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Utilizing Percutaneous Ventricular Assist Devices in Acute Myocardial Infarction Complicated by Cardiogenic Shock
Published on: June 12, 2021
Long-term outcomes following percutaneous coronary intervention to an unprotected left main coronary artery in
Julian Yeoh1, Nick Andrianopoulos2, Christopher M Reid3
1Department of Cardiology, Austin Health, Melbourne, Australia.
Insights
Percutaneous coronary intervention (PCI) for severe left main coronary artery stenosis (LM) in cardiogenic shock shows poor outcomes. While early mortality is high, long-term survival improves after the initial high-risk period.
Area of Science:
- Cardiology
- Interventional Cardiology
- Critical Care Medicine
Background:
- Cardiogenic shock with severe left main coronary artery stenosis (LM) has limited outcome data.
- Unprotected LM PCI is a high-risk procedure in this setting.
Purpose of the Study:
- To evaluate short-term and long-term outcomes of unprotected LM PCI in patients with cardiogenic shock.
- To compare outcomes of LM PCI versus non-LM PCI in cardiogenic shock.
Main Methods:
- Retrospective analysis of patients undergoing PCI for cardiogenic shock from 2005-2013.
- Comparison of outcomes between patients who received LM PCI and those who received non-LM PCI.
- 30-day, 12-month, and long-term mortality assessed via Australian National Death Index.
Main Results:
- LM PCI in cardiogenic shock was associated with significantly higher in-hospital, 30-day, 12-month, and long-term mortality (80.0% at 9 years) compared to non-LM PCI (46.0%).
- LM PCI independently predicted increased long-term mortality (HR 1.59).
- Survivors to discharge undergoing LM PCI still faced substantially higher long-term mortality (~60%) than those with non-LM PCI (~27%).
Conclusions:
- Long-term outcomes following PCI to the LM in cardiogenic shock are poor, with a significant portion of mortality occurring early.
- Despite the high initial risk, reasonable long-term survival can be achieved beyond the acute phase.
Background:
In cardiogenic shock with severe left main coronary artery stenosis (LM), limited information exists on short and longer-term outcomes. We sought to determine the outcomes of unprotected LM PCI in cardiogenic shock.
Methods:
Excluding patients with previous CABG, consecutive patients undergoing PCI in cardiogenic shock from the Melbourne Intervention Group registry between 2005 and 2013 were analysed. Those post LM PCI were compared to those post non-LM PCI. Patient and procedural data were collected with 30-day and 12-month follow-up. Australian National Death Index linkage was performed for long-term mortality analysis.
Results:
After excluding previous CABG, 18,069 procedures were performed during 1st January 2005 to 30th November 2013, 601 procedures in the setting of cardiogenic shock. Of these, 45 were performed to an isolated LM and 556 to a non-LM. Those with LM PCI were older and more likely to have a baseline left ventricular ejection fraction (LVEF) of <45%. The in-hospital, 30-day, 12-month and long-term mortality to 9 years in cardiogenic shock after LM PCI was 64.4%, 66.7%, 73.3% and 80.0% compared to 36.5%, 36.9%, 40.5% and 46.0%, after non-LM PCI (p < 0.001). On multivariate analysis, LM PCI was a significant independent predictor of long-term mortality (HR1.59, 95%CI 1.00-2.53, p = 0.048). Landmark analysis of survivors to discharge found the long-term mortality of LM PCI approaches 60% compared to 27% for those with non-LM PCI (p = 0.003).
Conclusion:
Long-term outcomes after PCI to LM in cardiogenic shock are poor, with much of the excess in mortality occurring early. However, reasonable long-term survival was found beyond the initial high-risk period.
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