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.     

Heart rescue in acute left main coronary artery occlusion with CABG using initial retrograde perfusion.

Acute occlusion of the left main coronary artery (LMCA) is a rare and almost invariably fatal condition. Here, we report on heart salvage in two such cases with CABG aided by emergent retrograde reperfusion as the initial operative step. Both cases were extremely unusual. The first patient had twice survived LMCA occlusion; the second also had right coronary artery occlusion. We will also review the literature on acute LMCA occlusion and coronary venous retroperfusion.     

Acute left main coronary artery occlusion--a case report and review of the literature

Acute left main coronary artery (LMCA) occlusion is rare and typically fatal. According to the recent literature, only three cases have been reported surviving emergent coronary artery bypass grafting (CABG) for acute myocardial infarction (AMI) caused by total LMCA occlusion. We report the case of a 52-year-old man presenting with total occlusion of the LMCA associated with acute anterolateral myocardial infarction and cardiogenic shock. The patient's dominant right coronary artery did not supply the collaterals to the left coronary system. After ineffective thrombolysis the patient underwent successful emergent CABG for the management of uncontrollable cardiogenic shock. Emergent CABG, though controversial, appears to be a feasible approach for patients with AMI in life-threatening situations, when other attempts at reperfusion have been unsuccessful.     

Left main coronary artery stenting in a patient with acute myocardial infarction and cardiogenic shock

Acute total occlusion of left main coronary artery (LMCA) is rarely found in patients presenting with acute coronary syndromes. It is a grave condition with poor prognosis. We present a case of successful stenting of a LMCA lesion in a patient presenting with acute myocardial infarct and cardiogenic shock.     

急性左主干病变的心电图分析

目的探讨急性左主干（LMCA）病变的心电图改变。方法分析因急性心肌梗死住院的76例患者（后经冠状动脉造影证实16例为左主干病变,60例为前降支病变）的心电图特点,按病变冠脉分为左主干组和前降支（LAD）组。结果STaVR↑发生率、STaVR↑〉STv1↑的发生率、STaVR↑伴STv1～STv3↑不明显的发生率、STaVR与STaVL均抬高的发生率、STv6↑／STv1↑≥1的发生率,LMCA组明显高于LAD组,二者差异有统计学意义（P〈0．05）。STaVR↑幅度,STaVR↑伴STⅡ、STⅢ、STaVF↓幅度,LMCA组明显高于LAD组,二者差异有统计学意义（P〈0．05）。结论左主干心电图表现为STaVR↑、STaVR↑〉STv1↑、STaVR↑伴STv1-v3↑不明显、STvVR与STaVL均抬高、STv6↑／STv1↑≥1。     

Successful treatment in a case of acute aortic dissection complicated with acute myocardial infarction due to occlusion of the left main coronary artery

The patient was a 67-year-old man who was diagnosed with acute myocardial infarction based upon the general symptoms and electrocardiographic findings. Emergent coronary angiography showed a 99% stenosis of the left main coronary artery (LMCA). After the 4.0 mm stent was implanted, he recovered from cardiogenic shock. An acute, Stanford type A aortic dissection was diagnosed by computerized tomography performed after the angioplasty. Transesophageal echocardiography showed that a retrograde dissection of the aorta was compressing the left main coronary ostium. Successful implantation of the stent at the LMCA contributed to saving the patient s life.     

Primary stenting of thrombotic occluded main coronary artery in cardiogenic shock

Acute left main coronary artery (LMCA) occlusion is associated with a high mortality rate. The majority of patients with this clinical condition die suddenly or from cardiogenic shock. We report a case of cardiogenic shock resulting from acute main coronary occlusion. Emergency cardiac catheterization was performed and coronary angiography showed a totally occluded LMCA. Prompt revascularization by means of primary LMCA stenting was successful and the patient was discharged 16 days later without neurological deficit or clinical signs of heart failure. We suggest that the rapid coronary angiography followed by angioplasty and primary stent implantation was instrumental in saving this patient's life.     

überlebter akuter Myokardinfarkt mit Hauptstammverschluss der linken Koronararterie

Survival of acute total occlusion of the left main coronary artery (LMCA) is rare. The majority of these patients die suddenly due to extensive acute myocardial infarction with cardiogenic shock and arrhythmias. Early recognition of symptoms and accurate detection of myocardial infarction, prompt percutaneous coronary intervention, shock treatment with intra-aortic balloon pump and early emergency coronary artery bypass grafting led to survival of a young male patient with acute occlusion of the left main artery in our case.     

Survival after sudden obstruction of the left main coronary artery

Left main coronary artery (LMCA) stenosis occurs in 10% of patients undergoing coronary arteriography, but total occlusion is rare. Goldberg et al reported 6 cases of complete obstruction of the LMCA among 2,200 patients studied arteriographically. Sudden obstruction of the LMCA should be lethal, and we found no report describing survival with sudden obstruction of the LMCA. The present report describes such a patient.     

Reciprocal changes in 12-lead electrocardiography can predict left main coronary artery lesion in patients with acute myocardial infarction

Acute left main coronary artery (LMCA) occlusion may result in acute myocardial infarction (AMI) or sudden death. ST elevation in the aVR and V1 leads is reported to be valuable in recognizing LMCA occlusion. Early recognition of electrocardiogram (ECG) changes, such as reciprocal ST depression in other leads, is helpful in averting this disaster. This study aimed to determine the reciprocal ST segment depression of 12-lead ECGs associated with acute LMCA occlusion. From January 2000 to December 2004, 61 patients who underwent emergency percutaneous coronary intervention in 3 hospitals due to AMI associated with LMCA (n = 18) and a left anterior descending coronary artery (LADCA) (n = 43) proximal lesion were selected. Reciprocal ST segment depression occurred in leads aVF, V(2), V(3), V(4), V(5), and V(6) with significantly higher incidence in the LMCA group than in the LADCA group. Stepwise linear multivariate discriminant analysis indicated that ST segment depression in leads aVF, V(2), and V(4) could distinguish the LMCA group from the LADCA group. We concluded that reciprocal ST segment depression in leads V(2), V(4), and aVF of a 12-lead ECG is an important predictor of acute LMCA occlusion.     

Primary stenting of an unprotected left main coronary artery total occlusion in a patient with acute myocardial infraction and cardiogenic shock

Acute total occlusion of the left main coronary artery (LMCA) is a rare angiographic finding with very poor prognosis. We report a case of a 39-year-old man who presented with pulmonary edema and cardiogenic shock due to an acute anterior myocardial infarction. Coronary angiography, which was performed under the support of an intra-aortic balloon pump, revealed total occlusion of the LMCA. Prompt and successful percutaneous transluminal coronary angioplasty with sirolimus-stent deployment in the LMCA allowed for an uneventful recovery and discharge of the patient.     

ST-segment elevation in lead augmented vector right may also be caused by diffuse left main coronary artery vasospasm without fixed stenosis

ST-segment deviation in lead augmented vector right (aVR) is useful for evaluating patients with acute coronary syndrome (ACS). The ST-segment elevation in this aVR in the patient with clinically suspected acute coronary syndrome suggests a strong possibility of left main coronary artery (LMCA) obstruction due to fixed stenosis. In this article, we report the first case, to our knowledge, of ST-segment elevation in lead aVR due to diffuse LMCA spasm.     

aVR 导联 ST 段抬高对冠脉左主干和／或3支血管病变的诊断价值

严重的冠脉病变包括冠脉左主干（left main coronary artery,LMCA）急性完全闭塞、次全闭塞以及3支血管病变（3-vessel disease,3-vd）。尽管 LMCA 急性完全闭塞患者能生存到达医院者很少,但 aVR 导联 ST 段抬高对其诊断的特异性和准确率均超过80％。对 LMCA 急性次全闭塞及3-vd 患者,aVR 导联 ST 段抬高的诊断价值高于心电图的任何其他单一或多个导联。aVR 导联 ST 段抬高幅度越大、持续时间越长,患者的病情就越重。本文对 aVR 导联 ST段抬高的诊断标准、电生理机制及国外研究进展进行综述。     

Primary percutaneous coronary intervention for the treatment of a patient with cardiogenic shock due to acute total occlusion of unprotected left main coronary artery without supportive collateral flow

Total occlusion of unprotected left main coronary artery (LMCA) is rarely encountered in clinical practice and the incidence cannot be determined precisely, since most of the patients die before hospital admission. Malignant arrhythmia, cardiogenic shock or sudden death due to pump failure develops in most of these patients. The cases complicated by cardiogenic shock have bad prognosis in both the short and long term, despite the advancements in reperfusion treatments. Successful treatment of sudden total occlusion of unprotected LMCA has been rarely reported. Over the last decade, many cases and comparisons in patients with LMCA lesions were reported on percutaneous interventions for unprotected LMCA using different stent and stenting procedures or in comparison to coronary bypass surgery. On the other hand, these patients either had stable coronary artery disease or a partially occluded LMCA in the setting of acute coronary syndromes with well supporting collateral flow. In our case, a 50 year-old male patient with cardiogenic shock and extensive anterior ST-elevation myocardial infarction due to acute total occlusion of unprotected LMCA, who was not receiving collateral flow from the right coronary system, was treated successfully through primary percutaneous coronary angioplasty, was presented. In our case, there was an totally occluded unprotected LMCA without any supportive coronary flow to left system. In this regard, our case is unique in literature.     

Ostial left main coronary artery chronic total occlusion presenting as chronic stable angina

Significant left main coronary artery (LMCA) disease is found in 5–6% of all patients undergoing coronary angiography. It usually presents as acute coronary syndrome and is commonly associated with multi-vessel coronary artery disease (CAD). Complete occlusion of LMCA is a much rarer finding, since these patients usually present as unstable angina, myocardial infarction and cardiogenic shock. We report a case of a young female, who presented with chronic stable angina and had an isolated chronic total occlusion (CTO) of LMCA with no lesions in the other coronary arteries. Aortogram failed to demonstrate the stump of occluded LMCA and demonstrated the filling of the left coronary system from the right coronary artery. Apart from dyslipidemia, she had no other risk factors for CAD. She was extensively evaluated for non-atherosclerotic causes of LMCA CTO including vasculitis. She underwent coronary artery bypass graft successfully without any peri-procedural complications.     

Successful Management of an Iatrogenic Left Main Coronary Artery Occlusion during Coronary Angiography: A Case Report and Brief Review

Abrupt left main coronary artery (LMCA) closure during diagnostic coronary angiography is a rare but catastrophic event with a poor prognosis. Emergency reperfusion of the LMCA with hemodynamic support should be the primary goal in patients with acute LMCA occlusion. Emergency coronary artery bypass graft surgery may be effective but time-consuming, and carries the risk of extensive and irreversible myocardial damage. We describe a case of abrupt closure of the LMCA due to plaque rupture by a diagnostic angiographic catheter without visible dissection following coronary angiography that was successfully treated with bail-out stenting during cardiopulmonary resuscitation.     

Myocardial reperfusion by thrombolysis after acute total left main artery occlusion--a case report

Coronary recanalization with thrombolytic agents is a new therapeutic approach to the treatment of acute myocardial infarction that can be beneficial even to patients in cardiogenic shock. Although few cases have been reported in the literature, treatment of acute occlusion of the left main coronary artery (LMCA) has been made possible by myocardial reperfusion. This communication concerns a patient with acute LMCA occlusion who was successfully treated by thrombolytic therapy with streptokinase followed by revascularization of the myocardium seventy-two hours after reperfusion was achieved.     

Sirolimus-eluting stent implantation for chronic total occlusion of the left main coronary artery

Chronic total occlusion of the left main coronary artery (LMCA) is rare. Recently, percutaneous coronary intervention has been increasingly applied to unprotected LMCA lesions. We describe a patient with chronic total occlusion of the LMCA who was successfully treated with bifurcation stenting with sirolimus-eluting stents.     

Stenting for left main coronary artery occlusion in adolescent: A case report

Acute total or subtotal occlusion of left main coronary artery (LMCA) is a catastrophic and mostly fatal event. Patients may present with cardiogenic shock and die whenever this event occurs. Survival is strongly dependent on the presence of collateral blood flow to the left coronary artery or a dominant right coronary artery, and emergency intervention for preserving the left ventricular function. Here, we present a case of a 14-year-old boy with subtotal occlusion of the LMCA accompanying acute myocardial infarction probably caused by congenital syphilis according to his positive serum syphilis antibody. His survival was closely associated with a dominant right coronary artery and timely thrombolytic therapy. Finally, he was treated with angioplasty and paclitaxel-eluting stent implantation. He was followed up after stenting and was doing quite well at the time when we wrote this paper.     

Potential risk of provisional stenting in left main coronary artery bifurcation in multivessel‐related acute coronary syndrome

We present a case of an elderly man suffering from an acute coronary syndrome (ACS) with preshock vital signs and remarkable ST–T wave depression in leads V4–V6, and ST elevation in lead aVR. Coronary angiography showed total occlusion of the right coronary artery (RCA) and impending occlusion in the distal left main coronary artery (LMCA) with a tandem lesion in the proximal left anterior descending artery (LAD). After insertion of an intra‐aortic balloon pump both the LAD and left circumflex artery (LCX) were dilated alternatively; and cross‐over stenting in the LMCA bifurcation was subsequently performed. However, total occlusion of the LCX occurred and it caused acute hemodynamic collapse and ventricular fibrillation storm. Immediate installation of percutaneous cardio‐pulmonary support system allowed stent deployment to be performed in the RCA and subsequent reopening of the LCX that led to a return to sinus rhythm. The patient recovered almost normal left ventricular wall motion and previous activity without any neurological deficit within 2 weeks. Provisional stenting in ACS in the LMCA bifurcation with multivessel disease has a potential risk of acute hemodynamic collapse; a planned two‐stent deployment strategy may assure a higher rate of safety in such cases. © 2011 Wiley‐Liss, Inc.