Primary Angioplasty in a Catastrophic Presentation: Acute Left Main Coronary Total Occlusion-The ATOLMA Registry

A Case Report of High-Risk Percutaneous Coronary Intervention of Left Main Coronary Artery With Cardiogenic Shock

Acute total occlusion of the left main artery is a fatal event and is often accompanied by cardiogenic shock. Patients who experience this event have high mortality rates. Early percutaneous coronary intervention (PCI) with hemodynamic support has proven to improve clinical outcomes for these patients. Here we report a case of a 60-year-old man, who came into our emergency room with an acute anterior wall myocardial infarction accompanied by cardiogenic shock. He had a totally occluded left main artery on coronary angiography, necessitating cardiopulmonary resuscitation, followed by PCI with implantation of a drug-eluting stent along with hemodynamic support. Identification of typical ECG changes is crucial in patients with acute coronary syndrome caused by the occlusion of the left main coronary artery. A quick decision to perform a PCI procedure using early circulatory mechanical devices (intra-aortic balloon pump) is critical to patient survival.

Clinical outcomes after unprotected left main coronary artery occlusion: A retrospective multicentre cohort analysis

AIMS

Unprotected left main coronary artery (ULMCA) occlusion is a rare and disastrous condition with scarce data on presentation and outcomes. Herein, we report data on patients presenting with acute coronary syndrome due to ULMCA occlusion at four different institutions.

METHODS

This is an international multicentre observational study. Baseline characteristics were retro- and prospectively collected. Clinical follow-up was prospective. The primary outcome was in-hospital death. Patients surviving the index hospitalization were compared with nonsurvivors to find predictors of survival.

RESULTS

The study population consisted of 55 patients. Eight patients (15%) died in the cath lab, and 23 (42%) died in hospital. Three (6%) deaths were noncardiac and due to major bleeding. Thirty-two (58%) patients survived the index hospitalization and were discharged. These patients were followed for a median of 17.5 months during which three cardiac deaths occurred. Repeat revascularization was performed in 25% (n = 8). Overall mortality at maximum follow-up was 47% (n = 26). The only significant predictor for hospital survival was left ventricular ejection fraction (odds ratio [OR]: 1.10 (per 1 point increase); 95% confidence interval [CI]: 1.02-1.19; p = 0.02).

CONCLUSION

ULMCA occlusion carries a high short-term mortality. Patients who survive index hospitalization have similar mortality rates as compared with other st elevation myocardial infarction patients.

The value of quantitative plaque analysis based on coronary computed tomography angiography in predicting the percutaneous coronary intervention outcome of chronic total occlusion lesions

Background

Due to the uncertainty of the success of percutaneous coronary intervention (PCI) and the complexity of selecting suitable treatment cases, the interventional outcome of coronary chronic total occlusion (CTO) remains challenging. The purpose of this study was to evaluate the role of quantitative plaque analysis based on coronary computed tomography angiography (CCTA) in predicting the CTO-PCI outcome.

Methods

We retrospectively included 78 patients with CTO (80 lesions) confirmed by invasive coronary angiography from July 2016 to December 2018. All patients underwent PCI treatment according to standard practice. A total of 47 lesions in 47 patients were successfully treated with PCI. PCI failed in the remaining 33 lesions in 31 patients. The following conventional CCTA morphologic parameters were evaluated and compared between the PCI-success and PCI-failure groups: stump morphology; occlusion length, tortuous course; CTO lesion calcium; bridging collateral vessel; retrograde collateral vessel; the appearance of the occluded distal segment; and quantitative CTO plaque characteristics, including total plaque volume, calcified plaque (CP) volume, noncalcified plaque (NCP) volume, low-density noncalcified plaque (LDNCP) volume, and plaque length. Univariate and multivariate logistic regression analyses were performed to determine independent parameters predictive of CTO-PCI outcomes. The predictive performances were assessed using receiver operating characteristic curve analysis.

Results

The blunt stump was the only independent CCTA morphologic parameter to predict the outcome of CTO-PCI [odds ratio (OR): 10.807; P<0.001]. NCP volume (OR: 1.018; P<0.001), CP volume (OR: 1.026; P=0.049), and plaque length (OR: 1.058; P=0.037) were independent quantitative CTO plaque characteristics predictive of CTO-PCI outcomes. The plaque-based model combining NCP volume with CP volume and plaque length had a higher area under the curve (AUC =0.96) than did the morphology-based model that included blunt stump (AUC 0.68) in predicting the outcomes of CTO-PCI (P<0.001).

Conclusions

The CCTA-based plaque characteristics, including NCP volume, CP volume, and plaque length, outperformed morphologic parameters in predicting the CTO-PCI outcomes.

Clinical and electrocardiographic features in acute total left main coronary artery occlusion without collateral circulation

BACKGROUNDS

Study concerning the clinical features, electrocardiogram (ECG) findings and outcomes in patients presenting with acute total occlusion of left main coronary artery (LM) without collateral circulation is limited.

METHODS

25 patients with acute total LM occlusion without collateral circulation by emergency coronary angiography, from muti-center registry, were retrospectively studied. The clinical and angiographic characteristics, ECG and in-hospital mortality were reviewed.

RESULTS

Nineteen patients (76%) presented with cardiogenic shock. Twelve (60%, 12/20) patients had coronary slow flow or no reflow phenomenon after primary percutaneous coronary intervention (PCI). The in-hospital mortality rate was 88% (n = 22). All the patients presented with ST-segment elevation myocardial ischemia (STEMI) pattern, mostly involving leads I, aVL, V2, V3, V4, V5 and ST-segment depression in leads II, III and aVF.

CONCLUSIONS

Acute total LM occlusion without collateral circulation portends high in-hospital mortality. Anterior ST elevation in the precordial leads from V2 to V4 through V6, and ST elevation in leads I and aVL, accompanying with ST depression in the inferior leads is associated with acute total LM occlusion without collateral circulation.

Electrocardiographic findings in true acute left main coronary total occlusion a subanalisys from ATOLMA registry

INTRODUCTION

Acute total occlusion of the left main coronary artery (ATOLMA) usually leads to a catastrophic presentation. Prediction of ATOLMA by electrocardiogram (ECG) may contribute to early detection and reperfusion. Limited data have been reported previously. This study aims to identify the admission 12‑leads ECG features that can predict the presence of ATOLMA and in-Hospital mortality in these patients.

METHODS

The admission ECGs findings in 24 patients from the previously reported ATOLMA multicenter registry were compared to the ECGs findings in 15 patients with an acute subtotal occlusion of the left main (ASOLMA) and to 15 patients with anterior ST-elevation myocardial infarction of the proximal left anterior descending (LADp-STEMI).

RESULTS

Some ECG features at presentation can predict an ATOLMA: QRS left axis deviation (-61.17 ± 9 degrees); ST-segment elevation in aVL (1.9 ± 0.65 mm); absence of ST-segment elevation in V1 (0.0 ± 0.6 mm); bifascicular block (58%); fragmented QRS (62.5%); prolongation of QTc interval (465 ± 19 ms) and of QRS interval (136 ± 12 mm). The multivariate analysis found that the independent predictors to distinguish ATOLMA from ASOLMA were aVL ST-segment deviation (OR 5.6(95% CI 1.5-21), p = 0.01) and absence of V1 ST-segment elevation (OR 27(95% CI 1.4-52), p = 0.01); and from LADp-STEMI was QRS width (OR 1.1(95% CI 1.02-1.2), p = 0.02). Fragmented QRS was the only independent predictor of in-hospital mortality in ATOLMA (OR 0.125(95% CI 0.01-0.81), p = 0.03).

CONCLUSIONS

aVL ST-segment elevation, the absence of V1 ST-segment elevation, left axis deviation, the presence of bifascicular block, and prolongation of QRS and QTc interval are predictors of ATOLMA. Fragmented QRS predicts in-hospital mortality in ATOLMA.

Electrocardiographic presentation of acute left main coronary artery occlusion misinterpreted as ventricular tachycardia

We present a case of acute left main coronary artery (LMCA) occlusion that manifested cardiogenic shock and an ST-segment elevation myocardial infarction (STEMI) electrocardiographic (ECG) pattern comprising "triangular" or "lambda-like" QRS-ST-T complexes. The presenting ECG pattern was misinterpreted as ventricular tachycardia (VT) with resultant delayed emergency percutaneous coronary intervention. The patient died of intractable cardiogenic shock. This case corroborates previous research findings associating the ECG pattern comprising "triangular" or "lambda-like" QRS-ST-T complexes observed in the clinical setting of acute myocardial ischemia with acute LMCA occlusion. Also, we demonstrate how this ECG pattern should be scrutinized for ST-segment elevation in order to avoid misdiagnosing a STEMI for VT.

Simultaneous kissing stents in acute left main total occlusion complicated with cardiogenic shock

We present a case of acute left main bifurcation lesion presenting as very high-risk non-ST elevation acute coronary syndrome. Consequently, an immediate invasive strategy for this complex anatomical lesion in an unstable patient requires an emergent bailout strategy to restore the haemodynamic condition.Our case shows the simultaneous kissing stents technique in a patient with a true left main bifurcation lesion (Medina 1-1-1) as a strategy to overcome the compromised haemodynamics. This protocol would be an alternative life-saving strategy in an acute setting.