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.     

Left main intervention revisited: Early and late outcome of PTCA and stenting

We reviewed our experience with 28 unselected, consecutive patients undergoing left main coronary artery (LMCA) angioplasty who had been considered unsuitable for coronary artery bypass graft surgery (CABG). Fourteen patients (50%) had a protected LMCA circulation. Balloon angioplasty was performed in 11 patients (39.3%), and stents were implanted in 17 patients (60.7%). The procedure was elective in 22 patients (78.6%) and acute in the setting of myocardial infarction/cardiogenic shock in (21.4%). The mean follow-up duration was 15.9 ± 12 months. There were 5 early (before hospital discharge) and 4 late deaths (total 32.1%), 1 myocardial infarction (3.6%), 6 repeat angioplasties (21.4%), and 3 subsequent CABG (10.7%). All 5 early deaths occurred in patients with cardiogenic shock and unprotected circulation. The results of our study suggest that when patients have prohibitive surgical risks, elective LMCA angioplasty and/or stenting may be undertaken with a high procedural success rate. However, our data do not support intervention in the presence of acute myocardial infarction/cardiogenic shock. Cathet. Cardiovasc. Diagn. 41:21–29, 1997. © 1997 Wiley-Liss, Inc.     

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.     

Acute left main coronary artery occlusion. Survival following emergent coronary bypass

Emergent aortocoronary bypass surgery for acute myocardial infarction is controversial. We describe a patient with total occlusion of the left main coronary artery associated with acute anterior wall infarction and refractory cardiogenic shock. The patient underwent successful emergent coronary bypass surgery to manage refractory cardiogenic shock. He has subsequently experienced a prolonged survival (60 months postsurgery). This report suggests that emergent aortocoronary bypass surgery should be considered in patients with acute myocardial infarction with refractory cardiogenic shock in whom other forms of reperfusion are unsuccessful.     

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.     

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.     

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.     

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.     

Emergency coronary stenting of unprotected critical left main coronary artery stenosis in acute myocardial infarction and cardiogenic shock

In the setting of acute myocardial infarction (MI) and cardiogenic shock in patients with significant unprotected left main coronary artery (LMCA) disease, treatment options are limited. In this report of a patient presenting in cardiogenic shock secondary to acute MI with critical LMCA stenosis, percutaneous coronary intervention with intra-aortic balloon pump support proved life saving.     

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.     

Acute reocclusion during percutaneous transluminal coronary angioplasty: immediate and long-term outcome

Acute total occlusion of a coronary artery during percutaneous transluminal coronary angioplasty (PTCA) has previously resulted in emergency surgical intervention (CABG). We retrospectively surveyed 211 elective procedures and 65 procedures for acute myocardial infarction (AMI). There were 42 patients (pts) [29 elective (14%) and 13 AMI (20%)] in whom total occlusion occurred after initial dilation had been achieved. In 30 of 42 pts reangioplasty successfully reperfused the vessel. Ten patients (24%) required CABG and two (5%) were treated medically for AMI. Death occurred in 2 pts due to irreversible cardiogenic shock despite successful angioplasty. After 6 months follow-up 22 pts remained asymptomatic. It is concluded that aggressive redilation of total occlusions which develop during PTCA will frequently result in a successful angioplasty with a long-term restenosis rate comparable to uncomplicated angioplasty.     

Early and late clinical outcomes after primary stenting of the unprotected left main coronary artery stenosis in the setting of acute myocardial infarction

BACKGROUND: Acute left main coronary artery occlusion is a dramatic condition with very high mortality. The study was aimed to evaluate the effect of primary stenting in patients with left main coronary artery (LMCA) disease in the setting of acute myocardial infarction (AMI). METHODS: Between June 1997 and April 2002, primary stenting for left main coronary artery disease was performed in 18 patients with acute myocardial infarction. We evaluated early and late clinical outcomes, and prognostic determinants in this clinical setting. RESULTS: Mean ages of patients were 59 +/- 12 years. Fourteen patients had cardiogenic shock on admission. Angiographic success (TIMI flow > or = 2 and diameter stenosis < 30% after stenting) was achieved in 17 patients (94%). In-hospital death occurred in eight patients (44%). Two patients (11%) received emergent bypass surgery because of hemodynamic instability after primary stenting. On univariate analysis, good pre-intervention TIMI flow (grade > or = 2) was identified as a good prognostic determinant of in-hospital survival. During mean follow-up of 39 +/- 22 months, there was no late death and one patient received bypass surgery. Probability of freedom from death at 3-year was 56 +/- 12%. CONCLUSION: Primary stenting is a valuable therapeutic strategy for left main coronary disease in the setting of acute myocardial infarction, and it might save the life especially in patients with good pre-intervention TIMI flow (grade > or = 2). Long-term clinical outcome of patients surviving to hospital discharge is favorable.     

左主干急性闭塞或狭窄所致急性心肌梗死的急诊介入治疗

目的总结左主干急性闭塞或狭窄所致急性心肌梗死(AMI)患者急诊经皮冠状动脉介入治疗(PCI)的经验,探讨急诊PCI在此类患者中的安全性和有效性。方法从1995年1月至2004年12月,在1343例急诊PCI中,共有11例梗死相关血管为左主干。11例患者均为男性,年龄43~70岁,平均(56·4±9·2)岁,其中6例(54·5%)入院时即存在严重心原性休克。所有患者均在主动脉内球囊反搏支持下接受急诊PCI治疗。结果8例急诊置入支架,余3例仅行球囊扩张,后者有2例术后接受急诊冠状动脉旁路移植术。住院期间死亡5例(45·5%),存活的6例患者均完成3个月随访,其中4例随访超过2年,1例于术后4年猝死,1例患者术后5年重复造影检查结果良好。对比分析提示术前存在良好的侧支循环可能是影响此类患者急诊PCI术后疗效的因素。结论左主干急性闭塞或严重狭窄所致的AMI患者病情凶险,急性期死亡率高。侧支循环形成与否,治疗策略和预后不同,主动脉内球囊反搏支持下急诊PCI治疗可以挽救部分患者的生命和改善预后,对于侧支循环不良的患者,部分再灌注策略可能为一种有效手段之一,值得进一步研究。     

Surgical treatment of acute myocardial infarction

In 1989 the following indications for surgical treatment of acute myocardial infarction are: (1) acute evolving myocardial infarction less than 6 h from onset, in patients in whom percutaneous transluminal coronary angioplasty (PTCA) or streptokinase (SK), depending on the coronary anatomy, has been unsuccessful; if single vessel disease, coronary artery bypass grafting (CABG) is unlikely; if multiple vessel disease, CABG is preferable to SK/PTCA unless a very major 'culprit' lesion can be identified with certainty; (2) postinfarction angina hours to days after a transmural myocardial infarction unyielding to maximal medical therapy and in patients with a coronary artery obstruction not amenable to PTCA; (3) occlusion of a coronary artery during cardiac catheterization that cannot be fixed by PTCA and/or SK; (4) occlusion of a coronary artery during PTCA causing hemodynamic obstruction and a threatened myocardium subtended by the obstructed coronary artery; (5) balloon-dependent patients in cardiogenic shock without mechanical defects who have adequate residual left ventricular function as determined by regional wall motion studies; (6) ventricular septal defect secondary to myocardial infarction unless there is terminal organ damage; (7) mitral valve replacement with coronary bypass for acute papillary muscle rupture; (8) semi-emergency cardiac transplantation, either with or without a mechanical bridge to transplant in young individuals (less than 50 years) who have suffered massive destruction of left ventricular myocardium by an acute coronary occlusion with or without recurring ventricular tachyarrhythmias. Ejection fraction in this clinical category is always under 0.20 and usually under 0.15.     

Primary angioplasty of unprotected left main coronary artery for acute anterolateral myocardial infarction

BACKGROUND: Mortality of acute unprotected left main coronary artery (LMCA) occlusion is very high. The objectives of this analysis were to determine the effect of primary angioplasty and the impact of cardiogenic shock on unprotected LMCA occlusion-induced acute anterolateral myocardial infarction (AAMI). METHODS: Of 1,736 consecutive patients with acute myocardial infarction (AMI), 38 (2.2%) had LMCA occlusion-induced AAMI with Thrombolysis in Myocardial Infarction (TIMI) flow less than or equal to 2. All were given primary angioplasty. RESULTS: Of these 38 patients, 17 (45%) were discharged, and 21 (55%) died in-hospital. Cardiogenic shock was overt in 28 patients; 47.1% of the survival group and 95.2% of the mortality group (p=0.0008). On arrival, the survival-group had higher pH (7.40+/-0.10 vs. 7.30+/-0.14; p=0.013) and base excess (-4.5+/-3.9 vs. -10.4+/-6.0 mEq/L; p=0.0013). In the survival group reperfusion was successful in 100% of patients, as opposed to 57.1% in the mortality group (p=0.0020), and the incident of stenting was not different between the two groups (64.7% vs. 71.4%, p=0.66). Shock patients had lower successful angioplasty rate (67.9% vs. 100%, p=0.040), higher in-hospital mortality (71.4% vs. 10.0%, p=0.0008), and higher 1-year mortality rates (p=0.0064), than stable patients. All shock patients with failed angioplasty died, but the mortality rate was 57.9% (p=0.021) when angioplasty was successful. CONCLUSIONS: Patients presenting with AAMI, LMCA occlusion, and cardiogenic shock have poor survival regardless of primary angioplasty in conjunction with coronary stents. Nevertheless, primary angioplasty is a feasible and effective procedure, and it may save lives in this clinical setting.     

Unprotected left main stenting in acute myocardial infarction

Left main stenosis is a rare cause of acute myocardial infarction. Emergent percutaneous transluminal coronary angioplasty (PTCA) of the left main coronary artery has been shown to have greatly increased procedural and short-term mortality. Stenting decreases the incidence of abrupt closure and has a lower restenosis rate after PTCA. We present a case of a patient presenting in cardiogenic shock due to an acute anterior myocardial infarction who underwent emergent left main coronary artery stenting.     

Factors predicting mortality in patients after myocardial infarction caused by left main coronary artery occlusion: significance of ST segment elevation in both aVR and aVL leads

Acute left main coronary artery obstruction is rare and most patients in this clinical setting die of sudden death or cardiogenic shock. During the past 8 years, we encountered 13 patients with acute myocardial infarction caused by total occlusion of the left main coronary artery (LMCA-AMI). Thus, we surveyed these patients, and attempted to elucidate helpful predictors related to the prognosis. Six of 13 patients with LMCA-AMI survived. Successful left coronary artery dilatation was achieved in all survivors (group S), and in 5 (71%) non-survivors (group non-S). The age was not different between the two groups. A past history of angina was confirmed in 83% of group S. while only in 29% of group non-S. Clinical findings such as time of onset of AMI, interval from the AMI onset to admission, elapsed period from the AMI onset to recanalization of LMCA and the value of CK on admission were not different between the two groups. However, cardiogenic shock occurred in only 1 patient (17%) in group S compared with 5 patients (71%) in group non-S. As emphasized in the literature, good collateral circulation to the left anterior descending artery was observed in 5 patients (83%) in group S, while not observed in group non-S. Electro cardiographically, ST elevation in the aVR lead was very characteristic. This finding was confirmed in 69% of the total patients. Noticeably, 5 out of 6 non-survivors (83%) showed ST elevation not only in leads aVR but also in the aVL lead. In addition to the absence of collateral circulation, this electrocardiographic finding, which obviously indicates the presence of extensive myocardial ischemia in the diseased heart, is a simple and important predictor suggesting a poor prognosis in LMCA-AMI patients.     

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.     

Stenting of an unprotected left main coronary artery stenosis in cardiogenic shock and ventricular fibrillation: three-year follow-up

We describe a case of stenting an unprotected left main coronary artery stenosis in an octogenarian patient with cardiogenic shock complicating acute myocardial infarction. Our patient had no in-stent restenosis of the left main for three years and remains asymptomatic. Since, in the octogenarian patient, the surgical risk for emergent coronary artery bypass graft is extremely high, coronary artery stenting of the unprotected left main for myocardial infarction complicated by cardiogenic shock is an alternative treatment in selected patients.     

左主干病变导致急性ST段抬高型心肌梗死的诊治体会

目的:总结左主干狭窄或闭塞导致急性ST段抬高型心肌梗死(AMI)患者的临床特点,并提出其早期诊断和治疗体会.方法:复习我院2年内246例AMI急诊经皮冠状动脉介入治疗(PCI)的临床资料,其中7例梗死相关血管为左主干,均为男性,年龄36～83岁,所有患者无论是否存在心源性休克,均立即行主动脉内球囊反搏术,并在其支持下尽早接受急诊造影检查.结果:7例患者心电图均存在aVR导联ST段抬高(≥0.05 mV),5例患者同时存在V1 -V6导联ST段抬高及新出现完全右束支传导阻滞,其中4例入院时即存在严重心源性休克,6例急诊置入支架,另1例仅行球囊扩张,并接受急诊冠状动脉旁路移植术,住院期间死亡3例(42.9％),存活患者4例均完成1年随访.其中2例于1月随访时对其LAD进行PCI,1例于3月随访时进行了LAD和LCX的冠状动脉旁路移植术.结论:左主干急性闭塞或严重狭窄所致的AM I患者急性期病死率高;根据心电图和临床特点早期识别梗死部位,早期评估,并且无论是否出现低血压或心源性休克早期行主动脉内球囊反搏术,并在其支持下尽早再灌注治疗,加强术后监护,提高随访质量,可以挽救部分患者的生命和改善预后.