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Postconditioning with Lactate-enriched Blood for Cardioprotection in ST-segment Elevation Myocardial Infarction
Published on: May 28, 2019
Outcomes following primary percutaneous coronary intervention for unprotected left main-related ST-segment elevation
Alfonso Ielasi1, Antonio Silvestro, Davide Personeni
1Department of Cardiology, Azienda Ospedaliera 'Bolognini', Seriate (BG), Italy *Drs Ielasi and Silvestro contributed equally to the manuscript and are joint first authors.
Insights
Primary percutaneous coronary intervention (PPCI) for unprotected left main (ULM) ST-segment elevation myocardial infarction (STEMI) is feasible without on-site surgery. Cardiogenic shock significantly increases in-hospital mortality, but survivors have excellent mid-term outcomes.
Area of Science:
- Cardiology
- Interventional Cardiology
- Acute Coronary Syndromes
Background:
- Unprotected left main (ULM) related ST-segment elevation myocardial infarction (STEMI) is a critical condition associated with high rates of circulatory failure and sudden cardiac death.
- While outcomes for ULM thrombosis treated with primary percutaneous coronary intervention (PPCI) are known, data from hospitals without on-site surgical backup are limited.
Purpose of the Study:
- To evaluate the feasibility and outcomes of PPCI for ULM-related STEMI in a hospital setting lacking on-site surgical facilities.
- To assess in-hospital mortality rates, particularly comparing patients with and without cardiogenic shock upon admission.
Main Methods:
- A retrospective cohort analysis of consecutive patients undergoing PPCI for ULM-related STEMI at a single center.
- Patients were stratified based on the presence or absence of cardiogenic shock at the time of admission.
- Primary endpoint was in-hospital mortality.
Main Results:
- Out of 1094 STEMI patients, 34 (3.1%) underwent PPCI for ULM-related STEMI; 22 (64.7%) were in cardiogenic shock.
- Patients in cardiogenic shock had lower ejection fraction, higher prevalence of cardiac arrest, Killip Class III-IV, and poorer coronary flow.
- In-hospital mortality was significantly higher in the cardiogenic shock group (36.4%) compared to the non-cardiogenic shock group (0%). Procedural success was also lower in the shock group (77.3% vs. 100%).
Conclusions:
- PPCI for ULM-related STEMI is technically feasible in hospitals without on-site surgical backup.
- Cardiogenic shock significantly impacts procedural success and in-hospital mortality.
- Patients surviving the acute phase demonstrated excellent mid-term outcomes, irrespective of initial clinical severity.
Introduction:
Unprotected left main (ULM) related ST-segment elevation myocardial infarction (STEMI) is a severe event, often leading to circulatory failure and/or sudden cardiac death. Although high-risk ULM thrombosis populations treated by primary percutaneous coronary intervention (PPCI) have been previously described, very little is known regarding the outcomes following PPCI for ULM-related STEMI in a hospital without on-site surgical back-up.
Methods:
A retrospective cohort analysis was performed on all consecutive patients who underwent PPCI for ULM-related STEMI in a single center. The primary end-point was to assess in-hospital mortality in the overall population and according to the presence/absence of cardiogenic shock at admission.
Results:
Between October 2006 and December 2012, 1094 patients underwent PPCI for STEMI. PPCI for ULM-related STEMI was performed in 34 (3.1%) patients. Among these, 22 (64.7%) were in cardiogenic shock at admission. Baseline mean ejection fraction was lower (P = 0.008), whereas the prevalence of patients with pre-procedural cardiac arrest and Killip Class III-IV was significantly higher in the cardiogenic shock (P = 0.05 and P < 0.001, respectively) compared with non-cardiogenic shock group. Furthermore, patients with cardiogenic shock had a higher prevalence of pre-procedural thrombolysis in myocardial infarction flow 0-1 (P = 0.05) and associated other vessel chronic total occlusion (P = 0.05) compared with non-cardiogenic shock group. Procedural success rate was lower in the cardiogenic shock compared with non-cardiogenic shock group (77.3 vs. 100%, P = 0.09), whereas in-hospital mortality rate was significantly higher in the cardiogenic shock compared with non-cardiogenic shock group (36.4 vs. 0%, P = 0.02). No deaths were reported among survivors of the acute phase at mid-term follow-up, whereas target lesion revascularization rate was 7.6%.
Conclusions:
PPCI for ULM-related STEMI in a hospital without on-site surgical back-up was technically feasible in most of the cases. Although the procedural success and in-hospital mortality rates were influenced by cardiogenic shock at admission, an excellent mid-term outcome among patients who survived the hospitalization was reported independently by the severity of clinical presentation.
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