⁎ Boulevard Vinte e Oito de Setembro, 77/2nd floor. Dept. of Cardiology, Arrhythmia Unit. Vila Izabel, Rio de Janeiro, 20551-900 Brazil. Tel./fax: +55 21 2255 1409. E-mail addresses: ecgar@yahoo.com, ecgar@uerj.br . Comments on the letter by Boztosun et al. “Left main coronary artery stenting in a patient with acute myocardial infarction and cardiogenic shock” Paulo R. Benchimol-Barbosa ⁎ Rio de Janeiro Military Fire Department Central Hospital, Rio de Janeiro, RJ Brazil Department of Cardiology, State University of Rio de Janeiro, Rio de Janeiro, RJ Brazil Department of Cardiology, Gama Filho University/National Institute of Cardiology, Rio de Janeiro, RJ Brazil Received 28 November 2007; accepted 20 January 2008 Available online 17 June 2008 Keywords: Left main coronary artery; Cardiogenic shock; Acute myocardial infarction; Coronary revascularization; Angioplasty To the Editor, I read with interest the article by Boztosun et al. [1], in which the authors report an extreme situation involving a 44 years old man with STEMI myocardial infarction in super-acute phase with ongoing left main coronary artery (LMCA) thrombosis and associated cardiogenic shock identified at the cath lab for primary intervention. The authors carried out a successful left anterior descending (LAD) stenting with protection of circumflex (Cx) artery after two guide wires were inserted surpassing LMCA using a perfect and timely technique achieving restora- tion of both LAD and Cx perfusion. The procedure proved to be life saving to the patient as demonstrated by post-procedure evolution in the coronary care unit, as reported. The authors are commended for their audacious reaction. LMCA occlusion is a dramatic situation, considering that up to 80% to 85% of left ventricular perfusion is provided by left coronary system. In young patients, collateral circulation is not particularly well developed, in contrast to older patients bearing chronic ischemic heart disease, imposing a significant burden on left ventricular viability when acute left main occlusion eventually supervenes as a first coronary event. The decision to promptly intervene after immediate identification of unprotected LMCA occlusion in a patient with acute STEMI and cardiogenic shock may be the only alternative at a moment and life saving. An option for LMCA occlusion and cardiogenic shock approach has been the ‘Kissing’ technique, where two stents are respec- tively inserted into the LAD and Cx after passing LMCA occlusion. Rahman et al. reported recently a successful unprotected LMCA stenting using kissing technique [2]. Karavolias et al. reported successful LMCA stenting in young patient in acute STEMI and cardiogenic shock using a sirulimus-coated stent [3]. Kim et al. reported a life saving although LMCA stent deployment in a teenager with cardiogenic shock after LMCA occlusion [4]. Although drug-eluted stent has showed a low rate of restenosis in mid mid-term follow-up of subjects submitted to elective angioplasty for unprotected LMCA revascular- ization [5], it has not been already demonstrated that drug drug-eluted stents are superior to bare metal stents in LMCA revascularization, in particular, in acute cardiogenic shock treatment. In this setting, I am particularly concerned about long term results of LMCA target lesion revascularization with drug drug-eluted stents. When available, a possible alternative procedure for LMCA occlusion and cardiogenic shock approach may be the deployment of an intracoronary balloon providing transient restoration of coronary circulation as a bridge to surgery [6]. References [1] Boztosun B, Dundar C, Aung AM, Kirma C. Left main coronary artery stenting in a patient with acute myocardial infarction and cardiogenic shock. Int J Cardiol 2009;132:e88–e90. [2] Rahman N, Dhakam S, Nadeem N. Simultaneous kissing stents for the treatment of left main stenosis in cardiogenic shock. J Coll Physicians Surg Pak 2007;17:272–4. [3] Karavolias GK, Georgiadou P, Iliodromitis EK, et al. Primary stenting of an unprotected left main coronary artery total occlusion in a patient with 141 Letters to the Editor