Unprotected Left Main “Kissing” Stent Implantation With a Percutaneous Ventricular Assist Device

Case Report. An 80-year-old man with severe chronic obstructive pulmonary disease, chronic renal insufficiency and significant carotid artery disease presented with a 4-day history of episodic severe substernal chest pressure at rest. Echocardiography showed severe left ventricular dysfunction (ejection fraction 10%), anterior wall akinesis and moderate mitral regurgitation. Cardiac catheterization revealed a 95% distal left main (LM) coronary artery stenosis that involved the ostia of both the left circumflex (LCx) artery and the left anterior descending (LAD) artery, which was also subtotally occluded, and a 50% stenosis in the mid right coronary artery. The LAD had TIMI grade 1 distal flow. Positron emission tomography revealed lateral wall ischemia and high anterolateral viability. The patient was felt to be at high risk for surgical revascularization, and thus we proceeded with hemodynamically supported LM angioplasty with the TandemHeart percutaneous ventricular assist device (Cardiac Assist Technologies, Inc., Pittsburgh, Pennsylvania). A 21 French (Fr) in-flow cannula was advanced via the transseptal technique into the left atrium under intracardiac guidance, a 15 Fr out-flow cannula was inserted into the right femoral artery and advanced to the right common iliac artery, and resultant left atrial-to-distal aorta bypass was achieved with a non-pulsatile flow rate of 3.0 liters per minute. The LAD and LCx were both wired, and stented utilizing two sirolimus-eluting stents simultaneously deployed with a “kissing” technique. During balloon inflation, hemodynamic monitoring revealed a significant decrease in aortic pulse pressure due to diminished stroke volume. Despite the drop in pulse pressure, mean perfusion pressure was maintained and the patient remained hemodynamically stable without angina or arrhythmia. The final angiographic result shows percutaneous reconstruction of the distal LM and the proximal portions of the LAD and the LCx. The bypass cannulae were successfully removed immediately post-procedure, and hemostasis was achieved via manual compression. The patient was discharged 2 days later and remains angina-free at 1-month follow-up. Discussion. This case demonstrates successful unprotected LM stenting using a percutaneous ventricular assist device in a patient at high risk for both peri-procedural and peri-operative mortality. Traditionally, left main coronary artery disease is optimally treated with surgical revascularization with low 30-day mortality rates (2–3%) and high long-term success.^1–5 However, patients with comorbidities including ventricular dysfunction, advanced age and renal disease are at significantly higher risk for short-term mortality and morbidity.⁶ In these high-risk subgroups, elective unprotected LM angioplasty may be considered.^5,7 Prophylactic insertion of an intra-aortic balloon pump (IABP) has been advocated and may be associated with improved outcome.^8–9 In high-risk candidates, a percutaneous left ventricular assist device provides superior hemodynamic support compared with IABP, and may reduce procedural morbidity and mortality.¹⁰

1. Boehrer JD, Lange RA, Willard JE, et al. Markedly increased periprocedure mortality of cardiac catheterization in patients with severe narrowing of the left main coronary artery. Am J Cardiol 1992;70:1388–1390. 2. Caracciolo EA, Davis KB, Sopko G, et al. Comparison of surgical and medical group survival in patients with left main coronary artery disease. Long-term CASS experience. Circulation 1995;91:2325–2334. 3. Chaitman BR, Fisher LD, Bourassa MG, et al. Effect of coronary bypass surgery on survival patterns in subsets of patients with left main coronary artery disease. Report of the Collaborative Study in Coronary Artery Surgery (CASS). Am J Cardiol 1981;48:765–777. 4. Yusuf S, Zucker D, Peduzzi, et al. Effect of coronary artery bypass surgery on survival: overview of 10-year results from randomized trials by the Coronary Artery Bypass Graft Surgery Trialists Collaboration. Lancet 1994;344:563–570. 5. Sadeghi HM, O’Neill WW, Grines CL. Percutaneous intervention of unprotected left main coronary artery. J Intervent Cardiol 2003;16:281–288. 6. Ellis SG, Hill CM, Lytle BW. Spectrum of surgical risk for left main coronary stenoses: benchmark for potentially competing percutaneous therapies. Am Heart J 1998;135:335–338. 7. Silvestri M, Barragan P, Sainsous J, et al. Unprotected left main coronary artery stenting: immediate and medium-term outcomes of 140 elective procedures. J Am Coll Cardiol 2000;35:1543–1550. 8. Anwar A, Mooney MR, Stertzer SH, et al. Intra-aortic balloon counterpulsation support for elective coronary angioplasty in the setting of poor left ventricular function: a two center experience. J Invas Cardiol 1990;2:175–180. 9. Kreidieh I, Davies DW, Lim R, et al. High-risk coronary angioplasty with elective intra-aortic balloon pump support. Int J Cardiol 1992;35:147–152. 10. Lemos PA, Cummins P, Lee C, et al. Usefulness of percutaneous left ventricular assistance to support high-risk percutaneous coronary interventions. Am J Cardiol 2003;91:479–481.