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Primary angioplasty in total acute left main coronary occlusion

Session Poster Session 1

Speaker Alfredo Chauca Tapia

Event : Acute Cardiovascular Care 2019

  • Topic : coronary artery disease, acute coronary syndromes, acute cardiac care
  • Sub-topic : Acute Coronary Syndromes – Epidemiology, Prognosis, Outcome
  • Session type : Poster Session

Authors : A Chauca Tapia (Cadiz,ES), A Gutierrez Barrios (Cadiz,ES), I Noval Morillas (Cadiz,ES), S Camacho Freire (Huelva,ES), D Canadas Pruano (Jerez de la Frontera,ES), R Vazquez Garcia (Cadiz,ES)

Authors:
A Chauca Tapia1 , A Gutierrez Barrios1 , I Noval Morillas1 , S Camacho Freire2 , D Canadas Pruano3 , R Vazquez Garcia1 , 1University Hospital Puerta del Mar, Cardiology - Cadiz - Spain , 2Hospital Juan Ramon Jimenez, Cardiology - Huelva - Spain , 3Hospital General Jerez de la Frontera, Cardiology - Jerez de la Frontera - Spain ,

Citation:

Background:
This study aim to determine the incidence, clinical features, and outcome in totally occluded left main coronary artery (LMCA) patients referred to primary angioplasty.
Methods and results:
Since April 2003 to December 2017 emergent primary angioplasty was performed in 1701 patients at the 3 participating centers and 17 of those patients had an acute totally occlusion in the LMCA(0.01%) The mean age was 61.4±10, 76.5% were males, 29.5% had documented hyperlipidemia, 59% prior tobacco abuse and 12% diabetes. The predominant symptoms at presentation were dyspnea (65%), chest pain (17.5%) and cardiac arrest (17.5%). Twelve patients(70.5%) presented in cardiogenic shock, 3 patients(17.5 %) had a Killip score 3, and 2 patients(12%) a Killip score 2. Six patients(35%) required orotracheal intubation, intra-aortic balloon pump was deployed in 5 patients(29.5%) and ECMO in one patient. 8 patients(47%) developed malignant ventricular tachyarrhythmias and required cardioversion/defibrillation. 12 patients(70.5%) suffered a cardiac arrest and required cardiopulmonary resuscitation. GP IIb/IIIa inhibitors were used in 70.5%(12/17) and intravenous vasoactive drugs in 88% of procedures(15/17). Cardiac catheterization was performed by femoral approach in 76.5%(13/17). Collateral circulation (CC) by right coronary artery was not angiographically assessed before LMCA PCI or the information was lost in 65%(11/17), 23.5%(4/17) had a RENTROP score of 0, and 2  patient, with a Killip score of two, had a RENTROP 3. A stent was deployed in 59%(10/17) of procedures, the mean stent diameter was 3.6±0.2 mm. In 70% of cases (7/10) a drug eluting stents was deployed, a bare metal stents in 2 cases(20%) and in one patient (10%) a bioabsorbible stent was implanted. LMCA angioplasty success rate was 70.5%(12/17) and a final TIMI flow of 3 was achieved in 47% of procedures(8/17). Mean contrast volume was 251±223 ml. An intracoronary technique was performed in 3 cases(17.5%). Mean peak creatine kinase value was 11379±1242. Five patients(29.5%) died in the catheterization laboratory during the procedure and 2(12%) died in the following 24 hours due to pump failure. Two patients died in the hospital on the ninth and sixteenth days due to cardiogenic shock and nosocomial sepsis. Total in hospital mortality rate was 53%. 7 patients (41%) survived at 30 days follow-up. The well-collateralized patients (RENTROP 3) were asymptomatic and free of event at 38 month follow up. 
Conclusion: 
Clinical presentation of LMCA occlusion patients referred to primary angioplasty is catastrophic, most of them presented in cardiogenic shock and required CPR maneuvers.  Although early developed CC was confirmed just in two patients, clinical presentation and follow-up compare to the rest of patients, suggests that CC may play an important role. Despite the high in-hospital mortality we found that primary LMCA occlusion angioplasty is feasible and it may save lives in this clinical setting.

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