Catheterization and Cardiovascular Interventions 85:416–420 (2015)

Percutaneous Coronary Intervention for Acute Myocardial Infarction Due To Unprotected Left Main Coronary Artery Occlusion: Status Update 2014 Michael S. Lee,* MD and Mufaddal Q. Dahodwala, MD Acute myocardial infarction (AMI) due to unprotected left main coronary artery (ULMCA) occlusion is an uncommon clinical entity, but often leads to severe clinical deterioration, with devastating sequalae including fatal arrhythmias, abrupt and severe circulatory failure, and sudden cardiac death. Recent guidelines have promoted treatment with percutaneous coronary intervention (PCI) as a class IIa recommendation alongside coronary artery bypass grafting (CABG), but the data are still unclear regarding optimal revascularization strategy for patients with ST-segment elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI) with ULMCA culprit. PCI has the advantages of offering rapid reperfusion to critically ill patients, often those with prohibitive risk for surgical revascularization, with acceptable short- and long-term outcomes. Recent studies demonstrate that PCI of the ULMCA is a viable alternative to CABG for appropriate patient populations, including those with ULMCA occlusion and those in cardiogenic shock, Thrombolysis In Myocardial Infarction (TIMI) flow grade 3, and significant comorbidities. A randomized trial comparing PCI with CABG is needed to clarify the ideal revascularization strategy, though the clinical picture of these critically ill patients may preclude such studies. VC 2014 Wiley Periodicals, Inc. Key words: left main coronary disease; percutaneous coronary intervention; complex PCI; acute myocardial infarction/STEMI

INTRODUCTION

The gold standard for the treatment of unprotected left main coronary artery (ULMCA) disease is coronary artery bypass grafting (CABG), while the gold standard for the treatment of acute myocardial infarction (AMI) is percutaneous coronary intervention (PCI) [1]. However, PCI is a reasonable treatment option for selected patients with ULMCA disease given the very high risk for any surgical procedure. The clinical manifestations of this rare event can be catastrophic, with critical sequelae including abrupt and severe circulatory failure, fatal arrhythmias, and sudden cardiac death [2]. There are still no prospective randomized studies comparing ULMCA PCI and CABG that can guide treatment decisions. However, in the setting of such acute presentations of this critical illness, it is crucial to better elucidate the body of evidence supporting ULMCA revascularization methods, and propose treatment recommendations. We review the contemporary literature regarding revascularization strategies and argue for PCI as an important alternative to surgical revascularization in the appropriate patient population.

nature of those with ULMCA disease [3]. The initial group included 6,666 patients who had ST-segment elevation myocardial infarction (STEMI) and were treated with PCI. This group was then divided into three subsets, depending on type of lesion: ULMCA alone (n ¼ 208), ULMCA plus another vessel (n ¼ 140), or non-ULMCA lesions (n ¼ 6,318). Compared to those with non-ULMCA disease, those with ULMCA culprit lesions had significantly higher rates of mortality, major adverse cardiac events (MACE), and initial presentation of and subsequent development of cardiogenic shock.

Division of Cardiology, UCLA Medical Center, Los Angeles, California Conflict of interest: Nothing to report. *Correspondence to: Michael S. Lee, MD, 100 Medical Plaza Suite 630, Los Angeles, CA 90095. E-mail: [email protected]

IMPACT OF CLINICAL PRESENTATION IN PATIENTS WITH ULMCA CULPRIT LESIONS

Received 14 July 2014; Revision accepted 10 October 2014

The AMIS Plus registry, which included 76 hospitals in Switzerland, highlights the acuity and critically ill

DOI: 10.1002/ccd.25704 Published online 16 October 2014 in Wiley Online Library (wileyonlinelibrary.com)

C 2014 Wiley Periodicals, Inc. V

PCI as a Viable Treatment Modality for AMI Due To ULMCA

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TABLE I. Recent Studies of of PCI for AMI Due To ULMCA Culprit Lesions Study

Year

Total patients (STEMI/NSTEMI)

% In cardiogenic shock

Short-term mortality

Follow-up mortality

Stent choicea,d

% Cases using IABP or Impella

PCI cases Pappalardo et al. [4]

2011

48 (45%/55%)

45%

In-hospital: 21%

1 year: 29%

54%

Parma et al. [5]

2012

58 (100%/0%)

51.7%

1 month: 39.6%

15.8 months: 44%

Gagnor et al. [6]

2011

200 (22%/12.5%)

16%

In-hospital:11%

2 years: 5%

Izumikawa et al. [7]

2012

72 (NA)

46%

In-hospital: 44%

1.8 years: 25%b

39% BMS 61% DES 26.6% BMS 74.4% DES 14% BMS 86% DES 69% BMS 15% DES

PCI and CABG cases Caggegi et al. [8]

2011

PCI: 222 (8.6%/91.4%c) CABG: 361 (0.8%/99.2%) PCI: 200 (NA)

NA

NA

1 year: PCI: 6.3%

Sim et al. [9]

2013

Grundeken et al. [10]

2013

CABG: 19 (NA) PCI: 55 (78%/7.5%)e CABG: 29 (58%/8.3%)e

51.7% 75.5% 89%

PCI: 100% DESc

NA

PCI: 94.5% DES

23%

PCI: 98% BMS

PCI: 67%

CABG: 3.6% 14.1%

PCI: 69% CABG: 28%

In-hospital PCI: 16% CABG: NA At 1 month PCI: 64% CABG: 24%

1 year: PCI: 18% CABG: NA At 1 year PCI: 69% CABG: 24%

CABG: 59%

a

AMI ¼ acute myocardial infarction; BMS ¼ bare metal stent; DES ¼ drug-eluting stent. Of those who survived beyond in-hospital stay. c Includes unstable angina. d % of those receiving stents. e % of patients with baseline ECG available. b

ADVANTAGES OF ULMCA PCI

Percutaneous revascularization of an occluded ULMCA can be performed much more expeditiously and less invasively compared with CABG. The 2011 American College of Cardiology (ACC)/American Heart Association (AHA) focused guidelines for PCI proposed that stenting of the ULMCA in AMI can be considered in appropriate patient groups, namely those with favorable anatomy, low procedural risk, and comorbid conditions that would prohibit safe surgical revascularization (class IIa) [1] Patients who present with AMI due to ULMCA occlusion are often in extremis and may have high surgical mortality, rendering them poor surgical candidates.

FAVORABLE OUTCOMES OF PCI IN TREATMENT OF ULMCA CULPRIT LESIONS

Recent data support the use of PCI for STEMI and nonSTEMI (NSTEMI) due to ULMCA lesions (Table I). A retrospective study included 48 patients with both STEMI (n ¼ 22, 45%) and NSTEMI (n ¼ 26, 55%) from two centers who were treated with emergent PCI of ULMCA culprit lesions due to lack of surgical backup teams or prohibitive pre-operative risk [4]. Coronary stents were used in 92% of cases, and of these, 61% were drug-eluting

stents (DES). Cardiogenic shock was present in 45%, intra-aortic balloon pump (IABP) was used in 54% of cases, and the majority had multivessel coronary artery disease. The in-hospital mortality rate was 21%, and one year mortality rate was 29%. Univariate regression analyses did not find any variables that were associated with in-hospital mortality; however, presentation with STEMI and intraprocedural IABP use were both associated with one-year mortality. Multivariate analyses did not show any variables to be independent predictors of in-hospital or one-year mortality. In a systematic meta-analysis of PCI for STEMI/ NSTEMI due to ULMCA disease, mortality rates appeared more modest when presented as aggregate data, but were largely influenced by clinical presentation [11]. In a composite group of 977 patients, 26% of patients were in cardiogenic shock. The 30-day mortality rate was 57% of those in cardiogenic shock and 11% for those not in shock (risk ratio 3.15, 95% confidence interval 1.90–5.23). When data were divided into subgroups based on stenting method, there was consistently increased mortality seen in those presenting with cardiogenic shock regardless of stent type. In a retrospective study of 58 patients who underwent primary PCI for STEMI due to ULMCA disease with a mean follow-up of 15.8 months, TIMI 3 flow was achieved in 93.1% [5]. The 30-day mortality was

Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).

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Lee and Dahodwala

39.6%. Logistic EuroScore was found to be a univariate, but not independent, predictor of 30-day mortality. Outcome analyses were not performed with respect to stent type, coronary anatomy, and antiplatelet use. Multivariate analysis revealed cardiogenic shock at presentation, age >75 years, and post-procedure TIMI flow

Percutaneous coronary intervention for acute myocardial infarction due to unprotected left main coronary artery occlusion: status update 2014.

Acute myocardial infarction (AMI) due to unprotected left main coronary artery (ULMCA) occlusion is an uncommon clinical entity, but often leads to se...
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