1. Left Main Coronary Artery Dissection Complicating 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

9. 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

10. Conservative Treatment

11. CABG Vs Medical Therapy

12. ACC / AHA Guidelines

13. 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

14. OPCAB in LMCA Disease Off PumpOn Pump n 2731,163 Predicted Mortality 4.1%3.6% Observed Mortality 2.6%4.5% Risk Adjusted Mortality 1.9%3.8% Dewey,et al, Ann Thorac Surg 2001

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

16. Stent Vs Conventional Rx for Abrupt Closure or Symptomatic Dissection

17. French Lt Main Registry May 2001-June 2002 (11 French Centers)

18. French Lt Main Registry 1 Yr Outcome

19. French Lt Main Registry 1 Month &1 Yr Outcome

22. IVUS Optimization for Stent Deployment

23. DES Vs BMS in Milan 6 Month Clinical & Angiographic F/Up

24. DES in Lt Main Disease RESEARCH & 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)

25. DES in Lt Main Disease RESEARCH & T-SEARCH Registry

26. LMCA Intervention in AMC

27. In Hospital Outcome

28. Overall Restenosis rate 7.9%

29. 6 Months Clinical Outcome

30. MACE Free Survival at 1 Year

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