Intracoronary Thrombus Burden Research Articles

Impact of triglyceride-glucose index on intracoronary thrombus burden in ST-elevation myocardial infarction patients undergoing primary percutaneous coronary intervention

Background and aimsWe aimed to investigate the relationship between triglyceride glucose (TyG) index and intracoronary thrombus burden in patients with ST-elevation myocardial infarction (STEMI) who underwent primary percutaneous coronary intervention (PCI). Methods and resultsA total of 468 consecutive patients who were admitted with STEMI and underwent primary PCI were included in the study. TyG index was calculated as ln [fasting triglycerides (mg/dL) × fasting plasma glucose (mg/dL)/2]. According to the angiographic reclassified thrombolysis in myocardial infarction (TIMI) thrombus grade, patients were divided into two groups as small thrombus burden (STB) with TIMI thrombus grade 0–3, and large thrombus burden (LTB) with TIMI thrombus grade 4–5. TyG index was significantly higher in the LTB group than in the STB group (9.11 ± 0.86 vs 8.89 ± 0.62; p = 0.002). In multivariate analysis, TyG index was found to be an independent predictor of LTB in STEMI patients who underwent primary PCI [OR (95 % CI): 1.470 (1.090–1.982), p = 0.012]. The area under the curve (AUC) of TyG index predicting LTB was 0.568 (95 % CI 0.506–0.631; p = 0.023), with the best cut-off value of 8.87. In the classification according to TyG index cut-off value, the frequency of LTB was found to be significantly higher in the high TyG index group than in the low TyG index group (33.6 % vs 21.2 %; p = 0.003). ConclusionTyG index, a valid surrogate marker of insulin resistance, is an independent predictor of LTB in STEMI patients who underwent primary PCI and can be used as an indicator of increased intracoronary thrombus burden.

High CRP-albumin ratio is associated high thrombus burden in patients with newly diagnosed STEMI.

In patients undergoing primary percutaneous coronary intervention (pPCI) due to ST-segment elevation myocardial infarction (STEMI), an increased intracoronary thrombus burden is a strong predictive factor for adverse cardiovascular events. The C-reactive protein (CRP)-serum albumin (SA) ratio (CAR), used as an inflammatory marker, is closely associated with thrombogenicity. In this study, we investigated the relationship between coronary thrombus burden and CAR in patients undergoing pPCI due to newly diagnosed STEMI. A total of 216 patients who underwent pPCI due to STEMI were retrospectively included for the study. Angiographic thrombus burden was assessed according to thrombolysis in myocardial infarction (TIMI) grading, and those with grade 1, 2, 3 were classified as low thrombus burden (n = 120) and those with grade 4, 5 were classified as high thrombus burden (HTB) (n = 96). CAR was calculated as the ratio of CRP to SA. The average age of the patients was 60 ± 9.8, and the male ratio was 61.1. Compared to the LTB group, the HTB group had higher CAR, age, SYNTAX score, baseline cTnT, peak cTnT, CRP, glucose, WBC, and NLR while the LVEF and SA levels were lower (P < .05). Spearman's correlation analysis revealed a significant correlation between thrombus burden and CAR. The multivariable logistic regression analysis revealed that CAR (odds ratio: 10.206; 95% confidence interval: 2.987-34.872, P < .001) was a independent risk factor for HTB. According to the receiver operating characteristic (ROC) analysis, when the cutoff value for CAR was taken as ≥1.105 CAR could predict HTB with a sensitivity of 70.8% and specificity of 67.7%. Our data indicate that CAR an independent risk factor for thrombus burden.

Relation of Monocyte Count to Thrombus Burden in ST-Segment Elevation Myocardial Infarction Patients Undergoing Primary Percutaneous Coronary Intervention

Objective: To determine the association of monocyte count to thrombus burden in ST-segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (P-PCI). Method: This analytical, cross-sectional study was done in the Angiography Department of Rawalpindi Institute of Cardiology, Rawalpindi from October 30, 2020 to April 30, 2021. After taking ethical approval, 180 STEMI patients undergoing P-PCI who presented within 24 hours of symptoms were included using nonprobability convenient sampling. Informed written consent of the patients was obtained. Primary PCI with stenting was done and the thrombolysis in myocardial infarction (TIMI) scale was applied to determine intracoronary thrombus burden. The blood samples of patients were taken to estimate monocyte count. The data was analyzed through the Statistical Package for the Social Sciences (SPSS) version 25. Results: The frequency of thrombus burden was high in 71(39.4%) patients and low in 109(60.6%) patients. The monocyte count showed a significant difference in patients with high thrombus versus low thrombus burden. In low thrombus burden patients, the mean monocyte count was 0.49±0.50 and in high thrombus burden patients, the mean monocyte count was 0.64±0.48. The results of stratification of thrombus burden with age group showed significant p-value and with others showed non-significant p-value. Conclusion: The monocyte count is a reliable, inexpensive and simple-to-measure predictor of high thrombus burden in coronary arteries in STEMI patients undergoing primary PCI

Trombosit Dağılım Genişliği Akut Koroner Sendrom Şiddeti ve Koroner Trombüs Yükü ile İlişkili mi?

Aim: Platelets play a pivotal role in the pathogenesis of acute coronary syndrome (ACS), and platelet distribution width (PDW) shows the activities of platelets in circulation. The purpose of this study was to determine the association of PDW with the ACS severity and angiographic intracoronary thrombus burden and Thrombolysis In Myocardial Infarction (TIMI) flow grade.&#x0D; Materials and Methods: One hundred forty-nine consecutive patients who were diagnosed as having ACS were retrospectively evaluated. Global Registry of Acute Coronary Events (GRACE) scores were calculated from the clinical and laboratory data for ACS severity. TIMI flow grades and thrombus grades of the culprit coronary arteries were calculated for each patient. Patients were grouped into two groups according to their PDW values: high PDW and low PDW. The SPSS 17.0 software was used for statistical analysis. &#x0D; Results: PDW was found to be correlated with GRACE scores (P

How to effectively manage the refractory coronary thrombus? A systemic mini-review.

The main management principle for patients with coronary thrombus should be "more removal and less implantation". Routine thrombus aspiration (TA) is ineffective for intracoronary thrombus or high residual thrombus burden after TA and may result in a refractory coronary thrombus. It is unwise to implant a stent in the vessel with high residual thrombus, which is associated with no-reflow, impaired microvascular perfusion, and consequently worse clinical outcomes. Therefore, increasing the efficiency of TA during percutaneous coronary intervention procedures, especially under some conditions of refractory coronary thrombus, is very important to restore myocardial reperfusion and improve microvascular dysfunction early. In the present work, we aimed to demonstrate the factors that may affect TA efficiency and introduce several highly effective approaches to treat refractory coronary thrombus.

Modified Glasgow Prognostic Score Predicted High-Grade Intracoronary Thrombus in Acute Anterior Myocardial Infarction.

High-grade intracoronary thrombus (ICT) burden leads to greater myocardial injury following anterior myocardial infarction (MI). The modified Glasgow prohgnostic score (mGPS) is a novel immune-inflammatory index, calculated by using C-reactive protein (CRP) and albumin levels, was shown to have prognostic value in heart diseases. The present study investigated the role of mGPS in predicting high grade ICT in patients with acute anterior MI admitted between February 2017 and March 2020. Blood samples were obtained at admission and mGPS was calculated. The ICT burden was evaluated visually from angiographic images. Patients were divided into 2 groups according to the ICT burden as high and low. A total of 1132 patients were enrolled: a mean age 61 ± 12.4 years and 370 males (32.7%). Serum albumin was lower, whereas mGPS and CRP were higher in high grade ICT group. CRP (odds ratio (OR): 1.404 95% CI: 1.312-1.502; P < .001), albumin (OR: .486; 95% CI: .301-.782 P < .001), and mGPS (0 vs ≥ 1) (OR: 7.391; 95% CI: 3.910-13.972; P < .001) were independent predictors of high-grade ICT burden in the left anterior descending coronary artery. The mGPS is a novel predictor of high-grade ICT burden and may be useful for risk stratification in patients with acute anterior MI.

D-Dimer to Creatinine Ratio (DCR) and Intracoronary Thrombus Burden as Risk Factors for Hospitalized Major Cardiovascular Events (MACE) in Patients with ST Elevation Myocardial Infarction (STEMI)

Background: STEMI pathophysiology is based on increased activity of coagulation, thrombosis, and inflammation. The role of STEMI biomarkers is essential for prognostic and risk stratification. Dimer-Creatinine Ratio (DCR) is a novel biomarker that could be combined with intracoronary thrombus burden according to TIMI Thrombus Grade to evaluate in hospital MACE in STEMI patients. Methods: A cohort prospective design was implemented in this study, with subjects of STEMI patients undergoing primary PCI. Low and high DCR values were determined by the ROC curve. Survival analysis with the Kaplan-Meier curve was used to evaluate MACE outcome according to DCR and intracoronary thrombus burden. Multivariate analysis Cox regression and stratification analysis were used to evaluate independent risk factors, the relationship of each variable, and in hospital MACE. Results: A total of 60 samples were included, 40 patients (66.7%) with high DCR and 36 patients (60%) with high intracoronary thrombus burden. 36 (59.8%) patients were known to have in hospital MACE. Cut-off point was used to determine high DCR was 1.51 (AUC 0.905; 95%CI: 0.825-0.989; p&lt;0.001). Cox regression model backward log rank showed high DCR (adjusted HR 20.81; 95%CI: 2.18-98.16; p=0.007) and high intracoronary thrombus burden (adjusted HR 31.38; 95%CI: 4.51-89.15; p=0.017), smoking (adjusted HR 2.70; 95% CI 0.88-3.29; p=0.012), and diabetes mellitus (adjusted HR 7.55; 95% CI 1.13-11.58; p=0.035) played a role as independent risk factors of in-hospital MACE in STEMI patients. A combination of both high DCR and high intracoronary thrombus burden had a higher incidence of 91.2% of in hospital MACE according to stratification analysis (Mantel-Haenzel Common Estimate 14.33; Breslow-Day Homogeneity p=0.803; Cochran’s and Mantel-Haenszel p=&lt;0.013). Conclusion: High DCR and high intracoronary thrombus burden can be used as additional information for risk stratification of in hospital MACE in STEMI patients, especially when both parameters are combined.

Manual thrombus aspiration during percutaneous coronary intervention: Cherish as “Blessing of Thanksgiving” in a case of spontaneous coronary artery dissection presenting with large intracoronary thrombus burden

Manual thrombus aspiration during percutaneous coronary intervention: Cherish as “Blessing of Thanksgiving” in a case of spontaneous coronary artery dissection presenting with large intracoronary thrombus burden

The relationship between intracoronary thrombus burden and atherogenic index in patients with ST-elevation myocardial infarction.

Increased coronary thrombus load is a strong predictor of adverse cardiovascular (CV) outcomes. Identifying predictors of intracoronary thrombus burden may contribute to the management of ST-segment elevation myocardial infarction (STEMI). We aimed at evaluating the relationship between the atherogenic index (ATI) and coronary thrombus burden in patients presenting with STEMI. 139 patients who presented with STEMI and underwent primary percutaneous coronary intervention were included in this study. Angiographic thrombus burden was classified as previously defined in the myocardial infarction (TIMI) study group. The patients were divided into two groups as those with high and low thrombus load. Independent predictors of high thrombus burden were ATI (OR: 4.23, 95% CI: 2.38-7.5; p<0.001), serum creatinine level (OR: 17.4, 95% CI: 3.03-101.4; p=0.001) and non-LAD involvement (OR: 0.363, 95% CI: 0.14-0.92; p=0.034). The association of ATI with thrombus load was independent from HDL and TGL levels. The atherogenic index can be used as a reliable marker for increased coronary thrombus burden, which is associated with adverse CV outcomes.

Well-Developed Coronary Collateral Circulation Is Associated With Higher Thrombus Burden in the Setting of ST-Segment Elevation Myocardial Infarction.

This study investigated the relationship between coronary collateral circulation (CCC) and intracoronary thrombus burden in patients undergoing primary percutaneous coronary intervention for ST-segment elevation myocardial infarction (STEMI). CCC and thrombus burden are predictive of clinical outcomes in patients with STEMI. Patients with STEMI undergoing primary percutaneous coronary intervention were enrolled (n = 172). CCC was graded according to the Cohen-Rentrop classification. Patients were classified as insufficient (grade 0 or 1, n = 134) or well-developed (grade 2 or 3; n = 38) CCC. The Thrombolysis in Myocardial Infarction scale was used to evaluate intra-coronary thrombus burden. The low-thrombus-burden group comprised those with grades 0 to 2, and the high-thrombus-burden group comprised those with grades 3 or 4. Right coronary artery infarcts had a 13.830-fold higher chance of having well-developed CCC than did left anterior descending artery infarcts (P &lt; .001). Circumflex artery infarcts had a 7.904-fold higher chance of well-developed CCC than did left anterior descending artery infarcts (P = .016). High thrombus burden was associated with a 4.393-fold higher chance for well-developed CCC than was low thrombus burden (P = .030). Low albumin levels were related to a greater chance of having well-developed CCC (P = .046). Patients with well-developed CCC have higher thrombus burden than do those with insufficient CCC. Because well-developed CCC is an indicator of more severe underlying lesions, we speculate that patients with severe lesions are more prone to experience more complicated STEMI with high thrombus burden.

Association of stress induced hyperglycemia with angiographic findings and clinical outcomes in patients with ST-elevation myocardial infarction

BackgroundStress induced hyperglycemia (SIH) is common among patients with ST-elevation myocardial infarction (STEMI), even in patients without diabetes mellitus. However, evidence regarding its role on the angiographic outcomes and the prognosis of patients presenting with STEMI is scarce.MethodsThis study included 309 consecutively enrolled STEMI patients undergoing primary percutaneous coronary intervention (pPCI). Patients were diagnosed with SIH if blood glucose on admission was > 140 mg/dl. Also, patients had to fast for at least 8 hours before blood sampling. The objective was to assess whether SIH was associated with major adverse cardiovascular and cerebrovascular (MACCE) events and explore its relationship with angiographic predictors of worse prognosis such as poor initial TIMI flow, intracoronary thrombus burden, distal embolization, and presence of residual thrombus after pPCI.ResultsSIH in diabetic and non-diabetic patients was associated with a higher incidence of LTB (aOR = 2.171, 95% CI 1.27–3.71), distal embolization (aOR = 2.71, 95% CI 1.51–4.86), and pre-procedural TIMI flow grade = 0 (aOR = 2.69, 95% CI 1.43–5.04) after adjusting for relevant clinical variables. Importantly, during a median follow-up of 1.7 years STEMI patients with SIH with or without diabetes experienced increased occurrence of MACCE both in univariate (HR = 1.92, 95% CI 1.19–3.01) and multivariate analysis (aHR = 1.802, 95% CI 1.01–3.21).ConclusionsSIH in STEMI patients with or without diabetes was independently associated with increased MACCE. This could be attributed to the fact that SIH was strongly correlated with poor pre-procedural TIMI flow, LTB, and distal embolization. Large clinical trials need to validate SIH as an independent predictor of adverse angiographic and clinical outcomes to provide optimal individualized care for patients with STEMI.

Relationship between intracoronary thrombus burden and systemic immune-inflammation index in patients with ST-segment elevation myocardial infarction

Aim This study aimed to evaluate the relationship between intracoronary thrombus burden and systemic immune-inflammation index (SII) and to compare the predictive capacity of SII together with the neutrophil-lymphocyte ratio (NLR), and the platelet-lymphocyte ratio (PLR) in patients with ST-elevation myocardial infarction (STEMI) who underwent primary percutaneous coronary intervention (PPCI) Patient & methods A total of 425 patients were included in the study. The clinical, laboratory, and demographic characteristics of the patients were recorded. The thrombus classification "Thrombolysis in myocardial infarction (TIMI)" was used to assess the intracoronary thrombus burden. According to the TIMI thrombus classification, 229 (54%) patients with low thrombus burden (grade 0–3) and 196 (46%) patients with high thrombus burden (grade 4 and 5) were compared. SII was calculated as platelet × neutrophil/lymphocyte counts. Results High NLR (OR: 1.068, 95% CI:1.023–1.404; p = 0.031), PLR(OR: 1.012, 95% CI:1.002–1.018; p = 0.043), SII(OR: 1.325, 95% CI: 1.156–1.879; p = 0.015) and low left ventricle ejection fraction (LVEF) (OR: 0.957, 95% CI:0.924–0.990; p = 0.012) were found to be independent predictors of high thrombus burden. SII values above 812 predicted a high thrombus burden with a sensitivity of 82% and specificity of 73% (AUC: 0.836; 95% CI:0.795–0.877; p < 0.001). This predictiveness of SII was stronger as compared to NLR (0.836 vs. 0.818, p = 0.043) and PLR (0.836 vs. 0.780, p < 0.001). Conclusion SII is an independent predictor of high thrombus burden in patients with STEMI. In addition, SII is superior to NLR and PLR in this regard.

Association of CHA2DS2-VASc score with thrombus burden in patients with acute myocardial infarction undergoing SVG-PCI.

The rate of saphenous vein graft (SVG) occlusion within the first year of bypass graft surgery is 15%. The CHA2DS2-VASc score is used to predict the risk of thromboembolic events in patients with nonvalvular atrial fibrillation. We aimed to evaluate the predictive role of the CHA2DS2-VASc score in the estimation of intracoronary thrombus burden in patients with acute myocardial infarction (AMI) who underwent SVG-PCI. We retrospectively evaluated 221patients who were admitted with AMI and underwent PCI of SVGs at the Department of Cardiology in the Turkiye Yuksek Ihtisas Education and Research Hospital between 2012 and 2018. The study population was divided into two groups according to their Thrombolysis in Myocardial Infarction (TIMI) thrombus grade: low thrombus burden (LTB; TIMI 0-3) and high thrombus burden (HTB; TIMI4 and5). The study included 221patients with amean age of 63.3 ± 6.7years. The patients with HTB had significantly higher CHA2DS2-VASc scores (p < 0.001) compared with LTB patients. Univariate and multivariate regression analysis demonstrated that both CHA2DS2-VASc score (OR: 1.573, 95% CI: 1.153-2.147, p = 0.004) as acontinuous variable and abinary cut-off level of the CHA2DS2-VASc score > 3 (OR: 3.876, 95% CI: 1.705-8.808, p = 0.001) were significantly associated with HTB. The ability of the CHA2DS2-VASc score to predict HTB burden was evaluated by receiver-operating characteristics analysis curve analysis. The optimum cut-off value of the CHA2DS2-VASc score for predicting HTB was 3(with asensitivity of 67.9% and aspecificity of 69.3%) according to the Youden index. The CHA2DS2-VASc score can be used as an easy practical tool to predict HTB in AMI patients undergoing SVG-PCI.

Serum Ceramides as Prognostic Biomarkers of Large Thrombus Burden in Patients with STEMI: A Micro-Computed Tomography Study.

ST-elevation myocardial infarction (STEMI) remains one of the leading causes of mortality worldwide. The identification of novel metabolic and imaging biomarkers could unveil key pathophysiological mechanisms at the molecular level and promote personalized care in patients with acute coronary syndromes. We studied 38 patients with STEMI who underwent primary percutaneous coronary intervention and thrombus aspiration. We sought to correlate serum ceramide levels with micro-CT quantified aspirated thrombus volume and relevant angiographic outcomes, including modified TIMI thrombus grade and pre- or post-procedural TIMI flow. Higher ceramide C16:0 levels were significantly but weakly correlated with larger aspirated thrombus volume (Spearman r = 0.326, p = 0.046), larger intracoronary thrombus burden (TB; p = 0.030) and worse pre- and post-procedural TIMI flow (p = 0.049 and p = 0.039, respectively). Ceramides C24:0 and C24:1 were also significantly associated with larger intracoronary TB (p = 0.008 and p = 0.001, respectively). Receiver operating characteristic analysis demonstrated that ceramides C24:0 and C24:1 could significantly predict higher intracoronary TB (area under the curve: 0.788, 95% CI: 0.629–0.946 and 0.846, 95% CI: 0.706–0.985, respectively). In conclusion, serum ceramide levels were higher among patients with larger intracoronary and aspirated TB. This suggests that quantification of serum ceramides might improve risk-stratification of patients with STEMI and facilitate an individualized approach in clinical practice.

Association of stress hyperglycemia ratio with intracoronary thrombus burden in diabetic patients with ST-segment elevation myocardial infarction.

BackgroundLarge intracoronary thrombus burden is not rare during primary percutaneous coronary intervention (PCI) in patients with acute ST-segment elevation myocardial infarction (STEMI). Stress hyperglycemia is independently associated with poor prognosis. However, the underlying relationship between stress hyperglycemia and thrombus burden remains unknown. This study aims to investigate the association of stress hyperglycemia, evaluated by the combination of acute and chronic glycemic levels, with intracoronary thrombus burden in diabetic patients with STEMI.MethodsWe enrolled 227 consecutive diabetic patients with STEMI undergoing primary PCI within 12 hours after symptom onset. Stress hyperglycemia was estimated using the stress hyperglycemia ratio (SHR), which was calculated as admission glycemia divided by estimated average glucose derived from glycosylated hemoglobin. Based on reclassified angiographic thrombolysis in myocardial infarction (TIMI) thrombus grades, patients were divided into small thrombus burden (STB) group (TIMI thrombus grades <4) and large thrombus burden (LTB) group (TIMI thrombus grades 4 or 5).ResultsOf the entire study population, 77 (33.9%) patients were categorized as LTB group, whereas 150 (66.1%) patients presented with STB. The mean age was 64.1 years, and 80.6% of the patients were male. The SHR levels were significantly higher in patients with LTB than in those with STB [1.31; interquartile range (IQR): 1.13–1.48 versus 1.11; IQR: 0.96–1.32; P<0.001]. The predictive performance of SHR for LTB was moderate (area under the curve: 0.669; 95% confidence interval: 0.604–0.730; P<0.001), with the best cut-off value 1.19 (sensitivity 71.4%, specificity 64.7%). The incidence of LTB with SHR ≥1.19 was significantly higher compared with SHR <1.19 (50.9% versus 18.5%; P<0.001). Based on the multivariable logistic regression analysis, the high SHR (≥1.19) was found to be an independent predictor of LTB following adjustment for baseline clinical confounders.ConclusionsA high SHR value was independently associated with large thrombus burden and has a better predictive value than glycemia at admission in diabetic patients with STEMI undergoing primary PCI. Stress hyperglycemia may play an important role on the intracoronary thrombus formation.

Evaluation of the relation between monocyte count and angiographic thrombosis burden in patients with myocardial infarction with STEMI under PPCI treatment

Introduction: Complete thrombotic occlusion of a major epicardial coronary artery is the common pathophysiological mechanism of acute ST-segment elevation myocardial infection (STEMI). Intravascular thrombosis is associated with poor prognosis in patients with STEMI. Methods:In this study, we enrolled 400 patients with STEMI undergoing PPCI . Based on TIMI ratings of the patients and reviewing their angiographic film, they were divided into two groups with high thrombus burden and low thrombus burden. Then, Monocytes were measured in two groups with higher and lower thrombus. Results:A total of 400 patients with STEMI (mean age of 58.71 ± 12.31, 80.5% male) who underwent PPCI enrolled in this study. There were no significant differences between the low thrombus and high thrombus group in In terms of diabetes, high blood pressure, previous history of MI and cardiac troponin levels, However, patients with high thrombus had lower EF .(p value < 0.001). Based on the multivariate analysis result, the amount of circulating monocytes during hospitalization is an independent factor in predicting the rate of thrombosis in angiography. Odds ratio= 3.099 , p value=0.019 .Analysis of the receiver-operating characteristic found an optimal monocyte count cut-off value to be ≤0.60*104 in predicting a high thrombus burden score. Conclusions: The results of the study showed that the number of monocytes is a predicator of high intracoronary thrombus burden in patients with acute STEMI and patients can be treated with antithrombotic treatments.

SUCCESSFUL MULTI-VESSEL CORONARY ARTERY BYPASS GRAFT IN A PATIENT WITH KAWASAKI DISEASE AND BILATERAL GIANT CORONARY ARTERY ANEURYSMS WITH INTRACORONARY THROMBUS BURDEN CAUSING A MYOCARDIAL INFARCTION: A CASE REPORT

SESSION TITLE: Medical Student/Resident Cardiothoracic Surgery Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Kawasaki Disease (KD) is a small to medium sized vessel vasculitis which usually occurs in children aged from 6 months to 5 years old [1]. A complication of KD is coronary artery aneurysms (CAA) which can pose a risk of thrombosis and progressive stenosis with the development of ischemic heart disease, myocardial infarction, and sudden cardiac death [2,3]. The following case report presents a young male with KD and giant CAA undergoing multi-vessel coronary artery bypass graft (CABG) surgery following a myocardial infarction. Consent for presentation was obtained from patient’s parents. CASE PRESENTATION: A 17 yo Caucasian male with known KD presented to the ED with new onset chest pain. Initial EKG showed T-wave inversions in aVL, V4-V6 leads. Laboratory analysis included a serum troponin of 54 ng/L and INR of 1.6. Initial therapy included aspirin and a heparin infusion. Echocardiogram demonstrated a dilated aortic root. Repeat EKG consistent with a lateral STEMI. Emergent coronary angiography remarkable for possible dissection of left main coronary artery vs intracoronary thrombus. Coronary CTA obtained which confirmed extensive thrombus burden in LM and RCA as well as 100% occlusion of LAD and distal portion of RCA. Admitted to the CVICU and started on infusions of altepase, heparin, and abiciximab. Two-vessel CABG surgery performed on hospital day #6 with internal mammary artery grafts to RCA and LAD. Discharged on post-op day #4/hospital day #10 on aspirin, statin, beta-blocker, and apixaban. DISCUSSION: KD associated giant coronary artery aneurysms (GCAA) are a serious complication associated with acute myocardial infarction. GCAA are defined as an internal diameter of >8mm. With GCAA >8mm, regression is less likely and often leads to myocardial ischemia or infarction with an increased mortality rate [2]. In a study of CABG vs PCI in KD patients, CABG patients were more likely to have complete revascularization and required less re-intervention then PCI patients [3]. Arterial graft usage (internal thoracic artery) in CABG showed improved graft patency, long-term life expectancy, and growth potential compared to saphenous vein harvesting [3]. CONCLUSIONS: Seventeen-year-old male with Kawasaki Disease and giant coronary artery aneurysms presents with a lateral STEMI secondary to intracoronary thrombus burden. Coronary angiography and Coronary CTA demonstrated enlargement of both known aneurysms and intracoronary thrombus inducing total occlusion of LAD and distal RCA requiring multi-vessel CABG surgery. Reference #1: 1: CME “Rare Refractory Kawasaki Dz in an Adolescent Boy with Cardiac and Diffuse Coronary artery involvement” Reference #2: 2: Lin MT, Sun LC, Wu ET, Wang JK, Lue HC, Wu MH (2015) Acute and late coronary outcomes in 1073 patients with Kawasaki disease with and without intravenous-immunoglobin therapy. Arch Dis Child 100(6):542-547 Reference #3: 3: Dionne A, Bakloul M, Manlhiot C, et al. Coronary artery bypass grafting and percutaneous coronary intervention after Kawasaki disease: the Pediatric Canadian series. Pediatric cardiology. 2017;38(1):36-43. DISCLOSURES: No relevant relationships by Matthew Ellison, source=Web Response No relevant relationships by Kevin McKillion, source=Web Response No relevant relationships by Patrick McKillion, source=Web Response

The role of intracoronary thrombolysis in selected patients presenting with ST-elevation myocardial infarction: a case series.

BackgroundPrimary percutaneous coronary intervention (PCI) is the cornerstone of management for ST-elevation myocardial infarction (STEMI). However, large intracoronary thrombus burden complicates up to 70% of STEMI cases. Adjunct therapies described to address intracoronary thrombus include manual and mechanical thrombectomy, use of distal protection device and intracoronary anti-thrombotic therapies.Case summaryThis series demonstrates the use of intracoronary thrombolysis in the setting of large coronary thrombus, bifurcation lesions with vessel size mismatch, diffuse thrombosis without underlying plaque rupture, and improving coronary flow to allow vessel wiring and proceeding to definitive revascularization.DiscussionLarger intracoronary thrombus burden correlates with greater infarct size, distal embolization, and the associated no-reflow phenomena, and propagates stent thrombosis, with subsequent increase in mortality and major adverse cardiac events. Intracoronary thrombolysis may provide useful adjunct therapy in highly selected STEMI cases to reduce intracoronary thrombus and facilitate revascularization.

Safety and efficacy of intracoronary thrombolytic therapy via a new infusion catheter in patients with ST-segment elevation myocardial infarction with large thrombus burden: a pilot study.

A large intracoronary thrombus burden is associated with adverse clinical results. The optimal management of this scenario remains unknown. We aimed to determine the efficacy and safety of a new rapid infusion catheter combined with low-dose intracoronary thrombolysis in patients with ST-segment elevation myocardial infarction (STEMI) with a large thrombus burden. This pilot study included 22 patients with STEMI with a large thrombus burden. A large thrombus burden was defined as a definite thrombus with the largest dimension of at least two vessel diameters [thrombolysis in myocardial infarction (TIMI) thrombus grades 4 and 5]. All patients received primary percutaneous coronary intervention guided by the presence of recurrent chest pain or clinical myocardial ischemia evidences. All patients regained myocardial perfusion immediately after the infusion catheter crossed the thrombus. Local fibrinolysis with low-dose recombinant human prourokinase was administered continuously via the infusion catheter for 30 min. Repeat coronary angiography revealed marked thrombus resolution, with an improvement in TIMI flow from 0.14 ± 0.35 at baseline to 2.82 ± 0.40. Only one patient with postlysis thrombus grades 4-5 was observed. No major bleeding events were observed. In patients with STEMI presenting with a large thrombus burden, all patients regained myocardial perfusion immediately after the infusion catheter crossed over the thrombus, and low doses of intracoronary thrombolysis could significantly reduce the thrombus burden and improve the coronary flow without major bleeding.

Association of Mean Platelet volume With Angiographic Thrombus Burden In Patient With ST-Segment Elevation Myocardial Infarction Undergoing Primary Percutanous Coronary Intervention

Background: ST-elevation myocardial infarction (STEMI) is one of the leading causes of mortality and morbidity worldwide. However, survival after acute STEMI has considerably improved due to increasing symptom recognition, accurate diagnosis and effective timely reperfusion. Objectives: To assess the association of mean platelet volume (MPV) as a biomarker for angiographic thrombus burden in patient with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention (PPCI). Patients and methods: This study was conducted on 125 patients admitted to El-Mokatem health insurance hospital, with the diagnosis of acute ST-segment elevation myocardial infarction (STEMI) treated with PPCI in the period between December 2018 and October 2019. Results: Thrombus burden level determined by TIMI thrombus grade (TIMITG) was significantly higher in the high MPV group (p-value 9.75 predicted LTB with 83.3% sensitivity and 86.2% specificity. Multivariate logistic regression analysis demonstrated MPV was an independent predictor of large intracoronary thrombus burden in patients with STEMI undergoing PPCI Conclusion: In STEMI patients who underwent PPCI, MPV on admission was significantly higher in those who experienced high thrombus burden. MPV on admission may serve as a readily available an independent predictor of the thrombus burden in STEMI patients undergoing PPCI. Keywords: Mean Platelet volume, TIMITG, HTB, PCI, PPCI, STEMI