Recent Anterior Myocardial Infarction Research Articles

Perioperative use of Impella device in very high-risk coronary artery bypass grafting

ABSTRACT This case study presents a high-risk coronary artery bypass grafting (CABG) patient with a recent anterior wall myocardial infarction and severely impaired left ventricular function. The patient underwent on-pump CABG with prolonged cardiopulmonary bypass support. The management strategy used hybrid mechanical circulatory support, intra-aortic balloon pump, and Impella CP, improved postoperative recovery, and prevented low cardiac output syndrome development.

Stent retrieval from renal artery by wire twist technique

ABSTRACT Wire twist technique is an important technique for retrieval of dislodged stent or broken coronary wire in areas where snare cannot be negotiated because of its bulky profile. In our patient dislodged coronary stent had been successfully retrieved from renal artery using twist wire technique. A 59 years gentleman, diabetic, hypertensive and smoker admitted with recent anterior wall myocardial infarction and ongoing chest pain. On coronary angiogram patient had approx. 80% stenosis in proximal LAD and approx. 80% stenosis in large OM1. PCI to LAD done with a 3X24 DES placed from ostium of LAD. But balloon dilation of OM lesion was difficult because of its tortuosity and also a 3X33 stent couldn’t be negotiated . During removal of stent balloon came out and the stent was struck and hanging in the LCX to LM to Aorta. It spontaneously dislodged from coronary artery and entered right renal artery. However PCI to OM done with a smaller stent of 3X28 DES. A snare had been tried but couldn’t be negotiated through the renal artery using right femoral route and JR(5F) guide cath. As an alternative approach three coronary wires had been passed through the side of the dislodged stent and multiple twisting done through a torquer. Thus the stent was entangled with the wires and the whole system was pulled and removed.

PO-717-08 UNUSUAL LETHAL COMPLICATION DURING SCAR-RELATED VT ABLATION: A CASE OF DRY TAMPONADE

Scar related ventricular tachycardia (VT) ablation has been shown to be more effective than anti-arrhythmic drugs in patients with ischemic cardiomyopathy (ICMP) and recurrent VT. In this particular population, complication rate can be as high as 10%, the most common ones being vascular damage, and pericardial complications. To identify a rare but severe complication of scar related VT ablation NA A 78 yo male with an old inferior and a recent anterior myocardial infarction (LVEF= 25%) was referred to our institution for VT ablation due to arrhythmic storm. Cardiac CT scan revealed inferior and anterior wall thinning (Inheart technology; figure panel A). Procedure was performed under conscious sedation in a stable patient. RF energy was delivered at 40 to 50W using a Smarttouch ST/SF catheter and the Carto 3 navigation system (Biosense Webster). After CT-channel ablation, a non clinical VT was induced. During ablation of this VT on the inferior wall, ST segment elevation in inferior leads became apparent, and arterial pressure dropped from 90 to 70mmHg. The patient was asymptomatic. Per-procedure coronary angiography showed no acute lesion and transthoracic echo demonstrated a dry pericardium. Ablation was continued and the patient was transferred to the ICU 1 hour later, with arterial pressure stabilized at 70 mm Hg. In the ICU, hemodynamic suddenly deteriorated 20 minutes after arrival and the patient went into cardiac arrest. After resuscitation, minimal pericardial effusion and clots were seen on TTE. Percutaneous pericardial drainage was attempted but failed to restore hemodynamics. The patient was then transferred to the operating room for surgical drainage. The diagnosis of circumferential intramyocardial hematoma contained by the epicardial layer (dry tamponade) was made (Figure panel B). Due to the extent of the hematoma, dilaceration of the myocardium and the clinical context, no further resuscitation was attempted and the patient finally died. This diagnosis of dry tamponade is rare in electrophysiology but well known by cardiologists performing chronic total occlusion angioplasty. It needs to be recognized by electrophysiologists at its early phase to avoid lethal outcome using hemodynamic support during the healing process.

Ventricular Septal Rupture following Anterior Acute Myocardial Infarction: A Challenge to a Sub-District Physician

Background: Ventricular septal rupture (VSR) is one of the most serious mechanical complications following acute myocardial infarction (AMI). Although a rare complication, it is associated with significant mortality and morbidity. The purpose of this report was to present a case of VSR following anterior AMI in our hospital.
 Case Description: A 54-year old Javanese male presented persistent episode of breathlessness and lower limb swelling for the last two days with prior chest pain 7 days ago. Physical examination revealed a grade 3/6 holosystolic murmer loudest over the apex, S3 gallop, rales bibasally of the lung. Electrocardiographic evidence revealed for a recent anterior myocardial infarction. Chest X-Ray showed a cardiomegaly and pulmonary congestion. Transthoracic echocardiography revealed VSR at mid-anteroseptal with estimated length of 8-10 mm, preserved LVEF 51% with mid-apicoseptal akinesis. Multiple readmissions were noted for this patient in the follow-up with worsened conditions.
 Discussion: This is a challenging case report since our hospital is an incapable cath-lab sub-district hospital and far from PCI-capable center. It is critical that all patients with AMI have a brief evaluation for mechanical complications such as VSR. All patients who developed hemodynamic instability during AMI should be comprehensively examined for the murmur and any other heart sound that may provide valuable information.
 Conclusion: Every clinician especially in the low-resource setting should be aware of this potentially fatal mechanical complication as the mortality remains significantly high. Early prompt diagnosis and treatment is the key of achieving an optimal outcome.

Optimal Use of Echocardiography in Management of Thrombosis After Anterior Myocardial Infarction.

Despite advancement in therapy and management, left ventricular thrombus (LVT) after anterior myocardial infarction (MI) is sporadically encountered and remains associated with a very high risk of major cardiovascular events and mortality. Cardiac magnetic resonance (CMR) is considered the gold standard technique for LVT detection, but it is a time-consuming and expensive test not available in all centers, especially when repeated examinations are necessary. Transthoracic echocardiography represents a useful tool to screen for LVT and to identify predictors of high risk of developing LVT. The advances in ultrasound technology and the use of contrast agents may potentially help clinicians to identify LVT and the use of sequential echocardiography for each patient with acute MI complicated by LVT may provide an opportunity to quantify regression and its correlation with outcomes to tailor the management of these patients. Hence, this narrative review focuses on the added value of echocardiographic-guided LVT management in patients with recent anterior MI to reduce mortality and morbidity excess related to LVT based on current evidence.

Congenital absence of left circumflex coronary artery and stenting of the stenosed proximal left anterior descending artery in a young male

Congenital absence of the left circumflex artery is a rare anomaly of the coronary circulation with a prevalence ranging from 0.6% to 1.3%. We report a 33-year-old male who presented with recent anterior wall myocardial infarction, in whom coronary angiography revealed absent left circumflex artery and stenosed left anterior descending artery. The left circumflex territory was being perfused by the superdominant right coronary artery. Although the absence of an artery is mostly considered as a benign condition, atherosclerotic lesions may diminish the compensatory mechanisms and worsen the outcome.

What a Surprise in a Healthy Veteran Athlete?

Figure 1: Old ECG. Figure 2: Last ECG. Figure 3: Focused 2D TT echocardiogram. Herewith the author describes the history of a healthy 60-year-old amateur rider who came to our sports cardiology medicine center for sports pre-participation screening. His family history was unremarkable and physical examination was normal. He claimed he felt fit and that he was taking regular physical activity by cycling. His old ECG was normal (Figure 1) while the last ECG (Figure 2) was abnormal for findings of recent anterior myocardial infarction. A subsequent focused 2D TT echocardiogram through classical and magnified apical 4 chamber view showed left ventricular apical akinesis with small apical thrombus (Figure 3 - see arrow) protruding into the left ventricular cavity and demonstrates mobility in real-time imaging. The athlete was admitted to cath lab for revascularization procedure and anticoagulation therapy was started. The risk of cardioembolic stroke was very high.

Successful stenting of all three branches in a patient with single anomalous coronary artery arising from the left sinus of valsalva: A case report

Single coronary artery with diffuse aterosclerothic disease is an extremely rare anomaly. The therapeuthic options of these case are controversial. We report a case of 53-year-old man with recent anterior myocardial infarction and post-infarction angina, in whom coronary angiography showed one coronary artery arising from a single ostium in the left sinus of Valsalva giving rise to all branches and severe atherosclerotic coronary disease. The patient underwent successful percutaneous transluminal coronary angioplasty and stenting of all three branches without any complication. Stenting, as an alternative to coronary artery bypass grafting, has become an increasingly attractive option for treatment of stenosis of anomalous coronaries because the long-term results of bypass are less than ideal. For selected cases with adequate guiding support, stenting of atherosclerotic stenosis of the anomalous coronary arteries may be preferrable to surgery.

Hyperacute rejection from a donor who died of carbamate intoxication—a case report

Acute carbamate intoxication can cause cardiac manifestations. We present the case of a 53-year-old man who had been a heavy smoker, admitted to our hospital for recent anterior wall myocardial infarction complicated with congestive heart failure. Percutaneous transluminal coronary angioplasty with stent implantation, coronary artery bypass graft, and mitral annuloplasty were performed, but refractory heart failure and ventricular arrhythmia were still noted. He received orthotropic heart transplantation 7 days later. The donor was a 50-year-old man who had died of brain death due to carbamate intoxication, and the crossmatch before transplantation was negative. The recipient died 24 hours after the operation due to acute left ventricular dysfunction. This report reviews the cardiac manifestations of acute carbamate intoxication and the possibility of heart transplantations from donors who died of carbamate intoxication.

A case of cardiac rupture subsequent to myocardial infarction diagnosed in emergency room

A 72-year-old woman was transferred to the emergency room because of left anterior chest pain with cold sweating. Electrocardiography revealed recent anterior myocardial infarction. Echocardiography showed akinesis of the mid-ventricular septum to the apex by apical view, a small amount of pericardial effusion and collapse of the right ventricular wall, indicating cardiac tamponade, by subcostal view. These echocardiographic findings strongly suggested cardiac rupture subsequent to the myocardial infarction. Emergent operation was successfully performed to repair the ruptured left ventricle.

Complete stent dislodgement after successful implantation‐a rare case

A successfully deployed stent is normally stable in position and unlikely to be dislodged from the coronary artery. We report a case of complete stent dislodgement after successful implantation in a patient with recent anterior myocardial infarction (AMI). Coronary angulation, a highly calcified coronary artery, an under-deployed stent, and the process of rewiring contributed to this unexpected event. Fortunately, no unwanted complication occurred as a consequence of this event.

Left-ventricular non-compaction with coronary artery disease

Left-ventricular non-compaction (LVNC) associated with coronary artery disease (CAD) is very rare. We present the case of a 48-year-old man who presented with recent anterior wall myocardial infarction and detected to have LVNC predominantly involving septum diagnosed by two-dimensional echocardiography. He also had significant two-vessel coronary artery disease. To the best of our knowledge, this is the first case of LVNC associated with CAD described in the literature.

Electrocardiographic change after recanalization in a patient with recent extensive anterior wall myocardial infarction

In a 66-year-old male with subacute extensive anterior wall myocardial infarction, we report a change in ST vector orientation from a basal anterior to a mid anterior after coronary artery recanalization of the proximal left anterior descending coronary artery with rotational atherectomy. The ST vector shift on the frontal plane after recanalization was consistent with a change toward more distal location of the ischemia on thallium-201 single photon emission computed tomography images compared to the findings during an exercise test before intervention. These findings may be correlated with local occlusion caused by distal microvascular embolization which was not visualized on coronary angiography following recanalization.

Biventricular Pulsus Alternans

Pulsus alternans is a rare hemodynamic condition characterized by beat-to-beat variability in systolic pressure. It is attributed to variations in stroke volume with alternate cardiac cycles and is typically seen in patients with advanced myopathic conditions. Left ventricular pulsus alternans is rare, and right ventricular pulsus alternans is even less common. There are only a few reports of biventricular pulsus alternans. We report the case of a 62-year-old female with a recent anterior wall myocardial infarction who had biventricular pulsus alternans at the time of cardiac catheterization.

Combined Assessment of Myocardial Perfusion and Diastolic Function Enhances Risk Stratification in Patients with Anterior Wall Myocardial Infarction

Evaluate the utility of a combined risk stratification scheme including diastolic dysfunction and "no-reflow," to identify high-risk patients following acute myocardial infarction (AMI). Recent studies have demonstrated that the "no-reflow" phenomenon (defined by myocardial contrast echocardiography) and severe diastolic dysfunction (identified by Doppler echocardiography) identify patients at high risk for mortality following AMI. We evaluated 111 patients with recent anterior acute myocardial infarction from July 2000 to June 2004. Diastolic function and myocardial perfusion was evaluated by echocardiography. Patients were placed into 1 of 3 groups based on diastolic function and myocardial perfusion: Group 1 (normal perfusion and normal diastolic function), Group 2 (abnormal perfusion or abnormal diastolic function), and Group 3 (abnormal perfusion and abnormal diastolic function). We compared the long term all-cause mortality within these groups. Patients in each group were similar with respect to myocardial infarction size as defined by biomarkers, extent and severity of coronary artery disease, and medical and interventional therapy. Mortality was much higher in Group 3 (26.9%) compared to Group 1 (0%) and Group 2 (15.2%) (p = 0.048). Combined assessment of diastolic function and myocardial perfusion enhances risk stratification post myocardial infarction.

Pheochromocytoma mimicking an acute myocardial infarction

We report a 42-year-old female who presented with retrosternal pain, dyspnoea and nausea. Electrocardiography suggested a recent anterior myocardial infarction. However, emergency coronary angiography showed normal blood flow through all the coronary arteries. Paroxysmal hypertension raised the suspicion of a pheochromocytoma. Indeed, abdominal ultrasonography and computed tomography revealed a mass in the left adrenal gland. Elevated levels of plasma and urine catecholamines supported the diagnosis of pheochromocytoma. Left adrenalectomy was performed without complications and pathological examination revealed a 5.5 cm pheochromocytoma. After surgery, all antihypertensive medication was discontinued and the blood pressure returned to normal within several days. Currently, the patient is asymptomatic, has normal catecholamine levels and the electrocardiographic signs of ischaemia have resolved entirely. This case illustrates that a rare clinical entity such as pheochromocytoma should be considered in the differential diagnosis of acute coronary syndrome. (Neth Heart J 2007;15:248-51.).

Severe disseminated intravascular coagulation caused by congestive heart failure and left ventricular thrombus

We present a patient who visited emergency department owing to the skin manifestation of disseminated intravascular coagulation. Recent anterior myocardial infarction induced congestive heart failure and left ventricular thrombus, which were considered to be the cause of disseminated intravascular coagulation. Anticoagulant therapy with heparin and warfarin was used successfully to treat the disseminated intravascular coagulation and left ventricular thrombus.

Left Ventricular Endocardial Irregularity: Evaluation Using Epicardial Echocardiography

A 78-YEAR-OLD MAN with history of hypertension and a recent anterior myocardial infarction was admitted for further evaluation of a positive stress transthoracic echocardiography (TTE) study. His TTE revealed mild systolic dysfunction with an estimated ejection fraction (EF) of 45%. The anterior wall was hypokinetic, and the apical cap was thinned and akinetic. Cardiac catheterization revealed 3-vessel coronary artery disease with 75% stenosis of the proximal right coronary artery, 95% stenosis of the midcircumflex coronary artery, and 100% occlusion of the left anterior coronary artery.

Severe Endothelial Dysfunction After Sirolimus-Eluting Stent Implantation

A 40-year-old man with a recent anterior myocardial infarction but with no history of coronary spasm and no risk factors for endothelial dysfunction such as diabetes mellitus, hypertension, smoking, or hypercholesterolemia was admitted to our hospital. Coronary angiography showed diffuse 90% proximal left anterior descending artery stenosis (Figure 1A). He received a sirolimus-eluting stent (Cypher, Cordis Corporation, Miami Lakes, Fla) to treat diffuse …

Myocardial Contrast Echocardiographic Estimates of Infarct Size Predict Likelihood of Left Ventricular Remodeling After Acute Anterior Wall Myocardial Infarction

We sought to determine the utility of myocardial contrast echocardiography (MCE) in predicting left ventricular (LV) remodeling (LVR) in patients with a recent anterior wall myocardial infarction and residual regional LV akinesis. Although recent studies have shown that MCE predicts recovery of regional and global LV systolic function after myocardial infarction, the relationship between myocardial perfusion patterns and likelihood of subsequent LVR has not been extensively studied. In all, 50 patients (mean age 62 years) underwent contrast-enhanced echocardiography for determination of LV volumes and ejection fraction, and MCE, 2 days after admission, with follow-up contrast-enhanced echocardiography 6 months later. LVR was defined as greater than 15% increase in LV end-diastolic volume index at follow-up. LVR occurred in 19 patients (38%) (group 1), with stable LV volumes in 31 patients (62%) (group 2). Routine clinical and angiographic variables did not differ between groups 1 and 2. Both transmural extent of infarction and number of abnormally perfused myocardial segments (assessed by MCE) predicted LVR. LVR occurred in 55% of patients with transmural perfusion defects, and was less common in those with subendocardial perfusion defects or normal perfusion (31% and 21%, respectively). The mean percent increase in LV size was significantly greater for transmural infarcts (15 +/- 7%) versus subendocardial infarcts or normal perfusion (-1 +/- 8 and 8 +/- 8, respectively). When more than 5 myocardial segments were abnormally perfused, remodeling always occurred and was extensive. MCE markers of infarct size are useful in predicting subsequent risk of LVR after myocardial infarction. Routine performance of MCE studies in select patients early after infarction may be helpful in further refining risk stratification.