Original title: Outcomes After Emergency Percutaneous Coronary Intervention in Patients UIT unprotected Left Main Stem Occlusion. The BCIS National Audit of Percutaneous Coronary Intervention 6-Years Experience. Reference: Niket Patel, et al. J Am Coll Cardiol Interv 2014;7:969-80

AMI involving unprotected left main is not frequent in catheterization labs since most of these cases present in shock. There is little information in the literature and follow up is scarce. Between January 2007 and December 2012 a total of 446,257 PCI procedures were registered at the British Cardiovascular Intervention Society.

All patients registered to primary PCI were analyzed; 568 of these patients presented unprotected left main stem occlusion, 1,045 presented non occlusive lesion and 97,974 had no left main compromise. 

Those with left main lesion were older, often women, diabetic and presented renal failure. The unprotected left main stem occlusion group presented reduced ejection fraction and cardiogenic shock. Time intervals from symptom onset to hospitalization and symptom onset to balloon were lower for those with left main occlusion. 

Femoral access, multi vessel PCI, mechanical respiratory assistance, pump support and hospitalization time were more frequent in the left main PCI group.  At hospital level, mortality was 6 times higher for those with left main lesion (26.4% vs 4.1% <0.001) and it was even higher in patients with left main occlusion vs. patients with non-occlusive lesions (43.3% vs. 20.6% <0.001).

Follow up at 1 and 3 years, mortality was higher in patients with left main compromise (39.8% and 60.4% vs. 9.8% and 20.7% respectively; p <0.001). 

Conclusion

Unprotected left main primary PCI outcomes are often poor and require additional therapies to be improved. However, long term outcomes in survivors are encouraging.

Commentary

Unprotected left main primary PCI is one of the worst scenarios we could face. It requires vast experience and fast action, with outcomes that are not auspicious. It is necessary to develop support circulatory systems as well as new drugs or strategies to obtain better results.

Corrtesy of Dr. Carlos Fava
Interventional Cardiologist
Favaloro Foundation
Buenos Aires- Argentina

Carlos Fava