Webinar 11 | LM Trifurcation-Slides, Dr. Kumar

Slides, Dr. Kumar

Pdf Summary

This presentation by Prof. Gautam Kumar discusses the management of left main (LM) trifurcation in acute myocardial infarction (AMI) complicated by cardiogenic shock (CS). LM trifurcation—a common anatomical variation occurring in 10-15% of humans—typically requires surgical treatment, but percutaneous coronary intervention (PCI) is increasingly used. PCI in this setting is complex due to challenges in stent sizing and the necessity for advanced imaging. Techniques such as two-step kissing balloon or “trissing” are mandatory but hard to perform in unstable patients.<br /><br />A case of a 69-year-old man with chest pain, hypotension (BP 84/60), tachycardia, elevated lactate (5.1), and signs of shock was presented. After transfer to a specialized center, invasive hemodynamics showed elevated left ventricular end-diastolic pressure (LVEDP 31 mm Hg). Mechanical circulatory support (MCS) using an Impella CP device was initiated. Multivessel PCI was performed using a combination of drug-eluting stents sized according to intravascular imaging guidance in the left anterior descending artery (LAD), ramus/OM1, left circumflex artery (LCX), and distal LAD.<br /><br />The patient’s condition improved rapidly: lactate normalized within 4 hours, vasopressor support was discontinued within 8 hours, and Impella was removed the next day. The patient was discharged after 3 days, although left ventricular ejection fraction (EF) remained low, requiring guideline-directed medical therapy and eventual ICD implantation six months later.<br /><br />The key takeaways emphasize clear goal setting, simplifying treatment strategies, essential use of MCS in AMI-CS, avoiding prolonged balloon inflations, and reliance on imaging for procedural success. Given extremely limited data, careful and rapid multidisciplinary approaches are critical in managing LM trifurcation in unstable patients.

Keywords

Left main trifurcation

Acute myocardial infarction

Cardiogenic shock

Percutaneous coronary intervention

Mechanical circulatory support

Impella device

Intravascular imaging

Drug-eluting stents

Multidisciplinary management

Left ventricular ejection fraction