Shands Hospital, University of Florida Health Science Center, Jacksonville, Florida 32209, USA
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Holm F, Lubanda JC, Semrad M, Rohac J, Vondracek V, Miler I, Vanek I, Golan L, Aschermann M. Les facteurs cliniques et opératoires associés à la mortalité hospitalière après chirurgie d’une sténose du tronc commun de l’artère coronaire gauche. ACTA ACUST UNITED AC 2004; 29:89-93. [PMID: 15229403 DOI: 10.1016/s0398-0499(04)96719-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
UNLABELLED Stenosis of left main coronary artery (LMCA) is a common finding on coronary angiographies (7 to 10%). Mortality is very high for conservative therapy in comparison with surgery, which provides very good long-term outcome and is accepted as the standard therapy of this condition. Over the last few years, percutaneous coronary intervention (PCI) has become a new alternative in selected patients. AIM OF THE STUDY To assess in hospital mortality in subjects referred to our surgical unit for coronary artery bypass grafting (CABG) and to identify the main clinical and surgical determinants of in-hospital mortality. METHODS Two year retrospective analysis (1998-1999) of in-hospital mortality and morbidity of patients having left main stenosis referred for CABG. RESULTS Among a group of 1443 patients operated for coronary heart disease, LMCA stenosis was found in 330 patients (22.9%). The mean age was 63 +/- 8.6 years. Elective surgery was done in 173 patients (52.4%), and acute operation (i.e. urgent, emergent or desperate) in 157 patients (47.6%). The total in-hospital mortality was 4.2% (14/330). Elective surgery in-hospital mortality was 1.7% (3/173) and urgent surgery in-hospital mortality was 7% (11/157). The main risk factors of in-hospital mortality were age > 68 years, low ejection fraction (LVEF<0.4), history of myocardial infarction, gender (female) and urgency of the operation. CONCLUSION The proportion of patients undergoing CABG for left main stenosis is relatively high in our center and their mortality is quite low especially for elective operations. As the mortality of patients treated by PCI for LMCA stenosis is similar to surgery in high-risk patients, we postulate that this approach can be a real alternative treatment for such patients. Because of its potential benefit, combined revascularisation is also an alternative that should be considered in some cases. Furthermore, as a new generation of coated stents has emerged in the treatment of restenosis after PCI, we hypothesize that this method can in the near future be accepted as equivalent to surgery. However several randomized clinical trials must first be conduced prove this point.
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Affiliation(s)
- F Holm
- Cardiocentrum du Centre Hospitalier Universitaire de la 1re Faculté de Médecine, Université Charles, U nemocnice 2, 12808 Prague 2, République Tchèque
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Mesquita SMF, Castro CRP, Ikari NM, Oliveira SA, Lopes AA. Likelihood of left main coronary artery compression based on pulmonary trunk diameter in patients with pulmonary hypertension. Am J Med 2004; 116:369-74. [PMID: 15006585 DOI: 10.1016/j.amjmed.2003.11.015] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2003] [Revised: 11/06/2003] [Accepted: 11/06/2003] [Indexed: 10/26/2022]
Abstract
PURPOSE In patients with pulmonary hypertension, extrinsic compression of the left main coronary artery by a dilated pulmonary trunk may cause angina, left ventricular ischemia, and sudden death. We assessed coronary artery compression in relation to pulmonary trunk diameter and other demographic, echocardiographic, hemodynamic, and scintigraphic variables. METHODS Thirty-six patients (aged 15 to 86 years) with pulmonary hypertension, either idiopathic or associated with congenital heart disease, were enrolled. Left main coronary artery compression was defined angiographically as > or =50% obstruction associated with downward displacement of the vessel. Pulmonary trunk and aortic diameters were measured by transthoracic echocardiography. RESULTS Twenty-six patients had angina, of whom 7 had left coronary artery compression. Compression was related to pulmonary trunk diameter (P = 0.002) and to the ratio of pulmonary trunk diameter to aortic diameter (P = 0.02). Compression was not seen at pulmonary artery diameters <40 mm; among 19 patients with values > or =40 mm, the rate was 37%. Similarly, compression did not occur at pulmonary trunk to aortic diameter ratios <1.21; among 27 patients with ratios > or =1.21, the rate was 26%. CONCLUSION In pulmonary hypertension, noninvasive measurement of pulmonary trunk diameter may be helpful in determining the likelihood of left coronary artery compression and in selecting patients for diagnostic coronary angiography.
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Affiliation(s)
- Sonia M F Mesquita
- Heart Institute (InCor), University of São Paulo School of Medicine, São Paulo, Brazil
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Sakurai K, Suzuki T, Nakazawa A, Okado T, Sugiura T, Ikeda K, Ueda R, Dohi Y. Coronary stenting in an elderly patient with an acute myocardial infarction at left main trunk. Am J Med Sci 2004; 327:94-7. [PMID: 14770027 DOI: 10.1097/00000441-200402000-00008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Acute myocardial infarction (AMI) caused by an occlusion of the left main trunk (LMT) is a rare angiographic finding. The prognosis is usually extremely poor, particularly in an elderly patient, unless complete reperfusion is rapidly established. We experienced a survival case of an elderly man with AMI at the LMT. A 91-year-old man with cardiogenic shock was referred to our hospital for the treatment of AMI. Left ventriculograms showed that akinesis in the anterolateral and apical wall segments had resulted in an ejection fraction of 30.8%. Coronary angiograms revealed a 90% narrowing at the ostium of the LMT. Intravascular ultrasound images showed a circumferential calcification at the site of the minimum lumen diameter of the LMT. We successfully dilated this calcified narrowing using a coronary stent, and the patient was discharged without complications 1 month later. The patient was asymptomatic 6 months later.
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Affiliation(s)
- Keita Sakurai
- Division of Cardiology, Toyokawa City Hospital, Toyokawa, Japan
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Gómez Varela S, Montes Orbe PM, Alcíbar Villa J, Egurbide MV, Sainz I, Barrenetxea Benguría JI. El stent en la compresión del tronco coronario izquierdo en la hipertensión pulmonar primaria. Rev Esp Cardiol 2004. [DOI: 10.1016/s0300-8932(04)77171-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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López-Palop R, Pinar E, Saura D, Pérez-Lorente F, Lozano Í, Teruel F, Hurtado J, Lacunza J, Picó F, Valdés M. Resultados a corto y medio plazo del intervencionismo coronario percutáneo sobre el tronco coronario común izquierdo no protegido en pacientes malos candidatos para revascularización quirúrgica. Rev Esp Cardiol 2004. [DOI: 10.1016/s0300-8932(04)77239-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Kosuga K, Tamai H, Kyo E, Hata T, Okada M, Nakamura T, Fujita S, Tsuji T, Takeda S, Inuzuka Y, Motohara S, Uehata H. Lesion regression after percutaneous coronary intervention for unprotected left main trunk disease. INTERNATIONAL JOURNAL OF CARDIOVASCULAR INTERVENTIONS 2003; 5:132-6. [PMID: 12959729 DOI: 10.1080/14628840310017366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Although some studies have documented the six-month angiographic outcomes of percutaneous coronary intervention (PCI) with new devices for unprotected left main trunk disease (ULMTD), a long-term angiographic analysis is mandatory to evaluate the safety and effectiveness of this procedure. This study aims to assess a long-term (one year or more) angiographic analysis after PCI for this lesion. METHODS PCI was performed for 225 ULMTD with de novo or restenotic lesions. There were 19 deaths and 12 repeat PCIs during the hospital stay. The remaining 194 lesions were followed, and 126 lesions showed no angiographic restenosis or target lesion revascularization within six months. Finally, long-term quantitative angiographic follow-up was completed in 78 lesions (mean 2.4 years, maximum 7.5 years after PCI). RESULTS Minimal lumen diameter increased significantly from 2.46 +/- 0.59 mm to 2.72 +/- 0.65 mm (p < 0.0001) and percent diameter stenosis decreased significantly from 26 +/- 14% to 19 +/- 14% (p < 0.0001) between the six-month and the long-term follow-ups. No additional restenosis or new lesions were found at long-term follow-up, and significant lesion regression was ascertained in each procedure (directional coronary atherectomy, p < 0.005; ballooning, p < 0.005; stenting, p < 0.05). CONCLUSIONS These findings support the safety and effectiveness of PCI for ULMTD during the long-term period.
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Affiliation(s)
- Kunihiko Kosuga
- Department of Cardiology, Shiga Medical Center for Adults, Japan
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Butman SM, Jamison K, Slepian M, Edling N, Arabia F, Copeland JG. Percutaneous intervention for unprotected left main disease prior to explantation of a left ventricular assist device. Catheter Cardiovasc Interv 2003; 59:471-4. [PMID: 12891610 DOI: 10.1002/ccd.10540] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Percutaneous coronary intervention of unprotected left main coronary arterial disease is an alternative to surgical revascularization in selected patients. In this report, a patient with an implanted left ventricular assist device (LVAD) underwent successful coronary intervention prior to its planned removal. The implanted LVAD clearly assisted the technical performance of the intervention.
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Affiliation(s)
- Samuel M Butman
- Sarver Heart Center, University of Arizona, University Medical Center, Tucson, Arizona 85724, USA.
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Park SJ, Park SW, Hong MKI, Lee CW, Lee JH, Kim JJ, Jang YS, Shin EK, Yoshida Y, Tamura T, Kimura T, Nobuyoshi M. Long-term (three-year) outcomes after stenting of unprotected left main coronary artery stenosis in patients with normal left ventricular function. Am J Cardiol 2003; 91:12-6. [PMID: 12505564 DOI: 10.1016/s0002-9149(02)02990-9] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The purpose of this study was to analyze long-term follow-up information from patients treated with stenting for unprotected left main coronary artery (LMCA) stenosis. Stenting of unprotected LMCA stenosis is often performed in selected patients, but the long-term safety of this therapy is not yet established. Between January 1995 and September 2000, 270 consecutive patients with unprotected LMCA stenosis and normal left ventricular function who underwent treatment at 4 clinical centers were included in this study. Data were forwarded to the coordinating center using a standard case report form. The procedural success rate was 98.9%. There were no deaths, 3 stent thromboses, and 3 Q-wave myocardial infarctions during the hospitalization. Angiographic follow-up was performed in 237 patients (follow-up rate 87.8%), and the restenosis rate was 21.1%. The reference size was an independent predictor of binary restenosis (odds ratio 0.543, 95% confidence interval 0.308 to 0.957, p = 0.03). During the follow-up period (32.3 +/- 18.5 months), there were 20 deaths (8 cardiac, 12 noncardiac) and 5 nonfatal myocardial infarctions. Target and new lesion revascularizations were required in 45 (16.7%) and 31 (11.5%) patients, respectively. The cumulative probabilities free from major adverse cardiac events were 81.9 +/- 2.4%, 78.4 +/- 2.6%, and 77.7 +/- 2.7%, respectively, at 1, 2, and 3 years. Combined coronary artery disease and postprocedural minimal luminal diameter were the significant predictors of major adverse cardiac events. Thus, the long-term prognosis of patients after stenting of unprotected LMCA stenosis was favorable in selected patients with normal left ventricular function.
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Affiliation(s)
- Seung-Jung Park
- Cardiac Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea.
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Park SJ, Lee CW, Kim YH, Lee JH, Hong MK, Kim JJ, Park SW. Technical feasibility, safety, and clinical outcome of stenting of unprotected left main coronary artery bifurcation narrowing. Am J Cardiol 2002; 90:374-8. [PMID: 12161225 DOI: 10.1016/s0002-9149(02)02492-x] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This study was performed to evaluate the acute and long-term results of stenting for unprotected left main coronary artery (LMCA) bifurcation lesions. Sixty-three consecutive patients with an unprotected LMCA bifurcation lesion and normal left ventricular function were included. Stenting was performed with (n = 32) or without debulking atherectomy (n = 31) at the operator's discretion. Slotted-tube stents, coil stents, or bifurcation stents were used. The procedural success rate was 100%. In-hospital events including stent thrombosis, Q-wave myocardial infarction, and emergency bypass surgery did not occur in any patients. The angiographic follow-up rate was 86% (43 of the 50 eligible patients), and the restenosis rate was 28% (parent vessel only 14%, side branch only 9%, and both 5%). Restenosis at the parent vessel occurred less frequently in the debulking group than in the nondebulking group (5% vs 33%, respectively, p = 0.02). In multivariate analysis, the debulking procedure was an independent predictive factor of restenosis for the parent vessel (odds ratio 0.10, 95% confidence intervals 0.01 to 0.91, p = 0.04). Clinical follow-up was obtained in all patients at 19.9 +/- 13.7 months. There were 2 deaths (noncardiac origin), but no myocardial infarction during follow-up. Target lesion revascularization was required in 6 patients. The event-free survival rate (death, nonfatal myocardial infarction, and repeat revascularization) was 86% at the end of the follow-up period. In conclusion, stenting for an unprotected LMCA bifurcation lesion may be performed with a high procedural success rate and a favorable clinical outcome in selected patients with normal left ventricular function, suggesting that stenting would be an effective alternative to surgery in these patients.
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Affiliation(s)
- Seung-Jung Park
- Department of Medicine, Asan Medical Center, University of Ulsan, Seoul, South Korea
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Tan WA, Tamai H, Park SJ, Plokker HW, Nobuyoshi M, Suzuki T, Colombo A, Macaya C, Holmes DR, Cohen DJ, Whitlow PL, Ellis SG. Long-term clinical outcomes after unprotected left main trunk percutaneous revascularization in 279 patients. Circulation 2001; 104:1609-14. [PMID: 11581137 DOI: 10.1161/hc3901.096669] [Citation(s) in RCA: 172] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Percutaneous coronary revascularization (PCI) has been increasingly applied to unprotected left main trunk (LMT) lesions, with varied long-term success. This study attempts to define the predictors of outcome in this population. METHODS AND RESULTS Two hundred seventy-nine consecutive patients who had LMT PCI at 1 of 25 sites between 1993 and 1998 were studied. Forty-six percent of these patients were deemed inoperable or at high surgical risk. Thirty-eight patients (13.7%) died in hospital, and the rest were followed up for a mean of 19 months. The 1-year incidence was 24.2% for all-cause mortality, 20.2% for cardiac mortality, 9.8% for myocardial infarction, and 9.4% for CABG. Independent correlates of all-cause mortality were left ventricular ejection fraction </=30%, mitral regurgitation grade 3 or 4, presentation with myocardial infarction and shock, creatinine >/=2.0 mg/dL, and severe lesion calcification. For the 32% of patients <65 years old with left ventricular ejection fraction >30% and without shock, the prevalence of these adverse risk factors was low. No periprocedural deaths were observed in this low-risk subset, and the 1-year mortality was only 3.4%. CONCLUSIONS Patients undergoing unprotected LMT PCI have frequent serious comorbidities and consequently have high event rates. PCI may be an alternative to CABG for a select proportion of elective patients and may also be appropriate for highly symptomatic inoperable patients. Meticulous follow-up of hospital survivors is required because of the rather high mortality during the first few months after treatment.
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Affiliation(s)
- W A Tan
- Pittsburgh Vascular Institute, UPMC Shadyside, Pittsburgh, PA, USA
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Rich S, McLaughlin VV, O'Neill W. Stenting to reverse left ventricular ischemia due to left main coronary artery compression in primary pulmonary hypertension. Chest 2001; 120:1412-5. [PMID: 11591592 DOI: 10.1378/chest.120.4.1412] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Angina is a common symptom of severe pulmonary hypertension. Although many theories for the source of this pain have been proposed, right ventricular ischemia is the one most commonly accepted as the cause. We report on two patients with primary pulmonary hypertension who had angina with normal activity or on provocation. One patient had severe left ventricular dysfunction. Both were found to have severe ostial stenosis of the left main coronary artery as a result of compression from a dilated pulmonary artery. Both patients underwent stenting of the left main coronary artery with excellent angiographic results, and complete resolution of the signs and symptoms of angina and left ventricular ischemia. Left ventricular ischemia due to compression of the left main coronary artery may be a much more common mechanism of angina and left ventricular dysfunction in patients with pulmonary hypertension than previously acknowledged. Stenting of the coronary artery can be done safely with the resolution of these symptoms.
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Affiliation(s)
- S Rich
- Section of Cardiology, Rush Medical College, Chicago, IL 60612-3824, USA
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Chan AW, Carere RG, Khatri S, Della Siega A, Ignaszewski AP, Webb JG. Unprotected left main coronary artery stenting for cardiac allograft vasculopathy. J Heart Lung Transplant 2001; 20:776-80. [PMID: 11448810 DOI: 10.1016/s1053-2498(00)00227-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Cardiac allograft vasculopathy is the leading cause of death after the first year of transplantation. Treatment outcomes with medication, balloon angioplasty, bypass surgery, and retransplantation have been disappointing. We present our initial experience with stenting of the left main coronary artery in the setting of allograft vasculopathy.
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Affiliation(s)
- A W Chan
- Division of Cardiology, St. Paul's Hospital, Vancouver, British Columbia, Canada
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Kosuga K, Tamai H, Ueda K, Kyo E, Tanaka S, Hata T, Okada M, Nakamura T, Komori H, Tsuji T, Takeda S, Motohara S, Uehata H. Initial and long-term results of directional coronary atherectomy in unprotected left main coronary artery. Am J Cardiol 2001; 87:838-43. [PMID: 11274937 DOI: 10.1016/s0002-9149(00)01523-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Angioplasty in the unprotected left main coronary artery (LMCA) has been controversial. Recently, several studies have suggested that new procedures and devices such as directional coronary atherectomy (DCA) and stents may change this situation. Although there are many reports of unprotected LMCA stenting, there are few reports of DCA of this lesion. Therefore, initial and long-term results were evaluated in 101 patients who underwent DCA for unprotected LMCA in our hospital. Emergency procedures were performed in 15 patients and electively in 86 patients. Scheduled angiographic follow-up was routinely performed, and all patients were clinically followed for >4 months after DCA. Technical success was achieved in 99%, and in-hospital outcomes were cardiac death (2%), noncardiac death (4%), Q-wave myocardial infarction (1%), non-Q-wave myocardial infarction (8.9%), coronary artery bypass grafting (0%), and repeat angioplasty (4%). In-hospital results varied considerably, depending on presentation. In-hospital mortality was significantly higher in the emergency, left ventricular ejection fraction < or =35%, and high-risk surgical subgroups. The angiographic restenosis rate was 20.4% at follow-up, and its predictor was postminimal lumen diameter by multivariate analysis. Mean clinical follow-up was 2.8 years; estimated 1- and 3-year survival rates were 87% and 80.7%, respectively. The cardiac survival rate of the low-risk surgical subgroup was significantly higher than that of the high-risk surgical subgroup (p <0.05). Thus, our data show that DCA can be performed safely and effectively in unprotected LMCA with an acceptable low restenosis rate and high survival rate.
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Affiliation(s)
- K Kosuga
- Department of Cardiology, Shiga Medical Center for Adults, Shiga, Japan
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Fernández-Avilés F, Alonso Martín J, María Augé Sanpera J, García Fernández E, Macaya de Miguel C, Melgares Moreno R, Valdés Chavarri M. [Continuous practice and advanced training in interventional cardiology. Recommendations for the assessment and maintenance of proficiency in interventional cardiology. A statement for physicians and advanced training units from the Section of Hemodynamics and Interventional Cardiology of the Spanish Society of Cardiology]. Rev Esp Cardiol 2000; 53:1613-25. [PMID: 11171484 DOI: 10.1016/s0300-8932(00)75287-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
This report reflects the interest of the Section of Hemodynamics and Interventional Cardiology of the Spanish Society of Cardiology in increasing quality, safety and applicability of percutaneous procedures, by giving scientific keys aimed at improving related functions of teaching or planning in this field and enhancing competence and prestige of Spanish interventional cardiologists. The purpose of the document is to describe the importance of current interventional cardiology, to identify quality references and to establish minimum acceptable requirements for assessing and maintaining the competence of practicing or providing advanced training in this discipline. To achieve this goal, a search for a gold standard of the different techniques of general interventional practice was carried out, and predictors of postprocedural outcome were analyzed, as well as their relation with different kinds of circumstances. This analysis identified coronary angioplasty as the standard on which recommendations regarding competence in overall interventional cardiology standards of quality and assessment and maintenance of proficiency must be based. On the other hand, the strong influence of experience and knowledge of results has been documented, especially in high-risk or high-complexity settings. On this basis, the report establishes specific recommendations about proficiency for practice and advanced training. It also suggests that interventional cardiology should be considered as a subspecialty, of cardiology requiring specific credentials.
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Affiliation(s)
- F Fernández-Avilés
- Instituto de Ciencias del Corazón, Hospital Clinico-Universitario de Valladolid.
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