Heart Diseases

Biography

Biography: Nazim MEGHERBI

Abstract

Introduction :

Acute total occlusion of the left main (LM) is rarely encountered in the cathlab, its incidence is difficult to determine because most often fatal. This is a frightening situation where there is a paucity of data and that we might be led to meet.

We report 4 cases of total occlusion of the left main revealed by an acute coronary syndrome observed between the year 2015 and 2016 in our cathlab

Results:

The age of patients was between 29 and 72 years with tobacco as a common risk factor; three patients were admitted for NSTEMI at high risk and two for STEMI, one of whom was thrombolysed with failure. Of the 5 patients 3 presented in shock. The delay for revascularization was between 1 hour and 5 hours for the first four patients, this delay was

26 hours for the last one. The EKG of our patients was characterized by a labile aspect from one patient to another, the ST segment elevation in AVR was observed in all the patients. Only one patient had an LVEF altered at the echography. In the first three patients, coronary angiography showed a completely occluded LM (TIMI 0, RENTROP 0), (figure 1) they underwent instrumental thrombectomy under anti-GPIIbIIIa treatment with restoration of a satisfactory coronary flow at a first step, a delayed angiographic control of 48 hours showed a coronary arteries without significant lesion in one patient while the two others underwent angioplasty (figure 2). The fourth patient had a complete occlusion of the LM, a dominant RCA with a tight stenosis on its second segment overtaking the LAD (RENTROP II), an urgent surgical revascularization was performed for this patient (figure 3). For these first four patients the evolution was favorable. The fourth patient illustrates the severity of this lesion, the patient came late to our level after the failure of thrombolysis where coronary angiography revealed an occluded LM without collaterals (REnTROP 0), thrombo-aspiration associated with anti GpIIbIIIa therapy could restor a TIMI III flow but a bad LAD artery, alas he continued to degrade its cardiac insufficiency leading to the death at the 5th day of hospitalization (figure 4).

Conclusion:

For this type of lesion angioplasty is a saving option; the prognosis is generally related to the right or left dominance, the development of collateral circulation and especially the celerity of revascularization. Delayed stenting seems to appear safe in order to reduce the risk of embolization and no reflow. Surgical revascularization is a reasonable attitude when the patient is stable with a low operative risk.