Inferior ST Elevation Myocardial Infarction Research Articles

ST Segment Score on Initial Electrocardiogram (ECG) as a Predictor of In-Hospital Outcome of ST-Elevated Myocardial Infarction (STEMI) Patients

Introduction: The process of myocardial infarction progresses over several hours and therefore most patients present when it is still possible to salvage myocardium. ECG is usually a sensitive and specific way of confirming diagnosis. ST segment score (STSS) in myocardial infarction is emphasized but not often quantified. HJ Wellens gave cutoff for STSS in anterior wall MI (AWMI)of 12 mm and inferior wall MI (IWMI)of 7 mm. In this study the predictive value of ST Segment Score (STSS) with patients of STEMI on admission ECG & after thrombolysis had been assessed. Objectives: Identify patients at higher risk early in the course of their hospital admission & correlation of initial ECG and post thrombolysis ECG regarding clinical outcome. Materials and Methods:Considering inclusion and exclusion criteria 112 patients admitted in CCU, DMCH during october 2007 to september 2008 were studied of which 64 were inferior STEMI and 48 were anterior STEMI. Like admission ECG, after 90 minutes of starting thrombolytic,another ECG was recorded and calculated. Echocardiography was done for each patient before discharge. Data was collected in a pre-designed form. Results: The mean age of Group-I was 55.2±12.2 years and that of Group-II 56.9±14.1 years, Group-III 59.2±11.7 years,Group-IV 55.0±12.6 years. Of the 30 patients studied in Group-I 76.7% was male and 23.3% female. Smoking was the most prevalent (60% in Group I, 58.8% in Group II) risk factor. In post thrombolytic ECG shows that in Group-I mean sum of ST elevation decreased to 3.9 ± 1.1 mm from 4.8 ± 1.2 mm. which was approximately (45+14)% of ST resolution, in Group-II(50+19%),in Group-III (55+19)%, in Group-IV(45+23)%. Conclusion: Significant differences were seen in chest pain, killip class,arrhythmia, echocardiographic LVEF, duration of hospital stay in patients with AWMI & STSS above 12 mm and IWMI & STSS above 7 mm in comparison with below these level even after use of thrombolytics. Medicine Today 2022 Vol.34(2): 88-92

Should we stay or should we go: assessment of the need for the implantation of a definite pacemaker in a population of acute coronary syndrome that evolved in advanced atrioventricular block

Abstract Introduction The incidence of advanced atrioventricular block (AVB) secondary to acute coronary syndrome (ACS) has been decreasing in the era of percutaneous revascularization and in most cases is transitory and does not require pacemaker (PM) implantation. Purpose Our aim was to assess the characteristics of patients with AVB as a consequence of the ACS and compare those with and without PM implantation, in what regards in-hospital and at 1 year outcomes. Methods We performed a retrospective analysis of all patients admitted with AVB secondary to ACS in Portugal between October of 2010 and August of 2021 with data from the Real World Portuguese Registry on Acute Coronary Syndromes (ProACS). Medical records were analysed for demographic, procedural data and outcomes. Results Sex hundred and seventy one (671) patients with AVB secondary to ACS were admitted, which corresponded to 2.2% of the total cohort. The mean age was 70±13 with a male preponderance (66%). The ACS was categorized as ST elevation Myocardial Infarction (STEMI) in 76.4%, non-STEMI (NSTEMI) in 22.1%, and unstable angina (UA) in 1.5%. Of the patients admitted with AVB, 8.6% implanted a permanent PM. The was no clinically relevant differences in both groups in what regards to medical priors or medication. Regarding the location of the infarction, an Anterior STEMI was the diagnosis of admission in 36.8% (vs 14.5%; OR 3.45, CI 95% 1.31–9.06, p<0.05) of patients that implanted a PM, and the left descending artery was more frequently the culprit artery, and an Inferior STEMI was the diagnosis of 63.2% (vs 83.7%; OR 0.31, CI 95% 0.12–0.82, p<0.05) of patients and a right coronary artery was more frequently the culprit artery. The presence of cardiovascular shock and in-hospital death was significantly more frequent in the group that did not implant a PM (OR 0.40; CI 95% 0.17–0.95, p<0.05 and OR 0.33; CI 0.12–0.92, p<0.05 respectively) and the implantation of PM was a negative predictor of in-hospital death (OR 0.28; CI 95% 0.08–0.93, p<0.05). The follow up at 1 year was performed in two hundred and sixty three (263) patients, 10.6% with an implanted PM. The survival analysis demonstrated increased mortality and a combined end-point of death and readmissions in the population of AVB that did not implant PM compared with a population who did not present with AVB (p<0.05) with the Kaplan Meier curves widening significantly (Figure 1). This difference was not observed compared with an AVB population that implanted PM. Conclusions In patients with AVB secondary to ACS, the implantation of a PM might have been withheld in more severe patients, accounting for the increased mortality observed, and this population has worse outcomes at 1 year, leaving open to the hypothesis if either due to a more severe clinical status or the recurrence of AVB. Funding Acknowledgement Type of funding sources: None.

Performance metrics of AI-enhanced single lead EKG maintained after entry of organised clustered data

Abstract Background Our experience in creating innovative Artificial Intelligence-guided single lead EKG methodologies for ST-Elevation Myocardial Infarction (STEMI) detection within complex EKG records has been previously validated. Purpose By expanding the intricate variables of our previously tested algorithm input, we seek to further improve our STEMI detecting tool. Methods 11,567 12-lead EKG records (10-s length, 500 Hz sample frequency) derived from the Latin America Telemedicine Infarct Network database from April 2014 to December 2019. From these records, we included the following balanced classes: angiographically confirmed and unconfirmed STEMI (divided by wall affected), branch blocks, non-specific ST-T changes, normal, and abnormal (Remaining 200+ CPT codes). Cardiologist annotations ensured precision (Ground truth). Determined classes were “STEMI” and “Not-STEMI”. A 1-D Convolutional Neural Network model was trained and tested for each lead with dataset proportions of 90/10, respectively. The last dense layer outputs a probability for each record being STEMI/Not-STEMI. The analysis also included performance metrics and false-negative reports. Results Overall, the most promising Single lead for STEMI detection was V2 (91.2% Accuracy, 89.6% Sensitivity, and 92.9% Specificity). 55% of false negatives were inferior wall STEMI (Table 1). Conclusion Appreciable progress of our new methodology compared to our previous experiences in AI-guided Single Lead for STEMI detection, especially for lead V2. By performing a thorough analysis of false-negative reports, we aspire to identify potential areas of STEMI detection weakness which will become the focus of future ventures. Funding Acknowledgement Type of funding sources: None.

Acute Mediastinal Bleeding with Pleural Escape: Case Report of a Rare Interventional Complication with Unusual Resolve

AbstractAcute mediastinal bleeding is a very rare complication of cardiac intervention. It is a life-threatening situation when this condition causes acute compression of the mediastinal area. A 59-year-old man was diagnosed with inferior ST-elevation myocardial infarction with ongoing chest pain and underwent an urgent percutaneous coronary intervention procedure. After coronary stent was implanted, patient complained of chest tightness, and suffocation, blood pressure dropped, O2 saturation dropped, and was difficultly intubated. Image acquisition by C-arm showed a large bulging in aortic arch area. Contrast-enhanced computed tomography ruled out aortic dissection, but noted a large mediastinal mass that was radiated to the neck. The bulging was spontaneously regressed, and a large left pleural effusion was developed. Left pleural tapping was performed on day 7, and a total of 1.5-L hemorrhagic fluid was evacuated. In our case, unusual drainage from mediastinal to pleural space has probably save the patient.

Inferior STEMI as the challenge of predicting the right coronary artery vs. the left circumflex artery as culprit lesion using the ECG criteria: a case report

Background: The morbidity and mortality in Inferior ST-elevation myocardial infarction (STEMI) is also determined by the location of the occlusion. Early Identification of the occlusion site is necessary to assist in the appropriate management of Inferior STEMI. This case study aims to evaluate the Electrocardiogram (ECG) examination, which has a basic role in the diagnosis of STEMI, both in determining the location of myocardial infarction and predicting the location of the culprit lesion. Case Presentation: A 48-year-old male patient complained of dull chest pain, such as being pressured by a heavy object and radiating to the back, followed by nausea, vomiting and cold sweats, and shortness of breath for 2 hours before coming to the hospital. On arrival, the patient was fully conscious with a blood pressure of 110/70 mmHg, pulse rate of 129x/minute with a SpO2 of 95% with electrocardiography (ECG) results showing atrial fibrillation with inferoposterolateral STEMI. Shortly after the ECG examination, the patient became unconscious, with blood pressure dropping to 60/palpation and bradycardia at 48 beats/minute. The patient underwent a fibrinolytic revascularization strategy with Streptokinase 1,500,000 U for 30 minutes, but soon the patient became unconscious with the ECG monitor showing ventricular fibrillation (VF). Hence, cardiopulmonary resuscitation was immediately performed with 360 J defibrillation twice, and the ECG returned to sinus rhythm. After stabilizing, the patient was referred for Rescue Percutaneous Coronary Intervention (PCI). The results of Coronary Angiography showed that the culprit lesion, in this case, was the Left Circumflex Artery with the Right Coronary Artery normal small, and non-dominant. Conclusion: ECG is still an important supporting examination in diagnosing and managing Acute Coronary Syndrome (ACS). An ECG can also help determine the culprit lesion in STEMI before angiography. Inferoposterolateral STEMI can be caused by blockage of the Right Coronary Artery (RCA) or Left Circumflex Artery (LCx).

Cardiac metastasis secondary to tongue cancer: An unusual mimicker of ST elevation myocardial infarction

We present a case of a 46-year-old female who presented with acute onset of worsening chest pain for 8 hours. Electrocardiogram (ECG) showed ST elevation in leads II, III and avF with diffuse T wave inversions. On admission, troponin-I was 0.124 ng/mL. Based on the symptoms, ECG changes and elevated troponin, there was a concern for inferior wall ST elevation myocardial infarction (STEMI). The patient was emergently taken for cardiac catheterization. Angiography showed mild non-obstructive coronary artery disease. Transthoracic echocardiogram (TTE) revealed thickened and hypokinetic inferoseptal, inferior and inferolateral walls. It also showed round echodensity in the left ventricular (LV) cavity arising from the thickened infero-lateral wall measuring 1.8x1.5 cm2 suspicious for metastatic intramyocardial tumor. For further evaluation, she underwent cardiac magnetic resonance imaging (MRI). It revealed 3.9 x 2.3 x 3.4 cm mass with imaging findings suggestive of malignant tumor attached to and infiltrating LV inferior myocardium, epicardial fat and pericardium. Based on the angiographic findings, echo and cardiac MRI, her symptoms were attributed to intramyocardial mass causing infiltration or displacement of myocardium. Her chest pain was controlled with tramadol. Our report demonstrates a rare case of cardiac metastasis secondary to tongue cancer presenting as STEMI.

Comparison of In-Hospital Mortality between Acute Inferior Wall STEMI Patients with and without Right Ventricular Infarction Undergoing Primary PCI

Background: Patients with acute inferior wall ST elevation myocardial infarction (STEMI) with right ventricular infarction (RVI) involvement have a worse prognosis. However, most patients in the previous studies were treated with intravenous fibrinolysis and they were in the Caucasian populations. Objective: To compare the in-hospital mortality rate of patients with acute inferior wall STEMI with and without RVI treated with primary percutaneous coronary intervention (PPCI). Materials and Methods: The present study was a retrospective descriptive study that enrolled patients with acute inferior wall STEMI treated with PPCI in King Chulalongkorn Memorial Hospital between January 1, 2007, and December 31, 2016. Results: Among 452 acute inferior wall STEMI patients treated with PPCI, 99 patients had RVI. The in-hospital mortality rate was 23.2% compared with 5.1% in patients without RVI (p<0.001). Patients with RVI had a significantly higher incidence of cardiogenic shock at 48.5% versus 15.6% (p<0.001), lower left ventricle ejection fraction at 51.15±17.27% versus 55.79±12.46% (p=0.037), higher incidence of complete heart block at 33.3% versus 11.9% (p<0.001), and ventricular tachycardia at 15.2% versus 5.9% (p=0.003). After adjustment for age, female gender, cardiogenic shock on admission, left ventricular ejection fraction (LVEF), ventricular tachycardia, and complete heart block, the RVI had a tendency to be the poor predictor for in-hospital death (adjusted HR 1.96; 95% CI 0.73 to 5.23; p=0.18). Nevertheless, the RVI was the significant independent predictor for 1-year mortality (adjusted HR 2.12; 95% CI 1.03 to 4.36; p=0.041). Conclusion: Patients with acute inferior wall STEMI and RVI treated with PPCI had higher in-hospital mortality compared to no RVI. The RVI tended to have worse outcomes than those without RVI. Keywords: Acute inferior wall STEMI; Right ventricular infarction; Mortality

P76 A ‘PARACHUTE EFFECT’ MOCKINGLY SEALING A SPONTANEOUS CORONARY ARTERY DISSECTION

Abstract We present a case of a 38–year–old female admitted for Non ST–Elevation Myocardial Infarction. 15 days before the patient experienced an inferior ST–Elevation Myocardial Infarction and underwent primary Percutaneous Coronary Intervention with 2 drug–eluting stent (DES) in the mid–Right Coronary Artery (RCA). At presentation ECG and echocardiogram was negative for myocardial ischemia. For the typical chest pain, an urgent coronary angiography (CA) was performed. The previously stented RCA did not show any significant stenosis but a posterolateral branch appeared occluded at the ostium, with a retrograde flow from the left anterior descending artery. However, suspecting a dissection distally to the stents previously implanted, an Optical Coherence Tomography (OCT) was performed after 2 guidewires placement. The presence of two guidewires and the contrast medium pushing from inside–out caused a ‘sealing effect’ of the intima to the media, hence hiding the presence of dissection. The day after, a new chest pain episode associated with transient ST–segment elevation in the inferior leads warranted a new CA. Another OCT of the RCA was performed, this time using a single guidewire: a clear imaging confirmed the spontaneous coronary artery dissection (SCAD) presence. To have a better understanding of the vessel morphology an Intravascular Ultrasound (IVUS) analysis was carried out and even this imaging modality confirmed the presence of a true and false lumen. The interventional cardiologist decided to treat the dissection with two overlapping drug–eluting stents and a TIMI–3 flow was restored, with the complete resolution of the symptoms The patient was discharged after 5 days with dual antiplatelet therapy and statin. At the 24 month follow–up she was still asymptomatic. SCAD expertise is of utmost importance in recognizing this entity and, perhaps, this is the reason why it is still underdiagnosed, also in view of the frequent absence of hallmarks at CA. This is a case in which a complete imaging evaluation (CA + OCT + IVUS) has discovered and documented a SCAD after a recent stent implantation and in which the exclusive acquisition of angiograms by inexperienced operators could have missed the dissection.

Primary Percutaneous Coronary Intervention of ST-segment Elevated Myocardial Infarction- Experiences in a Tertiary Care Hospital

Background: Primary percutaneous coronary intervention (pPCI) is the preferred and established mode of treatment in ST elevated myocardial infarction (STEMI). Exact data on procedural outcome in patient undergoing primary PCI in our population is not well documented. We have carried out this study to see the prognosis, in-hospital, and 12-month survival outcome of our patients. Methods: Patients were enrolled in the observational non-randomized prospective cohort between November 2017-Mar 2020, who were presented into our emergency department with acute onset of severe chest pain or angina with ECG evidenced acute ST elevated myocardial infarction. Total 182 patient (Female 14; Male 168) were enrolled in this study. Results: Out of 182 patients, anterior MI were 47.8% (n=87) and inferior MI 50.5% (n=92) and lateral MI 1.6% (n=3). Presentation to ER from the onset of chest pain for female :123 min vs. male: 112 min and average door-to-balloon time were for female: 53 min vs. male: 50 min. Hospital admission of STEMI were more after 5 pm to next morning 9 am. Death were more in anterior STEMI than inferior STEMI. At presentation 10.4% (n=19) patents were in cardiogenic shock with STEMI, 42.1%(n=8) patients with anterior MI, 57.9% (n=11) in inferior MI group. Total, 15 (8.2%) patients died; 93.3% (n=14) within one week of primary PCI due to shock and poor LV function and subsequent development of LVF with arrhythmia and 6.7% (n=1) patient died 6 months after pPCI due to other cause. Conclusion: In this prospective observational cohort study, we found that PCI is a good and effective treatment modality in treating STEMI patient with better myocardial salvage and avoidance of life-threatening complications. Our procedural success rate is 91.8% and patients are doing well with regular follow up at our OPD 12-months after primary PCI. Cardiovasc j 2022; 14(2): 111-120

PThe Case of Removal of Intracoronary Broken Stent Catheter’s Shaft and Its Balloon Trough Femoral Sheat During Primer PTCA

In the time of invasive area, catheter based complications is getting more frequent and interventionist deals with this kind of complications’ management more than vascular surgeons. Regardless of complication’s nature commonly management of complications are successful and requirements of surgery are needless. But the patient stability deteriorates the time of complications especially result of intracoronary foreign bodies. Quick Removal of these foreign bodies from coronary circulation can stabilize patient condition. After that externalization of these kind remnants from patient body is the final step of successfully management of complications. . We herein present an acute inferior ST elevation myocardial infarction (MI) with hemodynamic disturbance because of total obstruction of RCA with broken stent balloon shaft. After successfully catch and removal of broken part of stent catheter, patient’s situation was going well and discharged with medical therapy shortly after intervention

Anomalous Connection of the Coronary Artery Causing ST Segment Elevation Myocardial Infarction: A Case Report

Background: With an angiographic prevalence approaching 1%, Anomalous connections of the Coronary arteries (ANOCOR) are rare. The term connection is preferred over origin since the coronary arteries do not grow out of the aorta but grow into the aorta from the peri truncal ring of coronary arterial vasculature. Very often these anatomical shapes are incidental findings without clinical impact; however, in some specific cases, clinical symptoms may occur arriving to sudden cardiac death (SCD), this is particularly true when there is a an interarterial course between the ascending aorta and the pulmonary.
 Case Presentation: This case is about patient that we receive in emergency department presenting with an inferior ST segment elevation myocardial infarction (STEMI) which was found to be caused by compression of the proximal right coronary artery (RCA) between the aorta and the pulmonary trunk. Surgery was indicated by the heart team for the treatment of this condition.
 Conclusions: This case presents a severe manifestation of proximal anomalous connection of the right coronary artery with a “malignant” course between the aorta and the pulmonary artery. This variant has been called malignant because of its association with sudden death especially in young asymptomatic athletes. In current guidelines for symptomatic ANOCOR with interarterial course the treatment recommended is surgery.

Novel oral anticoagulant in treatment of left ventricular thrombus in acute coronary syndrome – A case series

Introduction: Left ventricular (LV) thrombus is a known complication of myocardial infarction (MI) and it usually occurs in areas of poorly contracting LV muscle as a result of endocardial injury with associated inflammation. There is a high risk of embolization within 3 months among patients with MI complicated by mural thrombus and this risk is maximum during the first 1–2 weeks. We report a case series of five patients who presented with acute coronary syndrome with LV apical thrombus and treated with triple anti-thrombotic therapy of rivaroxaban, aspirin, and clopidogrel. Case Series: Our series involves 5 cases who developed LV apical thrombus after acute coronary syndrome. Four patients had anterior wall ST-elevation MI (STEMI) whereas 1 patient had inferior wall STEMI. One of the patients with anterior STEMI also had COVID pneumonitis. All of these patients received triple anti-thrombotic therapy consisting of tab Aspirin 75 mg OD, tab clopidogrel 75 mg OD, and tab rivaroxaban 20 mg OD for 3 months duration. Repeat ECHO after 3 months showed complete resolution of LV thrombus in all of our cases. Discussion: LV thrombus reported in STEMI patients is from 1.6% up to 39% in various studies. The incidence of LV thrombus is on decreasing trend as a result of modern revascularization strategies. The role of novel oral anticoagulants (NOACs) in treating LV thrombus is scant as compared to oral Vitamin K antagonists (VKAs) like warfarin. The current recommendation for anticoagulation in the presence of a LV thrombus after acute coronary syndrome is with VKAs for up to 6 months. Conclusion: Although there is uncertainty in decision-making regarding antithrombotic therapy, our case series demonstrate that triple antithrombotic therapy with NOACs results in resolution of LV thrombus without any additional bleeding events in patients presenting with acute coronary syndrome. NOACs have an advantage of not requiring PT/INR monitoring and have less bleeding complications. Further large-scale research or randomized controlled trials are needed to find the optimal therapies in such cases.

Activation of PPCI team in the octogenarian and nonagenarians population: real-world single-centre experience

ObjectiveAdvancement in healthcare provision has led to increasing octogenarian ST elevation myocardial infarction (STEMI) presentation to hospital for early revascularisation therapies. Limited literature to date exists to suggest octogenarian STEMI...

Angiographic Significance of ST Depression in Anterior Leads in Acute Inferior ST Elevation Myocardial Infarction.

Background and aims: Electrocardiogram of acute ST elevation inferior myocardial infarction can show concomitant ST depression in anterior leads. We aimed to see its significance on coronary angiogram. Methods: Cross sectional study conducted in Department of Cardiology of Shahid Gangalal National Heart Centre from March 2021 to June 2021. Total of 64 patients of acute inferior myocardial infarction were included consecutively. Electrocardiogram were analyzed for the presence of ST depression in anterior leads (V1-V6). Coronary angiogram were obtained. Linear regression analysis was applied to see correlations. Results: Thirty-four (53.12%) participants had significant ST depression in anterior leads. Their mean age was 64.53±11.67 years. Twenty-two (64.70%) were male. Out of them, 13 (38.23%) were hypertensive, 9 (26.47%) were smoker and 7 (20.58%) were diabetic. Among 30 (46.88%) participants without ST depression, mean age was 56.73±13.31 years and 21 (70%) were male. Out of them, 11 (36.66%) were hypertensive, 12 (40%) were smoker and 11 (33.66%) were diabetic. Culprit vessel was right coronary artery in 22 (64.70%) of those with ST depression and 22 (73.33%) of those without ST depression. Significant left anterior descending artery lesion was seen in 19 (55.88%) of those with ST depression and 3 (10%) of those without depression. Anterior ST depression showed positive correlation with left anterior descending artery lesion. Conclusion: ST depression in anterior leads in acute inferior myocardial infarction can be due to presence of concomitant left anterior descending coronary artery disease.

C92. Successful Percutaneous Coronary Intervention (PCI) in Rare Case of Anomalous Aortic Origin of the Right Coronary Artery from the Opposite Sinus (AAORCA) Presenting as Inferior ST Elevation Myocardial Infarction (STEMI)

Abstract Background AAORCA from opposite sinus is a rare congenital anomaly that can present with symptoms similar to coronary artery disease, even sudden cardiac death. AAORCA with Inferior STEMI is a rare combination situation. Management of acute myocardial infarction with AAORCA is not well established and still debatable. Case Summary We presented a case 61 years old aged male with STEMI and AAORCA. He admitted to our hospital with complaint of retrosternal chest pain with ST segment elevation in inferior lead thus we diagnosed as Inferior STEMI. He underwent an emergency coronary angiography (CAG) that showed anomalous of right coronary artery (RCA) and total occlusion of the proximal RCA with atherosclerotic lesion. Stent then implanted at proximal of RCA. Further work-up by Computed Tomography Angiography (CTA) revealed an AAORCA with interarterial course. Discussion AAORCA with interarterial course that presents as inferior STEMI is a rare case. Diagnosis requires CAG and coronary CTA to identify anatomy and physiology so revascularization can be carried out appropriately. It is still arguable whether atherosclerosis or the interarterial course of AAORCA that caused acute MI. There is evidence that anomalous coronary arteries doesn’t increase atherosclerosis risk than normal. Total occlusion located at the distal to interarterial course reinforce that atherosclerosis may be the possible cause of acute MI. PCI could be the preferred choice in patients with inferior STEMI accompanied by AAORCA with evidence of atherosclerotic lesion, because may result in complete reperfusion and good clinical outcome.

C92. Successful Percutaneous Coronary Intervention (PCI) in Rare Case of Anomalous Aortic Origin of the Right Coronary Artery from the Opposite Sinus (AAORCA) Presenting as Inferior ST Elevation Myocardial Infarction (STEMI)

Abstract Background AAORCA from opposite sinus is a rare congenital anomaly that can present with symptoms similar to coronary artery disease, even sudden cardiac death. AAORCA with Inferior STEMI is a rare combination situation. Management of acute myocardial infarction with AAORCA is not well established and still debatable. Case Summary We presented a case 61 years old aged male with STEMI and AAORCA. He admitted to our hospital with complaint of retrosternal chest pain with ST segment elevation in inferior lead thus we diagnosed as Inferior STEMI. He underwent an emergency coronary angiography (CAG) that showed anomalous of right coronary artery (RCA) and total occlusion of the proximal RCA with atherosclerotic lesion. Stent then implanted at proximal of RCA. Further work-up by Computed Tomography Angiography (CTA) revealed an AAORCA with interarterial course. Discussion AAORCA with interarterial course that presents as inferior STEMI is a rare case. Diagnosis requires CAG and coronary CTA to identify anatomy and physiology so revascularization can be carried out appropriately. It is still arguable whether atherosclerosis or the interarterial course of AAORCA that caused acute MI. There is evidence that anomalous coronary arteries doesn’t increase atherosclerosis risk than normal. Total occlusion located at the distal to interarterial course reinforce that atherosclerosis may be the possible cause of acute MI. PCI could be the preferred choice in patients with inferior STEMI accompanied by AAORCA with evidence of atherosclerotic lesion, because may result in complete reperfusion and good clinical outcome.

Evolution of single-lead ECG for STEMI detection using a deep learning approach

BackgroundWhile ST-Elevation Myocardial Infarction (STEMI) door-to-balloon times are often below 90 min, symptom to door times remain long at 2.5-h, due at least in part to a delay in diagnosis. ObjectivesTo develop and validate a machine learning-guided algorithm which uses a single‑lead electrocardiogram (ECG) for STEMI detection to speed diagnosis. MethodsData was extracted from the Latin America Telemedicine Infarct Network (LATIN), a population-based Acute Myocardial Infarction (AMI) program that provides care to patients in Brazil, Colombia, Mexico, and Argentina through telemedicine. Sample: the first dataset was comprised of 8511 ECGs that were used for various machine learning experiments to test our Deep Learning approach for STEMI diagnosis. The second dataset of 2542 confirmed STEMI diagnosis EKG records, including specific ischemic heart wall information (anterior, inferior, and lateral), was derived from the previous dataset to test the STEMI localization model. Preprocessing: Detection of QRS complexes by wavelet system, segmentation of each EKG record into individual heartbeats with fixed window of 0.4 s to the left and 0.9 s to the right of main. Training & Testing: 90% and 10% of the total dataset, respectively, were used for both models. Classification: two 1-D convolutional neural networks were implemented, two classes were considered for first models (STEMI/Not-STEMI) and three classes for the second model (Anterior/Inferior/Lateral) each corresponding to the heart wall affected. These individual probabilities were aggregated to generate the final label for each model. ResultsThe single‑lead ECG strategy was able to provide an accuracy of 90.5% for STEMI detection with Lead V2, which also yielded the best results overall among individual leads. STEMI Localization model provided promising results for anterior and inferior wall STEMIs but remained suboptimal for Lateral STEMI. ConclusionsAn Artificial Intelligence-enhanced single‑lead ECG is a promising screening tool. This technology provides an autonomous and accurate STEMI diagnostic alternative that can be incorporated into wearable devices, potentially providing patients reliable means to seek treatment early and offers the potential to thereby improve STEMI outcomes in the long run.

Rescue transventricular off-pump mitral valve repair with artificial neochords for acute mitral regurgitation due to postinfarction papillary muscle rupture.

BackgroundWe report 3 cases of rescue transventricular off-pump mitral valve (MV) repair in high-risk patients with acute mitral regurgitation (MR) due to post–myocardial infarction (MI) papillary muscle rupture (PMR).MethodsThe 3 patients presented with acute inferior ST elevation myocardial infarction, cardiogenic shock, and pulmonary edema. Their preoperative peak troponin I levels were 1909 ng/L, 16,963 ng/L, and 8299 ng/L. All 3 patients underwent successful percutaneous intervention to the culprit coronary artery, and antiplatelet therapy was initiated. All patients required inotropic support and had an intra-aortic balloon pump inserted preoperatively. Transesophageal echocardiography (TEE) demonstrated severe eccentric MR due to the leaflet prolapse secondary to PMR. The patients’ estimated EuroSCORE II scores were 16.03%, 16.68%, and 7.81%, and their Society of Thoracic Surgeons scores were 14.77%, 18.24%, and 9.8%, respectively. All 3 patients underwent urgent transventricular off-pump MV repair using artificial chords, with 2 or 3 three neochords implanted. The duration of operation was <2 hours, and intraoperative and postoperative drainage was minimal in all cases. MV function was assessed by qualitative and semiquantitative TEE.ResultsIntraoperative MR reduction to a mild level was achieved in all 3 patients. All patients had moderate MR at discharge, likely due to left ventricular remodeling. Severe MR recurred in all patients, at 5, 4, and 2 months of follow-up, respectively. All 3 patients underwent an elective MV reoperation via conventional approach.ConclusionsOff-pump transventricular MV repair may offer a safe and feasible alternative to stabilize high-risk patients with acute MR due to post-MI PMR. Although early MR recurrence is concerning, urgent transventricular MV repair may serve as a bridge to conventional surgery in such unstable patients.

Assessment of right ventricular function in patients presenting with inferior ST segment elevation myocardial infarction and right ventricular infarction undergoing primary percutaneous intervention by different echocardiographic modalities in correlation with angiographic findings

Abstract Background Patients with inferior wall myocardial infarction who have right ventricular (RV) involvement appear to have a worse prognosis than those without RV involvement; infarcted RV tissue fails to offer a sufficient preload which is essential for adequate LV performance. Thus, assessment of RV function is an important step in dealing with patients presenting with inferior wall myocardial infarction that will help in adopting a proper management plan. Objective To assess the correlation between RV function and angiographic findings in patients presenting with inferior wall myocardial infarction associated with RV infarction undergoing primary percutaneous coronary intervention. Patients and Methods Study included 60 patients who presented to Ain shams university hospitals by inferior wall ST segment elevation myocardial infarction associated with RV infarction during the period from February 2019 to August 2019.All patients were subjected to history taking, clinical examination, ECG recording then primary percutaneous coronary intervention. Echocardiographic assessment was done to all patients within 48 hours of admission. Results Study included 60 patients, 43 males (71.7%) and 17 females (28.3%), with mean age of 56.73 ± 9.94 years. Commonest Infarction related Artery (IRA) associated with impaired RV function was proximal RCA (p-value: 0.003). In 23 patients (38.3%) heavy thrombus burden was found while in the other 37 patients (61.7%) there was no evidence of heavy thrombus burden. Regarding post procedural TIMI flow grade: 1 patient (1.7%) had final TIMI I flow, 9 patients (15.0%) had final TIMI II flow and 50 patients (83.3%) had final TIMI III flow. There was statistically significant relationship between RV function assessed through measuring RV free wall strain and both of thrombus burden and final TIMI flow grade. Abnormal RV function was more commonly associated with heavy thrombus burden (p-value:0.023) and less than TIMI III flow after angioplasty (p-value:0.011).RV free wall systolic strain assessment had highest accuracy (75%) in detection of proximal RCA occlusion compared to other parameters including TAPSE, S’ and FAC. Conclusion Impaired RV function in patients presenting with RV infarction can be predicted by different angiographic findings. Proximal RCA total occlusion being commonest IRA associated with impaired RV function. Also, presence of heavy thrombus burden and less than TIMI III flow after angioplasty are associated with increased risk of impaired RV function. RV free wall strain measured by 2D-speckle tracking echocardiography has highest accuracy in detection of proximal RCA occlusion compared to other echocardiographic indices including TAPSE, S’ and FAC.

The effect of the localisation of an underlying ST-elevation myocardial infarction on the VF-waveform: A multi-centre cardiac arrest study

IntroductionIn cardiac arrest, ventricular fibrillation (VF) waveform characteristics such as amplitude spectrum area (AMSA) are studied to identify an underlying myocardial infarction (MI). Observational studies report lower AMSA-values in patients with than without underlying MI. Moreover, experimental studies with 12-lead ECG-recordings show lowest VF-characteristics when the MI-localisation matches the ECG-recording direction. However, out-of-hospital cardiac arrest (OHCA)-studies with defibrillator-derived VF-recordings are lacking. MethodsMulti-centre (Amsterdam/Nijmegen, the Netherlands) cohort-study on the association between AMSA, ST-elevation MI (STEMI) and its localisation. AMSA was calculated from defibrillator pad-ECG recordings (proxy for lead II, inferior vantage point); STEMI-localisation was determined using ECG/angiography/autopsy findings. ResultsWe studied AMSA-values in 754 OHCA-patients. There were statistically significant differences between no STEMI, anterior STEMI and inferior STEMI (Nijmegen: no STEMI 13.0mVHz [7.9–18.6], anterior STEMI 7.5mVHz [5.6–13.8], inferior STEMI 7.5mVHz [5.4–11.8], p = 0.006. Amsterdam: 11.7mVHz [5.0–21.9], 9.6mVHz [4.6–17.2], and 6.9mVHz [3.2–16.0], respectively, p = 0.001). Univariate analyses showed significantly lower AMSA-values in inferior STEMI vs. no STEMI; there was no significant difference between anterior and no STEMI. After correction for confounders, adjusted absolute AMSA-values were numerically lowest for inferior STEMI in both cohorts, and the relative differences in AMSA between inferior and no STEMI was 1.4–1.7 times larger than between anterior and no STEMI. ConclusionThis multi-centre VF-waveform OHCA-study showed significantly lower AMSA in case of underlying STEMI, with a more pronounced difference for inferior than for anterior STEMI. Confirmative studies on the impact of STEMI-localisation on the VF-waveform are warranted, and might contribute to earlier diagnosis of STEMI during VF.