Percutaneous reperfusion of left main coronary disease complicated by acute myocardial infarction
Roberto Neri1, Angela Migliorini, Guia Moschi
1Division of Cardiology, Careggi Hospital, Florence, Italy.
Insights
Direct angioplasty and stenting for acute myocardial infarction (AMI) with left main disease and cardiogenic shock is feasible. While in-hospital mortality is high, survivors show good mid-term prognosis.
Area of Science:
- Cardiology
- Interventional Cardiology
- Acute Myocardial Infarction Management
Background:
- Direct angioplasty and stenting benefit acute myocardial infarction (AMI) patients with cardiogenic shock.
- Limited data exist for left main trunk disease (LMD) in AMI with cardiogenic shock.
Purpose of the Study:
- To evaluate the feasibility and effectiveness of percutaneous mechanical intervention for LMD in AMI with cardiogenic shock.
Main Methods:
- Analysis of 1,433 ST-elevation AMI patients treated with primary percutaneous coronary angioplasty (PTCA) between 1995-2000.
- Identified 22 patients (1.5%) with LMD as the culprit lesion.
- Assessed baseline characteristics, procedural success, and in-hospital/mid-term outcomes.
Main Results:
- Primary success rate was 91%, with stenting in 77% of cases.
- In-hospital mortality was 50%, primarily due to refractory shock.
- 6-month survival was 41%, increasing to 59% by follow-up; event-free survival was 27%.
Conclusions:
- Percutaneous mechanical intervention for LMD in AMI with cardiogenic shock is feasible.
- Despite high initial mortality, patients discharged alive have a good mid-term prognosis.
- This strategy offers a viable treatment option for a high-risk patient subset.
Abstract:
Previous studies have shown a benefit of a strategy of direct angioplasty and stenting in patients with acute myocardial infarction (AMI) complicated by early cardiogenic shock. However, few data exist for the subset of patients with left main trunk disease complicated by AMI and cardiogenic shock. We performed an analysis of patients with AMI who underwent mechanical intervention between January 1995 and December 2000. Out of 1,433 patients with ST segment elevation AMI treated with primary coronary angioplasty (PTCA), 22 patients (1.5%) had left main disease (LMD) as the culprit lesion. Baseline characteristics were age, 66 +/- 11 years; female gender, 9%; diabetes, 14%; previous myocardial infarction, 14%; mean systolic blood pressure, 77 +/- 24 mm Hg; time to treatment, 4.8 +/- 2.2 hr; TIMI 0-1, 77%; collateral flow (Rentrop grade >or= 2) 9%. The primary success rate was 91%. Primary stenting was performed in 17 patients (77%). The in-hospital mortality rate was 50%. All deaths were due to refractory shock. The 6-month survival rate was 41% +/- 1%, while the event-free survival rate was 27% +/- 10%. At 6-month follow-up, the mortality rate increased to 59%; the target vessel revascularization rate was 14%. A percutaneous mechanical intervention strategy in patients with left main disease complicated by AMI is feasible and effective, and patients discharged alive have a good mid-term prognosis.
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