Coronary Rupture Research Articles

Ruptured Noncoronary Sinus of Valsalva Aneurysm Presenting As Sudden Onset Heart Failure

Sinus of Valsalva Aneurysm (SOVA) is a rare congenital or acquired cardiac anomaly. SOVA can remain undiagnosed till it ruptures and can present as acute heart failure, acute coronary syndrome or cardiac tamponade [1]. The aneurysm usually involves the right coronary sinus and ruptures into the Right Atrium (RA) or Right Ventricle (RV) leading to significant left to right shunting and can subsequently cause acute heart failure. Management involves multimodality imaging to verify anatomy followed by surgical resection and repair [2].

Doença de Kawasaki com recorrência tardia

Report of a rare case of recurrence of Kawasaki Disease (KD) and, thus, draw the attention to the possibility of recurrence of the disease after the first episode and thee risk of coronary complications. Recorrence of KD is rare, occurs in only 3-5% of case described in Japan, and is even less frequent in other populations. The inscidence of recurrence in KD is highest in the first two years after the first diagnosis, being more frequent in male patients aged two years or less. Cardiac complications are more frequent in the recurrence of KD, and death can occur from coronary thrombosis or rupture of coronary aneurysm.

Intra- and Postprocedural Management of Coronary Artery Perforation During Percutaneous Coronary Intervention.

Background: Little is known regarding the postprocedural management of coronary artery perforation (CAP). Methods and Results: The characteristics, outcomes, and management of 115 CAP cases among 13,453 patients undergoing percutaneous coronary intervention (PCI) between 2001 and 2017 at Miyazaki Medical Association Hospital were analyzed retrospectively. The incidence of CAP was 0.85% (25 [0.19%] coronary ruptures [CRs], 90 [0.67%] wire perforations [WPs]). The most prevalent causes of CRs and WPs were rotational atherectomy (36.0%) and polymer-jacketed wires (41.1%), respectively. Fifty-two percent of CRs were treated using prolonged balloon inflation, whereas 50% of WPs were treated through embolization. Immediate and delayed cardiac tamponade (CT) occurred in 20% and 24% of CRs, respectively, and in 2.2% and 10% of WPs, respectively. The mean (±SD) right atrial pressure (RAP) during delayed CT in the CR and WP groups was 16.0±1.2 and 14.0±3.0 mmHg, respectively. New-onset atrial fibrillation developed in 24.0% and 11.1% of patients in the CR and WP groups, respectively, whereas late-onset coronary artery aneurysm (CAA) occurred in 24.0% and 0% of patients, respectively. One-year mortality rates in patients with immediate and delayed CT were 28.6% and 20.0%, respectively. Conclusions: Special attention should be paid to delayed CT, new-onset atrial fibrillation, and late-onset CAA after CAP treatment. Continuous monitoring of RAP after CAP during PCI may be useful for the early detection of delayed CT.

Giant Right Coronary Artery Pseudoaneurysm Exclusion With Atrial Septal Defect Closure Device Following Coronary Rupture

Giant Right Coronary Artery Pseudoaneurysm Exclusion With Atrial Septal Defect Closure Device Following Coronary Rupture

Secondary rotational atherectomy strategy may reduce the occurrence of prolonged ST-segment elevation following ablation

Abstract Background Rotational atherectomy (RA) has been widely used for severely calcified lesions in performing percutaneous coronary intervention (PCI). The slow flow phenomenon is the most frequently observed complication of RA and leads to prolonged ST-segment elevation. The incidence of the slow flow phenomenon was reported as approximately 5–20%. Several methods have been recommended to treat the slow flow phenomenon; however, the elevation of ST-segment may often persist after disappearance of slow flow phenomenon on angiography. Purpose The aim of the present study was to investigate the clinical factors on the incidence of prolonged ST-segment elevation following ablation of RA. Methods The subject comprised 140 consecutive stable angina patients with severe calcified lesions. All patients had undergone successfully elective PCI using RA and intravascular ultrasound, and had been prescribed strong statins more than 2 week before PCI regardless dyslipidemia. We investigated the occurrence of prolonged ST-segment elevation following ablation of RA with resistance to use of nitroprusside as intra-coronary vasodilators, and the clinical factors including of primary or secondary RA strategy for calcification lesions. Secondary RA strategy was defined as RA performed after pre-dilatation with small balloon (balloon/artery ratio = 0.6). Results Median of age was 71 years (66–80) and 98 cases (70%) were male. Of 140 target lesions, 82 (59%) were LAD (RCA; 24%, LCX; 16%, and LMT; 1%, respectively). The rates of hemodialysis and diabetes mellitus were 31% and 61%. The incidence of prolonged ST-segment elevation with resistance to use of nitroprusside as intra-coronary vasodilators was 8 cases (6%). Major complications of RA including coronary perforation, coronary rupture, burr entrapment and cardiogenic shock requiring the mechanical support were none. Univariate logistic regression analysis showed that age [Odds ratio (OR); 1.07, 95% confidence interval (CI) 0.99–1.17, p=0.103], hemodialysis (OR; 0.71, 95% CI: 0.10–3.25, p=0.688), diabetes mellitus (OR; 1.08, 95% CI: 0.25–5.46, p=0.915), use of β-blocker (OR; 0.70, 95% CI: 0.14–2.96, p=0.633), left ventricular ejection fraction (OR; 0.99, 95% CI: 0.94–1.05, p=0.781), lesion length ≥20mm (OR; 1.04, 95% CI: 0.23–7.33, p=0.962), and burr size (OR; 2.42, 95% CI: 0.53–16.95, p=0.289) were not associated with the incidence of prolonged ST-segment elevation. Multivariate logistic regression analysis for the incidence of prolonged ST-segment elevation revealed that secondary RA strategy and levels of low-density lipoprotein cholesterol (LDL-C) were independent factors of the incidence of prolonged ST-segment elevation following ablation of RA (OR; 0.05, 95% CI: 0.01–0.39, p=0.017 and LDL-C: OR 0.91, 95% CI 0.83–0.96, p=0.010, respectively). Conclusion Secondary RA strategy may be useful to reduce the occurrence of prolonged ST-segment elevation following ablation of RA. Funding Acknowledgement Type of funding sources: None.

Safety of clinical engineer-assisted percutaneous coronary intervention

Percutaneous coronary intervention (PCI) requires multiple staff members, including interventional cardiologists, with the physical burden of heavy protective measures to minimize radiation exposure. Here, we aimed to investigate the safety of task sharing with clinical engineers (CEs) working as 1st assistant during ad hoc PCI. We retrospectively included 286 patients who underwent ad hoc PCI following diagnostic catheterization for coronary artery disease between April 2019 and March 2021. Procedural complications including coronary perforation or rupture, myocardial infarction, cerebral embolism, cardiovascular death, decreased kidney function, and radiation parameters were compared between the two clinical settings [CE group, CEs as the 1st assistant from the beginning of diagnostic coronary angiography to the end of PCI vs. doctor (DR) group, others]. There was no increase in the ratio of procedural complications in the CE group (1.7%) versus the DR group (1.2%). Fluorescence time and radiation exposure dose were significantly reduced in the CE group {25 min [interquartile range (IQR), 19–35 min] vs. 28 min (IQR, 20–39 min), P = 0.036; 908 mGy (IQR, 654–1326 mGy) vs. 1062 mGy (IQR, 732–1594 mGy), P = 0.049}. The median amount of contrast medium was significantly reduced in the CE group [100 mL (IQR, 80–119 mL) vs. 110 mL (IQR 90–140 mL), P < 0.001]. After propensity matching, fluorescence time, radiation exposure dose, and contrast medium amount were similar between groups. Task sharing with CEs as the 1st assistant during ad hoc PCI could contribute to clinical safety in patients with coronary artery disease.

Multiple Spontaneous Coronary Artery Dissections and Ruptures in Vascular Ehlers-Danlos Syndrome.

Multiple Spontaneous Coronary Artery Dissections and Ruptures in Vascular Ehlers-Danlos Syndrome.

Transthoracic minimally invasive closure for the treatment of ruptured sinus of Valsalva aneurysm: immediate and mid-term follow-up results.

BackgroundWe aimed to evaluate the immediate and mid-term outcomes of transthoracic minimally invasive closure (TMIC) of ruptured sinus of Valsalva aneurysm (RSVA), which is a rare and mostly congenital heart disease.MethodsFrom January 2014 to November 2020, 19 patients (16 males, 3 females) with RSVA were selected for TMIC and were followed up at our centre. Data were analysed from our prospectively collected database and clinical mid-term follow-up was obtained.ResultsAmong these 19 cases, transthoracic echocardiography showed rupture of the right coronary sinus to the right atrium in 9 patients, non-coronary sinus rupture to the right atrium in 7 patients, and right coronary sinus rupture to the right ventricle in 3 patients. Most (13/19) cases were New York Heart Association (NYHA) functional class III or IV. The mean diameters of the defect from the aortic end and ruptured site were 8.8±3.0 and 6.4±2.6 mm, respectively. TMIC was attempted using ventricular septal defect (VSD)/patent ductus arteriosus (PDA) occluders 2–7 mm larger than the aortic ends of the defects. All patients were successfully treated by TMIC and achieved complete closure at discharge after a mean hospital stay length of 6.2±2.5 days. Seventeen patients were NYHA class I while 2 patients were NYHA class II. No cases of residual shunts, device embolization, infective endocarditis, or aortic regurgitation were observed during a median follow-up of 36 months (range, 16–84 months).ConclusionsIn appropriately selected cases with RSVA, TMIC is an attractive alternative to surgery, with a high technical success rate and encouraging short-term and mid-term outcomes. However, long-term follow-up is needed.

Is Coronary Artery Ectasia a Progressive Disease? A Self-Controlled Retrospective Cohort Study.

Objective: It is essential to understand whether coronary artery ectasia (CAE) progresses over time because the patients might be under the risk of coronary rupture, and stent implant should be avoided if ectatic changes progress.Methods: A consecutive series of 99 CAE patients who had undergone coronary angiography at least twice were enrolled and followed up for 1–16 years until they received a second angiogram. Subjects were divided into two groups (1–5 vs. 5–16 years of follow-up), then the basic clinical characteristics and coronary artery images were compared over time.Results: (1) All CAE patients exhibited atherosclerosis, and a majority presented with acute myocardial infarction. Most baseline clinical characteristics were relatively stable. (2) Atherosclerosis (indicated by the distribution of stenosis in coronary vessels) and the Gensini scores progressed significantly. Ectasia extent showed minimal changes as indicated by blood vessel involvement, Markis type, coronary blood flow, ectasia diameter, and ectasia length. (3) Multilinear regression analysis revealed that the underlying factors related to stenosis evolution indicated by fold of Gensini score were: longer time interval, lower baseline Gensini score, and higher hypersensitive C-reactive protein concentration. (4) There was a relationship between the ectatic diameter and the extent of stenosis.Conclusions: For CAE patients with atherosclerosis followed for 1–16 years, there was minimal CAE progression, while the atherosclerosis progressed and the ectasia extent was related to degree of stenosis. The results indicate that prevention and treatment of atherosclerotic changes might have more clinical significance than addressing ectatic changes.

Immediate outcomes of treatment of severe mitral annular calcification

Mitral annular calcification (MAC) is a chronic degenerative process involving the fibrous part of the mitral complex, characterized by calcium deposition and loss of valve function. MAC prevalence is 8–10%, but despite this, the clinical significance of MAC is underestimated. Currently, there are reports that complete decalcification leads to improved long-term outcomes in patients with severe MAC. An analysis of the immediate outcomes of mitral valve surgery in patients with severely calcified mitral annulus with decalcification was performed. The calcified annulus fibrosus underwent complete decalcification in all cases. Calcium deposits were removed in a single block, in 6 cases it was reconstructed with a xeno-pericardial patch; in 2 cases the annulus fibrosus was sutured. There were 2 cases of in-hospital mortality, caused by acute heart failure on day 8 in 1 patient and pulmonary embolism on day 30 after operation in the second patient. There were no complications associated with coronary artery injury and left ventricular posterior wall rupture. Experience in the treatment of severe mitral valve calcification with extensive annulus fibrosus decalcification and subsequent reconstruction is possible and gives satisfactory results.

A Giant Pseudoaneurysm Due to Coronary Rupture Caused by Stent Separation Following Percutaneous Coronary Intervention.

A Giant Pseudoaneurysm Due to Coronary Rupture Caused by Stent Separation Following Percutaneous Coronary Intervention.

Clinical Outcomes of Self-Made Polyurethane-Covered Stent Implantation for the Treatment of Coronary Artery Perforations.

Objectives The present study aimed to investigate the short- and long-term clinical outcomes of self-made polyurethane-covered stents (PU-CS) in patients for the management of coronary artery perforation (CAP) during percutaneous coronary intervention (PCI). Background Coronary artery perforation is reckoned as a serious complication in PCI and associated with considerable morbidity and mortality. Covered stents have been used for treating the life-threatening CAP during PCI. But in some catheterization laboratories, no commercial CS is immediately available when there is an urgent need for CS to rescue the coronary rupture site. Methods We retrospectively identified 24 patients who underwent 31 self-made PU-CS implantations due to CAP in Zhongshan Hospital, Fudan University, from June 2015 to January 2020. Results The total procedural success rate of CS to seal the perforation was 79.2%. Nine patients (37.5%) developed cardiac tamponade, of which 8 patients (33.3%) underwent pericardiocentesis and 4 patients (16.7%) underwent cardiac surgeries. Except for 4 cardiac death cases (16.7%), none of myocardial infarction (MI), target lesion revascularization (TLR), and stent thrombosis (ST) was reported during hospital stay. Data from 22 patients (91.7%) were available at 610.4 ± 420.9 days of follow-up. Major adverse cardiac events (MACE) occurred in 6 patients (27.3%), including 5 cases of cardiac death and one TLR case. Conclusions Self-made PU-CS demonstrates high rates of successful delivery and sealing of severe CAP during PCI. Although the in-hospital mortality remains high after PU-CS implantation, the long-term follow-up shows favorable clinical outcomes, indicating the feasibility of PU-CS in treating CAP.

Imaging Features of Complications after Coronary Interventions and Surgical Procedures.

Coronary artery interventions and surgical procedures are used in the treatment of coronary artery disease and some congenital heart diseases. Cardiac and noncardiac complications can occur at variable times after these procedures, with the clinical presentation ranging from asymptomatic to devastating symptoms. Invasive coronary angiography is the reference standard modality used in the evaluation of coronary arteries, with intravascular US and optical coherence tomography providing high-resolution information regarding the vessel wall. CT is the mostly commonly used noninvasive imaging modality in the evaluation of coronary artery intervention complications and allows assessment of the stent, lumen of the stent, lumen of the coronary arteries, and extracoronary structures. MRI is limited to the evaluation of the proximal coronary arteries but allows comprehensive evaluation of the myocardium, including ischemia and infarction. The authors review the clinical symptoms and pathophysiologic and imaging features of various complications of coronary artery interventions and surgical procedures. Complications of percutaneous coronary interventions are discussed, including restenosis, thrombosis, dissection of coronary arteries or the aorta, coronary wall rupture or perforation, stent deployment failure, stent fracture, stent infection, stent migration or embolism, and reperfusion injury. Complications of several surgical procedures are reviewed, including coronary artery bypass grafting, coronary artery reimplantation procedure (for anomalous origin from opposite sinuses or the pulmonary artery or as part of surgical procedures such as arterial switching surgery and the Bentall and Cabrol procedures), coronary artery unroofing, and the Takeuchi procedure. Online supplemental material is available for this article. ©RSNA, 2021.

Three-Dimensional Fluid Dynamical Features of Coronary Plaque Rupture Provoking Acute Coronary Syndrome.

Aim: Coronary plaque rupture is the main cause of acute coronary syndrome (ACS), but the role of blood flow features around plaque rupture for ACS is still unknown. The present study aimed to assess the relationship between the geometric configuration of ruptured plaque and ACS occurrence using computational fluid dynamics (CFD) by moving particle method in patients with coronary artery disease. Methods: In this study, 45 patients with coronary artery disease who underwent three-dimensional intravascular ultrasound (IVUS) and had a coronary ruptured plaque (24 plaques with provoked ACS, 21 without) were included. To compare the difference in blood flow profile around ruptured plaque between the patients with and without ACS, the IVUS images were analyzed via the novel CFD analysis. Results: There were no significant differences in localized flow profile around ruptured plaque between the two groups when the initial particle velocity was 10.0 cm/s corresponded to a higher coronary flow velocity at ventricular diastole. However, when it was 1.0 cm/s corresponded to lower coronary flow velocity at ventricular systole, particles with lower velocity (0 ≤ V ≤ 5 cm/s) were more prevalent around ACS-PR ( p =0.035), whereas particles with higher velocity (10 ≤ V ≤ 20 cm/s) were more often detected in silent plaque ruptures ( p =0.018). Conclusions: Three-dimensional IVUS revealed that coronary plaque rupture was a complex one with a wide variety of its stereoscopic configuration, leading to various patterns of the local coronary flow profile. A novel CFD analysis suggested that the local flow was more stagnant around ACS-provoked ruptures than in silent ones.

Novel Product for the Management of Coronary Ruptures Happening during Percutaneous Coronary Interventions

Coronary artery perforation during percutaneous coronary interventions is a rare but dreaded complication. One of the treatment methods for this complication is the injection of an obliterating material into the ruptured vessel. We will introduce a novel material named “Spongostan” for embolization with significant advantages over available treatment options.

Covered Stents for the Percutaneous Management of Delayed Coronary Wall Rupture Following Subadventitial Rotational Atherectomy

We present herein the case of a delayed covered coronary wall rupture occurring as a rare complication of rotational atherectomy performed in the subintimal space after antegrade dissection reentry for percutaneous recanalization of a long and heavily calcified left anterior descending chronic total occlusion, which was successfully managed percutaneously with the implantation of 2 covered stents. (Level of Difficulty: Intermediate.)

What leads to coronary heart disease

Coronary heart disease (CHD), or coronary artery disease, develops while the coronary arteries emerge as too narrow. The coronary arteries are the blood vessels that deliver oxygen and blood to the coronary heart. CHD tends to develop when cholesterol builds up on the artery walls, creating plaques. Due to CHD there is a reduction of blood flow to the heart muscle due to build-up of plaque (atherosclerosis) in the arteries of the heart. It is one of the most common cardiovascular diseases. A common symptom is chest pain or discomfort which may travel into the shoulder, arm, back, neck, or jaw. It may leads to heart attack if the flow of oxygen-rich blood to a section of heart muscle is cut off. This can happen if an area of plaque in a coronary artery ruptures (breaks open). The most common signs and symptoms of heart failure are shortness of breath or trouble breathing; fatigue; and swelling in the ankles, feet, legs, stomach, and veins in the neck. All of these symptoms are the result of fluid build-up in your body. When symptoms start, you may feel tired and short of breath after routine physical effort, like climbing stairs.

MANAGEMENT CONSIDERATIONS FOR DIFFUSE LARGE B-CELL LYMPHOMA WITH RIGHT ATRIAL METASTASES

Incidence of secondary metastatic cardiac tumors is about 10% in patients with known malignancies. Cardiac metastasis may cause conduction disturbances leading to arrhythmia, coronary artery invasion or cardiac rupture. A 64-year-old male with diffuse large B cell lymphoma presented for workup of

481 Mass compromising left atrium

Abstract A 47-year-old woman presented to the ER with a sudden-onset left side chest pain of less than one hour in duration that started at rest. The pain was severe and radiated to the left shoulder. This was accompanied with symptoms of shortness of breath and sweating but no similar episodes in the past. There was no significant history of coronary artery disease or any other illness in the family. She had dyslipidemia and a smoking habit of 1 pack/day for the previous 10years. In the ERt, she was hemodynamically stable and her physical examination was within normal limits. ECG showed ST-segment elevation in the inferior leads. No prior ECG was available for comparison. She underwent emergent PCI which showed spontaneous proximal segment circumflex (dominant) artery dissection with TIMI angiographic flow grade 0. All other coronaries were patent with TIMI III flow and no atherosclerotic changes. PCI was carried out, but unfortunately, it was complicated with coronary rupture having to implant a drug eluting stent in order to seal the vessel rupture, with optimal final result (TIMI 3). An urgent TTE was performed for evaluation of the patient due to persistence of chest pain after coronariography, revealing an echogenic mass at the left atrium suggesting extracardiac hematoma vs. left atrium dissection. TC scan confirmed space compromise of the left atrium by a mass, without being able to rule out active bleeding. The patient was transferred to our center for emergent CABG surgery. Upon arrival, the patient had persistent chest pain, sinus tachycardia, and hypertension. Intraoperative TOE findings consisted of a mass compromising left atrium and minimal pericardium effusion. Comprehensive study identified a mobile intimal flap of the atrial wall that was creating a false chamber. Intraoperative surgery findings were compatible with a huge left atrial desiccant hematoma . Two orifices were performed on the epicardium of the inferior and lateral border of the left atrium, in order to drain the retained blood and lavage. No active bleeding was evidenced. TTE control evidenced disappearance of the left atrium mass a The patient had a satisfactory evolution and discharged without complications. Even though left atrial desiccant hematoma is a rare STEMI complication , in this patient, we concluded the etiology was iatrogenic due to the performance of PCI. Conclusion Left atrial dissection is an uncommon entity. It is generally associated with mitral valve replacement, but other predisposing factors should be considered in pathogenesis. Its diagnosis requires a high index of suspicion. Predisposing factors and catheterization, surgical or pathologic findings should be reviewed in order to identify the pathogenic mechanism . Dissection of the coronary sinus secondary to retrograde cardioplegia, endocarditis, cardiac rupture after myocardial infarction, blunt chest trauma and iatrogenic PCI are related to its development. Abstract 481 Figure. MASS COMPROMISIN LEFT ATRIUM

1112 Discovering the origin of a mysterious heart cavity

Abstract Left atrial appendage aneurysm is an infrequent cardiac malformation, with less than 150 cases reported in the literature. It is a congenital anomaly in the majority of cases, related to a dysplasia of pectinate muscles and atrial muscle bands, which tends to grow with age. At the present time, and despite of being not considered in current guidelines, surgical resection is the standard of treatment in the current literature, even in asymptomatic cases, based on cardiovascular morbidity and mortality by predisposing to atrial tachyarrhythmia, thromboembolism, and other rare conditions as coronary or left ventricular compression and rupture of the aneurysm. We report the case of a 53-year-old male patient presenting an episode of supraventricular paroxysmal tachycardia with the casual finding of a mysterious cavity in the transthoracic echocardiography. We found out the presence of a 50 mm cavity adjacent to the left atrium and left ventricle, with a bidirectional blood flow between the left atrium and the cavity when applying Doppler color and with contrast echocardiography. Given this finding, several differential diagnosis had to be considered, including vascular and structural disorders. In order to clarify the diagnosis, a cardiac magnetic resonance was performed. It revealed the presence of a huge aneurysm of the left atrial appendage (50 x 53 mm) causing a mild compression of the left ventricle, with no thrombus and no other significant findings. Due to its size, the compression of the left ventricle and the history of atrial arrhythmia we decided to manage it with an invasive approach by performing a middle thoracotomy, in order to prevent potentially serious complications. Abstract 1112 Figure. CMR 3D reconstruction; echocardiography