Lee Michael S, Sillano Dario, Latib Azeem, Chieffo Alaide, Zoccai Giuseppe Biondi, Bhatia Ravi, Sheiban Imad, Colombo Antonio, Tobis Jonathan
Department of Medicine/Cardiology, University of California, Los Angeles Medical Center, Los Angeles, California 90095-171715, USA.
Catheter Cardiovasc Interv. 2009 Jan 1;73(1):15-21. doi: 10.1002/ccd.21712.
Patients who present with myocardial infarction (MI) and unprotected left main coronary artery (ULMCA) disease represent an extremely high-risk subset of patients. ULMCA percutaneous coronary intervention (PCI) with drug-eluting stents (DES) in MI patients has not been extensively studied.
In this retrospective multicenter international registry, we evaluated the clinical outcomes of 62 consecutive patients with MI who underwent ULMCA PCI with DES (23 ST-elevation MI [STEMI] and 39 non-ST-elevation MI [NSTEMI]) from 2002 to 2006.
The mean age was 70 +/- 12 years. Cardiogenic shock was present in 24%. The mean EuroSCORE was 10 +/- 8. Angiographic success was achieved in all patients. Overall in-hospital major adverse cardiac event (MACE) rate was 10%, mortality was 8%, all due to cardiac deaths from cardiogenic shock, and one patient suffered a periprocedural MI. At 586 +/- 431 days, 18 patients (29%) experienced MACE, 12 patients (19%) died (the mortality rate was 47% in patients with cardiogenic shock), and target vessel revascularization was performed in four patients, all of whom had distal bifurcation involvement (two patients underwent repeat PCI and two patients underwent bypass surgery). There was no additional MI. Two patients had probable stent thrombosis and one had possible stent thrombosis. Diabetes [hazard ratio (HR) 4.22, 95% confidence interval (CI) (1.07-17.36), P = 0.04), left ventricular ejection fraction [HR 0.94, 95% CI (0.90-0.98), P = 0.005), and intubation [HR 7.00, 95% CI (1.62-30.21), P = 0.009) were significantly associated with increased mortality.
Patients with MI and ULMCA disease represent a very high-risk subgroup of patients who are critically ill. PCI with DES appears to be technically feasible, associated with acceptable long-term outcomes, and a reasonable alternative to surgical revascularization for MI patients with ULMCA disease. Randomized trials are needed to determine the ideal revascularization strategy for these patients.
出现心肌梗死（MI）和无保护左主干冠状动脉（ULMCA）疾病的患者是极高风险的患者亚组。MI患者使用药物洗脱支架（DES）进行ULMCA经皮冠状动脉介入治疗（PCI）尚未得到广泛研究。
在这项回顾性多中心国际注册研究中，我们评估了2002年至2006年连续62例接受DES进行ULMCA PCI的MI患者的临床结局（23例ST段抬高型心肌梗死[STEMI]和39例非ST段抬高型心肌梗死[NSTEMI]）。
平均年龄为70±12岁。24%的患者出现心源性休克。平均欧洲心脏手术风险评估系统（EuroSCORE）评分为10±8。所有患者均实现血管造影成功。总体院内主要不良心脏事件（MACE）发生率为10%，死亡率为8%，均因心源性休克导致的心脏死亡，1例患者发生围手术期心肌梗死。在586±431天时，18例患者（29%）发生MACE，12例患者（19%）死亡（心源性休克患者的死亡率为47%），4例患者进行了靶血管血运重建，所有这些患者均有远端分叉病变（2例患者接受了重复PCI，2例患者接受了搭桥手术）。无额外的心肌梗死发生。2例患者可能发生支架血栓形成，1例患者可能发生支架血栓形成。糖尿病[风险比（HR）4.22，95%置信区间（CI）（1.07 - 17.36），P = 0.04]、左心室射血分数[HR 0.94，95%CI（0.90 - 0.98），P = 0.005]和插管[HR 7.00，95%CI（1.62 - 30.21），P = 0.009]与死亡率增加显著相关。
MI和ULMCA疾病患者是病情危重的极高风险亚组患者。DES PCI在技术上似乎可行，具有可接受的长期结局，是ULMCA疾病MI患者手术血运重建的合理替代方案。需要进行随机试验以确定这些患者的理想血运重建策略。
