Abdelghani Mohammad, Taha Salma, Shoeib Osama, Hamzaraj Kevin, Emam Amr Y, Elmaghraby Khaled M, Elsoudi Mohamed, Abdelshafy Mahmoud, de Winter Robbert J, Elguindy Ahmed, Hemetsberger Rayyan, Hassan Ahmed
Cardiology Department, Faculty of Medicine, Al-Azhar University, Cairo, Egypt; Cardiology Unit, Department of Internal Medicine, Sohar Hospital, Sohar, Oman; Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
Department of Cardiology, Assiut University, Assiut, Egypt.
Am J Cardiol. 2025 Mar 1;238:78-84. doi: 10.1016/j.amjcard.2024.12.001. Epub 2024 Dec 7.
Patients who undergo percutaneous coronary intervention (PCI) to the left main (LM) coronary artery in the setting of acute coronary syndrome (ACS) were not adequately studied in the era of modern PCI. We investigated early and long-term outcomes of these patients, especially those with a true LM bifurcation stenosis. The Left Main Intervention in Acute Coronary Syndrome (LIMACS) is a multicenter registry that enrolled patients who underwent PCI to unprotected LM disease in the setting of ACS using a drug-eluting stent. The study included 360 patients (age 65 ± 12 years, men 74%, ST-elevation myocardial infarction 65%). During index hospitalization, 25% of patients developed cardiogenic shock and 15% died. Cardiogenic shock (adjusted odds ratio [adjOR] 26, 95% confidence interval [CI] 7 to 93) and final Thrombolysis in Myocardial Infarction (TIMI) grade <3 flow (adjOR 7, 95% CI 1.6 to 31) were associated with in-hospital mortality. The 3-year mortality (37%) correlated with left ventricular ejection fraction ≤40% (adjHR 2.4 [1.4 to 4.2]), Killip class II to IV at presentation (adjHR 1.7 [1.02 to 2.8]), LM culprit (adjHR 1.7 [1.04 to 2.8]), true LM bifurcation stenosis (adjHR 1.8[1.1 to 2.9]), final TIMI grade <3 flow (adjHR 3.2 [1.7 to 5.8]), and radial access (adjHR 0.58 [0.38 to 0.99]). In patients with true LM bifurcation stenosis (n = 127), 2-stent strategy was adopted in 60% and was associated with lower 3-year mortality or repeat revascularization than 1-stent strategy (48% vs 69%, p = 0.012). In conclusion, patients who undergo PCI to the LM in the setting of an ACS sustain high adverse event rates. Hemodynamic status, LM culprit lesion, femoral access, and failure to restore normal flow are major determinants of adverse outcomes. In patients with LM true bifurcation lesions, outcomes are impaired, especially with 1-stent strategy.
在现代经皮冠状动脉介入治疗（PCI）时代，对于急性冠状动脉综合征（ACS）患者行左主干（LM）冠状动脉PCI的研究尚不充分。我们调查了这些患者的早期和长期预后，尤其是那些存在真正LM分叉狭窄的患者。急性冠状动脉综合征左主干介入治疗（LIMACS）是一项多中心注册研究，纳入了在ACS背景下使用药物洗脱支架对无保护的LM病变行PCI的患者。该研究包括360例患者（年龄65±12岁，男性占74%，ST段抬高型心肌梗死占65%）。在首次住院期间，25%的患者发生心源性休克，15%的患者死亡。心源性休克（校正比值比[adjOR]26，95%置信区间[CI]7至93）和最终心肌梗死溶栓（TIMI）血流分级<3级（adjOR 7，95%CI 1.6至31）与住院死亡率相关。3年死亡率（37%）与左心室射血分数≤40%（校正风险比[adjHR]2.4[1.4至4.2]）、就诊时Killip分级II至IV级（adjHR 1.7[1.02至2.8]）、LM罪犯病变（adjHR 1.7[1.04至2.8]）、真正的LM分叉狭窄（adjHR 1.8[1.1至2.9]）、最终TIMI血流分级<3级（adjHR 3.2[1.7至5.8]）以及桡动脉入路（adjHR 0.58[0.38至0.99]）相关。在存在真正LM分叉狭窄的患者（n = 127）中，60%采用双支架策略，与单支架策略相比，3年死亡率或再次血运重建率更低（48%对69%，p = 0.012）。总之，在ACS背景下对LM行PCI的患者不良事件发生率较高。血流动力学状态、LM罪犯病变、股动脉入路以及未能恢复正常血流是不良预后的主要决定因素。在存在LM真正分叉病变的患者中，预后较差，尤其是采用单支架策略时。
