Primary Angioplasty in a Catastrophic Presentation: Acute Left Main Coronary Total Occlusion—The ATOLMA Registry

Abstract

Objectives. To determine the outcome predictors of in-hospital mortality in acute total occlusion of the left main coronary artery (ATOLMA) patients referred to emergent angioplasty and to describe the clinical presentation and the long-term outcome of these patients. Background. ATOLMA is an uncommon angiographic finding that usually leads to a catastrophic presentation. Limited and inconsistent data have been previously reported regarding true ATOLMA, yet comprehensive knowledge remains scarce. Methods. This is a multicenter retrospective cohort that includes patients presenting with myocardial infarction due to a confirmed ATOLMA who underwent emergency percutaneous coronary intervention (PCI). Results. In the period of the study, 7930 emergent PCI were performed in the five participating centers, and 46 of them had a true ATOLMA (0.58%). At admission, cardiogenic shock was present in 89% of patients, and cardiopulmonary resuscitation was required in 67.4%. All the patients had right dominance. Angiographic success was achieved in 80.4% of the procedures, 13 patients (28.2%) died during the catheterization, and the in-hospital mortality rate was 58.6% (27/46). At one-year and at the final follow-up, 18 patients (39%) were alive, including four cases successfully transplanted. Multivariate analysis showed that postprocedural TIMI flow was the only independent predictor of in-hospital mortality (OR 0.23, (95% CI 0.1–0.36), p<0.001). Conclusions. Our study confirms that the clinical presentation of ATOLMA is catastrophic, presenting a high in-hospital mortality rate; nevertheless, primary angioplasty in this setting is feasible. Postprocedural TIMI flow resulted as the only independent predictor of in-hospital mortality. In-hospital survivors presented an encouraging outcome. ATOLMA and left dominance could be incompatible with life.

Clinical Outcomes after Percutaneous Coronary Intervention for Cardiogenic Shock Secondary to Total Occlusive Unprotected Left Main Coronary Artery Lesion-Related Acute Myocardial Infarction

“…In the abovementioned studies and the present study, the only common predictor significantly associated with reduced 30-day survival was successful reperfusion (final TIMI flow 3). Although in the present study, the use of mechanical support was found to be associated with 30-day mortality, in the studies by Galván-Román et al [ 40 ] and Gutiérrez-Barrios et al [ 20 ], this was not observed. In the study by Galván-Román et al [ 40 ] and the present study, mechanical support was inserted before PCI in the majority of cases.…”

“…In the present study, the incidence was 0.50%, a discrepancy related to the fact that previous studies also included subtotal occlusion or critical stenosis of the LMCA. The present study exclusively included patients with total occlusive ULMCA AMI referred for primary angioplasty and is in line with the findings of the Acute Left Main Coronary Total Occlusion (ATOLMA) Registry, as they reported an incidence of 0.58% [ 20 ]. Presumably, the true incidence of ULMCA lesion-related AMI may be underestimated as patients in this clinical setting may die before they reach hospital.…”

“…Only a few comparable studies have evaluated these patients at highest risk of mortality. The ATOLMA registry [ 20 ] is the only study that exclusively included patients with total occlusive (TIMI flow 0) ULMCA-related AMI, but the percentage of cardiogenic shock was “only” 89%. Two other studies exclusively included patients in cardiogenic shock due to ULMCA-related AMI but were liberal in the inclusion of pre-procedural TIMI flow (i.e., 0 to 3) [ 39 , 40 ].…”

“…Out of the seven patients treated with ECMO, five (71%) survived to the 1-year follow-up. Currently, in several studies, ECMO or TandemHeart support was used, but the comparison of mortality rates is hampered as the inclusion criteria and prevalence of cardiogenic shock varies strongly [ 1 , 13 , 20 , 24 , 29 , 31 , 37 , 40 ].…”

The value of quantitative plaque analysis based on coronary computed tomography angiography in predicting the percutaneous coronary intervention outcome of chronic total occlusion lesions

“…The retrograde approach was attempted if the anterograde approach failed for more than 1 hour and if the approach through the collaterals was feasible. The outcome of PCI was defined as a success if the successful opening of total occlusion and restoring flow was achieved (<30% residual stenosis and TIMI ≥2 flow) (1,23). If the guidewire was consistently unable to pass through the occluded segment, or if severe dissection, perforation, and other complications of coronary artery occurred, the operation was terminated and defined as PCI failure (24).…”