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Left Main Coronary Artery Dissection Complicating Diagnostic Coronary Angiography

Left Main Coronary Artery Dissection Complicating Diagnostic Coronary Angiography. Layth A. Mimish MBChB, FRCPC, FACC Medical Director The Cardiovascular Consultant Clinic Jeddah, KSA. I have no conflict of interest pertaining to this presentation. Left Main Coronary Dissection.

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Left Main Coronary Artery Dissection Complicating Diagnostic Coronary Angiography

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  1. Left Main Coronary Artery DissectionComplicating Diagnostic Coronary Angiography Layth A. Mimish MBChB, FRCPC, FACC Medical Director The Cardiovascular Consultant Clinic Jeddah, KSA

  2. I have no conflict of interest pertaining to this presentation

  3. Left Main Coronary Dissection • Definition and Classification • Incidence • Etiology • Management • Conservative • CABGS • Stenting

  4. NHLBI Classification

  5. Left Main Coronary Dissection • Spontaneous • Extension from Aortic Dissection • Complication of Diagnostic Coronary Angiography or Coronary Interventional procedure

  6. Iatrogenic Left Main Coronary Dissection • Calcification of Lt. Main Stem • Anatomical distortion in aortic root or origin of Lt main that makes selective intubation difficult • The angle formed by the tip of the catheter and the intima of the vessel • The depth with which the artery is cannulated • Forceful injection with dampened pressure • Femoral Vs radial approach • Diagnostic Vs PCI

  7. Left Main Coronary Dissection • Sone’s initial series 4200 diagnostic procedures, 1 reported dissection • Massachusetts General Hospital 1970-1975 2981 Pts, Lt. main dissection in 1 • Dennis, W., William O’Neil, Cath C V Intervention 2000, data review 43,143 diagnostic procedures and PCI (0.02%) • Carter AJC 1994 3cases, incidence 0.02 for diagnostic angiography, and 0.07% for PCI • Under-reported, with severity varying from type A to severe aortic root dissection

  8. Conservative Treatment

  9. CABG Vs Medical Therapy

  10. ACC / AHA Guidelines

  11. Clinical Outcomes with CABG in Lt. Main Disease • 18 Centers • Jan 2001-June 2003 • 5,494 Consecutive CABG with no exclusion • 1,394 Lt main (24.1%) • Operative mortality 4.1% (All other CABG 2.3%) • CVA 1.3% Katz, Mack, Simon

  12. OPCAB in LMCA Disease Dewey,et al, Ann Thorac Surg 2001

  13. Motality for CABG in Lt Main NYS Database 1997-2000

  14. Stent Vs Conventional Rxfor Abrupt Closure or Symptomatic Dissection

  15. French Lt Main RegistryMay 2001-June 2002 (11 French Centers)

  16. French Lt Main Registry1 Yr Outcome

  17. French Lt Main Registry1 Month &1 Yr Outcome

  18. French Lt Main Registry1 Month &1 Yr Outcome

  19. French Lt Main Registry1 Month &1 Yr Outcome

  20. IVUS Optimization for Stent Deployment

  21. DES Vs BMS in Milan6 Month Clinical & Angiographic F/Up

  22. DES in Lt Main DiseaseRESEARCH & T-SEARCH Registry • April 16, 2002-Dec 31, 2003 • > 50% Lt min • Consensus agreement with CV surgeon with patient and referring MD • 95 Consecutive Pts, with 1 DES (SES 52, PES 43) • Comparison group 86 Consecutive pts who got BMS for Lt main immediately before DES availability • Median F/UP 503 days (331-873)

  23. DES in Lt Main DiseaseRESEARCH & T-SEARCH Registry

  24. LMCA Intervention in AMC

  25. In Hospital Outcome

  26. Overall Restenosis rate 7.9%

  27. 6 Months Clinical Outcome

  28. MACE Free Survival at 1 Year

  29. Coclusion • Rapid & thorough assessment • CV Surgeon involved • Haemodynamic support • DES Vs emergency CABGS • IVUS

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