Catheterization Laboratory Research Articles

Evaluation of the ODISEA APP for improving a STEMI regional network

BackgroundThe use of technological innovations in ST elevation myocardial infarction (STEMI) care networks has been shown to be effective in improving information flow and coordination, and thus reducing the time to reperfusion. We developed a smartphone application called ODISEA to improve our STEMI care network and evaluated the results of its use. MethodQuasi-experimental study that compared the outcomes of STEMI suspected patients with an alert and indication for transfer to a cath lab during a previous period and a period in which the ODISEA APP was used. The main objective was to examine differences in reperfusion time and the proportion of patients with a final diagnosis other than acute coronary syndrome. ResultsA total of 699 patients were included (415 before and 284 during the ODISEA-APP period). No differences were observed in patient characteristics, infarct type, or acute complications. We observed a reduction in the time from diagnostic ECG to wire crossing with the use of the ODISEA APP (117 vs 102 min, p < 0.001) and a reduction in the percentage of patients with a final diagnosis other than acute coronary syndrome (17.1% vs 9.5%, p = 0.004). ConclusionsThe use of the ODISEA APP in the management of patients with suspected STEMI may be useful for reducing the time from diagnostic ECG to wire crossing and the percentage of patients with a final diagnosis other than acute coronary syndrome.

Use of Drug Eluting Balloons and 1–2-Year outcomes in Tauranga Hospital Cardiac Catheterisation Laboratory— An Audit

Use of Drug Eluting Balloons and 1–2-Year outcomes in Tauranga Hospital Cardiac Catheterisation Laboratory— An Audit

Hyperkalemia mimicking myocardial infarction with ST segment elevation; Brugada phenocopy – case report

Although classical guideline-based ST-segment elevation myocardial infarction diagnostic criteria have a high specificity (97.6%) for diagnosing myocardial infarction with acutely occluded coronary arteries, other clinical states may result in similar ECG abnormalities. Interpretation of those abnormalities is especially challenging in patients with an altered mental state, as it is usually impossible to correlate them with angina symptoms. This can result in unnecessary coronary cath lab activation and patient exposure to invasive procedures with potential complications. We present a rare case of a patient with ST-segment elevation on ECG that was secondary to hyperkalemia in the course of diabetic ketoacidosis.

Radiation Reduction in Paediatric Cardiac Catheterization: We Can Go Even Lower

BackgroundRadiation reduction is an integral component in the management of a paediatric cardiac catheterization laboratory. Simple and easily implementable protocol changes and technical upgrades have been shown to significantly reduce radiation exposure. MethodsRadiation exposures (2020-2022) at Safra Children’s Hospital, Sheba Medical Center, Israel (unit A: n = 672) were retrospectively reviewed, including dose area product (DAP) (μGy m2), DAP/kg, Air Kerma (mGy), and fluoroscopy time (minutes) for 16 procedural types. Median doses were compared with those measured (2011-2014) at the Hospital for Sick Children, Toronto, Canada (unit B: n = 2033). Radiation reduction techniques included fluoroscopy acquisition at 7.5 frames/s, removal of antiscatter grids for children <30 kg, limiting field of view, use of Philips ClarityIQ technology, and an institutional culture of radiation mindedness. ResultsExposure was significantly lower in unit A in 14 of 16 procedure types. Total median doses were lower in unit A (DAP: 91.4 [44.7-205.4] vs 387 [138.2-1339] μGy m2 [P < 0.001], DAP/kg: 9.33 [4.3-16.4] vs 29.22 [12.8-65.9] μGy m2/kg [P < 0.001], and Air Kerma: 14.9 [7.8-29] vs 61 [23-176.4] mGy [P < 0.001]) despite higher fluoroscopy time (14.1 [4.2-24.6] vs 12.3 [6.8-23.3] minutes [P = 0.03]). DAP was lower for specific procedures including pulmonary valvuloplasty (46.3 [14.3-219.3] vs 127 [60-323] μGy m2 [P < 0.001]) and patent ductus arteriosus closure (51.9 [18.8-111.8] vs 178 [96-410] μGy m2 [P < 0.001]). ConclusionsEnhanced radiation reduction techniques can lead to lower than previously published exposure levels across a wide range of procedure types when employing dose-limiting protocols and radiation reduction technology.

Impact of a Mobile, Cloud-Based Care-Coordination Platform on Door-to-Balloon Time in Patients With STEMI: Initial Results

Care-coordination platforms may optimize ST-elevation myocardial infarction (STEMI) treatment delays. This study aimed to assess the impact of Stenoa use on treatment delays in STEMI patients. We conducted a retrospective cohort study on local STEMI cases for the period between September 2020 and March 2023, comparing the times from first medical contact to device, before vs after the implementation of the Stenoa platform by the catheterization laboratory (cath-lab) and emergency department. A total of 180 patients were included. Significant reductions were found in times from first medical contact to electrocardiogram, from electrocardiogram to cath-lab activation, and from cath-lab activation to cath-lab arrival (P = 0.02, P = 0.04, and P = 0.02, respectively), after the platform was implemented. These findings suggest that use of Stenoa reduces STEMI door-to-balloon–time components.

Analisis Tingkat Paparan Radiasi Di Area Tiroid Dokter Kardiologi Intervensi Selama Pemeriksaan Diagnostik Percutaneous Coronary Intervention (PCI) Di Ruang Cath Lab RSUD dr Soedarso Pontianak

Background: Analysis of Radiation Exposure Levels in the Thyroid Area of ​​Interventional Cardiology Doctors During Percutaneous Coronary Intervention (PCI) Diagnostic Examinations in the Cath Lab Room at Dr Soedarso Pontianak Hospital, is research related to patient examinations in the Percutaneous Coronary Intervention Diagnostic Room. The main object in this research is the doctor who examines or treats patients in the room. Researchers wanted to see how many doses of radiation exposure were received by officers examining patients. Method: The research used in this research is quantitative methods. Quantitative research is research that emphasizes analysis on numerical data processed using statistical methods. Based on the type of research, this quantitative research leads to analytical (inferential) research, namely analyzing the relationship between variables by testing hypotheses. The object of focus in this research is an Interventional Cardiology doctor, using 30 patients who have received treatment from a doctor in the cath lab room then the data analysis process uses the measurement results from the pen dose, by conducting research for ten days from 10 August 2023 - 17 August 2023 Results: The results obtained from the average value of radiation dose exposure received by Dr. Interventional Cardiology in the Cath Lab Room at Dr. Soedarso Pontianak Hospital while examining 30 patients, were 0 Sv or the equivalent of 0.000 mSv. Based on these results, it was concluded that the PPE used in the cath lab room at Soedarso Regional Hospital was in accordance with applicable regulations. Conclusion: Based on the data that has been analyzed, it can be concluded that the average value of radiation dose exposure received by Dr. Interventional Cardiology in the Cath Lab Room at Dr. Soedarso Pontianak Hospital while examining 30 patients, is 0 Sv, and is equivalent to 0.000 mSv. Based on the average value of the exposure dose received, which is 0 Sv, the PPE used can reduce the radiation exposure received by doctors. The personal protective equipment includes: Hat, Google Glasses, Thyroid, Apron and protective screen used in accordance with applicable regulations can reduce radiation exposure received by cardiology doctors in the cath lab room at Dr Soedarso Hospital Pontianak.

Implementation of nurse administered propofol sedation for same-day discharge pulsed field ablation of atrial fibrillation is safe and has excellent patient reviews

Abstract Background In June 2022, we introduced Pulsed Field Ablation (PFA) for de novo pulmonary vein isolation (PVI) in patients with atrial fibrillation (AF). Simultaneously, deep sedation with propofol undertaken by trained nurses from the cath lab was introduced. Purpose To evaluate feasibility, safety and patient reported experience for same-day discharge AF ablations performed with PFA on propofol sedation. Methods Patients with an ASA physical status classification of 1 or 2 referred for de novo AF ablation were planned for PFA in propofol sedation. Three nurses with previous experience from the intensive care unit planned and undertook the sedation. In addition, two nurses were trained locally. The initial 200 consecutive patients were included in the observational cohort study after signing consent to participate in follow-up after the procedure. Study data were collected and managed using REDCap electronic data capture tools. In addition to procedure related data, patient-reported quality measures were acquired 30 days after the procedure by an internet based questionnaire including scaling and open questions. Results 96% of the procedures were successfully completed using only propofol while 4% were scheduled for general anesthesia, mainly because of sleep apnea and high BMI. The average procedure time for the first 100 procedures was 57 min (95% CI, 54.1-62.9) and 45 min (95% CI, 42.6-47.4) for the following 100 procedures. Acute PVI was achieved during all procedures. No sedation related adverse effects were observed. One patient experienced pericardial tamponade requiring prolonged hospitalization. 87% were discharged on the same day as planned while 12% remained hospitalized one additional day for reassurance and social reasons. 93% (186/200) completed the questionnaire. 56% of patient only responded "very little" or "not at all" to all questions about adverse symptoms during and after the procedure. For each specific symptom, 80 to 95 % were only experienced "very little" or "not at all" (Fig 1). In general, patients felt safe about the preparation for and handling of the sedation (Fig 2). Conclusions Nurse administered deep sedation with propofol, provides excellent pain relief for PFA procedures, facilitates an efficient workflow and can safely be implemented and administered by nurses from the cath lab. Propofol sedation constitutes an important alternative to general anesthesia that is not widely available.Figure 1Figure 2

The outcomes and complications of percutaneous interventions in chronic total coronary occlusion

BackgroundThe limited availability of complex coronary intervention facilities and qualified operators, due to the high cost associated with chronic total occlusion (CTO) percutaneous intervention (PCI) equipment and a shortage of necessary skills, has led to a scarcity of capable medical centers in Pakistan. This study seeks to examine the outcomes and potential complications associated with CTO PCI procedures conducted at the Cardiac Catheterization Laboratories of a prominent national institute in Pakistan, which handles a large volume of cases.ResultsThree hundred and six patients were included in the study in the study period of six months. The mean age was 59.49 (± 9.16) years: 256 (83.66%) were male and 50 (16.34%) were female. CTO was successfully re-vascularized in 237 (77.5%) with a complication rate of 13.7%. Two hundred and ninety-eight (97.39%) patients underwent an antegrade approach, while RCA was the most common target vessel (47.71%). Diabetes was the only significant associated risk factor with CTO PCI failure (30.43% vs. 30.43%, P-value = 0.015).ConclusionWe achieved an excellent procedural success rate with a low complication rate. CTO procedural failure is associated with a higher complication rate, and diabetes is among the risk factors that lead to higher procedural failure.

Assessment of Coronary Stenoses for Percutaneous Coronary Intervention: A Systematic Review and Network Meta-Analysis of Randomized Trials

Evidence regarding the comparative efficacy of the different modalities to determine the significance of coronary stenoses in the catheterization laboratory is lacking. We aimed to compare all available modalities guiding the decision to perform percutaneous coronary intervention (PCI). We searched Medline, Embase, and CENTRAL until October 5, 2023. We included trials that randomized patients with greater than 30% stenoses undergoing potential PCI and reported major adverse cardiovascular events (MACE). We performed a frequentist random-effects network meta-analysis and assessed the certainty of evidence using the GRADE approach. We included 15 trials with 16,333 participants with a mean weighted follow-up of 34 months. The trials contained a median of 49.3% (IQR 32.6%, 100%) acute coronary syndrome (ACS) participants. Quantitative flow ratio (QFR) was associated with a decreased risk of MACE compared to coronary angiography (CA) (Risk ratio (RR) 0.68, 95% Confidence Interval (CI) 0.56, 0.82; high certainty), fractional flow reserve (FFR) (RR 0.73, 95%CI 0.58, 0.92; moderate certainty), and instantaneous wave-free ratio (iFR) (RR 0.63, 95%CI 0.49, 0.82; moderate certainty), and ranked first for MACE (88.1% probability of being the best). FFR (RR 0.93; 95%CI 0.82, 1.06; moderate certainty) and iFR (RR 1.07, 95%CI 0.90, 1.28; moderate certainty) likely did not decrease the risk of MACE compared to CA. Intravascular imaging (IVI) may not be associated with a significant decrease in MACE compared to CA (RR 0.85; 95%CI 0.62, 1.17; low certainty) when used to guide the decision to perform PCI. In conclusion, a decision to perform PCI based on QFR was associated with a decreased risk of MACE compared to CA, FFR and iFR in a mixed stable coronary disease and ACS population. These hypothesis-generating findings should be validated in large, randomized, head-to-head trials.

Novel Uses of the SwiftNinja Steerable Microcatheter for Pediatric Cardiovascular Interventions.

In the present era, the intricacy of procedures undertaken by a pediatric interventional cardiologist has increased, primarily attributed to dealing with smaller, younger patients with more complex anatomies. To adapt to these smaller and more complex patients, we must adapt our interventions and our equipment to perform these procedures. This article outlines various innovative applications of the SwiftNinja steerable microcatheter within the pediatric cardiac catheterization laboratory.

Cost, efficiency, and outcomes of pulsed field ablation vs thermal ablation for atrial fibrillation: A real-world study

BackgroundWith the exponential growth of catheter ablation for atrial fibrillation (AF), there is increasing interest in associated health care costs. Pulsed field ablation (PFA) using a single-shot pentaspline multielectrode catheter has been shown to be safe and effective for AF ablation, but its cost efficiency compared to conventional thermal ablation modalities (cryoballoon [CB] or radiofrequency [RF]) has not been evaluated. ObjectiveThe purpose of this study was to compare cost, efficiency, effectiveness, and safety between PFA, CB, and RF for AF ablation. MethodsWe studied 707 consecutive patients (PFA: 208 [46.0%]; CB: 325 [29.4%]; RF: 174 [24.6%]) undergoing first-time AF ablation. Individual procedural costs were calculated, including equipment, laboratory use, and hospital stay, and compared between ablation modalities, as were effectiveness and safety. ResultsSkin-to-skin times and catheter laboratory times were significantly shorter with PFA (68 and 102 minutes, respectively) than with CB (91 and 122 minutes) and RF (89 and 123 minutes) (P < .001). General anesthesia use differed across modalities (PFA 100%; CB 10.2%; RF 61.5%) (P < .001). Major complications occurred in 1% of cases, with no significant differences between modalities. Shorter procedural times resulted in lower staffing and laboratory costs with PFA, but these savings were offset by substantially higher equipment costs, resulting in higher overall median costs with PFA (£10,010) than with CB (£8106) and RF (£8949) (P < .001). ConclusionIn this contemporary real-world study of the 3 major AF ablation modalities used concurrently, PFA had shorter skin-to-skin and catheter laboratory times than did CB and RF, with similarly low rates of complications. However, PFA procedures were considerably more expensive, largely because of higher equipment cost.

COMPARISON BETWEEN DIFFERENT TRANSRADIAL ARTERY HEMOSTASIS PROTOCOLS IN LIGURIAN CARDIOLOGIES

Abstract Background Transradial artery access (TRA) for coronary angiography and percutaneous coronary intervention is associated with lower bleeding and vascular complications than transfemoral artery access. In our hospital, TRA is widely used and hemostasis is usually achieved using TRBand device. We used to remove the device in about 10 hours according to our protocol. Aims The aim of this study is to describe and compare different TRA hemostasis protocols in order to understand if a shorter protocol could be more effective. Methods This is an observational study performed in all Hospitals of our region (Liguria). All Cardiology Departments were included in this analysis. We requested to all to self–refer: a) which radial hemostasis device was used; b) which deflation protocol (DP) was used. c) If they usually report and analyze adverse events. Adverse events are described as: bleeding, hematoma, ecchymosis, skin damage, local infection, pseudoaneurysm, or artery occlusion. RESULTS In Liguria there are 9 Cardiology Departments with Cath Lab (CL); 8 of them accepted to participate. All the Cath Labs use the TRBAND device but the deflation protocols are very different. 5 Cath Labs follows the DP suggested by the manufacturer. Only 2 CL adopted different DP if and higher dose of heparin was administered. Only one report bleedings or any delete in the DP. None analyze periodically the incidence of adverse events. Conclusions There are different methods to achieve radial hemostasis furthermore with the same device different deflating protocols are used. Further studies are necessary to evaluate the best DP. Regular audits must be strongly suggested in all Cardiology Departments in order to monitorate and improve the adverse events.

A COMPLEX POST CARDIAC–ARREST SYNDROME: FROM UNCERTAIN NEUROLOGICAL OUTCOME TO HEMORRHAGIC COMPLICATION

Abstract A 49–years–old woman with type II diabetes mellitus, hypothyroidism and Churg–Strauss syndrome experienced chest pain with loss of consciousness. Emergency service was called and CPR promptly started. Cardiac arrest with shockable rhythm was documented, DC–shock performed with sign of anterior STEMI after ROSC, then refractory cardiac arrest appeared. The patient was centralized in our hospital and VA–ECMO was positioned through a percutaneous femoral access in cath–lab. Coronary angiography showed acute occlusion of the mid–proximal LAD and subocclusive stenosis of the dominant Cx for which PCI with DES was performed, then intra–aortic balloon pump (IABP) was implanted. At ICCU admission the patient was supported by ECMO and IABP with MAP 65 mmHg and lactates 3.5 mmol/L. Echocardiography and chest X–ray showed severe biventricular dysfunction and pulmonary overload (Fig 1). She was ventilated via ECMO circuit and mechanical ventilation setting protective TV values of 6 ml/kg. Diuresis was good with low dose of furosemide, lactates progressively decreased. Temperature control was set within 36°C with the cooling system of the ECMO circuit. Cardioaspirin, ticagrelor and bivalirudin were administered. At early neurological stratification EEG documented absence of epileptiform anomalies, responsiveness to painful stimuli, SSPE showed normal and symmetrical morphology, NSE at 48 h was 59 ng/mL, she opened eyes and performed simple orders. Levosimendan was administered with partial recovery of the right ventricular dysfunction leading to ECMO removal on 5th day. Due to poor consciousness recovery despite sedation reduction, percutaneous tracheostomy was performed on 8th day, IABP removed and the following day all vasopressors suspended. Neurological improvement allowed transition to spontaneous breathing and weaning from mechanical ventilation; on 19th day tracheostomy was removed. Massive enterorrhagia appeared after ECMO removal (figure 2). The colonoscopy showed ischemic pancolitis, therefore ticagrelor was suspended. On 18th day clopidogrel was reintroduced based on hemoglobin stability and endoscopic improvement. She was discharged from the cardiology department after a total length of stay of thirty days, with normal neurological status, no motor deficits, recovery of left and right ventricular function, stable hemoglobin levels.

MYOCARDIAL INFARCTION DUE TO LEFT CIRCUMFLEX ARTERY OCCLUSION: A SUBTLE TROJAN HORSE

Abstract A 47–year–old man presented to the emergency department complaining of recurrent chest pain (CP) since the previous day. His medical history included active smoking and dyslipidemia. The ECG revealed sinus bradycardia (56 bpm) with widespread ST elevation, consistent with benign early repolarization, and hyperacute and broad–based T waves in V2–V3 (Fig. A). The echocardiography showed normal left and right ventricular systolic function and no valvular abnormalities. A low but abnormal initial high–sensitivity cardiac troponin I value (40 pg/mL, normal range: 1.7– 34,2 pg/mL) and a slightly and early increase after two hours (52 pg/ml) were seen. Therefore, the patient was admitted to our intensive cardiac care unit (ICCU) with a working diagnosis of non–ST–segment elevation myocardial infarction (NSTEMI). No sign or symptoms of heart failure on physical examination were recorded. GraceScore 2.0 was calculated as 68 points and coronary angiography was organized within 24h. Two hours after admission to the ICCU, the patient experienced a new episode of CP. Consequently, ECG and echo were repeated. Compared to the previous results, ECG showed dynamic changes in V2–V3, with the resolution of hyperacute T waves (Fig B); bedside echo remained unchanged. Considering the unresponsiveness to nitrate therapy, the cath lab was activated for a time–dependent coronary angiography. The exam showed an acute total thrombotic occlusion of the mid–segment of the circumflex branch (LCx) in the setting left–sided dominant circulation. A drug eluting stent was deployed into the culprit lesion (Fig. C), and the coronary flow was restored completely (TIMI Flow 3). The subsequent hospital stay proceeded without complications. The peak troponin level was 60’000 pg/ml. The patient was discharged on the fifth day, asymptomatic and hemodynamically stable, with instructions to continue dual antiplatelet therapy. The case report focuses on the electrocardiographic and angiographic expression of LCx total occlusion. Despite acute myocardial infarction (AMI) size was large, as confirmed by the abnormal troponin I values and the angiographic total occlusion, the first and the repeated ECGs showed only vague repolarization changes without clear ST–segment modifications. LCx occlusion is often characterized by the absence of significant ST–elevation, therefore categorized as NSTEMI. Greater awareness of the presentation of LCx–related AMI can be crucial to avoid delays in reperfusion.

SHOULD WE BE CONCERNED ABOUT USING INTRAVASCULAR LITHOTRIPSY ON THE LEFT MAIN? INSIGHT FROM ROLLING STONE RETROSPECTIVE REGISTRY

Abstract Background The use of rotational atherectomy is currently prevalent in the treatment of left main coronary artery lesions. However, it often necessitates the use of a large burr to achieve adequate debulking, which, in turn, demands highly experienced operators. Intravascular lithotripsy (IVL) is a promising, user–friendly and increasingly employed technique for calcific plaque modification before percutaneous coronary intervention. Although in many cath labs it is now routinely used to treat lesions of the three main coronary arteries, there are still concerns regarding its use in the left main, primarily due to prolonged inflations required for its optimal efficacy. Methods We conducted a retrospective analysis using data from the multicenter retrospective Rolling Stone registry. The analysis involved data from 474 patients, with a stratification between IVL procedures involving left main coronary artery (46 patients) and those that did not (428 patients). The primary effectiveness endpoint was procedural success (defined as achieving residual stenosis &amp;lt; 20% with TIMI III flow); secondary endpoints included the rate of procedural related adverse events, in hospital adverse events and MACE rate at 30 days and 6 months. Results Between April 2018 and January 2023, a total of 474 underwent IVL procedures. Most patients presented with calcific lesion requiring lithotripsy in non–left main segments, while IVL was performed on the left main artery in 46 patients. No significative differences were found on baseline characteristics between LM and non–LM groups. Treatment of IVL–LM lesion was marked by a high procedural success rate (97.8%) and a low incidence of procedural and peri–procedural complications. However, there was a higher rate of contrast–induced acute kidney injury in patients treated in LM (6.5% vs. 1.6%, p=0.030), although no other differences for in–hospital outcomes were observed. Furthermore, there were no differences in 30–day and 6–month follow–up outcomes between the two groups. Conclusions This study suggests that employing intravascular lithotripsy in the left main coronary artery is not only a safe procedure but also produces excellent results comparable to its application in other coronary branches. This provides a substantial level of confidence in the safety and effectiveness of IVL when used in this specific context.

Mixing properties of coronary infusion catheters assessed by in vitro experiments and computational fluid dynamics.

Continuous infusion thermodilution is an established technique for the assessment of absolute coronary blood flow and microvascular resistance due to its proven accuracy and reproducibility. However, for this technique to yield reliable measurements, direct and homogenous mixing of injected saline and blood is mandatory. This study aimed to assess and compare the mixing properties of two different microcatheters, namely the Rayflow® (with sideholes for infusion) and the Finecross® catheter (single end-hole for infusion), which are commonly used in the catheterization laboratory. The study employed three different methods to evaluate the mixing properties of the catheters. Firstly, a qualitative assessment of mixing was performed using ink injections in an in vitro bench model of a coronary artery. Secondly, in analogy to the human catheterization laboratory, mixing properties over the length of the coronary artery were assessed semi-quantitatively by temperature measurements in the bench model. Lastly, a quantitative assessment was performed by 3D computational fluid dynamics, where the standard deviation and entropy ratio of the temperature over the cross-section in the coronary artery model were calculated for both catheters. All three evaluation methods demonstrated that the Rayflow catheter's specific design leads to a more optimal, homogeneous mixture of blood and saline over both the cross-section and length of a coronary vessel, as compared with the standard end-hole catheter.

LEFT BUNDLE BRANCH BLOCK AND ACUTE CORONARY SYNDROME: WHAT IS THE ROLE OF MODIFIED SGARBOSSA–SMITH CRITERIA AND THE WELLENS‘ PATTERN?

Abstract A 55–year–old man presented to the emergency room with intermittent chest pain that started the day before. His medical history included hypertension, and dyslipidemia. The initial electrocardiogram (ECG) showed sinus rhythm (75 bpm) with pre–existing left bundle branch block (LBBB), without modified Sgarbossa–Smith criteria, despite the hyperacute appearance of T waves in V2–V4 (Fig. 1). Additionally, there were alterations in ventricular repolarization in the lateral region, morphologically not fully justifiable by the mentioned conduction delay. Echocardiography revealed normal left and right ventricular systolic function and no valvular abnormalities. Laboratory tests showed a pathological release of myocardial necrosis enzymes, with a typical rise–and–fall curve (10 pg/mL, 100 pg/mL, 200 pg/mL; normal range: 1.7–34.2 pg/mL). Therefore, the patient was admitted to the intensive cardiac care unit (ICCU) with a working diagnosis of non–ST–segment elevation myocardial infarction (NSTEMI). There were no recurrent angina episodes or signs/symptoms of heart failure on physical examination. During hospitalization, ECG and echocardiography were repeated. The follow–up ECG (12 hours after admission) showed persistent LBBB with biphasic T waves in leads V2–V5 with slight negative deflection at the end. This T wave abnormality can be interpreted as Wellens’ ECG Type A (Fig. 3A). The echocardiogram remained unchanged. Consequently, the catheterization lab was activated for urgent coronary angiography. The examination revealed subocclusion of the mid–segment of the left anterior descending artery (LAD). A drug–eluting stent was deployed in the culprit lesion (Fig. 2), restoring coronary flow completely (TIMI Flow 3). The subsequent hospital stay proceeded without complications. The ECG performed before discharge showed a typical LBBB, with normalization of T waves in precordial leads (Fig 3B). The presented case is about ECGs containing a pre–existing LBBB pattern in a patient with chest pain. The modified Sgarbossa–Smith criteria were not met in either the first recorded ECG or the second, whereas Wellens’ signs were detectable. Wellens’ syndrome can be diagnosed in a case of LBBB and help detect a high–grade LAD stenosis even if modified Sgarbossa–Smith criteria are not met.

AN UNUSUAL LEFT VENTRICULAR APICAL MASS COMPLICATING ACUTE MYOCARDIAL INFARCTION

Abstract An 34–year–old man presented to the emergency department of our hospital with palpitations and presyncope. He was a smoker but had no others known cardiovascular risk factors. At admission, his electrocardiogram (ECG) showed sustained monomorphic ventricular tachycardia (VT) at a rate of 187 beats per minute. The VT was successfully treated with synchronized direct current cardioversion. The ECG in sinus rhythm showed Qs from V1 to V6 with ventricular repolarization anomalies in the same site suspicious for previous anterior necrosis. A transthoracic echocardiogram revealed akinetic apex, akinesia of middle segments of the interventricular septum, anterior and lateral walls, Left Ventricular (LV) ejection fraction of 30% and a large apical mass suspicious for LV thrombus. The patient was admitted to the coronary care unit and taken to the Cath lab that showed total left anterior descending mid–segment occlusion. Due to the chronicity of the condition, the patient was recommended to optimal medical therapy. Suspecting LV thrombus, the patient began treatment with unfractionated heparin i.v. and subsequently imbricate therapy with enoxaparin s.c. and warfarin. Additionally, the patient underwent subcutaneous implantable cardioverter defibrillator (S–ICD) implantation for secondary prevention of sudden cardiac death. At echocardiographic follow–up one week after discharge, the apical mass remained unchanged despite warfarin therapy with INR at target. For this reason, the patient was recommended to perform a Cardiovascular magnetic resonance (CMR). Three months after S–ICD implantation, a CMR was performed which showed transmural areas of late gadolinium enhancement involving all apical segments and middle segments of the interventricular septum which allowed the diagnosis of a large intramyocardial dissecting hematoma (IDH) of left ventricle. IDH is a rare complication of ST–elevation myocardial infarction (STEMI), it is an unusual form of subacute cardiac rupture and could be fatal. It usually consists of a cavity or channels within the myocardium. Its prognosis varies according to its location, but generally apical IDH have more favorable outcome with a higher likelihood of spontaneous retraction. We report this case because the IDH is a diagnostic challenge and it represents an extremely rare and poorly described event in the literature.

CARDIOGENIC SHOCK DUE TO SPONTANEOUS CORONARY ARTERY DISSECTION

Abstract Spontaneous coronary artery dissection (SCAD) is an important but rare cause of myocardial infarction (MI) in young adults, particularly women. Current guidelines recommend conservative treatment, given the low angiographic success and the high complication rate of percutaneous coronary intervention. However, in SCAD patients presenting with STEMI or cardiogenic shock the needs of urgent revascularization is critical and PCI may be life threatening. We present a case report occurs in our Hospital of a 42–year–old young woman without cardiovascular risk factors or notable comorbidities which was admitted to our emergency department for typical chest pain. At admission the patient had a cardiovascular arrest from refractory ventricular fibrillation who was rescued according to ACLS protocol. After resumption of ROSC, EKG showed anterolateral STEMI (FIGURE 1). Bedside echocardiography showed a severe reduction in systolic function (EF 30%) due to akinesia of the apex, septum and antero–lateral wall, with absence of noticeable valvulopathy, pericardial effusion or pathological findings in the right heart sections. Therefore the patient underwent to Cath–lab for emergent coronary angiography that showed ostial DA subocclusion with SCAD type 2a on middle tract (Figure 2) IVUS (intravascular ultrasound) imaging confirmed the diagnosis of SCAD, served to guided angioplasty on the LM–DA axis and to confirme optimal stent placement (FIGURE 3). Subsequently, the course was complicated by a double shock component: first SCAI C cardiogenic shock that requested or IMPELLA CP implantation and second haemorrhagic shock due to profound hepatic bleeding because of traumatic injury caused by prolonged resuscitation maneuvers. Mechanical ventricular support ensured haemodynamic stability to allow percutaneous embolisation of the hepatic arteries and patient stabilization. Once the haemorrhagic focus was treated and cardiac function recovered, the patient‘s condition gradually improved leading to a rapid weaning of haemodynamic and respiratory support. No neurological sequelae were observed after the acute phase. Conclusions 1) Urgent revascularization in patients with SCAD and high clinical instability is life threatening. IVUS imaging is crucial to confirm the diagnosis and guide the procedure. 2) The IMPELLA support in this case provided short–term haemodynamic support in a double component of shock.

AN ISOLATED ACUTE RIGHT VENTRICULAR INFARCTION

Abstract Isolated right ventricular infarction occurs only in about 3% of the overall myocardial ischemic episodes. Clinical presentation is often insidious and variable case by case. The correct diagnosis is therefore crucial for a proper management, and a good prognosis in the short and long term. A 72–year–old patient suffering from arterial hypertension went to the emergency room of our hospital for malaise and asthenia for about 12 hours that have increased in 3–4 hours before the arrival. He was sweating, tachypneic with normal value of the oxygen saturation to the finger (SpO2:96%), with arterial hypotension (pressure values = 85/50 mmHg), turgor of the jugular veins in the absence of peripheral edema. Cardiac examination revealed no pathological noises and lung examination revealed clear lung fields. Electrocardiogram showed sinus tachycardia at a rate of 118 bpm, second degree atrioventricular (AV) block 2:1 type and an AV conduction delay with a first–degree AV block (P–Q interval: 320–330 msec). A pulmonary P wave was present and the QRS complex showed predominant R waves in V2–V3 with slight repolarization abnormalities (figure, panel A). An ST–elevation in right precordial leads, V3R and V4R was evident. (figure, panel B). Echocardiographic evaluation showed a hypertrophic left ventricle with normal volume and function, with marked enlarged right sections (figure, panels C–H). Moreover, we can observe the flattening of the interventricular septum with a D shaped left ventricle. Septal flattening occurred only in diastole, expression of RV volume overload (figure, panels F–H). After taking 180 mg of ticagrelor administrated orally and 150 mg of aspirin intravenously, the patient was immediately transferred to the catheterization laboratory for emergency coronary angiography. Coronary angiography highlighting an ostial thrombotic obstruction of a co–dominant right coronary artery (RCA) in the absence of significant stenosis of the left coronary circulation (figure, panels I–M). Primary percutaneous coronary intervention of RCA was performed with STENT implantation with a good postoperative result. (figure, panels L). During the hospital stay, the patient showed a good clinical status without any CV events, with progressively normalization of electrocardiographic abnormalities and persistent sinus rhythm. He was discharged after ten days.