Outcomes After Emergency Percutaneous Coronary Intervention in Patients With Unprotected Left Main Stem Occlusion: The BCIS National Audit of Percutaneous Coronary Intervention 6-Year Experience

Study Questions:

What are the in-hospital outcomes and 3-year mortality of patients presenting with unprotected left main stem occlusion (ULMSO) treated with primary percutaneous coronary intervention (PPCI)?

Methods:

From January 1, 2007 to December 21, 2012, 446,257 PCI cases were recorded in the British Cardiovascular Intervention Society database of all PCI cases in England and Wales. Of those, 568 were patients having emergency PCI for ST-segment elevation myocardial infarction (0.6% of all PPCI) who presented with ULMSO (TIMI [Thrombolysis In Myocardial Infarction] flow grade 0/1 and stenosis >75%), and they were compared with 1,045 emergency patients treated with nonocclusive LMS disease. Follow-up was obtained through linkage with the Office of National Statistics.

Results:

Presentation with ULMSO, compared with nonocclusive LMS disease, was associated with a doubling in the likelihood of periprocedural shock (57.9% vs. 27.9%; p < 0.001) and/or intra-aortic balloon pump support (52.5% vs. 27.2%; p < 0.001). In-hospital (43.3% vs. 20.6%; p < 0.001), 1-year (52.8% vs. 32.4%; p < 0.001), and 3-year mortality (73.9% vs 52.3%, p < 0.001) rates were higher in patients with ULMSO, compared with patients presenting with a patent LMS, and were significantly influenced by the presence of cardiogenic shock. ULMSO and cardiogenic shock were independent predictors of 30-day (hazard ratio [HR], 1.61; 95% confidence interval [CI], 1.07-2.41; p = 0.02, and HR, 5.43; 95% CI, 3.23-9.12; p < 0.001, respectively) and 3-year all-cause mortality (HR, 1.52; 95% CI, 1.06-2.17; p = 0.02, and HR, 2.98; 95% CI, 1.99-4.49, p < 0.001, respectively).

Conclusions:

The authors concluded that in patients undergoing PPCI for ULMSO, acute outcomes are poor and additional therapies are required to improve outcome.

Perspective:

This study suggests that despite aggressive invasive treatment of ULMSO, in-patient mortality remains very high. This information is valuable for health care professionals, and patients’ families should be counseled accordingly. Furthermore, among 30-day survivors of LMS PPCI, mortality differences in the subsequent year appear to be principally driven by the presence or absence of cardiogenic shock and not primarily by occlusion status. Overall, the data suggest the importance of prompt restoration of left coronary artery myocardial perfusion, the likelihood of requiring hemodynamic support during the acute management of ULMSO, and the frequent need for supplementary inotropic and ventilator support.

Clinical Topics: Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Acute Heart Failure

Keywords: Shock, Cardiogenic, Myocardial Infarction, Constriction, Pathologic, Confidence Intervals, Coronary Vessels, Angioplasty, Balloon, Coronary, Hemodynamics


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