Korean Circulation Journal

The Korean Society of Cardiology (대한심장학회)
권호 표지
DOI QR코드

DOI QR Code

Risk Factors Associated with Hemodynamic Instability during Stent Implantation in Unprotected Left Main Lesions without Routine IABP: Identification of the High Risk Patients

  • Kim, Woong (Cardiology Division, Department of Internal Medicine, Yeungnam University Medical Center) ;
  • Park, Jong-Seon (Cardiology Division, Department of Internal Medicine, Yeungnam University Medical Center) ;
  • Lee, Sang-Hee (Cardiology Division, Department of Internal Medicine, Yeungnam University Medical Center) ;
  • Hong, Geu-Ru (Cardiology Division, Department of Internal Medicine, Yeungnam University Medical Center) ;
  • Shin, Dong-Gu (Cardiology Division, Department of Internal Medicine, Yeungnam University Medical Center) ;
  • Kim, Young-Jo (Cardiology Division, Department of Internal Medicine, Yeungnam University Medical Center) ;
  • Shim, Bong-Sup (Cardiology Division, Department of Internal Medicine, Yeungnam University Medical Center) ;
  • Cho, Yoon-Kyung (Department of Internal Medicine, Keimyung University School of Medicine, Keimyung University Dongsan Hospital) ;
  • Kim, Hyung-Seop (Department of Internal Medicine, Keimyung University School of Medicine, Keimyung University Dongsan Hospital) ;
  • Nam, Chang-Wook (Department of Internal Medicine, Keimyung University School of Medicine, Keimyung University Dongsan Hospital) ;
  • Hur, Seung-Ho (Department of Internal Medicine, Keimyung University School of Medicine, Keimyung University Dongsan Hospital) ;
  • Kim, Yoon-Nyun (Department of Internal Medicine, Keimyung University School of Medicine, Keimyung University Dongsan Hospital) ;
  • Kim, Kwon-Bae (Department of Internal Medicine, Keimyung University School of Medicine, Keimyung University Dongsan Hospital) ;
  • Seol, Sang-Hoon (Department of Internal Medicine, Inje University College of Medicine, Inje University Paik Hospital) ;
  • Yang, Tae-Hyun (Department of Internal Medicine, Inje University College of Medicine, Inje University Paik Hospital) ;
  • Kim, Dae-Kyung (Department of Internal Medicine, Inje University College of Medicine, Inje University Paik Hospital) ;
  • Kim, Sung-Man (Department of Internal Medicine, Inje University College of Medicine, Inje University Paik Hospital) ;
  • Kim, Doo-Il (Department of Internal Medicine, Inje University College of Medicine, Inje University Paik Hospital) ;
  • Kim, Dong-Soo (Department of Internal Medicine, Inje University College of Medicine, Inje University Paik Hospital)
  • Published : 2007.03.30
⟨ Previous Next ⟩

Abstract

Background and Objectives：Percutaneous coronary intervention (PCI) of unprotected left main coronary artery (LMCA) stenosis is a promising approach during this era of drug-eluting stents. However, there is no available hemodynamic data on these type patients during the performance of LMCA stenting. The purpose of this study was to determine the risk factors affecting hemodynamic stability during LMCA stenting, and to evaluate whether hemodynamic support such as inotropics or intra-aortic balloon pump (IABP) is needed, based on the risk factors. Subjects and Methods：From July 2003 to January 2006, we enrolled 92 study patients (Male=55) who had visited Yeungnam University Hospital, Keimyung University Dongsan Hospital and InJe University Baik Hospital in Busan and they were all were diagnosed with angiographically detected unprotected LMCA stenosis. Group 1 (n=69) included those patients who did not need hemodynamic support during PCI. Group 2 (n=23) included patients who needed hemodynamic support during PCI. All patients had stents deployed in the LMCA lesions without hemodynamic support; the clinical, angiographic and procedural outcomes were compared between the two groups after the procedure. Results：The baseline patient characteristics were not statistically different between the two groups. On univariate analysis, Group 2 had more patients diagnosed with acute myocardial infarction (AMI) than Group 1 (40% vs. 15%, respectively, p=0.014). Group 1 had a greater frequency of an increased left ventricular (LV) ejection fraction than Group 2 (60±10 vs. 47±11, respectively, p=0.01). Regarding the lesion location in the LMCA, Group 2 had relatively more lesions at bifurcated locations than Group 1 (44% vs. 78%, respectively, p=0.004). Group 2 required more complex techniques to repair lesions, such as kissing or crush stenting, than did Group 1 (19% vs. 48%, respectively, p=0.006). Multivariate logistic regression analysis showed that the presence of AMI (Odds Ratio (OR)=3.74, p=0.014), a complex stenting procedure such as kissing or crushing (OR=3.99, p=0.006), a bifurcated lesion (OR=4.58, p=0.004) and poor LV function (OR=9.95, p= 0.0001) were independent risk factors for hemodynamic instability during LMCA stenting. Conclusion：The most important risk factor for hemodynamic instability during LMCA stenting was LV function. Therefore, preparation for hemodynamic support, including IABP before the procedure, is necessary for the high risk patients. (Korean Circulation J 2007;37:108-112)

Keywords

References

  1. Lopez JJ, Ho KK, Stoler RC, et al. Percutaneous treatment of protected and unprotected left main coronary stenoses with new devices: immediate angiographic results and intermediate-term follow-up. J Am Coll Cardiol 1997;29:345-52 https://doi.org/10.1016/S0735-1097(96)00488-3
  2. Ellis SG , Tamai H, Nobuyoshi M, et al. Contemporary percutaneous treatment of unprotected left main coronary stenoses: initial results from a multicenter registry analysis 1994-1996. Circulation 1997;96:3867-72 https://doi.org/10.1161/01.CIR.96.11.3867
  3. Park SJ, Park SW, Hong MK, et al. Long-term(three year) outcomes after stenting of unprotected left main coronary artery stenosis in patients with normal left ventricular function. Am J Cardiol 2003;91:12-6
  4. Tan WA, Tamai H, Park SJ, et al. Long-term clinical outcomes after unprotected left main trunk percutaneous revascularization in 279 patients. Circulation 2001;104:1609-14 https://doi.org/10.1161/hc3901.096669
  5. Park SJ, Park SW, Hong MK, et al. Stenting of unprotected left main coronary artery stenosis without angicoagulation: immediate and late outcomes. Korean Circ J 1997;27:947-57 https://doi.org/10.4070/kcj.1997.27.10.947
  6. Park JH, Cho YH, Lee SH, et al. Long term clinical follow-up in patients with left main coronary disease according to treatment strategies. Korean Circ J 2003;33:568-73 https://doi.org/10.4070/kcj.2003.33.7.568
  7. Park SJ, Lee CH, Kim YH, et al. Technical feasibility safety, and clinical outcome of stenting of unprotected left main coronary artery bifurcation narrowing. Am J Cardiol 2002;90:374-8 https://doi.org/10.1016/S0002-9149(02)02492-X
  8. Briguori C, Airoldi F, Chieffo A, et al. Elective versus provisional intraaortic balloon pumping in unprotected left main stenting. Am Heart J 2006;152:565-72 https://doi.org/10.1016/j.ahj.2006.02.024
  9. Lenzen MJ, Boersma E, Bertrand ME, et al. Management and outcome of patients with established coronary artery disease. Eur Heart J 2005;26:1169-79 https://doi.org/10.1093/eurheartj/ehi238
  10. Moses JW, Leon MB, Popma JJ, et al. Sirolimus-eluting stents versus standard stents in patients with stenosis in a native coronary artery. N Engl J Med 2003;349:1315-23 https://doi.org/10.1056/NEJMoa035071
  11. Chieffo A, Stankovic G , Bonizzoni E, et al. Early and mid-term results of drug-eluting stent implantation in unprotected left main. Circulation 2005;111:791-5 https://doi.org/10.1161/01.CIR.0000155256.88940.F8
  12. Valgimigli M, van Mieghem CA, Ong AT, et al. Short and long term clinical outcome after drug eluting stent implantation for the percutaneous treatment of left main coronary artery disease: insights from the Rapamycin-eluting and Taxus Stent Evaluated At Rotterdam Cardiology Hospital registries(RESEARCH and TSEARCH). Circulation 2005;111:1383-9 https://doi.org/10.1161/01.CIR.0000158486.20865.8B
  13. Park SJ, Kim YH, Lee BK, et al. Sirolimus eluting stent implantation for unprotected left main coronary artery stenosis: comparison with bare metal stent implantation. J Am Coll Cardiol 2005;45:351-6 https://doi.org/10.1016/j.jacc.2004.10.039
  14. Black A, Cortina R, Bossi I, Choussat R, Fajadet J, Marco J. Unprotected left main coronary artery stenting: correlates of midterm survival and impact of patient selection. J Am Coll Cardiol 2001; 37:832-8 https://doi.org/10.1016/S0735-1097(00)01176-1
  15. Park SJ, Hong MK, Lee CW, et al. Elective stenting of unprotected left main coronary artery stenosis: effect of debulking before stenting and intravascular untrasound guidance. J Am Coll Cardiol 2001;38:1054-60 https://doi.org/10.1016/S0735-1097(01)01491-7
  16. Takagi T, Stankovic G , Finci L, et al. Results and long-term predictors of adverse clinical events after elective percutaneous interventions on unprotected left main coronary artery. Circulation 2002;106:698-702 https://doi.org/10.1161/01.CIR.0000024983.34728.5D
  17. Kelley MP, Klugherz BD, Hashemi SM, et al. One-year clinical outcomes of protected and unprotected left main coronary artery stenting. Eur Heart J 2003;24:1554-9 https://doi.org/10.1016/S0195-668X(03)00314-2
  18. Smith SC Jr, Dove JT, Jacobs AK, et al. ACC/AHA guidelines of percutaneous coronary interventions(revision of the 1993 PTCA guidelines)-executive summary: a report of the American College of Cardiology/American Heart Association task force on practice guidelines(committee to revise the 1993 guidelines for percutaneous transluminal coronary angioplasty). J Am Coll Cardiol 2001;37:2215-39 https://doi.org/10.1016/S0735-1097(01)01344-4
  19. Szatmary LJ, Marco J. Haemodynamic and antiischemic protective effects of intraaortic balloon counterpulsation in high risk coronary heart patients undergoing percutaneous transluminal coronary angioplasty. Cor Vasa 1987;29:183-91
  20. Kern MJ, Aguirre F, Bach R, Donohue T, Siegel R, Segal J. Augmentation of coronary blood flow by intra-aortic balloon pumping in patients after coronary angioplasty. Circulation 1993;87:500-11 https://doi.org/10.1161/01.CIR.87.2.500
  21. Dietl CA, Berkheimer MD, Woods EL, Gilbert CL, Pharr WF, Benoit CH. Efficacy and cost-effectiveness of preoperative IABP in patients with ejection fraction of 0.25 or less. Ann Thorac Surg 1996;62:401-9 https://doi.org/10.1016/0003-4975(96)00244-5
  22. Stone GW, Marsalese D, Brodie BR, et al. A prospective randomized evaluation of prophylactic intraaortic balloon counterpulsation in high risk patients with acute myocardial infarction treated with primary angioplasty. J Am Coll Cardiol 1997;29:1459-67 https://doi.org/10.1016/S0735-1097(97)00088-0
  23. Van't Hof AW, Liem AL, de Boer MJ, Hoomtje JC, Suryapranata H, Zijlstra F. A randomized comparison of intraaortic balloon pumping after primary coronary angioplasty in high risk patients with acuty myocardial infarction. Eur Heart J 1999;20:659-65 https://doi.org/10.1053/euhj.1998.1348
  24. Alderman JD, Gabliani GI, McCabe CH, et al. Incidence and management of ischemia with percutaneous wire guided intraaortic balloon catheters. J Am Coll Cardiol 1987;9:524-30 https://doi.org/10.1016/S0735-1097(87)80044-X