A Chicken in Every Pot and a Drug-Eluting Stent in Every Lesion

Abstract

A 78-year-old man is admitted with episodes of severe angina associated with hypotension. Urgent angiography finds critical left main stenosis with well-preserved left ventricular function (Figure 1). While discussing the treatment plan with the physician, the patient suddenly manifests sustained ventricular fibrillation. Prompt electrocardioversion restores sinus rhythm, but there is electromechanical dissociation and no blood pressure. Chest compressions are initiated. A guiding catheter quickly inserted into the left coronary finds total occlusion of the left main (Figure 2). Between chest compressions, the left main is opened with balloon angioplasty (Figure 3), and a stent is implanted, restoring flow, contractility, and blood pressure. The patient is discharged 3 days later, sustaining only a small rise in cardiac enzymes. Figure 1. Urgent coronary angiography in a 78-year-old man with unstable angina finds critical left main stenosis (A). Figure 2. The left main occludes soon after the diagnostic angiogram, resulting in absent ventricular contraction. Figure 3. Emergency balloon angioplasty during cardiopulmonary resuscitation improves left main flow (note wrist watch on individual performing cardiopulmonary resuscitation at right upper corner of image). A DES is then implanted. See p 1942 and p 1948 Is this case unusual? Some might argue “no.” Stents and balloon angioplasty have been used for decades to rescue patients from disaster. However, in one way, this 78-year-old man underwent a revolutionary procedure. This patient’s left main coronary artery was treated with a drug-eluting stent (DES). Three months later, a follow-up angiogram found no evidence of restenosis (Figure 4). If further follow-up of this and other patients enrolled in left main DES trials prove favorable, the paradigm could shift, making DES the treatment of choice for obstructive left main coronary disease. Figure 4. Surveillance angiogram at 3 months documents excellent patency of the DES within the left main coronary artery. In the …