Anteroseptal Myocardial Infarction Research Articles

Intra-aortic balloon pump still has a role in late-onset myocardial infarction complicated by ventricular septal rupture with intractable heart failure: a case report

BackgroundThe current guidelines have discouraged the routine use of intra-aortic balloon pump (IABP) in cardiogenic shock complicating acute coronary syndrome (ACS). Since then, the trend of IABP utilization in ACS has been declining. Nevertheless, the guidelines still preserve the recommendation of IABP use in hemodynamic instability or cardiogenic shock caused by post myocardial infarction (MI) ventricular septal rupture (VSR).Case presentationA 46-years-old diabetic Southeast Asian female was referred from a peripheral facility with intractable heart failure despite treatment with vasoactive agents and diuretics for five days. The ECG suggested a recent anteroseptal myocardial infarction with normal high-sensitivity troponin-I value. The echocardiography detected a regional wall motion abnormality and a 10 mm wide ventricular septal defect. Invasive coronary angiography revealed a severe two-vessel coronary artery disease. We planned a delayed surgical strategy with preoperative optimization using IABP as a bridge to surgery. IABP implantation followed by significant hemodynamic improvement and rapid resolution of heart failure without any inotrope support. Afterwards, coronary artery bypass grafting (CABG) and VSR surgical repair were performed. We safely removed IABP on the third postoperative day with proper weaning and minimal vasoactive support.ConclusionWe report a case where IABP still provided benefits for a patient with intractable heart failure caused by undetermined onset MI complicated by VSR. The use of IABP in such a case is in accordance with the recommendation of the current guidelines. Several studies showed that IABP use during preoperative optimization in the case of post-MI VSR was associated with survival benefits.

In Hospital Outcome of Pharmaco-invasive Therapy versus Primary PCI In ST-segment elevation Myocardial Infarction in Dhaka, Bangladesh

Background & Objectives: In many low middle income countries (LMIC), it is difficult to treat patients with ST-segment elevation Myocardial Infarction (STEMI) with timely PPCI. Thus, many undergo fibrinolysis. Whether early fibrinolysis followed by timely coronary angiography provides a clinical outcome similar to that of primary percutaneous coronary intervention (PPCI) after acute STEMI in LMIC settings remains a question. In this observational study we primarily aimed to compare in-hospital outcomes of primary PCI versus pharmaco-invasive strategy (immediate fibrinolysis followed by coronary angiography with possible PCI within 3-24 hours) for reperfusion in eligible patients with STEMI at a tertiary cardiac care center. Methods: This prospective observational study was done in Ibrahim Cardiac Hospital & Research Institute, Dhaka from April 2022 to July 2022 where consecutive patients presenting with STEMI were enrolled and divided into two groups: those who underwent primary PCI (Group-I) and those who underwent immediate fibrinolysis with subsequent coronary angiography with PCI within 3 to 24 hours (Group-II). The main outcomes analyzed were all-cause death, cardiogenic shock, acute left ventricular failure, life threating arrhythmia, acute stent thrombosis, CVD, Contrast induced nephropathy (CIN), re-infarction, target-vessel revascularization, and major bleeding up to 7 days. Results: A total 122 patients presented with acute STEMI, 61 in each group. One group underwent primary PCI and another group treated with fibrinolysis by tenecteplase. The mean age of the studied patients was 53.86±9.72 years (range 18-75 years). Eighteen percent of patients presented with Extensive Anterior MI,19.7% showed Anterior MI, 21.3% showed Antero-septal MI, 21.3% showed Inferior MI, 9.8% showed Inferior with posterior and 3.3% showed Lateral MI. 35.5% had Single vessel disease, 31.1% had double vessel disease,28.7% had triple vessel disease, LM with LAD was 0.8% and 0.8% had recanalized infarct related artery in both groups overall. In group-I 45.9% of PPCI were undertaken in LAD and 32.8% patient. of group-II was done PCI in LAD. There were no significant differences between two groups in primary outcome and mortality. Conclusion: Immediate fibrinolysis followed by coronary angiography within 3-24 hours resulted in similar short-term outcomes in patients with STEMI compared to PPCI. Our study suggests that, compared with PPCI, fibrinolysis performed in the hospital setting is associated with similar mortality rates, acute CVD, CIN and acute left ventricular failure in with PPCI than STEMI. University Heart Journal 2023; 19(1): 10-14

Recurrent events of acute coronary syndrome in young adult patients after Kawasaki disease.

I encountered three adult patients with major coronary artery occlusion after Kawasaki disease in childhood, who had developed again acute coronary syndrome of adults in the peripheral branches, such as the 4thsegments, the atrioventricular node artery, and the posterior descending artery, of the right coronary artery. I reviewed their clinical course and coronary angiograms. Their age at onset of acute coronary syndrome ranged from 29 to 33 years. The male patient with a previous anteroseptal myocardial infarction in children had a symptomatic occlusion of the branch of the 4thposterior descending artery at 32 years of age. Acute coronary syndrome occurred in the area of 4thatrioventricular node artery in two female patients. The collateral arteries from the circumflex artery to the 4th atrioventricular node arteries were not clearly injected. It was suspected that they had developed bilateral giant aneurysms after acute Kawasaki disease. Two patients had an acute myocardial infarction due to thrombotic occlusion in a giant aneurysm of the right coronary artery or the left anterior descending artery, and one patient had an asymptomatic coronary occlusion of the right coronary artery and left anterior descending artery in children. Occlusion of peripheral coronary arteries in adulthood can occur in patients with multi-vessel disease caused by Kawasaki disease. Recurrent events of acute coronary syndrome can occur in adults, although its prevalence may be low. Carefulfollow-up in adults is also needed in this population.

A case report: anteroseptal ST elevation due to acute isolated right ventricular infarction

BackgroundElectrocardiogram (ECG) is the first diagnostic tool physicians use in diagnosing acute myocardial infarction (MI). In this case report, we present a case where the initial ECG diagnosis was that of an acute anteroseptal MI but emergency coronary angiography showed that the infarct-related artery was a small non-dominant right coronary artery (RCA) instead of the anticipated left anterior descending artery (LAD). Isolated right ventricular (RV) infarction from a non-dominant RCA is rarely seen in clinical practice, and it may exhibit ECG changes that can be confused with an acute anteroseptal MI. It is important to appreciate the subtle differences in the ECG changes that occur in either of these two types of MI for appropriate diagnosis and treatment.Case presentationA 49-year-old non-smoking male with prior coronary stent implantation in LAD presented with acute chest pain and his pre-hospital ECG indicated an anteroseptal STEMI possibly due to stent thrombosis, but an emergency angiogram showed patent LAD and Circumflex arteries. There was however thrombotic occlusion of the right, non-dominant coronary artery, which was revascularized with a drug-eluting stent. The patient’s chest pain and ST elevations resolved, and subsequent echo showed moderate RV systolic dysfunction in keeping with RV myocardial infarction.DiscussionRV myocardial infarction is usually due to an occlusion of the dominant RCA proximal to the origin of its RV wall branch, which often results in inferior ST elevation with reciprocal anterior ST depression. The ST elevation over V1 which would accompany RV infarction is often masked due to the more dominant electrical forces of inferior and posterior LV wall infarction. Our case demonstrates that in isolated RV infarction due to non-dominant proximal RCA occlusion, anterior ST elevation can be seen over V1-3, being most prominent in V1, which overlies the right ventricle, and resolved after restoring flow to the RCA. Spatial vector analysis of the ECG or right-sided ECG leads would be helpful to aid the diagnosis of RV infarction when clinical suspicion is present, for example when there is significant hypotension, raised jugular venous pressure but clear lung fields or deterioration after nitrate administration.

Detection of Ischemic ST-Segment Changes Using a Novel Handheld ECG Device in a Porcine Model

BackgroundPortable, smartphone-sized electrocardiography (ECG) has the potential to reduce time to treatment for patients suffering acute cardiac ischemia, thereby lowering the morbidity and mortality. In the UMC Utrecht, a portable, smartphone-sized, multi-lead precordial ECG recording device (miniECG 1.0, UMC Utrecht) was developed. ObjectivesThe purpose of this study was to investigate the ability of the miniECG to capture ischemic ECG changes in a porcine coronary occlusion model. MethodsIn 8 animals, antero-septal myocardial infarction was induced by 75-minute occlusion of the left anterior descending artery, after the first or second diagonal. MiniECG and 12-lead ECG recordings were acquired simultaneously before, during and after coronary artery occlusion and ST-segment deviation was evaluated. ResultsDuring the complete occlusion and reperfusion period, miniECG showed large ST-segment deviation in comparison to 12-lead ECG. MiniECG ST-segment deviation was observed within 1 minute for most animals. The miniECG was positive for ischemia (ie, ST-segment deviation ≥1 mm) for 99.7% (Q1-Q3: 99.6%-99.9%) of the occlusion time, while the 12-lead was only positive for 79.8% (Q1-Q3: 81.1%-98.7%) of the time (P = 0.018). ST-segment deviation reached maxima of 10.5 mm [95% CI: 6.5-14.5 mm] vs 5.0 mm [95% CI: 2.0-8.0 mm] for the miniECG vs 12-lead ECG, respectively. ConclusionsMiniECG ST-segment deviation was observed early and was of large magnitude during 75 minutes of porcine transmural antero-septal infarction. The miniECG was positive for ischemia for the complete occlusion period. These findings demonstrate the potential of the miniECG in the detection of cardiac ischemia. Although clinical research is required, data suggests that the miniECG is a promising tool for the detection of cardiac ischemia.

Cardiac toxicity of EGFR – 3rd generation TKI in patients with metastatic non-small cell lung cancer. Case report and literature data update

Purpose: The incidence of bronchopulmonary cancer has increased significantly in recent decades, especially in developed countries, and today it is the leading cause of death in men and the 3rd in women. The toxicities of tyrosine kinase inhibitor therapy are varied, with cardiac toxicities at the top of the pyramid. Because of the occurrence of these toxicities, depending on their intensity, the dose must be reduced or even treatment stopped. Patient and method: We present the case of a 72-year-old patient, diagnosed in 2019 with non-small bronchopulmonary neoplasm with histology of adenocarcinoma with EGFR mutation, stage IV. Results: In the oncology committee, it is decided to start targeted therapy with tyrosine kinase inhibitors of the first generation, Erlotinib, with a partial response to the treatment in the imaging evaluations, continued treatment until November 2020 when the T790M resistance mutation is detected. According to the new NCCN guidelines, therapy with the third-generation EGFR-TKI, Osimertinib, is initiated. In September 2021, the patient developed a non-ischemic acute antero-septal myocardial infarction that was complicated by LV apical aneurysm and severe LV systolic dysfunction, associated with therapy with tyrosine kinase inhibitors. Osimertinib treatment is stopped and third-line treatment with Vinorelbine is initiated. Conclusions: Investigation and permanent monitoring of patients, in treatment with 3rd generation tyrosine kinase inhibitors, who may develop cardiac toxicities, but also a good management of these toxicities, lead to both increased survival and improved status of performance.

Risk factors and clinical features in young patients with myocardial infarction: A cross-sectional study

Background: Changes in lifestyle with increased sedentary lifestyle are associated with its consequences such as obesity, metabolic syndrome, hypertension, diabetes, and eventually myocardial infarction (MI). Coronary artery diseases (CADs) although have been commonly seen in elderly individuals it’s now being increasingly recognized in a relatively younger age group (<45 years). The present study was aimed at analyzing risk factors and clinical presentation of MI in young (<45 years). Aims and Objectives: The aims of this study were to study risk factors and clinical profile of young patients with MI. Materials and Methods: This was a hospital-based prospective cohort study, in which 60 young patients (age <45 years) of age were included on the basis of a predefined inclusion and exclusion criteria. A thorough history was obtained and detailed general and cardiovascular examination was done. Electrocardiogram, basic hematological profile, and 2 D echo were done in all cases. Clinical profile, site of infarction, and severity of systolic dysfunction were studied. P<0.05 was taken as statistically significant. Results: A total of 60 patients were studied. Out of these 60 cases, there were 48 (80%) males and 12 (20%) females with a M: F ratio being 1:0.25. Although the mean age of female patients (40.25±3.44 years) was more than male patients (38.62±4.43 years), the difference was not found to be statistically significant (P>0.05). Obesity, family history of CADs, smoking, dyslipidemia, hypertension, and diabetes were common risk factors in studied cases. Majority of the patients (81.67%) presented with typical chest pain radiating to left arm. The atypical clinical features were seen in 11 (18.33%) patients. In m ost of the patients (63.33%) there was anterior wall infarction. Inferior wall infarction and anteroseptal MI were seen in 12 (20%) and 10 (16.67%) patients, respectively. Conclusion: MI in young patients is increasing. Majority of the risk factors associated with MI in young patients are modifiable risk factors. A high index of suspicion is necessary in diagnosing these patients in time particularly in cases, where there is atypical presentation.

Кардиальная автономная нейропатия как предиктор развития фибрилляции предсердий у пациентов с сахарным диабетом 2 типа после инфаркта миокарда

BACKGROUND: Type 2 diabetes mellitus is a widespread chronic disease having many factors that negatively affect the course of cardiovascular events. One of these factors is cardiac autonomic neuropathy. The possibility of assessing the effect of cardiac autonomic neuropathy on the risk of development of atrial fibrillation after myocardial infarction may help in choosing the management tactics for patients with myocardial infarction and type 2 diabetes mellitus. AIM: To evaluate the effect of cardiac autonomic neuropathy on the risk of development of atrial fibrillation in patients with past myocardial infarction. To develop a method for assessing the risk of atrial fibrillation in 12-month period in patients with type 2 diabetes mellitus. MATERIALS AND METHODS: The study involved 60 individuals with type 2 diabetes mellitus and 60 individuals with newly diagnosed type 2 diabetes hospitalized with anterior and anteroseptal myocardial infarction with Q wave. At the initial stage of the study, the formed groups were homogeneous in age, gender, and all general clinical research methods. The diagnosis of type 2 diabetes mellitus was made on the basis of anamnesis data and available medical documentation confirmed by examination of glycosylated hemoglobin and glycemic profile. The newly found diabetes mellitus was diagnosed based on the data of glycosylated hemoglobin > 6.5%, blood glucose > 11.1 mmol/l recorded two or more times, according to national clinical guidelines. On the 3rd day, in 3 and 12 months after hospitalization, a set of tests for detecting cardiac autonomic neuropathy was performed; the presence of atrial fibrillation, the dynamics of left ventricular hypertrophy were assessed by electrocardiography and echocardiography. Statistical processing of the obtained results was performed using Microsoft Office Excel 2019, SPSS Statistics Standart ver. 28 programs for Windows. In order to choose the method of analysis, the distribution was estimated using Kolmogorov–Smirnov test. Comparison of the groups was carried out using Mann–Whitney test. The risk of atrial fibrillation was assessed using logistic, multifactorial and ROC analysis. RESULTS: Prognostic models were formed to determine the risk of development of atrial fibrillation in patients with type 2 diabetes mellitus. The model for diabetes mellitus had determination coefficient (R2 = 0.7), Hosmer–Lemeshow criterion 0.83, and the area under the curve 0.93. The model for newly diagnosed diabetes mellitus had R2 coefficient 0.72, Hosmer–Lemeshow goodness-of-fit test 0.85, and the area under the curve 0.95. CONCLUSION: Use of the developed models based on the results of tests aimed at detecting cardiac autonomic neuropathy, permits to predict the development of atrial fibrillation in patients with existing and newly diagnosed type 2 diabetes mellitus in combination with diabetic polyneuropathy in 12-month period after anterior, anteroseptal myocardial infarction with high accuracy.

Anabolic Androgenic Steroids-Induced Acute “Tombstone” ST-Segment Elevation Myocardial Infarction

Anabolic-androgenic steroids (AAS) are frequently used to treat a wide variety of pathological medical conditions including but not limited to hypogonadism, aplastic anemia, and metastatic breast cancer. Nonetheless, the abuse of AAS continues to rise among professional and recreational athletes despite their deleterious adverse effects. Here, we report a 34-year-old male, with a history of nonmedical use of AAS for 2 months, who had persistent severe retrosternal chest pain. His electrocardiogram was suggestive of acute anteroseptal ST-segment elevation myocardial infarction. He underwent urgent coronary angiography which revealed a thrombotic burden in the left anterior descending artery without underlying atherosclerosis.

PO-701-03 ANATOMICAL CONSIDERATIONS AND CLINICAL INTERPRETATION OF PRONE 12-LEAD ECG: INSIGHTS FROM A MULTICENTER PROSPECTIVE STUDY

Prone positioning increases lung recruitment and improves oxygenation in acute respiratory distress syndrome (ARDS) and has been used for decades in spinal and orthopedic surgery. This study aims to provide guidance for the clinical interpretation of ECGs in prone position and to establish the electroanatomic explanations for the possible differences that may be observed. ECGs in supine, prone posterior and prone anterior position were prospectively examined on 85 subjects. Comparisons of ECG parameters between these positions were performed. Computed tomography (CT) scans were performed in both positions to determine possible electroanatomic etiologies for prone-associated ECG changes. There were significant differences in QRS amplitude in leads V1-V5 between supine and prone positions: V1: 1.08mV vs. 0.3mV, p<0.0001; V2: 1.61mV vs. 0.35mV, p<0.0001; V3: 1.62mV vs. 0.48mV, p<0.0001; V4: 1.65mV vs 0.63, p<0.0001 and V5: 1.41mV vs. 0.95mV, p<0.0001; respectively. Q waves were more frequently observed in prone posterior position than in supine position (V1: 74.5% vs. 10.6%, p<0.001; V2: 23.5% vs. 1.2%, p<0.001, respectively). Flat and inverted T waves were more common in posterior leads (V1: 98% vs. 66%, p<0.001; V2: 96% vs. 8%, p<0.001; V3: 45% vs. 7%, p<0.001; V4: 25% vs. 4%, p<0.001). A Pearson’s correlation analysis of the 3D-CT reconstructions measurements showed a significant inverse correlation between QRS amplitude and the distance from the center of the heart to the estimated lead positions. (V1: r=-0.816, p=0.0001; V2: r=-0.805, p=0.0002; V3: r=-0.77, p=0.0005; V4: r=-0.692, p=0.003; V5: r=-0.0422, p=0.10; V6: r=-0.02, p=0.95). Prone position can be used as an alternative of supine ECG in ARDS and healthy patients. In prone position ECGs, low QRS amplitude should not be misinterpreted as low voltage conditions neither should Q-waves in V1-V2 and abnormal T-waves in V1-V4 be considered anteroseptal myocardial infarction.

Angiographic Profile of Type 2 Diabetic Patients with ST Elevation Myocardial Infarction: A Cross-sectional Study

Introduction: Coronary atherosclerosis is common in diabetics, and it is diffuse in form, with multivessel involvement. It demonstrates the involvement of multiple vessels rather than a single vessel. Aim: To evaluate the angiographic profile of diabetic patients with ST Elevation Myocardial Infarction (STEMI). Materials and Methods: The present study was a cross-sectional study which enrolled 104 diabetic patients presenting with STEMI from December 2019 to March 2020. Seventy percent or more stenosis in any major coronary artery or its major branches (&gt;2.5 mm) was considered as significant. Results: Mean age of the patients was 55.61±11.32 years, with 75 subjects being males and 29 subjects being females. A total of 28 (26.92%) had Anterolateral Wall Myocardial Infarction (ALWMI), 4 (3.84%) had Anteroseptal Wall Myocardial Infarction (ASWMI) 39 (37.5%) had Anterior Wall Myocardial Infarction (AWMI), 1 (0.96%) had extensive AWMI, 2 (1.9%) had Inferolateral Wall Myocardial Infarction (ILWMI), while 30 (28.84%) patients had Inferior Wall Myocardial Infarction (IWMI). Furthermore, 51 (49.0%) were thrombolysed while 53 (50.96%) patients were non thrombolysed. Thirty eight (36.53%) had single vessel disease, 40 (38.46%) had double vessel disease, while 26 (25%) had triple vessel disease. Among these patients, Left Main Coronary Artery (LMCA) was involved in 3 (2.88%) of patients. Seventy three patients had a Glycated Haemoglobin (HbA1c) of greater than 8.5 and had multivessel involvement, whereas 31 had a HbA1c of less than 8.5. Major Adverse Cardiac Events (MACE) was observed during hospital stay in the form of death, recurrent myocardial infarction and cardiovascular stroke, which occurred in 20 (19.23%) patients of the total 104 diabetic patients. Conclusion: In the present study, the severity and extent of Coronary Artery Disease (CAD) and incidence of triple/multivessel disease was significantly high in diabetics. Diabetic patients with high HbA1c had more coronary vessel involvement. In this case, Coronary Artery Bypass Graft (CABG) is the mode of treatment

Measuring the QT/QTc Interval in the Presence of Wide QRS Complexes

Scenario: The electrocardiographic (ECG) rhythm strip below (leads V1 and II) is from a 68-year-old woman with pneumonia who was admitted to the step-down unit from a long-term care facility. Vital signs upon arrival included blood pressure, 107/61 mm Hg; body temperature, 98.9 °F (37.2 °C); heart rate, 68/min; respiratory rate, 21/min; and oxygen saturation (SpO2), 96% on 4 L of oxygen. The attending physician ordered intravenous levofloxacin based on culture of a blood sample collected in the emergency department. Per unit policy, because intravenous levofloxacin is known to prolong the QT/QTc, the nurse must measure and document the QT/QTc before starting the medication in order to determine whether QT/QTc prolongation occurs after administration. How should the QT/QTc be measured in this patient?Sinus rhythm, right bundle branch block (RBBB), possible prior anteroseptal myocardial infarction (MI), and old inferior wall MI.When measuring the QT/QTc in a patient with BBB (RBBB, in this case), because ventricular depolarization is delayed (ie, left to right ventricle), the QT/QTc is prolonged (compare “normal QRS” above). Therefore, the QT/QTc measured in patients with BBB (right or left) has to be adjusted to avoid overestimation. The Bogossian method can be used in patients with BBB, where the modified QT (QTM) is calculated using QT – (QRS/2).1 The QTM is then used to calculate the QTc to account for heart rate using the Bazett formula, or QTM/RR. In this example, QT/QTc would be calculated as follows: QTM = 440 – (160/2) = 360 milliseconds, and RR is 800 milliseconds or 0.8 seconds, so QTc=0.36/0.8=0.402 seconds or 402 milliseconds, which is within the normal range. In comparison, whereas the QT interval is within normal range without using the Bogossian formula, when corrected for heart rate the QTc was prolonged (ie, QTc without Bogossian correction = 0.44/0.8 = 0.492 seconds = 492 milliseconds); hence, adjusting QTc to account for the RBBB in this patient was important.In patients with RBBB, while conduction down the right bundle branch is “blocked,” an initial r wave should be present in lead V1, resulting in the classic rsR’ pattern associated with RBBB (see normal QRS above). However, in patients with a prior septal wall MI, the initial r wave will not be present because depolarization is disrupted in this myocardial region, as is seen in this example. Acute ischemia may be present when examining lead V1 because one would expect the ST segment to be sloping downward and not to be isoelectric with the PR interval. A Q wave is also seen in lead II, which is ~40 milliseconds, suggesting that this patient may also have a prior inferior wall MI, although this feature may be associated with the RBBB.Based on the QT/QTc calculated using the Bogossian correction and Bazett formulas, the antibiotic can be administered to this patient safely. However, QT/QTc should be measured every 8 to 12 hours as it can become prolonged after antibiotic administration. Because of the ECG waveform changes suggestive of prior septal and inferior wall MI and possible acute ischemia, a 12-lead ECG should be obtained to rule out these conditions. In this patient, prior inferior wall (abnormal Q wave in leads III and aVF) and septal wall (missing r wave in lead V2) MI was confirmed. The 12-lead ECG also showed possible acute myocardial ischemia in the other precordial leads; hence, a cardiac workup (ie, cardiac troponin blood test, serial ECGs, and echocardiogram) was ordered. The QT/QTc measured in lead V1 of the 12-lead ECG did not differ from the above measurement. Careful continuous ECG monitoring for ventricular arrhythmias (ie, torsades de pointes, ventricular tachycardia/fibrillation) is paramount in this patient because of the possibility of QT/QTc prolongation and ECG changes suggestive of acute ischemia. Ultimately, this patient was treated for both pneumonia and myocardial ischemia. She did not have QT/QTc prolongation or ventricular arrhythmias and was discharged back to the long-term care facility.

Atypical Presentation of Acute Myocardial Infarction

Introduction: Chest pain has been reported as the cardinal clinical feature of Acute Myocardial Infarction (AMI). However, a substantial number of patients may have atypical or no symptoms on initial evaluation. The absence of typical chest pain and the vagueness of symptoms might result in a delay in seeking medical care. In this study atypical presentations of AMI and in-hospital mortality and outcome were evaluated. Material and Methods: A hospital based cross sectional study was performed among 110 patients of AMI admitted in the CCU who fulfilled the inclusion criteria. The Study was done from July, 2013 to January, 2014 in Dhaka Medical College Hospital, Dhaka, and National Institute of Cardiovascular Diseases (NICVD), Dhaka. Results: Among the 110 patients with AMI, 22 (20%) patients presented with atypical presentation. The maximum incidence of AMI with atypical presentations was in the age group of 65-74 years (28.57%). Dyspnoea (36.36%) was the most among the atypical symptom followed by vomiting 22.72% and the least incident with vertigo 4.54%. Inferior MI being the highest 46% among atypical MI where as mortality rate was high among the antero-septal MI (22.86%). The in hospital mortality of myocardial infarction patients who presented with typical and atypical symptoms were 15% and 36.36 %. Conclusion: The patients without chest pain represent a substantial segment of the MI population. Older patients presented with more atypical symptoms with breathlessness being the commonest atypical symptoms. Mortality was high among the patients who presented with atypical symptoms, increasing age, and who presented lately. J MEDICINE 2021; 22: 88-94

Updated results of hybrid transcatheter and minimally invasive left ventricular reconstruction for the treatment of ischemic cardiomyopathy

Abstract Aims Remodelling of the left ventricle (LV) after anterior myocardial infarction can result in a pathological increase in LV volume and reduction in LV ejection fraction (EF). We describe the updated results of an l hybrid transcatheter and minimally invasive surgical technique to reconstruct the negatively remodelled LV by myocardial scar plication and exclusion to rehape and reduce the excess volume, decrease the wall stress and increase LVEF. Methods and results Patients were considered eligible for the procedure when they presented with symptomatic heart failure (NYHA-class ≥II or more) and ischemic cardiomyopathy (EF&amp;lt;40%) after anterior myocardial infarction. All patients had a dilated LV with either a- or dyskinetic scar in the anteroseptal wall and/or apex of ≥50% transmurality. Hybrid transcatheter and minimally technique that relies on micro-anchoring technology is used to reconstruct the LV by plication of the fibrous scar. A series of internal and external micro anchors are brought together over a PEEK (poly-ether-ether-ketone) tether to form a longitudinal line of apposition between the LV free wall and the anterior septum from the mid-ventricle to the apex. Internal anchors are deployed by transcatheter technique on the right side of the ventricular septum through the right internal jugular vein. Paired external anchors are advanced through a left sided mini-thoracotomy and deployed on the LV epicardium (figure 1). A specialized Force Gauge is used to bring these “RV-LV” anchors together under measured compression forces. “LV-LV” anchor pairs through the LV apex beyond the distal tip of the RV complete the reconstruction. Between October 2016 and March 2021 28 patients (23 males, 5 females; mean age 61±12 years) were operated in a single Dutch centre. Procedural success was 100%. On average 2.3±0.8 anchor-pairs were used to reconstruct the LV. Comparing echocardiographic data pre- and directly postoperatively, LVEF increased from 33±8% to 44±10% (change +35%, P&amp;lt;0.0001) and LV-volumes decreased: LVESV 116 ml ± 52 ml to 69±39 ml (change −35%, P&amp;lt;0.0001) and LVEDV 170 ml ± 72 ml to 118±55 ml (change −29%, P&amp;lt;0.0001). Hospital mortality was 0%. Also no strokes occurred. Median duration of ICU–stay was 2 days (IQR 1–48 days) and median length of hospital stay was 7 days (IQR 5–61 days). Survival at 48 months was 84%. At latest follow-up, 9670% of surviving patients were in NYHA-class I-II compared to 18% preoperatively. Conclusions Hybrid transcatheter and minimally invasive LV reconstruction is a promising novel treatment option for patients with symptomatic heart failure and ischemic cardiomyopathy after anteroseptal myocardial infarction. Updated results demonstrate that the procedure is safe and results in significant improvement in EF, reduction in LV volumes and sustained improvement in heart failure symptoms. Funding Acknowledgement Type of funding sources: None. Figure 1

Clinical Application of Dynamic SPECT/CT in a Patient with Prior Myocardial Infarction Underwent Percutaneous Coronary Intervention Twice.

We present a case of CAD with anteroseptal MI after stent insertion for revascularization due to symptoms presented. MPI with dynamic SPECT/CT provided useful information in terms of flow parameters and matched territories of stenting results as well as providing coronary artery flow phenomenon underwent PCI. In this case, dynamic SPECT/CT may minimize errors with proper stents treatment, especially for controversial MPI results.

A Study of Clinical Profile and Complications In Patients with ST-Elevation Myocardial Infarction Attending In College of Medical Sciences Teaching Hospital, Bharatpur (Chitwan), Nepal.

Background and Aims: ST-Elevation Myocardial Infarction (STEMI) is a leading cause of morbidity and mortality. This study aims to summarize the clinical profile and complications of patients with STEMI in a teaching hospital.&#x0D; Methods: This was a prospective hospital based descriptive and observational study conducted at College of Medical Sciences Teaching Hospital (CoMSTH), Bharatpur from January 2017 to July 2018 in 110 patients with a diagnosis of acute STEMI.&#x0D; Results: Out of 110 patients the mean age of presentation was 59.31 years and 64.5% were male. Typical chest pain (90%) was the most common presenting symptom and 45.5% patients presented within six hours of chest pain. Most common traditional risk factors were hypertension and smoking which were present in 44 (40%) cases, followed by diabetes in 33 (30%), dyslipidemia in 22 (20%). Majority of patients (49.1%) were in killips class I, and only 9 (8.2%) patients were in cardiogenic shock (killips class IV). Inferior wall was the most common in 30% patients followed by anteroseptal wall MI (23.6%), anterior wall MI (11.8%) and combined (anterior and inferior) in 10%. Revascularization with primary Percutaneous Coronary Intervention (PCI) was done in 46 (41.8%) patients, thrombolysis was done in 41 (37.3%) patients. Arrhythmias (39.1%) followed by heart failure (24.5%) were the common complications. The overall in-hospital mortality was 16 (14.5%).&#x0D; Conclusions: Patients with acute STEMI at College of Medical Sciences Teaching Hospital (CoMSTH) were predominantly male with hypertension and smoking as the commonest risk factors. Arrhythmias were the most common complications and in-hospital mortality rate was 14.5%.

Quantification of Cardiac Kinetic Energy and Its Changes During Transmural Myocardial Infarction Assessed by Multi-Dimensional Seismocardiography.

Introduction: Seismocardiography (SCG) records cardiac and blood-induced motions transmitted to the chest surface as vibratory phenomena. Evidences demonstrate that acute myocardial ischemia (AMI) profoundly affects the SCG signals. Multidimensional SCG records cardiac vibrations in linear and rotational dimensions, and scalar parameters of kinetic energy can be computed. We speculate that AMI and revascularization profoundly modify cardiac kinetic energy as recorded by SCG.Methods: Under general anesthesia, 21 swine underwent 90 min of myocardial ischemia induced by percutaneous sub-occlusion of the proximal left anterior descending (LAD) coronary artery and subsequent revascularization. Invasive hemodynamic parameters were continuously recorded. SCG was recorded during baseline, immediately and 80 min after LAD sub-occlusion, and immediately and 60 min after LAD reperfusion. iK was automatically computed for each cardiac cycle (iKCC) in linear (iKLin) and rotational (iKRot) dimensions. iK was calculated as well during systole and diastole (iKSys and iKDia, respectively). Echocardiography was performed at baseline and after revascularization, and the left ventricle ejection fraction (LVEF) along with regional left ventricle (LV) wall abnormalities were evaluated.Results: Upon LAD sub-occlusion, 77% of STEMI and 24% of NSTEMI were observed. Compared to baseline, troponins increased from 13.0 (6.5; 21.3) ng/dl to 170.5 (102.5; 475.0) ng/dl, and LVEF dropped from 65.0 ± 0.0 to 30.6 ± 5.7% at the end of revascularization (both p < 0.0001). Regional LV wall abnormalities were observed as follows: anterior MI, 17.6% (three out of 17); septal MI, 5.8% (one out of 17); antero-septal MI, 47.1% (eight out of 17); and infero-septal MI, 29.4% (five out of 17). In the linear dimension, , , and dropped by 43, 52, and 53%, respectively (p < 0.0001, p < 0.0001, and p = 0.03, respectively) from baseline to the end of reperfusion. In the rotational dimension, and dropped by 30 and 36%, respectively (p = 0.0006 and p < 0.0001, respectively), but did not change (p = 0.41). All the hemodynamic parameters, except the pulmonary artery pulse pressure, were significantly correlated with the parameters of iK, except for the diastolic component.Conclusions: In this very context of experimental AMI with acute LV regional dysfunction and no concomitant AMI-related heart valve disease, linear and rotational iK parameters, in particular, systolic ones, provide reliable information on LV contractile dysfunction and its effects on the downstream circulation. Multidimensional SCG may provide information on the cardiac contractile status expressed in terms of iK during AMI and reperfusion. This automatic system may empower health care providers and patients to remotely monitor cardiovascular status in the near future.

An interesting case of hyperhomocysteinemia presenting as acute myocardial infarction and cerebral venous thrombosis

When a young patient presents with ischemic stroke or recurrent venous thromboembolism of unknown aetiology or “young” myocardial infarction in the absence of traditional risk factors, a detailed thrombophilia workup becomes an imperative. In a setting of arterial and venous occlusive disorders hyperhomocysteinemia is an important risk factor in the absence of traditional contributory aetiologies. Here we present a case of 28-year-old man, never-smoker with no known comorbidities who initially presented to the hospital with acute, retrosternal chest pain, radiating to the left side. His ECG showed ST elevation in V1-V3 in the setting of raised cardiac enzymes, and 2d-echo demonstrating regional wall motion abnormality. He was diagnosed to have acute anteroseptal MI and thrombolysed with streptokinase. Subsequently, his coronary angiogram showed a non-occluded LAD. CT Angio with IVUS done at a staged interval revealed minimal luminal irregularities suggestive of MINOCA. 8 months later the patient presented with headeache, fever, and left focal seizure accompanied by signs of increased intracranial pressure. MRI brain with contrast-MR venogram showed complete thrombosis of superior sagittal sinus. Due to the previous history of MI, and present CVT the patient was subjected to detailed thrombophilic evaluation which was normal except the levels of vitamin B12 (126.9 pg/mL) was low his homocysteine level was abnormally elevated to a level of 38.23 μM/L. The patient was treated with heparin, anti-oedema measures and anti-epileptics followed by oral anticoagulant plus folate, vitamin B6, and vitamin B12. Young patients presenting with arterial or venous thrombosis without any risk factors for atherosclerosis and venous thrombosis which is recurrent, unexplained, or at unusual sites, need screening for thrombophilic states and hyperhomocysteinemia should be ruled out as it can lead to both arterial and venous disease.

Hybrid transcatheter and minimally invasive left ventricular reconstruction for the treatment of ischemic cardiomyopathy: mid-term results

Abstract Background Remodelling of the left ventricle (LV) after anterior myocardial infarction can result in a pathological increase in LV volume and reduction in LV ejection fraction (EF). Purpose We describe the mid-term results of a novel hybrid transcatheter and minimally invasive surgical technique to reconstruct the remodelled LV by plication and exclusion of the scar and reduction of the excess volume, resulting in decreased wall stress and increased EF. Methods Patients were considered eligible for the procedure when the presented with symptomatic heart failure (NYHA-class II or more) and ischemic cardiomyopathy (EF&amp;lt;40%) after anterior myocardial infarction. All patients had a dilated LV with either an a- or dyskinetic scar in the anteroseptal wall and/or apex of &amp;gt;50% transmurality. An hybrid transcatheter and minimally technique was used that relies on deploying a series of paired internal and external micro-anchors to plicate fibrous scar of infarcted anterior wall myocardial tissue to reconstruct the LV. Results Between October 2016 and January 2020 24 patients (21 males, 3 females; mean age 61±13 years) were operated in a single Dutch centre. Procedural success was 100%. On average 2.3±0.9 anchor-pairs were used to reconstruct the LV. Comparing echocardiographic data pre- and directly postoperatively, LVEF increased from 34±9% to 44±11% (change +34%, P&amp;lt;0.0001) and LV-volumes decreased: LVESV 113 ml ± 54 ml to 68±41 ml (change −39%, P&amp;lt;0.0001) and LVEDV 166 ml ± 75 ml to 116±57 ml (change −30%, P&amp;lt;0.0001). One patient was converted peroperatively to full sternotomy, ECC and cardioplegic arrest because of partial dislodgement of an apical mural thrombus. After removal of the thrombus, the LV was reconstructed with 2 anchor-pairs. One patient underwent a postoperative revision because of RV restriction. After removal of 1 “RV-LV” anchor-pair, the patient made a full recovery. One patient underwent an uncomplicated minimally invasive tricuspid valve replacement because of a lesion to the tricuspid valve during the procedure. Hospital mortality was 0%. Median duration of ICU–stay was 2 days (IQR 1–46 days) and median length of hospital stay was 7 days (IQR 5–57 days). Survival at 36 months was 88%. At latest follow-up, 86% of surviving patients were in NYHA-class I-II compared to 21% preoperatively. Conclusions Hybrid transcatheter and minimally invasive LV reconstruction is a promising novel treatment option for patients with symptomatic heart failure and ischemic cardiomyopathy after anteroseptal myocardial infarction. Mid-term results demonstrate that the procedure is safe and results in significant improvement in EF, reduction in LV volumes and improvement in heart failure symptoms. Revivent TC technique Funding Acknowledgement Type of funding source: None

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