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El Nasasra A, Hochadel M, Zahn R, Schneider A, Thiele H, Darius H, Behrens S, Schumacher B, Ince H, Zeymer U. Outcomes After Left Main Percutaneous Coronary Intervention in Patients With Acute Myocardial Infarction Complicated by Cardiogenic Shock (from the German ALKK PCI Registry). Am J Cardiol 2023; 197:77-83. [PMID: 37173201 DOI: 10.1016/j.amjcard.2023.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 03/05/2023] [Accepted: 04/06/2023] [Indexed: 05/15/2023]
Abstract
Early revascularization therapy with percutaneous coronary intervention (PCI) has been shown to improve outcomes in patients with acute myocardial infarction (AMI) complicated by cardiogenic shock (CS). Data from consecutive patients with AMI and CS treated with PCI enrolled into the prospective Arbeitsgemeinschaft Leitende Kardiologische Krankenhausärzte-PCI registry were centrally collected and analyzed. Patients were divided into 4 groups with PCI for left main (LM), 1-vessel, 2-vessel, and 3-vessel diseases. Patients' characteristics, procedural features, antithrombotic therapies, and in-hospital complications were compared between the 4 groups. Between 2010 and 2015 a total of 2,348 consecutive patients with AMI and CS were treated by PCI in 51 hospitals, 295 for LM (15 for protected, 280 for unprotected) and single-vessel (n = 491), 2-vessel (n = 524), and 3-vessel disease (n = 1,038). Thrombolysis in myocardial infarction 3 patency of the culprit lesion after PCI was 84.3%, 84.0%, 80.8%, and 84.6% in single-vessel, 2-vessel, 3-vessel disease, and LM PCI, respectively, whereas in-hospital mortality was 27.9%, 33.9%, 46.5%, and 55.9%. Bleeding rates were low (2.0%-2.3 %) and not different between groups. In a multivariate analysis a higher age, thrombolysis in myocardial infarction flow <3 after PCI, 3-vessel disease, and LM PCI were independent predictors of mortality. In conclusion, PCI of the LM is performed in about 12.5% of patients with AMI and CS and was associated with a high procedural success rate, whereas mortality is increased with LM PCI.
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Affiliation(s)
- Aref El Nasasra
- Department of Cardiology, Klinikum Ludwigshafen, Ludwigshafen, Germany; Department of Cardiology, Soroka University Medical Center, Be'er Sheva, Israel.
| | - Mathias Hochadel
- Institut für Herzinfarktforschung Ludwigshafen, Ludwigshafen, Germany
| | - Ralf Zahn
- Department of Cardiology, Klinikum Ludwigshafen, Ludwigshafen, Germany
| | | | - Holger Thiele
- Heart Center Leipzig at University of Leipzig and Leipzig Heart Institute, Leipzig, Germany
| | | | | | | | | | - Uwe Zeymer
- Department of Cardiology, Klinikum Ludwigshafen, Ludwigshafen, Germany; Institut für Herzinfarktforschung Ludwigshafen, Ludwigshafen, Germany
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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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Taguchi Y, Kubo S, Ikuta A, Osakada K, Takamatsu M, Takahashi K, Ohya M, Shimada T, Miura K, Murai R, Tada T, Tanaka H, Fuku Y, Goto T, Komiya T, Kadota K. Percutaneous coronary intervention for left main coronary artery malperfusion in acute type A aortic dissection. Cardiovasc Interv Ther 2021; 37:333-342. [PMID: 34255294 PMCID: PMC8926951 DOI: 10.1007/s12928-021-00793-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 07/02/2021] [Indexed: 01/16/2023]
Abstract
The clinical outcomes of patients undergoing percutaneous coronary intervention (PCI) for left main coronary artery (LMCA) malperfusion caused by acute type A aortic dissection (AAAD) remains largely unexplored. The aim of this study was to determine the clinical outcomes of patients undergoing PCI for LMCA malperfusion caused by AAAD. We examined nine consecutive patients undergoing PCI for LMCA malperfusion caused by AAAD between 1995 and 2020. The mean age was 55.4 ± 7.7 years. Eight patients presented cardiogenic shock, and five patients cardiopulmonary arrest. Two patients were diagnosed with AAAD before coronary angiography using computed tomography and transthoracic echocardiography, respectively, and in the other seven patients after coronary angiography using other modalities. Four patients underwent PCI on intra-aortic balloon pumping support, and four patients on venoarterial extracorporeal membrane oxygenation (VA-ECMO) support, including one patient on both. PCI was successful in eight patients, with final thrombolysis in myocardial infarction grade 2 or 3. The four patients on VA-ECMO did not undergo aortic dissection repair due to poor recovery of cardiac function and died during the hospital stay, and the other five patients had successful PCI, underwent aortic dissection repair, and remained alive at 5 year follow-up. In conclusion, LMCA malperfusion caused by AAAD seemed to have clinical presentations and electrocardiogram changes similar to acute coronary syndrome. PCI and subsequent surgical aortic repair saved the lives of all AAAD patients with LMCA malperfusion who had not required VA-ECMO.
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Affiliation(s)
- Yuya Taguchi
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, 1-1-1, Miwa, Kurashiki, 710-8602, Japan.
| | - Shunsuke Kubo
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, 1-1-1, Miwa, Kurashiki, 710-8602, Japan
| | - Akihiro Ikuta
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, 1-1-1, Miwa, Kurashiki, 710-8602, Japan
| | - Kohei Osakada
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, 1-1-1, Miwa, Kurashiki, 710-8602, Japan
| | - Makoto Takamatsu
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, 1-1-1, Miwa, Kurashiki, 710-8602, Japan
| | - Kotaro Takahashi
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, 1-1-1, Miwa, Kurashiki, 710-8602, Japan
| | - Masanobu Ohya
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, 1-1-1, Miwa, Kurashiki, 710-8602, Japan
| | - Takenobu Shimada
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, 1-1-1, Miwa, Kurashiki, 710-8602, Japan
| | - Katsuya Miura
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, 1-1-1, Miwa, Kurashiki, 710-8602, Japan
| | - Ryosuke Murai
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, 1-1-1, Miwa, Kurashiki, 710-8602, Japan
| | - Takeshi Tada
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, 1-1-1, Miwa, Kurashiki, 710-8602, Japan
| | - Hiroyuki Tanaka
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, 1-1-1, Miwa, Kurashiki, 710-8602, Japan
| | - Yasushi Fuku
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, 1-1-1, Miwa, Kurashiki, 710-8602, Japan
| | - Tsuyoshi Goto
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, 1-1-1, Miwa, Kurashiki, 710-8602, Japan
| | - Tatsuhiko Komiya
- Department of Cardiovascular Surgery, Kurashiki Central Hospital, 1-1-1, Miwa, Kurashiki, Japan
| | - Kazushige Kadota
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, 1-1-1, Miwa, Kurashiki, 710-8602, Japan
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Gutiérrez-Barrios A, Gheorghe L, Camacho-Freire S, Valencia-Serrano F, Cañadas-Pruaño D, Calle-Pérez G, Alarcón de la Lastra I, Silva E, García-Molinero D, Agarrado-Luna A, Zayas-Ruedas R, Vázquez-García R, Serra A. Primary Angioplasty in a Catastrophic Presentation: Acute Left Main Coronary Total Occlusion-The ATOLMA Registry. J Interv Cardiol 2020; 2020:5246504. [PMID: 32774186 PMCID: PMC7403907 DOI: 10.1155/2020/5246504] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 07/01/2020] [Indexed: 02/03/2023] Open
Abstract
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.
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Affiliation(s)
- A. Gutiérrez-Barrios
- Departamento de Cardiología Hospital Universitario Puerta del Mar, Cádiz, Spain
- Instituto de Investigación e Innovación en Ciencias Biomédicas de Cádiz, INiBICA, Cádiz, Spain
| | - L. Gheorghe
- Departamento de Cardiología Hospital Universitario Puerta del Mar, Cádiz, Spain
- Instituto de Investigación e Innovación en Ciencias Biomédicas de Cádiz, INiBICA, Cádiz, Spain
| | - S. Camacho-Freire
- Departamento de Cardiología Hospital Juan Ramón Jiménez, Huelva, Spain
| | | | - D. Cañadas-Pruaño
- Instituto de Investigación e Innovación en Ciencias Biomédicas de Cádiz, INiBICA, Cádiz, Spain
- Departamento de Cardiología Hospital de Jerez, Cádiz, Spain
| | - G. Calle-Pérez
- Departamento de Cardiología Hospital Universitario Puerta del Mar, Cádiz, Spain
- Instituto de Investigación e Innovación en Ciencias Biomédicas de Cádiz, INiBICA, Cádiz, Spain
| | | | - E. Silva
- Instituto de Investigación e Innovación en Ciencias Biomédicas de Cádiz, INiBICA, Cádiz, Spain
| | - D. García-Molinero
- Departamento de Cardiología Hospital Universitario Puerta del Mar, Cádiz, Spain
| | | | - R. Zayas-Ruedas
- Departamento de Cardiología Hospital Universitario Puerta del Mar, Cádiz, Spain
- Instituto de Investigación e Innovación en Ciencias Biomédicas de Cádiz, INiBICA, Cádiz, Spain
| | - R. Vázquez-García
- Departamento de Cardiología Hospital Universitario Puerta del Mar, Cádiz, Spain
- Instituto de Investigación e Innovación en Ciencias Biomédicas de Cádiz, INiBICA, Cádiz, Spain
| | - A. Serra
- Departamento de Cardiología Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
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Does stress hyperglycemia affect mortality? Acute myocardial infarction - case control study. ACTA ACUST UNITED AC 2019; 4:e201-e207. [PMID: 31538125 PMCID: PMC6749178 DOI: 10.5114/amsad.2019.87303] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 07/18/2019] [Indexed: 11/28/2022]
Abstract
Introduction We aimed to investigate the effect of stress (acute) hyperglycemia in patients with acute coronary syndrome who had not been previously diagnosed with diabetes mellitus (DM) on the prognosis of the disease in terms of mortality. Material and methods Patients who were admitted to the Adana Numune Training and Research Hospital Emergency Service Clinic between August 2010 and August 2013 and whose plasma blood glucose level was over 140 mg/dl at the time of admission but were not previously diagnosed with DM, who were over the age of 18 and considered to have acute myocardial infarction were included. Results A total of 259 patients whose data were fully attainable were included in the study. 80.3% (n = 208) of the patients were male and 19.7% (n = 41) were female. Non-ST elevation myocardial infarction was found in 71.6%, ST elevation myocardial infarction was found in 28.4% of the patients with stress hyperglycemia. It was determined that 10.1% of patients with stress-related hyperglycemia and 1.3% of patients without stress-related hyperglycemia had died. Conclusions The plasma blood glucose level at presentation of patients diagnosed with acute myocardial infarction at the emergency room is associated with early in-hospital mortality.
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Yamauchi T, Masai T, Fujii K, Sawa Y, Shirai S, Kamigaki M, Itou N. Long-term clinical results of acute myocardial infarction at the left main trunk requiring percutaneous cardiopulmonary support. J Artif Organs 2017; 20:303-310. [PMID: 28887708 DOI: 10.1007/s10047-017-0972-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Accepted: 06/25/2017] [Indexed: 11/28/2022]
Abstract
The clinical results of patients with acute myocardial infarction (AMI) at the left main trunk (LMT) remain unclear, especially in cases requiring percutaneous cardiopulmonary support (PCPS). Twenty seven cases of AMI at the LMT requiring emergent PCPS were retrospectively investigated. These 27 patients were aged 44-83 years (65.6 ± 8.6 years) and 20 (81.5%) were men. Peak creatine kinase (CK) leakage ranged from 538 to 34,010 IU/l (13,553 ± 7656 IU/l). Eight (29.6%) patients were discharged without mechanical support. Ten (37.0%) patients underwent left ventricular assist device (LVAD) implantation, five of whom with preoperative organ failure could not survive more than 6 months after implantation. The other nine (33.3%) patients died of low output syndrome or brain damage. The overall survival rates were 53.7, 41.3, 33.0, and 28.3% at 3 months, 6 months, 1 year, and 2 years, respectively. Multivariate analysis showed that Killip class 3/4 at hospital arrival was an independent risk factor for hospital mortality (odds ratio 20.4). Patients with more than 5 days of PCPS support period (n = 6), ≥ 4 h to revascularization (n = 6) or maximum CK leakage ≥20,000 IU/dl (n = 3) were not associated with successful PCPS or IABP weaning. The long-term clinical outcomes of patients with LMT disease requiring PCPS is devastating. Rapid cardiopulmonary resuscitation and coronary revascularization and timely insertion of LVAD before the onset of complications might lead to better survival.
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Affiliation(s)
- Takashi Yamauchi
- Department of Cardiovascular Surgery, KKR Sapporo Medical Center, 6-3-40 Ichijo Hiragishi, Toyohira, Sapporo, Hokkaido, 062-0931, Japan.
| | - Takafumi Masai
- Department of Cardiovascular Surgery, Sakurabashi Watanabe Hospital, 2-4-32 Umeda, Kitaku, Osaka, Osaka, 530-0001, Japan
| | - Kenji Fujii
- Department of Cardiology, Sakurabashi Watanabe Hospital, 2-4-32 Umeda, Kitaku, Osaka, Osaka, 530-0001, Japan
| | - Yoshiki Sawa
- Department of Cardiovascular Surgery, Osaka Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan.
| | - Shinya Shirai
- Department of Cardiology, KKR Sapporo Medical Center, 6-3-40 Ichijo Hiragishi, Toyohira, Sapporo, Hokkaido, 062-0931, Japan
| | - Mitsunori Kamigaki
- Department of Cardiology, KKR Sapporo Medical Center, 6-3-40 Ichijo Hiragishi, Toyohira, Sapporo, Hokkaido, 062-0931, Japan
| | - Naofumi Itou
- Department of Cardiology, KKR Sapporo Medical Center, 6-3-40 Ichijo Hiragishi, Toyohira, Sapporo, Hokkaido, 062-0931, Japan
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Xu L, Sun H, Wang LF, Yang XC, Li KB, Zhang DP, Wang HS, Li WM. Long-term prognosis of patients with acute myocardial infarction due to unprotected left main coronary artery disease: a single-centre experience over 14 years. Singapore Med J 2017; 57:396-400. [PMID: 27439434 DOI: 10.11622/smedj.2016121] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Acute myocardial infarction (AMI) due to unprotected left main coronary artery (ULMCA) disease is clinically catastrophic although it has a low incidence. Studies on the long-term prognosis of these patients are rare. METHODS From January 1999 to September 2013, 55 patients whose infarct-related artery was the ULMCA were enrolled. Clinical, angiographic and interventional data was collected. Short-term and long-term clinical follow-up results as well as prognostic determinants during hospitalisation and follow-up were analysed. RESULTS Cardiogenic shock (CS) occurred in 30 (54.5%) patients. During hospitalisation, 22 (40.0%) patients died. Multivariate logistic regression analysis showed that CS (odds ratio [OR] 5.86; p = 0.03), collateral circulation of Grade 2 or 3 (OR 0.14; p = 0.02) and final flow of thrombolysis in myocardial infarction (TIMI) Grade 3 (OR 0.05; p = 0.03) correlated with death during hospitalisation. 33 patients survived to discharge; another seven patients died during the follow-up period of 44.6 ± 31.3 (median 60, range 0.67-117.00) months. The overall mortality rate was 52.7% (n = 29). Kaplan-Meier analysis showed that the total cumulative survival rate was 30.7%. Cox multivariate regression analysis showed that CS during hospitalisation was the only predictor of overall mortality (hazard ratio 4.07, 95% confidence interval 1.40-11.83; p = 0.01). CONCLUSION AMI caused by ULMCA lesions is complicated by high incidence of CS and mortality. CS, poor collateral blood flow and failure to restore final flow of TIMI Grade 3 correlated with death during hospitalisation. CS is the only predictor of long-term overall mortality.
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Affiliation(s)
- Li Xu
- Heart Center, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Hao Sun
- Heart Center, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Le-Feng Wang
- Heart Center, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Xin-Chun Yang
- Heart Center, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Kui-Bao Li
- Heart Center, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Da-Peng Zhang
- Heart Center, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Hong-Shi Wang
- Heart Center, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Wei-Ming Li
- Heart Center, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
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Cheng HY, Wang KT, Lin WH, Tsai JP, Chen YT. Percutaneous Coronary Intervention for Left Main Coronary Artery Disease - A Single Hospital Experience without On-Site Cardiac Surgery. ACTA CARDIOLOGICA SINICA 2016; 31:267-79. [PMID: 27122882 DOI: 10.6515/acs20150119d] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND To investigate the safety and outcome of percutaneous coronary intervention for left main coronary artery disease in hospital without on-site cardiac surgery. METHODS Between January 2007 and December 2010, all patients diagnosed with left main coronary artery disease and refused coronary artery bypass graft surgery in our hospital or a tertiary center, were enrolled. Data including clinical course, angiographic characteristics, and 1- and 3-years outcomes were recorded and analyzed. RESULTS Seventy patients (mean age 73.4 ± 10.2 years, 47 male, 23 females) were treated with a mean SYNTAX score of 34.8 ± 12.6 and EuroSCORE of 6.7 ± 3.3. Thirty-two (45.7%) patients had stable angina, 35 (50.0%) had unstable angina/non ST-elevation myocardial infarction, and 3 (4.3%) had ST-elevation Myocardial infarction. Forty-three (61.4%) patients received a single-stent, 26 (37.1%) received two-stents, and 1 (1.4%) received balloon angioplasty. No procedure-related mortalities were noted and no emergency coronary artery bypass graft surgery was required. In the 3-year follow-up period, 2 (2.9%) patients had non-fetal myocardial infarction, 11 (15.7%) had left main target lesion revascularization. The major adverse cardiac and cerebrovascular events rates were 24.3% at 1 year and 37.1% at 3-years. The all-cause mortality rate was 41.4% (29 patients), including 18 (25.7%) cases of septic shock, 7 (10.0%) of sudden cardiac death, 2 (2.8%) of hypovolemic shock due to upper gastrointestinal bleeding, 1 (1.4%) of terminal stage malignancy, and 1 (1.4%) of suffocation at 3 years. CONCLUSIONS Percutaneous coronary intervention for patients with left main coronary artery disease was found to be a safe and effective strategy in our hospital without on-site cardiac surgery. KEY WORDS Incomplete revascularization; Left main coronary artery (LM); No cardiac surgery; Percutaneous coronary intervention (PCI).
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Affiliation(s)
- Hsiao-Yang Cheng
- Division of Cardiology, Department of Internal Medicine, Mackay Memorial Hospital, Taitung Branch, Taitung
| | - Kuang-Te Wang
- Division of Cardiology, Department of Internal Medicine, Mackay Memorial Hospital, Taitung Branch, Taitung
| | - Wen-Hsiung Lin
- Division of Cardiology, Department of Internal Medicine, Mackay Memorial Hospital, Taitung Branch, Taitung
| | - Jui-Peng Tsai
- Division of Cardiology, Department of Internal Medicine, Mackay Memorial Hospital, Taitung Branch, Taitung; ; Division of Cardiology, Department of Internal Medicine, Mackay Memorial Hospital, Taipei, Taiwan
| | - Yung-Tzi Chen
- Division of Cardiology, Department of Internal Medicine, Mackay Memorial Hospital, Taitung Branch, Taitung
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9
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Ielasi A, Silvestro A, Personeni D, Saino A, Angeletti C, Costalunga A, Tespili M. Outcomes following primary percutaneous coronary intervention for unprotected left main-related ST-segment elevation myocardial infarction. J Cardiovasc Med (Hagerstown) 2016; 16:163-9. [PMID: 24892217 DOI: 10.2459/jcm.0000000000000075] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Unprotected left main (ULM) related ST-segment elevation myocardial infarction (STEMI) is a severe event, often leading to circulatory failure and/or sudden cardiac death. Although high-risk ULM thrombosis populations treated by primary percutaneous coronary intervention (PPCI) have been previously described, very little is known regarding the outcomes following PPCI for ULM-related STEMI in a hospital without on-site surgical back-up. METHODS A retrospective cohort analysis was performed on all consecutive patients who underwent PPCI for ULM-related STEMI in a single center. The primary end-point was to assess in-hospital mortality in the overall population and according to the presence/absence of cardiogenic shock at admission. RESULTS Between October 2006 and December 2012, 1094 patients underwent PPCI for STEMI. PPCI for ULM-related STEMI was performed in 34 (3.1%) patients. Among these, 22 (64.7%) were in cardiogenic shock at admission. Baseline mean ejection fraction was lower (P = 0.008), whereas the prevalence of patients with pre-procedural cardiac arrest and Killip Class III-IV was significantly higher in the cardiogenic shock (P = 0.05 and P < 0.001, respectively) compared with non-cardiogenic shock group. Furthermore, patients with cardiogenic shock had a higher prevalence of pre-procedural thrombolysis in myocardial infarction flow 0-1 (P = 0.05) and associated other vessel chronic total occlusion (P = 0.05) compared with non-cardiogenic shock group. Procedural success rate was lower in the cardiogenic shock compared with non-cardiogenic shock group (77.3 vs. 100%, P = 0.09), whereas in-hospital mortality rate was significantly higher in the cardiogenic shock compared with non-cardiogenic shock group (36.4 vs. 0%, P = 0.02). No deaths were reported among survivors of the acute phase at mid-term follow-up, whereas target lesion revascularization rate was 7.6%. CONCLUSIONS PPCI for ULM-related STEMI in a hospital without on-site surgical back-up was technically feasible in most of the cases. Although the procedural success and in-hospital mortality rates were influenced by cardiogenic shock at admission, an excellent mid-term outcome among patients who survived the hospitalization was reported independently by the severity of clinical presentation.
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Affiliation(s)
- Alfonso Ielasi
- Department of Cardiology, Azienda Ospedaliera 'Bolognini', Seriate (BG), Italy *Drs Ielasi and Silvestro contributed equally to the manuscript and are joint first authors
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10
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Uretsky BF, Mathew J, Ahmed Z, Hakeem A. Percutaneous management of patients with acute coronary syndromes from unprotected left main disease: A comprehensive review and presentation of a treatment algorithm. Catheter Cardiovasc Interv 2015; 87:90-100. [DOI: 10.1002/ccd.26034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Revised: 04/24/2015] [Accepted: 05/07/2015] [Indexed: 11/08/2022]
Affiliation(s)
- Barry F. Uretsky
- Cardiology Division; University of Arkansas for Medical Sciences, Central Arkansas Veterans Health System; Little Rock Arkansas
| | - Jacob Mathew
- Cardiology Division; University of Arkansas for Medical Sciences, Central Arkansas Veterans Health System; Little Rock Arkansas
| | - Zubair Ahmed
- Cardiology Division; University of Arkansas for Medical Sciences, Central Arkansas Veterans Health System; Little Rock Arkansas
| | - Abdul Hakeem
- Cardiology Division; University of Arkansas for Medical Sciences, Central Arkansas Veterans Health System; Little Rock Arkansas
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11
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Serpooshan V, Zhao M, Metzler SA, Wei K, Shah PB, Wang A, Mahmoudi M, Malkovskiy AV, Rajadas J, Butte MJ, Bernstein D, Ruiz-Lozano P. Use of bio-mimetic three-dimensional technology in therapeutics for heart disease. Bioengineered 2014; 5:193-7. [PMID: 24637710 PMCID: PMC4101012 DOI: 10.4161/bioe.27751] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2013] [Revised: 01/05/2014] [Accepted: 01/06/2014] [Indexed: 11/19/2022] Open
Abstract
Due to the limited self-renewal capacity of cardiomyocytes, the mammalian heart exhibits impaired regeneration and insufficient ability to restore heart function after injury. Cardiovascular tissue engineering is currently considered as a promising alternative therapy to restore the structure and function of the failing heart. Recent evidence suggests that the epicardium may play critical roles in regulation of myocardial development and regeneration. One of the mechanisms that has been proposed for the restorative effect of the epicardium is the specific physiomechanical cues that this layer provides to the cardiac cells. In this article we explore whether a new generation of epicardium-mimicking, acellular matrices can be utilized to enhance cardiac healing after injury. The matrix consists of a dense collagen scaffold with optimized biomechanical properties approaching those of embryonic epicardium. Grafting the epicardial patch onto the ischemic myocardium--promptly after the incidence of infarct--resulted in preserved contractility, attenuated ventricular remodeling, diminished fibrosis, and vascularization within the injured tissue in the adult murine heart.
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Affiliation(s)
| | - Mingming Zhao
- Stanford University; Department of Pediatrics; Stanford, CA USA
| | - Scott A Metzler
- Stanford University; Department of Pediatrics; Stanford, CA USA
| | - Ke Wei
- Sanford-Burnham Medical Research Institute; La Jolla, CA USA
| | - Parisha B Shah
- Stanford University; Department of Pediatrics; Stanford, CA USA
| | - Andrew Wang
- Stanford University; Department of Pediatrics; Stanford, CA USA
| | | | - Andrey V Malkovskiy
- Stanford University; Biomaterials and Advanced Drug Delivery Laboratory; Stanford, CA USA
| | - Jayakumar Rajadas
- Stanford University; Biomaterials and Advanced Drug Delivery Laboratory; Stanford, CA USA
| | - Manish J Butte
- Stanford University; Department of Pediatrics; Stanford, CA USA
| | | | - Pilar Ruiz-Lozano
- Stanford University; Department of Pediatrics; Stanford, CA USA
- Sanford-Burnham Medical Research Institute; La Jolla, CA USA
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12
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Baek JY, Seo SM, Park HJ, Kim PJ, Park MW, Koh YS, Chang KY, Jeong MH, Park SJ, Seung KB. Clinical outcomes and predictors of unprotected left main stem culprit lesions in patients with acute ST segment elevation myocardial infarction. Catheter Cardiovasc Interv 2013; 83:E243-50. [DOI: 10.1002/ccd.23420] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2011] [Revised: 09/28/2011] [Accepted: 10/09/2011] [Indexed: 11/07/2022]
Affiliation(s)
- Ju Yeol Baek
- Department of Medicine; Division of Cardiology; The Catholic University, Seoul St. Mary's Hospital, Korea; Seocho-Gu Seoul 137-701 Republic of Korea
| | - Suk Min Seo
- Department of Medicine; Division of Cardiology; The Catholic University, Seoul St. Mary's Hospital, Korea; Seocho-Gu Seoul 137-701 Republic of Korea
| | - Hun-Jun Park
- Department of Medicine; Division of Cardiology; The Catholic University, Seoul St. Mary's Hospital, Korea; Seocho-Gu Seoul 137-701 Republic of Korea
| | - Pum Joon Kim
- Department of Medicine; Division of Cardiology; The Catholic University, Seoul St. Mary's Hospital, Korea; Seocho-Gu Seoul 137-701 Republic of Korea
| | - Mahn Won Park
- Department of Medicine; Division of Cardiology; The Catholic University, Seoul St. Mary's Hospital, Korea; Seocho-Gu Seoul 137-701 Republic of Korea
| | - Yoon Seok Koh
- Department of Medicine; Division of Cardiology; The Catholic University, Seoul St. Mary's Hospital, Korea; Seocho-Gu Seoul 137-701 Republic of Korea
| | - Ki Yuk Chang
- Department of Medicine; Division of Cardiology; The Catholic University, Seoul St. Mary's Hospital, Korea; Seocho-Gu Seoul 137-701 Republic of Korea
| | - Myung Ho Jeong
- Department of Medicine; Division of Cardiology; The Catholic University, Seoul St. Mary's Hospital, Korea; Seocho-Gu Seoul 137-701 Republic of Korea
| | - Seung Jung Park
- Department of Medicine; Division of Cardiology; The Catholic University, Seoul St. Mary's Hospital, Korea; Seocho-Gu Seoul 137-701 Republic of Korea
| | - Ki-Bae Seung
- Department of Medicine; Division of Cardiology; The Catholic University, Seoul St. Mary's Hospital, Korea; Seocho-Gu Seoul 137-701 Republic of Korea
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13
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Abdelmalak HD, Omar HR, Mangar D, Camporesi EM. Unprotected left main coronary stenting as alternative therapy to coronary bypass surgery in high surgical risk acute coronary syndrome patients. Ther Adv Cardiovasc Dis 2013; 7:214-23. [DOI: 10.1177/1753944713488637] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Acute coronary syndrome has a high mortality rate that dramatically increases in the presence of left main coronary artery (LMCA) disease. Over the past decades, coronary artery bypass graft (CABG) surgery has been commonly accepted as the standard of care for patients with LMCA stenosis and is still considered the first-line treatment in current practice guidelines. Percutaneous coronary intervention (PCI) of protected and unprotected LMCA has gained popularity and is increasingly utilized with comparable outcomes to CABG in randomized controlled trials. In-stent restenosis and the need for revascularization provide the main obstacle to LMCA revascularization. The advent of better PCI equipment, stents, ablative devices, intravascular ultrasound, hemodynamic support devices and antithrombotic agents have ignited a renewed interest in the practice of LMCA PCI, especially for high surgical risk patients who are neither candidates nor agreeable to CABG surgery. Herein, we review the studies comparing unprotected LMCA stenting with CABG surgery in regard to 3 main endpoints: mortality, major adverse events and the incidence of repeat revascularization.
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Affiliation(s)
- Hany D. Abdelmalak
- Cardiology Department, Advocate Illinois Masonic Medical Center. Chicago, Illinois, USA
| | - Hesham R. Omar
- Internal Medicine Department, Mercy Hospital and Medical Center, 2525 South Michigan Avenue, Chicago, IL 60616, USA
| | - Devanand Mangar
- Anesthesia Department, Tampa General Hospital, Tampa, Florida, USA
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14
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Hussain F, Nguyen T, Elmayergi N, Ducas J, Minhas K, Vo M, Kass M, Ravandi A, Parmar G, Jassal DS, Tam JW, Freed D, Menkis AH, Philipp RK. 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. Can J Physiol Pharmacol 2012; 90:1325-31. [DOI: 10.1139/y2012-111] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
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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Affiliation(s)
- Farrukh Hussain
- Department of Cardiology, Saint Boniface General Hospital, 409 Tache Avenue, University of Manitoba, Winnipeg, MB R2H 2A6, Canada
| | - Thang Nguyen
- Department of Cardiology, Saint Boniface General Hospital, 409 Tache Avenue, University of Manitoba, Winnipeg, MB R2H 2A6, Canada
| | - Nader Elmayergi
- Department of Cardiology, Mt. Sinai Hospital, University Health Network, University of Toronto, 600 University Avenue, Toronto, ON M5G 1X5, Canada
| | - John Ducas
- Department of Cardiology, Saint Boniface General Hospital, 409 Tache Avenue, University of Manitoba, Winnipeg, MB R2H 2A6, Canada
| | - Kunal Minhas
- Department of Cardiology, Saint Boniface General Hospital, 409 Tache Avenue, University of Manitoba, Winnipeg, MB R2H 2A6, Canada
| | - Minh Vo
- Department of Cardiology, Saint Boniface General Hospital, 409 Tache Avenue, University of Manitoba, Winnipeg, MB R2H 2A6, Canada
| | - Malek Kass
- Department of Cardiology, Saint Boniface General Hospital, 409 Tache Avenue, University of Manitoba, Winnipeg, MB R2H 2A6, Canada
| | - Amir Ravandi
- Department of Cardiology, Saint Boniface General Hospital, 409 Tache Avenue, University of Manitoba, Winnipeg, MB R2H 2A6, Canada
| | - Gurpreet Parmar
- Department of Cardiology, Saint Boniface General Hospital, 409 Tache Avenue, University of Manitoba, Winnipeg, MB R2H 2A6, Canada
| | - Davinder S. Jassal
- Department of Cardiology, Saint Boniface General Hospital, 409 Tache Avenue, University of Manitoba, Winnipeg, MB R2H 2A6, Canada
| | - James W. Tam
- Department of Cardiology, Saint Boniface General Hospital, 409 Tache Avenue, University of Manitoba, Winnipeg, MB R2H 2A6, Canada
| | - Darren Freed
- Department of Cardiac Surgery, Saint Boniface General Hospital, 409 Tache Avenue, University of Manitoba, Winnipeg, MB R2H 2A6, Canada
| | - Alan H. Menkis
- Department of Cardiac Surgery, Saint Boniface General Hospital, 409 Tache Avenue, University of Manitoba, Winnipeg, MB R2H 2A6, Canada
| | - Roger K. Philipp
- Department of Cardiology, Saint Boniface General Hospital, 409 Tache Avenue, University of Manitoba, Winnipeg, MB R2H 2A6, Canada
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PARMA ANTONIO, FIORILLI ROSARIO, DE FELICE FRANCESCO, CHINI FRANCESCO, ROSSI PAOLOGIORGI, BORGIA PIERO, NAZZARO MARCOSTEFANO, MUSTO CARMINE, GUASTICCHI GABRIELLA, VIOLINI ROBERTO. Early and Mid-Term Clinical Outcome of Emergency PCI in Patients with STEMI due to Unprotected Left Main Coronary Artery Disease. J Interv Cardiol 2012; 25:215-22. [DOI: 10.1111/j.1540-8183.2011.00712.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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16
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Puricel S, Adorjan P, Oberhänsli M, Stauffer JC, Moschovitis A, Vogel R, Goy JJ, Müller O, Eeckhout E, Togni M, Wenaweser P, Meier B, Windecker S, Cook S. Clinical outcomes after PCI for acute coronary syndrome in unprotected left main coronary artery disease: insights from the Swiss Acute Left Main Coronary Vessel Percutaneous Management (SALVage) study. EUROINTERVENTION 2012; 7:697-704. [PMID: 21986328 DOI: 10.4244/eijv7i6a112] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS Unprotected left main (ULM) coronary artery disease is encountered in 3%-10% of coronary angiograms and is associated with high mortality. The survival of patients with ULM disease presenting with acute coronary syndromes (ACS) depends on different variables and is lowest in those with cardiogenic shock (CS). The aim of the present study was to estimate the impact of baseline characteristics on the subsequent clinical outcome in patients treated by percutaneous coronary intervention (PCI) of ULM for ACS. METHODS AND RESULTS One hundred and thirty-four patients were retrieved from our database and followed by phone or physician visit. Patients were classified into two groups according to their presentation (CS/STEMI group: patients presenting with CS or ST-elevation myocardial infarction; NSTEMI/UA group: patients with non-STEMI or unstable angina). Data collected were baseline characteristics, procedural information, and clinical outcome. The primary endpoint was all-cause mortality at 6-month follow-up. The secondary end point was a composite of cardiac death, myocardial infarction, and any repeat revascularisation, i.e., major adverse cardiac events (MACE). Kaplan-Meier curves were computed for survival. Logistic regression determined that hypercholesterolaemia (OR 6.22, p=0.03), high pre-procedural TIMI score (OR 3.89, p=0.01), preserved left ventricular ejection fraction (OR 1.07, p=0.01) and LM as culprit lesion (OR 8.57, p=0.01) protected against development of CS. Primary outcome occurred in 44% of patients in the CS/STEMI group compared to 6% in the NSTEMI/UA group (p<0.001). MACE were observed in 30 patients (48%) of the CS/STEMI group and in 12 patients (19%) of the NSTEMI/UA group (p=0.001). CONCLUSIONS Acute coronary syndrome due to critical ULM stenosis is associated with high mortality even after successful PCI. Patients presenting with CS or STEMI are at particular risk.
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Affiliation(s)
- Serban Puricel
- Department of Cardiology, University of Fribourg, Fribourg, Switzerland
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17
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Izumikawa T, Sakamoto S, Takeshita S, Takahashi A, Saito S. Outcomes of primary percutaneous coronary intervention for acute myocardial infarction with unprotected left main coronary artery occlusion. Catheter Cardiovasc Interv 2012; 79:1111-6. [PMID: 22234952 DOI: 10.1002/ccd.23396] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2011] [Accepted: 10/02/2011] [Indexed: 11/06/2022]
Abstract
BACKGROUND We determined the in-hospital and the long-term outcomes of primary percutaneous coronary intervention (PCI) for acute left main coronary artery (LMCA) occlusion. METHODS Between 1988 and 2009, 72 patients with acute myocardial infarction (AMI) underwent primary PCI for unprotected LMCA occlusion. The short- and the long-term outcomes of primary PCI in these patients were retrospectively evaluated. RESULTS Upon arrival, cardiogenic shock was observed in 33 (46%) patients and cardiopulmonary arrest (CPA) in 12 (17%). Twenty-three (32%) required extracorporeal life support and 64 (89%) intra-aortic balloon pumping. Although successful reperfusion was achieved in 60 (83%) patients, in-hospital death was observed in 32 (44%). Multivariate analysis revealed predictors of in-hospital death to be CPA on arrival (RR, 7.05; 95% CI: 1.28-39.0; P = 0.025). During 1.7 ± 2.9 years of follow-up, 10 of the 40 hospital survivors died. All presenting CPA on arrival died within 2 years. Although the estimated survival of the all study patients was only 26.2% at 8 years by the Kaplan-Meier methods, those without shock/CPA on arrival showed nearly flat survival curve after 4 years. CONCLUSIONS Despite performance of primary PCI, patients with AMI due to LMCA occlusion were associated with >50% in-hospital mortality. Hemodynamic deficit upon arrival was the major determinant of their poor hospital outcomes. The hospital survivors, however, were associated with favorable long-term outcomes.
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Affiliation(s)
- Takuya Izumikawa
- Department of Cardiology and Catheterization Laboratory, Shonan Kamakura General Hospital, Kamakura, Japan
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18
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Pappalardo A, Mamas MA, Imola F, Ramazzotti V, Manzoli A, Prati F, El-Omar M. Percutaneous coronary intervention of unprotected left main coronary artery disease as culprit lesion in patients with acute myocardial infarction. JACC Cardiovasc Interv 2011; 4:618-26. [PMID: 21700247 DOI: 10.1016/j.jcin.2011.02.016] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2010] [Revised: 11/23/2010] [Accepted: 02/04/2011] [Indexed: 11/16/2022]
Abstract
OBJECTIVES This study sought to evaluate short- and long-term outcomes of patients undergoing emergency percutaneous coronary intervention (PCI) for acute myocardial infarction due to a culprit lesion in an unprotected left main coronary artery. METHODS In this retrospective, 2-center, international observational study, 5,261 patients were admitted between February 2005 and December 2008 with acute myocardial infarction and treated with PCI; of these, 1,277 were ST-segment elevation myocardial infarction and 3,984 non-ST-segment elevation myocardial infarction. We identified 48 patients among this cohort who underwent emergency PCI to an unprotected left main coronary artery culprit lesion. RESULTS Mean age was 70 ± 12.5 years, and 45% of the patients presented with ST-segment elevation myocardial infarction or new left bundle branch block. Cardiogenic shock was present in 45%, and distal left main coronary artery disease was present in 71% of patients. Angiographic procedural success was achieved in 92% of patients. Overall in-hospital mortality was 21%, due in all cases to refractory, multiorgan failure. Twenty-five percent experienced major adverse cardiac events, defined as death, myocardial infarction, stent thrombosis, and target vessel revascularization. In patients presenting in cardiogenic shock, in-hospital mortality was 32%. At 1-year follow-up, in-hospital survivors had a mortality rate of 10.5%, whereas 18.4% experienced subsequent major adverse cardiac events. Long-term prognosis was excellent in hospital survivors with a 1-year survival rate of 89.5%. CONCLUSIONS Patients with acute myocardial infarction and thrombosis of the unprotected left main coronary artery are a high-risk subgroup with a substantial mortality, particularly if they present in cardiogenic shock. We demonstrate that in these patients, PCI is a feasible treatment option associated with reasonably good outcomes. Long-term prognosis is excellent in hospital survivors with an 89.5% survival rate at 1 year.
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Affiliation(s)
- Alessandro Pappalardo
- Department of Interventional Cardiology, San Giovanni-Addolorata Hospital, Rome, Italy.
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19
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Barone-Rochette G, Vanzetto G, Fluttaz A, Marlière S, Bouvaist H, Durand M, Chavanon O, Blin D, Machecourt J. Cardiogenic shock due to unprotected left main coronary artery thrombosis in the era of mechanical circulatory support. Int J Cardiol 2011; 148:394-6. [DOI: 10.1016/j.ijcard.2010.12.109] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2010] [Accepted: 12/30/2010] [Indexed: 11/16/2022]
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20
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Chieffo A, Magni V, Colombo A. Percutaneous Coronary Intervention in Unprotected Left Main. Interv Cardiol 2011. [DOI: 10.1002/9781444319446.ch18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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Triantafyllou K, Metaxopoulos P, Babalis D. Primary percutaneous coronary intervention of an unprotected left main using mini-crush drug-eluting stents facilitated by intracoronary reteplase. Catheter Cardiovasc Interv 2011; 77:515-21. [DOI: 10.1002/ccd.22815] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2010] [Accepted: 09/02/2010] [Indexed: 11/06/2022]
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Friedenberger J, Thiele H. Survival of acute ST-elevation myocardial infarction with total occlusion of the left main coronary artery. BMJ Case Rep 2010; 2010:2010/oct27_1/bcr1120092467. [PMID: 22791736 DOI: 10.1136/bcr.11.2009.2467] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
This image demonstrates the survival of a patient with total acute occlusion of the left main stem, which was treated by primary percutaneous coronary intervention (PCI). Before the patient was referred to the emergency room, she had already suffered from chest pain for about 11 h. Remarkably, the patient survived the acute myocardial infarction despite extreme myocardial necrosis of >60% of the left ventricle as demonstrated by delayed enhancement MRI. The attached images show angiography before and after PCI, the impressive initial ECG and delayed enhanced MRI with mainly transmural contrast enhancement.
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Percutaneous coronary intervention for unprotected left main disease in very high risk patients: safety of drug-eluting stents. Heart Vessels 2010; 26:17-24. [DOI: 10.1007/s00380-010-0027-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2009] [Accepted: 01/21/2010] [Indexed: 01/19/2023]
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Kang SH, Park KH, Choi DJ, Park KW, Chung WY, Lim C, Kim KB, Kim HS. Coronary artery bypass grafting versus drug-eluting stent implantation for left main coronary artery disease (from a two-center registry). Am J Cardiol 2010; 105:343-51. [PMID: 20102946 DOI: 10.1016/j.amjcard.2009.09.036] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2009] [Revised: 09/22/2009] [Accepted: 09/22/2009] [Indexed: 01/22/2023]
Abstract
Recent studies have suggested that percutaneous coronary intervention (PCI) in patients with unprotected left main coronary artery (LMCA) disease renders outcomes comparable to those from coronary artery bypass grafting (CABG). It is necessary to stratify individual patient risk and select the optimal revascularization strategy. We compared the clinical outcomes of patients with unprotected LMCA disease who had undergone PCI with drug-eluting stents or CABG. We identified 462 patients who were treated from January 2003 to December 2006 for unprotected LMCA or LMCA-equivalent disease: 257 had undergone CABG and 205 had undergone PCI with drug-eluting stents. Analyses using propensity scores were performed to minimize the selection bias in the present observational study. After a median follow-up of 33.5 months, no significant difference was found between the CABG and PCI groups in the risk of death (12.1% vs 14.1%, respectively; p = 0.428) or the risk of a composite of death, myocardial infarction, or cerebrovascular accident (17.5% vs 20.0%, respectively; p = 0.434). The rate of major adverse cardiac and cerebrovascular events was significantly lower in the CABG group than in the PCI group (21.8% vs 35.1%, respectively; p = 0.001); the difference was mainly driven by a decrease in the rate of repeat revascularizations (5.1% vs 22.4%; p <0.001). The analyses after propensity score adjustment and matching corroborated the crude group results. In conclusion, PCI with drug-eluting stents showed a safety profile comparable to that of CABG in patients with unprotected LMCA disease. However, the risk of repeat revascularization was significantly greater in the PCI group.
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Affiliation(s)
- Si-Hyuck Kang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Republic of Korea
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25
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Ghrissi I, Nallet O, Amara W, Michaud P, Estève JB, Cattan S. [Acute non protected main left coronary artery occlusion: a report of six cases treated by angioplasty]. Ann Cardiol Angeiol (Paris) 2009; 58:293-8. [PMID: 19793577 DOI: 10.1016/j.ancard.2009.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2009] [Accepted: 08/28/2009] [Indexed: 11/24/2022]
Abstract
AIM Acute main left coronary artery occlusion is rarely observed during primary angioplasty in myocardial infarction. This retrospective study reports the results of six patients treated by angioplasty in a hospital without cardiac surgery department. PATIENTS AND METHODS From 2002 to 2009, 746 patients were treated by primary angioplasty for acute coronary syndromes with ST elevation. Among those patients, six (0,7%) had acute non protected main left coronary occlusion. We report clinical, angiographical data and follow-up. RESULTS The population was composed of six patients (five males) with an average age of 64+/-7 years. Five patients were admitted with cardiogenic shock and four were mechanically ventilated. Distal occlusion of main left coronary artery and dominant right coronary artery were noted in all cases. Sub-occluded lesion of right coronary artery was noted in one case. Successful procedure with bare metal stent was achieved in five cases. Mortality rate was 66% (n=4): three patients died in hospital and another 1 or 2 months later of congestive heart failure. Coronary artery bypass grafting was performed at 4 and 12 months later for two patients. They are alive after 12 and 72 months of follow-up. CONCLUSION We demonstrate the feasibility of percutaneous coronary intervention of acute main left coronary occlusion. Inspite successful procedure, intrahospital mortality rate is still high and prognosis is related to cardiogenic shock.
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Affiliation(s)
- I Ghrissi
- Fédération de Cardiologie, Centre Hospitalier Intercommunal Le-Raincy-Montfermeil, Montfermeil, France
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Hurtado J, Bermúdez EP, Redondo B, Ruiz JL, Blanes JRG, de Lara JG, Aguilar RV, Teruel F, Chavarri MV. Emergency Percutaneous Coronary Intervention in Unprotected Left Main Coronary Arteries. Predictors of Mortality and Impact of Cardiogenic Shock. ACTA ACUST UNITED AC 2009; 62:1118-24. [DOI: 10.1016/s1885-5857(09)73326-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Hurtado J, Bermúdez EP, Redondo B, Ruiz JL, Blanes JRG, de Lara JG, Aguilar RV, Teruel F, Chavarri MV. Intervencionismo percutáneo urgente sobre el tronco coronario izquierdo no protegido. Factores predictores de mortalidad y análisis del shock cardiogénico. Rev Esp Cardiol 2009. [DOI: 10.1016/s0300-8932(09)72380-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Carrié D, Maupas E, Hmem M, Lhermusier T, Elbaz M, Puel J. Clinical and angiographic outcome of stenting of unprotected left main coronary artery bifurcation narrowing. ACTA ACUST UNITED AC 2009; 7:97-100. [PMID: 16093219 DOI: 10.1080/14628840510011243] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
PURPOSE Improvements in techniques and equipments may result in the wider applicability of percutaneous coronary intervention (PCI) for unprotected left main coronary artery (ULMCA) stenosis. This report is a prospective study focused on the feasibility, effectiveness and long-term results of stenting for treatment of ULMCA bifurcation lesions. METHODS From November 2002 to October 2003, 57 consecutive patients were stented with bare metal stents and the technique of kissing balloon followed by T-provisional stenting was applied for ostial left anterior descending, left circumflex or distal left main coronary lesion. RESULTS Mean age was 69.5+/-10.7 years. Acute coronary syndrome occurred in 68.4% of patients with a majority of two or three vessel disease (45.10% and 35.30% respectively). GpIIbIIIa inhibitors were used in only 5.8% of cases. Angiographic success was obtained in 100% of patients. Hospital stay was 7.03+/-2.26 days without major adverse cardiac events. At eight months follow-up, cardiac death was 1.7%, non-fatal myocardial infarction 5.1% and target vessel revascularisation 22.8% including CABG 15.7% and repeated PCI 10.5% with an angiographic restenosis rate of 29.8%. CONCLUSION In the setting of coronary stenting of the ULMCA stenosis, the use of bare metal stents can no longer be considered contemporary technique and another strategy such as coated stent may be needed.
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Affiliation(s)
- Didier Carrié
- Service de Cardiologie B, CHU de Toulouse, Hôpital Rangueil, Toulouse, France.
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Chia PL, Khoo BCH, Ng CK, Lim JTW. Primary percutaneous coronary intervention for acute myocardial infarction secondary to acute left main coronary occlusion in an institution without on-site cardiothoracic surgical support. EUROINTERVENTION 2009; 4:617-9. [DOI: 10.4244/eijv4i5a103] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Teirstein PS. Percutaneous Revascularization Is the Preferred Strategy for Patients With Significant Left Main Coronary Stenosis. Circulation 2009; 119:1021-33. [PMID: 19237673 DOI: 10.1161/circulationaha.107.759712] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Paul S. Teirstein
- From the Department of Cardiology, Interventional Cardiology, Scripps Clinic, La Jolla, Calif
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Prasad SB, Whitbourn R, Malaiapan Y, Ahmar W, MacIsaac A, Meredith IT. Primary percutaneous coronary intervention for acute myocardial infarction caused by unprotected left main stem thrombosis. Catheter Cardiovasc Interv 2009; 73:301-7. [DOI: 10.1002/ccd.21886] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Lee MS, Sillano D, Latib A, Chieffo A, Zoccai GB, Bhatia R, Sheiban I, Colombo A, Tobis J. Multicenter international registry of unprotected left main coronary artery percutaneous coronary intervention with drug-eluting stents in patients with myocardial infarction. Catheter Cardiovasc Interv 2009; 73:15-21. [PMID: 19089930 DOI: 10.1002/ccd.21712] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Michael S Lee
- Department of Medicine/Cardiology, University of California, Los Angeles Medical Center, Los Angeles, California 90095-171715, USA.
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Lee MS, Tseng CH, Barker CM, Menon V, Steckman D, Shemin R, Hochman JS. Outcome after surgery and percutaneous intervention for cardiogenic shock and left main disease. Ann Thorac Surg 2008; 86:29-34. [PMID: 18573394 DOI: 10.1016/j.athoracsur.2008.03.019] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2007] [Revised: 03/05/2008] [Accepted: 03/07/2008] [Indexed: 11/28/2022]
Abstract
BACKGROUND The ideal revascularization strategy (bypass surgery versus percutaneous coronary intervention [PCI]) for patients with cardiogenic shock in the setting of left main coronary artery disease is unknown. METHODS The Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock Trial and Registry included 164 patients with left main disease who underwent revascularization. Although the standard of care at the time and the trial protocol recommended coronary artery bypass graft surgery for patients with left main disease, the revascularization strategy (79 coronary artery bypass graft surgery and 85 PCI) was individualized for each patient by site investigators. RESULTS The median time from myocardial infarction to revascularization was 24.3 hours (interquartile range, 8.7 to 82.5 hours) in the surgical group and 7.4 hours (interquartile range, 3.7 to 19.5 hours) in the PCI group (p < 0.05). Overall 30-day survival with surgery in this setting was 54% (95% confidence interval, 0.43 to 0.69) and was significantly superior to the 14% (95% confidence interval, 0.09 to 0.35) in the PCI group (p <or= 0.001). When the left main was the infarct-related artery, the 30-day survival rate was 40% in the surgical group (n = 6) and 16% in the PCI group (n = 15; p = 0.03). Coronary artery bypass graft surgery (hazard ratio, 0.41; 95% confidence interval, 0.22 to 0.77; p = 0.006) and age (per 10 years, hazard ratio, 1.04; 95% confidence interval, 1.01 to 1.08; p = 0.02) were independently associated with 30-day survival. CONCLUSIONS Coronary artery bypass graft surgery appeared to provide a survival advantage over PCI at 30-day follow-up in patients with left main coronary artery disease. The impact of current PCI strategies on this subgroup is undetermined.
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Affiliation(s)
- Michael S Lee
- Division of Cardiology, University of California, Los Angeles Medical Center, Los Angeles, CA 90095-171715, USA.
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Sakakura K, Kubo N, Hashimoto S, Ikeda N, Funayama H, Hirahara T, Sugawara Y, Yasu T, Ako J, Kawakami M, Momomura SI. Determinants of in-hospital death in left main coronary artery myocardial infarction complicated by cardiogenic shock. J Cardiol 2008; 52:24-9. [PMID: 18639774 DOI: 10.1016/j.jjcc.2008.03.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2008] [Revised: 02/17/2008] [Accepted: 03/18/2008] [Indexed: 12/24/2022]
Abstract
BACKGROUND Acute myocardial infarction (AMI) due to left main coronary artery disease is associated with significantly elevated morbidity and mortality. The aim of this study was to identify the predictors of in-hospital death from left main AMI complicated by cardiogenic shock. METHODS Clinical record review identified a total of 25 cases of left main AMI with cardiogenic shock. Patients' background characteristics, laboratory data, and angiographic findings were analyzed according to the in-hospital mortality. RESULTS In this patient subset, in-hospital mortality (60%) was associated with a history of hypertension (p=0.02) and a higher heart rate (p=0.02). Furthermore, in-hospital mortality was also associated with a complete right bundle branch block (CRBBB) pattern in the admission ECG (p=0.01) and low HCO(3)(-) (p=0.0004). In stepwise logistic regression analysis, a CRBBB pattern (OR 48.59, 95% CI 1.34-1768.10, p=0.03) and low HCO(3)(-) (OR 0.62, 95% CI 0.40-0.94, p=0.02) were found to be independent predictors of mortality. CONCLUSIONS Left main AMI with cardiogenic shock was associated with high in-hospital mortality. A CRBBB pattern in the ECG on admission and a low HCO(3)(-) concentration were significant independent predictors of in-hospital death.
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Affiliation(s)
- Kenichi Sakakura
- Division of Cardiovascular Medicine, Department of Integrated Medicine I, Jichi Medical University Saitama Medical Center, Omiya, Japan
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Tan CH, Hong MK, Lee CW, Kim YH, Lee CH, Park SW, Park SJ. Percutaneous coronary intervention with stenting of left main coronary artery with drug-eluting stent in the setting of acute ST elevation myocardial infarction. Int J Cardiol 2008; 126:224-8. [PMID: 17493695 DOI: 10.1016/j.ijcard.2007.03.131] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2006] [Revised: 03/08/2007] [Accepted: 03/30/2007] [Indexed: 10/23/2022]
Abstract
AIM Primary angioplasty of the left main coronary is not a common procedure. We present 16 cases of angioplasty of left main coronary artery with drug-eluting stent (DES) implantation in the setting of acute ST elevation myocardial infarction. METHOD Between December 2003 and November 2005, sixteen patients presented with acute ST elevation myocardial infarction where the left main coronary artery was shown to be involved with or without the left anterior descending or left circumflex arteries. Primary angioplasties were performed on the unprotected left main coronary artery. Five patients received direct stenting while the rest had pre-dilatation. Only one patient received Taxus(R) while the rest received Cypher(R) stents. RESULTS Of the sixteen patients, eleven developed cardiogenic shock necessitating intra-venous inotropic and intra-aortic balloon counter-pulsation support. Seven perished in hospital (46%); four within the first day while one had a complicated course and perished on the 42nd day of hospitalization. There was no difference in clinical history (hypertension, diabetes, age, and previous coronary intervention) or hemodynamic features (presenting blood pressure, duration of infarct, stent length, and maximum balloon size or pressure) between the two groups. However, the use of inotropes and intra-aortic balloon counter-pulsation (100% vs. 44% p=0.034) was significantly more common in the group which perished. Patient with cardiogenic shock had increased mortality of 63%. Of the nine survivors, one required repeat intervention for subacute stent thrombosis at sixteenth day and one underwent coronary bypass surgery at three months. All remained well up to mean follow up of 420 days. CONCLUSION Left main coronary artery infarct especially in the setting of cardiogenic shock has a very high mortality rate. Percutaneous intervention can be performed on these patients with minimal delay. In our series, we have shown that primary intervention of the unprotected left main coronary artery with a drug-eluting stent carries an acceptable level of major adverse coronary event. In those who survived the initial event, there is a low rate of mortality or morbidity.
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Affiliation(s)
- Chong-Hiok Tan
- Department of Medicine, University of Ulsan College of Medicine, Asan Medical Center, 388-1 Poongnap-dong, Songpa-gu, Seoul, 138-736, Republic of Korea
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Unprotected Left Main Intervention. JACC Cardiovasc Interv 2008; 1:5-13. [DOI: 10.1016/j.jcin.2007.12.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2007] [Revised: 11/28/2007] [Accepted: 12/03/2007] [Indexed: 11/22/2022]
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Cheng CI, Hsueh SK, Lee FY, Wu CJ, Fang CY, Sheu JJ, Chen SM, Yang CH, Hsieh YK, Chen MC, Fu M, Yip HK. Clinical Presentation and Prognostic Factors of Patients With Acute ST-Segment Elevation Myocardial Infarction Following Emergent Revascularization for Left Main Coronary Artery Obstruction. Circ J 2008; 72:1598-604. [DOI: 10.1253/circj.cj-08-0258] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Cheng-I Cheng
- Graduate Institute of Clinical Medical Sciences, Chang Gung University College of Medicine
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital - Kaohsiung Medical Center
| | - Shu-Kai Hsueh
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital - Kaohsiung Medical Center
| | - Fan-Yen Lee
- Division of Cardiovascular Surgery, Department of Surgery, Chang Gung Memorial Hospital - Kaohsiung Medical Center
| | - Chiung-Jen Wu
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital - Kaohsiung Medical Center
| | - Chih-Yuan Fang
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital - Kaohsiung Medical Center
| | - Jiunn-Jye Sheu
- Division of Cardiovascular Surgery, Department of Surgery, Chang Gung Memorial Hospital - Kaohsiung Medical Center
| | - Shyh-Ming Chen
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital - Kaohsiung Medical Center
| | - Cheng-Hsu Yang
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital - Kaohsiung Medical Center
| | - Yuan-Kai Hsieh
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital - Kaohsiung Medical Center
| | - Mien-Cheng Chen
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital - Kaohsiung Medical Center
| | - Morgan Fu
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital - Kaohsiung Medical Center
| | - Hon-Kan Yip
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital - Kaohsiung Medical Center
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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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Barlis P, Horrigan M, Elis S, Chan R, Wong M, Farouque O, Proimos G, Ajani AE, Clark DJ. Treatment of unprotected left main disease with drug-eluting stents in patients at high risk for coronary artery bypass grafting. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2007; 8:84-9. [PMID: 17574165 DOI: 10.1016/j.carrev.2006.11.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2006] [Accepted: 11/28/2006] [Indexed: 11/24/2022]
Abstract
BACKGROUND Percutaneous coronary intervention (PCI) for high-grade stenosis of the left main coronary artery with bare-metal stents has been limited by restenosis, and most patients are managed with coronary artery bypass grafting (CABG). Recently, drug-eluting stents (DES) have reduced instent restenosis after PCI, but their role in the treatment of left main disease remains unclear. AIMS The aim of this study was to determine the outcomes after utilizing DES to treat left main disease. METHODS Twenty consecutive symptomatic patients with >50% angiographic stenosis of the left main coronary artery with no prior history of CABG ["unprotected left main" (ULM)] underwent PCI with DES. Patients were divided into two groups based on the presence (Group A, n=5) or absence (Group B, n=15) of preprocedural cardiogenic shock. At follow up (median, 14 months), cumulative major adverse cardiac events (MACE-death, myocardial infarction, or target vessel revascularization) were determined. RESULTS Sixteen (80%) of 20 patients were at high risk for CABG because of comorbidity, advanced age, or cardiogenic shock. Procedural success was 100% (20/20). Three of five patients in Group A (60%) died in hospital and the two surviving patients experienced no MACE at follow up. In Group B (n=15), there was no in-hospital MACE, but one patient died suddenly 8 weeks postprocedure [cumulative MACE of 7% (1/15)]. CONCLUSIONS Our study demonstrates the feasibility of ULM treatment with DES with acceptable medium-term outcomes. While CABG remains the best form of revascularization for the majority of patients with ULM, DES should be considered in those who are at high risk.
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Affiliation(s)
- Peter Barlis
- Department of Cardiology, Austin Hospital, Melbourne, Victoria 3084, Australia
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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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Barlis P, Tanigawa J, Kaplan S, di Mario C. Complex Coronary Interventions: Unprotected Left Main and Bifurcation Lesions. J Interv Cardiol 2006; 19:510-24. [PMID: 17107366 DOI: 10.1111/j.1540-8183.2006.00203.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Percutaneous coronary intervention has moved forward with great speed since the advent of stents and now more recently the introduction of drug-eluting technologies. This has seen the modern interventional cardiologist tackle more and more complex coronary lesions, of which unprotected left main (ULM) and bifurcations still remain challenging and controversial. ULM coronary artery stenosis traditionally remains a surgical indication although there have been recent reports and studies demonstrating the feasibility of a percutaneous strategy in select patient groups. Furthermore, drug-eluting stents have shown great benefit in reducing the problem of restenosis and have also become the mainstay treatment modality for bifurcation lesions with a choice between one- or two-stent strategies determined by the extent of disease burden in the main vessel and side branch and the response of the side branch ostium following treatment of the main vessel. This article will provide a contemporary review of percutaneous intervention for these two lesion subsets and describe the relative merits of each of the different strategies in current use with a glimpse into what the future may hold.
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Affiliation(s)
- Peter Barlis
- Department of Cardiology, Royal Brompton Hospital, Sydney Street, London SW3 6NP, United Kingdom
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Claver E, Curós A, López-Ayerbe J, Serra J, Mauri J, Fernández-Nofrerias E, Rodríguez-Leor O, Bernal E, Valle V. Variables clínicas predictoras de enfermedad del tronco común en pacientes de alto riesgo con un primer episodio de síndrome coronario agudo sin elevación del segmento ST. Rev Esp Cardiol (Engl Ed) 2006. [DOI: 10.1157/13091883] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Germing A, Mügge A, Lindstaedt M. Recurrent myocardial ischemia due to riding left main coronary artery bifurcation thrombus--noninterventional therapy with glycoprotein blocker and thrombolysis. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2006; 7:76-80. [PMID: 16757405 DOI: 10.1016/j.carrev.2005.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2005] [Revised: 11/10/2005] [Accepted: 11/10/2005] [Indexed: 11/21/2022]
Abstract
BACKGROUND Acute coronary syndrome (ACS) comprises different manifestations of coronary artery disease. Angiograms performed at the time of an ACS may present different coronary morphologies; mostly there are acute vessel occlusions, ruptured atherosclerotic plaques, or thrombotic lesions that require reperfusion therapy. In the presence of intracoronary thrombi localized in the left main coronary artery, the clinical situation is challenging. Hemodynamic situation, symptoms, and rhythm status may change immediately and entail high mortality. Catheter-based therapy and surgical revascularization are associated with a high mortality rate. A noninterventional approach may be chosen in patients with stable hemodynamics and reestablished perfusion. METHODS AND PATIENT We describe a patient with acute ST-elevation myocardial infarction with chest pain and stable hemodynamics. Angiography revealed a large thrombus in the left main coronary artery bifurcation with ostial subtotal narrowing of the circumflex and left anterior descending artery. However, coronary perfusion was maintained. Immediate treatment with the glycoprotein IIb/IIIa inhibitor abciximab was performed. The patient became asymptomatic. Angiography the next day showed no change in thrombus formation, so abciximab infusion was prolonged. Initial elevated enzymes decreased to normal values. Three days later the patient developed a new unstable angina with newly elevated cardiac enzymes. At this time, a thrombolytic agent was administered. Angiography 2 days later demonstrated normal coronaries. CONCLUSION This case demonstrates the impact of intracoronary thrombi on repetitive myocardial ischemia and the effectiveness of a noninterventional pharmacological approach for the treatment of acute myocardial infarction due to intracoronary thrombus even in the left main coronary bifurcation.
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Affiliation(s)
- Alfried Germing
- Medical Clinic II, Cardiology and Angiology, BG-Kliniken Bergmannsheil, University of Bochum, 44789 Bochum, Germany.
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Migliorini A, Moschi G, Giurlani L, Valenti R, Vergara R, Parodi G, Carrabba N, Dovellini EV, Antoniucci D. Drug-eluting stent supported percutaneous coronary intervention for unprotected left main disease. Catheter Cardiovasc Interv 2006; 68:225-30. [PMID: 16817178 DOI: 10.1002/ccd.20815] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVES This study sought to determine the clinical and angiographic outcomes of unselected patients receiving drug-eluting stents for unprotected left main disease. BACKGROUND The results of several series of percutaneous coronary intervention (PCI) for left main disease in the pre-drug-eluting stent era have arisen concerns on the safety and mid-term efficacy of PCI. METHODS Consecutive patients with unprotected left main disease were considered eligible for drug-eluting stent supported PCI. The surgical risk score (risk of death within 1 month) of each patient was calculated according to the European System for Cardiac Operative Risk Evaluation (EuroSCORE) model. RESULTS One-hundred and one patients with unprotected left main disease underwent PCI. The mean EuroSCORE was 19 +/- 23. Successfully left main stenting was performed in 98 patients (primary success rate 97%). The overall 1-month mortality rate was 9.9%. The 1-month mortality rate was 50% in patients with acute myocardial infarction (AMI) on presentation, and 4.5% in patients without AMI on presentation. The 1-month mortality rate of patients with a risk score <13 was 3%, while it was 21% in patients with a risk score >or=13. At 6 months, the mortality rate of the entire cohort of patients increased to 12.8%, and the one of the non-AMI patients to 7.8%. Survival rate was 86% +/- 4% (mean follow-up 295 +/- 175 days). Target vessel revascularization was performed in 14 patients (16%). The 6-month in-segment restenosis rate was 16%. CONCLUSION Drug-eluting stent supported PCI may provide early and mid-term outcomes comparable or superior to those expected from coronary artery surgery. (c) 2006 Wiley-Liss, Inc.
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Diamond MJ, Gujral J, Kapoor D. Percutaneous intervention of left main coronary artery disease: a fresh look at a class III recommendation. South Med J 2005; 98:1153-4. [PMID: 16351042 DOI: 10.1097/01.smj.0000184811.04728.2f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Tanigawa J, Sutaria N, Goktekin O, Di Mario C. Treatment of Unprotected Left Main Coronary Artery Stenosis in the Drug-Eluting Stent Era. J Interv Cardiol 2005; 18:455-65. [PMID: 16336426 DOI: 10.1111/j.1540-8183.2005.00086.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Coronary angiography is often inadequate for estimating the severity of ambiguous left main coronary artery (LMCA) stenoses. Our assessment of these lesions can be improved by the techniques of intravascular ultrasound and fractional flow reserve which provide indices of stenosis severity to enable the prediction of future events and planning of treatment. For patients requiring LMCA revascularization, coronary artery bypass graft (CABG) surgery has been gold standard for decades. However, this technique continues to be limited by factors such as periprocedural mortality, prolonged hospital stay and rehabilitation, and long-term graft patency. LMCA stenosis remains one of the few serious challenges for the interventional cardiologists and, in the bare metal stent era, the long-term results were not sufficient to replace CABG surgery, mainly because of the high restenosis rate. Drug-eluting stents (DES) have dramatically reduced the restenosis rate and early results in small series (approximately 300 patients in total) treated with DES in LMCA have been encouraging, especially for lesions at the ostium and in the left main shaft. Before changes are made in the guidelines for treatment, we must wait for a refinement in the technique and stent design used for bifurcational left main lesion and the results of randomized, specific multicenter studies (SYNTAX trial). It is likely that, for selected patients, LMCA stenosis will be regarded as an indication for PCI.
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Affiliation(s)
- Jun Tanigawa
- Cardiology, 1st Department of Internal Medicine, Osaka Medical College, Osaka, Japan
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Gupta R, Rahman MA, Uretsky BF, Schwarz ER. Left main coronary artery thrombus: a case series with different outcomes. J Thromb Thrombolysis 2005; 19:125-31. [PMID: 16052304 DOI: 10.1007/s11239-005-1924-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Left main coronary artery (LMCA) thrombosis with acute myocardial infarction is an uncommon condition with an extremely high mortality. The small number of reported cases prevents the development of an evidence-based approach. Hence there are no clear-cut guidelines describing the best management approach for this condition. We describe our experience with six patients who presented with LMCA thrombosis and discuss the epidemiology, etiology and management options available for this high-risk subgroup.
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Affiliation(s)
- Rajiv Gupta
- Division of Cardiology, Department of Internal Medicine, The University of Texas Medical Branch, Galveston, Texas, 77555-0553, USA
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Grip L. A cath lab hero is something to be? Comments on left main stem percutaneous coronary intervention for ST-elevation myocardial infarction. SCAND CARDIOVASC J 2005; 39:6-9. [PMID: 16097407 DOI: 10.1080/14017430410022948] [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: 10/23/2022]
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Kosuga K, Tamai H. Left main stem coronary disease: the case for percutaneous coronary intervention in a high risk patient with complex disease. Heart 2005; 91 Suppl 3:iii35-8. [PMID: 15919651 PMCID: PMC1876358 DOI: 10.1136/hrt.2004.058453] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- K Kosuga
- Department of Cardiology, Shiga Medical Center for Adults, Moriyama, Japan
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