Tan Chong-Hiok, Hong Myeong-Ki, Lee Cheol-Whan, Kim Young-Hak, Lee Chang-Hoon, Park Seong-Wook, Park Seung-Jung
Department of Medicine, University of Ulsan College of Medicine, Asan Medical Center, 388-1 Poongnap-dong, Songpa-gu, Seoul, 138-736, Republic of Korea.
Int J Cardiol. 2008 May 23;126(2):224-8. doi: 10.1016/j.ijcard.2007.03.131. Epub 2007 May 10.
Primary angioplasty of the left main coronary is not a common procedure. We present 16 cases of angioplasty of left main coronary artery with drug-eluting stent (DES) implantation in the setting of acute ST elevation myocardial infarction.
Between December 2003 and November 2005, sixteen patients presented with acute ST elevation myocardial infarction where the left main coronary artery was shown to be involved with or without the left anterior descending or left circumflex arteries. Primary angioplasties were performed on the unprotected left main coronary artery. Five patients received direct stenting while the rest had pre-dilatation. Only one patient received Taxus(R) while the rest received Cypher(R) stents.
Of the sixteen patients, eleven developed cardiogenic shock necessitating intra-venous inotropic and intra-aortic balloon counter-pulsation support. Seven perished in hospital (46%); four within the first day while one had a complicated course and perished on the 42nd day of hospitalization. There was no difference in clinical history (hypertension, diabetes, age, and previous coronary intervention) or hemodynamic features (presenting blood pressure, duration of infarct, stent length, and maximum balloon size or pressure) between the two groups. However, the use of inotropes and intra-aortic balloon counter-pulsation (100% vs. 44% p=0.034) was significantly more common in the group which perished. Patient with cardiogenic shock had increased mortality of 63%. Of the nine survivors, one required repeat intervention for subacute stent thrombosis at sixteenth day and one underwent coronary bypass surgery at three months. All remained well up to mean follow up of 420 days.
Left main coronary artery infarct especially in the setting of cardiogenic shock has a very high mortality rate. Percutaneous intervention can be performed on these patients with minimal delay. In our series, we have shown that primary intervention of the unprotected left main coronary artery with a drug-eluting stent carries an acceptable level of major adverse coronary event. In those who survived the initial event, there is a low rate of mortality or morbidity.
左主干冠状动脉的直接血管成形术并非常见手术。我们报告16例在急性ST段抬高型心肌梗死情况下行左主干冠状动脉血管成形术并植入药物洗脱支架（DES）的病例。
2003年12月至2005年11月期间，16例患者表现为急性ST段抬高型心肌梗死，左主干冠状动脉显示有或无左前降支或左旋支受累。对无保护的左主干冠状动脉进行直接血管成形术。5例患者接受直接支架置入，其余患者进行预扩张。仅1例患者接受紫杉醇洗脱支架，其余患者接受西罗莫司洗脱支架。
16例患者中，11例发生心源性休克，需要静脉使用正性肌力药物和主动脉内球囊反搏支持。7例患者在医院死亡（46%）；4例在第一天内死亡，1例病程复杂，在住院第42天死亡。两组在临床病史（高血压、糖尿病、年龄和既往冠状动脉介入治疗）或血流动力学特征（就诊时血压、梗死持续时间、支架长度以及最大球囊尺寸或压力）方面无差异。然而，死亡组使用正性肌力药物和主动脉内球囊反搏的比例（100%对44%，p = 0.034）显著更高。发生心源性休克的患者死亡率增加63%。9例幸存者中，1例在第16天因亚急性支架血栓形成需要再次干预，1例在3个月时接受冠状动脉搭桥手术。至平均随访420天时，所有患者情况良好。
左主干冠状动脉梗死，尤其是在心源性休克情况下，死亡率非常高。可对这些患者进行最小延迟的经皮介入治疗。在我们的系列研究中，我们表明对无保护的左主干冠状动脉进行药物洗脱支架的直接介入治疗，主要不良冠状动脉事件发生率处于可接受水平。在最初事件中存活的患者，死亡率或发病率较低。
