When the situation almost cannot be worse…

A 60-year-old man without a history of coronary artery disease presented with ST-elevation myocardial infarction (STEMI). During transportation to the hospital, he developed ventricular fibrillation and later pulseless electrical activity. Chest compressions with an automated mechanical compression–decompression device (aMCD) were initiated. Coronary angiography showed total occlusion of the unprotected left main coronary artery (uLM), and primary percutaneous coronary intervention (PCI) was performed during continuous cardiopulmonary resuscitation (CPR). After the reperfusion, the patient’s heart started to generate effective contractions and aMCD could be discontinued. Return of spontaneous circulation was achieved after 90 min of cardiac arrest. The patient died of cardiogenic shock 11 h later [1].
This is one of several potential clinical scenarios of patients with uLM occlusion. Reperfusion was performed in a timely manner, but the patient still died. What are the causes of such unfavorable progress? Is there any possibility of discovering how to increase the chance of surviving this critical situation?
The authors of the article “Acute, total occlusion of the left main stem: coronary intervention options, outcomes, and recommendations” published in the current issue of “Advances in Interventional Cardiology/Postępy w Kardiologii Interwencyjnej” presented their own experience with this uncommon but often catastrophic event. In a group of 23 patients, they found that these patients frequently experience cardiogenic shock (87%), after or during CPR (52%), and even with a procedural success rate of 91%, the in-hospital and 6-month mortality rates were high (57% and 65%, respectively).
Patients with uLM lesions represent a subgroup of acute coronary syndrome patients with the largest amount of jeopardized myocardium. They therefore have higher mortality and a higher probability of developing cardiogenic shock. In a meta-analysis of a group of 977 patients with PCI for acute myocardial infarction (AMI) due to uLM disease, 26% of patients were in cardiogenic shock. The 30-day mortality rate was 55% and 11%, respectively, for those with or without cardiogenic shock [2].
Severe hemodynamic instability of patients with uLM occlusion can result in the necessity for CPR before or during PCI. Type and length of CPR influences performance of the revascularization procedure. A mechanical chest compression device has some advantages over...


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