Anterior ST Elevation Research Articles

Intermittent Isorhythmic Dissociation after Revascularization Treatment in ST-Elevation Myocardial Infarction

A 62-year-old male was admitted with anterior wall ST-elevation myocardial infarction, angiography reported a proximal lesion in the left descendant artery. Percutaneous coronary intervention was performed, with no complications, still, 72 h the electrocardiogram showed intermittent isorhythmic dissociation.

Anterior wall ST-elevation myocardial infarction complicated by a ruptured left ventricular aneurysm: a case report

ST-segment elevation myocardial infarction (STEMI) remains the most frequent cause of death worldwide. Nowadays, its management has been revised with the aim of rapid revascularization to avoid its fatal complications. Among its complications, mechanical complications, especially left ventricular aneurysm, have a high risk of death by rupture as illustrated in this case. We report the case of a 63-year-old male, who was referred to our tertiary hospital for shortness of breath and worsening chest pain evolving for 3 days after a delayed consultation. The electrocardiography (EKG) showed sequelae of anterior myocardial infarction with echocardiography of a giant apical aneurysm of the left ventricle. The evolution was rapidly marked by hemodynamic failure and cardiac arrest following rupture of the aneurysm. Until now, there is no proven benefit of aneurysm surgery yet, hence the importance of its prevention by urgent revascularization of any STEMI.

Congenital Absence of Left Coronary Artery Ostium in a Patient Presenting With Anterior ST-Elevation Myocardial Infarction

A 73-year-old man developed chest pain 12 hours before arriving at our hospital. An electrocardiogram revealed ST-segment elevation in leads V2–V6 (Figure 1A); therefore, an emergent coronary angiography was performed. Several attempts were made to engage the left coronary artery (LCA), but they were unsuccessful. Left coronary cusp angiography and subsequent right coronary angiography demonstrated a single right coronary artery (RCA) with blood flow to the left circumflex coronary artery (LCX) and the congenital absence of the LCA ostium at the left, right, and posterior Valsalva sinuses (Figure 1B, Video 1).

Study of Acute Coronary Syndrome in Premenopausal Women in Correlation with Sex Hormones

Objectives: Higher testosterone and lower Estrogen levels are associated with cardiovascular disease in women. However, studies on endogenous sex hormones and acute coronary syndrome (ACS) in pre-menopausal women are sparse. Material and Methods: We studied 50 pre-menopausal women presenting with ACS and age-matched controls who consented to the study with Testosterone, Estradiol, and Sex hormone-binding globulin (SHBG) levels at baseline. They were clinically followed up for 6 months duration. Results: The mean age was 37.42 ± 5.7 years. 48% patients were obese. The mean body mass index was 27.53 ± 5.41 kg/m2. Hypertension followed by Diabetes was the most common risk factor. 14% had family history of coronary artery disease (CAD). 24% had atypical chest pain at presentation. Anterior wall ST elevation myocardial infarction was the most common presentation. Single-vessel disease was seen in 38%; 24% had Non-Obstructive CAD. Ratios of Bioavailable Testosterone: Estradiol, Estradiol: Low-density Lipoprotein (LDL), Estradiol: High-density Lipoprotein, SHBG: LDL, and SHBG: HbA1c were analyzed in cases and controls and were not found to be significantly associated. Conclusion: Endogenous sex hormones were not found to be significantly associated with ACS in premenopausal women.

194 THROMBOEMBOLIC ACUTE ST ELEVATION MYOCARDIAL INFARCTION AFTER TRANSCATHETER VALVE IMPLANTATION

Abstract Transcatheter aortic valve implantation (TAVI) is an established treatment of severe symptomatic aortic valve stenosis and is an effective and less invasive treatment option compared with conventional surgical aortic valve replacement (SAVR) for patients considered inoperable or at high surgical risk. Thromboembolic and bleeding complications negatively impact recovery and survival after TAVI. This case describes one of the few reported TAVI-associated myocardial infarction due to thrombosis of the prosthetic aortic valve. A 82-years-old woman, suffering from severe symptomatic aortic stenosis, underwent TAVI. Before the procedure, coronary artery disease was excluded by invasive coronary angiography. Since the time of the discharge the patient didn't assume any therapy with aspirin or other antithrombotic drugs. A month after TAVI she complained persistent epigastric pain and was admitted to our department for anterior ST elevation myocardial infarction. Coronary angiography highlighted a monovascular coronary artery disease with thrombotic occlusion of the first diagonal and of the distal left anterior descending coronary artery. In consideration of the thrombotic load thyrofiban was started and it was performed a chest contrast CT which confirmed the diagnostic suspicion of bioprosthetic valve thrombosis. She was first treated with unfractionated heparin (UFH) and then oral anticoagulant therapy with warfarin was started. Echocardiograms (echo) showed a severely reduced systolic function (EF 25%) and high trans-prosthetic gradients (mean transprosthetic pressure gradient of 30 mmHg). On the 8th day after hospitalization she complained chest pain with evidence of moderate pericardial effusion. Epistenocardica pericarditis was therefore diagnosed and the patient started acetylsalicylic acid therapy with progressive clinical, instrumental and laboratory improvement. After 10 days of anticoagulation therapy, she underwent a transesophageal echocardiogram which turned out negative for bioprosthetic valve thrombosis. The predischarge transthoracic echocardiography showed severely reduced systolic function (EF 30%) with a mean transprothesic gradient of 12 mmHg; the circumferential pericardial effusion was mild-moderate but not haemodynamically significative. Therapy at discharged included warfarin and aspirin. Ten days after an echo showed a reduction of the pericardial effusion, an improved systolic function (EF 42%) and mean transprothesic gradient not changed significantly since discharge. Prosthetic valve thrombosis has been reported in up to 40% of patients after TAVI and this case hightlights the importance of antithrombotic therapy after this procedure. Therapeutic anticoagulation appears to be the only non-invasive treatment for resolving valve thrombosis but it is not clear how long this therapy should last for the prevention of prosthetic valve thrombosis.

177 TRANSCATHETER EDGE-TO-EDGE REPAIR OF SEVERE FUNCTIONAL MITRAL REGURGITATION TO OVERCOME ACUTE DECOMPENSATION IN A YOUNG MAN CANDIDATE TO HEART TRANSPLANTATION.

Abstract Background Chronic severe functional mitral regurgitation (FMR) is common in patients with HF as it reflects left ventricle dysfunction and portends poor prognosis. Case report A 42 years old man with cardiovascular risk factors (former smoker, obesity) but without previous cardiological history presented anterior ST-elevation myocardial infarction (STEMI) treated with primary PCI of the anterior descending artery. He developed severe ventricular dysfunction leading to congestive heart failure (HF) requiring early re-hospitalization for pulmonary edema. Despite optimal medical therapy patient remained symptomatic (NYHA class III, INTERMACS 6) with persistence of left ventricle ejection fraction (LVEF) depression, therefore he received an implantable cardiac defibrillator for primary prevention and was referred to our institution for further evaluation. Trans-esophageal echocardiography showed severe left ventricle dilatation and disfunction (EDD 6.9 cm, iEDV 113 ml/m2, LVEF 24%) and presence of severe FMR with EROA 37 mm2 and RV 44 ml. Right heart catheterization (RHC) revealed combined pulmonary hypertension (mean PA pressure 43 mmHg, PCWP 32 mmHg, PVR 4.6 WU) with severely reduced cardiac index obtained (CO 3.4 l/min, CI 1.9 l/min/m2). After infusion of inodilator (enoximone) a decrease of PA pressure and PVR was reported, concluding for reversible pulmonary hypertension. After screening for non-cardiac contraindications, the patient was listed for heart transplantation. Chances to get a donation with a short waiting list time were low because of patient's high BMI and blood group B. Therefore, after Heart Team evaluation, transcatheter edge-to-edge repair of the mitral valve (TEER) was performed as bridge to transplant. A single NTR clip was used, placed centrally between A2-P2 segments, reducing regurgitation from severe to mild. Patient was discharged on heart transplantation waiting list. At three months follow up he presented clinical improvement with reduction of NYHA class from III to II. RHC was repeated and showed normal filling pressures, reduction of pulmonary pressure (mPAP 20 mmHg) and increased cardiac output (CO 5.2 l/min, CI 2.5 l/min/m2). According to his preferences, the patient was suspended from the waiting list with indication to continue outpatient follow-up. At 1-year control he was stable in NYHA II class and the daily diuretic dose had been reduced, echocardiography showed severe LVEF depression (28%) with mild to moderate residual mitral regurgitation. Conclusions TEER recently emerged as an option for patients with FMR who are not suitable for surgery. Latest guidelines suggest its use in presence of specific criteria (LVEF 20-50%, ESD < 7 cm, sPAP <70 mmHg, hemodynamic stability, absence of right ventricle disfunction and severe TR) rarely fulfilled by patients with advanced HF requiring evaluation for transplant. On the other hand, access to surgical strategies for end stage HF is limited by scarce availability of donors and by temporary or definitive contraindications. Evidences are emerging that in this population TEER can improve hemodynamic profile and lead to reduction of pulmonary hypertension, providing temporary stability before definitive treatment or allowing candidacy. In this setting, TEER might be performed to reduce symptoms. Considering TEER as bridge strategy to transplant, candidacy or decision can expand the number of patients suitable for heart transplantation or delay urgency.

A Case of Middle Aged Women with Isolated Left Coronary ostial stenosis with Non ST Elevation Myocardial Infarction

Background: The stenosis of the ostial left anterior descending artery represents one of the challenges for the interventional cardiologist. In contrast ostial stenosis of the left main trunk shows very good results after percutaneous interventions and implantation of drug-eluting stents. The indications for percutaneous transluminal coronary angioplasty (PTCA) of an ostial lesion correspond to the indications for treatment of all other lesions. Case: A-56-year-old woman was admitted to our hospital who was initially admitted in the intensive care unit for a severe acute chest pain. She had no coronary risk factors. No hormonal disorders were observed. Physical and laboratory examinations revealed that she had not suffered from syphilis or aortitis syndrome or any other inflammatory diseases. An electrocardiogram (ECG) was immediately performed and showed ST segment non elevation in the precordial leads (Figure 1) suggesting an acute anterior ST Non elevation myocardial infarction (NSTEMI). On coronary angiography, a 80% stenosis of the left coronary ostial stenosis was found, but no abnormality was found in other arterial trees. (Figure 2) The patient was diagnosed as having isolated coronary ostial stenosis. Conclusion: The patients are almost always middle aged woman with no coronary risk factors. , the involved coronary artery is the left main coronary artery, so its obstruction results in a serious condition. Therefore, though its pathogenesis remains to be determined, isolated left coronary ostial stenosis seems to be a distinct clinical entity.

An Unconventional Approach to Overcome the Extreme Angulation of LAD: A Challenging Percutaneous Coronary Intervention.

We herein describe a challenging acute anterior ST-elevation myocardial infarction (STEMI) case. The patient was hemodynamically unstable during the procedure and the extremely angulated culprit vessel hindered our repeated attempts of wiring. Procedural complexity and risks were increased not only due to angulation but also the bifurcational nature of the culprit lesion. We report an innovative solution that enabled the successful revascularisation of such a complex situation, after the failure of multiple attempts of conventional methods for wiring. We also briefly review the literature about recommended methods for such severely angulated vessels. Key Words: Angulation, infarction, Vessel, Angiography.

In-Hospital Outcomes of Patients Presenting with Acute Anterior STEMI with Right Bundle Branch Block

Objective: To assess the in-hospital outcomes in Anterior wall ST Elevation Myocardial Infarction patients presenting with Right Bundle Branch Block with different reperfusion strategies.
 Study Design: Analytical Cross-Sectional Study.
 Place and Duration of Study: Department of Cardiology, Rawalpindi Institute of Cardiology, Rawalpindi Pakistan, from Sep 2020 to Feb 2021.
 Methodology: Patients with myocardial infarction who presented to the emergency department of the hospital were included in the study. Further evaluation was performed on individuals with ST elevation in anterior chest leads and new-onset or presumably new Right bundle branch block on electrocardiogram. Anterior wall myocardial infarction was diagnosed based on 4th universal definition of Myocardial infarction. Patients excluded were those with non-anterior ST-elevation myocardial infarction, prior coronary artery bypass grafting, previous percutaneous coronary intervention, or Left bundle branch block.The treatment plan was chosen by the interventional cardiologist. Various parameters were used to measure the outcomes ofdifferent therapies.
 Results: 93 patients were included with 72(77.4%) males and 21 females (22.5%). Mean age was 59.91±11.93 years. Premorbid seen was 41.9% diabetes, 32.3% hypertension, 18.3% smoking. Transient RBBB was seen in 64.5% of the study population and persistence RBBB was 35.5%. Mortality was associated with higher Killip class (p=<0.001), AV block (p=0.078), increased no of coronary vessels involved (p=0.014), increased amplitude of ST elevation (p=0.083) and with lower EF values (p=0.032). Worst outcomes were common in patients on medical treatment.
 Conclusion: Poor outcomes in Anterior Wall Myocardial Infarction with Right Bundle Branch Block are linked to length ofstay, co morbidities, Killip class, amplitude of ST elevation, coronary artery disease complexity and those managed on medicaltreatment.

Clinical and electrocardiographic features in acute total left main coronary artery occlusion without collateral circulation

BackgroundsStudy concerning the clinical features, electrocardiogram (ECG) findings and outcomes in patients presenting with acute total occlusion of left main coronary artery (LM) without collateral circulation is limited. Methods25 patients with acute total LM occlusion without collateral circulation by emergency coronary angiography, from muti-center registry, were retrospectively studied. The clinical and angiographic characteristics, ECG and in-hospital mortality were reviewed. ResultsNineteen patients (76%) presented with cardiogenic shock. Twelve (60%, 12/20) patients had coronary slow flow or no reflow phenomenon after primary percutaneous coronary intervention (PCI). The in-hospital mortality rate was 88% (n = 22). All the patients presented with ST-segment elevation myocardial ischemia (STEMI) pattern, mostly involving leads I, aVL, V2, V3, V4, V5 and ST-segment depression in leads II, III and aVF. ConclusionsAcute total LM occlusion without collateral circulation portends high in-hospital mortality. Anterior ST elevation in the precordial leads from V2 to V4 through V6, and ST elevation in leads I and aVL, accompanying with ST depression in the inferior leads is associated with acute total LM occlusion without collateral circulation.

Abstract 13019: LV Thrombus With Embolic Phenomena: Identifying the Culprit

Background: Left ventricular (LV) thrombus occurs with prior myocardial infarction (MI), particularly anterior ST-elevation MI (STEMI), dilated cardiomyopathy, and prothrombotic conditions. Case: A 38-year-old female with poorly controlled type 2 diabetes mellitus presented with leg pain and dyspnea. Her left lower extremity was cold and mottled, with absent pulses in both legs. EKG revealed lateral STEMI. Emergent coronary angiogram revealed 85% proximal left circumflex stenosis and 100% stenosis of the proximal first obtuse marginal branch (not amenable to intervention due to small vessel caliber). The patient then underwent bilateral iliofemoral and popliteal embolectomy. Transthoracic echocardiogram revealed ejection fraction (EF) of 40% and a 1 x 1 cm thrombus attached to the posteromedial papillary muscle; heparin was started. The patient later developed right-sided weakness; brain MRI revealed multiple acute-subacute infarcts in the left cerebral hemisphere. Transesophageal echocardiogram was negative for patent foramen ovale or shunt. Decision-making: LV thrombus with embolic phenomena raised suspicion for underlying thrombophilia. The patient was started on warfarin and clopidogrel, with outpatient follow-up for hypercoagulability workup, which was negative. Cardiac MRI later revealed resolution of LV thrombus, and oral anticoagulation was discontinued after 3 months, and switched to aspirin. Conclusion: LV thrombus is far more common after anterior STEMI as it affects a larger area of myocardium, but it can also occur with lateral STEMI. Hypercoagulability state should be considered on the differential of LV thrombus in the setting of lateral STEMI. If hypercoagulability workup is negative, aggressive risk factor modification for coronary disease should be pursued.

Abstract 15016: Inferior ST Segment Depression Identifies Proximal Left Anterior Descending Culprit Lesions in Anterior ST Elevation Myocardial Infarction

Introduction: Anterior wall ST elevation myocardial infarction (STEMI) is caused by occlusion of the left anterior descending (LAD) coronary artery. Proximal LAD occlusions are associated with larger infarcts and more complications. However, there is limited data demonstrating a relationship between ECG changes and the location of the LAD culprit lesion. Objective: To determine if patterns of ST elevations (STE)/depressions (STD) on the 12 lead ECG can predict if the culprit lesion in an anterior STEMI is in the proximal LAD. Methods: We performed a retrospective chart review of ECGs obtained from a database of patients diagnosed with myocardial infarction at Robert Wood Johnson University Hospital from January 2009 to December 2016. Lesions, defined as proximal or non-proximal with respect to the first diagonal of the LAD, were assigned according to the Bypass Angioplasty Revascularization Investigation (BARI) Protocol. Each lesion was assigned to one of the 4 ECG patterns described in Table 1. An analysis of variance was used to determine if the difference in ECG characteristics between groups was significant. Results: Of 447 ECGs denoted as anterior wall STEMIs, 227 met inclusion criteria. In total, 104 lesions were defined as proximal and 123 were non-proximal. There was a difference in the ECG pattern of proximal versus non-proximal culprits category (p = 0.006). Proximal culprit lesions were more likely to have STE in the precordial leads combined with STD in the inferior leads, whereas non-culprit lesions were more likely to have STE in the precordial leads without any STE or STD in the limb leads. Conclusions: In anterior STEMIs, proximal culprit lesions were more likely to exhibit ST elevations in precordial leads and ST depressions in inferior leads, compared to non-proximal culprit lesions, which were more likely to have ST elevations in only the precordial leads. Concomitant STE in lateral leads without inferior STD did not distinguish between the 2 groups.

Abstract 15478: Obscure Back Pain - A Case of Spontaneous Retroperitoneal Bleed

Introduction: We present a case of spontaneous retroperitoneal bleed that presented as back pain until it required multiple transfusions. Case presentation: A 66-year-old gentleman with past medical history of only dyslipidemia, presented with chest pain and was found to have an anterior wall ST-elevation myocardial infarction. He underwent stenting to proximal LAD and was found to be in cardiogenic shock with elevated biventricular filling pressures and ejection fraction of 5-10%. IABP was inserted, which had to be upgraded to axillary Impella 5.5 the next day, and LVAD workup was initiated. He gradually improved with decreasing Impella needs when he started complaining of back pain 5 days into his admission. At the same time, his Impella requirements started to go up. He went on to develop sweating, pallor & hemodynamic compromise. Since he was on anticoagulation due to Impella, a CT scan was obtained, which showed a spontaneous left-sided retroperitoneal bleed (F1) (IABP had been on the right side) and drop in hemoglobin from 15.8 mg/dl on admission to 7.2 mg/dl. He went on to develop hemorrhagic shock requiring massive blood product transfusion with subsequent vessel embolization by interventional radiology. Afterwards, he continued to improve, and Impella was eventually removed. Later in the course, he had another drop in hemoglobin & was taken back for CT, which showed expanding retroperitoneal hematoma (F2). Hematology team was consulted due to 2 spontaneous bleeds; however, no underlying bleeding disorder was suspected. He stabilized; was weaned off of Impella and, was subsequently discharged on milrinone infusion. Conclusions: We conclude that providers highly suspect retroperitoneal bleeds in the proper clinical setting for optimum patient care.

Abstract 13918: Combined ECG Precordial Voltage and Troponin-T in Stress Cardiomyopathy versus Anterior STEMI

Introduction: Stress cardiomyopathy (SC) and anterior ST elevation myocardial infarction (AMI) share similar clinical and echocardiographic features on initial presentation, complicating their differentiation. Previously, subtle differences in 12-lead ECG between the two have been reported. Hypothesis: We propose that higher precordial R-wave amplitude on ECG and lower biomarkers values can serve as reliable predictors of SC during initial triage. Methods: Among patients admitted to a single center from 2015-2019 undergoing left heart catheterization (LHC) for suspected AMI, 76 patients with either LHC-proven SC or AMI (38 each) were included. All patients had transthoracic echocardiography (TTE) performed within 24 hours of LHC. Patients were excluded when TTE quality was poor. Left ventricular ejection fraction (LVEF) and speckle-tracking global longitudinal strain (GLS) were calculated from transthoracic apical views. Non-parametric variables were analyzed using Wilcoxon rank sum test. Sensitivity and specificity analyses were performed using ROC curves. Results: LVEF (33 + 9% vs 33 + 8%) and GLS (-7.5 + 2.8% vs -7.9 + 3.3%) were similar in both groups. R-wave amplitude in ECG leads V1-V2 was higher in SC compared to AMI (V1: 0.96 vs 0.54 mV, p = 0.035; V2: 1.46 vs 0.75 mV, p = 0.037). At index admission, peak pro-BNP was higher (22198 vs 3098, p = 0.002) and peak Troponin-T (1.43 vs 236, p <0.001) was lower in SC. Integrating peak Troponin-T and V1+V2 R-wave amplitudes differentiated SC from AMI with sensitivity = 92% and specificity = 73%. Conclusions: Despite having similar extent of LV systolic dysfunction when compared to AMI patients, SC patients have lower troponin elevation and R-wave amplitude reduction at presentation. These characteristics may be useful for selecting patients who do not require urgent invasive diagnostic evaluation.

Trajectories of Cardiac Function Following Treatment With an Impella Device in Patients With Acute Anterior ST-Elevation Myocardial Infarction

BackgroundLeft ventricular (LV) unloading via the percutaneous micro-axial Impella pump is increasingly used in patients with anterior ST-segment elevation myocardial infarction (STEMI) and overt cardiogenic shock. In this context, the evolution of cardiac function and dimensions beyond hospital discharge remains uncertain. We aimed to characterize echocardiographic changes over time in patients with acute anterior STEMI treated with an Impella device. MethodsFrom an ongoing prospective registry, consecutive patients with acute anterior STEMI managed with an Impella device were extracted. Transthoracic echocardiography was performed at index hospitalization and at first outpatient follow-up. Predictors of response, defined as a ≥ 10% absolute increase in left ventricular ejection fraction (LVEF) at follow-up, were sought. ResultsA total of 66 patients (89.4% male, aged 64.3 ± 11.6 years) with anterior STEMI were treated with an Impella device in the first 24 hours of hospitalization, from 2014 to 2022. In-hospital mortality was 24%. Major bleeding and vascular complications requiring surgery occurred in 24% and 11% of patients, respectively. At baseline, mean LVEF was 34% ±12%. At follow-up, survivors showed a significant increase in LVEF (P < 0.0001), whereas LV dimensions, diastolic parameters, and measures of right ventricular dimension and function remained stable. Overall, 28 patients had a ≥ 10% absolute increase in LVEF at follow-up. Baseline creatinine was the only significant predictor of response at univariate analysis. ConclusionsAmong patients with anterior STEMI requiring mechanical hemodynamic support with an Impella device, the majority of survivors showed a sustained increase in LV function, without evidence of adverse remodelling. This signal warrants further investigation in dedicated trials.

Association of Neutrophil to Lymphocyte Ratio with In- hospital Outcome of Acute Heart Failure due to Acute Anterior ST-elevation Myocardial Infarction

Background: Early detection and appropriate management play a key role in reducing the morbidity and mortality of acute heart failure in patients with acute myocardial infarction. Many prognostic factors have been assessed till date. This study aimed to evaluate the prognostic effect of NLR on in-hospital outcomes in patients with acute heart failure due to acute anterior ST elevation myocardial infarction. Methods: The present study was carried out in the Department of cardiology, Sir Salimullah Medical College &amp; Mitford Hospital, Dhaka from January 2020 to December 2020. A total of 88 cases of acute heart failure due to acute anterior ST elevation Myocardial infarction patients are enrolled in this study. NLR was estimated and patients were divided into two groups based on the NLR (Group I NLR &lt;6; Group II NLR ≥6). Then in-hospital outcome was observed and compared between two groups. Results: In-hospital mortality and length of hospital stay were higher among NLR ≥6 patients with statistical significance (11.6% vs. 40.9%, p&lt;0.001). These patients also had high incidence of cardiogenic shock (25% vs. 43%, p&gt;0.072), Arrhythmia (18% vs. 34%, p&gt;0.089) but without statistically significant difference. Conclusion: In this study, we observed that in-hospital outcomes were worse in patients with acute heart failure due to acute anterior myocardial infarction with NLR ≥6. So NLR can be used as a predictor of outcome in acute heart failure patients. This association is independent of conventional cardiovascular risk factors. Cardiovasc j 2022; 15(1): 13-19

Primary left ventricular unloading with delayed reperfusion in patients with anterior ST-elevation myocardial infarction: Rationale and design of the STEMI-DTU randomized pivotal trial

Despite successful primary percutaneous coronary intervention (PCI) in ST-elevation myocardial infarction (STEMI), myocardial salvage is often suboptimal, resulting in large infarct size and increased rates of heart failure and mortality. Unloading of the left ventricle (LV) before primary PCI may reduce infarct size and improve prognosis. STEMI-DTU (NCT03947619) is a prospective, randomized, multicenter trial designed to compare mechanical LV unloading with the Impella CP device for 30 minutes prior to primary PCI to primary PCI alone without LV unloading. The trial aims to enroll approximately 668 subjects, with a potential sample size adaptation, with anterior STEMI with a primary end point of infarct size as a percent of LV mass evaluated by cardiac magnetic resonance at 3-5 days after PCI. The key secondary efficacy end point is a hierarchical composite of the 1-year rates of cardiovascular mortality, cardiogenic shock ≥24 hours after PCI, use of a surgical left ventricular assist device or heart transplant, heart failure, intra-cardiac defibrillator or chronic resynchronization therapy placement, and infarct size at 3 to 5 days post-PCI. The key secondary safety end point is Impella CP-related major bleeding or major vascular complications within 30 days. Clinical follow-up is planned for 5 years. STEMI-DTU is a large-scale, prospective, randomized trial evaluating whether mechanical unloading of the LV by the Impella CP prior to primary PCI reduces infarct size and improves prognosis in patients with STEMI compared to primary PCI alone without LV unloading.

A Complex Case of Pregnancy-related Left Main Stem Spontaneous Coronary Artery Dissection.

Spontaneous coronary artery dissection (SCAD) is a less common cause of acute coronary syndrome. Pregnancy-related SCAD is uncommon, but often presents with a more severe phenotype. This report describes a 30-year-old woman with an anterior ST elevation MI, presenting 1 day postpartum. Left main stem (LMS) SCAD with extensive intramural haematoma (IMH) and resultant LMS occlusion was confirmed by angiography and intravascular imaging. Given the extent of disease, the patient underwent emergency cardiac surgery. Coronary flow was initially improved by decompressing the IMH using cutting balloons. The coronary wires were successfully left in situ during transfer in an effort to both maintain flow and allow the surgeon to identify true LMS. Ideally, SCAD can be managed conservatively given the risk of intervention worsening IMH, and hence myocardial ischaemia/MI. However, emergency revascularisation is indicated in cases of persistent ischaemia. This case demonstrates percutaneous therapies to bridge towards and help with subsequent surgical revascularisation.

P203 CHALLENGES IN THE MANAGEMENT OF RECTUS MUSCLE HEMATOMA DURING TRIPLE ANTITHROMBOTIC THERAPY IN RECENT ANTERIOR STEMI COMPLICATED BY LEFT ENDOVENTRICULAR THROMBOSIS

Abstract A 69–year–old woman suffering from hypercholesterolemia, GERD, was admitted to our department for anterior ST elevation myocardial infarction and was treated with primary PCI and DES on the mid–distal LAD. Dual antiplatelet therapy (DAPT) with ticagrelor and cardioaspirin was started. The pre–discharge echocardiogram (echo) showed the presence of left ventricular thrombus (LVT) and anticoagulant therapy (enoxaparin and warfarin) was started. On the 9th day the patient complained abdominal pain with onset of chills and hyperthermia and was suspected an uro–septic fever. The day after a mass appeared on the right abdominal wall at the site of the enoxaparin injection and abdominal contrast CT showed a mass of inhomogeneous density, actively supplied by the inferior epigastric artery and its terminal branches, indicative of hematoma of the abdominal rectus muscle. Anticoagulant therapy was suspended. Interventional radiologists in consideration of clinical stability and stable Hb value and the absence of the signs of active arterial bleeding on CT have not indicated an urgent endovascular treatment and DAPT with clopidogrel and cardioaspirin was continued. After V days, echo showed persistent pedunculated and mobile LVT and aspirin was therefore suspended and anticoagulant therapy was reintroduced with fondaparinux 2.5 mg daily. After two days, considering the stability of hematoma dimensions and the Hb values but the persistence of the extremely floating LVT, fondaparinux was increased at dose of 5 mg daily. In the following days, echo showed LVT reworking until its complete disappearance. On the 32th day blood test showed significant reduction in Hb values and a contrast CT showed an increase in size of the hematoma and resumption of micro bleeding. Fondaparinux was stopped and the patient was transferred to the interventional radiology center. Angiography highlights point–like spreads of extravascular contrast from branches of the inferior epigastric artery and branches of the external circumflex iliac artery. Embolization was performed. After a close monitoring of the hemoglobin values and of the echo which showed no LVT and recovery of LV function, in consideration of her thrombotic and hemorragic risks, she was discharged with DAPT with clopidogrel and low dose of aspirin. Abdominal wall hematoma may be a rare complication of subcutaneous enoxaparin therapy especially in STEMI patients undergoing also a DAPT therapy.

Interarterial Pseudoaneurysm

Femoral artery pseudoaneurysm (FAP) is one of the most troublesome complications related to femoral artery access site after cardiovascular catheterization procedures and occurs in 0.8%–2.2% of the cases of cardiovascular interventional procedures. Management is by ultrasound-guided compression repair (UGCR). A 75-year-old male presented with anterior wall ST-elevation myocardial infarction and after percutaneous transluminal coronary angioplasty, developed FAP. This pseudoaneurysm had an interarterial communication between superficial femoral artery and deep femoral artery. It is unusual to have communication of pseudoaneurysm with two branches of femoral artery. Diagnosis was made using vascular sonography and Doppler study. Closure of this aneurysm was done by simple pressure with Doppler probe at both the narrow ends of the aneurysm. Arterial color Doppler is the mainstay for diagnosing FAPs. This case describes an interarterial pseudoaneurysm which is a rare entity to witness and the different modalities for its management, the most common one being UGCR.