Percutaneous coronary intervention for acute myocardial infarction due to unprotected left main coronary artery occlusion

Acute myocardial infarction (AMI) due to unprotected left main coronary artery (ULMCA) occlusion is an uncommon clinical entity, but often leads to severe clinical deterioration, with devastating sequalae including fatal arrhythmias, abrupt and severe circulatory failure, and sudden cardiac death. Recent guidelines have promoted treatment with percutaneous coronary intervention (PCI) as a class IIa recommendation alongside coronary artery bypass grafting (CABG), but the data are still unclear regarding optimal revascularization strategy for patients with ST‐segment elevation myocardial infarction (STEMI) and non‐STEMI (NSTEMI) with ULMCA culprit. PCI has the advantages of offering rapid reperfusion to critically ill patients, often those with prohibitive risk for surgical revascularization, with acceptable short‐ and long‐term outcomes. Recent studies demonstrate that PCI of the ULMCA is a viable alternative to CABG for appropriate patient populations, including those with ULMCA occlusion and those in cardiogenic shock, Thrombolysis In Myocardial Infarction (TIMI) flow grade 3, and significant comorbidities. A randomized trial comparing PCI with CABG is needed to clarify the ideal revascularization strategy, though the clinical picture of these critically ill patients may preclude such studies. © 2014 Wiley Periodicals, Inc.     

Primary percutaneous coronary intervention of an unprotected left main using mini‐crush drug‐eluting stents facilitated by intracoronary reteplase

Patients suffering from acute myocardial infarction with involvement of unprotected left main (LM) coronary artery disease represent a very high‐risk subgroup. A 37‐year‐old male patient was admitted with posterolateral acute myocardial infarction and in borderline hemodynamic condition. His left ventricular ejection fraction was 30% with posterior, lateral wall, and apical akinesis along with mild mitral regurgitation. Emergency coronary angiography demonstrated ostial occlusion of the left circumflex artery (without stump, flow Thrombolysis in Myocardial Infarction 0/Rentrop 0) and severe distal LM disease with superimposed thrombus. The primary percutaneous coronary intervention procedure combined intracoronary reteplase plus thrombus aspiration to restore flow in the left circumflex and deployment of two everolimus‐eluting stents with mini‐crush technique to successfully reconstruct the LM bifurcation. The patient recovered without complications and had a favorable outcome at mid‐term.© 2011 Wiley‐Liss, Inc.     

Long‐term follow‐up after nonurgent percutaneous coronary intervention in unprotected left main coronary arteries

Objectives : To evaluate the long‐term outcomes of the selected patients by the local Heart Team to undergo percutaneous coronary intervention (PCI) of unprotected left main coronary artery (ULMCA) stenosis and to compare patients considered at low surgical risk versus at high surgical risk for coronary artery bypass grafting (CABG). Background : CABG is recommended in patients with ULMCA stenosis according to the AHA/ACC and ESC guidelines, and there are limited data on the long‐term outcomes in patients selected by the local Heart Team to undergo PCI. Methods : Between 1996 and 2007, 227 patients underwent PCI for ULMCA stenosis based on decision of the local Heart Team and patient's and/or physician's preference. All patients were contacted at 1 year and in November 2008. Results : Long‐term follow‐up was up to 8 years with a mean of 3.9 ± 2.6 years. Overall, the Kaplan–Meier estimate of the composite of cardiac death, myocardial infarction (MI), or target lesion revascularization (TLR) was 14.8% at 1 year, 18.3% at 3 years, and 20.9% at 5 years with no events occurring thereafter. Patients considered at low surgical risk for CABG had a significantly lower incidence of cardiac death or MI compared to patients considered at high surgical risk at 8 years (1.4 vs. 16.8%; 1.4 vs. 14.8%, respectively); however, no significant difference was observed for cardiac death, MI, or TLR (18.6 vs. 24.4%). Conclusions : PCI of ULMCA stenosis in patients selected by the Heart Team resulted in good long‐term clinical outcomes with most events occurring within the 1st year. Patients considered at low surgical risk for CABG have a significantly better long‐term survival than patients at high risk for surgery. © 2010 Wiley‐Liss, Inc.     

Percutaneous coronary intervention of unprotected left main coronary artery disease

Data have emerged demonstrating the safety and efficacy of percutaneous coronary intervention (PCI) of the unprotected left main (ULM) artery. The 2009 American College of Cardiology/American Heart Association/Society for Cardiovascular Angiography and Interventions focused guidelines for PCI no longer state that ULM PCI is contraindicated in patients with anatomic conditions that are associated with a low risk of procedural complications and clinical conditions that predict an increased risk of adverse surgical outcomes. ULM PCI should be performed by operators with experience in the management of the anatomic complexities of left main and multivessel disease, specifically in issues relating to bifurcation disease, calcification, and hemodynamic support. Patients with ostial or shaft disease have lower risk of restenosis compared with distal bifurcation disease. Drug‐eluting stents (DES) should be used whenever possible as they reduce clinical restenosis. Intravascular ultrasound is an integral component of the procedure as it provides accurate assessment of lesion severity and can confirm optimal stent expansion and apposition. Compliance with dual antiplatelet therapy for at least 12 months is essential if DES are used. A collaborative, multidisciplinary approach with a “Heart Team” represented by a cardiac surgeon, interventional cardiologist, and non‐invasive cardiologist may optimize patient education and objective decision making when obtaining informed consent. Application of clinical and angiographic variables into risk models facilitates appropriate patient selection. Randomized clinical trials will address unanswered issues and help build consensus between cardiology and surgical societies to inform clinical decision making and optimize the outcomes for patients with ULM coronary artery disease. © 2011 Wiley Periodicals, Inc.     

Early and long‐term results of percutaneous coronary intervention for unprotected left main trifurcation disease

Objectives: We aimed to conduct a retrospective cohort study focusing on our 5‐year experience in the percutaneous treatment of unprotected left main (ULM) trifurcation disease. Background: Percutaneous treatment of ULM trifurcation remains a challenging and rare procedure for most interventional cardiologists. Moreover, data on long‐term outcomes are lacking. Methods: We retrieved all patients with ULM trifurcation disease treated percutaneously at our Institution since 2002, and adjudicated baseline, procedural, and outcome data. The primary end point was the long‐term rate of major adverse cardiovascular events (MACE, i.e., cardiac death, myocardial infarction, bypass surgery, or target vessel revascularization). Results: A total of 27 patients underwent percutaneous coronary intervention with stent implantation for ULM trifurcation disease, with 14 (52%) cases of true trifurcations, i.e., with concomitant significant stenoses of the distal ULM/ostial left anterior descending plus ostial ramus intermedius and ostial circumflex. Bare‐metal stents were implanted in 8 (29%) patients and drug‐eluting stents (DES) in 26 (96%), with a main branch stent only strategy in 11 (40%), T stenting in 9 (33%), and V stenting in 6 (27%). Procedural and clinical success occurred in 26 (96%), with one postprocedural death. Angiographic follow‐up was obtained in 22 patients (81%), and clinical follow‐up was completed in all subjects after a median of 28 ± 17 months, showing overall MACE in 9 (33%), with cardiac death in 4 (15%), myocardial infarction in 1 (4%), coronary artery bypass grafting (CABG) in 4 (15%), and percutaneous target vessel revascularization in 5 (19%). Definite stent thrombosis was adjudicated in 1 (3%) patient. Treatment of a true trifurcation lesion and recurrence of angina during follow‐up were significantly associated with an increased risk of MACE (P = 0.029 and P = 0.050, respectively). Conclusions: Percutaneous treatment of ULM trifurcation disease is feasible, associated with favorable mid‐term results, and may be considered given its low invasiveness in patients at high surgical risk or with multiple comorbidities. © 2008 Wiley‐Liss, Inc.     

Robotic‐assisted percutaneous coronary intervention

Performance of percutaneous coronary intervention (PCI) is associated with several occupational hazards including radiation exposure and musculoskeletal injury. Current methods to mitigate these risks range from suspended radiation suits to adjustable lead‐lined glass shields. Robotic‐assisted PCI is a novel approach to PCI that utilizes remote‐controlled technology to manipulate catheters thereby significantly reducing radiation exposure to the operator and catheterization laboratory staff. Although limited, current evidence indicates that robotic‐assisted PCI is associated with a high technical success rate and may have additional advantages over conventional PCI, such as a decreased incidence of geographical miss. However, as the technology is nascent, further studies including larger, randomized controlled trials are needed to expand on the long‐term clinical and safety outcomes.     

左心室收缩功能正常的老年冠心病患者无保护左主干病变PCI治疗预后的影响因素

目的 探讨左心室收缩功能正常（左心室射血分数≥40％）的老年冠状动脉粥样硬化性心脏病（冠心病）患者无保护左主干（unprotected left main,ULM）病变经皮冠状动脉介入（percutaneous coronary intervention,PCI）治疗预后的影响因素.方法 回顾性分析2009年1月至2011年12月在广西壮族自治区人民医院因ULM接受PCI治疗的左心室收缩功能正常的患者112例的临床资料和冠状动脉造影结果.根据患者的情况分为非老年组（年龄＜60岁）和老年组（≥60岁）,比较两组间的基线资料和冠状动脉造影结果.应用多因素回归分析法观察年龄对ULM介入治疗结果的预测价值.结果 总计入选符合条件的患者112例,其中非老年组42例和老年组70例.老年组糖尿病、高脂血症、吸烟史、既往PCI治疗、主要心脑血管不良事件（MACCE）、术后心肌梗死发生率明显高于非老年组,差异有统计学意义（分别为42.9％ vs.21.1％,P=0.021;40％ vs.11.9％,P=0.040; 28.6％ vs.9.5％,P=0.017;18.6％ vs.4.8％,P=0.038;48.6％ vs.23.8％,P=0.009;22.9％ vs.0％,P=0.001）.Logistics回归分析得出女性、年龄、吸烟史、合并多支血管病变、远端或分叉病变均为主要心脑血管不良事件的独立预测因素.结论 左心室收缩功能正常的患者,其年龄因素是ULM介入治疗预后不良的强力预测因素.     

经桡动脉行无保护左主干病变介入治疗

目的:回顾性总结29例冠状动脉造影发现为无保护左主干开口及体部狭窄病例的冠脉介入治疗(PCI)资料,以探讨手术的安全性和可行性。方法:术前给予常规药物治疗,经桡动脉途径行PCI,观察桡动脉穿刺成功率、PCI即刻成功率、手术时间、支架扩张时间和扩张压力、住院期间严重并发症发生率、出院前心绞痛发作情况评估及术前心电图(ECG)特点分析。结果:29例患者桡动脉穿刺成功率和PCI即刻成功率均为100%,手术时间25～50(38±8)min,支架扩张时间3～7(5±1.3)s,支架扩张压力14～20(16.0±1.9)atm(1atm=101.325kPa),住院期间无严重并发症发生,前臂肿胀3例,术后心绞痛显著缓解。术前胸痛发作时ECG特点:典型"左主干"心电图17例,胸前导联ST-T改变者10例,间歇性左束支阻滞2例。结论:经桡动脉途径对无保护左主干开口和体部病变行PCI治疗,成功率高,安全有效。     

Axillary Impella insertion under regional nerve block: A case report

Percutaneous coronary interventions with the Impella (Abiomed, MA) catheter‐based, micro‐axial mechanical left ventricular assist device is a safe option for patients undergoing higher risk interventions. However, severe peripheral arterial disease limits vascular access for Impella insertion. Upper extremity arterial access has been traditionally obtained under general anesthesia. We present the first case, to our knowledge, of using peripheral nerve blocks for Impella 3.5 CP insertion into the axillary artery.     

Results of percutaneous drug‐eluting stent implantation for unprotected left main coronary disease according to left ventricular systolic function

Objectives: We aimed to appraise the early and long‐term outcome after percutaneous coronary intervention (PCI) with drug‐eluting stents (DES) in patients with unprotected left main disease (ULM) and left ventricular systolic dysfunction (LVD). Background: PCI with DES has being performed with increasing frequency in subjects with ULM and LVD, but few specific data are available. Setting and Patients: We identified patients undergoing PCI with DES for ULM at our Center and distinguished those with ejection fraction (EF) >50% from those with 40% <EF ≤50% and those with EF ≤40%. The primary end‐point was the rate of major adverse cerebro‐cardiovascular events (MACCE, ie death, myocardial infarction [MI], stroke, repeat PCI or bypass surgery). Results: A total of 197 patients were included, 57.4% with EF >50%, 32.0% with 40% <EF ≤50%, and 10.6% with EF ≤40%. In‐hospital mortality was significantly higher in those with EF ≤40% (9.5% vs. 0 and 3.2%, P < 0.001). A total of 96% patients were followed for 23 ± 14 months, yielding a MACCE rate of 44.2% (41.6% in those with EF >50%, 41.6% in those with 40% <EF ≤50%, and 61.9% in those with EF ≤40%, P = 0.4). Specifically, death occurred in 2.7%, 7.9%, and 28.6% (P < 0.001), cardiac death in 1.8%, 4.8%, and 23.8% (P = 0.001), MI in 8.0%, 7.9% and 0 (P = 0.4), and TVR in 15.9%, 11.1% and 33.3% (P = 0.6). Conclusion: Systolic ventricular dysfunction is highly correlated with in‐hospital and long term death rates in patients undergoing PCI with DES for ULM disease. However it does not confer an increased risk of nonfatal adverse events or stent thrombosis. © 2009 Wiley‐Liss, Inc.     

无保护左主干病变血运重建的临床评价

冠脉旁路移植术为无保护左主干病变的首选治疗。随着经皮冠脉介入治疗技术的进步,在有选择的无保护左主干患者中,PCI与CABG的疗效相当。本文对无保护左主干病变几种血运重建方法进行综述。     

老年女性无保护左主干病变患者经皮冠状动脉介入术的长期疗效观察

目的：探讨合并冠状动脉左主干（LMCA）病变老年女性患者经皮冠状动脉介入（PCI）术后的长期预后。方法从1997年12月～2012年10月,共有302例女性患者在我院首次行冠状动脉造影提示LMCA并行PCI,其中≥65岁的老年女性156例,年龄（72.0±4.31）岁;＜65岁非老年女性146例,年龄（55.5±7.06）岁。两组成功PCI患者随访（42.0±19.3）个月,比较两组患者的临床基本特征、冠状动脉病变特点、PCI特点及随访结果。结果老年组高血压和急性心肌梗死的比例较非老年组虽有增高的趋势,但差异无统计学意义。老年组的Syntax评分明显高于非老年组[（26.6±8.49） vs （23.5±9.10）,P＜0.01]。老年组与非老年组PCI成功率均为100%,两组所采用手术术式、植入支架平均直径及长度,以及药物洗脱支架的比例均无明显差异。与非老年组相比较,老年组在总的主要不良心血管事件发生率、支架内血栓及全因死亡的发生率均无明显增加。结论合并LMCA病变的老年女性患者接受PCI是安全的,通过强化抗血小板治疗、选择合理的手术策略可改善其长期预后。