Background: Acute myocardial infarction in the left main trunk (LM-AMI) is a rare but serious condition. The purpose of the present study was to clarify differences in prognosis and factors associated with in-hospital death for patients with LM-AMI with or without CS on admission. Methods: The present retrospective observational study cohort consisted of 183 patients with LM-AMI in the registry of the Cardiovascular Research Consortium-8 Universities in eastern Japan between 1997 and 2016. The patients with LM-AMI were divided into two groups: those with CS on admission and those who did not have CS on admission. Results: In-hospital mortality in the CS and the non-CS group was 70.8% and 22.3%, respectively. In the non-CS group, the in-hospital mortality significantly increased along with increased Killip class (p = 0.028). Multivariate analysis showed a significantly elevated HR of 5.59 (95% CI, 1.24 to 25.26; p = 0.025) for in-hospital death among patients in the non-CS group categorized into Killip classification III. In contrast, in the CS group, the HR of coronary slow-flow after percutaneous coronary intervention for in-hospital death was 3.08 (95% CI, 1.52 to 6.25; p = 0.002). Conclusions: The prognosis of the non-CS group among patients with LM-AMI was also worse. The risk factors for in-hospital death between the CS and non-CS groups were different. Even for the non-CS group, the severity of heart failure was correlated with in-hospital death.

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BioFreedom is drug-coated stent (DCS) which has polymer-free design. Although it is expected to achieve earlier arterial repair after DCS implantation as compared to the other drug-eluting stents, angioscopic findings have not been described to date. This is the first report of serial angioscopic observation of DCS implanted at acute coronary syndrome (ACS) culprit.
A 75-year-old man was admitted with ACS. Coronary angiogram revealed severe stenosis and thrombus in a large diagonal artery. DCS (BioFreedom 3.0 × 18 mm) was implanted at the culprit of ACS. Coronary angioscopy was performed immediately, one and a half months, and 1 year after stent implantation to evaluate arterial repair after the implantation. Coronary angioscopy showed that uncovered stent struts on the white vessel wall and culprit ruptured yellow plaque with stent struts penetration were observed immediately after stent implantation. At one and a half months, majority of stent struts were not yet covered by neointima and the ruptured yellow plaque remained unhealed with thrombus adhesion. At one year under continued dual antiplatelet therapy, ruptured yellow plaque was covered by white neointima and no thrombus was observed.
Although DCS implanted at ACS culprit was well covered by white neointima without thrombus at 1 year, arterial repair at one and half months after DCS implantation did not appear good yet.

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