Left Main Coronary Artery Stenting During Cardiopulmonary Resuscitation: A Life‐saving Experience

Cardiogenic shock secondary to a ruptured left main coronary artery (LMCA) plaque is an uncommon and usually lethal clinical situation. Here we report a 45-year-old man who was scheduled for coronary artery bypass graft (CABG) surgery for a significant left main coronary lesion. However, he developed ventricular tachycardia and cardiac arrest immediately before surgery. The culprit LMCA lesion was successfully stented during cardiac resuscitation. We discuss the patient and then review the management strategies in these cases. Left main coronary artery lesions are found in 5% to 7% of elective left heart catheterizations.1 A ruptured LMCA plaque frequently leads to cardiogenic shock, and the outcome is dismal.2 Myocardial infarctions secondary to LMCA lesions jeopardize significant amount of myocardial tissue. This commonly results in pump failure and/or lethal arrhythmias. Most such patients do not make it to the hospital alive. In addition, LMCA stenting in a patient with acute myocardial infarction has a high in-hospital mortality (13.7%).3 A 45-year-old man presented to the emergency department (ED) with retrosternal chest pain of 1-hour duration. His blood pressure was 115/70 mm Hg, and his pulse rate was 85/min. He described exertional angina that was relieved with rest for 1 week. He was a smoker. The 12-lead electrocardiogram (ECG) showed 1-mm ST-segment depression in leads III and aVF, and 2- to 3-mm ST-segment elevation in leads V2 to V5 and aVL, suggesting hyperacute anterolateral myocardial infarction (Figure 1). He received aspirin (300 mg, by mouth [po]), clopidogrel (600 mg, po), unfractionated heparin (10,000 IU, intravenously [IV]), and tirofiban bolus (25 μg/kg IV), followed by an 18-hour infusion of 0.15 μg kg−1 min. Emergent coronary angiogram revealed a subtotally occluded ostial LMCA lesion (Video Clip S1, available as supporting information in the online version of this paper). There was also an 80% stenosing lesion in the distal segment of the right coronary artery. Echocardiography revealed preserved left ventricular systolic function. Cardiovascular surgery was consulted for emergent CABG. Right after the coronary angiogram, the patient developed ventricular tachycardia, hemodynamic collapse, and cardiac arrest. Cardiopulmonary resuscitation (CPR) was immediately started, and the patient was transferred back to the catheterization laboratory. A coronary angiogram performed during CPR revealed thrombolysis in myocardial infarction (TIMI) I flow at LMCA (Video Clip S2 and S3, available as supporting information in the online version of this paper). The patient was cardioverted four times during the procedure. The LMCA lesion was immediately wired with the standard technique, and the lesion was predilated with a 2.5 × 20-mm balloon (Video Clip S4, available as supporting information in the online version of this paper). The LMCA lesion was then stented with a 3.5 × 15-mm bare metal stent (BMS) (Video Clip S5, available as supporting information in the online version of this paper), and TIMI 3 flow was obtained (Video Clip S6 and S7, available as supporting information in the online version of this paper). The cardiac catheterization is summarized in Video Clip S8 (available as supporting information in the online version of this paper). The LMCA stent was then postdilated with high-pressure inflations. Hemodynamic support was achieved by an intraaortic balloon pump and dopamine. Blood pressure, heart rate, and ST-segment changes improved. The intraaortic balloon pump was discontinued on the second day, and the patient was extubated. Left ventricular systolic function was normal by echocardiography. Neurologic examination was normal on the third day. The right coronary artery lesion was stented the next day, and the patient was discharged home on the sixth day of his hospital stay. His ECG on discharge was unremarkable (Figure 2). Twelve-lead electrocardiogram (ECG) on admission. Twelve-lead electrocardiogram (ECG) on discharge. Significant LMCA lesions are usually managed with CABG because percutaneous coronary intervention in this group is relatively risky.4 The in-hospital mortality following CABG for an LMCA lesion is 2.3%, and 1-year mortality is 11.3% in elective cases.5 In the same cohort, 1-year mortality is even better (5.7%) in the lower-risk patients. However, in-hospital mortality increases dramatically in patients with cardiogenic shock following acute myocardial infarction.2 Percutaneous coronary intervention (PCI) is becoming an acceptable alternative treatment in patients with cardiogenic shock secondary to acute myocardial infarction, advanced age (>75 years), prior cardiac surgery, depressed left ventricular systolic function (ejection fraction < 35%), and chronic renal or respiratory failure. Subgroup analysis of a study that included both emergent and elective cases with LMCA lesions treated with either CABG or PCI reported that PCI is an acceptable alternative to CABG when patient selection is done carefully.6 In the emergent group that included eight patients, major adverse cardiac events, in-hospital length of stay, and 1-year follow up were not significantly different between CABG and PCI. For the 30-day postoperative period, major adverse cardiac and cerebral events were higher in the CABG (17%) than the PCI group with drug-eluting stents (DES; 2%) in patients with uncomplicated LMCA stenosis (p < 0.01). This difference disappears during the 6th and 12th months of follow-up.7 In general, studies comparing PCI with CABG have revealed conflicting results, and therefore the management depends on clinical judgment and on the available personnel and facility. Restenosis is the major problem associated with PCI, and it increases the long-term mortality.8 Therefore, DES were recommended in patients with diabetes, vessel size < 3.5 mm, and distal bifurcation lesions. Restenosis rates in the distal LMCA stents is significantly higher than osteal and midsegment LMCA lesions.9 Rotational atherectomy with stenting is also an alternative strategy for LMCA lesions, although randomized controlled trials are lacking. This approach is associated with improved residual stenosis rates, especially in severely calcific LMCA lesions.10 Chieffo and coworkers9 compared the early and midterm results of unprotected LMCA intervention with BMS or DES. Eighty-five patients received DES and 64 patients received BMS in this study. Patients who received DES included more patients with diabetes (21.2% vs. 10.9%, p = 0.12), distal LMCA lesions (81% vs. 58%, p = 0.003), and lower left ventricular ejection fractions. Although the DES group included higher-risk patients, major adverse cardiac events at 6 months were less frequent in the DES than the BMS group (20% vs. 35%, p = 0.039). Similarly, all-cause mortality was significantly lower in the DES group (3.5% vs. 14.1%). Restenosis rates were high in both groups (19% in DES vs. 30.6% in BMS). The most important concern following DES implantation for LMCA lesion is late stent thrombosis. Abrupt cessation of dual antiplatelet therapy, diabetes mellitus, chronic renal failure, bifurcation lesions, long stents, left ventricular systolic failure, and distal LMCA lesions increase the risk of the late stent thrombosis. The BASKET-LATE study revealed the increased late stent thrombosis-associated myocardial infarction and death rates in patients with DES compared to BMS following the cessation of clopidogrel (2.6% vs. 1.3%).11 To the best of our knowledge, there are no randomized controlled studies on the best revascularization strategy for the LMCA lesions complicated by cardiogenic shock. CABG requires technical delays. Therefore, PCI appears to be a life-saving alternative in patients with LMCA lesion and cardiogenic shock. Our case represents a successful example of PCI in an unprotected LMCA lesion in a patient with cardiogenic shock. The authors thank Dr. Kenneth Nugent from Texas Tech University Health Sciences Center, Department of Internal Medicine, Lubbock, TX, for his assistance during the preparation of this manuscript. Video Clip S1. Subtotally occluded ostial left main coronary artery lesion. The video clip is in QuickTime. Video Clip S2. Coronary angiogram performed during cardiopulmonary resuscitation reveals TIMI I flow at left main coronary artery: Part 1. The video clip is in QuickTime. Video Clip S3. Coronary angiogram performed during cardiopulmonary resuscitation reveals TIMI I flow at left main coronary artery: Part 2. The video clip is in QuickTime. Video Clip S4. Left main coronary artery lesion wired with the standard technique and the lesion predilated. Video Clip S5. Left main coronary artery lesion stented with a 3.5 × 15-mm bare metal stent. The video clip is in QuickTime. Video Clip S6. TIMI 3 flow obtained: Part 1. The video clip is in QuickTime. Video Clip S7. TIMI 3 flow obtained: Part 2. The video clip is in QuickTime. Video Clip S8. Summary of cardiac catheterization. Please note: Wiley Periodicals Inc. is not responsible for the content or functionality of any supporting information supplied by the authors. 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