Emergency angioplasty of the left main coronary artery

Current Understanding of the Pathophysiology of Myocardial Fibrosis and Its Quantitative Assessment in Heart Failure

Myocardial fibrosis is an important part of cardiac remodeling that leads to heart failure and death. Myocardial fibrosis results from increased myofibroblast activity and excessive extracellular matrix deposition. Various cells and molecules are involved in this process, providing targets for potential drug therapies. Currently, the main detection methods of myocardial fibrosis rely on serum markers, cardiac magnetic resonance imaging, and endomyocardial biopsy. This review summarizes our current knowledge regarding the pathophysiology, quantitative assessment, and novel therapeutic strategies of myocardial fibrosis.

Clinical and angiographic results of angioplasty with a paclitaxel-eluting stent for unprotected left main coronary artery disease (a study of 101 consecutive patients)

BACKGROUND

After coronary stenting with drug eluting stents, long-term clinical outcome of unprotected left main coronary artery disease is unknown, even large scale registries or randomised trials with coronary artery bypass graft are ongoing.

AIMS

To report clinical and angiographic results of paclitaxel-eluting stent implantation for left main coronary artery stenosis (a series of 101 consecutive patients).

METHODS

This report is a prospective study performed to evaluate the immediate and mid-term clinical and angiographic outcomes of patients undergoing paclitaxel-eluting stent (PES) implantation for unprotected left main coronary artery (LMCA) stenosis. From January 2004 to December 2005, 101 consecutive patients were stented with paclitaxel-eluting stents (the provisional T stenting technique followed by Kissing balloon for distal left main vessel disease).

RESULTS

Mean age was 68.9+/-11.07 years. 73.3% of patients were male. Acute coronary syndrome was present in 65% of patients, of whom 22.8% had ST elevation. Distal left main trunk lesions were present in 87.1% of cases. Three-vessel disease represented 7% of cases. Angiographic success was obtained in 97.03% of patients with an acute gain of 2.18+/-0.53mm. GpIIbIIIa inhibitors were used in only 8.9% of cases. Hospital stay was 7.6 +/- 3.7 days. In-hospital complications were present in 7.9%, with a hospital mortality rate of 2%. At six month follow-up, the rate of target lesion revascularization (TLR) was 3%, and the rate for major adverse cardiac events (MACE) was 8.9%. Angiographic control was performed in 88.1% and a late loss of 0.1mm (0.04-0.2mm) was noted. Re-stenosis occurred in 4 patients (4.5% of cases). 4 patients (4%) died, including 2 from cardiac causes.

CONCLUSION

Paclitaxel-eluting stent implantation for unprotected left main coronary disease appears to be safe with high procedural success rate and a low re-stenosis rate at six month-follow-up.

Prediction of acute left main coronary artery obstruction by 12-lead electrocardiography. ST segment elevation in lead aVR with less ST segment elevation in lead V(1)

OBJECTIVES

We sought to determine the electrocardiographic (ECG) features associated with acute left main coronary artery (LMCA) obstruction.

BACKGROUND

Prediction of LMCA obstruction is important with regard to selecting the appropriate treatment strategy, because acute LMCA obstruction usually causes severe hemodynamic deterioration, resulting in a less favorable prognosis.

METHODS

We studied the admission 12-lead ECGs in 16 consecutive patients with acute LMCA obstruction (LMCA group), 46 patients with acute left anterior descending coronary artery (LAD) obstruction (LAD group) and 24 patients with acute right coronary artery (RCA) obstruction (RCA group).

RESULTS

Lead aVR ST segment elevation (>0.05 mV) occurred with a significantly higher incidence in the LMCA group (88% [14/16]) than in the LAD (43% [20/46]) or RCA (8% [2/24]) groups. Lead aVR ST segment elevation was significantly higher in the LMCA group (0.16 +/- 0.13 mV) than in the LAD group (0.04 +/- 0.10 mV). Lead V(1) ST segment elevation was lower in the LMCA group (0.00 +/- 0.21 mV) than in the LAD group (0.14 +/- 0.11 mV). The finding of lead aVR ST segment elevation greater than or equal to lead V(1) ST segment elevation distinguished the LMCA group from the LAD group, with 81% sensitivity, 80% specificity and 81% accuracy. A ST segment shift in lead aVR and the inferior leads distinguished the LMCA group from the RCA group. In acute LMCA obstruction, death occurred more frequently in patients with higher ST segment elevation in lead aVR than in those with less severe elevation.

CONCLUSIONS

Lead aVR ST segment elevation with less ST segment elevation in lead V(1) is an important predictor of acute LMCA obstruction. In acute LMCA obstruction, lead aVR ST segment elevation also contributes to predicting a patient's clinical outcome.

Coronary stenting of unprotected left main stem stenoses in elderly patients unsuitable for coronary surgery

We describe five patients with severe unstable angina refractory to medical management in whom coronary angiography demonstrated a severe stenosis of the left main stem. Due to severe co-existing illnesses bypass surgery was deemed inappropriate. Angioplasty to the left main stem stenosis followed by stent deployment was performed. All five patients were successfully discharged from hospital.

[Direct dilatation and emergency bypass operation of main branch occlusion in acute anterior wall infarct and cardiogenic shock]

Occlusion of the left main coronary artery (LMCA) is the cause of myocardial infarction in about 0.04%. Those patients who do not die during the acute phase often do have a dominant right coronary artery with extensive collaterals to the left coronary artery. Because this is a very rare situation there are only some cases reports dealing with the management of these patients. A 60 years old woman was admitted to our hospital with the signs of an acute Q-wave anterior myocardial infarction. Within a few minutes after the arrival she developed a cardiogenic shock. Coronary angiography was performed immediately. The left main coronary artery was occluded and a big right coronary artery showed a significant stenosis. There were many collaterals from the right coronary artery supplying the left coronary artery. After information of the cardiac surgeons, primary angioplasty of the LMCA was performed in order to achieve hemodynamic stabilisation and to relieve symptoms. Reperfusion of the left anterior descendent coronary artery (LAD) could be achieved within 30 minutes. This led to hemodynamic stabilisation of the patient. But a significant residual stenosis of the LMCA remained and the circumflex artery was still occluded. In the meanwhile cardiac surgery was able to be performed and so the patient was transferred to surgery without further dilatation or stent implantation. Four venous grafts (LAD, first diagonal branch, circumflex artery and right coronary artery) were inserted. After 4 weeks the patient was in a good shape and could be discharged at home. Primary angioplasty seems to be an effective treatment in patients with acute myocardial infarction and an occlusion of the LMCA. But coronary bypass surgery is nearly almost necessary during the following period in order to achieve complete revascularisation and to improve survival.

Nondiagnosed left main ostial stenosis partly due to the use of 5 French coronary angiographic catheters

Two cases have been reported in which the use of 5 F angiographic catheters is associated with a failure to diagnose an ostial stenosis of the left main coronary artery (LMCA). In both cases, the erroneous diagnosis led to an inappropriate indication for percutaneous transluminal coronary angioplasty (PTCA) on other stenosed vessels, and the ostial left main lesion was unexpectedly discovered when using 8F guiding catheters. It is supposed that the ability of performed 5F catheters to pass easily through an ostial lesion makes detection of such proximal stenosis much more difficult. We suggest that the choice of 5F catheters must be approached with caution when left main disease is potentially expected from the clinical features.