International Journal of Cardiology 184 (2015) 473–474
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
A quick bailout ongoing of cardiogenic shock and iatrogenic dissection of the left main coronary artery M. Vatrano a, G. Dattilo b, G. Mandraffino b, S. Gangemi b, V.A. Ciconte a, S. Quartuccio b, R. Ceravolo a, E. Imbalzano b,⁎ a b
UTIC and Cardiology, Hospital “Pugliese-Ciaccio” of Catanzaro, Italy Department of Clinical and Experimental Medicine, University of Messina, Italy
a r t i c l e
i n f o
Article history: Received 17 January 2015 Accepted 1 March 2015 Available online 3 March 2015 Keywords: Acute myocardial infarction Cardiogenic shock Left main coronary artery Stenting Arterial hypertension Immune systems
Acute occlusion of the left main coronary artery (LMCA) is a catastrophic clinical circumstance rarely observed, as most patients die before seeking medical attention. It manifests as an acute myocardial infarction (AMI) with cardiogenic shock (CS), usually known as left main shock syndrome [1,2]. Left main shock syndrome is undoubtedly the nightmare of every cardiologist because it carries a high rate of mortality despite when appropriate treatment is administered [3, 4]. The etiology of left main shock syndrome can be generally classified as spontaneous or iatrogenic, both related to thrombosis or dissection of LMCA. In any case, immediate revascularization could be life-saving [5]. Emergency CABG in these patients may be effective but time consuming, and carries the risk of extensive and irreversible myocardial damage, especially when there is a scarce or total absence of collateralization between the right coronary artery and the left coronary system. Percutaneous revascularization is a potential option, especially in patients presenting with acute coronary syndrome and cardiogenic shock by quick reperfusion of the cardiac muscle [6,7]. A hypertensive and obese 70-year-old male with no known coronary artery disease presented to our hospital 1 h after sudden-onset chest pain occurred while he was sleeping. The patient's past medical history also included
⁎ Corresponding author at: Department of Clinical and Experimental Medicine, Policlinic University of Messina, Via Consolare Valeria n.1, 98125 Messina, Italy. E-mail address: [email protected] (E. Imbalzano).
http://dx.doi.org/10.1016/j.ijcard.2015.03.001 0167-5273/© 2015 Elsevier Ireland Ltd. All rights reserved.
severe disease of the left femoral artery shown recently by computed tomography. On presentation, the patient was dyspnoic, his blood pressure was 90/50 and heart rate was 120 b.p.m. Twelve-lead electrocardiography demonstrated ST-segment elevation in the anterior and lateral leads. After echocardiogram that revealed a markedly depressed ejection fraction (25%), the patient was immediately transferred to the cardiac catheterization laboratory. An intra-aortic balloon pump (IABP) was not inserted immediately because of the known occlusion of the left femoral artery. Coronary angiography was performed with a 6Fr JR 3.5 diagnostic catheter and a 7Fr EBU 3.5 guide catheter (both Medtronic). It revealed staining in the body of the LMCA due to the total occlusion of distal segment (Fig. 1A) with TIMI (thrombosis in myocardial infarction) 0 flow and without any collateral circulation. An episode of ventricular fibrillation requiring efficacious defibrillation occurred. Next, a Medium guidewire (Asahi Intecc, Japan) was passed beyond the occlusion to the left anterior descending (LAD) artery and a series of balloon inflation were done (Fig. 1B). Angiography demonstrated a trifurcation with TIMI 1 flow to the LAD, intermediate and nondominant circumflex (Cx) arteries (Fig. 1C). Two other floppy guidewires were crossed to the Cx and intermediate artery and a series of further balloon inflations were done to the ostium of each vessel. After flow restoration, the decision to proceed with a kissing drugeluting stent (KS) technique for treating LAD (3.0 × 30 mm) and intermediate (3.0 × 26 mm) artery ostial lesions was made (Fig. 1D), into account the suitable size of the coronary and the right coronary dominance. After stent implantation, angiography revealed in-stent dissection, from the ostium of LMCA to the LAD, with TIMI 0–1 distally (Fig. 1E). Following many balloon inflations, the decision to proceed with a further stenting was made. To avoid entrapment, the intermediate's guidewire was removed and a drug-eluting stent (3.5 × 22 mm) was dilated inside previous stent, from the LMCA ostium to the LAD ostium, crushing the stent in intermediate artery. After crossing the Pilot guidewire (Abbott Vascular) in the intermediate artery successfully, the stent struts were dilated and the expansion of all the stents was optimized with a series of non-compliant balloon inflations. Subsequently, TIMI 3 flow was restored in the left coronary circulation (Fig. 1F). Finally, an IABP (CS100 Datascope, Maquet Getinge Group) was inserted into the right femoral artery. The patient was transferred to the cardiovascular intensive care unit. A follow-up ECG showed a marked improvement in ST-segment changes in all leads. Due to a severe respiratory complication,
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M. Vatrano et al. / International Journal of Cardiology 184 (2015) 473–474
Fig. 1. Panel A: Total occlusion of the left main coronary artery (LMCA). Panel B: Flow restoration after balloon inflation. Panel C: Trifurcation of the left anterior descending (LAD), intermediate and nondominant circumflex (Cx) arteries. Panel D: Kissing stent technique. Panel E: Iatrogenic dissection of LMCA. Panel F: Flow restoration after implantation of stent inside the previous stent in the LAD and crush of previous stent in the intermediate.
mechanical ventilation was initiated through oral-tracheal intubation and the patient was immediately transferred to the intensive care unit. Ventilatory support and the intra-aortic balloon were continued, and the patient remained hypotensive and required inotropic support [8]. Two days later when IABP was removed and the patient's left ventricular ejection fraction was 40%, his medical condition improved greatly. Growing evidence indicates that the subsequent prognosis is related to the inflammatory response and it is characterized by the involvement of cells from immune systems. An increased knowledge of immune components may help improve the treatments of those who survive after acute myocardial infarction [9]. In conclusion, both spontaneous and iatrogenic LMCA acute diseases are rare, but do occur, also simultaneously. Emergency reperfusion of the LMCA is the primary goal in these patients. Emergency bailout stenting could be the only key to obtain a coronary reperfusion rapidly and hopefully possible survival. This case describes a very rare condition because two extreme clinical situations overlapped. Moreover, a very complex, bailout and, specially, tailored coronary stenting technique has been used to solve a potentially deadly procedural complication, in a basal extremely serious clinical situation. Conflict of interest The authors report no relationships that could be construed as a conflict of interest.
Acknowledgments The authors of this manuscript have certified that they adhere to the statement of ethical publishing as it appears in the International Journal of Cardiology. References [1] R.M. Gowda, J.T. Fox, I.A. Khan, Cardiogenic shock: basics and clinical considerations, Int. J. Cardiol. 123 (3) (Jan 24 2008) 221–228. [2] B. Boztosun, C. Dundar, S.M. Aung, C. Kirma, Left main coronary artery stenting in a patient with acute myocardial infarction and cardiogenic shock, Int. J. Cardiol. 132 (2) (Feb 20 2009) e88–e90. [3] S.C. Wong, T. Sanborn, L.A. Sleeper, et al., Angiographic findings and clinical correlates in patients with cardiogenic shock complicating acute myocardial infarction: a report from the SHOCK Trial Registry. SHould we emergently revascularize Occluded Coronaries for cardiogenic shocK, J. Am. Coll. Cardiol. 36 (2000) 1077. [4] R.L. Quigley, C.A. Milano, L.R. Smith, et al., Prognosis and management of anterolateral myocardial infarction in patients with severe left main disease and cardiogenic shock: the left main shock syndrome, Circulation 88 (1993) II65–II70. [5] N. Aygül, M.Ü. Aygül, K. Özdemir, B.B. Altunkeser, Emergency revascularization procedures in patients with acute ST-elevation myocardial infarction due to acute total occlusion of unprotected left main coronary artery: a report of five cases, Turk Kardiyol. Dern. Ars. 38 (2010) 131–134. [6] M. Spiecker, R. Erbel, H.T. Rupprecht, J. Meyer, Emergency angioplasty of totally occluded left main coronary artery in acute myocardial infarction and unstable angina pectoris: institutional experience and literature review, Eur. Heart J. 15 (1994) 602–607. [7] M.M. Abuzahra, A. Mesa, B. Treistman, Unprotected left main coronary artery intervention for acute myocardial infarction and cardiogenic shock, Tex. Heart Inst. J. 34 (2007) 479–484. [8] A. Lilli, S. Vecchio, T. Chechi, G. Vittori, G. Giuliani, G. Spaziani, L. Consoli, F. Giannotti, G. Baldereschi, M. Margheri, Left ventricular support device for cardiogenic shock during myocardial infarction due to stent thrombosis: a single centre experience, Int. J. Cardiol. 148 (3) (May 5 2011) 337–340. [9] S.C. Latet, V.Y. Hoymans, P.L. Van Herck, C.J. Vrints, The cellular immune system in the postmyocardial infarction repair process, Int. J. Cardiol. 179C (Jan 20 2015) 240–247.
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
A quick bailout ongoing of cardiogenic shock and iatrogenic dissection of the left main coronary artery M. Vatrano a, G. Dattilo b, G. Mandraffino b, S. Gangemi b, V.A. Ciconte a, S. Quartuccio b, R. Ceravolo a, E. Imbalzano b,⁎ a b
UTIC and Cardiology, Hospital “Pugliese-Ciaccio” of Catanzaro, Italy Department of Clinical and Experimental Medicine, University of Messina, Italy
a r t i c l e
i n f o
Article history: Received 17 January 2015 Accepted 1 March 2015 Available online 3 March 2015 Keywords: Acute myocardial infarction Cardiogenic shock Left main coronary artery Stenting Arterial hypertension Immune systems
Acute occlusion of the left main coronary artery (LMCA) is a catastrophic clinical circumstance rarely observed, as most patients die before seeking medical attention. It manifests as an acute myocardial infarction (AMI) with cardiogenic shock (CS), usually known as left main shock syndrome [1,2]. Left main shock syndrome is undoubtedly the nightmare of every cardiologist because it carries a high rate of mortality despite when appropriate treatment is administered [3, 4]. The etiology of left main shock syndrome can be generally classified as spontaneous or iatrogenic, both related to thrombosis or dissection of LMCA. In any case, immediate revascularization could be life-saving [5]. Emergency CABG in these patients may be effective but time consuming, and carries the risk of extensive and irreversible myocardial damage, especially when there is a scarce or total absence of collateralization between the right coronary artery and the left coronary system. Percutaneous revascularization is a potential option, especially in patients presenting with acute coronary syndrome and cardiogenic shock by quick reperfusion of the cardiac muscle [6,7]. A hypertensive and obese 70-year-old male with no known coronary artery disease presented to our hospital 1 h after sudden-onset chest pain occurred while he was sleeping. The patient's past medical history also included
⁎ Corresponding author at: Department of Clinical and Experimental Medicine, Policlinic University of Messina, Via Consolare Valeria n.1, 98125 Messina, Italy. E-mail address: [email protected] (E. Imbalzano).
http://dx.doi.org/10.1016/j.ijcard.2015.03.001 0167-5273/© 2015 Elsevier Ireland Ltd. All rights reserved.
severe disease of the left femoral artery shown recently by computed tomography. On presentation, the patient was dyspnoic, his blood pressure was 90/50 and heart rate was 120 b.p.m. Twelve-lead electrocardiography demonstrated ST-segment elevation in the anterior and lateral leads. After echocardiogram that revealed a markedly depressed ejection fraction (25%), the patient was immediately transferred to the cardiac catheterization laboratory. An intra-aortic balloon pump (IABP) was not inserted immediately because of the known occlusion of the left femoral artery. Coronary angiography was performed with a 6Fr JR 3.5 diagnostic catheter and a 7Fr EBU 3.5 guide catheter (both Medtronic). It revealed staining in the body of the LMCA due to the total occlusion of distal segment (Fig. 1A) with TIMI (thrombosis in myocardial infarction) 0 flow and without any collateral circulation. An episode of ventricular fibrillation requiring efficacious defibrillation occurred. Next, a Medium guidewire (Asahi Intecc, Japan) was passed beyond the occlusion to the left anterior descending (LAD) artery and a series of balloon inflation were done (Fig. 1B). Angiography demonstrated a trifurcation with TIMI 1 flow to the LAD, intermediate and nondominant circumflex (Cx) arteries (Fig. 1C). Two other floppy guidewires were crossed to the Cx and intermediate artery and a series of further balloon inflations were done to the ostium of each vessel. After flow restoration, the decision to proceed with a kissing drugeluting stent (KS) technique for treating LAD (3.0 × 30 mm) and intermediate (3.0 × 26 mm) artery ostial lesions was made (Fig. 1D), into account the suitable size of the coronary and the right coronary dominance. After stent implantation, angiography revealed in-stent dissection, from the ostium of LMCA to the LAD, with TIMI 0–1 distally (Fig. 1E). Following many balloon inflations, the decision to proceed with a further stenting was made. To avoid entrapment, the intermediate's guidewire was removed and a drug-eluting stent (3.5 × 22 mm) was dilated inside previous stent, from the LMCA ostium to the LAD ostium, crushing the stent in intermediate artery. After crossing the Pilot guidewire (Abbott Vascular) in the intermediate artery successfully, the stent struts were dilated and the expansion of all the stents was optimized with a series of non-compliant balloon inflations. Subsequently, TIMI 3 flow was restored in the left coronary circulation (Fig. 1F). Finally, an IABP (CS100 Datascope, Maquet Getinge Group) was inserted into the right femoral artery. The patient was transferred to the cardiovascular intensive care unit. A follow-up ECG showed a marked improvement in ST-segment changes in all leads. Due to a severe respiratory complication,
474
M. Vatrano et al. / International Journal of Cardiology 184 (2015) 473–474
Fig. 1. Panel A: Total occlusion of the left main coronary artery (LMCA). Panel B: Flow restoration after balloon inflation. Panel C: Trifurcation of the left anterior descending (LAD), intermediate and nondominant circumflex (Cx) arteries. Panel D: Kissing stent technique. Panel E: Iatrogenic dissection of LMCA. Panel F: Flow restoration after implantation of stent inside the previous stent in the LAD and crush of previous stent in the intermediate.
mechanical ventilation was initiated through oral-tracheal intubation and the patient was immediately transferred to the intensive care unit. Ventilatory support and the intra-aortic balloon were continued, and the patient remained hypotensive and required inotropic support [8]. Two days later when IABP was removed and the patient's left ventricular ejection fraction was 40%, his medical condition improved greatly. Growing evidence indicates that the subsequent prognosis is related to the inflammatory response and it is characterized by the involvement of cells from immune systems. An increased knowledge of immune components may help improve the treatments of those who survive after acute myocardial infarction [9]. In conclusion, both spontaneous and iatrogenic LMCA acute diseases are rare, but do occur, also simultaneously. Emergency reperfusion of the LMCA is the primary goal in these patients. Emergency bailout stenting could be the only key to obtain a coronary reperfusion rapidly and hopefully possible survival. This case describes a very rare condition because two extreme clinical situations overlapped. Moreover, a very complex, bailout and, specially, tailored coronary stenting technique has been used to solve a potentially deadly procedural complication, in a basal extremely serious clinical situation. Conflict of interest The authors report no relationships that could be construed as a conflict of interest.
Acknowledgments The authors of this manuscript have certified that they adhere to the statement of ethical publishing as it appears in the International Journal of Cardiology. References [1] R.M. Gowda, J.T. Fox, I.A. Khan, Cardiogenic shock: basics and clinical considerations, Int. J. Cardiol. 123 (3) (Jan 24 2008) 221–228. [2] B. Boztosun, C. Dundar, S.M. Aung, C. Kirma, Left main coronary artery stenting in a patient with acute myocardial infarction and cardiogenic shock, Int. J. Cardiol. 132 (2) (Feb 20 2009) e88–e90. [3] S.C. Wong, T. Sanborn, L.A. Sleeper, et al., Angiographic findings and clinical correlates in patients with cardiogenic shock complicating acute myocardial infarction: a report from the SHOCK Trial Registry. SHould we emergently revascularize Occluded Coronaries for cardiogenic shocK, J. Am. Coll. Cardiol. 36 (2000) 1077. [4] R.L. Quigley, C.A. Milano, L.R. Smith, et al., Prognosis and management of anterolateral myocardial infarction in patients with severe left main disease and cardiogenic shock: the left main shock syndrome, Circulation 88 (1993) II65–II70. [5] N. Aygül, M.Ü. Aygül, K. Özdemir, B.B. Altunkeser, Emergency revascularization procedures in patients with acute ST-elevation myocardial infarction due to acute total occlusion of unprotected left main coronary artery: a report of five cases, Turk Kardiyol. Dern. Ars. 38 (2010) 131–134. [6] M. Spiecker, R. Erbel, H.T. Rupprecht, J. Meyer, Emergency angioplasty of totally occluded left main coronary artery in acute myocardial infarction and unstable angina pectoris: institutional experience and literature review, Eur. Heart J. 15 (1994) 602–607. [7] M.M. Abuzahra, A. Mesa, B. Treistman, Unprotected left main coronary artery intervention for acute myocardial infarction and cardiogenic shock, Tex. Heart Inst. J. 34 (2007) 479–484. [8] A. Lilli, S. Vecchio, T. Chechi, G. Vittori, G. Giuliani, G. Spaziani, L. Consoli, F. Giannotti, G. Baldereschi, M. Margheri, Left ventricular support device for cardiogenic shock during myocardial infarction due to stent thrombosis: a single centre experience, Int. J. Cardiol. 148 (3) (May 5 2011) 337–340. [9] S.C. Latet, V.Y. Hoymans, P.L. Van Herck, C.J. Vrints, The cellular immune system in the postmyocardial infarction repair process, Int. J. Cardiol. 179C (Jan 20 2015) 240–247.
