Acute Left Main Coronary Artery Research Articles

Iatrogenic coronary artery dissection that occurred during postpartum coronary angiography

Dissection of the left main coronary artery (LMCA) during diagnostic coronary angiography is a rare but catastrophic event with a poor prognosis. Immediate reperfusion with hemodynamic support should be the primary goal in patients who develop impaired blood flow distal to the acute LMCA and the first option is coronary artery by-pass grafting. We present a 37-year-old female patient in the postpartum period who was admitted to the emergency department because of chest pain and was urgently admitted to our catheterization laboratory with the diagnosis of NONSTMI. During coronary angiography, the patient developed a dissection that started with the left main coronary artery and progressed to the circumflex and left descending artery. The patient was successfully treated with emergency percutaneous intervention.

Scary Acute Left Main Coronary Artery Thrombus as an Initial Presentation of a Hereditary Thrombophilia: When to Go Out of Routine?

Patients with either hereditary or acquired thrombophilia can present with arterial and venous thrombotic complications. However, it is unclear to whom the thrombophilia panel should be assessed, particularly in patients presenting with a common cardiovascular risk factor and acute coronary thrombus. Herein, we presented the management of an active smoker female patient who presented to our emergency room with inferior acute ST-segment elevation myocardial infarction, and hereditary thrombophilia has been diagnosed due to the presence of substantial left main coronary artery thrombus.

Cardiac arrest in patients with acute left main coronary artery occlusion: a real-world multicenter registry

Abstract Funding Acknowledgements Type of funding sources: None. Introduction and objective Acute coronary syndrome (ACS) patients with unprotected left main coronary artery (LMCA) occlusion are at increased risk of mortality. Most studies have shown an association between LMCA occlusion and cardiac arrest. We aimed to evaluate the clinical characteristics and the prognosis of patients with ACS due to LMCA occlusion with cardiac arrest at presentation. Methods We performed a retrospective multicenter study of 128 consecutive patients with ACS due to LMCA occlusion admitted in three Portuguese tertiary hospitals between 2008 and 2020. Patients were divided according to the presentation with cardiac arrest. Results Among this cohort, 26% patients presented with cardiac arrest. Regarding baseline characteristics, they were younger (58 vs 65 years; p=0.001) but no other significant differences were found. Cardiac arrest was associated to shorter symptoms-to-balloon time (150 vs 195 minutes; p=0.042) and higher recourse to fibrinolysis (12.1% vs 0%, p=0.004). They also had higher prevalence of cardiogenic shock (88% vs 51%; p<0.001) and need for aminergic support (91% vs 64%; p=0.004). Furthermore, in-hospital (79% vs 45%; p=0.001) and 5-year (97% vs 73%; p=0.008) mortality were significantly higher, as predicted by Kaplan-Meier survival curves (p=0.002; log-rank test). Finally, in multivariable analysis, younger age [odds ratio (OR),1.12;95% CI,1.04-1.20] and lower median symptoms-to-balloon time (OR, 1.35;95% CI,1.02-1.82) were independently associated to cardiac arrest at presentation. Conclusion In our real-world cohort, more than one quarter of patients with ACS due to LMCA occlusion presented with cardiac arrest, which correlates to a higher incidence of cardiogenic shock, as well as higher short- and long-term mortality. Only younger age and lower symptoms-to-balloon time were independently associated to cardiac arrest. Despite cardiac care improvements, technological evolution, and better patient/system-delay times, this is still a subpopulation with poor prognosis. Further studies are needed to find innovative strategies that can make a difference in this subgroup of patients.

Transesophageal echocardiography: a tool for intraoperative assessment of coronary blood flow

Transesophageal echocardiography (TEE) has become an indispensable part of cardiac surgery, but its potential for assessing coronary anatomy and blood flow remains underutilised. This case report presents a case of acute iatrogenic left main coronary artery obstruction following re-operative aortic valve replacement that was promptly diagnosed by intraoperative TEE and managed successfully by Bentall operation. We also emphasise the technique of TEE for coronary evaluation, its caveats and its clinical application during cardiac surgery.

Clinical and electrocardiographic features in acute total left main coronary artery occlusion without collateral circulation

BackgroundsStudy concerning the clinical features, electrocardiogram (ECG) findings and outcomes in patients presenting with acute total occlusion of left main coronary artery (LM) without collateral circulation is limited. Methods25 patients with acute total LM occlusion without collateral circulation by emergency coronary angiography, from muti-center registry, were retrospectively studied. The clinical and angiographic characteristics, ECG and in-hospital mortality were reviewed. ResultsNineteen patients (76%) presented with cardiogenic shock. Twelve (60%, 12/20) patients had coronary slow flow or no reflow phenomenon after primary percutaneous coronary intervention (PCI). The in-hospital mortality rate was 88% (n = 22). All the patients presented with ST-segment elevation myocardial ischemia (STEMI) pattern, mostly involving leads I, aVL, V2, V3, V4, V5 and ST-segment depression in leads II, III and aVF. ConclusionsAcute total LM occlusion without collateral circulation portends high in-hospital mortality. Anterior ST elevation in the precordial leads from V2 to V4 through V6, and ST elevation in leads I and aVL, accompanying with ST depression in the inferior leads is associated with acute total LM occlusion without collateral circulation.

Combining electrocardiographic criteria for predicting acute total left main coronary artery occlusion.

BackgroundPrediction of left main artery (LM) occlusion may contribute to the administration of early reperfusion. We sought to identify electrocardiographic (ECG) features associated with acute total LM occlusion and explore the relationship between ECG features and collateral circulation.MethodsWe retrospectively studied ECGs in 84 consecutive patients with LM occlusion between January 2001 and April 2022. The ECG findings in these patients were compared with those in 468 consecutive patients with LM subtotal occlusion and non-LM occlusion.ResultsThree main ECG patterns were described according to the characteristics of ST elevation (STE) in LM occlusion: ST-segment elevation myocardial infarction (STEMI), STE in aVR with diffuse ST depression, and STE in both aVR and aVL. These ECG patterns were associated with different collateral filling territories. One-third STEMI in LM occlusion showed STE in the precordial leads including V1, while 2/3 STEMI showed STE in the precordial leads from V2 to V5 without STE in V1. The following ECG characteristics predicted LM occlusion: STE in both aVR and aVL; STE in I, aVL, and V2–V5 without V1; left anterior fascicular block (LAFB); right bundle branch block (RBBB) + LAFB; and prolongation of the QRS interval. The incidences of STE in aVR and STE in aVR and V1 were higher in LM subtotal occlusion than in LM occlusion. The combination of two different STE criteria (STE in aVR and aVL and STE in I, aVL, V2-V5 without V1) predicted LM occlusion with 62% sensitivity and 95% specificity. The combination of the STE criteria and fascicular block criteria (LAFB and LAFB + RBBB) further improved the specificity to 99% but reduced the sensitivity to 39%.ConclusionThe combination of STE criteria predicted LM occlusion with high specificity and moderate sensitivity, and the addition of fascicular block criteria further improved the specificity with some loss of sensitivity.

Abstract 12972: Acute Left Main Coronary Artery Thrombosis During Exercise Testing

Background: Exercise stress testing (EST) is safe and effective in evaluating suspected coronary artery disease (CAD). Serious complications are rare. We present a unique case of acute left main coronary artery (LMCA) thrombosis during EST. Case presentation: A 58-year old man with hypertension and hyperlipidemia presented with two episodes of substernal chest pressure within 2 weeks. He had no known CAD, led an active lifestyle and did not smoke, drink, or use drugs. Initial vital signs, routine labs, troponin, ECG, and echocardiogram (TTE) were normal. EST (Bruce Protocol) was terminated at 3’ 54” due to chest pain, hypotension and down-sloping ST segment depressions in inferolateral leads followed by ST segment elevation in leads V1, V2, aVL and aVR. TTE showed severe hypokinesis of apex and anterior, anteroseptal, and anterolateral walls. Emergent coronary angiography (Figure) revealed complete thrombotic occlusion of LMCA. LMCA was wired and ballooned restoring antegrade flow and resolving ST segment elevation. Minutes later, recurrent ST elevations were noted due to LMCA reocclusion. Flow was restored and patient underwent emergent coronary artery bypass surgery. TTE two days later showed preserved LV systolic function with mild hypokinesis of the LV apex and apical septal wall. Conclusions: Pathophysiology of AMI triggered by exercise is only partially understood. Vigorous exercise is shown to increase relative risk of AMI particularly within first hour following exertion. In such a scenario, exercise likely acts as a trigger for plaque rupture in presence of an underlying vulnerable atherosclerotic lesion. Compared to other forms of AMI, those triggered by exercise occur more commonly in men and are more often characterized by total thrombotic occlusion of culprit coronary artery. To our knowledge, acute thrombosis of LMCA has not previously been reported as a complication of EST.

The role of coronary collateral circulation in patients presenting with acute left main coronary artery occlusion

Abstract Introduction Acute occlusion of the unprotected left main coronary artery (LMCA) is an uncommon occurrence associated with a dismal prognosis. Whereas the role of early recruited coronary collateral circulation (CC) in prognosis of ST-segment elevation acute myocardial infarction (STEMI) patients is still controversial, it seems to be important in patients with acute LMCA occlusion. This study aimed to evaluate the coronary CC in patients with acute LMCA occlusion and its impact in short and long-term outcomes. Methods In a retrospective two-center study, we identified 7630 patients with STEMI or high-risk non-ST segment elevation myocardial infarction who underwent emergent coronary angiography between January 2008 and December 2020. Among this cohort, we analyzed 83 patients who presented with unprotected LMCA acute occlusion (Thrombolysis In Myocardial Infarction – TIMI ≤2) and classified them in 2 groups based on the degree of CC through the right coronary artery as seen in the emergent angiography: patients with no filling of collateral vessels or filling of collateral vessels without any epicardial filling of the occluded vessel [Rentrop class 0–1 (71 patients)]; and patients with partial or complete epicardial filling by collateral vessels [CC Rentrop class 2–3 (12 patients)]. Results Compared to patients with CC Rentrop 0–1, patients with CC Rentrop 2–3 presented significantly later to medical attention (symptom to coronary angiography time 8.7 vs 4.3 hours, p=0.02). Despite that, patients with CC Rentrop 2–3 had a significantly lower prevalence of cardiogenic shock at admission (16.7 vs 57.7%, p=0.01). During hospitalization, Killip class III-IV presentation (33.3 vs 88.7%, p<0.001) and inotropic/vasopressor therapy use (25.0 vs 69.0%, p=0.01) were less frequent in CC Rentrop 2–3 patients. The CC Rentrop 2–3 group had a significantly lower in-hospital (16.7 vs 53.5%, p=0.02) and 30-day mortality (9.1 vs 52.2%, p=0.01). In patients surviving hospitalization there was no significant difference in 1-year (30.0 vs 19.4%, p=0.48) and 5-year mortality (70.0 vs 77.4%, p=0.68). Conclusion A well-developed coronary CC was associated to lower short-term mortality in patients presenting with acute occlusion of the unprotected LMCA. Nevertheless, in patients surviving index-event, there was no difference in the long-term outcomes. Further studies are needed to clarify if clinical approach (eg. early short-term mechanical circulatory support) of patients with CC Rentrop 0–1 should be different from those with CC Rentrop 2–3 in order to improve the outcomes of the former patients. Funding Acknowledgement Type of funding sources: None.

Cardiogenic shock in patients presenting with acute left main coronary artery occlusion

Abstract Background and purpose Acute myocardial infarction (AMI) due to left main coronary artery (LMCA) occlusion is a rare event, often catastrophic. Limited data are available about management and outcomes of patients with acute LMCA occlusion, including those presenting with cardiogenic shock (CS) at hospital admission. This study sought to describe patients with AMI due unprotected LMCA occlusion presenting with CS and to evaluate their in-hospital outcomes and 1-year mortality. Methods In this retrospective 2-center study, we identified 7630 patients with ST-segment elevation myocardial infarction (STEMI) or hight risk non-ST segment elevation myocardial infarction who underwent to emergent coronary angiography between January 2008 and December 2020. Among this cohort, we analysed 94 patients who presented with unprotected LMCA occlusion (Thrombolysis In Myocardial Infarction – TIMI ≤2) and divided them in 2 groups according to presence of signs of cardiogenic shock at admission: CS and no-CS. Results Of 94 patients with AMI due LMCA occlusion, 52 patients presented with CS (53.3%). Mean age was 62.8±11.5 years in CS and 62.0±15.9 years in no-CS patients, p=0.766. In both groups, most patients were male. STEMI presentation was more frequent in CS group (80.4% vs. 52.4%, p=0.004). Severe systolic dysfunction of left ventricle was more frequent in CS patients (81.1% vs. 33.3%, p<0.001). Compared to no-CS patients, CS group shown more often TIMI=0 (67.3% vs. 26.2%, p<0.001), collateral coronary circulation Rentrop 0–1 (95.3% vs. 75.0%, p=0.008), and slow-reflow/no-reflow phenomena (30.6% vs 3.8%, p=0.019) in emergent coronary angiography. The need of invasive mechanical ventilation (68.9% vs. 21.4%, p<0.001), and haemodialysis (20.5% vs. 2.4%, p=0.010) were more prevalent in CS patients. Likewise, mechanical circulatory support (MCS) was more frequently used in patients presented with CS (52.9% vs. 26.2%, p=0.009). In subgroup analysis, MCS implantation was not a survival predictor in CS patients (Odds ratio: 3.9 [95% confidence interval: 0.4 to 36.3], p=0.229). Ultimately, in-hospital mortality (78.8% vs. 16.7%, p<0.001) was higher in CS patients. On the other hand, in hospital survivors, there was no significant differences in 1-year mortality (11.1% vs. 23.5%, p=0.42) between both groups. Conclusions Nearly half of patients with AMI due LMCA occlusion presented with CS signs at first medical evaluation. This subgroup of patients had higher in-hospital mortality compared to those without CS, despite MCS implantation. Whether the use of a specific MCS device or whether early use of MCS can change the outcome remains to be elucidated. CS patients who survive to index-hospitalization, had similar long-term outcomes compared to no-CS patients. Further studies are imperative in this population to refine initial medical treatment in order to improve their prognosis. Funding Acknowledgement Type of funding sources: None.

Electrocardiographic presentation of acute left main coronary artery occlusion misinterpreted as ventricular tachycardia

We present a case of acute left main coronary artery (LMCA) occlusion that manifested cardiogenic shock and an ST-segment elevation myocardial infarction (STEMI) electrocardiographic (ECG) pattern comprising “triangular” or “lambda-like” QRS-ST-T complexes. The presenting ECG pattern was misinterpreted as ventricular tachycardia (VT) with resultant delayed emergency percutaneous coronary intervention. The patient died of intractable cardiogenic shock. This case corroborates previous research findings associating the ECG pattern comprising “triangular” or “lambda-like” QRS-ST-T complexes observed in the clinical setting of acute myocardial ischemia with acute LMCA occlusion. Also, we demonstrate how this ECG pattern should be scrutinized for ST-segment elevation in order to avoid misdiagnosing a STEMI for VT.

Left Main Coronary Artery Spasm: Case Report

Abstract Vasospasm of coronary artery is a well-known cause for acute coronary syndrome (ACS) but left main coronary artery (LMCA) spasm is very rare. It may be iatrogenic or spontaneous. Here we report a case of a 44-year-old female who presented with chronic stable angina and experienced LMCA vasospasm while undergoing coronary angiography.

Percutaneous coronary intervention in acute unprotected left main coronary artery disease: Provisional strategy or two-stent technique?

Background: Primary percutaneous coronary intervention in acute unprotected left main coronary artery disease, however, tends to be a complex procedure as it lasts longer, requires more expertise, and frequently involves critical bifurcation and often results in more than one stent. Here we present a retrospective analysis of a specific group of patients treated with percutaneous coronary intervention in our center. Methods: Retrospectively 55 patients with unprotected left main coronary artery lesions and acute coronary syndrome diagnosis treated with per cutaneous coronary intervention were identified: The two-stent technique was applied in 28 cases, and provisional stenting (PS) was applied in 27 cases. Results: Current smoking (82.1% vs. 48.1%, p=0.007), prior myocardial infarction (35.7% vs. 7.4%, p=0.010) and prior coronary stent implantation history (28.6% vs. 3.7%, p=0.012) were more common in the two-stent technique group. While procedure duration was higher in the two-stent technique group compared to PS (58.21 vs. 33.15, p<0.001), door-balloon time was lower (29.7 vs. 42.1, p=0.006). However, creatinine levels 48-72 hours post-procedure (1.08 vs. 1.33, p=0.422) and in-hospital mortality rates were similar between the two groups (28.6% vs. 14.8%, p=0.229). Conclusion: In the treatment of acute unprotected left main coronary artery with percutaneous coronary intervention, two-stent technique is a viable, effective and safe strategy as it has similar contrast-induced nephropathy and mortality rates compared to provisional strategy.

A rare case of concomitant acute occlusion of left main coronary artery and right coronary artery with characteristic electrocardiographic pattern

Acute Left Main Coronary Artery (LMCA) occlusion is a rare clinical presentation which often manifests as a cardiogenic shock with worse prognosis. However the clinical outcome depends on the age of the patient, co-morbidities and the patency and dominancy of Right coronary artery.

Massive Myocardial Infarction Due to Acute Left Main Coronary Artery Occlusion in a Young Organophosphorus Poisoning: Case Report

Massive Myocardial Infarction Due to Acute Left Main Coronary Artery Occlusion in a Young Organophosphorus Poisoning: Case Report

Different ECG patterns of left main coronary artery occlusion signifying varying degrees of ischemic severity

Many ischemic ECG patterns are found in patients with acute left main coronary artery occlusion. We present a patient with dynamic ECG changes that corresponded to changes in his clinical symptoms and hemodynamic status. These changes signify different severity of myocardial ischemia caused by left main coronary artery disease. Take-home Message: Our case with left main coronary artery disease illustrated three distinct ECG patterns with different severity of clinical symptoms signifying varying severity of ischemia. In left main coronary artery disease, the ST deviations in the precordial leads can be relatively minor. Left axis deviation or left anterior fascicular block with broad QRS possibly reflects left ventricular depolarization delay secondary to extensive ischemia.

Atypical 'de Winter pattern' mimicking acute left main coronary artery lesion.

Atypical 'de Winter pattern' mimicking acute left main coronary artery lesion.

Akut Total LMCA Tıkanıklığı ve Başarılı TAP Stentleme: STEMI'da Hangi Stratejiyi İzlemeliyiz?

The incidence of acute total left main coronary artery (LMCA) occlusion cannot be fully determined precisely, given that most of patients die unfortunately before hospital arrival. This patient group is rarely encountered but mortality is very high due to endangered a large area of myocardium and increases the risk of cardiogenic shock and lethal arrhythmia quickly. We report a case of a 40-year-old woman presented with acute anterolateral myocardial infarction and was managed successful with percutaneous intervention with TAP (T-stenting And small Protrusion) technique stenting. According to current guidelines in LMCA disease, coronary artery bypass graft (CABG) is preferred, but percutaneous coronary intervention (PCI) is life-saving treatment strategy in emergencies for hemodynamic instability patient. On the other hand, there is no specific recommendations given concerning treatment for STEMI due to LMCA and optimal revascularitazion strategy is still uncertain because of absence of a randomized trial. Alternative treatments are; primary angioplasty-stenting, emergency CABG, primary angioplasty followed by emergency CABG.

A Rare Complication after TAVI: Acute Left Main Coronary Artery Occlusion and Successful Percutaneous Treatment

Aortic valve stenosis (AS) is common in the elderly. Nowadays surgical aortic valve replacement still has been the gold standard of management, but many patients have been excluded from surgery given that they were very old, frail, or had co-morbidities that increased operative risks. In the last decade, transcatheter aortic valve implantation (TAVI) has emerged as a new treatment option for these patients. Despite being less invasive than surgery, TAVI has rare but fatal complications like vascular injuries. Vascular injuries are the most common complications after TAVI, and range from dissection, to perforation, to acute thrombotic occlusion. We report a case of left main coronary artery (LMCA) occlusion following TAVI that caused cardiac arrest and was managed successfully with emergency percutaneous coronary intervention (PCI).

SYNTAX score and coronary artery bypass graft surgery in Bangladesh.

Background The SYNTAX score is a helpful tool for determining the optimal myocardial revascularization strategy in complex coronary artery disease. The aim of this study was to assess whether the SYNTAX score predicts postoperative mortality in patients undergoing coronary artery bypass grafting. Methods The study included 1100 consecutive patients referred for coronary artery bypass graft surgery over a 4-year period. Angiographic data were interpreted by both experienced intervention cardiologists and cardiac surgeons. The patients were divided into three groups based on SYNTAX score tertiles: low ≤22 ( n = 560), intermediate 23–32 ( n = 360), and high ≥33 ( n = 180). Results Compared to patients with a low SYNTAX score, those with intermediate and high scores were significantly older ( p &lt; 0.001), had a lower left ventricular ejection fraction ( p &lt; 0.001), higher pulmonary artery pressure ( p &lt; 0.001), and higher incidences of acute coronary syndrome and left main coronary artery disease. A significantly higher EuroSCORE ( p = 0.003) was also observed in patients with a higher SYNTAX score. Patients with intermediate and high SYNTAX scores had higher 5-year mortality rates (18.6% and 19.5%, respectively) than patients with low SYNTAX scores (9.5%, p &lt; 0.05). In multivariate analysis, SYNTAX score was not an independent predictor of late mortality. Conclusion Although SYNTAX score is not independently predictive of late mortality in patients with complex coronary artery disease undergoing myocardial revascularization surgery, patients with lower SYNTAX scores had a lower mortality rate after coronary artery bypass graft surgery.

ST-ELEVATED MYOCARDIAL INFARCTION IN A LEFT MAIN CORONARY ARTERY: A CLINICAL DILEMMA

Management of an acute left main coronary artery (LMCA) thrombus is challenging. A 39 year-old healthy Russian male presented with 24h of chest pain radiating down his left arm associated with dyspnea and diaphoresis. He was in mild distress. Electrocardiogram revealed an evolving anterolateral ST-