Acute Inferior ST-elevation Myocardial Infarction Research Articles

Response to the letter regarding the article "Neutrophil/lymphocyte ratio is associated with right ventricular dysfunction in patients with acute inferior ST-elevation myocardial infarction".

Response to the letter regarding the article "Neutrophil/lymphocyte ratio is associated with right ventricular dysfunction in patients with acute inferior ST-elevation myocardial infarction".

From Myocardial Infarction to Peripheral Stenting

Degenerated saphenous vein grafts (SVGs) are associated with high risk of myocardial infarction (MI). They are difficult to treat percutaneously because of large variability in their wall diameters. We report a case of a 71-year-old male, who presented with an acute inferior ST elevation MI (STEMI) 16 years following revascularization with triple coronary artery bypass graft (sequential SVG to the posterior interventricular and to the second marginal branch of the left circumflex artery, and left internal mammal artery to the left anterior descending). Coronary angiography revealed a massive thrombotic occlusion of the second part of the sequential graft, which was aneurysmal just after the posterior interventricular artery. Thromboaspiration was performed and revealed an 8 mm diameter aneurysmal degenerated graft. We decided to use a balloon-expandable peripheral stent to treat this lesion. TIMI 3 outflow was restored without any no-reflow phenomenon. Patient was discharged to his origin hospital 3 days later. He had an uneventful evolution at the 3 months follow-up. J Med Cases. 2016;7(4):133-135 doi: http://dx.doi.org/10.14740/jmc2451w

Dual Coronary Artery Fistula from Left Anterior Descending and Right Coronary Artery to Pulmonary Trunk in a Patient with Myocardial Infarction—A Case Report

Coronary artery fistulas (CAF) are precapillary communications between a coronary artery and a cardiac chamber or vessel. CAF have been described as the most common hemodynamically significant congenital coronary anomal. However, it remains a relatively uncommon clinical problem. Coronary fistulas originates slightly more common from the right than from the left coronary artery, but the bilateral fistulas—those that originate from both coronary arteries—accounts for only 5% of total cases. These bilateral fistulas have a unique tendency to terminate in the pulmonary artery. More than half of the bilateral and only 17% of unilateral fistulas, terminates in this manner [1]. CAF are believed to be embryological remnants of sinusoidal connections between the lumens of the primitive tubular heart. This was first described by Maude Abbott in 1908 [2]. These fistulas are usually discovered incidentally upon coronary angiography [3]. Their incidence in the overall population is reported about 0.002% and constitutes 0.13% of congenital cardiac lesion, however, they are found in 0.05% to 0.25% of patients who undergo coronary angiography. The most common site of drainage is the right ventricle seen in 41% of patients. Congenital CAFs usually result from abnormal embryological development of the myocardial vascular system. Acquired CAFs are seen after trauma, endovascular procedures like coronary angiography, endomyocardial biopsy etcor cardiac transplantation. True fistulas of the circulatory system are characterized by an ectatic vascular segment that shows aberrant flow connecting two vascular territories governed by large pressure differences. We report a case of double coronary to pulmonary artery fistula discovered during emergent coronary angiography for acute inferior wall ST-elevation myocardial infarction (STEMI) in a patient with no prior cardiac symptoms.

Comprehensive right heart systolic function assessment using cardiac magnetic resonance imaging after inferior ST elevation myocardial infarction

Background Acute Inferior ST Elevation Myocardial Infarction (Ac-Inf-STEMI) and associated posterior and right ventricular (RV) infarction has been extensively studied with electrophysiology and echocardiography. A recent CMR study showed that poor RV function was associated with poor long term survival post myocardial infarction. However, limited CMR data exists especially on short term clinical outcomes in Ac-Inf-STEMI.

Trombose Muito Tardia de Stent pela Angiografia. Um Caso de Progressão da Aterosclerose pela OCT

Em pacientes submetidos à intervenção coronária percutânea, a natureza progressiva da doença coronária aterosclerótica é frequentemente negligenciada. Geralmente, infartos muito tardios (> 1 ano) acometendo o território tratado são atribuídos a complicações relacionadas ao dispositivo. Apresentamos o caso de uma paciente com infarto agudo do miocárdio com supradesnivelamento do segmento ST na parede inferior, que apresentava oclusão trombótica de um stent não farmacológico implantado 8 anos antes. Apesar do diagnóstico angiográfico de trombose muito tardia, a tomografia de coerência óptica revelou que a etiologia foi a ruptura de placa aterosclerótica no leito distal, fora do segmento previamente tratado.

ST-segment elevation of right precordial lead (V4 R) is associated with multivessel disease and increased in-hospital mortality in acute anterior myocardial infarction patients.

ST segment elevation of chest lead V4 R is associated with worse prognosis in acute inferior ST-elevation myocardial infarction (STEMI). This study tried to determine the relationship between ST elevation in the right precordial lead V4 R and acute anterior STEMI. Prospective study of 144 consecutive anterior STEMI patients: all had 15-lead ECG recordings (12 conventional leads and V3 R-V5 R) obtained. Patients were classified into two groups on the basis of presence (Group I, 50 patients) or absence (Group II, 94 patients) of ST-segment elevation ≥0.5 mm in lead V4 R. Multivessel involvement was significantly higher in Group I compared with Group II (54% and 23% respectively, P < 0.001). Major adverse cardiac events and in-hospital mortality was also significantly higher for those in Group I (P < 0.02 for both). A significant correlation was found between in-hospital mortality and those in Group I (P = 0.03, OR: 6.27, CI: 1.22-32.3). There was an independent relationship between in-hospital mortality and V4 R-ST elevation (P = 0.03, OR: 11.64, CI: 1.3-27.4). ST segment elevation in chest lead V4 R is associated with multivessel disease and increased in-hospital mortality in patients with anterior STEMI that had undergone primary percutaneous coronary intervention to the left anterior descending artery.

Complex percutaneous coronary intervention for unprotected distal left main bifurcation lesion in a patient with cardiac allograft vasculopathy

Introduction: Cardiac allograft vasculopathy (CAV) is a progressive form of coronary disease that defines the long term prognosis in heart transplant patients. The mortality of surgical revascularization in post-transplant patients is very high. Percutaneous coronary intervention (PCI) has a relatively low periprocedural mortality and high acute angiographic success, but still high restenosis rate and poor long-term results. Bypass surgery (CABG) is considered the gold-standard for unprotected left main coronary artery (LMCA) disease in non-transplant patients, especially with the distal bifurcation lesion. Optimal PCI techniques are needed to improve the results and complex double kissing crush technique seems to be promising. Case Report: We present a case of a 27-year-old patient who received heart transplant at the age of 24. During the second post-transplant year, he developed acute inferior ST-elevation myocardial infarction and primary PCI of RCA was performed. An eccentric LMCA stenosis with an involvement of large ramus intermedius (RI) and almost occluded, minor left circumflex (LCx) were detected on control angio. We decided to perform PCI on this complex lesion with double kissing crush technique. Two wires were positioned distally to the lesions in both the LAD and ramus intermedius (RI). A stent was positioned in the RI with few proximal millimeters protruding into the LMCA, a balloon with a length long enough to cover the protruding stent segment was concurrently positioned in the LAD. The RI stent was deployed. The SB stent-balloon and wire were removed. The balloon in LAD was then inflated at a high pressure to crush the protruding RI stent. The RI ostium was rewired and dilated with a balloon. The bifurcation was then kissed with two balloons. Afterwards, a stent was deployed in the LMCA toward LAD at a high pressure. The RI ostium was rewired for the second time through the LMCA stent strut and dilated with a balloon at a high pressure. The final kissing balloon inflation in the bifurcation was performed at a high pressure and finished with proximal optimization of LMCA. The control angio performed 6 months later showed no signs of restenosis. Summary: The treatment of CAV is very challenging and while CABG remains a poor revascularization option, PCI of complex lesions such as those of LMCA require optimal technique to reduce the incidence of adverse cardiac events and prevent further graft deterioration.

Significance of ST-segment deviation in lead aVR for prediction of culprit artery and infarct size in acute inferior wall ST-elevation myocardial infarction

Abstract Background In patients with acute ST-segment elevation myocardial infarction identification of the culprit artery either due to right coronary artery or left circumflex artery was studied. The electrocardiogram can help in earlier risk stratification and better guidance of therapy for reperfusion. Patients and methods 50 patients with acute inferior myocardial infarction were divided into two groups. Group A: patients with ST segment depression in lead aVR ⩾ 1 mv. Group B: patients with isoelectric ST segment or with ST segment depression in lead aVR Results Fifty patients with acute inferior myocardial infarction were included in the present study. There were 35 males (70%) and 15 females (30%), with a mean age 55.6 ± 8.8. In Group A, left circumflex artery was the culprit artery in 8 (47%) and right coronary artery was the culprit artery in 9 (53%). Group B, left circumflex artery was the culprit artery in 4 (12%) and right coronary artery was the culprit artery in 29 (88%) patients with aVR depression had significantly larger infarctions (estimated by peak creatine phosphokinase (CPK-MB) levels and transthoracic echocardiography) than patients without aVR depression. Conclusion In patients with inferior wall STEMI, ST-segment depression in aVR was more common in LCX infarcts than RCA infarcts. Patients with aVR depression had significantly larger infarctions, (estimated by peak creatine phosphokinase (CPK-MB) levels and transthoracic echocardiography) than patients without aVR depression.

An unusual case of silent acute ST-elevation myocardial infarction following amphetamine use

We report a case of silent acute ST-elevation myocardial infarction associated with amphetamine use in a 62 years old diabetic man. The patient was devoid of chest pain and had a normal cardiac enzyme analysis at the initial presentation. A routine electrocardiogram demonstrated acute inferior wall ST-elevation myocardial infarction. Coronary angiography confirmed a total occlusion of the posterior lateral branch of right coronary artery. The patient underwent successful percutaneous transluminal coronary angioplasty with stent placement. Amphetamine abuse may play a role in acute myocardial infarction. Adverse cardiovascular manifestations of amphetamine can occur with sudden overt chest pain or present insidiously. In view of the potential association of amphetamine and myocardial infarction, physicians should not rely only upon clinical symptoms. This report highlights the diabetic patients with amphetamine abuse should undergo a routine electrocardiogram in such circumstances.

Routine invasive versus ischemia-guided strategy in patients with acute inferior ST-elevation myocardial infarction who received fibrinolytic therapy: A prospective randomized controlled pilot trial

We sought to compare a routine invasive strategy of early coronary angiography and intended revascularization, with an ischemia-guided strategy in patients with acute inferior ST elevation myocardial infarction (STEMI) who received fibrinolytic therapy. We enrolled 60 consecutive patients with acute inferior STEMI who received fibrinolytic therapy within 6 h. Patients were randomly assigned to either a routine invasive strategy in which coronary angiography was performed within 48 h with intended revascularization if eligible (Group A), or an ischemia-guided strategy in which catheterization was based on the presence of myocardial ischemia and viability as demonstrated by stress myocardial perfusion imaging (Group B). Patients were prospectively followed up for 6 months. The primary endpoint was a composite of cardiac death, recurrent myocardial infarction, recurrent ischemia or stroke at 6-month follow-up. Total costs per patient were calculated over 6 months. The mean age of the whole series was 52 ± 9.8 years (15% females). The primary endpoint occurred more frequently in group A as compared to group B, however, the difference did not meet statistical significance (36.7% versus 23.3%, respectively, p > 0.05). The mean cost per patient at 6-month follow-up was significantly higher in Group A as compared to that in Group B ($4953.5 ± 3108.5 versus $2764.6 ± 2636.7, respectively, p < 0.01). In patients presenting with inferior STEMI who received fibrinolytic therapy, a routine invasive strategy with early coronary angiography and intended revascularization, achieved a clinical outcome similar to an ischemia-guided strategy; yet, at a significantly higher cost.

Intravascular ultrasound virtual histology imaging in acute ST-elevation myocardial infarction: A useful clinical tool during primary percutaneous coronary intervention

We described the novel use of intravascular ultrasound-virtual histology (IVUS-VH) imaging in two young adult male patients who presented with acute inferior ST-elevation myocardial infarction (STEMI) and we highlight the usefulness of this new invasive coronary imaging technique. Both patients had thrombotic occlusion of the right coronary arteries but the underlying pathophysiological mechanisms leading to acute thrombosis were different. The in vivo information obtained by IVUS-VH imaging was invaluable in pinpointing the likely etiology of STEMI and thus, guided our primary percutaneous coronary intervention strategy appropriately.

An unusual cause of embolic myocardial infarction

A 35-year-old female presented with acute inferior ST-elevation myocardial infarction and underwent emergency cardiac catheterization. Diagnostic images revealed an occlusive filling defect at the first bifurcation of a large dominant circumflex artery ( Panel A ). The other epicardial coronary arteries were normal. Aspiration thrombectomy removed a significant volume of thrombus and angiography then demonstrated the circumflex …

Acute myocardial infarction and the five‐chambered heart

The case of a patient presenting with acute inferior ST-elevation myocardial infarction is described. Emergent coronary angiography of the right coronary artery revealed what appeared to be the abrupt drainage of contrast into a large, peculiar cavity or chamber. Echocardiography and cardiac computed tomography demonstrated a giant right coronary aneurysm in the right coronary artery that gave the impression of a "fifth heart chamber." The patient underwent successful surgical resection of the aneurysm. Diagnostic and treatment approaches to giant coronary aneurysms are discussed.

Comparison of Prognostic Outcome Between Left Circumflex Artery–Related and Right Coronary Artery–Related Acute Inferior Wall Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention

This study evaluated the 30-day clinical outcome of patients with acute inferior wall ST-elevation myocardial infarction (AIW-STEMI) from occlusion of the left circumflex artery (LCX) vs the right coronary artery (RCA) undergoing primary percutaneous coronary intervention (PCI). The clinical outcomes of AIW-STEMI caused by RCA and LCX occlusion may be different for patients undergoing primary PCI. Between May 2002 and September 2009, 646 consecutive patients with AIW-STEMI undergoing primary PCI were enrolled. Of these patients, 520 (80.5%) with AIW-STEMI caused by RCA occlusion were categorized into group 1, whereas the remaining 126 (19.5%) whose AIW-STEMI was caused by LCX occlusion served as group 2. The results demonstrated that the frequency of advanced congestive heart failure, respiratory failure requiring mechanical ventilatory support, and 30-day mortality were remarkably higher in group 2 than in group 1 (all P < 0.01). Conversely, the incidence of right ventricular infarction and complete heart block were notably higher in group 1 than in group 2 (all P < 0.001). Additionally, the peak level of creatine kinase-isoenzyme MB was significantly higher, whereas the left ventricular ejection fraction was notably lower in group 2 than in group 1. Multivariate analysis demonstrated that advanced CHF, high serum creatinine level, low systolic blood pressure, low left ventricular ejection fraction, and LCX as the infarct-related artery were significantly and independently predictive of 30-day mortality (all P < 0.05). The 30-day prognostic outcome was less favorable in LCX-related AIW-STEMI compared with RCA-related AIW-STEMI undergoing primary PCI.

Acute myocardial infarction secondary to a spontaneous right coronary artery dissection resulting from a sinus of valsalva aneurysm

We describe a case of a female aged 55 years, presenting with an acute inferior ST-elevation myocardial infarction. The coronary ischaemia has resulted from a spontaneous right coronary artery dissection due to a right coronary cusp sinus of valsalva aneurysm (SVA). Sinus of valsalva aneurysm is a rare, often congenital, cardiac condition. The SVA rupture may lead to acute haemodynamic instability; therefore, recognition of the condition is important, generally requiring definitive surgical intervention. Right coronary artery ischaemia may result commonly from osteal compression by the SVA, however has never been previously described to occur from spontaneous coronary dissection.

Ischemic stroke after administration of fibrinolytics in a patient with a ventricular pseudoaneurysm

We present a case of a 66-year-old man with a preexisting left ventricular pseudoaneurysm as a sequel of an old inferoposterior myocardial infarction. The patient currently presented with respiratory insufficiency and chest pain. Based on his admittance electrocardiogram, he was treated with fibrinolytics for a presumed acute inferior ST-elevation myocardial infarction (in fact, the ST-elevations were the hallmark of the pseudoaneurysm). This treatment caused extensive ischemic stroke, as a consequence of dissolution and embolization of thrombi that were abundantly present in the pseudoaneurysm. The admittance electrocardiogram pointed out to be misleading to the treating physician and led to the unnecessary administration of fibrinolytics with serious complications.

Acute myocardial infarction due to coronary artery embolism in a patient with atrial fibrillation

A 66-year-old female was referred for primary coronary intervention because of acute inferior STelevation myocardial infarction. Electrocardiography also showed atrial fibrillation. Coronary angiography showed a distal occlusion of the right coronary artery. Two different wires did not pass the occlusion, but dislodged the apparent thrombus more distally. No abnormalities were seen in the course of the recanalised part of the vessel. The sequential angiographic images together with the presence of atrial fibrillation are highly suggestive of coronary embolism as the cause of the myocardial infarction. Anticoagulation and rate control strategy was initiated. The patient was discharged in good condition. (Neth Heart J 2009;17:297-9.).

Tricuspid Valvular Papillary Muscle Rupture With Intractable Hypoxia: A Rare Complication Post MI

Acute inferior ST-elevation myocardial infarction (STEMI) alone contributes to approximately 10% of in-hospital mortality due to ischemic heart disease. Right ventricular involvement occurs in 50% of patients who present with inferior STEMIs, increasing in-hospital mortality to 31%. In the setting of concomitant severe tricuspid regurgitation, acute rupture of the papillary muscles within the right ventricle should be considered in the differential diagnosis. The authors present the case of a patient with intractable hypoxia in the setting of an acute inferior STEMI complicated by rupture of the posterior tricuspid valve papillary muscle.

Should All Patients With Asymptomatic but Significant (&gt;50%) Left Main Coronary Artery Stenosis Undergo Surgical Revascularization?

The incidental detection of asymptomatic but significant (>50%) left main coronary artery disease (LMCAD) has become more frequent with the increased use of coronary angiography for acute myocardial infarction. Most would agree that such LMCAD cannot be ignored. Yet, clarity is somewhat lacking as to the best approach to managing such patients. The long-running debate of the best revascularization method of LMCAD has flared up again. However, medical management also may be a viable option for some of these patients. A 64-year-old nondiabetic man without a history of cardiovascular disease is admitted with an acute inferior ST-elevation myocardial infarction. He undergoes successful primary angioplasty of a dominant right coronary artery. Left ventriculography reveals inferior hypokinesis with an estimated ejection fraction of 45% to 50%. However, the patient also has a smooth mid-to-distal 60% LMCAD without any significant lesions in the left anterior descending or left circumflex artery. A month later, a stress echocardiogram reveals no new wall motion abnormalities. On the basis of this presentation, should he be referred for coronary artery bypass graft (CABG) surgery? The American College of Cardiology/American Heart Association (ACC/AHA) 2002 guidelines for stable angina1 discuss the indications for CABG surgery separately for symptomatic and asymptomatic LMCAD, but the recommendations are the same for both: Revascularization with CABG is a class I recommendation with level of evidence B. (Class I recommendations indicate situations for which evidence or general agreement exists that a given procedure or treatment is beneficial, useful, and effective.) An abbreviated version of these same guidelines was published in 2003.2 These guidelines acknowledged that the evidence behind the recommendation for asymptomatic patients is weak, yet the class IB recommendation was not changed. The ACC/AHA 2004 guidelines for use of CABG surgery also separate symptomatic and asymptomatic LMCAD recommendations and propose that CABG …

Subacute Thrombotic Occlusion and Spontaneous Recanalization of the Right Coronary Artery After Percutaneous Coronary Intervention for ST-Elevation Myocardial Infarction Visualized by Coronary Angiography and Cardiac Magnetic Resonance Imaging

A 58-year-old male was admitted to the emergency room with an acute inferior ST-elevation myocardial infarction (Figure 1). His coronary risk factors included arterial hypertension and hypercholesterolemia. Emergency percutaneous coronary intervention (PCI) was performed with stenting of the occluded right posterolateral branch with a 2.5×18 mm Zotarolimus-eluting stent (Medtronic, Minneapolis, Minn.) (Figure 1A and 1B). The left ventricular ejection fraction was 41% and the postinterventional TIMI flow was grade II with reduced flow of the entire right coronary artery (RCA) and persistent ST elevation within the inferior leads. The maximum creatine kinase level was 1863 U/L and peaked 36 hours after PCI. 99mTechnetium-sestamibi scans to assess coronary perfusion immediately before and 6 days after intervention (Figure 2) revealed no myocardial salvage subsequent to PCI within the inferior wall. Contrast-enhanced coronary magnetic resonance angiography with the use of 0.2 mmol/kg gadolinium-DTPA of the RCA 8 days after PCI revealed a signal void along …