Long-term outcomes following percutaneous coronary intervention to an unprotected left main coronary artery in cardiogenic shock

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Highlights

  • In cardiogenic shock with severe left main coronary artery stenosis, limited amount of information is available on outcomes.

  • Outcomes after PCI to the LM in cardiogenic shock are poor, with an excess of early mortality.

  • Reasonable long-term survival was found beyond the initial high-risk period.

  • LM PCI in cardiogenic shock was a significant independent predictor of long-term mortality.

  • Research should focus on the utility of cardiogenic shock centres and mechanical support devices.

Abstract

Background

In cardiogenic shock with severe left main coronary artery stenosis (LM), limited information exists on short and longer-term outcomes. We sought to determine the outcomes of unprotected LM PCI in cardiogenic shock.

Methods

Excluding patients with previous CABG, consecutive patients undergoing PCI in cardiogenic shock from the Melbourne Intervention Group registry between 2005 and 2013 were analysed. Those post LM PCI were compared to those post non-LM PCI. Patient and procedural data were collected with 30-day and 12-month follow-up. Australian National Death Index linkage was performed for long-term mortality analysis.

Results

After excluding previous CABG, 18,069 procedures were performed during 1st January 2005 to 30th November 2013, 601 procedures in the setting of cardiogenic shock. Of these, 45 were performed to an isolated LM and 556 to a non-LM. Those with LM PCI were older and more likely to have a baseline left ventricular ejection fraction (LVEF) of <45%. The in-hospital, 30-day, 12-month and long-term mortality to 9 years in cardiogenic shock after LM PCI was 64.4%, 66.7%, 73.3% and 80.0% compared to 36.5%, 36.9%, 40.5% and 46.0%, after non-LM PCI (p < 0.001). On multivariate analysis, LM PCI was a significant independent predictor of long-term mortality (HR1.59, 95%CI 1.00–2.53, p = 0.048). Landmark analysis of survivors to discharge found the long-term mortality of LM PCI approaches 60% compared to 27% for those with non-LM PCI (p = 0.003).

Conclusion

Long-term outcomes after PCI to LM in cardiogenic shock are poor, with much of the excess in mortality occurring early. However, reasonable long-term survival was found beyond the initial high-risk period.

Introduction

Several studies have shown a significant benefit following the treatment of left main stenosis with coronary artery bypass graft (CABG) surgery compared with medical treatment or percutaneous coronary intervention (PCI) in stable coronary artery disease [1,2]. CABG has thus, until recently, been considered as the gold standard treatment of left main coronary artery (LM) disease in the stable setting [3,4]. However, in the setting of an acute coronary syndrome with cardiogenic shock, acute LM occlusion leads to a large area of at risk myocardium, a high burden of arrhythmia and a very high risk of early mortality. There is limited information available on short and longer-term outcomes in the setting of cardiogenic shock with a significant LM stenosis. Time to revascularization is often delayed with CABG and there is significant morbidity associated with surgical revascularization when performed emergently [5]. Therefore, emergent PCI to the LM is often performed as the preferred treatment despite a paucity of information regarding the long-term outcomes after this approach.

The aim of this study was to analyze the multi-centre Australian Melbourne Interventional Group (MIG) Registry, to identify the short and long-term outcomes after isolated LM stenting compared to non-LM PCI in patients with cardiogenic shock.

Section snippets

Methods

This is a multi-centre, observational cohort study of consecutive patients with cardiogenic shock undergoing PCI from January 1, 2005 to November 30, 2013 enrolled in the MIG registry. Patients with previous CABG were excluded. Patients with cardiogenic shock with PCI to an LM were compared to those with a PCI to a non-LM.

Cardiogenic shock was defined as a sustained (>30 min) episode of systolic blood pressure (SBP) <90 mmHg (or vasopressors required to maintain SBP ≥ 90 mmHg), evidence of

Results

Of a total of 18,069 PCI procedures (excluding prior CABG) performed during the period of 1st January 2005 to 30th November 2013, 601 procedures were performed in the setting of cardiogenic shock. Among patients with cardiogenic shock, 45 patients (7.5%) had an LM PCI and 556 patients (92.5%) had a non-LM PCI.

Table 1 shows the baseline demographic, clinical and procedural characteristics of the two groups. Those that had an LM PCI in this setting were significantly older, were more likely to

Discussion

The most striking finding in our study is the very high rate of mortality of LM PCI in the setting of cardiogenic shock, especially early. After discharge, LM PCI survivors exhibited a plateau phase relative to the in-hospital period, although their long-term mortality was still significantly higher than the non-LM group. The LM cohort was older with a lower baseline LVEF but was significantly less likely to present with an out-of-hospital cardiac arrest or STEMI. After adjustment for the

Conclusion

Outcomes after PCI to an LM in cardiogenic shock are very poor with much of the excess mortality occurring early, despite improvements in PCI technique with high rates of procedural success. Given the paucity of evidence, the decision to perform CABG or PCI in patients with cardiogenic shock and LM disease still needs to be individualized, taking into account hemodynamic status, coronary anatomy, procedural and operator factors such as experience and immediate availability. Rigorous evaluation

Authorship statement

All authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and the discussed interpretation.

Disclosures

Professor Stephen Duffy's work is supported by a NHMRC grant. Professor Reid is supported by a NHMRC Senior Research Fellowship (reference no. 1045862). A/Prof Stub is supported by a NHF Future Leader Fellowship (reference no. 101908), and a Viertel Foundation Clinical Investigator award.

The Melbourne Interventional Group acknowledges funding from Abbott Vascular, Astra-Zeneca, BMS and Pfizer. These companies do not have access to data and do not have the right to review manuscripts or

CRediT authorship contribution statement

Julian Yeoh: Conceptualization, Methodology, Formal analysis, Writing - original draft. Nick Andrianopoulos: Formal analysis. Christopher M. Reid: Writing - review & editing. Matias B. Yudi: Writing - review & editing. Garry Hamilton: Methodology, Writing - review & editing. Melaine Freeman: Writing - review & editing. Samer Noaman: Writing - review & editing. Ernesto Oqueli: Writing - review & editing. Sandra Picardo: Writing - review & editing. Angela Brennan: Methodology. William Chan:

Acknowledgements

MIG Data Management Centre, CCRE, Monash University:

Professor Chris Reid, Dr. Nick Andrianopoulos, Ms. Angela Brennan, Dr. Diem Dinh.

MIG Steering Committee:

Professor Chris Reid, Associate Professor Andrew Ajani, Professor Stephen Duffy

Associate Professor David Clark, Dr. Melanie Freeman, Dr. Chin Hiew

Associate Prof Ernesto Oqueli, Ms. Angela Brennan.

The following investigators, data managers and institutions participated in the MIG Database:

Alfred Hospital: SJ Duffy, D Stub, JA Shaw, A Walton,

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