Mechanical thrombectomy as a bailout therapy for highly resistant coronary thrombus in a young patient with ST-segment elevation myocardial infarction.

COVID-19 and elevated coronary thrombus burden \u2014 a persistent risk even after recovery?

Background: Spontaneous recanalized coronary thrombus (SRCT) is an uncommon and often underrecognized coronary pathology that may be angiographically subtle despite having functional significance. Optical coherence tomography (OCT) enables accurate diagnosis and treatment planning. However, optimal treatment strategies remain incompletely defined. Materials and Methods: A 55-year-old man presenting with severe exertional dyspnea, atypical chest pain episodes, and abnormal stress echocardiography underwent invasive coronary assessment with angiography, fractional flow reserve (FFR), and OCT. An SRCT of the left anterior descending artery (LAD) was identified and treated using OCT-guided lesion preparation followed by sirolimus-coated drug-coated-balloon (DCB) angioplasty. Results: Although there was only moderate angiographic disease, a functional assessment confirmed significant ischemia. OCT revealed a characteristic honeycomb morphology. Post-procedural OCT demonstrated satisfactory lumen gain, with preserved vessel integrity. Follow-up imaging showed vessel-healing and late lumen enlargement, and the patient remained asymptomatic. Conclusion: OCT-guided drug-coated-balloon angioplasty may be an effective “leave-nothing-behind” strategy for selected SRCT lesions, highlighting the importance of intracoronary imaging beyond angiography.

Clinical and speckle tracking echocardiographic predictors of left ventricular thrombus following primary percutaneous coronary intervention for anterior ST-elevation myocardial infarction.

An adolescent female with a prior diagnosis of Kawasaki disease (KD) presented with systemic inflammatory symptoms, including periorbital swelling, odynophagia and transient fever following initiation of statin therapy. Several months earlier, she experienced a prolonged febrile illness with unilateral neck pain and a desquamating rash, but without classic KD features. Imaging later revealed significant progression of coronary artery aneurysms and thrombus formation, raising concern for KD recurrence. Extensive autoimmune and infectious evaluations were largely unremarkable, apart from a primary Epstein-Barr virus infection. She was treated with intravenous immunoglobulin, corticosteroids and anticoagulation. This case highlights the diagnostic challenges posed by atypical presentations in a condition associated with rare recurrence rates. It underscores the need for long-term cardiovascular surveillance in patients with previous KD, even into adolescence.

Managing large coronary thrombus burden (LCTB) in patients with ST-segment-elevation myocardial infarction (STEMI) remains challenging. Although deferred stenting emerged to potentially improve outcomes in this high-risk population, the optimal antithrombotic regimen remains unclear. The ARISE-ARMYDA 7 (Alternative Anti-Thrombotic Pathways in Acute Myocardial Infarction-Antiplatelet Therapy for Reduction of Myocardial Damage 7) trial evaluated low-dose rivaroxaban in addition to dual antiplatelet therapy for LCTB reduction in patients with STEMI managed with deferred stenting. This single-center, randomized, pilot study included patients with STEMI with angiographic evidence of LCTB undergoing primary percutaneous coronary intervention and deferred stenting. Patients were randomized to rivaroxaban 2.5 mg BID plus aspirin and ticagrelor or aspirin plus ticagrelor alone. Thrombus burden was assessed by optical coherence tomography at baseline and after 5 to 7 days of treatment. The primary end point was reduction of thrombus score after this period. A total of 40 patients with STEMI and LCTB were randomized 1:1. Posttreatment thrombus score at re-optical coherence tomography imaging was significantly lower in the rivaroxaban arm (39 [27-52] versus 82 [50-111] in controls, P=0.005). Relative reduction of the thrombus score versus baseline was greater with rivaroxaban use (61% [50%-81%] versus 36% [0%-50%], P=0.002). The relative thrombus volume decrease was 77% with rivaroxaban versus 39% in the control arm (P=0.001). Deferred stenting was safe, with no abrupt vessel closures, distal embolization, or no reflow. Clinical outcomes at 30 days, including major adverse cardiovascular events and bleeding complications, were not significantly different. The ARISE-ARMYDA 7 trial shows that adding low-dose rivaroxaban to dual antiplatelet therapy significantly reduces thrombus burden in patients with STEMI with LCTB, while maintaining a favorable safety profile. URL: https://www.clinicaltrialsregister.eu/; Unique identifier: EudraCT 2020-005156-38.

Background: Left main (LM) coronary artery thrombus is a rare but life-threatening condition, typically associated with acute coronary syndromes requiring urgent intervention. Certain conditions such as myopericarditis contribute to a prothrombotic state through systemic inflammation. In rare cases, this may predispose to coronary thrombosis, particularly in patients with additional risk factors. We describe a case in which myopericarditis likely contributed to the formation of a non-obstructive left main coronary artery thrombus in the setting of overlapping systemic inflammation and underlying prothrombotic risk, managed conservatively without percutaneous intervention. Case Presentation: A 36-year-old male with a history of well-controlled HIV on ART, presented with fever, hypotension, and a morbilliform rash shortly after initiation of trimethoprim-sulfamethoxazole for a skin and soft tissue infection. He was found to have elevated troponins (peak 661 ng/L) and diffuse ST elevations on EKG, consistent with myopericarditis. He was vitally stable and did not complain of chest pain or shortness of breath throughout his hospital course. Initial investigation with coronary CTA revealed a possible LM thrombus, which was confirmed on left heart catheterization (LHC) as a non-obstructive thrombus (30% stenosis) in the mid-LM. The patient was managed with a tirofiban bolus and infusion, a heparin drip, and dual antiplatelet therapy with aspirin and clopidogrel. Repeat LHC five days later demonstrated complete resolution of the thrombus. TEE was performed to exclude possible sources of embolization including valvular vegetation or left ventricular thrombus. This was notable for a small mobile echodensity on the tricuspid valve which appeared to be consistent with redundant tissue, but no left-sided source of embolism, and he did not have evidence of a patent foramen ovale. The patient was discharged on apixaban and clopidogrel for 6 and 12 months respectively, with plans for outpatient cardiology follow-up and cardiac MRI. Conclusion: In patients with non-obstructive coronary thrombus trigerred by a prothrombotic state, conservative management with anticoagulation and antiplatelet therapy may be appropriate in those who are hemodynamically stable. Clinicians should maintain a high index of suspicion for thrombotic complications in patients with systemic inflammation, especially those with HIV or other prothrombotic risk factors.

Rationale:Although coronary angiography (CAG) can occasionally lead to cerebral infarction, the detachment of a thrombus from the coronary ostium resulting in blockage of head and neck vessels is rare. We present a case of cerebral infarction caused by thrombus detachment from the right coronary artery (RCA) ostium following CAG. This case underscores the importance of accurate identification and management of coronary ostial thrombus during CAG.Patient concerns:A 72-year-old woman was admitted to the hospital with chest pain lasting for 2 hours.Diagnoses:Based on the electrocardiogram findings, the patient was diagnosed with an acute inferior ST-Segment Elevation Myocardial infarction accompanied by third-degree atrioventricular block in accordance with established guidelines.Interventions:The patient was promptly scheduled for CAG. During RCA angiography, the angiography catheter was inserted into the base of the aortic sinus, and a small volume of contrast agent was injected. The ostium of the RCA was observed to become opacified. However, after the catheter was engaged in the RCA ostium, no further opacification was observed upon contrast injection, and no stenosis was detected in the proximal, middle, or distal segments. We suspected that the thrombus had dislodged.Outcomes:The patient’s chest symptoms resolved immediately. Moreover, her mental status improved significantly, with normal motor strength and muscle tone in all 4 extremities. However, subsequent computed tomography angiography of the head and neck, cranial magnetic resonance imaging, and magnetic resonance angiography examinations revealed the presence of carotid artery thrombus and acute cerebral infarction.Lessons:This case underscores the critical importance of accurate identification and management of coronary ostial thrombus during CAG. Notably, when coronary ostial thrombosis is encountered, prompt postprocedural evaluation, including computed tomography angiography of the head and neck to assess for systemic embolization, is warranted.

Coronary microvascular obstruction (CMVO) significantly increases the incidence of major adverse cardiovascular events in patients with acute myocardial infarction (AMI). However, no studies to date have specifically examined the relationship between intracoronary thrombus composition and CMVO formation in AMI patients. This proof-of-concept study aims to investigate the association between coronary thrombus composition and CMVO during AMI. This study enrolled fifty-one patients diagnosed with acute ST-segment elevation myocardial infarction (STEMI) who underwent emergency percutaneous coronary intervention. Intracoronary thrombus specimens were systematically collected during the procedure. Based on established diagnostic criteria for CMVO, participants were stratified into 2 cohorts: the CMVO group exhibiting CMVO (n = 32) and the non-CMVO group without CMVO (n = 19). Histochemical profiling of coronary thrombi was performed to quantify inflammatory and vascular biomarkers including soluble CD40 ligand (sCD40-L), high-sensitivity C-reactive protein (hs-CRP), vascular cell adhesion molecule-1 (VCAM-1), endothelial cell-specific molecule-1 (Endocan), peptidoglycan recognition protein 1 (PGLYRP1), tumor necrosis factor receptor 1 (TNFR1), growth differentiation factor 15 (GDF15), TNF receptor superfamily member 10C (TNFRSF10C), and galectin-3.For quantitative assessment, 2 to 5 random microscopic fields were selected in both the peripheral and core regions of each thrombus specimen. The percentage of positively stained areas was calculated using digital image analysis software (ImageJ, NIH), with mean values derived from all examined fields for intergroup comparisons. Statistical analyses were conducted using SPSS 26.0 with significance threshold set at P < .05. Histochemical quantification showed differential expression of inflammatory mediators in percentage of positively stained areas: sCD40-L, hs-CRP, and VCAM-1 were markedly elevated in thrombi from CMVO patients. Multivariate logistic regression incorporating significant univariate predictors demonstrated, Biomarker analysis revealed significant positive correlations: sCD40-L: B = 0.540, P = .001; hs-CRP: B = 0.264, P = .007; VCAM-1: B = 0.281, P = .013. In addition,the CMVO group (CMVO-positive) demonstrated elevated mean levels of door-to-wire time, Low-Density Lipoprotein Cholesterol (LDL-C), body mass index, and serum interleukin-6 (IL-6) compared to controls. Quantitative analysis of coronary thrombus components revealed significant positive correlations between sCD40-L, hs-CRP, VCAM-1 levels and CMVO prevalence. Moreover, systemic metabolic disturbances - particularly type 2 diabetes mellitus, elevated serum LDL-C concentrations and heightened IL-6 levels were identified as independent predisposing factors for CMVO development.

Neutrophil extracellular traps (NETs) are implicated in thrombosis and inflammation during acute myocardial infarction (AMI), but their kinetics, local distribution, and clinical relevance remain unclear. We conducted a prospective study in 144 patients with ST-segment elevation (STEMI) and non-ST-segment elevation AMI (NSTEMI) undergoing coronary angioplasty (PCI), quantifying double-stranded DNA (dsDNA), myeloperoxidase (MPO), and neutrophil elastase (NE) in the infarct-related artery (IRA), contralateral coronary artery (CCA), and peripheral blood. Coronary thrombi and DNASE1 Q222R were also analysed. NET markers were elevated in the IRA, and NE and dsDNA increased peripherally after PCI. IRA NE levels independently predicted cardiovascular events (HR, 1.76; 95%CI: 1.24 - 2.51). Thrombi with higher NE and citrullinated histone H3 content were associated with suboptimal PCI results. dsDNA levels were significantly higher in patients with the GG DNASE1 genotype. These findings indicate a compartmentalized NET response in AMI and support a potential prognostic impact of NETs.

BackgroundEpicardial adipose tissue has been identified as a significant marker in the assessment of coronary artery disease (CAD), with a possible impact on the development of acute coronary events including ST-elevation myocardial infarction (STEMI).AimTo assess the association and predictability of echocardiographic-measured epicardial fat thickness (EFT) for the severity of CAD and mortality risk among STEMI patients.MethodsThis study included 159 STEMI patients who underwent primary percutaneous coronary intervention (PPCI) and survived the in-hospital duration. Anthropometric measurements, lipid profiles, and angiographic data were recorded. The correlations between echo-measured EFT and CAD severity indicated by the syntax score (SS) were assessed. In-hospital and 6-month major adverse cardiovascular events (MACE) were reported, and mortality risk was evaluated using the Grace score.ResultsAmong the study population, 104 patients (65.4%) had low SS, 45 patients (28.3%) had moderate SS, and 10 patients (6.3%) had high SS. STEMI patients with moderate/high SS had significantly larger EFT. EFT showed a significant correlation with BMI (r = 0.57), fat mass (kg) (r = 0.44), LDL (r = 0.40), the syntax score (r = 0.74), and the Grace score (r = 0.68), (p < 0.001 for all). Our ROC-derived cutoff value of EFT ≥ 5.45 mm significantly discriminated STEMI patients with moderate/high-SS, high coronary thrombus burden, 6-months high mortality risk, and 6-months MACE with reasonable respective sensitivity and specificity. Increased EFT independently predicted moderate/high-SS and high mortality risk on multivariable regression analysis.ConclusionEcho-measured EFT ≥ 5.45 mm might be a reliable non-invasive marker for predicting CAD severity, high coronary thrombus burden, 6-months high mortality risk, and 6-months MACE among STEMI patients.Supplementary InformationThe online version contains supplementary material available at 10.1186/s44156-025-00087-y.

Microplastics and nanoplastics (MNPs) have implicated in cardiovascular disease in preclinical studies. Our objective is to investigate the relationship between MNPs in the coronary arteries and major adverse cardiac events (MACE) in patients with myocardial infarction (MI).We conducted a prospective observational study involving patients undergoing coronary angiography for MI. Coronary blood samples were analyzed for the presence of MNPs using pyrolysis-gas chromatography-mass spectrometry. A total of 142 patients were enrolled, with 110 completing a 31.5-month follow-up. Among them, 48 (43.6 %) had detectable polystyrene, 79 (71.8 %) had polyethylene, 105 (95.4 %) had polyvinyl chloride (PVC), and 68 (61.8 %) had polyamide 66 in their coronary blood. PVC concentration was higher in patients who experienced MACE. Furthermore, PVC levels were positively associated with proinflammatory factors (IL-1β, IL-6, IL-18, and TNF-α), and associated with higher odds of MACE (OR: 1.090, 95 %CI: 1.032-1.1523, P = 0.002). Notably, for each 10-unit increase in PVC, there was a 1.374-fold increase in the risk of MACE (OR=2.374, 95 %CI: 1.366-4.128, P = 0.002). Additionally, we collected blood and thrombus samples from an additional 21 MI patients, finding that PVC levels in coronary thrombi were positively correlated with inflammatory markers and monocyte/macrophage infiltration.

Propensity score analysis of very long-term outcome after coronary thrombus aspiration in acute myocardial infarction.

Considerable research has been conducted in recent years on patients afflicted with myocardial infarction with nonobstructive coronary disease (MINOCA), focussing on its prognosis, prevalence and predisposing risk factors. Nevertheless, there remains a dearth of information regarding the baseline characteristics and outcomes of MINOCA patients with a history of smoking. This study endeavours to examine the in-hospital complications and baseline characteristics of a presumed MINOCA cohort comprising individuals with a history of smoking. In this study, a total of 373 patients (85 current smokers and 283 non-smokers), who exhibited elevated troponin levels but had no evidence of obstructive coronary artery disease, were enrolled between 2010 and 2021. MINOCA patients had to fulfil the modified criteria for acute myocardial infarction (AMI) based on the 'Fourth Universal Definition of Myocardial Infarction', including an up- or downregulated troponin level with at least one value exceeding the 99th percentile, along with clinical evidence of infarction (e.g. ischaemic ECG changes, myocardial damage or coronary thrombus). Additionally, patients with less than 50% stenosis of a major epicardial vessel without intervention and those with alternative diagnoses mimicking troponin-positive nonobstructive coronary disease were excluded. It should be noted that there were five patients for whom data regarding smoking status were not available. The primary objective of this investigation was to evaluate the occurrence of various in-hospital events, including pulmonary oedema, invasive ventilation, cardiogenic shock, stroke, cardiopulmonary resuscitation, malignant cardiac arrhythmias, supraventricular arrhythmias, left ventricular thrombus, thromboembolic events and in-hospital mortality. Additionally, long-term cardiovascular events were assessed over an 11-year follow-up period. Baseline demographics in smokers and non-smokers showed notable differences in the prevalence of supraventricular arrhythmia, particularly atrial fibrillation (5.8% vs. 17.4%; p = .020), diabetes mellitus (DM) (10.5% vs. 19.7%; p = .051), kidney disease (9.3% vs. 15.9%; p = .075) and chronic obstructive pulmonary disease (COPD) (18.6% vs. 10.8%; p = .057). The occurrence of in-hospital cardiovascular events and mortality rates was found to be comparable between smokers and non-smokers. However, non-smokers experienced a higher incidence of long-term cardiovascular events compared to smokers. A multivariable Cox analysis for long-term outcomes indicated that individuals under the age of 50 who were smokers had a more favourable outcome. Nonetheless, the presence of DM, supraventricular tachycardia, pulmonary disease and neurological disease were all associated with a diminished long-term prognosis. Although the long-term health outcomes for smokers are comparatively superior to those of non-smokers, this contrast can be attributed to the increased incidence of cardiovascular comorbidities and the older age distribution within the non-smoking population.

Background: Acute ST-Elevation Myocardial Infarction (STEMI) is one of the life-threatening coronary events with sudden cardiac death. It is the most severe clinical presentation of coronary artery disease. The acute STEMI results from an occlusive coronary thrombus at the site of a ruptured atherosclerotic plaque. The aim of the study is to assess 2-year survival rate of patients with acute STEMI received and treatment initiated at the Dedicated Heart Attack Treatment Centre. Materials and Methods: A retrospective observational study was conducted at SKY Hospital &amp; Research Centre, Imphal, India between January 2018 and January 2020 in the population of fifty patients with acute STEMI discharged from the hospital during that period. Results: A rapid and intense diagnosis and treatment of patients with acute STEMI resulted in an improvement of 2-year survival with good quality of life with 92.00% survival rate. Conclusion: The present study of patients with acute ST-Elevation Myocardial Infarction received and treatment started at the Dedicated Heart Attack Centre of SKY Hospital &amp; Research Centre, Imphal, India demonstrated an increase in 2-year survival rate which is higher than many previously published survival rate.

BackgroundThis cohort study aimed to evaluate the potential myocardial arrhythmic substrate in people with coronary artery disease who died from sudden arrhythmic death (SAD) without acute coronary thrombosis or myocardial infarction.Methods and ResultsWe performed histological analysis of the left ventricular free wall obtained at autopsy from decedents with ≥1 coronary artery and ≥75% area stenosis who died suddenly from either noncardiac causes (25 men, 23 women) or SAD (25 men, 25 women), matched for age and sex. Decedents with acute coronary thrombosis, myocardial infarction, or other myocardial abnormality were excluded. Decedents with either noncardiac death or SAD had similar height, weight, and heart weight. Decedents with SAD had higher cumulative area stenosis of coronary arteries (mean, 162% versus 134%; mean difference, 29% [95% CI, 1%–56%], P=0.042) and a higher proportion of decedents with SAD had diabetes (mean, 10% versus 0%; mean difference, 10% [95% CI, 2%–18%], P=0.025) and chronic, nonocclusive, organized coronary artery thrombus (mean, 16% versus 0%; mean difference, 16% [95% CI, 6%–26%], P=0.0040). Moreover, decedents with SAD had lower cardiomyocyte width (mean, 18.6 μm versus 19.6 μm; mean difference, 1.0 μm [95% CI, 0.2–1.8], P=0.014) and higher capillary length density (mean, 3618 mm/mm3 versus 3164 mm/mm3; mean difference, 453 mm/mm3 [95% CI, 210–697], P=0.0003) than decedents with noncardiac death.ConclusionsSAD in people with coronary artery disease without acute coronary thrombosis or myocardial infarction was associated with greater coronary artery plaque burden and cardiomyocyte atrophy that may have contributed to myocardial substrate for arrhythmia.

The thrombogenic potential of cells within atherosclerotic plaques is critical in the formation of a coronary thrombus. We hypothesized that a combination of inflammatory and hypoxic stimuli enhances tissue factor (TF) expression and glycolysis in cells in atherosclerotic plaques and contributes to coronary thrombus formation. To identify TF- and hexokinase (HK)-II-expressing cells in coronary atherosclerotic plaques and thrombi and determine the effects of combined inflammatory and hypoxic stimuli and glycolysis on TF expression in peripheral blood mononuclear cell-derived macrophages. We immunohistochemically assessed TF and HK-II expression in stable (n = 20) and unstable (n = 24) human coronary plaques and aspirated acute coronary thrombi (n = 15). The macrophages were stimulated with tumor necrosis factor-α, interferon-γ, or interleukin-10 under normoxic (21% O2) or hypoxic (1% O2) conditions, and TF expression was assessed. TF and HK-II expression were increased in unstable plaques compared with stable plaques. The number of CD68- and HK-II-immunopositive cells positively correlated with the number of TF-immunopositive cells. TF- and HK-II-expressing macrophages, which expressed M1- or M2-like markers, were involved in platelet-fibrin thrombus formation in ruptured plaques. The combination of inflammatory and hypoxic conditions additively augmented TF expression and procoagulant activity in the cultured macrophages. Inhibition of glycolysis with 2-deoxyglucose reduced the augmented TF expression and procoagulant activity. Combined inflammatory and hypoxic conditions in atherosclerotic plaques may markedly enhance procoagulant activity in macrophages and contribute to coronary thrombus formation following plaque disruption. Macrophage TF expression may be associated with glycolysis.

Background Previous studies have demonstrated an association between larger platelet volume and coronary thrombus formation in acute coronary syndrome (ACS). Objectives We aimed to investigate the association of platelet distribution width (PDW) levels with both the clinical severity and the extent of coronary artery disease (CAD) in patients diagnosed with ACS. Methods A retrospective evaluation was conducted on 1043 consecutive patients diagnosed with ACS. Patients were stratified into two groups based on their PDW values: group 1 (PDW > [...]

Acute ST-Elevation Myocardial Infarction (STEMI) usually results from an occlusive coronary thrombus at the site of a ruptured atherosclerotic plaque. Thrombolysis has a role in the management of patient with acute STEMI and restoration of culprit vessel arterial flow as normal as possible. Early thrombolytic therapy in acute STEMI reduced mortality by the time of hospital discharge and better functional outcomes at 6 months. Thrombolytic therapy when given within 10 minutes of arrival at the Emergency Room helped restore the patency of culprit vessel patency to 0-30% in our 3 patients with acute STEMI. This may indicate that thrombolytic therapy augmented with loading anti-platelet drugs and bolus intravenous drug enoxaparin given in ≤ 10 minutes may be a viable alternative to primary percutaneous coronary intervention when the later is not available or not possible within Door-to-Balloon time of 120 minutes.

Abstract Takotsubo cardiomyopathy (TCMP) is a form of transient left ventricular (LV) dysfunction which is almost completely reversible. Among the wide range of etiological factors, thyroid hormone dysfunction is considered a rare but potentially treatable cause of TCMP. Other than LV dysfunction patients can present with mechanical as well as electrical complications. LV thrombus is one of the dreadful mechanical complications predisposing to systemic thromboembolic events. QT prolongation though rare can be seen in patients with TCMP either because of the catecholamine excess or the underlying etiology. We present a rare case of a 63-year-old female presenting with acute decompensated heart failure with the presentation of acute coronary syndrome, LV thrombus, and QT prolongation eventually turning to be a case of TCMP with newly detected hypothyroidism and reversal of LV dysfunction, resolution of LV thrombus, and normalization of QT interval within 4 days of treatment.