Original article
Outcomes following primary percutaneous coronary intervention for unprotected left main-related ST-segment elevation myocardial infarction Alfonso Ielasi, Antonio Silvestro, Davide Personeni, Antonio Saino, Chiara Angeletti, Alessandra Costalunga and Maurizio Tespili Introduction Unprotected left main (ULM) related ST-segment elevation myocardial infarction (STEMI) is a severe event, often leading to circulatory failure and/or sudden cardiac death. Although high-risk ULM thrombosis populations treated by primary percutaneous coronary intervention (PPCI) have been previously described, very little is known regarding the outcomes following PPCI for ULM-related STEMI in a hospital without on-site surgical back-up.
with non-cardiogenic shock group. Procedural success rate was lower in the cardiogenic shock compared with noncardiogenic shock group (77.3 vs. 100%, P U 0.09), whereas in-hospital mortality rate was significantly higher in the cardiogenic shock compared with non-cardiogenic shock group (36.4 vs. 0%, P U 0.02). No deaths were reported among survivors of the acute phase at mid-term follow-up, whereas target lesion revascularization rate was 7.6%.
Methods A retrospective cohort analysis was performed on all consecutive patients who underwent PPCI for ULMrelated STEMI in a single center. The primary end-point was to assess in-hospital mortality in the overall population and according to the presence/absence of cardiogenic shock at admission.
Conclusions PPCI for ULM-related STEMI in a hospital without on-site surgical back-up was technically feasible in most of the cases. Although the procedural success and in-hospital mortality rates were influenced by cardiogenic shock at admission, an excellent mid-term outcome among patients who survived the hospitalization was reported independently by the severity of clinical presentation.
Results Between October 2006 and December 2012, 1094 patients underwent PPCI for STEMI. PPCI for ULM-related STEMI was performed in 34 (3.1%) patients. Among these, 22 (64.7%) were in cardiogenic shock at admission. Baseline mean ejection fraction was lower (P U 0.008), whereas the prevalence of patients with pre-procedural cardiac arrest and Killip Class III–IV was significantly higher in the cardiogenic shock (P U 0.05 and P < 0.001, respectively) compared with non-cardiogenic shock group. Furthermore, patients with cardiogenic shock had a higher prevalence of pre-procedural thrombolysis in myocardial infarction flow 0–1 (P U 0.05) and associated other vessel chronic total occlusion (P U 0.05) compared
Introduction Acute ST-segment elevation myocardial infarction (STEMI) related to an unprotected left main coronary artery (ULM) ‘culprit lesion’ often leads to acute left ventricular failure, refractory arrhythmia, and sudden cardiac death. Presumably, a substantial number of patients die before being able to contact emergency medical care, and probably only a small number of them reaches the hospital. STEMI resulting from an ULM thrombosis accounts for 0.8–4% of all primary percutaneous coronary interventions (PPCIs).1 – 3 Current European and American guidelines recommend coronary
Drs Ielasi and Silvestro contributed equally to the manuscript and are joint first authors. 1558-2027 Copyright ß 2015 Wolters Kluwer Health, Inc. All rights reserved.
J Cardiovasc Med 2015, 16:163–169 Keywords: left main, primary percutaneous coronary intervention, STEMI Department of Cardiology, Azienda Ospedaliera ‘Bolognini’, Seriate (BG), Italy Correspondence to Maurizio Tespili, MD, Department of Cardiology, Azienda Ospedaliera ‘Bolognini’, Via Paderno 21, 24068 Seriate (BG), Italy Tel: +39 035 3063315; e-mail: [email protected] Received 29 October 2013 Revised 21 February 2014 Accepted 21 February 2014
artery bypass grafting to treat an ULM stenosis particularly in the case of stable patients.4 – 6 However, these guidelines do not assist with the treatment of patients with ULM-related STEMI, which is frequently associated with hemodynamic instability requiring prompt restoration of the blood flow to the myocardium. Particularly for these patients, emergency percutaneous coronary intervention (PCI) is often the only possible therapeutic option mainly in hospital without on-site cardiac surgical back-up. As data are limited, reporting clinical outcomes for this specific patient subgroup remains important. The aim of this study was to evaluate the clinical outcomes following PPCI for ULM-related STEMI in a high-volume center without on-site surgical back-up. DOI:10.2459/JCM.0000000000000075
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
164 Journal of Cardiovascular Medicine 2015, Vol 16 No 3
Methods A retrospective cohort analysis was performed on all consecutive patients undergoing PPCI for ULM-related STEMI at ‘Bolognini’ Hospital, Seriate (BG), Italy. Our center is a community hospital without on-site cardiac surgery, but with a high-volume catheterization laboratory (PCI volume >1000/year including 175/200 PPCI/year), which provides a 24-h PPCI service to a population of 300 000 inhabitants and is only 3.2 km from the nearest cardiac surgery unit. STEMI was defined as 1 mm ST-segment elevation in two or more contiguous leads; left main STEMI-equivalent, defined as 1 mm ST-segment elevation in lead aVR with ST-segment elevation in aVR>V1 and ST-segment depressions larger than 0.5 mm in more than six leads, as previously described,7 without 1 mm ST-segment elevation in two or more contiguous leads. ULM-related STEMI was defined as the evidence of a thrombotic lesion involving the mid-shaft and/or the distal ULM associated with ECGraphic modifications compatible with STEMI (see above). Patients with ULM-related STEMI were divided in two groups according to the absence or presence of cardiogenic shock at initial presentation. The decision to proceed to emergency cardiac catheterization was based on the presence of prolonged chest pain (>30 min) associated with ECGraphic signs of acute STEMI or new left bundle branch block with or without cardiogenic shock. PPCI was performed using standard techniques. Adjunctive pharmacological treatment was administered according to STEMI guidelines, as applicable at the moment of intervention.8,9 In general, patients received 500 mg of aspirin and 5000 IU of unfractionated heparin as intravenous bolus prior to emergency angiography during the entire study period. Before 2012, a loading dose of 300–600 mg of clopidogrel was administered before the procedure, whereas from January 2012 onwards, every patient (without contraindications) received a loading dose of 180 mg of ticagrelor. In our center, bare metal stenting (BMS) was considered the default strategy in PPCI up to December 2009. The use of glycoprotein IIb/IIIa inhibitor and/or antithrombotic medications (i.e., bivalirudin), pre/postdilatation, thrombectomy devices, and use of an intra-aortic balloon pump (IABP) was at the discretion of the operator. Significant lesions other than the ‘culprit’ ULM were treated in the same procedure if considered suitable for percutaneous intervention in case of cardiogenic shock while in a staged procedure (preferably within 2 months) in patients without cardiogenic shock (non-cardiogenic shock group). The anti-platelet regimens used after PPCI were low-dose aspirin (100 mg daily) recommended indefinitely, and a 75-mg dose of clopidogrel daily (90 mg of ticagrelor bid from January 2012) for 12 months (as secondary prevention after STEMI independently from BMS implantation). Procedural success was defined as angiographic success [final thrombolysis in myocardial infarction (TIMI) flow 3]
without in-hospital major adverse events (death, Q-wave myocardial infarction, acute stent thrombosis, or need for emergent revascularization) within 24 h from the end of the procedure. Clinical data were collected by hospital visit or telephone contact at 6-month intervals. Angiographic follow-up was scheduled for all the survivors at 6–9 months or earlier if non-invasive evaluation or clinical presentation suggested the presence of ischemia. Cardiogenic shock was defined as sustained (at least 30 min) hypotension with systolic blood pressure less than 90 mmHg or the need for supportive measures to maintain a systolic blood pressure more than 90 mmHg and endorgan hypoperfusion (cool extremities, an altered level of consciousness or a urine output 60 bpm), or patients presenting with cardiac arrest.10 Death was considered cardiac in origin unless obvious noncardiac causes could be identified. Clinical end-points (death, cardiac death, peri-procedural myocardial infarction, and stent thrombosis) were defined on the basis of the Academic Research Consortium (ARC) definitions.11 Target lesion revascularization (TLR) was defined as any revascularization performed to treat a stenosis inside the implanted stent or within the 5-mm segments adjacent to the stent including the ostium of left anterior descending artery (LAD) or left circumflex (LCx). Target vessel revascularization (TVR) was defined as any revascularization performed on the treated vessel considering also treatment of any segment in the LAD and LCx.12 Bleeding were defined according to the Bleeding ARC (B-ARC)13. The EuroScore was used to stratify the clinical risk of death at 30 days.14,15 The primary end-point of the study was to assess in-hospital mortality in the overall population and according to the presence/absence of cardiogenic shock at hospital arrival. Statistical analysis
Continuous variables are presented as mean (standard deviation) or median (interquartile range). Categorical variables are presented as raw numbers with percentages. The normality of the distribution of all the continuous variables was assessed by the Kolmogorov–Smirnov test. Continuous variables were compared by the independent sample t test or Mann–Whitney U test. Categorical variables were compared by the chi-square statistic or Fisher’s exact test. A P value less than 0.05 was considered to be statistically significant. All reported P values are two-sided. The statistical analysis was performed using SPSS (SPSS-PC, Inc, Chicago, Illinois, USA) software version 16.0.
Results Between October 2006 and December 2012, 1094 patients underwent PPCI for STEMI in our catheterization laboratory. Among these, 34 (3.1%) had an ULM ‘culprit lesion’. Baseline demographic and clinical
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Primary PCI for ULM-related STEMI Ielasi et al. 165
characteristics of patients undergoing PPCI for ULM thrombosis are shown in Table 1. The mean age of the overall cohort was 69.0 11.0 years. The risk profile of the overall population was relatively high as documented by a mean logistic Euroscore of 36.4 19.6. A total of 22 (64.7%) patients were in cardiogenic shock upon arrival in the catheterization laboratory. Baseline demographic and clinical characteristics between patients with cardiogenic shock vs. non-cardiogenic shock were found to be similar (Table 1). However, the mean ejection fraction at arrival was significantly lower in the cardiogenic shock group (25.7 14.0% vs. 39.1 8.6%, P ¼ 0.008), whereas the number of patients with pre-procedural cardiac arrest (40.9 vs. 4.3%, P ¼ 0.05), Killip Class III–IV (86.4 vs. 8.3%, P < 0.001), and the need for invasive ventilatory support (54.5 vs. 0%, P ¼ 0.001) was significantly higher in the cardiogenic shock group. Baseline angiographic and procedural characteristics are listed in Table 2. Distal ULM was involved as a ‘culprit’ site in 31 patients (91.2%) without difference between the groups (90.9 vs. 91.7%, P ¼ 0.7). Among the 31 distal ULM ‘culprit’ lesions, 18 (58.1%) were treated with ‘Provisional’ stenting (one stent from ULM toward LAD), five (16.1%) with a two-stent technique as intention to treat (four ‘T-stenting’ and one ‘V-stenting’), whereas the other eight (25.8%) were treated with a ‘bail-out’ two-stent strategy (‘T and minimal protrusion’) when the residual diameter stenosis was more than 70% after kissing inflation and/or in case of flow limiting dissection (TIMI flow
Outcomes following primary percutaneous coronary intervention for unprotected left main-related ST-segment elevation myocardial infarction Alfonso Ielasi, Antonio Silvestro, Davide Personeni, Antonio Saino, Chiara Angeletti, Alessandra Costalunga and Maurizio Tespili Introduction Unprotected left main (ULM) related ST-segment elevation myocardial infarction (STEMI) is a severe event, often leading to circulatory failure and/or sudden cardiac death. Although high-risk ULM thrombosis populations treated by primary percutaneous coronary intervention (PPCI) have been previously described, very little is known regarding the outcomes following PPCI for ULM-related STEMI in a hospital without on-site surgical back-up.
with non-cardiogenic shock group. Procedural success rate was lower in the cardiogenic shock compared with noncardiogenic shock group (77.3 vs. 100%, P U 0.09), whereas in-hospital mortality rate was significantly higher in the cardiogenic shock compared with non-cardiogenic shock group (36.4 vs. 0%, P U 0.02). No deaths were reported among survivors of the acute phase at mid-term follow-up, whereas target lesion revascularization rate was 7.6%.
Methods A retrospective cohort analysis was performed on all consecutive patients who underwent PPCI for ULMrelated STEMI in a single center. The primary end-point was to assess in-hospital mortality in the overall population and according to the presence/absence of cardiogenic shock at admission.
Conclusions PPCI for ULM-related STEMI in a hospital without on-site surgical back-up was technically feasible in most of the cases. Although the procedural success and in-hospital mortality rates were influenced by cardiogenic shock at admission, an excellent mid-term outcome among patients who survived the hospitalization was reported independently by the severity of clinical presentation.
Results Between October 2006 and December 2012, 1094 patients underwent PPCI for STEMI. PPCI for ULM-related STEMI was performed in 34 (3.1%) patients. Among these, 22 (64.7%) were in cardiogenic shock at admission. Baseline mean ejection fraction was lower (P U 0.008), whereas the prevalence of patients with pre-procedural cardiac arrest and Killip Class III–IV was significantly higher in the cardiogenic shock (P U 0.05 and P < 0.001, respectively) compared with non-cardiogenic shock group. Furthermore, patients with cardiogenic shock had a higher prevalence of pre-procedural thrombolysis in myocardial infarction flow 0–1 (P U 0.05) and associated other vessel chronic total occlusion (P U 0.05) compared
Introduction Acute ST-segment elevation myocardial infarction (STEMI) related to an unprotected left main coronary artery (ULM) ‘culprit lesion’ often leads to acute left ventricular failure, refractory arrhythmia, and sudden cardiac death. Presumably, a substantial number of patients die before being able to contact emergency medical care, and probably only a small number of them reaches the hospital. STEMI resulting from an ULM thrombosis accounts for 0.8–4% of all primary percutaneous coronary interventions (PPCIs).1 – 3 Current European and American guidelines recommend coronary
Drs Ielasi and Silvestro contributed equally to the manuscript and are joint first authors. 1558-2027 Copyright ß 2015 Wolters Kluwer Health, Inc. All rights reserved.
J Cardiovasc Med 2015, 16:163–169 Keywords: left main, primary percutaneous coronary intervention, STEMI Department of Cardiology, Azienda Ospedaliera ‘Bolognini’, Seriate (BG), Italy Correspondence to Maurizio Tespili, MD, Department of Cardiology, Azienda Ospedaliera ‘Bolognini’, Via Paderno 21, 24068 Seriate (BG), Italy Tel: +39 035 3063315; e-mail: [email protected] Received 29 October 2013 Revised 21 February 2014 Accepted 21 February 2014
artery bypass grafting to treat an ULM stenosis particularly in the case of stable patients.4 – 6 However, these guidelines do not assist with the treatment of patients with ULM-related STEMI, which is frequently associated with hemodynamic instability requiring prompt restoration of the blood flow to the myocardium. Particularly for these patients, emergency percutaneous coronary intervention (PCI) is often the only possible therapeutic option mainly in hospital without on-site cardiac surgical back-up. As data are limited, reporting clinical outcomes for this specific patient subgroup remains important. The aim of this study was to evaluate the clinical outcomes following PPCI for ULM-related STEMI in a high-volume center without on-site surgical back-up. DOI:10.2459/JCM.0000000000000075
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
164 Journal of Cardiovascular Medicine 2015, Vol 16 No 3
Methods A retrospective cohort analysis was performed on all consecutive patients undergoing PPCI for ULM-related STEMI at ‘Bolognini’ Hospital, Seriate (BG), Italy. Our center is a community hospital without on-site cardiac surgery, but with a high-volume catheterization laboratory (PCI volume >1000/year including 175/200 PPCI/year), which provides a 24-h PPCI service to a population of 300 000 inhabitants and is only 3.2 km from the nearest cardiac surgery unit. STEMI was defined as 1 mm ST-segment elevation in two or more contiguous leads; left main STEMI-equivalent, defined as 1 mm ST-segment elevation in lead aVR with ST-segment elevation in aVR>V1 and ST-segment depressions larger than 0.5 mm in more than six leads, as previously described,7 without 1 mm ST-segment elevation in two or more contiguous leads. ULM-related STEMI was defined as the evidence of a thrombotic lesion involving the mid-shaft and/or the distal ULM associated with ECGraphic modifications compatible with STEMI (see above). Patients with ULM-related STEMI were divided in two groups according to the absence or presence of cardiogenic shock at initial presentation. The decision to proceed to emergency cardiac catheterization was based on the presence of prolonged chest pain (>30 min) associated with ECGraphic signs of acute STEMI or new left bundle branch block with or without cardiogenic shock. PPCI was performed using standard techniques. Adjunctive pharmacological treatment was administered according to STEMI guidelines, as applicable at the moment of intervention.8,9 In general, patients received 500 mg of aspirin and 5000 IU of unfractionated heparin as intravenous bolus prior to emergency angiography during the entire study period. Before 2012, a loading dose of 300–600 mg of clopidogrel was administered before the procedure, whereas from January 2012 onwards, every patient (without contraindications) received a loading dose of 180 mg of ticagrelor. In our center, bare metal stenting (BMS) was considered the default strategy in PPCI up to December 2009. The use of glycoprotein IIb/IIIa inhibitor and/or antithrombotic medications (i.e., bivalirudin), pre/postdilatation, thrombectomy devices, and use of an intra-aortic balloon pump (IABP) was at the discretion of the operator. Significant lesions other than the ‘culprit’ ULM were treated in the same procedure if considered suitable for percutaneous intervention in case of cardiogenic shock while in a staged procedure (preferably within 2 months) in patients without cardiogenic shock (non-cardiogenic shock group). The anti-platelet regimens used after PPCI were low-dose aspirin (100 mg daily) recommended indefinitely, and a 75-mg dose of clopidogrel daily (90 mg of ticagrelor bid from January 2012) for 12 months (as secondary prevention after STEMI independently from BMS implantation). Procedural success was defined as angiographic success [final thrombolysis in myocardial infarction (TIMI) flow 3]
without in-hospital major adverse events (death, Q-wave myocardial infarction, acute stent thrombosis, or need for emergent revascularization) within 24 h from the end of the procedure. Clinical data were collected by hospital visit or telephone contact at 6-month intervals. Angiographic follow-up was scheduled for all the survivors at 6–9 months or earlier if non-invasive evaluation or clinical presentation suggested the presence of ischemia. Cardiogenic shock was defined as sustained (at least 30 min) hypotension with systolic blood pressure less than 90 mmHg or the need for supportive measures to maintain a systolic blood pressure more than 90 mmHg and endorgan hypoperfusion (cool extremities, an altered level of consciousness or a urine output 60 bpm), or patients presenting with cardiac arrest.10 Death was considered cardiac in origin unless obvious noncardiac causes could be identified. Clinical end-points (death, cardiac death, peri-procedural myocardial infarction, and stent thrombosis) were defined on the basis of the Academic Research Consortium (ARC) definitions.11 Target lesion revascularization (TLR) was defined as any revascularization performed to treat a stenosis inside the implanted stent or within the 5-mm segments adjacent to the stent including the ostium of left anterior descending artery (LAD) or left circumflex (LCx). Target vessel revascularization (TVR) was defined as any revascularization performed on the treated vessel considering also treatment of any segment in the LAD and LCx.12 Bleeding were defined according to the Bleeding ARC (B-ARC)13. The EuroScore was used to stratify the clinical risk of death at 30 days.14,15 The primary end-point of the study was to assess in-hospital mortality in the overall population and according to the presence/absence of cardiogenic shock at hospital arrival. Statistical analysis
Continuous variables are presented as mean (standard deviation) or median (interquartile range). Categorical variables are presented as raw numbers with percentages. The normality of the distribution of all the continuous variables was assessed by the Kolmogorov–Smirnov test. Continuous variables were compared by the independent sample t test or Mann–Whitney U test. Categorical variables were compared by the chi-square statistic or Fisher’s exact test. A P value less than 0.05 was considered to be statistically significant. All reported P values are two-sided. The statistical analysis was performed using SPSS (SPSS-PC, Inc, Chicago, Illinois, USA) software version 16.0.
Results Between October 2006 and December 2012, 1094 patients underwent PPCI for STEMI in our catheterization laboratory. Among these, 34 (3.1%) had an ULM ‘culprit lesion’. Baseline demographic and clinical
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Primary PCI for ULM-related STEMI Ielasi et al. 165
characteristics of patients undergoing PPCI for ULM thrombosis are shown in Table 1. The mean age of the overall cohort was 69.0 11.0 years. The risk profile of the overall population was relatively high as documented by a mean logistic Euroscore of 36.4 19.6. A total of 22 (64.7%) patients were in cardiogenic shock upon arrival in the catheterization laboratory. Baseline demographic and clinical characteristics between patients with cardiogenic shock vs. non-cardiogenic shock were found to be similar (Table 1). However, the mean ejection fraction at arrival was significantly lower in the cardiogenic shock group (25.7 14.0% vs. 39.1 8.6%, P ¼ 0.008), whereas the number of patients with pre-procedural cardiac arrest (40.9 vs. 4.3%, P ¼ 0.05), Killip Class III–IV (86.4 vs. 8.3%, P < 0.001), and the need for invasive ventilatory support (54.5 vs. 0%, P ¼ 0.001) was significantly higher in the cardiogenic shock group. Baseline angiographic and procedural characteristics are listed in Table 2. Distal ULM was involved as a ‘culprit’ site in 31 patients (91.2%) without difference between the groups (90.9 vs. 91.7%, P ¼ 0.7). Among the 31 distal ULM ‘culprit’ lesions, 18 (58.1%) were treated with ‘Provisional’ stenting (one stent from ULM toward LAD), five (16.1%) with a two-stent technique as intention to treat (four ‘T-stenting’ and one ‘V-stenting’), whereas the other eight (25.8%) were treated with a ‘bail-out’ two-stent strategy (‘T and minimal protrusion’) when the residual diameter stenosis was more than 70% after kissing inflation and/or in case of flow limiting dissection (TIMI flow
