doi: 10.1161/01.CIR.0000064688.47914.4F
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
(Circulation. 2003;107:e91.)
© 2003 American Heart Association, Inc.
Correspondence |
Beneficial Outcome After Angioplasty of Unprotected Left Main Stenosis in Patients During Resuscitation
Department of Cardiology,, Ernst-Moritz-Arndt-University, Greifswald, Germany, klaus.empen@t-online.de
To the Editor:
With great interest, we have read the article by Takagi et al1 that reported favorable results of elective percutaneous interventions (PCI) of unprotected left main (LM) coronary arteries in comparison with previous studies.2,3 However, because of a lack of well-designed prospective studies comparing aorto-coronary bypass (ACB) surgery with PCI, unrestricted recommendations for elective PCI of obstructed LM trunks cannot be made for patients with low surgical risk.4 However, in severely ill patients (under resuscitation and in cardiogenic shock), in whom surgical revascularization cannot be carried out, PCI of the LM trunk can also lead to favorable results:
We retrospectively analyzed the clinical outcome of all patients admitted to our hospital in cardiogenic shock during the last 2 years who had PCI of a critical lesion in the LM trunk immediately after or during cardiopulmonary resuscitation. During this period, 5 patients out of approximately 1000 who received PCI had been treated for critical LM stenosis. In all patients, PCI was successful (no catheter laboratory complications). Two patients died, one because of refractory rhythm disturbances and the other because of progressive heart failure. The remaining 3 patients survived, had no neurological deficit, and were successfully discharged from the hospital after a maximum stay of 3 weeks. In these patients, follow-up angiography after 2 months revealed no significant restenosis. Before follow-up, 2 of the 3 patients had also undergone ACB surgery because of severe diffuse coronary artery disease. On the basis of these encouraging data, we think coronary angiography and PCI of LM stenosis are beneficial and should be recommended in patients with cardiogenic shock shortly after or even during cardiopulmonary resuscitation because suitable alternatives are lacking.
References
1. Takagi T, Stankovic G, Finci L, et al. Results and long-term predictors of adverse clinical events after elective percutaneous interventions on unprotected left main coronary artery. Circulation. 2002; 106: 698–702.
2. Tan WA, Tamai H, Park SJ, et al. Long-term clinical outcomes after unprotected left main trunk percutaneous revascularization in 279 patients. Circulation. 2001; 104: 1609–1614.
3. Silvestri M, Barragan P, Sainsous J, et al. Unprotected left main coronary artery stenting: immediate and long-term outcomes of 140 elective procedures. J Am Coll Cardiol. 2000; 35: 1543–1550.
4. Takaro T, Peduzzi P, Detre KM, et al. Survival in subgroups of patients with left main coronary artery disease. Veterans Administration Cooperative Study of Surgery for Coronary Artery Occlusive Disease. Circulation. 1982; 66: 14–22.
Response
EMO Centro Cuore Columbus, Milan, Italy
San Raffaele Hospital, Milan, Italy
We thank Dr Empen and colleagues for their interest in our article1 and the comments with respect to percutaneous treatment of unprotected left main (LM) trunk.
We agree that the advances in stent design and performance, along with improvements in operator technique and additional pharmacology, widen indications for coronary stenting, making feasible treatment of most complex lesion subsets, including LM trunk.2–5 However, results of percutaneous coronary interventions (PCI) performed on the LM trunk are inferior to the ones obtained after PCI in other locations; the incidence of in-hospital mortality rates range from 0% to 4% for elective procedures,3,4 and up to 13.7% when emergency procedures are included.2,5
We reported our experience with elective percutaneous treatment of lesions involving unprotected LM, as we believe that including elective and emergency interventions makes the results difficult to interpret when recommending this procedure to a specific patient. Nevertheless, emergency treatment of severe stenosis or occlusions of the LM trunk with PCI can be a viable and live-saving option.
As Empen et al point out, it is important to maintain a critical attitude toward usage of PCI as a destination therapy in this setting. In fact, 2 of their 3 patients later underwent coronary artery bypass grafting.
References
1. Takagi T, Stankovic G, Finci L, et al. Results and long-term predictors of adverse clinical events after elective percutaneous interventions on unprotected left main coronary artery. Circulation. 2002; 106: 698–702.
2. Ellis SG, Tamai H, Nobuyoshi M, et al. Contemporary percutaneous treatment of unprotected left main coronary stenoses: initial results from a multicenter registry analysis 1994–1996. Circulation. 1997; 96: 3867–3872.
3. Silvestri M, Barragan P, Sainsous J, et al. Unprotected left main coronary artery stenting: immediate and medium-term outcomes of 140 elective procedures. J Am Coll Cardiol. 2000; 35: 1543–1550.
4. Park S, Hong M, Lee CW, et al. Elective stenting of unprotected left main coronary artery stenosis: effect of debulking before stenting and intravascular ultrasound guidance. J Am Coll Cardiol. 2001; 38: 1054–1060.
5. Tan WA, Tamai H, Park SJ, et al. Long-term clinical outcomes after unprotected left main trunk percutaneous revascularization in 279 patients. Circulation. 2001; 104: 1609–1614.
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||