Emergency Stenting of the Left Main Coronary Artery After Diagnostic Coronary Angiography
M. Rizwan Khalid, MD,
Douglas C. Morris, MD,
S. Tanveer Rab, MD*
Andreas Gruentzig Cardiovascular Center, Emory University Hospital, Emory University, Atlanta, Georgia
A 76-year-old female presented with an acute coronary syndrome manifested by chest pain, a new left bundle branch block, and positive troponin. She had a previous history of aortic valve replacement. Emergent diagnostic coronary angiography via the right femoral arterial approach with a 5-F Left Judkins 4.0 catheter demonstrated significant left main coronary artery (LMCA) stenosis (Fig. 1, Online Video 1). Immediately following the angiogram, the patient became hypotensive, asystolic, and unresponsive. Advanced cardiac life support protocol was started promptly and the patient was intubated. A temporary pacemaker was placed in addition to an intra-aortic balloon pump, via the left femoral approach. Inotropes were started. Aggressive and continuous chest compressions were performed during the entire procedure. A 7-F Left Judkins 3.5 guide catheter was used to engage the ostium of the LMCA. The lesion was crossed with difficulty with a 0.014-inch Whisper high-torque guide wire (Abbott Corporation, San Francisco, California) after multiple guidewires had failed. Pre-dilation was performed with a 2.0 x 15-mm Maverick balloon (Boston Scientific Corporation, Natick, Massachusetts) followed by placement of a 3.5 x 12-mm Driver bare-metal stent (Medtronic Inc., Minneapolis, Minnesota) (Fig. 2, Online Video 2) during chest compressions. Thrombolysis In Myocardial Infarction (TIMI) flow grade 3 was achieved (Fig. 3, Online Video 3) with gradual hemodynamic improvement. The patient had full recovery and was discharged 3 days later on long-term daily doses of aspirin 325 mg and clopidogrel 75 mg. A follow-up angiogram at 3 months demonstrated patency of the LMCA stent.
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Figure 1 First Diagnostic Angiogram of the Left Coronary Circulation
This is performed with a Left Judkins 4.0 catheter, which reveals subtotal occlusion of the left main coronary artery. Patient has a previous history of aortic valve replacement. See Online Video 1.
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Figure 2 Angiogram During Balloon Dilation of the Left Main Coronary Artery Occlusion
Balloon dilation being performed concurrently with aggressive cardiopulmonary resuscitation/advanced cardiac life support. Temporary pacemaker and intra-aortic balloon pump can also be seen. See Online Video 2.
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Diagnostic coronary angiography is a safe procedure with a mortality rate of 0.08% to 0.14% in the National Cardiovascular Data Registry (1). The predominant cause of death in this registry was abrupt LMCA closure. This is a rare but catastrophic event with a grim prognosis (2–4). When left main disease is suspected, nonselective left coronary cusp injection is of value. We reviewed a total of 26,237 percutaneous coronary intervention procedures from Emory University Hospital and Emory Crawford Long Hospital between 2002 and 2008 and identified 5 patients with abrupt LMCA occlusion, of whom, 2 survived. The 2 survivors had abrupt LMCA occlusion in the catheterization laboratory and both patients received cardiopulmonary resuscitation/advanced cardiac life support protocol with continuous, uninterrupted, and aggressive chest compressions, even during fluoroscopy. Because surgery was not immediately available, percutaneous coronary intervention remains the only viable option for these patients.
Newer percutaneous left ventricular assist devices such as the Tandem Heart (Cardiac Assist Inc., Pittsburgh, Pennsylvania) are time-consuming and require trained personnel and interventionalists skilled in transseptal puncture. The Impella device (Abiomed, Danvers, Massachusetts) also requires skilled personnel, some degree of left ventricular function, and forward cardiac output. The ISAR-SHOCK (Impella LP 2.5 versus Intra-Aortic Balloon Pump in Cardiogenic Shock) trial demonstrated no advantage of the Impella device over a conventional intra-aortic balloon pump (5). In a patient with cardiogenic shock, asystole, and on-going chest compressions, time is of the essence, and emergent stenting of the LMCA with the goal of establishing antegrade coronary blood flow would be the only hope for survival.
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Appendix
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For Online Videos 1 to 3
 , please see the online version of this article.
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Video 1 Video 1
First diagnostic angiogram of the left coronary circulation.
This is performed with a Left Judkins 4.0 catheter which reveals subtotal occlusion of the left main coronary artery. Patient has a previous history of aortic valve replacement.
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View larger version (121K):
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Video 2 Video 2
Angiogram during balloon dilatation of the left main coronary artery occlusion.
Balloon dilatation being performed concurrently with aggressive CPR/ACLS. Temporary pacemaker and Intra-aortic balloon pump can also be seen.
CPR – Cardio-pulmonary resuscitation, ACLS – Advanced Cardiac Life Support.
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* Reprint requests and correspondence: Dr. S. Tanveer Rab, Cardiac Catheterization Laboratory, Emory University Hospital, 1364 Clifton Road NE, Suite C430, Atlanta, Georgia 30322 (Email: srab{at}emory.edu).
Manuscript received December 22, 2008;
revised manuscript received March 19, 2009,
accepted March 24, 2009.
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REFERENCES
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- American College of Cardiology–National Cardiovascular Data Registry, version 3.0 www.ncdr.com/cathpci 2004.
- Ellis SG, Myler RK, King III SB, et al. Causes and correlates of death after unsupported coronary angioplasty: implications for use of angioplasty and advanced support techniques in high-risk settings Am J Cardiol 1991;68::1447-1451.[CrossRef][Web of Science][Medline]
- Block P, Peterson E, Krone R, et al. Identification of variables needed to risk adjust outcome of coronary interventions: evidence-based guidelines for efficient data collection J Am Coll Cardiol 1998;32::275-282.[Abstract/Free Full Text]
- Sakai K, Nakagawa Y, Kimura T, et al. Primary angioplasty of unprotected left main coronary artery for acute anterolateral myocardial infarction J Invasive Cardiol 2004;16::621-625.[Medline]
- Seyfarth M, Sibbing D, Bauer I, et al. A randomized clinical trial to evaluate the safety and efficacy of a percutaneous left ventricular assist device (Impella LP 2.5) versus intra-aortic balloon pumping for treatment of cardiogenic shock caused by myocardial infarction J Am Coll Cardiol 2008;52::1584-1588.[Abstract/Free Full Text]
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