041 Percutaneous coronary intervention of unprotected left main coronary artery for cardiogenic shock

Abstract

Primary coronary angioplasty (PCA) of unprotected left main coronary artery (LM) in patients (pts) with cardiogenic shock (CS) is a high-risk procedure, carrying a high morbi-mortality. Accordingly we aimed to assess the prevalence, clinical presentation, therapeutic workout and in-hospital and long-term prognosis of pts presenting with CS due to TIMI flow 0-1 LM thrombosis. Over a 6-years period, and out of a prospective cath-lab database of 6062 files, 17 cases of CS secondary to LM thrombosis were identified and confirmed by reanalysis of angiograms. Therapeutic management and in-hospital outcome were obtained from medical files and prospective follow-up was obtained. The study population consisted in 13 men (76%) with a mean age of 64±16 years, corresponding to a prevalence of 0.28% of pts proposed for coronary procedure. Clinical presentation was an ACS with and without persistent ST-elevation in 11 (65%) and 6 cases (35%) respectively. Five patients (29%) received pre-hospital thromboysis, which failed to achieved reperfusion in all cases. Twelve patients (71%) undergone mechanical support (intra-aortic balloon pumping alone in 55%, extracorporeal life support alone in 5%, and both in 45%). The majority of PCA were performed with bare metal stent (n=14, 82%), under GPIIbIIIa antagonists in 8 cases, and instrumental thrombectomy in 3 cases. In-hospital death occurred in 5 pts (29%). At mean follow-up of 23 months (100% completed) survival rate was 53% for entire cohort and 75% among discharged pts. Most patients were in NYHA class I (7/9), with averaged left ventricular ejection fraction of 50+17%. One pts was implanted with a Thoratec device and is awaiting heart transplantation, and one is in terminal heart failure. LM occlusion with CS has a very high mortality rate. However, PCA in such setting with use of aggressive mechanical life support carries an acceptable level of major adverse coronary event at medium and long-term prognosis.