Emergency Coronary Angiography Research Articles

Double coronary artery occlusion presenting as inferior ST-segment elevation myocardial infarction and Wellens syndrome type A: a case report

Abstract Background ST elevation myocardial infarctions (STEMI) are usually a consequence of the occlusion of a single coronary artery but in 2.5% of the cases two or more culprit lesions are found. Simultaneous coronary arteries occlusion is a potentially life-threatening condition when leads to cardiogenic shock or ventricular arrythmias. Case summary We presented the case of a 74-years-old man presenting with chest pain and ST segment elevation (STE) in inferior leads and evidence of alternating STE in anterior leads in a pattern like Wellens syndrome type A in subsequent EKGs. Emergency coronary angiography (CA) revealed thrombotic occlusion of the proximal right coronary artery (RCA) and sub-occlusion of mid left anterior descending artery (LAD). During the CA he became hemodynamically unstable requiring intravenous inotropes and vasopressors and he underwent primary PCI of both RCA and LAD culprit lesions. His subsequent hospital stay was uneventful, and he was discharged 5 days later. Discussion STEMI with more than one culprit coronary artery is a rare but at high-risk of hemodynamic decompensation. The causes of occlusion of multiple coronary arteries may be several: coronary embolism, coronary ectasia, simultaneous plaque disruption, coronary vasospasm, hypercoagulability states, smoking, and illicit drug abuse. The presumed mechanism behind the presented case may be a combination of release of pro-thrombotic cytokines due to the thrombotic occlusion of the first coronary and low output state secondary to myocardial disfunction leading to impaired flow in a severe stenotic coronary artery with subsequent thrombosis.

Distal versus traditional radial access in patients undergoing emergency coronary angiography or percutaneous coronary intervention: a systematic review and meta-analysis.

Distal radial access (DRA) is a well-tolerated and effective alternative to traditional radial access (TRA) for coronary procedures. However, the comparative value of these modalities remains unknown in the emergency setting, particularly in patients with ST-elevation myocardial infarction (STEMI). To compare DRA versus TRA for emergency coronary procedures through a meta-analysis. We systematically searched PubMed, Embase, and Cochrane databases to identify studies comparing DRA versus TRA in patients undergoing emergency coronary angiography (CAG) or percutaneous coronary intervention (PCI). All statistical analyses were performed using R software version 4.3.1 with a random-effects model. We included four studies comprising 543 patients undergoing emergency CAG or PCI, of whom 447 (82.3%) had STEMI. As compared with TRA, DRA was associated with lower radial artery occlusion rates (RR, 0.21; 95% CI, 0.06-0.72) and shorter hemostasis time (MD, -4.23 h; 95% CI, -6.23 to 2.13). There was no significant difference between modalities in terms of puncture failure (RR, 1.38; 95% CI, 0.31-6.19), crossover access (RR, 1.37; 95% CI, 0.42-4.44), puncture time (SMD, 0.33; 95% CI, -0.16 to 0.81), procedure time (MD, 0.97 min; 95% CI, -5.19 to 7.13), or rates of cannulation success (RR, 0.94; 95% CI, 0.83-1.06). In terms of other periprocedural complications, there were no differences between both groups. These findings remained consistent in a subgroup analysis of patients with STEMI. In this meta-analysis, DRA was superior to TRA in terms of radial artery occlusion and hemostasis time, with similar rates of periprocedural complications.

Correlation between Glycated Hemoglobin, Extra cranial Carotid Artery Disease, Peripheral Arterial Disease in Type ll Diabetic Patients with Coronary Artery Disease

Abstract Background Diabetes mellitus (DM) is the most common endocrine disorder where the body does not either produce enough insulin or has a resistance to the circulating insulin, and is characterized by high blood sugar levels over prolonged periods. DM is a growing global health issue. In 2000, DM affected an estimated 171 million people in the whole world increased on 2011 to more than 366 million people and expected to be more than 552 million by 2030. Aim of the Work to correlate between HBA1C, carotid, peripheral and coronary artery disease in type II DM patients. Patients and Methods This is an observational study conducted at the coronary care unit & coronary catheterization lab unit of National Institute of Diabetes and Endocrinology, Egypt. Its aim was to correlate between HBA1C, carotid, peripheral and coronary artery disease in type II DM patients. 122 patients with eligible criteria were recruited to the study after signing consent. A full history was taken from every patient, a full clinical examination, 12 lead-ECG, Echocardiography, Carotid duplex, ABI measurement, HbA1C and Invasive non emergent coronary angiography were done. Results Data was collected, tabulated, and analyzed, which revealed that carotid IMT in patients with HbA1C >7% was significantly higher than those with HbA1C<7, HbA1C had a significant positive correlation with carotid IMT, ABI was significantly lower in patients with HbA1C>7% compared to those with HbA1C<7%, ABI had a significant negative correlation with carotid IMT, Number of diseased coronary vessels was significantly higher in patients with higher HbA1C >7% compared to those with HbA1C>7%, ABI had a significant negative correlation with number of diseased coronary vessels and IMT had a significant positive correlation with number of diseased coronary vessels in patients with higher HbA1C >7% with no significant correlation in those with HbA1C<7%, HbA1C can significantly predict peripheral artery disease and carotid atherosclerosis. Conclusion HbA1C correlates significantly with Carotid atherosclerosis, PAD and CAD severity based on number of diseased coronary vessels in uncontrolled TIIDM patients. Also, PAD and carotid atherosclerosis correlate significantly with CAD severity based on number of diseased coronary vessels in uncontrolled TIIDM patients. Also, PAD correlates significantly with carotid atherosclerosis in uncontrolled TIIDM patients. HbA1C can significantly predict carotid artery disease and PAD.

Reducing Door-to-Balloon Time Using EMS-initiated App-based Communication

BackgroundReducing door-to-balloon (D2B) time for ST-segment elevation myocardial infarction (STEMI) has been shown to improve outcomes. Delays still occur due to various factors such as time to laboratory activation and diagnostic clarification in equivocal cases. We propose that early communication through a mobile application (app) between emergency medical services (EMS) and in-hospital providers can reduce EMS-to-balloon time and provide coordinated care to impact D2B time. MethodsThe General Devices e-Bridge mobile app, which allows real-time communication and data transmission between EMS providers and the cardiac catheterization laboratory and emergency department staff, was implemented on May 14, 2019. A single-center, retrospective observational study was conducted on 795 STEMI activations undergoing emergent coronary angiography between January 2017 and July 2020. After exclusions, EMS transmissions of 428 cases were analyzed, of which 132 used the app. ResultsImplementation of e-Bridge significantly reduced D2B time by 7.2 minutes (61.2 vs 68.36 minutes; 95% CI, −12.2 to −2.14; P = .005,) and emergency department board time by 4.41 minutes (29.38 vs 24.98 minutes; 95% CI, −7.8 to −1; P = .01). First medical contact to balloon (FMC2B) time trended toward reduction but was not statistically significant. The app did not significantly reduce D2B or FMC2B time during the day shift but significantly improved these metrics during the night shift. ConclusionsImplementation of app-based communication between EMS and in-hospital providers resulted in statistically significant reductions in D2B time at our institution. This approach holds promise in improving the timely management of STEMI patients, particularly during the night shift.

Non-chest pain symptoms and likelihood of coronary occlusion in emergency department patients with ST segment elevation undergoing emergent coronary angiography.

Patients presenting with suspected ST segment elevation myocardial infarction frequently have symptoms in addition to chest pain, including dyspnea, nausea or vomiting, diaphoresis, and lightheadedness or syncope. These symptoms are often regarded as supporting the diagnosis of infarction. We sought to determine the prevalence of the non-chest pain symptoms among patients who were confirmed as having a critically diseased coronary vessel as opposed to those with no angiographic culprit lesion. Data from 1393 consecutive patients with ST segment elevation who underwent emergent coronary angiography were analyzed. Records were reviewed in detail for symptoms, ECG findings, prior history, angiographic findings, and in-hospital outcomes. Dyspnea was present in 50.8% of patients, nausea or vomiting in 36.5%, diaphoresis in 51.2%, and lightheadedness/syncope in 16.8%. On angiography, 1239 (88.9%) patients had a culprit lesion and 154 (11.1%) were found not to have a culprit. Only diaphoresis had a higher prevalence among the patients with, as compared with those without a culprit, with an odds ratio of 2.64 (P < 0.001). The highest occurrence of diaphoresis was among patients with a totally occluded artery, with an intermediate frequency among patients with a subtotal stenosis, and the lowest prevalence among those with no culprit. These findings were consistent regardless of ECG infarct location, affected vessel, patient age, or sex. Among the subset of patients who presented without chest discomfort, none of the symptoms were associated with the presence of a culprit. The presence of diaphoresis, but not dyspnea, nausea, or lightheadedness is associated with an increased likelihood that patients presenting with ST elevation will prove to have a culprit lesion. In patients who present with ST elevation but without chest discomfort, these symptoms should not be regarded as 'chest pain equivalents'. Further objective data among patients with angiographic confirmation of culprit lesion status is warranted.

ENTRECTINIB–INDUCED ACUTE RIGHT HEART FAILURE IN A PATIENT WITH METASTATIC LUNG ADENOCARCINOMA

Abstract We report a case report of a 45–year–old woman with a recent diagnosis of stage IV lung adenocarcinoma (PDL1 60%) with brain metastases, who started entrectinib 600 mg orally once daily. Four days after entrectinib initiation, the patient activated the emergency medical services for acute onset of marked fatigue and hypotension. The ECG performed by the emergency unit showed a marked ST–segment elevation in the infero–lateral leads. Therefore, emergent coronary angiography was performed and no evidence of coronary disease was reported. Subsequently, the patient was admitted to the Coronary Care Unit. Clinical evaluation revealed labile hemodynamics, as the patient presented mental confusion, persistent hypotension (BP 90/50 mmHg) and bradycardia (HR 30 bpm). Laboratory testing showed elevated NT–pro BNP, troponin I and transaminases, normal CRP. The electrocardiogram showed persistent diffuse ST–segment elevation. Transthoracic echocardiogram showed severe dilatation and hypokinesia of the right ventricular (GLS VDx –4.5%), with diastolic “D–shape”, normal left ventricular ejection fraction, no significant valvular disease, circumferential pericardial effusion. Clinical, laboratory and instrumental findings suggested a condition of acute right heart failure. We performed urgent computed tomography pulmonary angiography (CTPA) which resulted negative for acute pulmonary embolism. Hence, supportive therapy with dobutamine, norepinephrine and fluid resuscitation was started, with subsequent hemodynamic stabilization. Since no other etiology was demonstrated by the extensive testing, we attributed the acute right ventricular dysfunction to the recent introduction of entrectinib therapy. Therefore, the drug was discontinued. During the hospitalization we observed a rapid normalization of electrocardiogram and right ventricle function by transthoracic echocardiogram, accompanied by a progressive improvement of laboratory parameters. In order to better define right ventricle function and dimension, the patient underwent cardiac magnetic resonance imaging which showed a normal right ventricle ejection fraction (RV EF 52%), the absence of myocardial edema or late gadolinium enhancement and normal volume of the right ventricle. After six days of hospitalization the patient was discharged. Our case report adds to the limited available literature of cardiac toxicity of entrectinib.

SCARY ECG IN TAKOTSUBO CARDIOMYOPATHY

Abstract Takotsubo cardiomyopathy (TTC) is characterized by a transient ventricular wall motion abnormality and shares common features with acute coronary syndrome (ACS) with a wide spectrum of triggers, such as both emotional or physical, activating common toxic catecholamines–mediated pathways. TTC might be associated with severe clinical complications. We report a case of a 74–year female patient with circulatory shock with mixed phenotype, distributive due to sepsis and cardiogenic due to TTC. The patient presented to the emergency department with severe hypotension, pathological qSOFA score and clinical and laboratory findings consistent with severe sepsis. ECG showed diffuse lambda ST–segment elevation, also called “shark fin”(fig.1). According to hemodynamically unstable scenario and ECG pattern, emergency coronary angiography was performed, showing absence of coronary artery disease(fig. 2). Echocardiography revealed severe LV systolic disfunction (EF 20–25%) with apical ballooning and severe systolic anterior motion (SAM) of the anterior mitral leaflet eliciting dynamic LVOTO with peak gradient greater than 90 mmHg; fig. 3) and severe MR. Patient was treated with cautious fluid administration, hemotrasfusion and empiric large spectrum antibiotic therapy. According to TTC working diagnosis, even if septic state was thought to contribute to cardiogenic shock, norepinephrine was not administered due to concerns for LVOTO and SAM. After overcoming of dramatic first phase and after hemodynamic steadiness was achieved, beta blockade and ACEi were progressively administered. Seriate transthoracic echocardiogram revealed progressive improvement of LV systolic function, regression of apical ballooning, SAM and LVOTO. ECG monitoring showed regression of ischemic ST elevation. ST elevation has been described in about 56% of TTC cases, however with amplitude tipically lower than in STEMI. Lambda–wave ST elevation has been rarely reported. Vasospasm, local intermittent microvascular constriction, catecholamine–induced metabolic toxicity, transmural systolic wall tension and its the mechano–electric feedback can explain scaring ECG–pattern. Despite its rare prevalence in TTC “shark fin” pattern appears to relate to adverse outcome and it should be used as an early marker of potential further clinical deterioration, suggesting more intensive monitoring to avoid delays in possible therapy escalation.

VASOSPASTIC INFARCTION STARTED WITH PULSELESS ELECTRICAL ACTIVITY CARDIAC ARREST

Abstract We report the case of a 48–year–old female with a special history of ischemic heart disease. It started in 2021 with an acute anterior ST myocardial infarction: the coronary angiography showed subocclusive stenosis at the first tract of the left anterior descending (LAD), without other coronary stenoses. The patient was treated with primary PCI + DES; the echocardiogram showed EF 30% and akinesia of apex, intermediate segments of anterior wall and interventricular septum. During the same hospitalization the patient experienced recurrence of angina with transient ST elevation in the anterior and inferior leads; a control coronary angiography was unchanged. She was started on therapy with nitrates and diltiazem up to the tolerated dose, statin as well as antiplatelet and anticoagulant therapy due to apical thrombus. She underwent ICD implantation in primary prevention in January 2022. During 2022, there were several accesses to the ED for vasospastic angina despite medical therapy at the maximum tolerated dose. In October 2023 the patient experienced an acute chest pain followed by cardiac arrest, pulseless electrical activity and acute cardiogenic shock. After resuscitation procedures, she underwent an emergency coronary angiography which showed excellent result of the previous PCI, as well as stenosis of the distal edge of the stent resolving after injection of i.c. nitrates. No arrhythmic events at ICD recording and continuous electrocardiographic monitoring in ICU were observed. Cardiac MRI showed areas of subendocardial LGE involving the apex, anterior, anterolateral and septal segments due to ischemic scar; we also observed areas of edema and LGE with an ischemic pattern at the infero–septal and inferior wall in toto, suggesting recent ischemia; EF was 31%. During hospitalization the patient experienced episodes of typical angina with poor response to medical therapy at the maximum tolerated dose. The current clinical case most likely points to acute myocardial infarction due to vasospasm of the right coronary artery with acute pump failure resulting in cardiac arrest and no specific recommendations exist in recent cardiologic guidelines on the strategy to adopt for this acute clinical setting. In the hypothesis of a vasospastic pathogenesis of the problem, counseling for modulation of the stellate ganglion was requested.

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.

AN ACUTE MYOCARDIAL INFARCTION IN A VERY YOUNG MAN DUE TO HYPERHOMOCYSTEINEMIA

Abstract Introduction A young 17–year–old boy smoker and obese was admitted to our cardiology unit for continuous oppressive chest pain radiating to the left arm that had arisen three days earlier. In the emergency room, he had performed blood tests with evidence of an increased troponin and an electrocardiogram that showed mild ST–elevation in inferior leads with ST depression in aVL. We performed an urgent transthoracic echocardiography examination that was unremarkable Investigation Once diagnosed with acute ST–segment elevation myocardial infarction, the patient underwent emergency coronary angiography. Coronary angiography highlighted an intermediate stenosis of the first branch diagonal to the proximal tract and a possible occlusion of the periapical branch of the anterior descending artery. It was decided not to perform PTCA as we could not exclude a distal coronary dissection and considering the vessel was of small caliber. We decided to complete the diagnostic process by performing a cardiac MRI showing edema in the apex and distal inferior wall and transmural gadolinium enhancement at the level of the septum and inferior wall of the distal section. In the context of the damaged wall a focal area of hypointensity to be referred to the "no–reflow" phenomenon Management The patient was treated with DAPT, low molecular weight heparin and high dose statin. A few hours after the coronary angiography the patient stopped having chest pain and remained asymptomatic for the rest of the hospital stay. We performed complete blood tests including with evidence of hyperhomocysteinemia. The lipid panel was normal. Hematological consultation recommended folate and Vitamine B12 treatment. After 12 months the patient is asymptomatic, has stopped smoking and continues to take DAPT. He repeated the echocardiogram which showed no alterations. Genetic testing was performed after hospital discharge and was positive for Methylenetetrahydrofolate reductase (MTHFR) homozygous mutation Conclusion Our clinical case shows a rare case of acute myocardial infarction in a very young person. Diagnosis and treatment were complicated by the extreme distality of the occlusion and the few modifiable risk factors identified (smoker, obesity and hyperhomocysteinemia). Hyperhomocysteinemia is an often underestimated cardiovascular risk factor associated with a high risk of cardiovascular events and multivessel coronary disease that should be sought in all young patients with AMI.

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.

Current post-resuscitation management of out-of-hospital cardiac arrest patients admitted to intensive cardiovascular care units

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Consell Català de Resucitació 2022. Background Out-of-hospital cardiac arrest (OHCA) accounts the 50% of cardiovascular deaths. Neuroprognostication must be done in a multimodal approach as recommended by ILCOR guidelines but its application in real life is challenging. Aim To investigate current post-resuscitation care and neurological prognostication of OHCA patients admitted to a mediterranean Intensive Cardiac Care Unit (ICCU) during the 2020s. Methods PCR-Cat was a prospective observational multicenter registry. OHCA patients admitted to the ICCU of 8 catalan hospitals were included from October/2020 to December/2021. Post-OHCA management in the ICCU was analyzed including neuroprognostication tools and targeted temperature management (TTM) approach. Patients were classified into 2 groups according to main outcome at 6-month follow-up: good (CPC 1-2, GO) or poor outcome (death or CPC 3-4, PO). Results 288 patients were included, mean age 61.45 ± 13.76 and only 17.36% were female. GO at 6-month follow-up occurred in 48.95% of patients. Total medium time until ROSC was 28 min and first rhythm was shockable in 80%. An emergent coronary angiography was done in 68.9% and during any moment of the hospitalization in 83.5% (PCI 56.5%). There was no association between the presence and type of significant coronary artery disease and the main outcome. TTM was applied in 65.33% and the target temperature was 33ºC in 71.76%, 34ºC in 3.53%, 35ºC in 2.35% and 36ºC in 22.35%, with no statistically significant differences between the GO and PO groups. The neuronal specific enolase (NSE) was determined in 57 % of patients at 24 hours, 45% at 48h and 57% at 72 h. Myoclonus were statistically significant more frequent in patients with PO (51.20% vs. 7.52%, p&amp;lt;0.001). Almost one electroencephalogram was performed in 60.4% of patients, somato-sensorial evoked potentials in 53.01%, a cerebral computed tomography in 57.75% and a cerebral magnetic resonance imaging in 19.38%. As expected, an abnormal result of all those neurological tests, when performed, were related to poor outcome (Table 1). In-hospital mortality was 46%. Main cause of death was neurological in 72.90%. The percentage of CPC 1-2 increased throughout the follow-up period (Figure 1). Conclusions Although ILCOR guidelines clearly indicate the use of a multimodal approach for neuroprognostication, in real-life setting, the conventional tests for neurological evaluation are used in a differently in every center, depending on their expertise and facility of resources.Figure 1

Perioperative multivessel coronary artery spasm and cardiac arrest after cardiac surgery.

Postoperative coronary artery spasm, a rare but potentially fatal complication following cardiac surgery, warrants significant attention. This report discusses a 64-year-old male who suffered a severe coronary artery spasm leading to cardiac arrest following surgery. Initially stable, the patient rapidly developed critical ventricular arrhythmias and hypotension, resulting in cardiac arrest 4 h post-surgery. Emergency coronary angiography revealed extensive spasms, successfully managed with intracoronary nitroglycerine. This case stresses prompt recognition and management of coronary artery spasm after non-coronary cardiac procedures, underscoring coronary angiography's vital role in diagnosis and treatment.

Regulation of platelet activation and thrombus formation in acute non-ST segment elevation myocardial infarction: Role of Beclin1.

This study aims to investigate the mechanism of platelet activation-induced thrombosis in patients with acute non-ST segment elevation myocardial infarction (NSTEMI) by detecting the expression of autophagy-associated proteins in platelets of patients with NSTEMI. A prospective study was conducted on 121 patients with NSTEMI who underwent emergency coronary angiography and optical coherence tomography. The participants were divided into two groups: the ST segment un-offset group (n = 64) and the ST segment depression group (n = 57). We selected a control group of 60 patients without AMI during the same period. The levels of autophagy-associated proteins and the expression of autophagy-associated proteins in platelets were measured using immunofluorescence staining and Western blot. In NSTEMI, the prevalence of red thrombus was higher in the ST segment un-offset myocardial infarction (STUMI) group, whereas white thrombus was more common in the ST segment depression myocardial infarction (STDMI) group. Furthermore, the platelet aggregation rate was significantly higher in the white thrombus group compared with the red thrombus group. Compared with the control group, the autophagy-related protein expression decreased, and the expression of αIIbβ3 increased in NSTEMI. The overexpression of Beclin1 could activate platelet autophagy and inhibit the expression of αIIbβ3. The results suggested that the increase in platelet aggregation rate in patients with NSTEMI may be potentially related to the change in autophagy. And the overexpression of Beclin1 could reduce the platelet aggregation rate by activating platelet autophagy. Our findings demonstrated that Beclin1 could be a potential therapeutic target for inhibiting platelet aggregation in NSTEMI.

Abstract 2112: Silent Killer: The Rare And Potentially Lethal Right Coronary Artery Aneurysm

Giant coronary artery aneurysms, defined as diameters larger than 20 mm, are exceedingly rare and constitute a life-threatening occurrence. This case involves a patient with a giant right coronary artery (RCA) aneurysm and multivessel coronary artery disease, successfully managed by surgical intervention through quintuple coronary artery bypass grafting (CABG). A 65-year-old male with a history of hypertension presented with acute-onset chest pain. The initial workup revealed an inferolateral ST-segment elevation myocardial infarction (STEMI). The patient underwent emergency coronary angiography revealing a high-grade stenosis in the proximal and mid left anterior descending coronary artery, along with a remarkably tortuous and enlarged mid to distal RCA aneurysm measuring (21mm wide x 20mm long) and featuring significant post aneurysmal stenosis. Attempts at percutaneous angioplasty were unsuccessful due to extensive thrombosis in the RCA. The patient continued to experience active chest pain, necessitating the placement of an intra-aortic balloon pump in the right common femoral artery, the insertion of a temporary pacemaker wire to address bradycardia, and the initiation of pressor support for hypotension. Additionally, intravenous heparin and antiplatelet therapy were administered. Finally, the patient underwent a quintuple CABG to address the multivessel disease. Coronary artery aneurysm is an uncommon yet potentially perilous condition. The selection of appropriate management and intervention is crucial for averting fatal consequences associated with coronary artery aneurysms.

Rapid progression of a coronary artery aneurysm caused by IgG4-related disease

BackgroundIgG4-related disease (IgG4-RD) is a recently recognized fibro-inflammatory disorder that can affect almost any organ. IgG4-RD has also been reported in coronary arteries as periarteritis. IgG4-related coronary periarteritis may cause coronary artery aneurysms, and IgG4-related coronary artery aneurysms (IGCAs) are life-threatening. We describe a case of a patient with IGCA that highlights the usefulness and limitations of various IGCA evaluation modalities and provides insight into disease pathophysiology. Case summaryA 60-year-old man with IgG4-RD diagnosed 2 years before and with IGCA at the proximal right coronary artery (RCA) on coronary angiography (CAG) 9 months prior to admission to the hospital presented with acute coronary syndrome. Emergent CAG revealed the rapid progression of IGCA at the RCA, an obstruction of the diagonal branch, and stenosis of the left anterior descending artery (LAD) and the high lateral branch (HL). The patient underwent percutaneous coronary intervention for the diagonal branch. The RCA aneurysm was resected and bypassed with a saphenous vein graft (SVG); coronary bypass grafting (left internal mammary artery to LAD and SVG to HL) was performed. Pathological findings showed inflammatory cell infiltration and disruption of the elastic plate. ConclusionIGCAs require careful follow-up with computed tomography scans for early detection of aneurysmal enlargement.

Impact of time to revascularization on outcomes in patients after out-of-hospital cardiac arrest with STEMI

BackgroundInternational guidelines recommend emergency coronary angiography in patients after out-of-hospital cardiac arrest (OHCA) with ST-segment elevation on 12‑lead electrocardiography. However, the association between time to revascularization and outcomes remains unknown. This study aimed to evaluate the association between time to revascularization and outcomes in patients with OHCA due to ST-segment-elevation myocardial infarction (STEMI) who underwent percutaneous coronary intervention (PCI). MethodsThis multicenter, retrospective, nationwide observational study included patients aged ≥18 years with OHCA due to STEMI who underwent PCI between 2014 and 2020. The time of the first return of spontaneous circulation (ROSC) was defined as the time of first ROSC during resuscitation, regardless of the pre-hospital or in-hospital setting. The primary outcome was a 1-month favorable neurological outcome, defined as cerebral performance category 1 or 2. Multivariable logistic regression analysis was used to assess the association between the time to revascularization and favorable neurological outcomes. ResultsA total of 547 patients were included in this analysis. The multivariable logistic regression analysis showed that a shorter time from the first ROSC to revascularization was associated with 1-month favorable neurological outcomes (63/86 [73.3%] in the time from the first ROSC to revascularization ≤60 min group versus 98/193 [50.8%] in the >120 min group; adjusted OR, 0.26; 95% CI, 0.11–0.56; P for trend, 0.015). ConclusionsShorter time to revascularization was significantly associated with 1-month favorable neurological outcomes in patients with OHCA due to STEMI who underwent PCI.

Successful sutureless repair of multiple left ventricular free wall ruptures due to Takotsubo cardiomyopathy: a case report

BackgroundTakotsubo cardiomyopathy (TCM) is a temporary and reversible systolic abnormality of the left ventricular apical area resembling a myocardial infarction. Cardiac rupture due to TCM is a rare but fatal complication. Without cardiac surgery, 94% of patients with left ventricular free wall rupture (LVFWR) due to TCM die. Furthermore, successful surgical cases are rare. We report herein the successful treatment of multiple LVFWRs due to TCM using a sutureless repair.Case presentationAn 80-year-old man quarreled with his daughter and had a sudden onset of chest pain. He was transferred to our hospital in shock. Electrocardiography showed ST elevation and contrast-enhanced computed tomography revealed a bloody pericardial effusion. Emergent coronary angiography showed no significant stenosis. Cardiac arrest ensued because of cardiac tamponade. Emergent surgery was undertaken and three oozing lacerations on the lateral and inferior walls were noted. A sutureless repair was performed using TachoSil® patches. We also applied Surgicel Nu-Knit® absorbable hemostat with Hydrofit® where TachoSil® failed to completely adhere because of hematoma formation and achieved complete hemostasis. We diagnosed the ruptures due to TCM according to the Mayo criteria. The patient was discharged on postoperative day 71.ConclusionsA sutureless repair using TachoSil® patches and Surgicel® with Hydrofit® is a minimally invasive and effective method for the treatment of multiple LVFWRs due to TCM.

A Rare Case of Pyopneumopericardium Diagnosed by Coronary Angiography in a Patient Presented as STEMI

Abstract Pyopneumopericardium is a rare pathology with a poor prognosis. Accurate diagnosis may be difficult and, in very rare cases, can mimic ST-elevation myocardial infarction (STEMI). We present the case of a 44-year-old man, with clinical, ECG, and ultrasound criteria of inferior STEMI. Emergency coronary angiography excluded obstructive coronary artery disease. However, a hydroaeric level image in the pericardium drew our attention. The chest computed tomography scan and Gastrografin study confirmed the diagnosis of pyopneumopericardium. An exploratory thoracotomy was performed to drain the liquid from the pericardium, without highlighting a fistulous path. The etiology of the pyopneumopericardium was detected by performing an upper endoscopy, which revealed a complex lesion suggestive for a foreign body perforation, which was treated with a covered esophageal stent. The outcome of the patient was unfavorable despite the complex treatment, with cardiac arrest and death occurring on the 14th day of hospitalization.

Ventricular septal defect complicating anterior acute myocardial infarction : A Case of transcatheter closure

IntroductionPost-infarction ventricular septal defect (PIVSD) is one of the most serious mechanical complications of acute myocardial infarction (AMI). Over the last decade, percutaneous closure is increasingly undertaken, with results similar to cardiac surgery. We present a case of ST-elevated anterior AMI, complicated by apical PIVSD successfully treated with transcatheter closure. Case ReportAn 83-year-old man was hospitalized for chest pain occurred 18 hours before, during the night time. He was an active smoker. Clinical examination revealed normal heart sounds and pulmonary bibasilar crackles. ST-segment elevation with deep T waves inversion in anterior leads were detected on the electrocardiogram. A mildly-reduced ejection fraction (40%) was found by transthoracic echocardiogram. The patient underwent emergency coronary angiography, which revealed a subocclusive stenosis of the mid left anterior descending artery with a TIMI 2 flow, treated by balloon angioplasty and drug-eluting stent. Four days after revascularization, the patient developed an acute deterioration with signs of decompensated heart failure and a new holosystolic murmur with large irradiation. Inotropic agents’ administration was required to maintain a precarious hemodynamic condition. A bedside Echo revealed an apical VSD, measuring 15 × 10 mm, with left-to-right shunting, and pulmonary hypertension. The patient was scheduled for transcatheter PIVSD closure. The procedure was performed under fluoroscopic guide. Two vascular access sites were placed, femoral arterial and right internal jugular vein. Through the right internal jugular vein, a 24-mm Amplatzer atrial septal occluder on a 9 French Amplatzer TREVISIO™ intravascular delivery system was advanced via right ventricle into the PIVSD. Contrast fluoroscopy was used to assess apposition and the degree of shunt reduction before release. Echocardiographic evaluation performed 48 hours later confirmed a correct apposition of the device with insignificant residual shunt. At 6 months follow-up, he was asymptomatic, with unchanged prosthetic findings. ConclusionPercutaneous closure has been emerged as a valid cost-effective alternative to surgery and should be advised. However, debate remains on the optimal preprocedural optimization, timing of repair and modality of treatment.