Rescue Percutaneous Coronary Intervention Research Articles

Predictive Value of Global Longitudinal Strain on the Recovery of Left Ventricular Function Following ST-Segment Elevation Myocardial Infarction

Background: Identifying reliable predictors for ventricular recovery at the outset is crucial for patients with ST-segment elevation myocardial infarction (STEMI) treated with percutaneous coronary intervention (PCI). Objectives: This study aimed to evaluate the role of baseline global longitudinal strain (GLS) in predicting myocardial recovery following an acute infarction. Methods: We enrolled 60 consecutive patients diagnosed with STEMI and admitted to Al-Zahra Hospital for PCI from March 2022 to March 2023. Echocardiography was performed on all patients within 48 hours after revascularization to measure baseline parameters, including left ventricular ejection fraction (LVEF) and GLS. Follow-up echocardiography was conducted 6 months later to reassess LVEF. Results: At the 6-month follow-up, 38 (63.3%) patients showed a ≥ 5% improvement in LVEF, indicating ventricular recovery. The change in GLS was significantly different between the groups (recovered: -4.72 ± 2.00, not recovered: -2.41 ± 2.15, P < 0.001). A baseline GLS ≤ -4.5 and > -14.8 was predictive of either failure to recover or successful recovery of LVEF with 100% negative and positive predictive values, respectively. Baseline GLS values > -9.2 were predictive of LV recovery with 50% sensitivity and 83.3% specificity (P = 0.0002, AUC (95% confidence interval) = 0.697 (0.594, 0.799)). The type of revascularization was linked to better prediction outcomes, with patients undergoing primary and rescue PCIs more likely to recover during the follow-up period compared to those receiving deferred PCI after 24 hours (P = 0.032). Conclusions: While certain baseline GLS value thresholds may serve as predictors of LVEF recovery in patients with STEMI undergoing primary PCI, further prospective studies with larger cohorts are needed to establish more precise cut-off values.

P 022: Myopericarditis associated with herpes zoster infection presented with STEMI

We describe a case of an 18-year-old male with no known medical illness who presented with a history of fever and skin rash for the previous 2 days. The patient presented with symptoms of acute nausea, vomiting, and chest discomfort. The initial electrocardiogram (ECG) revealed an inferior ST-segment elevation myocardial infarction (STEMI), which prompted the administration of thrombolysis using streptokinase at the district hospital. However, consecutive ECGs showed no change, prompting the patient to be referred to our centre for a rescue percutaneous coronary intervention (PCI). The coronary angiography showed normal coronaries, whereas an echocardiogram showed good LV functions without any regional wall motion abnormalities and with normal valves. Upon further examination, the patient exhibited herpes zoster lesions along the T5–T6 dermatome. Blood investigations revealed elevated levels of thyroid hormones, as well as increased creatinine kinase and troponin I. The cardiac MRI showed the presence of mid-wall enhancement in the septal and lateral myocardium of the left ventricle, sub-epicardium of the right ventricle, and apical region of the left ventricle, which is indicative of myocarditis. The patient was diagnosed with myopericarditis and was treated with IV acyclovir, colchicine, high-dose aspirin, and carbimazole. He subsequently showed significant improvement and was successfully discharged. Although type 1 STEMI remains the prevailing diagnosis, this case emphasises the distinctive differential diagnosis of myopericarditis in patients presenting with chest discomfort and herpes zoster. Clinicians must obtain a thorough medical history and conduct a comprehensive evaluation to identify potential secondary aetiologies.

Circumflex Coronary Artery Injury during Modern Mitral Valve Surgery-A Review of Current Concepts and Perspectives.

The devastating impact of a circumflex coronary artery (CX) injury during mitral valve (MV) surgery is well reported. Despite significant improvements in preoperative risk assessment, intraoperative diagnosis and perioperative treatment strategies of CX injury during MV surgery, recent reports re-emphasize the variability in presentation, the unpredictable mechanisms of injury and the conflicting evidence regarding perioperative management. The progressive transition from conventional sternotomy access to minimally invasive surgical and transcatheter (TC) interventions for MV disease are associated with significant learning curves and require additional single-shaft and robotic console suture manipulation skills with special attentiveness to the potential risk of CX injury. The introduction of hybrid theatres that facilitate single stage surgical and TC interventions also provides new intraoperative diagnostic and therapeutic options without transporting unstable patients for percutaneous coronary intervention (PCI) assessment. By utilizing a MeSH terms-based PubMed search, a total of 89 patients with CX injury that occurred during MV surgery was identified from 49 reports between 1967 and 2022. MV surgery was performed by conventional sternotomy (n = 76, 85.4%), endoscopic (n = 12, 13.4%) and robotic access (n = 1, 1.1%), with 35 injuries (39.3%) resulting in total CX occlusion. Rescue PCI was utilized in 40 patients (44.9%). This manuscript provides a systematic overview of all available historic and contemporary reports on CX injury during MV surgery, outlines recent refinements in CX injury mechanisms, describes current MV surgery associated CX injury prevention and diagnosis and treatment strategies and highlights important MV procedural aspects that may minimize the risk and consequences of CX injury.

Role of fibrinolysis after the generalization of the primary percutaneous coronary intervention in the setting of ST-Elevation Acute Myocardial Infarction

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Primary percutaneous coronary intervention (PCI) is the treatment of choice in patients with ST-Elevation Acute Myocardial Infarction (STEMI). Fibrinolysis is relegated to situations in which the intervention cannot be performed in the appropriate time. The indications for fibrinolysis and the criteria for reperfusion were established long ago. Furthermore, in many areas, patients undergoing fibrinolysis therapy represent a minority due to increased access to primary PCI-centres. Purpose We sought to evaluate the effectiveness of fibrinolysis and its safety compared to primary PCI in a real-world analysis. Methods This is a retrospective, observational, single-centre study in which we included patients with STEMI diagnosis admitted to the coronary unit from June-2011 to August-2022. It was differentiated if the patients underwent primary PCI or fibrinolysis (time to catheterization room >2 hours). The efficacy of fibrinolysis regarding the coronary reperfusion capability was analysed using the TIMI coronary grade flow scoring system. Similarly, the need for rescue PCI (<50% ST normalization, persistent chest pain or hemodynamic instability) was observed. We compared the baseline characteristics of the patients who underwent fibrinolysis versus those who only underwent a primary angioplasty strategy and the results in terms of complications and in-hospital mortality. Results 1604 patients were included with an average age of 62 years, in which 137 (8,4%) of them underwent a fibrinolysis strategy. The rate of patients with coronary occlusion (TIMI 0) at the time of PCI was significantly lower in the fibrinolysis group (77.1% vs 36.1%; p<0.001), which represents an estimated effectiveness of coronary recanalization of 53.2%. Initially, we found more smokers (46,0% vs 57,4% p = 0.01), and a younger age (62 vs 58, p<0,01) among patients who underwent fibrinolysis. No other differences were found in the remaining baseline characteristics (Table). A higher rate of ventricular arrhythmias (10,4% vs 16,0%; p=0.04) was demonstrated in the fibrinolysis group, but without showing differences in terms of mortality (5.7% vs 2.1%; p= NS.). No significant differences in bleeding (8.9% vs 10.9%; p=NS.) or intracranial hemorrhage (0.1% vs 0.7%, p= NS.) were found. Regarding rescue-PCI, it was necessary in 81 (59,12%) of the patients who underwent fibrinolysis. 70% of the patients who underwent rescue PCI had TIMI 0-1. In the patients treated with fibrinolysis who underwent early-PCI but not rescue-PCI, only 3 patients (6,5%) presented coronary occlusion (TIMI 0) at catheterization. Conclusion Fibrinolysis should continue to play an important role in patients who cannot reach PCI on time, given its effectiveness and because it does not represent a significant increase in mortality or adverse effects, except for ventricular arrhythmias. Likewise, the reperfusion criteria seem to be effective in differentiating patients with coronary reperfusion.

Fibrinolytic therapy use for ST-segment elevation myocardial infarction and long-term outcomes in China: 2-year results from the China Acute Myocardial Infarction Registry

BackgroundData on fibrinolytic therapy use for ST-segment elevation myocardial infarction (STEMI) and long-term clinical outcomes in developing countries are limited. We aimed to investigate the management and 2-year mortality of fibrinolytic-treated patients in China.MethodsA total of 19,112 patients with STEMI from 108 hospitals participated in the China Acute Myocardial Infarction registry between January 2013 and September 2014. We investigated the 2-year all-cause mortality among patients treated with fibrinolysis. Non-invasive clinical indexes were used to diagnose successful fibrinolysis or not.ResultsOnly 1823 patients (9.5%) enrolled in the registry underwent fibrinolysis and 679 (37.2%) could be treated within 3 h after symptom onset. The overall use of rescue percutaneous coronary intervention was 8.9%. Successful fibrinolysis, which could be achieved in 1428 patients (78.3%), was related to types of fibrinolytic agents, symptom to needle time, infarction site, and Killip class. Follow-up data were available for 1745 patients (95.7%). After multivariate adjustment, successful fibrinolysis was strongly associated with a decreased risk of death compared with failed fibrinolysis at 2 years (8.5% vs. 29.0%, hazard ratio: 0.27, 95% confidence interval: 0.20–0.35).ConclusionWithin a minority of STEMI patients in the CAMI registry underwent fibrinolysis, most of them could achieve successful clinical reperfusion, presenting a much benign 2-year survival outcome than those with failed fibrinolysis. Quality improvement initiatives focusing on fibrinolysis are warranted to achieve its promise fully.Trial registration: URL: https//www.clinicaltrials.gov. Unique identifier: NCT01874691. Registered 11/06/2013.

Discussion on the causes of thrombolysis failure in a patient with STEMI: a case report

BackgroundSpontaneous coronary artery dissection (SCAD) has emerged as an increasingly diagnosed cause of ST-segment elevation myocardial infarction (STEMI), which is easily missed or delayed. The effective use of coronary angiography (CAG) and advanced intracoronary imaging examinations in STEMI patients has led to increased detection of SCAD.Case presentationA 59-year-old woman with acute angina pectoris was diagnosed with STEMI detected by electrocardiography combined with measurement of myocardial enzymes. Due to the ongoing pandemic of coronavirus disease 2019 (COVID-19) in Wuhan, she was first given thrombolytic therapy after excluding contraindications according to the requirements of the current consensus statement; however, subsequently, both the symptoms of ongoing chest pain and the electrocardiographic results indicated the failure of thrombolytic therapy, so the intervention team administered rescue percutaneous coronary intervention treatment under third-grade protection. CAG confirmed total occlusion in the distal left anterior descending (LAD) artery, with thrombolysis in myocardial infarction (TIMI) 0 flow, whereas the left circumflex and right coronary arteries appeared normal, with TIMI 3 flow. Intravenous ultrasound (IVUS) was further performed to investigate the causes of occlusion, which verified the absence of atherosclerosis but detected SCAD with intramural haematoma. During the operation, the guidewire reached the distal end of the LAD artery smoothly, the balloon was dilated slightly, and the reflow of TIMI blood could be seen by repeated CAG. During the follow-up period of one and a half years, the patient complained of occasional, slight chest tightness. The repeated CAG showed that the spontaneous dissection in the LAD artery had healed well, with TIMI 3 flow. The repeated IVUS confirmed that the SCAD and intramural haematoma had been mostly resorbed and repaired.ConclusionThis was a case of failed STEMI thrombolysis in our hospital during the outbreak of COVID-19. This case indicates that doctors need to consider the cause of the disease when treating STEMI patients, especially patients without traditional cardiovascular risk factors. Moreover, CAG and intracoronary imaging examinations should be actively performed to identify the aetiology and improve the treatment success rate.

SARS-CoV-2 Positivity, Stent Thrombosis, and 30-day Mortality in STEMI Patients Undergoing Mechanical Reperfusion.

SARS-Cov-2 has been suggested to promote thrombotic complications and higher mortality. The aim of the present study was to evaluate the impact of SARS-CoV-2 positivity on in-hospital outcome and 30-day mortality in ST-segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI) enrolled in the International Survey on Acute Coronary Syndromes ST-segment elevation Myocardial Infarction (ISACS-STEMI COVID-19 registry. The 109 SARS-CoV-2 positive patients were compared with 2005 SARS-CoV-2 negative patients. Positive patients were older (P = .002), less often active smokers (P = .002), and hypercholesterolemic (P = .006), they presented more often later than 12h (P = .037), more often to the hub and were more often in cardiogenic shock (P = .02), or requiring rescue percutaneous coronary intervention after failed thrombolysis (P < .0001). Lower postprocedural Thrombolysis in Myocardial Infarction 3 flow (P = .029) and more thrombectomy (P = .046) were observed. SARS-CoV-2 was associated with a significantly higher in-hospital mortality (25.7 vs 7%, adjusted Odds Ratio (OR) [95% Confidence Interval] = 3.2 [1.71-5.99], P < .001) in-hospital definite in-stent thrombosis (6.4 vs 1.1%, adjusted Odds Ratio [95% CI] = 6.26 [2.41-16.25], P < .001) and 30-day mortality (34.4 vs 8.5%, adjusted Hazard Ratio [95% CI] = 2.16 [1.45-3.23], P < .001), confirming that SARS-CoV-2 positivity is associated with impaired reperfusion, with negative prognostic consequences.

Spanish cardiac catheterization and coronary intervention registry. 31st official report of the Interventional Cardiology Association of the Spanish Society of Cardiology (1990-2021)

Introduction and objectivesThe Interventional Cardiology Association of the Spanish Society of Cardiology (ACI-SEC) presents its annual activity report for 2021. MethodsAll Spanish centers with catheterization laboratories were invited to participate. Data were collected online and were analyzed by an external company, together with the members of the ACI-SEC. ResultsA total of 121 centers participated (83 public and 38 private). Compared to 2020, both diagnostic coronary angiograms and percutaneous coronary interventions (PCI) increased by 11,4% and 10,3%, respectively. The radial approach was the most used access (92,8%). Primary PCI also increased by 6.2% whereas rescue PCI (1,8%) and facilitated PCI (2,4%) were less frequently conducted. Transcatheter aortic valve implantation was one of the interventions with the most relevant increase. A total of 5720 transcatheter aortic valve implantation procedures were conducted with an increase of 34,9% compared to 2020 (120 per million in 2021 and 89,4 per million in 2020). Other structural interventions like transcatheter mitral or tricuspid repair, left atrial appendage occlusion and patent foramen oval closure also experienced a significant increase. ConclusionsThe 2021 registry demonstrates a clear recovery of the activity both in coronary and structural interventions showing a relevant increase compared to 2020, the year of the COVID-19 pandemic.

Registro español de hemodinámica y cardiología intervencionista. XXXI informe oficial de la Asociación de Cardiología Intervencionista de la Sociedad Española de Cardiología (1990-2021)

Introduction and objectivesThe Interventional Cardiology Association of the Spanish Society of Cardiology (ACI-SEC) presents its annual activity report for 2021. MethodsAll Spanish centers with catheterization laboratories were invited to participate. Data were collected online and were analyzed by an external company, together with the members of the ACI-SEC. ResultsA total of 121 centers participated (83 public and 38 private). Compared to 2020, both diagnostic coronary angiograms and percutaneous coronary interventions (PCI) increased by 11,4% and 10,3%, respectively. The radial approach was the most used access (92,8%). Primary PCI also increased by 6.2% whereas rescue PCI (1,8%) and facilitated PCI (2,4%) were less frequently conducted. Transcatheter aortic valve implantation was one of the interventions with the most relevant increase. A total of 5720 transcatheter aortic valve implantation procedures were conducted with an increase of 34,9% compared to 2020 (120 per million in 2021 and 89,4 per million in 2020). Other structural interventions like transcatheter mitral or tricuspid repair, left atrial appendage occlusion and patent foramen oval closure also experienced a significant increase. ConclusionsThe 2021 registry demonstrates a clear recovery of the activity both in coronary and structural interventions showing a relevant increase compared to 2020, the year of the COVID-19 pandemic.

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

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

TIMI flow and myocardial blushing after rescue PCI and cardiac magnetic resonance: Results from the Myocardial Salvage After Rescue Angioplasty: Evaluation by Magnetic Resonance (SAVE-ME) study

IntroductionThrombolysis is currently reserved for ST-elevation myocardial infarction (STEMI) patients who cannot access timely percutaneous coronary intervention (PCI). In case of failed thrombolysis, rescue PCI is a viable option. Substantial data concerning the outcomes in terms of infarct size and myocardial function after rescue PCI are lacking. MethodsForty patients treated with rescue PCI underwent serial contrast-enhanced cardiac magnetic resonance imaging (CMR) at 1 week, 3 months and 6 months from the index STEMI. Angiographic images were reviewed to assess Thrombolysis in Myocardial Infarction (TIMI) blood flow and TIMI Myocardial Blush Grade (TMBG) in the infarct related artery after PCI. ResultsPatients with lower TMBG at the end of procedure, but not patients with worse TIMI flow, had lower left ventricular ejection fraction (LVEF) and higher volume of late gadolinium enhancement (LGE) on baseline CMR (44 ± 13% vs 52 ± 9%, p = 0.026, and 41 ± 21 ml vs 26 ± 12, p = 0.030, respectively). Patients with lower TMBG remained with significantly lower LVEF at 6 months follow up (48 ± 16% vs 59 ± 14, p = 0.049). ConclusionTMBG after rescue PCI is associated with reduced LVEF and increased LGE burden. As TMBG is a known marker of microvascular damage after STEMI, novel strategies aimed at improving microvascular function in the setting of rescue PCI are needed to improve the outcomes in this patient population.

Reperfusion Times in a Telemedicine-guided Program for the Management of ST-segment Elevation Myocardial Infarction in the Province of La Pampa

Background: Timing of medical care is a relevant factor for ST-segment elevation myocardial infarction (STEMI) mortality. Objectives: The aim of the present study is to evaluate reperfusion times in STEMI patients participating in a telemedicine-based cardiology care program in the province of La Pampa between August 2018 and December 2021. Methods: This program consists of a protocol for the management of patients with acute coronary syndrome (ACS) in the different locations of the province, with 24-hour remote assistance provided by cardiologists, including both diagnostic support and coordination of on-site thrombolysis. Results: Of a total of 72 STEMI patients evaluated, 44 received thrombolysis as reperfusion therapy, 25 received primary percutaneous coronary intervention, and 3 received thrombolysis followed by rescue percutaneous coronary intervention. Of the 47 subjects who received thrombolysis, only 5 required to be transferred to the referral center for this procedure. Median door-to-needle time was 24 minutes and door-to balloon-time was 105 minutes. Twenty-eight percent of the subjects with primary percutaneous coronary intervention had a door-to-balloon time &lt; 90 minutes and 53.2% of patients who received thrombolysis fulfilled a door-to-needle time &lt; 30 minutes. Conclusions: The implementation of a telemedicine-guided program for decentralized management of STEMI patients was associated with a high percentage of compliance with the goals of implementing fibrinolytic-based reperfusion therapy

Allopurinol pretreatment effects on coronary blood flow and revascularization outcomes in acute STEMI patients underwent emergency percutaneous coronary intervention

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): Isfahan University of Medical Sciences, Isfahan, Iran. Introduction Todays, acute ST-segment elevation myocardial infarction (STEMI) is considered as a most important component of acute coronary syndrome. In this regards, reperfusion therapy with percutaneous coronary intervention (PCI) is the most effective treatment for establishing coronary blood flow; which despite reperfusion of ischemic myocardium, it can also induce secondary injury as myocardial ischemia-reperfusion injury. The generation of reactive oxygen species by activation of xanthine oxidase (XO) enzymatic system is one of the major causes of ischemia-reperfusion injury in the ischemic myocardium and allopurinol, a XO inhibitor, has an inhibitory role on free radical productions in STEMI patients. Purpose In this study, we aimed to assess impact of allopurinol pre-treatment on revascularization outcomes, according to Thrombolysis in Myocardial Infarction (TIMI) flow and ST segment elevation recovery as well as clinical finding and major cardiac events incidence in STEMI patients underwent emergency PCI. Methods In this randomized double blind clinical trial, we enrolled 90 patients with acute STEMI in two equal groups. Allopurinol group received 600 mg allopurinol loading dose before the emergency PCI and the control group received the same shape medication as a placebo. Both groups also received the standard pretreatment protocol for PCI in acute STEMI setting. TIMI flow, ECG changes, Troponin level and major cardiac events (MACE) occurrence including death, myocardial infarction and ischemic stroke after 1 month follow up were assessed. In case group, allopurinol 100 mg daily and matched placebo pill for control group was continued for one month in addition to standard medications. Results Finally, 81 patients with acute STEMI has completed the study. The mean age of study population was 59.52 (11.31) and 61.3 (9.25) in case and control groups respectively (p = 0.49). Troponin level 48 hour after the PCI had not significant difference between the groups (p = 0.25). ECG ST-elevation regression also had not significant difference between the groups [75.0%1 vs 67.10% in case and control groups, respectively (p = 0.21)]. TIMI flow had improved in allopurinol group rather than placebo (p = 0.02). PCI success rate was 78.6% and 61.5% in allopurinol and control group respectively (p = 0.09). MACE and other clinically outcomes in follow up period were similar between groups (p &amp;gt; 0.05). Conclusions This study indicated that allopurinol pre-treatment loading dose could improve minimally revascularization outcomes based on TIMI flow in the patients undergoing primary or rescue PCI in acute STEMI setting.

Utility of a smartphone application in assessing palmar circulation prior to radial artery harvesting for coronary artery bypass grafting: rationale and design of the randomised CAPITAL iRADIAL-CABG trial

IntroductionThere is emerging evidence supporting the use of the radial artery (RA) as a preferred secondary conduit for coronary artery bypass grafting (CABG) as it is associated with higher rates...

A Patient with Acute Myocardial Infarction who Experienced Mortality due to Ventricular Septal Rupture: A Case Report

Ventricular septal rupture (VSR) is one of the rare complications of acute myocardial infarction (AMI). Although the incidence decreased in percutaneous coronary intervention (PCI) era, the mortality rate remained extremely high. We report a case of an AMI patient who developed a post-fibrinolytic VSR, which was confirmed by echocardiography. Although rescue PCI had been performed, the clinical condition did not improve because he was also having coronary slow flow (CSF). Then he fell into cardiogenic shock and acute lung edema, and died. The main key to dealing with VSR is to reduce afterload so that the left-to-right bypass flow can be reduced in order to maintain the adequate LV stroke volume. In addition to pharmacological therapy, mechanical supportive therapy and correction of VSR both surgically or transcatheterly are required. However, AMI patients with VSR still have a poor prognosis even with the optimal treatment.

Diagnosis of coronary artery rethrombosis after effective systemic thrombolytic therapy in patients with ST-segment elevation myocardial infarction

The aim of the study was to evaluate the diagnostic significance of ST-segment re-elevation episodes registered with telemetric ECG monitoring in patients with ST-segment elevation myocardial infarction (STEMI) treated with...

Poor Outcome of Right Bundle Branch Block Coexist with ST-Elevation Myocardial Infarction

BACKGROUND: The incidence of new-onset right bundle branch block (RBBB) coexistence with ST-elevation myocardial infarction (STEMI) has been associated with higher in-hospital mortality compared with those without RBBB. CASES: We present three cases of new-onset RBBB coexist with STEMI. Case I: a 64 years old male presented Killip I STEMI inferior-anterior with RBBB as new-onset. Rescue percutaneous coronary intervention (PCI) after failed thrombolytic was performed. New-onset atrial fibrillation (AF) with rapid ventricular response worsened his hemodynamic profile, leading to cardiogenic shock. Case II: an 80 years old male presented Killip IV late-onset anterior STEMI with new-onset RBBB. Cardiogenic shock got worsened after PCI stent. Case III: a 65 years old male presented Killip II extensive anterior STEMI with new-onset RBBB who underwent a primary PCI stent. Recurrent ventricular tachycardia (VT), worsening cardiogenic shock, and transient AV block occurred after PCI. The right bundle branch blood supply is mainly provided by a septal branch of left descending artery (LAD). Therefore, it may indicate proximal LAD occlusion and extensive infarction. Thus, catastrophic events may occur, which including acute heart failure, AV block, malignant ventricular arrhythmia, new-onset AF, and mostly cardiogenic shock, despite initiate reperfusion was performed without delay once the diagnosis is confirmed. CONCLUSION: New RBBB suggests poor short-term prognosis due to its complication. Higher mortality is mostly linked to worsening cardiogenic shock.

A study to compare fibrinolytic therapy versus primary percutaneous coronary intervention in ST-segment elevation myocardial infarction in a tertiary care hospital

Background: ST-segment elevation myocardial infarction (STEMI) is the most dramatic manifestation of coronary artery disease, acute STEMI is a clinical syndrome defined by characteristic symptoms of myocardial ischemia in association with persistent electrocardiographic ST elevation and subsequent release of biomarkers of myocardial necrosis. Reperfusion with thrombolysis or PCI (percutaneous coronary intervention) is the current standard of care for STEMI. Aims and Objectives: The aim of the study was to compare the effectiveness of fibrinolytic therapy and primary PCI which are the available reperfusion strategies for STEMI. Materials and Methods: This prospective and observational study was conducted at a tertiary care hospital in Bangalore. Patients presenting with STEMI to emergency department were treated with either fibrinolysis or PCI as per protocol. Patients in each arm were followed up to know the differences in outcome at discharge and 30-day follow-up. Results: Patients admitted with STEMI had overall in hospital mortality of 17 (7.1%) patients, of which 9 (7.6%) patients were from fibrinolysis group and 8 (6.6%) patients from PCI group with no statistically significant difference (P = 0.760). There was significant incidence (P = 0.001) of reinfarct in fibrinolysis group (9.3%) when compared to PCI group (0%). Conclusion: There was no statistically significant mortality difference at discharge and at 30 day between fibrinolysis and primary PCI in patients with STEMI in our study, this may be attributed to use of rescue PCI in failed fibrinolysis patients and early tricuspid valve repair in many patients after fibrinolysis.

Reperfusion After Fibrinolytic Therapy (RAFT): An open-label, multi-centre, randomised controlled trial of bivalirudin versus heparin in rescue percutaneous coronary intervention.

BackgroundThe safety and efficacy profile of bivalirudin has not been examined in a randomised controlled trial of patients undergoing rescue PCI.ObjectivesWe conducted an open-label, multi-centre, randomised controlled trial to compare bivalirudin with heparin ± glycoprotein IIb/IIIa inhibitors (GPIs) in patients undergoing rescue PCI.MethodsBetween 2010–2015, we randomly assigned 83 patients undergoing rescue PCI to bivalirudin (n = 42) or heparin ± GPIs (n = 41). The primary safety endpoint was any ACUITY (Acute Catheterization and Urgent Intervention Triage Strategy) bleeding at 90 days. The primary efficacy endpoint was infarct size measured by peak troponin levels as a multiple of the local upper reference limit (Tn/URL). Secondary endpoints included periprocedural change in haemoglobin adjusted for red cells transfused, TIMI (Thrombolysis in Myocardial Infarction) bleeding, ST-segment recovery and infarct size determined by the Selvester QRS score.ResultsThe trial was terminated due to slow recruitment and futility after an interim analysis of 83 patients. The primary safety endpoint occurred in 6 (14%) patients in the bivalirudin group (4.8% GPIs) and 3 (7.3%) in the heparin ± GPIs group (54% GPIs) (risk ratio, 1.95, 95% confidence interval [CI], 0.52–7.3, P = 0.48). Infarct size was similar between the two groups (mean Tn/URL, 730 [±675] for bivalirudin, versus 984 [±1585] for heparin ± GPIs, difference, 254, 95% CI, -283-794, P = 0.86). There was a smaller decrease in the periprocedural haemoglobin level with bivalirudin than heparin ± GPIs (-7.5% [±15] versus -14% [±17], difference, -6.5%, 95% CI, -0.83–14, P = 0.0067). The rate of complete (≥70%) ST-segment recovery post-PCI was higher in patients randomised to heparin ± GPIs compared with bivalirudin.ConclusionsWhether bivalirudin compared with heparin ± GPI reduces bleeding in rescue PCI could not be determined. Slow recruitment and futility in the context of lower-than-expected bleeding event rates led to the termination of this trial (ANZCTR.org.au, ACTRN12610000152022).

Successful Rescue Intervention of Internal Mammary Artery Anastomotic Site Acute Graft Failure With Direct New Generation Covered Stenting

Acute, perioperative myocardial infarction (MI) from acute left internal mammary artery (LIMA) to left anterior descending (LAD) graft failure immediately following coronary artery bypass grafting (CABG) surgery is associated with significantly increased in-hospital mortality. The leading etiology of such acute graft failure is acute thrombosis, dissection, spasm, anastomosis failure or no-reflow phenomenon. Repeat bypass surgery carries incremental risk and may not be feasible in hemodynamically unstable patients. Traditional percutaneous coronary intervention (PCI), with or without stent placement is sometimes used in such cases; however, graft anatomy and lesion location increase procedural complexity and challenge technical feasibility. This is particularly true of the LIMA to LAD graft anastomosis, where PCI carries the risk of anastomotic site perforation or avulsion. Therefore, the best revascularization strategy for such a lesion involving the LIMA to LAD graft anastomosis in the immediate perioperative period remains unknown. We present a case of 75-year-old male who suffered an acute MI complicated by cardiogenic shock less than 24 h after two-vessel CABG. Selective angiography revealed acute LIMA to LAD anastomotic site closure, posing a risk for perforation if treated with traditional angioplasty or stenting. We successfully performed rescue PCI, by directly deploying a PK Papyrus covered stent (Biotronik, Berlin, Germany) across the anastomosis. Our case report describes the upfront (rather than a bail out) use of the new covered stent as a novel revascularization strategy to treat “perforation prone” LIMA to LAD anastomotic site acute graft failure. J Med Cases. 2021;12(7):271-274 doi: https://doi.org/10.14740/jmc3695