Ajello, L

Andolina, G

Asciutto, S

Assennato, P.

Candela, P

Coppola, G

Di Girolamo, P

Farinella, M

NOVO, Salvatore

Nugara, C

Piraino, D

Rotolo, A

Sansone, A

Sucato, V

Vincenzo Sucato

Angela Sansone

Giuseppe Coppola

Cinzia Nugara

Laura Ajello

Pietro Candela

Paola Di Girolamo

Salvatore Asciutto

Michele Farinella

Davide Piraino

Antonino Rotolo

Giuseppe Andolina

Salvatore Novo

Pasquale Assennato

Crossref

International Journal of Cardiology

Decision making and devices approach in a case of left main coronary artery thrombus

Archivio istituzionale della ricerca - Università di Palermo

International Journal of Cardiology 172 (2014) e273–e275Contents lists available at ScienceDirectInternational Journal of Cardiologyj ourna l homepage: www.e lsev ie r .com/ locate / i j ca rdLetter to the EditorDecision making and devices approach in a case of left main coronaryartery thrombus☆,☆☆Vincenzo Sucato ⁎, Angela Sansone, Giuseppe Coppola, Cinzia Nugara, Laura Ajello, Pietro Candela,Paola Di Girolamo, Salvatore Asciutto, Michele Farinella, Davide Piraino, Antonino Rotolo, Giuseppe Andolina,Salvatore Novo, Pasquale AssennatoDivision of Cardiology II, Department of Internal Medicine and Cardiovascular Diseases, University Hospital Paolo Giaccone, Palermo, Italy☆ This statement is to certify that all authors have seenbeing submitted, have contributed signiﬁcantly to the wlegitimacy of the data and its interpretation, and agInternational Journal of Cardiology. We attest that the artichas not received prior publication and is not underelsewhere. We adhere to the statement of ethical pub(Shewan LG et al 2013 in press).☆☆ On behalf of all co-authors, the corresponding authorthe submission.⁎ Corresponding author at: Division of Cardiology II, Dand Cardiovascular Diseases, University Hospital Paolo Gi90127 Palermo, Italy. Tel.: +39 1 6554303; fax: +39 1 65E-mail address: odisseos86@alice.it (V. Sucato).0167-5273/$ – see front matter © 2014 Elsevier Ireland Lhttp://dx.doi.org/10.1016/j.ijcard.2013.12.205a r t i c l e i n f oArticle history:Received 12 November 2013Accepted 28 December 2013Available online 8 January 2014Keywords:Left main coronary arteryThrombusIntravascular ultrasoundElectrocardiogramshowed normal sinus rhythm(79 bpm)and rightbundle branch block (RBBB) (Fig. 1). Echocardiography study revealedpreserved global left ventricular ejection fraction (EF 55%), no segmen-tary hypokinetic segments. Patient gave history of similar pain at rest, aday before admission. Cardiac I troponin on admissionwas negative andso also at the subsequent samplings. Given the peculiarity of chest painthat had the characteristic of angina and the presence of cardiovascularrisk factors, standard medical management based on pharmacotherapywith aspirin, clopidogrel, fondaparinux, bisoprolol, rosuvastatin andDear EditorA left main coronary artery (LMCA) thrombosis is a life-threateningcondition demanding immediate therapeutic management. Clinicalpresentation varies andoften includes -ST or non-ST elevationmyocardialinfarction (STEMI/NSTEMI), unstable angina (UA), and sudden cardiacdeath (SCD) [1].A 56-year-old woman was admitted to our Coronary Care Unit foracute chest pain lasting for half an hour, radiating to the jugulum andleft shoulder and resolved spontaneously. She was hypertensive butshe did not have past medical history. On examination, heart rate(HR) was 79/min, and blood pressure (BP): 150/90 mmHg. Graceand approved the manuscriptork, attest to the validity andree to its submission to thele is the authors' original work,consideration for publicationlishing as appears in IJC 2013shall bear full responsibility forepartment of Internal Medicineaccone, Via Del Vespro no 129,54304.td. All rights reserved.risk score and Crusade bleeding score were low (78 and 17 pointsrespectively).ranitidine.The patientwas scheduled for invasive coronary angiography (CAG),that showed subocclusion of the distal leftmain coronary artery (LMCA)engaging the emergence of the left coronary artery (LCA) and leftcircumﬂex coronary artery (LCx) (Fig. 1). No other signiﬁcant lesionswe observed. Because of the clinical stability of the patient, no chestpain recurrence, and the likely thrombotic nature of the angiographicimage ofminus; a decision to administer a 12-hour infusion of abciximab(GpIIb/IIIa receptor inhibitor- GpIIb/IIIa RI), was made.In order to clearly evaluate the features of LMCA lesion, intravascularultrasound (IVUS) examination was performed, conﬁrming the presenceof critical calciﬁc plaque involving distal LMCA and its bifurcation into LCAand LCx, and a superimposed thrombus, unresponsive to GpIIb/IIIaRItreatment (Fig. 2).Then, it made anunsuccessful attempt to angioplasty and thrombus-aspiration with AngioJet® Ultra Thrombectomy System, Bayer HealthCare. On angiographic and IVUS data, so it was recommended amyocar-dial revascularization by coronary artery bypass grafting (CABG), thatthe patient refused. She discharged home on dual antiplatelet therapyincluding aspirin and prasugrel stressing her high-risk clinical conditionand the importance of a prompt surgical revascularization.LMCA thrombus is caused by a variety of pathologic causes includingsecondary to plaque rupture with subsequent thrombus formation,persistent hypercoagulable state, cocaine use, and vasospasm. The inci-dence of LMCA thrombus is unknown, but is thought to be ~0.8%. This islikely an underrepresentation given that presentation may be suddencardiac death that may not be classiﬁed as being secondary to LMCAthrombus.In the ﬁrst time, like in our case, approach to management of LMCAthrombus is often conservative in patients with following conditions: noFig. 1. Upper panel: ECG showing sinus rhythm (79 bpm) and right bundle branch block. Lower panel: coronary angiography showing subocclusion of distal left main coronary artery(LMCA) involving the emergence of the left coronary artery and left circumﬂex coronary artery.e274 V. Sucato et al. / International Journal of Cardiology 172 (2014) e273–e275evidence of ongoing ischemia, absence of signiﬁcant ﬂow-limiting diseasein LMCA, absence of signiﬁcant atherosclerotic disease in remaining por-tions of coronary three, and TIMI III ﬂow in LAD and LCx [2]. Conservativemanagement includes 24–48 h of IV heparin or glycoprotein IIb/IIIa inhi-bition, and aspirin. After conservative treatment, patients should undergorepeat angiography to reevaluate the thrombus to determine resolutionversus further intervention [3]. Intravascular ultrasound (IVUS) use iscontroversial; IVUS guidance is helpful in assessing vessel size, adequatestent expansion, and absence of stent malposition [4].Non-conservative management includes percutaneous interventionincluding stenting, and mechanical aspiration thrombectomy or CABG.Several aspiration or active thrombectomy have been introduced tointerventional cardiology. There is no evidence supporting routinethrombus extraction during primary PCI in terms of mortality or areduction in major adverse cardiac events [5]. On the other hand, severalsingle-center studies have shown that manual thrombus aspirationcontributed to better epicardial ﬂow, lower risk of distal embolizationandno reﬂow in ST elevationAMIpatients [6]. It is not clear if this strategycan be incorporated into routine treatment of LMCA thrombosis, but inselective cases it might be useful to start with catheter aspiration. Thisprocedure is both technically simple and safe. However, there is noreliable evidence that aspiration thrombectomy is more effective thansurgical revascularization in such cases.Most of the clinical risk-scoring systemused for unprotected LMCAhasbeen extrapolated from patients treated with CABG. Recently, theFig. 2. IVUS showing the presence of critical calciﬁc plaque involving distal LMapplication of a coronary anatomical risk score based on lesion severityand extent (SYNTAX score) has provided insight into both patientselection [7]. In our case the patient have a distal LM lesion that in mostcases treated as true bifurcation lesions. True distal bifurcation lesionsmay be treated either by a single-stent or by a two-stent strategy. Choiceof strategy is based on vessel and lesion characteristics but also on op-erator experience and expertise. The provisional stenting is a single-stent strategy, although it allows the placement of a second stent if re-quired. More complex lesions may require double-stent strategy. Inthis case, after mechanical aspiration thrombectomy failure, weopted to surgery that should be preferred in these followingsituations: patientswith heavy calciﬁed LMdisease; reduced LV function;diabetics; multiple vascular disease suitable for CABG (particularly withlow EuroSCORE); distal LM bifurcation lesion with reduced LV functionor with occluded RCA or with additional complex lesions on the othercoronary vessels (high SYNTAX score) [8].The new anti-platelet agents (prasugrel and ticagrelor) could im-prove the safety of PCI in complex LM lesions, but they need to beevaluated in this particular setting. The future EXCEL trial (evaluationof Xience Prime or Xience V-eluting stent vs. CABG for effectivenessof LM revascularization) will evaluate the safety and efﬁcacy of PCIwith Xience Prime or Xience V EES vs. CABG in patients with ULMCAdisease with a low or intermediate SYNTAX score (b33) for whichchoosing of appropriated therapeutic strategy is currently oftenproblematic [9].CA and its bifurcation into LCA and LCx, and a superimposed thrombus.e275V. Sucato et al. / International Journal of Cardiology 172 (2014) e273–e275References[1] Stone P, Goldschlager N. Left main coronary artery disease: review and appraisal.Cardiovasc Med 1979;4:165–77.[2] Klein AJ, Casserly IP, Messenger JC. Acute left main coronary arterial thrombosis — acase series. J Invasive Cardiol Aug 2008;20(8):E243–6.[3] Mischie AN, Nazzaro MS, Sinescu C, Violini R. Successful management of ostial leftmain thrombus by systemic thrombolysis. Eur Heart J 2011;32(5):654.[4] Park SJ, Kim YH, Park DW, et al. Impact of intravascular ultrasound guidance onlong-term mortality in stenting for unprotected left main coronary artery stenosis. CircCardiovasc Interv 2009;2:167–77.[5] Lefe'vre T, Garcia E, Reimers B, et al. X-sizer for thrombectomy in acute myocardialinfarction improves ST-segment resolution: results of the X-sizer in AMI for negligibleembolization and optima ST resolution (X AMINE ST) trial. J Am Coll Cardiol2005;46(2):246–52.[6] Silva-Orrego P, Colombo P, Silva-Orrego BP, et al. Thrombus aspiration before primaryangioplasty improves myocardial reperfusion in acute myocardial infarction: theDEAR-MI (dethrombosis to enhance acute reperfusion in myocardial infarction)study. J Am Coll Cardiol 2006;48(8):1552–9.[7] Sianos G, Morel MA, Kappetein AP, et al. The SYNTAX score: an angiographic toolgrading the complexity of coronary artery disease. EuroIntervention 2005;1:219–27.[8] Park SJ, Kim YH, Park DW, et al. Randomized trial of stents versus bypass surgery forleft main coronary artery disease. N Engl J Med 2011;364:1718–27.[9] Capodanno D, Tamburino C. Unraveling the EXCEL: promises and challenges of thenext trial of left main percutaneous coronary intervention. Int J Cardiol Apr 52012;156(1):1–3.

Decision making and devices approach in a case of left main coronary artery thrombus.

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Decision making and devices approach in a case of left main coronary artery thrombus.

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Archivio istituzionale della ricerca - Università di Palermo