Hindawi Journal of Interventional Cardiology Volume 2020, Article ID 5246504, 8 pages https://doi.org/10.1155/2020/5246504 Research Article Primary Angioplasty in a Catastrophic Presentation: Acute Left Main Coronary Total Occlusion—The ATOLMA Registry A. Gutiérrez-Barrios ,1,2 L. Gheorghe,1,2 S. Camacho-Freire,3 F. Valencia-Serrano,4 D. Cañadas-Pruaño,2,5 G. Calle-Pérez,1,2 I. Alarcón de la Lastra,1 E. Silva,2 D. Garcı́a-Molinero,1 A. Agarrado-Luna,5 R. Zayas-Ruedas,1,2 R. Vázquez-Garcı́a,1,2 and A. Serra6 1 Departamento de Cardiologı́a Hospital Universitario Puerta del Mar, Cádiz, Spain 2 Instituto de Investigación e Innovación en Ciencias Biomédicas de Cádiz, INiBICA, Cádiz, Spain 3 Departamento de Cardiologı́a Hospital Juan Ramón Jiménez, Huelva, Spain 4 Departamento de Cardiologı́a Hospital Torrecárdenas, Almerı́a, Spain 5 Departamento de Cardiologı́a Hospital de Jerez, Cádiz, Spain 6 Departamento de Cardiologı́a Hospital de la Santa Creu i Sant Pau, Barcelona, Spain Correspondence should be addressed to A. Gutiérrez-Barrios; aleklos@hotmail.com Received 30 April 2020; Accepted 1 July 2020; Published 27 July 2020 Academic Editor: Patrizia Presbitero Copyright © 2020 A. Gutiérrez-Barrios et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Objectives. To determine the outcome predictors of in-hospital mortality in acute total occlusion of the left main coronary artery (ATOLMA) patients referred to emergent angioplasty and to describe the clinical presentation and the long-term outcome of these patients. Background. ATOLMA is an uncommon angiographic finding that usually leads to a catastrophic presentation. Limited and inconsistent data have been previously reported regarding true ATOLMA, yet comprehensive knowledge remains scarce. Methods. This is a multicenter retrospective cohort that includes patients presenting with myocardial infarction due to a confirmed ATOLMA who underwent emergency percutaneous coronary intervention (PCI). Results. In the period of the study, 7930 emergent PCI were performed in the five participating centers, and 46 of them had a true ATOLMA (0.58%). At admission, cardiogenic shock was present in 89% of patients, and cardiopulmonary resuscitation was required in 67.4%. All the patients had right dominance. Angiographic success was achieved in 80.4% of the procedures, 13 patients (28.2%) died during the cathe- terization, and the in-hospital mortality rate was 58.6% (27/46). At one-year and at the final follow-up, 18 patients (39%) were alive, including four cases successfully transplanted. Multivariate analysis showed that postprocedural TIMI flow was the only independent predictor of in-hospital mortality (OR 0.23, (95% CI 0.1–0.36), p < 0.001). Conclusions. Our study confirms that the clinical presentation of ATOLMA is catastrophic, presenting a high in-hospital mortality rate; nevertheless, primary angioplasty in this setting is feasible. Postprocedural TIMI flow resulted as the only independent predictor of in-hospital mortality. In-hospital survivors presented an encouraging outcome. ATOLMA and left dominance could be incompatible with life. 1. Background [1, 2]; nevertheless, the availability of PCI offers a reasonable therapeutic option in patients who are too critically ill to Patients with myocardial infarction (MI) caused by left main tolerate surgery [3]. coronary artery (LMCA) represent a high-risk group of Prior RCTs have never included subjects with the most patients, and treatment of such lesions is an issue of debate. critical ofcoronary pathology circumstances: acute total Contemporary randomized controlled trials (RCTs) have occlusion of the left main coronary artery (ATOLMA). shown that both coronary artery bypass grafting surgery and ATOLMA is a quite uncommon angiographic finding that percutaneous revascularization (PCI) may be considered usually leads to a catastrophic presentation. This entity may 2 Journal of Interventional Cardiology be susceptible to associated cardiogenic shock (CS), ma- A multiple logistic regression analysis was performed to lignant ventricular arrhythmias, and sudden death unless identify independent variables associated with in-hospital there are substantial preexisting intercollaterals and com- mortality. plete reperfusion is rapidly established [3–5]. Variables related to the dependent variable in univariate Only limited and inconsistent data have been reported analysis (p < 0.05) were included in the multivariate models. regarding to percutaneous treatment of true ATOLMA. Survival curves were generated by the Kaplan–Meier Previously reported studies have been largely confined to method, and differences between groups were analyzed with small cohorts and also included subtotal occlusion or critical the log-rank test; a landmark analysis was performed with a stenosis of the LMCA [6–11]. landmark of 30 days among patients who were survivors or This study aims to determine the outcome predictors of MACE-free at this time. A p value < 0.05 was considered in-hospital mortality in true ATOLMA (100% occlusion) statistically significant. All statistical analyses were per- and to describe clinical presentation and long-term prog- formed using SPSS version 22.0 (SPSS Inc., Chicago, IL). nosis of these patients. 3. Results 2. Methods 3.1. Incidence and Presentation. Since Jan 2005, in two of the 2.1. Study Population and Procedure. This is a multicenter five participating centers, and since Jan 2011, in the other three retrospective cohort study. The inclusion criteria included centers, to Dec 2019, primary angioplasty was performed in patients presenting with ST-elevation MI with the culprit 7930 patients; 131 (1.6%) of those were caused by acute un- being the unprotected LMCA with a total angiographic protected LMCA disease and 46 of those patients had a true occlusion (100%) who underwent emergency primary PCI. ATOLMA and were included in the present study (0.58%). Patients with an LMCA subtotal occlusion, previous Clinical characteristics of the overall study population are patent coronary artery bypass grafting, or iatrogenic acute shown in Table 1. The prevalence of the main cardiovascular ATOLMA were excluded. risk factors and the presence of a prior history of ischemic An independent investigator blinded to all data, except cardiopathy were found to be relatively low. The predominant for the coronary angiograms, reviewed all angiograms. The symptom at presentation was chest pain in 47.8%. Forty-one study was carried out in accordance with the principles of patients (89%) developed CS, only one patient presented in the Declaration of Helsinki. The study protocol was ap- Killip class II (2.1%), and the rest of the patients (4/46) had a proved by the ethics committee. Killip score 3. Electrocardiograms at presentation were avail- Angiographic success was defined as a residual stenosis able for only 18 patients. Anterolateral STelevation was present of <30% with a thrombolysis in myocardial infarction in 15 patients (83%), ST-segment elevation in lead aVR in 10 (TIMI) flow ≥2. patients (55%), left bundle branch block (LBBB) in three cases Two experienced interventional cardiologists retro- (17%), and lateral ST-segment depressions showing signs of spectively evaluated the angiographies in a blinded manner extensive transmural ischemia in one patient (5.5%). to classify collateral circulation (CC) into grades. Dis- Mechanical support devices were performed in patients agreement between these assessments was resolved by a with a very poor haemodynamic condition; all of them pre- third interventional cardiologist. The CC was graded sented Killip class IV (21/21, 100%), and the mean systolic according to Rentrop’s classification: grade 0, no filling of the pressure was 61 ± 10 mmHg. Intra-aortic balloon pump and occluded vessel; grade 1, filling of the side branches; grade 2, extracorporeal membrane oxygenation (ECMO) were used in partial filling of the epicardial vessel; grade 3, complete filling 19 (41.3%) and 3 (6.5%) cases, respectively. ECMO was suc- of the epicardial vessel by collateral [12]. cessfully used as a bridge for transplantation in two patients. To complete follow-up and to determine the clinical 37% (17/23) of the patients in which CC was assessed events and vital status of the patients, electronic medical before performing PCI had a Rentrop score of 0, 13% (3/23) records, scheduled visits, and telephone interviews were used. had a Rentrop 1, one patient had a Rentrop 2, and the patient The primary aim of the study was to determine the who presented a Killip score of two had a Rentrop 3. significant predictors of in-hospital total mortality. The secondary aims were to describe the incidence and clinical presentation of these patients and to evaluate long-term 3.2. Procedural Data. Treatment and procedural charac- mortality and major adverse events (MACE) encompassing teristics are shown in Table 2. Most of the procedures were all-cause mortality, cardiac transplant, new-onset MI, target performed by the femoral approach (29/46, 63%) and using a lesion revascularization (TLR), and definite or probable 6-French guiding catheter (37/46, 80.5%). Intracoronary stent thrombosis (ST) according to the ARC criteria [13]. imaging was performed in order to optimize the final result in five cases (11%): intravascular ultrasound in four cases and optical coherence tomography in one (Table 2). 2.2. Statistical Methods. Data were expressed as mean- PCI with stent implantation was performed in 69.6% ± standard deviation for continuous variables and compared (32/46) of the procedures. Most of the cases received a drug- using the unpaired t-test. Categorical variables were eluting stent (DES) (25/32, 78%). Exceptionally, in a patient expressed as numbers or percentages and compared using with Rentrop 3, a bioresorbable stent was successfully chi-square analysis or Fisher’s exact test. implanted (Figure 1). Twenty-two patients presented a Journal of Interventional Cardiology 3 Table 1: Clinical and angiographic characteristics. In-hospital mortality Overall (n � 46) Yes (n � 27) No (n � 19) p Age, y (SD) 62.8 ± 12 65 ± 5 59 ± 4.8 0.1 Male, n (%) 36 (78) 20 (74) 16 (84) 0.5 Diabetes, n (%) 7 (15.2) 6 (22) 1 (5) 0.2 Hypertension, n (%) 16 (34.8) 7 (37) 9(33) 0.8 Dyslipidemia, n (%) 12 (26.1) 9 (33) 3 (16) 0.2 Smoking, n (%) 23 (50) 12 (44) 11 (58) 0.3 Prior IC (%) 3 (6.5) 3 (11) 0 (0) 0.25 Presentation (%) Cardiogenic shock 41 (89) 26 (96) 15 (79) 0.08 Heart rate (bpm)∗ 106.5 ± 15 109 ± 14 102 ± 15 0.2 Systolic blood pressure (mmHg)∗ 70.5 ± 20 67 ± 17 75.5 ± 24 0.3 Cardiac arrest at presentation 8 (17.4) 4 (15) 4 (21) 0.5 Ventricular tachyarrhythmia 17 (37) 10 (37) 7 (37) 1 TIMI flow 0 at presentation 100% 27 (100) 19 (100) 1 Multivessel disease 21 (45.7) 11 (41) 11 (58) 0.37 Right coronary disease 9 (19.6) 4 (15) 5 (26) 0.45 Right coronary dominance 46 (100%) 27 (100) 19 (100) 1 Rentrop 0 17/23 (74) 15 (79) 2 (50) 0.2 Symptom to balloon 187 ± 51 208.5 ± 81 158 ± 49 0.3 FMC to balloon 117 ± 52 139.7 ± 90 87.7 ± 19 0.3 ∗ Data available from 23 patients. IC: ischemic cardiopathy; OTI: orotracheal intubation; CC: collateral circulation; FMC: first medical contact. Table 2: Treatment and procedural characteristics. In-hospital mortality Overall (n � 46) Yes (n � 27) No (n � 19) p Orotracheal intubation 31 (67.4) 23 (85) 7 (37) 0.06 Ventricular assistance device 21 (45.6) 11 (40) 10 (53) 0.4 IABP 20 (43.5) 11 (41) 9 (47.4) 0.65 ECMO 3 (6.5) 0 (0) 3 (15.8) 0.06 CPR 31 (67.4) 21 (78) 10 (53) 0.07 GP IIa/IIIb inhibitors 22 (47.8) 12 (44) 15 (56) 0.2 Vasoactive drugs 41 (89.2) 25 (96) 15 (79) 0.07 Angioplasty Angiographic success 37 (80.4) 18 (67) 19 (100) <0.001 Radial approach 16 (34.8) 6 (22) 10 (53) 0.03 Seven French catheter 8 (17.4) 2 (7) 6 (32) 0.05 LM stent deployed 32 (69.6) 15 (56) 17 (90) 0.01 LM bare metal stent 7 (21.8) 2 (13) 5 (30) 0.4 LM stent diameter (mm) 3.5 ± 0.4 3.5 ± 0.5 3.5 ± 0.2 1 Complex LM technique 6 (13) 3 (11) 3 (16) 0.7 LM stent predilation 15/32 (47) 10 (67) 13 (77) 0.7 LM stent postdilation 15/32(47) 7 (47) 8 (47) 1 Thrombus aspiration 19 (41.7) 13 (48) 6 (32) 0.2 Intracoronary imaging 5 (10.9) 1 (4) 4 (21) 0.14 Contrast volume (ml) 177 ± 132 189 ± 161 161 ± 87 0.6 Final TIMI flow 2.2 ± 0.3 1.78 ± 0.4 2.8 ± 0.2 <0.001 Final TIMI flow 3 23 (50) 8 (30) 19 (70) 0.001 IABP: intra-aortic balloon pump; ECMO: extracorporeal membrane oxygenation; CPR: cardiopulmonary resuscitation; LM: left main. multivessel disease, and multivessel PCI was performed in 12 hours due to pump failure. Seven patients (15.2%) died of them (12/22, 58.3%). during hospitalization, between the second and the twenty- sixth day due to CS (5/7, 71%) and nosocomial sepsis (2/7, 28.5%). The in-hospital mortality rate was 58.6% (27/46). 3.3. Mortality and Major Cardiovascular Events. Thirteen Two patients with INTERMACS profile 3 dependent on patients (28.2%) died in the catheterization laboratory ECMO had an emergency transplant due to refractory CS on during the procedure, and 7 (15.2%) died in the following 24 the 14th and on the 30th day, respectively. 4 Journal of Interventional Cardiology (a) (b) (c) (d) (e) (f ) Figure 1: (a) The angiography showed an acute thrombotic occlusion of the unprotected left main coronary artery (ATOLMA). (b) A dominant right coronary artery that contributed Rentrop 3 collateral circulation. (c) The OCT revealed a correct apposition of the bioresorbable vascular scaffold (Absorb 3.5 × 28 mm). (d) Final angiographic result. (e) At 40-month follow-up, an excellent result is maintained in the angiography. (f ) The OCT showed reabsorption in process with partial disappearance of the black boxes. Mean follow-up, among the survivors, was 31 months Table 3: Outcomes of the study population. (interquartile range, 1.4–67 month). One patient, in which a In-hospital outcomes, n (%) BMS was successfully implanted, died suddenly on day 19 In-cath lab mortality, N (%) 13 (28.2) In-hospital total mortality 27 (58.6) after discharge. Therefore, 16 patients (34.7%) survived Cardiac arrest 31 (67.4) without transplantation at 30-day follow-up. Cardiac transplant 2 (4.3) Among the survivors, three patients were admitted to Major bleeding complications 0 (0) the hospital due to heart failure (HF) on the 21st day and on One-year outcomes, n (%) the second month after discharge. Two patients, with re- Total mortality 28 (60.9) fractory HF, were transplanted in the second and the sixth Cardiac transplant 4 (8.7) month. Another patient with a BMS restenosis was suc- TLR 1 (2.2) cessfully treated with a new DES, seven months after Definite or probable ST 1 (2.2) discharge. No other patient died during the first-year Non-fatal MI 1 (2.2) follow-up. MACE 33 (71.7) Therefore, at one-year follow-up, 18 patients (39%) were Heart failure admission 4 (8.7) still alive, including the four cases successfully transplanted, Non-fatal stroke 0 (0) and only 11 patients (24%) were alive and free of MACE or Total follow-up outcome, n (%) admission for HF. At final follow-up, 10 (21.7%) patients Total mortality 28 (60.9) were alive and free of any event (Table 3). The patient treated MACE 34 (73.9) with a bioresorbable stent was asymptomatic and free of Heart failure admission 5 (10.8) event at 40-month follow-up. Univariate predictors of in-hospital mortality are re- MACE were significantly higher in patients with Rentrop 0 flected in Tables 1 and 2. Multivariate analysis showed that at the initial angiography (81% vs. 19%, p � 0.01). postprocedural TIMI flow was the only independent pre- Kaplan–Meier MACE-free and survival curves at 30-day dictor of in-hospital mortality (Table 4). follow-up showed that both events were significantly lower CC was not a significant univariate predictor of mor- in patients with a postprocedural TIMI flow 3 compared to tality; nonetheless, CS (100% vs. 50%, p � 0.01) and one-year those with a final TIMI flow ≤3 (Figure 2). Journal of Interventional Cardiology 5 Table 4: Predictors of in-hospital mortality (multivariate analysis). In-hospital mortality HR (95% CI) p Final TIMI flow 0.23 (0.1–0.36) <0.01 LM stent 0.1 (−0.21 to 4.3) 0.5 Radial approach 0.25 (0.005–0.5) 0.054 Angiographic success 0.12 (−0.5 to 0.8) 0.6 1.0 1.0 0.8 0.8 Final TIMI flow < 3 Final TIMI flow < 3 Cum MACE-free Cum survival 0.6 0.6 0.4 0.4 0.2 Final TIMI flow 3 0.2 Final TIMI flow 3 0.0 Log-rank test p < 0.001 0.0 Log-rank test p < 0.001 0 10 20 30 0 10 20 30 No. at risk Time (days) No. at risk Time (days) TIMI 3 23 18 16 15 TIMI 3 23 18 17 16 TIMI < 3 23 5 3 2 TIMI < 3 23 5 3 3 Figure 2: Kaplan–Meier curves showing that the final TIMI flow 3 was significantly associated with 30-day death and 30-day MACE (log- rank test p ≤ 0.01 for both). Data for dual antiplatelet therapy (DAPT) were missing 4.2. Clinical Presentation. ATOLMA usually results in se- in 11 patients; 51% (18/35) of the patients were treated with vere ventricular dysfunction leading to a rapid haemody- ticagrelor, 40% with clopidogrel (14/27), and the rest with namic deterioration and a catastrophic clinical presentation prasugrel (3/35, 9%) [4, 6]. Previously reported studies showed an incidence of CS 4. Discussion ranged between 62 and 83% [5–7, 11, 16–19] and of me- chanical ventilatory support requirement (invasive or Emergency presentation with occlusion of the LMCA is a noninvasive) between 23 and 89% [6, 11, 16]. dramatic and catastrophic coronary event. Except the de- Our study, in agreement with that reported by Edes et al., scriptive cohort reported by Edes et al. [14], the rest of the including strictly true ATOLMA, reflects even a poorer existing literature includes patients with severe stenosis or clinical presentation: 89% (41/46) of the patients developed subtotal occlusion of the LMCA. As far as we concern, this is CS [14]; 67.4% (31/46) required orotracheal intubation and the largest reported cohort including exclusively patients with a invasive ventilatory support, and cardiopulmonary resus- true ATOLMA (TIMI flow 0) referred to primary angioplasty. citation maneuvers were necessary in 67.4% (31/46) patients. All except one patient presented Killip class III-IV, which reflect the poor clinical status of these patients at 4.1. Incidence. Previous studies have reported that the in- presentation. ATOLMA should be suspected in patients with cidence of ST-elevation myocardial infarction (STEMI) STEMI accompanied by these potentially devastating pre- caused by LMCA ranged from 0.8 to 2.5% in patients un- sentations, and an early invasive strategy should be en- dergoing cardiac catheterization [3, 6, 11, 15–17]. couraged in these patients [3, 6, 8]. In the present study, a lower incidence was found (0.58%). The discrepancy is related to the fact that previous studies also included subtotal occlusion or critical stenosis of 4.3. Prognosis. The “LMCA shock syndrome” originally the LMCA, while in this cohort, exclusively, patients with a described by Quigley et al. in 1993 showed that when STEMI true ATOLMA referred to primary angioplasty were occurs with CS and severe LMCA stenosis, prognosis, re- recruited [4, 6–8, 10, 11, 16]. gardless of management, was extraordinarily poor with a However, the true incidence of ATOLMA may be mortality rate of 94% [5, 11, 20, 21]. underestimated because most of the patients in this clinical A more contemporary approach using new-generation setting died before angiography can be performed. stents, haemodynamic support, and new treatments, in 6 Journal of Interventional Cardiology particular new antiplatelet therapies, and also the increased model. Certainly, the role of CC in ATOLMA remains to be experience with treating LMCA percutaneously and PCI in further elucidated. the context of STEMI, have slightly improved results and prognosis. However, STEMI caused by LMCA disease still 4.4.2. Right Dominance. In STEMI treated with primary has a poor prognosis, with the exception of the study by Liu angioplasty, right coronary dominance confers a better et al., in which a surprisingly low in-hospital mortality rate prognosis than left dominance, and it is explained by the fact (5.1%) and 30-day mortality (6.2%) were found [8]. Most of that right dominance has a greater division of vasculature the studies reported an in-hospital mortality rate of 31–58% supplying the left ventricle (into 3 “parts”), whereas left and a 30-day mortality of 36–63% dominance means that most of the myocardium is essen- [3, 6, 7, 10, 11, 16–18, 22–25]. tially dependent on 2 arteries [31]. Little evidence exists regarding the mortality rate in true Concerning ATOLMA, this vasculature division de- ATOLMA (TIMI 0). However, as expected, the limited pendent on coronary dominance becomes even more rel- available information shows a poorer prognosis in this evant since LMCA supplies those two arteries. Therefore, it is scenario when compared with critical or subtotal LMCA not surprising that dominance has been related to survival in occlusion. De Luca et al. reported a mortality rate of 60% in patients with subtotal LMCA occlusion [11]. In true the subgroup of patients with a TIMI flow 0, very similar to ATOLMA, it has been suggested that only patients with right that reported by Edes et al. (56%) and Yip et al. (62%, 5/8) in dominance will survive to receive a diagnosis and invasive those subgroup of patients. treatment [5, 14]. Two more contemporary studies revealed a similar In agreement with these observations, we found that outcome: YAP et al. found a mortality rate of 54% (22/41) 100% (46/46) of the patients included in our study had right and Homorodean et al. 63% (12/19), despite these results dominance, probably because left main dominance patients referring to TIMI 0-1 patients and not exclusively to TIMI 0 may die before being transferred to cardiac catheterization. cases [6, 10, 11, 14, 18]. Our findings and previous results suggest that most probably Concordantly with previous observations, in the present ATOLMA and left dominance could be incompatible with study, although restoration of the coronary flow is mostly life, especially in the absence of well-developed CC [14]. successful (80.4%), a rather significant in-hospital mortality was observed (58.6%, 27/46). But, even the true mortality of ATOLMA may be underestimated as many patients could 4.4.3. Final TIMI Flow. TIMI flow grades have been shown not be taken to the catheterization laboratory before dying. to have significant prognostic implications among patients In this cohort, patients surviving the initial hospitali- undergoing reperfusion therapy for STEMI [32–34], and zation showed an encouraging prognosis; only one patient similar results have been reported in the setting of primary died during follow-up (6%, 1/19), which is comparable to the angioplasty in LMCA [6, 10, 16]. findings previously reported with a survival rate of 83–90% Concordantly, our study proved that postprocedural among in-hospital survivors [3, 5, 6, 11, 14, 17, 22, 25]. TIMI flow in ATOLMA patients was the only independent predictor of in-hospital mortality in the multivariate model. The TIMI flow achieved was also significantly related to 4.4. Predictors of Mortality short-term MACE and mortality as reflected in the Kaplan–Meier curve (Figure 2). Therefore, restoration of 4.4.1. Collateral Circulation. The role of early recruited CC TIMI 3 flow is crucial in this situation. However, TIMI flow 3 in STEMI remains controversial. Some previous reports was only achieved in 50% (23/46) of our patients, which is have shown lower mortality and morbidity rates in well- significantly lower than general STEMI where TIMI 3 is collateralized patients, but others have not [26–29]. obtained in >90% of procedures, or with not-true ATOLMA Regarding LMCA PCI in the setting of primary angio- where it ranges from 66% to 86% [6, 10, 11, 18, 34]. plasty, it has been suggested that the presence of well-de- Obtaining a final TIMI 3 flow can be challenging in this veloped collateralization is a crucial predictor of survival catastrophic scenario, but according to our data and pre- [4, 5, 11, 16, 18, 30]. vious knowledge reported, every effort must be made to As only true ATOLMA was included in our study, the achieve this goal. clinical presentation was often devastating, and the operator decided not to perform a contralateral injection before the LMCA PCI in 23/46. Therefore, CC grade information was 5. Limitations missing in 50% of the procedures, and well-developed CC This was a retrospective study with a small sample size. Like (Rentrop class ≥2) was confirmed only in two cases (8.7%). all observational studies, the present study is prone to biases Nevertheless, the absence of CC (Rentrop 0) was signifi- from its nonrandom assignment of exposures. CC was not cantly higher in patients with CS at presentation and was assessed before PCI in 50% of the procedures. Furthermore, related to one-year MACE, which highlights the role that CC while this study focused on in-hospital mortality, the un- may play in ATOLMA patients. Nonetheless, in our study, questionably high prehospital mortality was not quantified. since the CC grade was assessed only in 50% of the pro- One inherent limitation is that there are differences in the cedures, CC was not a univariate predictor of in-hospital nature and the type of hospital facilities (e.g., intra-aortic mortality and consequently excluded in the multivariate balloon pump, ECMO, or in-site transplant availability). The Journal of Interventional Cardiology 7 long period of inclusion may have introduced bias due to [4] H. Kim, M. Dittel, and W. Enenkel, “Acute occlusion of left changes in technology and management. main coronary artery without ventricular damage,” Clinical Cardiology, vol. 14, no. 2, pp. 176–179, 1991. [5] M. Spiecker, R. Erbel, H.-J. Rupprecht, and J. Meyer, 6. 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Redondo et al., “Inter- be made to achieve this goal. Long-term mortality rates for vencionismo percutáneo urgente sobre el tronco coronario survivors are reasonably encouraging. izquierdo no protegido. Factores predictores de mortalidad y Interestingly, all of our patients had right coronary análisis del shock cardiogénico,” Revista Española de dominance, suggesting that presumably ATOLMA and left Cardiologı́a, vol. 62, no. 10, pp. 1118–1124, 2009. [8] H.-W. Ruiz, Y.-L. Han, Q.-M. Jin et al., “One-year outcomes dominance could be incompatible with life. in patients with ST-segment elevation myocardial infarction caused by unprotected left main coronary artery occlusion Data Availability treated by primary percutaneous coronary intervention,” Chinese Medical Journal, vol. 131, no. 12, pp. 1412–1419, 2018. The SPSS database data used to support the findings of this [9] N. Wang, A. Badiye, D. R. Yavagal, and C. E. 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