Anterior ST-segment Elevation Research Articles

Safety of Selective Intracoronary Hypothermia During Primary Percutaneous Coronary Intervention in Patients With Anterior STEMI.

The aim of this study was to determine the safety of selective intracoronary hypothermia during primary percutaneous coronary intervention (PPCI) in patients with anterior ST-segment elevation myocardial infarction (STEMI). Selective intracoronary hypothermia is a novel treatment designed to reduce myocardial reperfusion injury and is currently being investigated in the ongoing randomized controlled EURO-ICE (European Intracoronary Cooling Evaluation in Patients With ST-Elevation Myocardial Infarction) trial (NCT03447834). Data on the safety of such a procedure during PPCI are still limited. The first 50 patients with anterior STEMI treated with selective intracoronary hypothermia during PPCI were included in this analysis and compared for safety with the first 50 patients randomized to the control group undergoing standard PPCI. In-hospital mortality, occurrence of rhythm or conduction disturbances, stent thrombosis, onset of heart failure during the procedure, and subsequent hospital admission were assessed. In-hospital mortality was 0%. One patient in both groups developed cardiogenic shock. Atrial fibrillation occurred in 0 and 3 patients (P=0.24), and ventricular fibrillation occurred in 5 and 3 patients (P=0.72) in the intracoronary hypothermia group and control group, respectively. Stent thrombosis occurred in 2 patients in the intracoronary hypothermia group; 1 instance was intraprocedural, and the other occurred following interruption of dual-antiplatelet therapy consequent to an intracranial hemorrhage 6days after enrollment. No stent thrombosis was observed in the control group (P=0.50). Selective intracoronary hypothermia during PPCI in patients with anterior STEMI can be implemented within the routine of PPCI and seems to be safe. The final safety results will be reported at the end of the trial.

Effect of Paroxetine-Mediated G-Protein Receptor Kinase 2 Inhibition vs Placebo in Patients With Anterior Myocardial Infarction

Left ventricular remodeling following acute myocardial infarction results in progressive myocardial dysfunction and adversely affects prognosis. To investigate the efficacy of paroxetine-mediated G-protein-coupled receptor kinase 2 inhibition to mitigate adverse left ventricular remodeling in patients presenting with acute myocardial infarction. This double-blind, placebo-controlled randomized clinical trial was conducted at Bern University Hospital, Bern, Switzerland. Patients with acute anterior ST-segment elevation myocardial infarction with left ventricular ejection fraction (LVEF) of 45% or less were randomly allocated to 2 study arms between October 26, 2017, and September 21, 2020. Patients in the experimental arm received 20 mg of paroxetine daily; patients in the control group received a placebo daily. Both treatments were provided for 12 weeks. The primary end point was the difference in patient-level improvement of LVEF between baseline and 12 weeks as assessed by cardiac magnetic resonance tomography. Secondary end points were changes in left ventricular dimensions and late gadolinium enhancement between baseline and follow-up. Fifty patients (mean [SD] age, 62 [13] years; 41 men [82%]) with acute anterior myocardial infarction were randomly allocated to paroxetine or placebo, of whom 38 patients underwent cardiac magnetic resonance imaging both at baseline and 12 weeks. There was no difference in recovery of LVEF between the experimental group (mean [SD] change, 4.0% [7.0%]) and the control group (mean [SD] change, 6.3% [6.3%]; mean difference, -2.4% [95% CI, -6.8% to 2.1%]; P = .29) or changes in left ventricular end-diastolic volume (mean difference, 13.4 [95% CI, -12.3 to 39.0] mL; P = .30) and end-systolic volume (mean difference, 11.4 [95% CI, -3.6 to 26.4] mL; P = .13). Late gadolinium enhancement as a percentage of the total left ventricular mass decreased to a larger extent in the experimental group (mean [SD], -13.6% [12.9%]) compared with the control group (mean [SD], -4.5% [9.5%]; mean difference, -9.1% [95% CI, -16.6% to -1.6%]; P = .02). In this trial, treatment with paroxetine did not improve LVEF after myocardial infarction compared with placebo. ClinicalTrials.gov Identifier: NCT03274752.

Combined protocol for remote ischemic conditioning as the method of cardioprotection in patients with acute ST-segment elevation myocardial infarction

Background. There is currently no commonly accepted strategy for limiting the reperfusion injury that occurs after revascularization in patients with myocardial infarction. This study aimed to investigate the efficacy of a promising cardioprotective method.Material and Methods. Patients with acute anterior ST-segment elevation myocardial infarction (STEMI) (n = 87) were included in an open-label prospective randomized controlled trial. Control group comprised patients with STEMI who underwent only primary percutaneous coronary intervention (PPCI) (n = 44). Patients of intervention group (n = 43) underwent PPCI and remote ischemic perconditioning combined with postconditioning (RIC). The efficacy of RIC was assessed based on cardiac magnetic resonance (CMR) imaging data.Results. The medians of left ventricular (LV) infarct size were significantly higher in patients of control group: 44.8 (33.6; 55.5) versus 52.7 (35.5; 73.9) mL (p = 0.039) at day 10 after STEMI and 34.0 (25.8; 39.8) mL versus 46.0 (32.8; 55.0) mL six months after STEMI in control and intervention groups, respectively (p = 0.004). The groups of patients did not differ in the sizes of area at risk relative to the total LV myocardial volume: 40 (35; 45) and 43 (34; 49)% in control and intervention groups, respectively (р = 0.232). The groups significantly differed in the ratios of infarct size to area at risk: 70.3 (65.1; 86.6)% in control group versus 63.5 (52.7; 72.0)% in intervention group (р = 0.014) as well as in the myocardial salvage indexes: 29.7 (13.5; 34.9)% in control group versus 36.5 (28.0; 47.3)% in intervention group (р = 0.014). The study showed the tendency to greater LV myocardial salvage in intervention group versus control group at six-months follow-up (р = 0.073). The groups significantly differed in the medians of microvascular obstruction volume: 1.9 (1.4; 2.9) mL in intervention group versus 2.5 (1.8; 8.1) mL in control group (p = 0.049) as well as in the proportions of microvascular obstruction in the LV myocardium: 0.94 (0.79; 1.37)% in intervention group versus 1.50 (0.89; 3.66)% in control group (р = 0.046).Conclusion. The RIC method combined with PPCI contributed to the limitation of infarct and microvascular obstruction sizes and was associated with an increase in the myocardial salvage index in STEMI patients.

Correlation of Myocardial Strain and Late Gadolinium Enhancement by Cardiac Magnetic Resonance After a First Anterior ST-Segment Elevation Myocardial Infarction.

Objectives: To investigate the correlation of cardiac magnetic resonance (CMR) feature-tracking with conventional CMR parameters in patients with a first anterior ST-segment elevation myocardial infarction (STEMI).Methods: This sub-analysis of OCTAMI (Optical Coherence Tomography Examination in Acute Myocardial Infarction) registry included 129 patients who finished a CMR examination 1 month after a first anterior STEMI. Cine images were applied to calculate both global and segmental left ventricular peak strain parameters. The patients were divided into two groups by left ventricular ejection fraction (LVEF) and compared with 42 healthy controls. Segmental late gadolinium enhancement (LGE) was graded according to LGE transmurality as follows: (1) >0 to ≤ 25%; (2) >25 to ≤ 50%; (3) >50 to ≤ 75%; (4) >75%. Left ventricle was divided into infarcted, adjacent, and remote regions to assess regional function.Results: Compared with controls, global radial (28.39 ± 5.08% vs. 38.54 ± 9.27%, p < 0.05), circumferential (−16.91 ± 2.11% vs. −20.77 ± 2.78%, p < 0.05), and longitudinal (−13.06 ± 2.15 vs. −15.52 ± 2.69, p < 0.05) strains were impaired in STEMI patients with normal LVEF (≥55%). Strain parameters were strongly associated with LGE (radial: r = 0.65; circumferential: r = 0.69; longitudinal: r = 0.61; all p < 0.05). A significant and stepwise impairment of global strains was observed in groups divided by LGE tertiles. Furthermore, segmental strain was different in various degrees of LGE transmurality especially for radial and circumferential strain. Strains of adjacent region were better than infarcted region in radial and circumferential directions and worse than remote region in all three directions.Conclusion: Global and regional strain could stratify different extent and transmurality of LGE, respectively. Although without LGE, adjacent region had impaired strains comparing with remote region.

Implications of Iron Deficiency in STEMI Patients and in a Murine Model of Myocardial Infarction

In patients with a first anterior ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention, iron deficiency (ID) was associated with larger infarcts, more extensive microvascular obstruction, and higher frequency of adverse left ventricular remodeling as assessed by cardiac magnetic resonance imaging. In mice, an ID diet reduced the activity of the endothelial nitric oxide synthase/solubleguanylate cyclase/protein kinase G pathway in association with oxidative/nitrosative stress andincreased infarct size after transient coronary occlusion. Iron supplementation or administration ofansGCactivator before ischemia prevented the effects of the ID diet in mice. Not only iron excess,butalsoID, may have deleterious effects in the setting of ischemia and reperfusion.

The Comparing of Short Clinical Cardiovascular Outcomes with Wraparound and Nonwraparound Left Anterior Descending Artery in Patients with Anterior ST-Segment Elevation Myocardial Infarction.

Background:The relation between left anterior descending artery (LAD) anatomy and clinical outcomes in patients with anterior ST-segment elevation myocardial infarction (STEMI) has not been fully investigated. The aim of this study was to determine the frequency and severity of short-term cardiovascular outcomes in patients with Anterior ST-Segment Elevation Myocardial Infarction (STEMI) undergoing primary percutaneous intervention (PCI), based on wraparound and non-wraparound left anterior descending artery (LAD).Methods:In a cross-sectional study, 126 patients with anterior STEMI who were admitted to Shahid Chamran Hospital in Isfahan during 2020 were studied. Patients were evaluated for anatomical features of LAD coronary artery and clinical outcomes determined and compared based on wraparound LAD and non-wraparound LAD during hospitalization and up to one month after PCI.Results:The prevalence of wraparound LAD in the studied patients was 73% and left ventricular systolic dysfunction in admission was greater and more severe in patients with wraparound LADs compared with those with non-wraparound. Severe LV systolic dysfunction in the wraparound and non-wraparound groups was 39.6% and 8.8%, respectively (P < 0.001). Also, the frequency of arrhythmias in the wraparound group (21.7%) was higher than the non-wraparound group (5.9%) (P = 0.037).Conclusion:The patients with anterior STEMI and wraparound LAD have a worse clinical outcome and more severe left ventricular systolic dysfunction. Therefore, it seems that the study of the anatomical condition of the LAD artery at the time of angiography is of great importance in the way of observation and care, and treatment of patients.

Spatio-Temporal Hybrid Neural Networks Reduce Erroneous Human “Judgement Calls” in the Diagnosis of Takotsubo Syndrome

Background: Distinguishing Takotsubo syndrome (TTS) from acute anterior wall myocardial infarction is often difficult based on clinic characteristics, biomarkers, electrocardiograms and noninvasive images, leading to dilemmas regarding treatment decisions. The aim of this study was to determine whether deep learning (DL) neural networks can reduce erroneous human “judgment calls” on bedside echocardiograms and improve differential diagnostic accuracy. Methods: We developed deep convolution neural networks (DCNNs), including a single-channel (DCNN[2D SCI]), a multi-channel (DCNN[2D MCI]) and a 3-dimensional (DCNN[2D+t]) network, and a recurrent neural network (RNN) based on the same database consisting of 17,280 still-frame images and 540 videos from 2-dimensional (2D) echocardiograms in a 12-year retrospective cohort of 540 patients in the University of Iowa (UI) and eight other medical centers in the United States. The diagnosis of anterior wall ST segment elevation myocardial infarction (STEMI) and TTS were all confirmed by the coronary angiography. Echocardiograms from 450 UI patients were randomly divided into training and testing sets for internal training, testing, and model construction. Echocardiograms of 90 patients from the other medical centers were used for external validation to evaluate the model generalizability. A total of 49 board-certified human readers (22 cardiologists, 11 senior echocardiographers, and 8 point-of-care ultrasound-trained clinicians) performed human-side classification on the same echocardiography dataset to compare the diagnostic performance and help data visualization. Findings: The DCNN (2D SCI), DCNN (2D MCI), DCNN(2D+t), and RNN models established based on UI dataset for the control versus disease prediction showed mean diagnostic accuracy of 78%, 83%, 92%, and 81% respectively. The DCNN (2D SCI), DCNN (2D MCI), DCNN(2D+t), and RNN models established based on UI dataset for TTS versus STEMI prediction showed mean diagnostic accuracy 73%, 75%, 80%, and 75% respectively, and the mean diagnostic accuracy of 74%, 74%, 77%, and 73%, respectively, on the external validation. The area under the receiver operating characteristic curve (AUC) analysis showed that DCNN(2D+t) (0·787 vs. 0·699, P = 0·015) and RNN models (0·774 vs. 0·699, P = 0·033) consistently outperformed human readers in differentiating TTS and STEMI by reducing the erroneous judgement calls on TTS from human readers. Interpretation: Spatio-temporal hybrid DL neural networks reduce erroneous human “judgement calls” in distinguishing TTS from anterior wall STEMI based on bedside echocardiographic videos, demonstrating the potential of DL neural networks to support frontline triage and management of cardiovascular emergencies. Funding: University of Iowa Obermann Center for Advanced Studies Interdisciplinary Research Grant, and Institute for Clinical and Translational Science Grant. Declaration of Interest: We declare no competing interests. Ethical Approval: The research protocols and waiver of informed consent were approved by the human subjects committee of the UI institutional review board.

Midventricular takotsubo syndrome: different dyskinesia location leading to a different electrocardiogram?

Abstract Funding Acknowledgements Type of funding sources: None. Background Takotsubo syndrome (TKS) is characterized by the appearance of apical reversible dyskinesia in its typical form. Electrocardiogram (ECG) in the acute phase (&amp;lt;12 from symptom onset) generally shows anterior ST segment elevation. Nonetheless, other atypical forms of TKS have been described depending on the location of the dyskinetic segments, such as, mid-ventricular, basal and focal forms. Considering the different segments involved in these atypical forms, it seems reasonable to consider that ST changes in acute phase ECG could be different. Purpose To compare ECG in the acute phase of typical TKS versus mid-ventricular TKS, as it was the more frequent form of atypical TKS in our registry. Methods Patients included in the prospective TKS registry of our center according to the Mayo Clinic diagnostic criteria, with the first ECG performed less than 12 hours from the symptoms onset were reviewed. All cardiac left ventriculographies were reviewed to ensure a correct classification of the different types of TKS. Results A total of 297 patients were included in our local registry. 80 patients met our study inclusion criteria. 56 ECGs of typical apical TKS were compared to 24 ECGs of atypical midventricular TKS. There were no differences between the baseline characteristics in both groups, except for mid-ventricular TKS, that was more frequently triggered by physical stressor. Regarding the ECG analysis, the main difference found in our serie was related to ST-segment deviation (Table 1). While ST-segment elevation was more common in typical TKS than in atypical TKS (73% vs 50%), ST-segment depression (generally in inferior leads) was observed in 54% of patients with atypical TKS and in no patient with typical TKS (figure 1). Conclusion The different location of dyskinesia between typical TKS and mid-ventricular TKS is associated to significant differences in the ECG obtained in the first hours after the onset of the clinical symptoms. The presence of ST-segment depression is highly suggestive of mid-ventricular TKS. ECG characteristicsTypical (n = 56)Midventricular (n = 24)pSTe &amp;gt; 1mm, no (%)41 (73)12 (50)0,044STd &amp;gt;0,5 mm, no (%)013 (54)&amp;lt; 0,001T wave inversion, no (%)12 (21)4 (17)0,626Q wave, no (%)22 ( 39)12 (50)0,374cQT, mean (SD)445 (54)438 (37)0,578QRS low voltages*, n (%)9 ( 16)1 (4)0,328STe ST-segment elevation, STd: ST-segment depression, cQT: corrected QT interval *Voltages &amp;lt;5mm in all limb leads or &amp;lt;10mm in all precordial leads Abstract Figure. 12-lead ECG and left ventriculography

Decreased nuclear translocation of FoxP3 transcription factor in patients with ST-segment elevation myocardial infarction

Abstract Funding Acknowledgements Type of funding sources: Other. Main funding source(s): Ministry of Science and Higher Education of Russian Federation T regulatory lymphocytes (Treg) participate in resolution of inflammation and are essential in post-infarct myocardial healing. The crucial mediator of Treg activity is transcription factor FoxP3. Nuclear localization of FoxP3 is an obligatory requirement for anti-inflammatory properties of the cells. FoxP3 is also expressed in conventional T-lymphocytes at the stage of their activation. Data on functional state of FoxP3 in chronic and acute coronary syndromes are absent. Purpose Our aim was to comparatively evaluate the level of FoxP3 nuclear translocation in subpopulations of FoxP3+ T-lymphocytes in patients with chronic and acute coronary syndromes. Methods We have recruited 14 patients with chronic coronary syndrome (CCS) (8 males; 6 females; 63.2 ± 9.0 y.o.) and 5 patients with acute anterior ST-segment elevation myocardial infarction (STEMI) (4 males; 1 female; 61.4 ± 11.2 y.o.). Reperfusion of the infarct-related artery (IRA) has been achieved in all STEMI patients (the mean time of recanalization constituted 5 hours), and coronary angioplasty and IRA stenting were performed. Health status was evaluated and functional class of chronic heart failure was assessed according to the 6-minute walk test. Peripheral blood mononuclear cells were isolated from heparinized blood of CCS patients and STEMI patients during the first day after the event. Frequency of T regulatory and T conventional lymphocytes and degree of FoxP3 nuclear translocation in them were evaluated by imaging flow cytometry. Results Numbers of T regulatory lymphocytes in STEMI patients were lower than in patients with CCS, while numbers of T conventional lymphocytes were higher. However these differences did not reach the level of statistical significance: 7.2 (6.2; 8.4)% vs. 6.7 (3.8; 7.0)% of T regulatory lymphocytes (p = 0.298) and 1.6 (1.3; 1.8)% vs. 2.1 (1.0; 2.8)% of T conventional cells (p = 0.754), in CCS and in STEMI patients, respectively. Meanwhile, STEMI patients displayed significantly lower nuclear translocation of FoxP3 in lymphocytes compared to CCS patients: 74.8 (64.9; 92.9)% vs. 98.2 (96.8; 98.7)% in T regulatory cells (p = 0.026) and 58.7 (33.9; 67.7)% vs. 88.3 (73.1; 96.9)% in T conventional lymphocytes (p = 0.034). Conclusions Our study is the first one to comparatively describe the FoxP3 nuclear translocation in patients with chronic coronary syndrome and STEMI. We showed that STEMI is primarily associated with the decrease of nuclear localization of FoxP3 rather than with changes in numbers of FoxP3+ T-lymphocytes in peripheral blood. The revealed phenomenon demonstrates that alterations of the balance between the suppressive and inflammatory activities of T-lymphocytes are observed already in the early inflammatory phase of STEMI, long before their expected clonal expansion.

Calcium/Calmodulin-Dependent Protein Kinase II Delta Inhibition and Ventricular Remodeling After Myocardial Infarction

After anterior ST-segment elevation myocardial infarction (STEMI), left ventricular (LV) remodeling results in heart failure and death. Calcium/calmodulin-dependent protein kinase II delta (CaMKIId) is a key molecular mediator of adverse LV remodeling. To determine whether NP202, an orally active inhibitor of CaMKIId, prevents LV remodeling in patients after anterior STEMI with early residual LV dysfunction. A randomized, double-blind, placebo-controlled multicenter clinical trial of NP202 vs placebo in patients after primary percutaneous coronary intervention (PCI) for anterior STEMI was performed from November 19, 2015, to August 1, 2018. The study was performed at 32 sites across the US, Australia, and New Zealand. Patients presenting with anterior STEMI who underwent PCI within 12 hours of symptom onset and left ventricular ejection fraction (LVEF) less than 45% on screening echocardiogram 48 hours after primary PCI were included in the study. Baseline cardiovascular magnetic resonance (CMR) imaging was performed within 5 days of the STEMI and before administration of the study drug. Follow-up CMR was performed after 3 months. Data were analyzed from November 19, 2015, to August 1, 2018. Patients were randomly assigned to NP202, 1000 mg, daily for 3 months vs corresponding placebo. The primary end point was change in LV end-systolic volume index (LVESVi) on CMR. Secondary end points were change in LV end-diastolic volume index, change in LVEF, change in infarct size, and change in diastolic function. Safety and tolerability were also assessed. A total of 147 patients (mean [SD] age, 58 [11] years; 129 men [88%]; 130 White patients [88%]) who experienced anterior STEMI treated with primary PCI were randomized to receive NP202 (73 [49.7%]) or placebo (74 [50.3%]). Baseline LVEF was similar between groups. At baseline, patients randomized to NP202 had greater LVESVi (48.2 mL/m2) than that in the placebo group (41.3 mL/m2; P = .03). However, the groups were otherwise well matched. For the primary end point of change in LVESVi from baseline to 3 months, there was no significant difference between the placebo (median [interquartile range] change, -0.60 [-9.28 to 5.99] mL/m2) and NP202 groups (-3.53 [-9.24 to 4.81] mL/m2) (P = .78). There was also no difference in the secondary efficacy end points assessed by CMR. NP202 was well tolerated and demonstrated an acceptable safety profile. Major adverse cardiac and cerebrovascular event rates were similar between groups. Two deaths occurred in each group during the follow-up period. Three months of treatment with NP202 after primary PCI for anterior STEMI with residual LV dysfunction did not improve LV remodeling. The drug was safe and well tolerated. ClinicalTrials.gov Identifier: NCT02557217.

Risk Prediction Model Based on Biomarkers of Remodeling in Patients with Acute Anterior ST-Segment Elevation Myocardial Infarction.

BackgroundThe aim of the present study was to develop a risk prediction model in patients with acute anterior ST-segment elevation myocardial infarction (STEMI).Material/MethodsClinical data from 333 patients with acute anterior STEMI were retrospectively analyzed. Clinical echocardiographic and angiographic data from patients with left ventricular remodeling (LVR) and those without LVR were compared. Factors that influenced risk were identified using multivariate logistic regression analysis. The area under the curve (AUC) of the receiver operating characteristic curve was used to assess the diagnostic performance of the model.ResultsAfter 6-month follow-up, 135 of the patients experienced LVR (LVR group), whereas 198 did not (non-LVR group). Results of multivariate analysis showed that the number of stenosed coronary vessels, left ventricular end-diastolic volume (LVEDV), left ventricular ejection fraction (LVEF), transforming growth factor-beta (TGF-β) at admission, and cardiac troponin I 3 days after admission (3-d cTnI) were all factors predictive of LVR in patients with acute anterior STEMI (all P<0.05). The established prediction model was Y=−20.639+0.711×number of stenosed coronary vessels + 0.137×LVEDV-0.129×LVEF+0.026×TGF-β at admission + 0.162×3-d cTnI. The estimated AUC of this model was 0.978 (95% confidence interval [CI] 0.955–0.991), significantly superior to the single-factor numbers for stenosed coronary vessel of 0.650 (95% CI 0.597–0.702), LVEDV of 0.876 (95% CI 0.836–0.910), LVEF of 0.684 (95% CI 0.631–0.734), TGF-β at admission of 0.696 (95% CI 0.644–0.745), cTnI at admission of 0.913 (95% CI 0.877–0.941), and 3-d cTnI of 0.945 (95% CI 0.914–0.967).ConclusionsThe established model had excellent diagnostic accuracy for predicting LVR in patients with acute anterior STEMI.

Management of left ventricular thrombus: a narrative review.

Left ventricular thrombus (LVT) is a serious complication of acute myocardial infarction (MI) and also non-ischemic cardiomyopathies. We performed a narrative literature review, manual-search of reference lists of included articles and relevant reviews. Our literature review indicates that the incidence of LVT following acute MI has decreased, probably due to improvement in patient care as a result of better and earlier reperfusion techniques. Predictors of LVT include anterior MI, involvement of left ventricular (LV) apex (regardless of the coronary territory affected), LV akinesis or dyskinesis, reduced LV ejection fraction (LVEF), severe diastolic dysfunction and large infarct size. LVT is associated with increased risk of systemic embolism, stroke, cardiovascular events and death, and there is evidence that anticoagulant therapy for at least 3 months can reduce the risk of these events. Cardiac magnetic resonance (CMR) has the highest diagnostic accuracy for LVT, followed by echocardiography with the use of echocardiographic contrast agents (ECAs). Although current guidelines suggest use of vitamin K antagonist (VKA) for a minimum of 3 to 6 months, there is growing evidence of the benefits of direct acting oral anticoagulants in treatment of LVT. Embolic events appear to occur even after resolution of LVT suggesting that anticoagulant therapy needs to be considered for a longer period in some cases. Recommendations for the use of triple therapy in the presence of the LVT are mostly based on extrapolation from outcome data in patients with atrial fibrillation (AF) and MI. We conclude that the presence of LVT is more likely in patients with anterior ST-segment elevation MI (STEMI) (involving the apex) and reduced ejection fraction (EF). LVT should be considered a marker of increased long-term thrombotic risk that may persist even after thrombus resolution. Ongoing clinical trials are expected to elucidate the best management strategies for patients with LVT.

A rare cause of acute ST-elevation myocardial infarction: a case of coronary embolism secondary to calcified bicuspid aortic valve

Abstract Coronary embolism is an uncommon cause of acute myocardial infarction, which can have a similar clinical presentation to a plaque rupture event with acute onset of ischaemic symptoms, ST segment elevation on electrocardiogram (ECG) and significant elevation in cardiac troponin, requiring immediate intervention. We report the case of a middle-aged female with a background history of previous non-ST elevation myocardial infarction, bicuspid aortic valve with severe stenosis and metastatic breast cancer. The patient underwent emergency coronary angiography following acute onset central chest pain and evidence of anterior ST segment elevation on ambulance 12-lead ECG. The procedure revealed complete occlusion of the mid left anterior descending coronary artery with immediate flow restoration following embolus aspiration and subsequent normal appearance of the left anterior descending coronary artery. Gross examination of the aspirated specimen resembled a calcified hard lump, which was further confirmed on microscopic examination revealing calcified fibrous tissue most likely an embolus from the calcified bicuspid aortic valve. The patient had evidence of near transmural myocardial infarction in the distribution of the left anterior descending coronary on cardiac magnetic resonance imaging (MRI). She made full recovery and was discharged on short-term dual antiplatelet therapy followed by lifelong aspirin and further assessment for aortic stenosis management.

Index of microcirculatory resistance predicts long term cardiac systolic function in patients with STEMI undergoing primary PCI

BackgroundTo evaluate the predictive value of the index of microcirculatory resistance (IMR) for long-term cardiac systolic function after primary percutaneous coronary intervention (pPCI) in patients with acute anterior wall ST-segment elevation myocardial infarction (STEMI).MethodsA total of 53 acute anterior wall STEMI patients were included and followed up within 1-year. IMR was measured to evaluate the immediate intraoperative reperfusion. IMR > 40 U was defined as the high IMR group and ≤ 40 U was defined as the low IMR group. Left ventricular ejection fraction (LVEF) was measured by echocardiography at 24 h, 1 month, 3 months, and 1 year after PCI to analyze the correlation between IMR and cardiac systolic function. Heart failure was estimated according to classification within one year.ResultsThe ratio of TMPG (TIMI myocardial perfusion grade) 3 (85.7% vs. 52%, p = 0.015) and STR (ST-segment resolution) > 70% (82.1% vs. 48%, p = 0.019) were significantly higher in the low IMR group. The LVEF in the low IMR group was significantly higher than that in the high IMR group at 3 months (43.06 ± 2.63% vs. 40.20 ± 2.67%, p < 0.001) and 1 year (44.16 ± 2.40% vs. 40.13 ± 3.48%, p < 0.001). IMR was negatively correlated with LVEF at 3 months (r = − 0.1014, p = 0.0040) and 1 year (r = − 0.1754, p < 0.0001).ConclusionsThe IMR showed significant negative correlation with the LVEF value after primary PCI. The high IMR is a strong predictor of heart failure within 1 year after anterior myocardial infarction.

Clinical predictors and prognostic role of high Killip class in patients with a first episode of anterior ST-segment elevation acute myocardial infarction

Aims Killip classification is a simple and fast clinical tool for risk stratification of patients presenting with acute coronary syndrome (ACS). However, the clinical features and predictors of high Killip class at admission, and its prognostic impact in patients presenting with anterior ST elevation MI (STEMI) as first clinical cardiovascular event are still poorly known. The aim of this study was to identify the predictors of high Killip class and its impact on in-hospital and follow-up outcomes. Methods We prospectively enrolled patients with unheralded anterior STEMI because of proximal or mid left anterior descending (LAD) artery categorized according to Killip classification. Patients’ characteristics, in-hospital complications and major adverse cardiovascular events (MACEs; composite of all-cause death, heart failure hospitalization and new-onset ACS) at follow-up were collected. Results We enrolled 147 patients [age 66.16±13.33, 113 male patients (76.9%)]. Killip class III--IV occurred in 22 (15%) patients. The median duration of follow-up was 12 [6--15.1] months. At multivariate analysis age [hazard ratio 1.137, 95% CI (1.068--1.209), P &lt; 0.001], prehospital cardiac arrest [hazard ratio 12.145, 95% CI (1.710--86.254), P = 0.013] and proximal LAD lesion [hazard ratio 5.066, 95% CI (1.400--18.334), P = 0.013] were predictive of Killip class III--IV at admission. At multivariate analysis, Killip class III--IV was an independent predictor of in-hospital mortality [hazard ratio 7.790, 95% CI (1.024--59.276], P = 0.047 and of MACEs [hazard ratio 4.155 (1.558--11.082), P = 0.004) at follow-up. Conclusion Killip classification performed at the time of admission is a simple and useful clinical marker of a high risk of early and late adverse cardiovascular events.

Efficacy of percutaneous coronary interventions in acute period of anterior myocardial infarction with consideration of differently organized endovascular radiology service

The aim of the study was a comparative assessment of the treatment efficacy in patients with anterior myocardial infarction with ST segment elevation (STEMI) in two periods: 2003–2007 and 2008–2017 with different endovascular service organization. For 5 years of the first period, the percutaneous coronary interventions (PCIs) were performed in the ERS Unit of the Urgent Cardiology Department. A total of 446 patients were hospitalized; a thrombolytic therapy (TLT) was undertaken in 177 patients, PCI was performed in 155, including primary PCI, life-saving PCI, and PCI after successful TLT in 72, 44, and 39 patients, respectively. Due to daytime working schedule of ERS, PCI was performed within the first 12 hours of STEMI onset in 54 patients, within 12–72 hours in 101 patients selected with regard to an initially high risk of death (RD) according to TIMI. In the 2nd period from 2008 to 2017, the patients’ age was 28–95 years old. Over those 10 years, PCIs were performed in a multi-disciplinary ERS Department working around the clock; 1,052 patients were hospitalized, TLT was undertaken in 177, PCIs were performed in 760, including primary PCI, life-saving PCI, and PCI after successful TLT in 583, 110, and 67 patients, respectively. The PCI ratio in the first 12 and 12–72 hours was 394 to 366. There was no patient selection with regard to the initial high RD. There were 291 and 292 patients without PCI in periods I and II, respectively. A 5-year total and cardio-vascular (CV) post-discharge mortality was assessed in 97 patients treated in period I and in 192 patients treated in period II, and in 128 patients without PCI. The initial RD in patients with anterior STEMI in periods I and II was scored 4.8 or 11.5% and 5.1 or 13%, respectively; in periods I and II the in-hospital mortality was 1.3% and 3.9% after PCI, 7.9% and 13.7% of patients without PCI; 5.6% and 6.7% of patients with and without PCI. In patients with PCI a 5-year post-discharge mortality increased by 13.0% and 16.7%, including the CV mortality that increased by 5.2% and 13.0%; and a 5-year post-discharge mortality in those without PCI increased by 33.6% and 28.9%, respectively. During the first 5 years of the day-time ERS working schedule, the number of PCI, mainly with an initially high RD, increased from 19% to 45%; that was accompanied by a mortality decrease from 12.6% to 3.9%. Over the following 10 years, the number of PCI increased from 57% to 88%; the increased number of unresolved complications during procedures was reflected by more frequent death cases, especially in elderly people; that was accompanied by the mortality increase to 7.1% in the first 7 years, and to 8.6%, 18.6% and 6.9% in the following 3 years due to increased number of hospitalized elderly patients, respectively. Based on the comparative assessment of the presented data, the cause for the differences between the results of PCI performed in the first and second periods lies in a differently organized ERS. Being established as integrated with a cardiology unit, ERS provides a high professional level of service, practical skills and individual patient approach necessary for the successful use of various types of PCI, including delayed PCI, PCIs at late admission, which is typical for STEMI patients of older age with a severe coronary artery disease.

Acute marginal branch occlusion presenting with anterior wall ST segment elevation during percutaneous coronary intervention of the mid right coronary artery

Acute marginal branch occlusion presenting with anterior wall ST segment elevation during percutaneous coronary intervention of the mid right coronary artery

Role of Speckle Tracking in the Evaluation of Left Ventricular Remodeling After Streptokinase Infusion in Patients with Acute Anterior Myocardial Infarction

Background. Left ventricular (LV) remodeling is an adverse consequence after acute myocardial infarction.Aim. To assess the role of speckle tracking in the evaluation of LV remodeling after streptokinase infusion in patients with acute anterior ST-segment elevation myocardial infarction (STEMI).Material and methods. A total of 200 patients with first acute anterior STEMI received streptokinase as a reperfusion therapy were included. Conventional echocardiography and speckle tracking were performed within 3 days of admission and 3 months later. According to the development of LV remodeling, patients were classified into two groups. Group (I) patients with LV remodeling (60 patients) and group (II) patients without remodeling (140 patients).Results. Patients with LV remodeling had lower global longitudinal (GLS) and circumferential (GCS) strain values (-13.19±4.57 vs. -18.90±4.23 % and -13.16±4.27 vs. -17.16±3.3 %, respectively, p&lt;0.001). GLS cutoff value of &gt;-13.5 was shown to have the best diagnostic accuracy (sensitivity =60.0% &amp; specificity =87.1%) in predicting LV remodeling (AUC 0.816, 95% confidence interval [CI] 0.754-0.877, p&lt;0.001). GCS cutoff value of &gt;-16.21 was shown to have the best diagnostic accuracy (sensitivity =75.0% &amp; specificity =71.4%) in predicting LV remodeling (AUC 0.785, 95%CI 0.719-0.85, p&lt;0.001).Conclusion. Speckle tracking echocardiography either longitudinal or circumferential strain has good sensitivity and specificity in predicting LV remodeling after acute myocardial infarction.

Acute coronary syndrome caused by extrinsic coronary compression from an aortic root abscess in a patient with mechanical aortic valve endocarditis: a case report and literature review.

Background Extrinsic coronary compression is an extremely rare complication of aortic root abscess formation and can manifest as an acute coronary syndrome in infective endocarditis. Optimal management strategies are unknown and therefore illustrative case reports may be informative.Case summary We describe a 63-year-old man with a background history of a mechanical aortic valve who developed sepsis due to Escherichia coli bacteraemia from a presumed urinary source. He suddenly deteriorated with cardiogenic shock and anterior ST-segment elevation myocardial infarction on Day 16 and received emergency percutaneous coronary intervention for severe stenoses of left anterior descending and diagonal arteries. A transoesophageal echocardiogram 2 days later demonstrated a large aortic root abscess. He was transferred for emergency surgery which revealed a large aortic abscess surrounding the left main stem confirming extrinsic coronary compression. He received a redo tissue aortic valve replacement and repair of his abscess cavity.Discussion We describe a case where percutaneous coronary intervention and emergency surgery was used to treat extrinsic compression from an aortic root abscess; a complication that is associated with a high mortality. This is also a rare case of E. coli causing prosthetic valve endocarditis. We also explore the findings of 11 previous cases of extrinsic coronary compression from aortic root abscess.

Trimethylamine N-Oxide Was Not Associated With 30-Day Left Ventricular Systolic Dysfunction in Patients With a First Anterior ST-Segment Elevation Myocardial Infarction After Primary Revascularization: A Sub-analysis From an Optical Coherence Tomography Registry.

Objective: Left ventricular systolic dysfunction (LVSD) after ST-segment elevation myocardial infarction (STEMI) is associated with poor outcome. Trimethylamine N-oxide (TMAO), a gut metabolite, is linked to cardiovascular diseases but its relationship with LVSD after STEMI remains unclear. The present study therefore aimed to investigate the relationship between TMAO and LVSD at 30 days after a first anterior STEMI.Methods: This was a sub-study from the OCTAMI (Optical Coherence Tomography Examination in Acute Myocardial Infarction) registry. Eligible patients were included in current study if they: (1) presented with a first anterior STEMI; (2) had available baseline TMAO concentration; (3) completed a cardiovascular magnetic resonance examination at 30 days after STEMI. LVSD was defined as left ventricular ejection fraction < 50%. Associations between TMAO and left ventricular ejection fraction, infarct size and left ventricular global strain were examined.Results: In total, 78 patients were included in final analysis. Overall, TMAO was moderately associated with peak cTnI (r = 0.27, p = 0.01), age (r = 0.34, p < 0.01), and estimated glomerular filtration rate (r = −0.30, p < 0.01). At 30-day follow-up, 41 patients were in the LVSD group and 37 in the non-LVSD group. Baseline TMAO levels were not significantly different between the two groups (LVSD vs. non-LVSD: median 1.9 μM, 25−75th percentiles 1.5–3.3 μM vs. median 1.9 μM, 25−75th percentiles 1.5–2.7 μM; p = 0.46). Linear regression analyses showed that TMAO was not associated with left ventricular ejection fraction, infarct size or left ventricular global strain at 30 days (all p > 0.05).Conclusions: TMAO was not significantly correlated with 30-day LVSD in patients with a first anterior STEMI after primary revascularization.Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT03593928.