Acute, total occlusion of the left main stem: coronary intervention options, outcomes, and recommendations

Introduction: Acute, total occlusion of the unprotected left main stem (uLMo) in acute coronary syndrome (ACS) patients is a catastrophic event often accompanied by sudden cardiac death (SCD) and/or cardiogenic shock (CS) with high mortality rates and limited methods of successful treatment.Emergent, surgical and percutaneous revascularization has been reported before, yet comprehensive data remains scarce.Aim: To examine emergency percutaneous coronary intervention (PCI) outcomes in ACS cases presenting with uLMo.Material and methods: Data on 23 subjects undergoing primary PCI in uLMo cases were analyzed.The primary end-point was in-hospital death; secondary end-points were successful salvage of coronary anatomy and 90-day major cardiac adverse events (MACE).Results: About 40% of LM occlusion cases presented following successful on-site cardio-pulmonary resuscitation (CPR).Of all patients arriving for treatment the occluded LM was successfully opened and stented in ~90% of cases.CS was present in > 85% of cases, and circulatory support in the form of intra-aortic balloon pump and/or extracorporeal membrane oxygenation systems was applied in every eligible case (~80%).The in-hospital death rate was 56%, mostly including individuals requiring prior CPR.At 6 months, additional MACE rates were low at 8.7%.Conclusions: We found that uLMo ACS cases often present with preceding CPR and mostly in manifest CS.Coronary salvage is generally successful, yet uLMo even with optimal present day complex treatment yields quite high mortality rates.This is especially true for patients receiving prior CPR.In surviving patients, however, 6-month MACE rates are acceptable. Key words: acute myocardial infarction/STEMI, left main coronary disease, coronary occlusion, percutaneous coronary intervention. S u m m a r yUnprotected left main stem occlusion in the setting of acute coronary syndrome is a catastrophic event with limited methods of successful treatment.Clinical presentation often includes sudden cardiac death with the need for cardiopulmonary resuscitation and manifest cardiogenic shock.Optimal treatment involves emergent percutaneous revascularization with circulatory augmentation.In-hospital mortality, even with complex care is quite high (~50%), despite overwhelmingly successful coronary salvage (~90%).Most important determining factor of primary survival is the need for resuscitation at any timepoint during care.In initial survivors, mid-term results are acceptable.