Acute Inferior Wall Research Articles

Non Surgical Management of Mini Guide Wire Embolism with Self Made Guide Wire Snare

A 5 3 years old male presented in emergency department of local hospital with acute inferior wall myocardial infarction During his initial course of treatment he dev eloped symptomatic bradycardia and 2:1 artioventricular block, for which he was tried for implantation of temporary pacing lead through right subclavian vein with 6 F venous sheath. During the procedure the operator embolized the J-tip mini guide wire in the heart, for which the patient was shifted to our hospital for the management of the embolised guide wire and coronary angiography. The patient was immediately brought to cardiac catheterization laboratory and the position of mini guide wire was located under fluoroscopy. Its upper end was lying near the junction of superior vena cava with right atrium and the lower end was in the right common iliac vein. ContinuedÂ

In hospital outcome of acute inferior wall Myocardial Infarction with or without right ventricular infarction

Patients of acute inferior wall MI with concomitant right ventricular infarction is considered as high risk patients because of associated high morbidity and mortality. Total of 50 patients were enrolled for seven days of hospital stay. They were divided into two groups; one with only acute inferior wall MI and the other with acute inferior wall MI associated right ventricular involvemen. The fatality rate was 33.3% with right ventricle involvement compared with 2.6% without right ventricle involvement. (p=0.003).The major cause of death was cardiogenic shock. Complications were as follow; cardiogenic shock (p=0.012), Tricuspid regurgitation (p=0.04), AV Block (p=0.04), tachyarrhythmia (p=0.077) and VSD in both groups. The conclusion was that right ventricle involvement was an independent predictor of prognosis in patients with acute inferior wall myocardial infarction.

Assessment of validity of the ‘Culprit Score’ for predicting the culprit lesion in patients with acute inferior wall myocardial infarction

IntroductionMany electrocardiographic criteria have been developed to determine the infarct-related artery in acute inferior wall myocardial infarction. The aim of this study was to test the commonly used criteria and devise a simplified score to further improve the diagnostic accuracy. Materials and methodsFrom 2011 to 2013, 100 patients with acute inferior wall myocardial infarction were recruited for electrocardiographic and angiographic analyses. ResultsThe mean age of the patients was 65±12 years with 74% of patients being male. In our study population, significantly more ST-segment depression was seen in lead aVL and ST elevation in lead III in those with right coronary artery (RCA) occlusions. In left circumflex artery (LCX) occlusions, significantly more ST depression was seen in leads V1–3 (most significantly in lead V2) and ST elevation in lead II. In addition, more prominent ST depression was seen in lead aVL and ST elevation in V1 in proximal RCA occlusions. Based on the findings, we devised a score named Culprit Score, which was defined as [II−V2/III+V1−aVL]. The sensitivity and specificity of Culprit Score ≤0.5 to predict proximal RCA occlusions; 0.5 to ≤1.5 to predict distal RCA occlusions; and score >1.5 to predict LCX occlusions were 85% and 85%; 80% and 86%; and 80% and 94%, respectively. Similarly, the negative predictive value was more than 80%. ConclusionThe Culprit Score was found to have high specificity and negative predictive value to identify the infarct-related artery in inferior wall myocardial infarction.

TCTAP C-185 Retrieval of a Dislodged Coronary Stent from the Left Internal Carotid Artery

### Patient initials or identifier number LC ### Relevant clinical history and physical exam A 55 yr old male presented with Acute Inferior wall MI. CAG showed 80% stenosis with dissection in mad LAD and 80% tubular calcific lesion with thrombus in Proximal RCA. During PTCA to RCA, undeployed

Successful Primary Percutaneous Intervention with Stenting in Anomalous Right Coronary Artery Arising from left Coronary sinus in case of Acute Inferior wall Myocardial Infarction Complicated by Cardiac Tamponade

Anomalous origin of the right coronary artery (RCA) from the left sinus of valsalva is a rare congenital abnormality. The unusual location and noncircular orifice of this anomaly poses a great technical challenge for selective catheterization and percutaneous coronary intervention (PCI). Hemopericardium leading to tamponade complicating acute MI is rare and leads to hemodynamic instability. We report a case of acute inferior wall MI with a moderate pericardial effusion in cardiac tamponade who was treated with immediate pericardiocentesis followed by PCI and stenting of an anomalously arising RCA from the left sinus. Key words: Anomalous coronary artery, Primary PCI, Tamponade, Hemopericardium, Inferior wall MI.

Acute Inferior Myocardial Infarction in a Young Female; Initial Presentation of Takayasu Arteritis: A Case Report

Takayasu’s arteritis (TA) is a chronic large-vessel inflammation of unknown etiology that mainly affects the aorta and its major branches. Coronary involvement is not uncommon (9%-11% of cases). Coronary artery involvement consists mostly of stenosis at the coronary ostia. We report the case of a 42-year-old lady who presented with acute inferior wall MI. although our patient is older than 40 years at the time of presentation, the diagnosis has been confirmed by anatomic imaging.

Reversibility of High-Grade Atrioventricular Block with Revascularization in Coronary Artery Disease without Infarction: A Literature Review.

Complete atrioventricular (AV) block is known to be reversible in some cases of acute inferior wall myocardial infarction (MI). The reversibility of high-grade AV block in non-MI coronary artery disease (CAD), however, is rarely described in the literature. Herein we perform a literature review to assess what is known about the reversibility of high-grade AV block after right coronary artery revascularization in CAD patients who present without an acute MI. To illustrate this phenomenon we describe a case of 2 : 1 AV block associated with unstable angina, in which revascularization resulted in immediate and durable restoration of 1 : 1 AV conduction, thereby obviating the need for permanent pacemaker implantation. The literature review suggests two possible explanations: a vagally mediated response or a mechanism dependent on conduction system ischemia. Due to the limited understanding of AV block reversibility following revascularization in non-acute MI presentations, it remains difficult to reliably predict which patients presenting with high-grade AV block in the absence of MI may have the potential to avoid permanent pacemaker implantation via coronary revascularization. We thus offer this review as a potential starting point for the approach to such patients.

Acute Inferior Wall Myocardial Infarction with Anaphylactic Shock Due to Bee Sting: What Should We Do?

The electrocardiogram showed 1 mm ST segment elevation in leads DII, DIII, aVF derivations and also complete AV block. His general condition and hemodynamic parameters were suddenly deteriorated. His blood pressure and heart rate dropped to 60/40 mmHg and 40/min respectively. Isotonic solution infusion started 1000 cc/hour and Atropin 1 mg initiated intravenously. After that his cardiac rhythm changed to the ventricular fibrillation. Following cardiac defibrillation, immediately coronary angiography performed.

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.

Updated cardiac concerns with rituximab use: A growing challenge

A 62-year-old male was undergoing treatment of NHL with bone marrow involvement with thrombocytopenia. After 15min of starting of IV infusion of rituximab, he started having severe retrosternal chest pain, diagnosed as acute ST elevation inferior wall MI. Patient was pre-loaded with dual anti platelets. Coronary angiogram showed 100% occlusion of proximal RCA. Thrombosuction of this culprit RCA revealed underlying 90% stenosis. After that, PCI with balloon angioplasty of RCA was done. The procedure was terminated in the view of successful balloon angioplasty with good TIMI flow. He was kept on dual antiplatelet therapy for one month with regular platelet monitoring. With the growing increasing global use of rituximab for various oncological and immunological diseases, this complication of myocardial infarction should be kept in mind. Associated thrombocytopenia with high thrombus burden in this case heed primary coronary balloon angioplasty without stent placement a more suitable modality.

Assessment of Right Ventricular Function in Acute Inferior Wall Myocardial Infarction in Patients Treated with Primary Percutaneous Coronary Intervention

Assessment of Right Ventricular Function in Acute Inferior Wall Myocardial Infarction in Patients Treated with Primary Percutaneous Coronary Intervention

Trauma induced myocardial infarction

Chest Trauma in athletes is a common health problem. However, myocardial infarction secondary to coronary dissection in the setting of blunt chest trauma is extremely rare. We report a case of acute inferior wall myocardial infarction following blunt chest trauma. A 32-year-old male with no relevant medical problems was transferred to our medical center for retrosternal chest pain after being elbowed in the chest during a soccer game. Few seconds later, he started experiencing sharp retrosternal chest pain that was severe to that point where he called the emergency medical service. Upon arrival to the trauma department patient was still complaining of chest pain. ECG demonstrated ST segment elevation in the inferior leads with reciprocal changes in the lateral leads all consistent with active ischemia. After rolling out aortic dissection, patient was loaded with ASA, ticagerlor, heparin and was emergently taken to the cardiac catheterization lab. Coronary angiography demonstrated 100% thrombotic occlusion in the distal right coronary artery with TIMI 0 flow distally. After thrombus aspiration, a focal dissection was noted on the angiogram that was successfully stented. Two days after admission patient was discharged home. Echocardiography prior to discharge showed inferior wall akinesis, normal right ventricular systolic function and normal overall ejection fraction.

Acute focal Myocarditis with Preserved Ventricular Function Masquerading as Acute ST-elevation Inferior Wall Myocardial Infarction

Myocarditis is a pathological inflammatory condition which can result in significant damage to the myocardium and more specifically the myocytes. Acute myocarditis can present similarly to myocardial infarction, and can rise to the top of the differential diagnosis when chest pain, cardiac enzymes, and ECG that suggest myocardial infarction are followed by a normal coronary angiogram. The gold standard of diagnosis for myocarditis is an endomyocardial biopsy as a positive biopsy is very specific; however, the inflammation of myocarditis may be diffuse or focal, limiting the biopsy’s sensitivity. We present a case of a 19 year old man with acute focal myocarditis masquerading as an acute ST-elevation inferior wall myocardial infarction on ECG with elevated troponin I. This is an unusual presentation as the patient’s echocardiogram and cardiac catheterization did not show ventricular dysfunction. Our diagnosis was confirmed by cardiac MRI rather than endomyocardial biopsy, due to the high risk of adverse events associated with the latter. Acute myocarditis that mimicks a myocardial infarction in presentation is a rare, but well known occurrence [1]. Acute myocarditis typically presents with a less distinct prodromal illness period, in contrast with fulminant myocarditis, which has a more defined viral prodrome and associated with more severe cardiovascular compromise. Acute myocarditis is also more likely to present in those patients with established ventricular dysfunction, with the potential to progress to dilated cardiomyopathy [2].

A retrospentive analysis of blood flow perfusion among coronary arteries during double vessel acute simultaneous occlusion in acute ST-elevation myocardial infarction patients

Objective To explore the impact on intervascular blood flow perfusion among coronary arteries in order to illuminate the mechanism of acute simultaneous occlusion of double vessels in patients with ST-elevation myocardial infarction (STEMI) . Methods A cohort of 15 consecutive STEMI patients with acute simultaneous occlusion of double vessels admitted from February 2013 to February 2014 were enrolled in this study. Those patients were treated with emergency primary percutaneous coronary intervention (p-PCI) after admission. The clinical data, the procedure of emergency p-PCI and the findings of coronary artery angiography (CAG) were retrospectively analyzed. Results Of 15 patients with STEMI, there were 8 with acute anterior and inferior wall MI, 5 with acute inferior and posterior wall MI and 2 with acute anterior and lateral wall MI. Of them, 14 patients manifested abruptly in the clinical feature of cardiagenic shock, and treatment strategy was one-step revascularization with p-PCI or multiple-step revascularization procedures. All patients were survived after emergency p-PCI and then cared continuously in the Coronary Care Unit. They were checked with CAG, and CAG showed that 6 totally occluded coronary arteries resumed blood perfusion of more than TIMI 2 grade of the blood flow after p-PCI. Conclusions The double vessel occlusion STEMI is rare occurred in clinical medicine. The perfusion of non-culprit artery may be impaired and blocked as soon as the culprit artery was obstructed by thrombus to produce an acute double vessel occlusion of STEMI. And cardiogenic shock might be involved in the pathogenesis process. One-step treatment strategies for STEMI with cardiogenic shock could have clinical practice value. Key words: Acute ST-segment elevation myocardial infarction; Double vessel acute occlusion; Blood flow perfusion

Mitral Stenosis and Acute St Elevation Myocardial Infarction

We describe a patient who presented with acute (inferior wall) ST elevation myocardial infarction. Her echocardiogram showed severe mitral stenosis with ball valve thrombus in the left atrial body and thrombus in the left atrial appendage. Coronary angiogram revealed thromboembolic material in the right coronary artery. Mitral valve replacement was scheduled.

Clinical Significance of ST Segment Depression in Lead aVR to Predict Culprit Artery in An Acute Inferior Wall Myocardial Infarction

Background and Aims: The main objective of this study is to analyze between left circumflex artery and right coronary artery as a presumptive predictor of a culprit artery in patients with an acute inferior wall ST elevation myocardial infarction according to ST segment change in lead aVR. Methods: This study included 145 consecutive patients who presented with an inferior wall ST elevation myocardial infarction and underwent coronary angiography. Clinical and angiographic findings were compared between patients with and without aVR depression ≥ 0. 1mV. Results: The sensitivity and specificity of ST segment depression in lead aVR to predict left circumflex artery as the culprit artery were 69% and 85%, respectively, and the positive predictive value and negative predictive value to predict left circumflex artery as the culprit arteries were 66% and 87%, respectively. Conclusion: Our study supports, the presence of ST segment depression in lead aVR is associated with good specificity and negative predictive value and modest sensitivity and positive predictive value to determine left circumflex artery as an infarct related artery in an acute ST segment elevation inferior wall myocardial infarction.DOI: http://dx.doi.org/10.3126/njh.v12i1.12324 Nepalese Heart Journal Vol.12(1) 2015: 5-9

The masquerading myxoma – Presentation as acute STEMI

Primary cardiac neoplasms are very rare, with an incidence less than 0.2% in unselected patients at autopsy. Of these, cardiac myxomas are the most common benign cardiac tumors in the adult. Atrial myxomas are a rare source of coronary artery embolism. Coronary embolism as the first presentation of cardiac myxoma is extremely uncommon. We report a case of acute inferior wall ST elevation myocardial infarction (STEMI) caused by embolization of the tumor fragment from left atrial myxoma into the left circumflex coronary artery. The patient was successfully treated by percutaneous coronary intervention with catheter aspiration of the embolized tumor fragment followed by surgical excision of the tumor.

Clinical Implication of ST Segment Depression in aVR & aVL in Patients with Acute Inferior Wall Myocardial Infarction

Objectives: The aim of the study was to assess the role of ST segment depression in the limb leads aVR and aVL for the diagnosis of acute posterior wall infarction and the identification of infarct related artery (IRA) in patients with acute inferior wall MI. Methods: In 159 patients with I-STEMI, 127 (80%) had RCA occlusion and 32 (20%) had LCX occlusion. In the ECG algorithms, RCA occlusion was indicated by ST depression in lead aVL higher than lead aVR and no ST depression in lead aVL and aVR. LCX occlusion was indicated by ST depression in lead aVR higher than or equal to lead aVL and no ST depression in aVL and aVR. Results: The sensitivity, specificity, positive and negative predictive values of these algorithms were high (98%, 82%, 92% and 95% for RCA occlusion and 83%, 98%, 95% and 92% for LCX occlusion). Conclusion: The ECG algorithms can reliably identify the culprit artery in I-STEMI. ST segment depression in limb leads aVR and aVL with avR ≥ aVL helps to diagnose left circumflex artery as a culprit IRA in an acute inferior wall MI.

Outcome comparison between left circumflex and right coronary artery-related acute inferior wall myocardial infarction

Background: Left circumflex artery (LCx) related acute ST-segment elevation inferior wall myocardial infarction (IWMI) is less well-reported in literature than the right coronary artery (RCA)-related IWMI. Little is known about the outcome of patients with LCx infarct-related acute IWMI. Recently, studies have shown that LCx-related infarcts carried less favorable outcome. Materials and Methods: Between January 2007 and December 2012, data of all patients with acute IWMI, who presented to a university hospital in Saudi Arabia were reviewed, and the various in-hospital outcomes were compared. Results: A total of 90 patients comprising 63 (70%) patients in the RCA-related IWMI group and 27 (30%) in the LCx-related IWMI group were reviewed. Diabetes mellitus, dyslipidemia and renal impairment were more prevalent in the RCA-related infarct group. The prevalence of atrio-ventricular block (14.3% vs. 0%, P = 0.053) and the frequency of cardiogenic shock needing inotropic support (14.3% vs. 0%, P = 0.053) were higher in the RCA related infarcts. Conclusions: Our study showed that in a sample from Saudi Arabia, the in-hospital prognostic outcomes were less favorable in patients with RCA-related acute IWMI when compared to LCx-related infarcts.

Mechanical extraction of a massive intracoronary thrombus from the super-dominant right coronary artery in thrombogenic lung cancer patient.

The congenital absence of the left circumflex artery and a compensatory super-dominant right coronary artery (RCA) is a very rare benign coronary anomaly in the clinic. The presence of a massive thrombus in the super-dominant RCA can lead to fatal results in cases of acute myocardial infarction, unless the thrombus is mechanically removed. Aspiration of the thrombus using a 6 Fr right Judkins guide catheter is useful to extract a massive thrombus and is both safe and effective. We report a case of complete revascularization of the super-dominant RCA after thrombus aspiration using a 6 Fr Judkins right catheter in a patient with acute inferior and inferolateral wall myocardial infarction.