Inferior ST Elevation Research Articles

C29 SEEING BEYOND APPEARANCES: INTRACORONARY IMAGING TECHNIQUES IN SPONTANEOUS CORONARY ARTERY DISSECTION (SCAD)

Abstract Over recent years, mainly due to a broad use of coronary angiography and intracoronary imaging techniques (IIT), SCAD has emerged as a no longer rare cause of acute coronary syndrome (ACS). Early diagnosis is extremely important to avoid potentially lethal complications; nevertheless, considerable uncertainty remains about optimal acute and post–discharge management. Current endorsed therapeutic strategy lean towards an initial conservative approach, relegating percutaneous or surgical coronary intervention to high–risk coronary anatomy or in case of hemodynamic instability. We report our experience in the field by presenting a clinical case of a 36–year–old woman admitted to emergency department with acute, anginal pain started 24 hours earlier, referring no medical history, except for a syncopal episode occurred four days earlier, in correspondence of a mournful event. She was hemodynamically stable, with work–up significant only for elevated troponin level of 3649.5 ng/ml (n.v. <11). Coronary angiogram showed atherosclerotic–like changes limited to right coronary artery (RCA), with focal subcritical stenosis at its proximal segment (Fig 1). In the absence of major precipitating factors for atherosclerotic coronary disease, SCAD was suspected. IVUS and OCT were performed, with evidence of dissection and intra–mural haematoma (Fig. 2), extending from proximal RCA to posterior descending branch take–off, compressing the true lumen. Considering both anatomical (coronary ostium not involved) and clinical (patient asymptomatic and hemodynamically stable) factors, conservative treatment with low dose aspirin and beta blocker was prescribed. After three days of hospitalization occurred a single episode, lasted 5 minutes, of anginal pain associated with ST elevation in inferior leads, managed with nitrates administration; subsequent cardiac computed tomography angiography excluded disease progression (Fig.2). On the 23rd day, due to angiographic evidence of SCAD partial healing (Fig.3), the patient was discharged. This case highlights the importance of keeping in mind the possibility of SCAD, especially when healthy young women with prior emotional stress present with ACS. IIT allow to shed light on the true mechanism of ACS without significant obstructive coronary disease. Finally, in case of conservative approach, close in–hospital monitoring is mandatory, given the highest probability of complications in the first days after clinical onset.

C83 USE OF CANGRELOR IN A 63 YEARS OLD MEN SUFFERING FROM ACUTE INFERIOR ST–ELEVATION MYOCARDIAL INFARCTION AND SEVERE IDIOPATHIC THROMBOCYTOPENIC PURPURA: A CASE REPORT

Abstract A 63–year–old man suffering from systemic arterial hypertension, thalassemic trait, recent right ureteral stent implantation, dysthyroidism and thrombocytopenia presented to the Emergency Department with acute chest pain and ST elevation in inferior leads and 2nd degree atrioventricular block. He suffered from idiopathic thrombocytopenic purpura since February 2020, with baseline platelet level (PLT) <10,000/mm³ requiring treatment with deltacortene 5 mg, tranexamic acid 1000 mg x 3/day and fostamatimib 100 mg x 2/day. Upon arrival in the Cardiology Intensive Care Unit (UTIC) an echocardiogram was performed and confirmed inferior myocardial infarction. First laboratory results were significant for PLT of 9,000/mm³ and Troponin I peaked at 31,838 pg/mL. The patient received Acetylsalicylic acid (ASA) 300 mg iv then was urgently transported to the Cath–Lab. Coronary angiography revealed mid right coronary artery occlusion, subsequently underwent primary percutaneous coronary intervention with multiple pre–dilations and placement of dual 3.5x28mm and 4.0x28mm TiNO bioactive metal stent with excellent angiographic results. A temporary Pacemaker was implanted. It was started Cangrelor bolus 30 µ/kg followed by infusion at 4 µ/kg/min for 6 hours associated with unfractionated sodium heparin at a reduced dosage of 50 IU/kg during the procedure and with a subsequent switch to Clopidogrel after an oral bolus of 300 mg. After 24 hours, the patient removed the temporary PMK for resolution of the AV block. The haematologist consultant advised to increase fosfatimib to 150 mg x 2/day and recommended the use of Human Immunoglobulin iv from the second day of hospitalization for 2 days. The patient was discharged on the seventh day, asymptomatic, with dual antiplatelet therapy (DAPT) with ASA 100 mg and Clopidogrel 75 mg daily and did not experience any bleeding during hospitalization. At a one–month follow–up, the patient is symptomatic and continued to tolerate ASA and Clopidogrel with stable PLT of 11,000/mm³. In treating for STEMI, the treatment regimen consists of DAPT that increases risks for bleeding. In patients with thrombocytopenia, the risk for bleeding is multiplied and there are no clinical trials where patients with low platelet count are included, all therapeutic decisions must be made based on clinician’s experience and experts’ consensus. The use of Cangrelor proved to be safe and effective during STEMI even in patient with severe thrombocytopenia.

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.

Abstract #1165887: Metastatic Anterior Mediastinal Paraganglioma Treated with Lu-177-DOTATATE

Peptide receptor radionuclide therapy (PRRT) may be an option for the treatment of patients with surgically inoperable paragangliomas. We present a case of metastatic anterior mediastinal paraganglioma treated with Lu-177-DOTATATE. A 55 year old male with unexplained tachycardia was evaluated in the emergency department for severe hypotension, chest tightness and dizziness. An ECG showed inferior lead ST elevations prompting emergent cardiac catheterization. Coronary angiography revealed complete obstruction of the mid-right coronary artery and a hypervascular extracardiac mass perfused from the right and left coronaries. Subsequent aortic CT and cardiac MRI demonstrated a 7.3 cm hypervascular epicardial mass and an indeterminate hepatic lesion. Further evaluation with Gallium-68 DOTATATE PET-CT revealed an intensely avid anterior mediastinal mass and slightly avid liver lesion. A 24 hour urine study revealed normal metanephrines and epinephrine but elevated norepinephrine 159mcg/24hr [15-80] and an unmeasurably high dopamine. He was started on alpha and beta-adrenergic blockade, which improved his palpitations and tachycardia. Liver biopsy confirmed the diagnosis of metastatic paraganglioma. Cardiothoracic surgery recommended neoadjuvant chemotherapy followed by debulking surgery. Following 3 cycles of CyADIC (cyclophosphamide, doxorubicin, dacarbazine), PET-CT imaging demonstrated increasing size of liver metastases and tumor burden not amenable to surgery. Furthermore, he experienced chemotherapy side effects including thrush, grade 2 fatigue, grade 2 mucositis and dose delay from grade 3 neutropenia. A multi-disciplinary tumor board discussed palliative treatment options to include PRRT with Lu-177-DOTATATE. His first administration of Lu-177-DOTATATE was 100 mCi and performed in the medical ICU due to concern of precipitating a catecholamine crisis. The patient tolerated the infusion without complications. After the first dose of Lu-177-DOTATATE, his neuroendocrine neoplasms test (NETest) score decreased from 53 to 27, reflecting disease stabilization. The patient later received a second dose of 100 mCi Lu-177-DOTATATE followed by two doses of 200 mCi approximately 8 weeks apart. Serial post-treatment scans did not demonstrate new sites of metastatic disease while undergoing PRRT. Two months following his final dose of Lu-177-DOTATATE, the patient expired from liver failure related to his extensive hepatic metastases. Our patient with inoperable metastatic anterior mediastinal paraganglioma achieved disease stabilization with Lu-177-DOTATATE with minimal toxicity. Lu-177-DOTATATE should be considered as a palliative treatment option for inoperable metastatic paraganglioma.

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

Prediction of an Infarct Related Artery on Electrocardiogram and its Correlation with Coronary Angiography in an Acute Myocardial Infarction

Aim: To Predict an infarct related artery on Electrocardiogram and its correlation with Coronary angiography in an Acute myocardial Infarction. Materials and Methods: The study was carried out as a prospective observational study of 70 patients at medical college & tertiary health care Centre, over a period of two years that included cases of patients diagnosed to have acute myocardial infarction on ECG for the first time & have also undergone coronary angiography. Results: Study showed most common age group amongst study population was 51 to 60 yrs (42.9%) followed by 61 to 70 yrs (37.1%). LAD (71%) was the most common coronary artery amongst study population followed by RCA (25%) and LCX (4%). Most of the study population had ECG findings like ST depression III + aVF ≥ 2.5 (36%) and ST segment in III and aVF isoelectric or elevated (36%) followed by ST depression in III + aVF ≤ 2.5 and ≥ 0.5 (28%) in LAD occlusion. In the present study, most of the study population had ECG findings like ST↑LIII > ST↑ LII > 1 (94.12%), ST↓LI, aVL (82.35%) and ST↑V4R > 1 mm (70.59%) in RCA occlusion. In the present study, most of the study population had ECG findings like ST ↑ LII > LIII (100%) and Isoelectric or ST ↑ I,aVL (66.7%) in LCX occlusion. Conclusion: ECG criteria have excellent sensitivity and specificity in predicting the culprit artery Anterior ST elevation identified all patients with LAD as the culprit artery with 100 % accuracy in our study population. In patients with inferior ST elevation, relative ratio of ST elevation in lead II and lead III, correctly identified the culprit artery as RCA or LCx with 100 % accuracy. (ST elevation in lead II > III predicts LCx occlusion and the reverse predicts RCA occlusion.

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.

Angiographic Correlates of Acute ST Elevation Inferior Wall Myocardial Infarction with or Without Right Ventricular Involvement

Objectives: Right ventricular infarction (RVI) poses as an added risk factor in patients presenting with acute ST elevation inferior wall myocardial infarction (IWMI) with considerable high mortality. An early interventional therapeutic strategy after a prompt and accurate non-invasive investigative correlate is needed. Material and methods: We sampled 104 patients diagnosed with inferior wall infarction presenting with angina within 12 hours of angina. Investigations included routine blood investigation, 12 lead and right precordial lead electrocardiography, right ventricular (RV) systolic echocardiographic indices, and coronary angiography. Results: Majority of the patients had angiographic evidence of a dominant distal right coronary artery (RCA) culprit lesion. Those patients having ST elevation in RV4 lead had significantly higher incidences of RVI and high-grade atrio-ventricular (AV) blocks. Elderly diabetic patients with azotemia and deranged liver function predicted RVI among the study population. RV systolic indices like TAPSE was most accurate and S’ was found to be most specific in detecting RVI. Chi square test and multivariate regression analysis of echocardiographic parameters like RVDD, RVMPI, and S’ proved excellent surrogate non-invasive surrogate markers for specific angiographic culprit lesions. Conclusion: RV systolic echocardiographic indices shows a diagnostic accuracy of variable degrees in detecting right ventricular involvement in IWMI patients and also act as a surrogate marker in predicting the culprit lesion.

Acute Coronary Syndrome Revealing Coronary Artery Ectasia: Case Report

Coronary artery ectasia (CAE) is a dilation of the coronary artery lumen. The term "ectasia" differs from "coronary aneurysm". The first one refers to diffuse dilation of a coronary artery, while the second designate a focal coronary dilation. In most of cases, it is associated with atherosclerotic disease. CAE predispose to acute coronary events because it disturbs coronary flow and increases blood viscosity. Conventionally, CAE was treated by oral anticoagulants and it has been considered as a valid treatment option. The usual treatment of acute coronary syndrome (ACS) including dual antiplatelet therapy (DAPT) is widely employed in CAE patients presenting with ACS.We report the case of a 71year-old man who suffered from angina chest pain revealing a myocardial infraction with inferior ST-elevation. Coronary angiography demonstrated diffused coronary artery ectasia with thrombotic occlusion in the distal segment of right coronary artery. It was managed with medical treatment including DAPT and oral anticoagulation.

T2 mapping should be utilized in cases of suspected myocarditis to confirm an acute inflammatory process.

Dear Editor, I read with interest the case series by Kiozumi et al.,1 which describes two cases of vaccine-induced myocarditis. The second case describes a 27-year-old male who presents 3 days after receiving a second dose of the mRNA-1273 coronavirus disease 2019 (Moderna) vaccine with chest pain, inferior ST-elevation on a resting 12-lead electrocardiogram and an elevated serum troponin-T. An invasive coronary angiogram revealed no coronary artery lesions and an endomyocardial biopsy was unremarkable. Cardiac magnetic resonance (CMR) imaging demonstrated inferolateral epicardial late gadolinium enhancement, along with elevated native T1 and extracellular volume measurements and in the inferolateral wall. Although the symptomatology, electrocardiogram changes and elevated cardiac enzymes are all consistent with active myocarditis; the CMR imaging findings described are not confirmatory of an acute inflammatory process. The elevated native T1, extracellular volume measurements and late gadolinium enhancement could be consistent with a previous myocardial insult and represent a chronic fibrotic process/myocardial scar. This hypothesis is supported by the unremarkable myocardial biopsy, which failed to demonstrate any active inflammation.

533 Uncommon ECG presentation in Tako-tsubo syndrome

Abstract Aims We present the case of an 80-year-old woman without prior cardiovascular history, recent instrumental diagnosis of peritoneal carcinomatosis and ongoing oncologic diagnostic work up. Methods and results The patient was admitted to our ED for acute-onset worsening dyspnoea. On first clinical evaluation, she denied typical angina, remarkable clinical features were dyspnoea, tachycardia and hypotension. Admission ECG showed sinus rhythm with posterior and inferior ST elevation (leads DII, aVF, V5, V6) with reciprocal ST segment depression in leads V1–V2. Echocardiography confirmed infero-postero-lateral akinesia determining moderate reduction of LVEF (35–40%), normal aortic root, no pericardial effusion. Laboratory tests revealed normal WBC count, mild anaemia (HB 10.7 g/dl), normal renal function, elevated C-reactive protein (139 mg/l, n.v. < 8). Cardiac troponin I (cTnI) was normal on admission, with significant delta on second determination (0.012 > 2.5 ng/ml, nv < 0.023). ST elevation persisted after BP normalization and hypoxia treatment; so, taken into account the increased procedural risk due to patient’s age and comorbidities, however we decided to perform urgent coronary angiography. Surprisingly, coronary angiography revealed absence of any significant stenosis, with TIMI 3 flow in any coronary segment. The patient was then admitted to the ICU with diagnosis of MINOCA. The next day ECG revealed normalization of ST segment and Q wave in V2–V3. On day 2 new ECG showed new ventricular repolarization abnormalities with T wave inversion in precordial leads. Peak hs-cTnI was >15 000 ng/l. Repeat echocardiography on day 2 reported complete akinesia of all the apical segments of the LV with normo-hyperkinesia of the mid-basal segments (apical ballooning pattern) and severely depressed systolic function (FE 32–35%). During the following days patient’s symptoms improved, with rapid weaning from oxygen therapy and stable haemodynamic parameters. After 10 days the patient repeated echocardiography, which revealed improvement of global LVEF and persisting mild apical hypokinesia, suggesting the diagnostic hypothesis of Tako-Tsubo Syndrome (TTS) or TTS-phenocopy (unfortunately cardiac MRI was not performed). The patient was therefore transferred to oncology department to complete the diagnostic work-up; primary mammary neoplasia was identified, moreover associated with metastasis in the liver and the brain. Unfortunately, the patient died a month later due to non-cardiac causes. This is the case report of an uncommon MINOCA, which presented mimicking inferolateral acute STEMI, but subsequent ECG and echocardiographic evolution showed the more typical TTS pattern, with apical ballooning on echo and deep negative T waves in anterior leads. Conclusions The prevalence of MINOCA is estimated to be 6% to 8% among patients diagnosed with MI, especially women, however it is more common in patients with NSTEMI compared with STEMI; moreover in cases of TTS presenting with ST elevation, usually the elevation is found in anterior leads without reciprocal ST depression; in this patient instead ST elevation was inferolateral with reciprocal anterior ST depression. Absence of obstructive CAD and clinical/echocardiographic evolution allowed us to confirm the diagnosis of MINOCA/TTS.

De Winter syndrome or inferior STEMI?

BackgroundThe de Winter electrocardiography (ECG) pattern is associated with acute total or subtotal occlusion of the left anterior descending coronary artery (LAD) characterized by upsloping ST-segment depression at the J point in leads V1–V6 without ST-segment elevation.Case presentationWe report an atypical style case of the de Winter ECG pattern accompanied by ST elevation in inferior leads. The patient underwent emergency coronary angiography, which revealed total occlusion of the proximal LAD with no observable stenosis in the right coronary artery.ConclusionECG-related changes in acute total LAD occlusion can present with the de Winter pattern and ST elevation in inferior leads. Recognizing this atypical ECG pattern is critical for immediate reperfusion therapy.

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.

C26. Case report: COVID-19 associated Takotsubo cardiomyopathy

BackgroundCOVID-19 infection can lead to several cardiovascular sequelae, including Takotsubo cardiomyopathy (TCM), which may portend worse clinical outcomes.Case DescriptionA 56-years-old woman with history of hypertension presented to the emergency room for dyspnea and gradual decrease of consciousness for seven days. She was positive for COVID-19 and transferred to intensive care unit to receive mechanical ventilation due to respiratory failure. Electrocardiogram showed pathological Q wave and ST elevation in inferior and anterior. Troponin I was mildly elevated (5.52 ng/ml). Inflammatory marker CRP and procalcitonin were increased (3.6 mg/dl and 0.235 ng/ml, respectively). Serum cortisol level was 525.8 ng/ml. Echocardiography showed reduced left ventricular ejection fraction (LVEF 41%), with severe hypokinetic of the apical segments and preserved basal myocardial function consistent with visual signs of apical ballooning in TCM. Her follow-up echocardiography showed normal contractility of the apical myocardial segments, with normalization of the left ventricular systolic function, further supporting the reversibility of acute stress cardiomyopathy.DiscussionMechanisms of TCM in viral infections include catecholamine-induced myocardial toxicity and inflammation related to sepsis. A presumptive diagnosis of TCM was made based on the characteristic echocardiogram findings of apical ballooning, normalization of left ventricular systolic function, unremarkable past cardiac history and spontaneous improvement in serum troponin-I levels in the setting of a severe systemic illness.ConclusionClinicians should be aware of the diversity of cardiovascular complications of COVID-19, including Takotsubo cardiomyopathy and should strategize appropriately for diagnosing and managing them.

C26. Case report: COVID-19 associated Takotsubo cardiomyopathy

BackgroundCOVID-19 infection can lead to several cardiovascular sequelae, including Takotsubo cardiomyopathy (TCM), which may portend worse clinical outcomes.Case DescriptionA 56-years-old woman with history of hypertension presented to the emergency room for dyspnea and gradual decrease of consciousness for seven days. She was positive for COVID-19 and transferred to intensive care unit to receive mechanical ventilation due to respiratory failure. Electrocardiogram showed pathological Q wave and ST elevation in inferior and anterior. Troponin I was mildly elevated (5.52 ng/ml). Inflammatory marker CRP and procalcitonin were increased (3.6 mg/dl and 0.235 ng/ml, respectively). Serum cortisol level was 525.8 ng/ml. Echocardiography showed reduced left ventricular ejection fraction (LVEF 41%), with severe hypokinetic of the apical segments and preserved basal myocardial function consistent with visual signs of apical ballooning in TCM. Her follow-up echocardiography showed normal contractility of the apical myocardial segments, with normalization of the left ventricular systolic function, further supporting the reversibility of acute stress cardiomyopathy.DiscussionMechanisms of TCM in viral infections include catecholamine-induced myocardial toxicity and inflammation related to sepsis. A presumptive diagnosis of TCM was made based on the characteristic echocardiogram findings of apical ballooning, normalization of left ventricular systolic function, unremarkable past cardiac history and spontaneous improvement in serum troponin-I levels in the setting of a severe systemic illness.ConclusionClinicians should be aware of the diversity of cardiovascular complications of COVID-19, including Takotsubo cardiomyopathy and should strategize appropriately for diagnosing and managing them.

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.

High take-off of coronary arteries contributing to lethal myocardial ischemia: report of two cases

Abstract Introduction/Objective High take-off coronary arteries (HTO) are defined by coronary ostia arising above the sinotubular junction (STJ). Although asymptomatic in most individuals, there is increasing evidence that HTO is a risk factor for sudden cardiac death. Here we present two patients where HTO contributed to death. Methods/Case Report Patient A was a 52 year old morbidly obese male with atypical chest pain, new inferior ST elevations and troponinemia. Multiple coronary angiographies did not reveal any stenosis, but 3 stents were placed in the RCA due to concern for vasospasm. 3 days later the patient died. Autopsy revealed cardiac tamponade and non- atherosclerotic ischemic heart disease with remote apical LV scar and diffuse patchy interstitial fibrosis in the myocardium, which could be attributed to HTO of the RCA 0.5 cm above the STJ and early intramuscular courses of both coronaries. Multiple angiographies likely caused iatrogenic coronary injury and subsequent tamponade. Patient B was a healthy 33 year old female at 34 weeks gestation, who developed anaphylaxis during IV iron infusion for severe iron deficiency anemia. She was transferred to the OR for emergent C-section. Minutes after delivery she died. Autopsy revealed HTO, with coronary ostia being 0.4 cm and 0.7 cm above the STJ, respectively and acute angle take-off of LCA. No atherosclerosis was noted. The inability to increase myocardial perfusion through the coronary arteries during a high stress situation due to pregnancy, iron deficiency anemia and anaphylaxis likely contributed to lethal myocardial ischemia. Results (if a Case Study enter NA) NA Conclusion HTO and other coronary artery anomalies (CAAs) should be considered in cases of cryptogenic acute and chronic myocardial ischemia. Hemodynamic characterization of HTO, including those < 1 cm above the STJ in presence and absence of other CAAs may help better understand their pathophysiologic significance. Antemortem diagnosis requires high clinical suspicion and appropriate surgical intervention could be life-saving.

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.