Primary Angioplasty in a Catastrophic Presentation: Acute Left Main Coronary Total Occlusion-The ATOLMA Registry
A Gutiérrez-Barrios1,2, L Gheorghe1,2, S Camacho-Freire3
1Departamento de Cardiología Hospital Universitario Puerta del Mar, Cádiz, Spain.
Insights
Acute total left main coronary artery occlusion (ATOLMA) is a severe condition with high mortality. Achieving good post-procedure blood flow is key to survival after emergency angioplasty.
Area of Science:
- Cardiology
- Interventional Cardiology
- Vascular Medicine
Background:
- Acute total left main coronary artery occlusion (ATOLMA) is a rare but critical condition.
- Existing data on true ATOLMA and its management is limited and inconsistent.
Purpose of the Study:
- Identify predictors of in-hospital mortality in ATOLMA patients undergoing emergency angioplasty.
- Describe the clinical presentation and long-term outcomes of these patients.
Main Methods:
- Multicenter retrospective cohort study.
- Included patients with myocardial infarction due to confirmed ATOLMA who underwent emergency percutaneous coronary intervention (PCI).
Main Results:
- ATOLMA occurred in 0.58% of emergent PCI cases (46 patients).
- High rates of cardiogenic shock (89%) and need for CPR (67.4%) were observed.
- In-hospital mortality was 58.6%, with postprocedural TIMI flow being the sole independent predictor of mortality (OR 0.23, p < 0.001).
Conclusions:
- ATOLMA presents catastrophically with high mortality, but emergency angioplasty is feasible.
- Postprocedural TIMI flow is the only independent predictor of in-hospital mortality.
- Survivors had encouraging long-term outcomes, suggesting feasibility of intervention despite severity.
Objectives:
To determine the outcome predictors of in-hospital mortality in acute total occlusion of the left main coronary artery (ATOLMA) patients referred to emergent angioplasty and to describe the clinical presentation and the long-term outcome of these patients.
Background:
ATOLMA is an uncommon angiographic finding that usually leads to a catastrophic presentation. Limited and inconsistent data have been previously reported regarding true ATOLMA, yet comprehensive knowledge remains scarce.
Methods:
This is a multicenter retrospective cohort that includes patients presenting with myocardial infarction due to a confirmed ATOLMA who underwent emergency percutaneous coronary intervention (PCI).
Results:
In the period of the study, 7930 emergent PCI were performed in the five participating centers, and 46 of them had a true ATOLMA (0.58%). At admission, cardiogenic shock was present in 89% of patients, and cardiopulmonary resuscitation was required in 67.4%. All the patients had right dominance. Angiographic success was achieved in 80.4% of the procedures, 13 patients (28.2%) died during the catheterization, and the in-hospital mortality rate was 58.6% (27/46). At one-year and at the final follow-up, 18 patients (39%) were alive, including four cases successfully transplanted. Multivariate analysis showed that postprocedural TIMI flow was the only independent predictor of in-hospital mortality (OR 0.23, (95% CI 0.1-0.36), p < 0.001).
Conclusions:
Our study confirms that the clinical presentation of ATOLMA is catastrophic, presenting a high in-hospital mortality rate; nevertheless, primary angioplasty in this setting is feasible. Postprocedural TIMI flow resulted as the only independent predictor of in-hospital mortality. In-hospital survivors presented an encouraging outcome. ATOLMA and left dominance could be incompatible with life.
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