ST-segment Elevation In aVR Research Articles

Abstract 4119260: Anomalous Origin Of Left Circumflex Artery From Right Pulmonary Artery Resulting In Heart Failure: A Rare Vascular Steal Phenomenon

Background: Anomalous origin of coronary arteries from the pulmonary artery usually presents at a younger age. However, we encountered a case of a 62-year-old female with an anomalous origin of the left circumflex (LCx) artery from the right pulmonary artery. Case summary: A 62-year-old female presented with complaints of dyspnea and angina on exertion for 1 month and had paroxysmal nocturnal dyspnea for the last 4-5 days. She also had an episode of ventricular tachycardia which required DC cardioversion. She had diabetes mellitus type 2 and hypertension. ECG showed diffuse horizontal ST segment depression in precordial, and limb leads and ST segment elevation in aVR suggesting subendocardial ischemia. The echocardiogram showed hypokinesia in basal, mid-inferior and inferolateral segments and LVEF of 42%. There was a marked reduction in global longitudinal strain (average GLPS of -9.2%). Her coronary angiogram revealed extensive collaterals to the left circumflex artery (from the left anterior descending artery and right coronary artery). The left circumflex artery was arising from the pulmonary artery. Exact localization of origin was done by simultaneous contrast injections in the right pulmonary artery and LAD. The anomalous origin of LCx from the right pulmonary artery was hooked using a Tiger catheter. The patient was advised for surgical management; however, the patient has opted for medical therapy. Conclusion: The anomalous origin of coronary arteries from pulmonary arteries is usually detected in childhood e.g. ALCAPA and is associated with other congenital heart diseases. Anomalous origin of LCx from the right pulmonary artery is a rare variant. It can result in a steal phenomenon which may result in angina, heart failure and risk of sudden cardiac arrest.

ST-segment elevation in aVR and coronary patterns in acute coronary syndrome (insights from 200 patients)

ST-segment elevation in aVR and coronary patterns in acute coronary syndrome (insights from 200 patients)

Predictive factors for type A aortic dissection mortality based on electrocardiogram parameters and clinical presentations.

Aortic dissection is a rare but potentially lethal disorder and may be associated with electrocardiogram (ECG) changes. In this study, we aim to investigate ECG-related parameters alongside clinical presentations of type A aortic dissection to come up with the predictive factors for the severity of the disease and its mortality rate. In this retrospective study, 201 patients with type A aortic dissection were studied between March 2015 and March 2020. Two expert cardiologists blinded to the diagnosis studied former and new patients' ECGs and recorded changes. Two-hundred and one patients, including 143 (71.1%) men and 58 (28.9%) women, presented with acute dissection of the aorta, were studied. Forty-four (21.8%) and 84 (41.7%) patients had ST-segment elevation and depression in ECG, respectively. Bivariate analysis revealed that higher heart rate (p=0.006), longer QTc (p=0.044), and ST-segment elevation in aVR lead (p=0.044) were associated with mortality in the patients. Multivariate regression showed higher heart rate (OR=1.022, CI=1.003-1.041, p=0.012) and ST-segment elevation in aVR (OR=4.854, CI=2.255-10.477, p<0.001) were independently associated with increased odds of mortality in aortic dissection patients. ROC curve analysis showed heart rate equal to or >60 per minute (AUC=0.625, sensitivity=86%, specificity=10%, p=0.019) and ST-segment elevation in aVR >0.5mm (AUC=0.854, sensitivity=75%, specificity=92%, p<0.001) were associated with a higher mortality rate. Heart rate equal or >60 and ST-segment elevation >0.5mm in aVR lead can be used as predictive factors for mortality of patients with type A aortic dissection.

ST-segment elevation in aVR following return of spontaneous circulation is associated with worse outcomes in cardiac arrest

Abstract Funding Acknowledgements Type of funding sources: Private hospital(s). Main funding source(s): Boston Medical Center Background ST-segment elevation in lead aVR (STE-aVR) is suggestive of global myocardial ischemia, typically in the setting of left main disease, triple vessel disease, or severe metabolic derangements, and is associated with increased mortality in acute coronary syndrome. The prevalence and prognostic significance of STE-aVR in patients presenting with cardiac arrest has not been previously described. Purpose We sought to describe the prevalence of STE-aVR among comatose survivors of cardiac arrest and evaluate the association of STE-aVR with in-hospital mortality and favorable neurologic outcome at hospital discharge. Methods We conducted a retrospective analysis of patients enrolled in the Multimodal Outcome CHAracterization in cardiac arrest patients (MOCHA) study at a single academic center. Participants were comatose survivors of cardiac arrest aged 18-89 years who had an initial electrocardiogram (ECG) obtained after ROSC between 2011-2020. STE-aVR was defined as ST elevation at the J point of ≥1 mm as measured by two trained assessors. Outcomes included in-hospital mortality and favorable neurologic outcome at hospital discharge (Cerebral Performance Category 1-2). Multivariable logistic regression, adjusted for age, medical comorbidities (diabetes, chronic kidney disease, heart failure, malignancy) and arrest characteristics (location, initial rhythm, witnessed status, bystander CPR) was used to test the association between outcomes and STE-aVR on ECG. Results 471 (89.0%) patients met inclusion criteria and were included in this analysis; 58 (11.0%) were excluded due to missing post-ROSC ECG. The median age was 62 years (Interquartile range: 51-73 years), and 284 (60.4%) were male. 297 (63.2%) presented with out-of-hospital cardiac arrest and 138 (29.4%) presented with a shockable rhythm. STE-aVR was present in 87 patients (18.5%). STE-aVR was more common in patients presenting with out-of-hospital cardiac arrest (22.9% vs 11.0%, P&amp;lt;0.01) but did not differ by initial rhythm (21.8% vs 31.1%, P=0.09). Patients with STE-aVR had higher mortality (83.9% vs 66.1%, P&amp;lt;0.01), which persisted after adjustment for confounding variables (Odds ratio (OR) 2.36; 95% Confidence Interval (CI): 1.23-4.52, P&amp;lt;0.01). Patients with STE-aVR had lower incidence of favorable neurologic outcome (13.8% vs 26.1%, P=0.01), however this association was not significant after adjusting for covariates (OR 0.52; 95% CI:0.26-1.05, P=0.07). Conclusion STE-aVR was present in nearly 1 in 5 comatose survivors of cardiac arrest. STE-aVR was independently associated with in-hospital mortality. Further research is needed to clarify the clinical significance and mechanism of STE-aVR in patients presenting with cardiac arrest.

Acute Coronary Syndrome Treated with Percutaneous Coronary Intervention in Hutchinson–Gilford Progeria

Hutchinson-Gilford progeria syndrome is an extremely rare genetic disease caused by a de novo mutation in the LMNA gene, leading to an accumulation of a form of Lamin A, called Progerin, which results in a typical phenotype and a marked decrease in life expectancy, due to early atherosclerosis and cardiovascular disease. We report the case of a fourteen-year-old Chinese boy with Hutchinson-Gilford progeria syndrome admitted to the emergency room because of precordial pain. Physical examination showed tachycardia 130 beats/min and arterial hypertension: 170/120 mmHg, normal respiratory rate, no neurological impairment; ECG evidenced sinus tachycardia, left ventricular hypertrophy, horizontal ST-segment depression in I, aVL, II, III, aVF leads, and V4-V6 and ST-segment elevation in aVR and V1 leads. Echocardiography highlighted preserved global left ventricular function with concentric hypertrophy, altered diastolic flow pattern, mitral valve insufficiency, and minimal aortic regurgitation. Blood tests evidenced an increase in high-sensitivity troponin T level (335 pg/mL). NSTEMI diagnosis was performed, and the patient was admitted to the intensive care unit. A coronary CT angiography showed a severe obstruction of the common trunk of the left coronary artery, for which an urgent percutaneous coronary intervention (PCI) was proposed. A selective coronary angiography imaged complete chronic occlusion of the left main coronary artery as well as severe stenosis at the origin of a very enlarged right coronary artery that vascularized the left coronary artery through collaterals. Afterwards, the right coronary artery was probed using an Amplatz right (AR1) guiding catheter, through which a large 3.5 mm drug-eluting coronary stent (Xience Sierra, Abbott, Abbott Park, IL, USA) was implanted. At the end of the procedure, no residual stenosis was imaged and improved vascularization of the left coronary artery distribution segments was observed. Dual antiplatelet therapy (DAPT) consisting of aspirin (75 mg daily) and clopidogrel (37.5 mg daily) and anti-hypertensive therapy were started. At the one-year follow-up, the patient had not reported any occurrence of anginal chest pain.

Subendocardial Ischemia Caused by Acute Severe Aortic Regurgitation Due to Aortic Root Dissection: A Case Report and Literature Review.

Electrocardiogram (ECG) findings showing ST-segment depression in a wide range of leads and ST-segment elevation in aVR are found in patients with acute coronary syndrome with multivessel coronary lesions and left main trunk lesions. A 64-year-old man with a history of eosinophilic granulomatosis presented with chest pain and dyspnea. Although an ECG showed the above findings, he was diagnosed with acute severe aortic regurgitation (AR) complicating aortic root dissection and successfully underwent urgent Bentall operation. These ECG findings indicated that acute severe AR caused subendocardial ischemia.

Rare Etiology of Reversible Hypokinetic Dilatated Heart Disease in Infants: Bland-White-Garland Syndrome (ALCAPA)

Bland-White-Garland syndrome or ALCAPA is an abnormality of birth of the left coronary artery from the pulmonary artery. It is a diagnostic and therapeutic emergency because it is a curable cause of hypokinetic dilated heart disease in infants. We report through this clinical case, the fourth case of infantile ALCAPA diagnosed in Senegal in a 7-month-old infant. The symptomatology began around the age of 2 months, with a grumpy state associated with more marked crying and moaning during feedings and bowel movements. The mother reported hospitalization for a severe lung infection when she was 6 months old. The examination noted an infant in poor general condition, retarded growth and weight, and a 3/6th holosystolic murmur at the apex. Troponinemia was positive at 43.90 ng/L. The electrocardiogram showed Q waves on the lower side, a sub endocardial lesion on the upper side and a ST segment elevation in aVR. Doppler echocardiography showed dilated cardiomyopathy with a mean alteration of systolic function of the left ventricle at 37%, a mean mitral insufficiency and a strong suspicion of a birth anomaly of the left coronary artery. The CT scan confirmed the diagnosis of ALCAPA. Surgicalreimplantation of the left coronary artery at the aortic level was performed at 10 months of life with a favourable outcome at D50 postoperative.

ECG patterns suggestive of high-risk coronary anatomy in non-ST-segment elevation acute coronary syndrome - an analysis of real-world patients.

Electrocardiographic (ECG) patterns suggestive of high-risk coronary anatomy are indications for an urgent invasive approach in non-ST-segment elevation acute coronary syndrome (NSTE-ACS). To estimate the frequency of the observed phenomenon and assess the clinical characteristics of NSTE-ACS subjects associated with Wellens syndrome, the de Winter sign, or ST-segment depressions by ≥ 1 mm in ≥ 6 classic ECG leads with simultaneous ST-segment elevation in aVR and/or V1. Out of 207 pre-screened subjects diagnosed with NSTE-ACS, 64 patients (26 women and 38 men) with complete medical records (including admission ECG and coronary angiography during the index hospitalization), and significant culprit stenosis or occlusion of the left main coronary artery (LMCA) or the proximal/middle segment of the left anterior descending artery (LAD) entered the final analysis. Clinical characteristics of patients exhibiting any of the high-risk ECG patterns was compared to their counterparts with significant lesions in LMCA or proximal/middle LAD without any of the high-risk ECG patterns. Among 64 patients with significant culprit lesions in LMCA or LAD, 19 (29.69%) exhibited one of the high-risk ECG patterns: Wellens syndrome (n = 10), the de Winter sign (n = 0), or multiple ST-segment depressions (n = 9). Clinical characteristics were comparable in 19 NSTE-ACS patients with the high-risk ECG patterns and their 45 counterparts. Because ECG patterns suggestive of high-risk coronary anatomy are relatively frequent in patients with NSTE-ACS and culprit lesions in LMCA or LAD, their early recognition is of clinical importance.

Myocardial infarction due to left main coronary artery total occlusion: A unique electrocardiographic presentation

Left main coronary artery (LMCA) total occlusion typically presents as anterolateral ST-segment myocardial infarction with or without right bundle branch block with left anterior fascicular block, and ST-segment elevation in aVR. On the contrary to the previously described electrocardiographic pattern we describe a distinct electrocardiographic presentation in a patient with total LMCA occlusion characterized by the presence of complete LBBB co-existing with upsloping ST-segment depression in precordial leads leading to symmetrical, tall, positive T waves, the so called de Winter's sign.

Combining qualitative and quantitative ECG criteria with the ESC 0/1h-hs-cTn-algorithm in the early diagnosis of non-ST-elevation myocardial infarction

Abstract Background The electrocardiogram (ECG) is one of the three main diagnostic tools for the assessment of patients with suspected non-ST-elevation myocardial infarction (NSTEMI). However, it is unknown how established qualitative or novel quantitative ECG criteria can best be combined with high-sensitivity cardiac troponin (hs-cTn)-based diagnostic algorithms, such as the ESC 0/1h-algorithm, for the early diagnosis of NSTEMI. Methods ST-segment depression, T-wave inversion, and a novel modified ST-segment deviation score (1), defined as the sum of ST-segment elevation in aVR plus absolute, unsigned ST-segment depressions in the remaining leads, were assessed blinded to all clinical data among unselected patients presenting with acute chest discomfort to the emergency department in an international multicentre prospective diagnostic study. Final diagnoses were centrally adjudicated by two independent cardiologists based on complete cardiac work-up, cardiac imaging and serial hs-cTn. Direct rule-in thresholds for the modified ST-segment deviation score, achieving a positive predictive value (PPV) of &amp;gt;70% justifying early monitorization and management, were derived, validated and compared to ST-segment depression and T-wave inversion and applied 1) alone and 2) in combination with the ESC 0/1h-hs-cTnT/I-algorithms. Results Among 3299 eligible patients, NSTEMI was present in 581 (17.6%) patients. ST-segment depression identified 243/3299 patients (7.4%) with a specificity of 96.5% (95% CI 95.7–97.1) and a PPV of 60.5% (95% CI 54.2–66.4) for the rule-in of NSTEMI, while T-wave inversion had a low PPV (38.0%; 95% CI 33.1–43.1). A modified ST-segment deviation score ≥6mm triaged 108/3299 patients (3.3%) towards direct rule-in upon ED arrival, resulting in a PPV of 71.3% (95% CI 62.1–79.0) and a specificity of 98.9% (95% CI 98.4–99.2), Figure 1. Bootstrap internal validation confirmed the robustness of these findings. Most patients ruled-in by ST-segment depression or a modified ST-segment deviation score ≥6mm would have been also ruled-in by the ESC 0/1h-hs-cTnT/I-algorithm, albeit 1–2h later. Combining ST-segment depression or a modified ST-segment deviation score ≥6mm with the ESC 0/1h-hs-cTnT-algorithm (Figure 2) accelerated the rule-in in those identified already by the ECG-criteria, and resulted in a modest number of reclassifications from rule-out or observe to rule-in. These results were confirmed in a secondary analysis assessing the combination of these ECG signatures with two ESC 0/1h-hs-cTnI-algorithms (Architect and Centaur). Conclusion Combining either ST-segment depression or a modified ST-segment deviation Score ≥6mm with the ESC 0/1h-hs-cTnT/I-algorithms accelerated and improved the early diagnosis of NSTEMI. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Swiss Heart Foundation (SHF) and Swiss National Science Foundation (SNSF)

Predictive value of ST-segment deviation in aVR in patients suffering from acute coronary syndrome: A retrospective cohort study.

Changes in the ST-segment in aVR of electrocardiogram have been used to predict the morbidity of left main and/or 3-vessel disease (LM/3-VD) in patients with acute coronary syndrome (ACS). However, the association with patient prognosis has rarely been reported.A total of 274 patients diagnosed with ACS were retrospectively evaluated following allocation into 1 of 3 groups: the ST-segment elevation (STE) group ≥ 0.05 mV, ST-segment depression (STD) group ≥ 0.05 mV, and the Isoelectric group in aVR. A comparison of clinical characteristics, coronary angiography results, major adverse cardiovascular events (MACE), and GRACE risk score was made.Patients in the STE and STD groups were older and had a lower LVEF, a greater number of MACE and higher GRACE risk score, compared with patients in the isoelectric group. Patients in the STE group had significantly greater morbidity due to LM/3-VD than did the non-STE groups. In addition, as the amplitude of STE in aVR increased, the number of MACE, GRACE risk score, and the incidence of LM/3-VD increased. Furthermore, after adjusting for other clinical factors, multivariate statistical results indicated that STE ≥ 0.05 mV in aVR was the only predictor of LM/3-VD, whereas STD ≥ 0.05 mV was not. It was found that STE or STD ≥ 0.05 mV in aVR was an independent predictor of MACE.STE ≥ 0.05 mV in aVR is associated with LM/3-VD. Furthermore, ST-segment deviation in aVR may have prognostic value of MACE and associated with higher GRACE risk scores in patients with ACS.

Electrocardiographic patterns predict the presence of collateral circulation and in-hospital mortality in acute total left main occlusion

BackgroundData on the clinical characteristics, electrocardiogram (ECG) findings and outcomes of patients with acute myocardial infarction (AMI) due to total unprotected left main (ULM) artery occlusion is limited.MethodsBetween 2009 and 2021, 44 patients with AMI due to total ULM occlusion underwent primary percutaneous coronary intervention (PCI) at our institution. The ECG, collateral circulation, clinical and procedural characteristics, and in-hospital mortality were retrospectively evaluated.ResultsTwenty five patients presented with shock and 18 patients had in-hospital mortality. Nineteen patients presented with ST-segment elevation myocardial infarction (STEMI), while 25 presented with non-ST-segment elevation myocardial infarction (NSTEMI). ST-segment elevation (STE) in I and STEMI were associated with the absence of collateral circulation, while STE in aVR was associated with its presence. In the NSTEMI group, patients with STE in both aVR and aVL showed more collateral filling of the left anterior descending coronary artery (LAD) territory, while patients with STE in aVR showed more collateral filling of the LAD and the left circumflex artery territory. Compared with total ULM occlusion, patients with partial ULM obstruction presented with more STE in aVR, less STE in aVR and aVL, and less STEMI. Shock, post-PCI TIMI 0–2 flow, non-STE in aVR, STEMI, and STE in I predicted in-hospital mortality. STEMI and the absence of collateral flow were significantly associated with shock.ConclusionsSTE in the precordial leads predicted the absence of collateral circulation while STE in aVR and STE in both aVR and aVL predicted different collateral filling territories in ULM occlusion. STE in I, non-STE in aVR, and STEMI predicted in-hospital mortality in these patients.

Acute Anterior Wall Myocardial Infarction

Background: According to recent research, examining the ST-segment shift in lead aVR provides valuable information on coronary angiographic anatomy and risk categorization. In acute anterior wall myocardial infarction (MI), lead aVR has diagnostic and prognostic relevance. The purpose of this study is to look at the relationship between presenting clinical status and coronary artery disease risk factors and ST-segment deviation in lead aVR. Methods: This prospective observational hospital-based study was carried out in the Department of Cardiology at Batra Hospital and Medical Research Centre in New Delhi. Patients with acute anterior wall ST-elevation MI who presented within 24 h of symptoms were included in the study. Continuous data were expressed as mean standard deviation and categorical variables as the number or percentage of patients. Results: The study involved 73 individuals who met the inclusion and exclusion criteria and had acute anterior wall ST-elevation MI. Thirty of the 73 patients (41%) had ST-segment elevation in lead aVR larger than 0.5 mm. In two groups, the distribution of various cardiovascular risk factors was examined. In all of the cases, the left anterior descending artery was affected. Patients with double- and triple-vessel disease were seen in more significant numbers in Group A than in Group B. Cardiogenic shock occurred in 6 of 30 patients in Group A and 3 of 43 patients in Group B. Conclusions: ST-elevation in lead aVR has predictive value. Patients with higher ST-segment elevation in aVR are more likely to suffer angina, CHF, and cardiogenic shock complications. Providing these patients with percutaneous or surgical revascularization therapy as soon as possible can reduce mortality.

The Value of Stress Echocardiography Imaging and Functional Parameters in Patients with aVR Lead ST-Segment Elevation during an Exercise Stress Test to Detect Significant Left Main Stenosis.

To evaluate the role of functional and imaging parameters during exercise stress echocardiography (SE) in the presence of ST-segment elevation (ST-E) in aVR leads to predict significant left main/left main equivalent/or ostial left anterior descending (LAD) stenosis (LM+). The study population included 548 patients with ECG and echo markers of myocardial ischemia, in whom diagnostic coronary angiography was performed. We analyzed the patients' clinical characteristics, ECG changes, wall motion score index (WMSI) by stress echocardiography (SE), as well as functional capacity during exercise (METs) and Duke treadmill score. aVR ST-segment elevation was found in 60/548 (11%) patients, whereas aVR ST-E was found in 23/57 patients with left main LM stenosis (Sn 40%, Sp 92%, PPV 38%, NPV 93%). When aVR ST-E was combined with other functional/imaging parameters, patients with aVR ST-E and LM+ had significantly worse functional capacity in METs (5.0±2.2 vs. 6.7±2.3, P=0.005), lower Duke score (-6.8±6.8 vs. -3.6±4.1, P=0.049), and higher deterioration of WMSI (0.51±0.24 vs. 0.39±0.24, P=0.046). Significant multivariable predictors of the left main (LM) stenosis were aVR ST-E and positive SE in LAD territory in the whole group of patients, and Delta WMSI, Duke score and METs achieved in patients presented with aVR ST-E during exercise. The aVR ST-segment alone has intermediate sensitivity in detecting significant LM stenosis in patients referred to SE testing for chest pain. When combined with other functional and imaging parameters, including poor exercise functional capacity in METs, lower Duke score or greater WMA in the territory of LAD, its diagnostic power to detect LM significantly increases.

Association of aVR ST-elevation with outcomes in patients with acute coronary syndrome

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Evaluation of the lead aVR in the diagnosis of acute coronary syndrome has been neglected before.1 However, there is evidence that an ST segment elevation in that lead correlates to a significant coronary artery disease.1,2 This study aimed to determine the association with clinical outcomes of an aVR ST elevation in patients with acute coronary syndrome. Purpose Identify patients who are at high risk on presentation at the emergency department. Methods This was a retrospective cohort study. Patients aged 19 years and above who were diagnosed with either unstable angina, non ST-elevation MI or ST elevation MI were eligible subjects. The medical records of patients in a tertiary referral government hospital were evaluated. The independent variable was the lead aVR ST elevation, while the primary outcome was the in-hospital mortality. Descriptive statistics was used to summarise the demographic and clinical characteristics of the patients. Frequency and proportion was used for categorical variables, median and inter quartile range for non-normally distributed continuous variables, and mean and standard deviation for normally distributed continuous variables. Independent Sample T-test and Fisher’s Exact test was used to determine the difference of mean and frequency, respectively, between patients with and without in-hospital outcomes. Odds ratio and corresponding 95% confidence intervals from binary logistic regression was computed to determine significant predictors of in-hospital outcomes. Missing variables was neither replaced nor estimated. Null hypotheses was rejected at 0.05α-level of significance. Results There were a total of 108 patients included. Most subjects were males and aged 57-62 years old. Majority had NSTE-ACS and STEMI at presentation. Lead aVR ST elevation group had an OR of 17 (95% CI 4.38-67.50 and p &amp;lt; 0.001) for in-hospital mortality, compared to the group without. On coronary angiogram, these patients had either a significant left main coronary artery disease or a multi-vessel coronary artery disease. Conclusion The presence of a lead aVR ST segment elevation in patients with acute coronary syndrome at presentation in the emergency department is associated with increased in-hospital mortality.

Prognostic value of ST segment elevation in aVR in patients with non ST elevation myocardial infarction

Although the presence of an ST segment elevation in the aVR lead was more common in patients with multivessel and/or left main disease, its long-term prognostic value is poorly understood. This study aims to describe the association of an ST segment elevation in AVR with the occurrence of MACE following a non ST elevation myocardial infarction (NSTEMI). A total of 340 patients admitted for NSTEMI were included. Patients were classified as having an ST elevation or having a normal ST segment in aVR based on the admission ECG. The primary endpoint was the onset of major cardiovascular events (MACE) at 1 year. Among 340 patients, 20 patients (5.3%) had ST segment elevation in aVR. Patients with ST elevation had a higher rate of multivessel disease. The ST elevation in AVR was not an independent predictor of in-hospital mortality in patients with NSTEMI (OR: 6.58, 95% CI 1.23-30.22 P = 0.061). However, patients with ST segment elevation in aVR had a higher rate of MACE at 1 year (38% vs. 13%, P = 0.03). The ST segment elevation was an independent predictor of MACE at 1 year (OR 4.31; 95% CI 1.3-14.32; P = 0.03). Based on these results, the ST segment elevation, as a simple marker, appears to be an independent predictor of MACE at 1 year in patients admitted with NSTEMI and may be a useful endpoint in risk stratification for the occurrence of MACE in these patients.

ANGIOGRAPHIC CORRELATION OF ST ELEVATION IN LEAD aVR DURNG TMT IN PATIENTS WITH LMCA DISEASE

BACKGROUND:Treadmill testing is the most widely used method for evaluating patients with coronary artery disease. Predicting the left main coronary artery disease (LMCA) before invasive procedure is important in risk assessment because of its grave clinical outcome. Lead aVR can be very useful in identifying LMCAobstruction. It is also valuable lead not only in diagnosis but also predicting the prognosis. AIM: To examine whether STelevation in aVR during TMTcorrelates with LMCAdisease in coronary Angiogram METHOD: In this study 100 patients with positive TMT were included. The study group consisted of 60 patients with ST elevation of &gt; 1mm in aVR. 40 patients also have TMT positive but with &lt; 1mm of ST elevation in aVR is the control group. All patients underwent coronary angiography. RESULTS: Coronary Angiography in the study group revealed signicant LMCA disease in 36 (63%) patients whereas no LMCA disease in control group 12 (20%) patients had ostioproximal LAD leisions in study group 4 (10%) patients in the control group. Triple vessel disease in 10 (17%) patients in study group 6 (15%) patients in control group. Since the p value was signicant, ST Elevation in aVR during TMT strongly predicts the presence of LMCADisease. CONCLUSION: STsegment elevation in aVR &gt; 1mm during Treadmill testing is a strong predictor of LMCAdisease.

272 Combined rotational atherectomy and intravascular lithotripsy for heavy calcified coronary artery

Abstract Aims Percutaneous coronary intervention (PCI) of heavily calcified coronary lesions still represents a challenge for interventional cardiologists, with higher risk of immediate complications, late failure due to stent underexpansion or malapposition and consequent poor clinical outcome. Rotational atherectomy (RA) is a well-known calcium debulking modality. However, when coronary plaques present a significant amount of circumferential deep calcium, RA alone may not be able to achieve adequate lesion preparation. The combined use of intravascular lithotripsy (IVL) and RA, a technique called ‘Rotatripsy’, can be an effective approach in order to enable optimal stent implantation. We present a case of a calcific right coronary artery (RCA) PCI successfully treated by ‘Rotatripsy’ technique. Methods and results A 78-years-old man presented to our emergency department complaining of acute chest pain and dyspnoea. The electrocardiogram revealed ST-segment elevation in aVR and a diffuse ST-segment depression. Transthoracic echocardiography showed left ventricular anterior, septal, and apical walls akinesia. An urgent coronary angiography showed a critical distal left main (LM) stenosis involving the left anterior descending (LAD) artery ostium and a heavy calcified dominant RCA with two tandem sub-occlusive stenosis in the mid segment (Figure 1A). An immediate PCI with two drug eluting stents (DES) in the LM and LAD was performed. The patient was scheduled two days later for RCA PCI. RCA was engaged via left radial approach with a 6-Fr AL1 guiding catheter and the lesions were crossed with a Sion Blue wire. Using a Finecross MG microcatheter, an extra-support Rotawire was placed distally in the RCA. However, after multiple rotablation with 1.5 mm burr (Figure 1B), the mid segment lesion (Figure 1C) was still undilatable with a 3.5 mm non-compliant balloon (NCB) at 22 atm showing a partial dog bone effect (Figure 1D). We decided to attempt adjunctive IVL for calcium debulking. Using a Finecross MG and the trapping technique, a Gran Slam wire was placed distally; a 4.0 mm IVL balloon was delivered at the undilatable lesion and 80 pulses were applied (Figure 1E). Once the IVL treatment was completed (Figure 1F), a 4.0 mm NCB was inflated to 20 atm to further dilate the segment with an optimal expansion (Figure 1G). Finally, a DES Synergy 4.0 × 48 mm was implanted (Figure 1H) and it was post-dilated with a 4.5 mm NCB inflated to 22 atm (Figure 1I) with a perfect angiographic result (Figure 1J). Conclusions Coronary calcifications can lead to stent underexpansion, which is related to a higher rate of future complications, such as restenosis or thrombosis. If conventional lesion dilatations are not effective, alternative techniques should be considered (cutting balloon, scoring balloon, RA, orbital atherectomy, IVL). In case of circumferential deep calcium plaques, RA may not be able to achieve an adequate lesion preparation. RA allows the treatment of intimal calcium and permits to cross balloons or stents through severe lesions. However, when adequate expansion of the balloons is not achieved after RA, Shockwave IVL, that is not usually able to cross critical stenosis due to its bulky profile, represents an optimal complementary device, in order to fracture deep calcium and facilitate stent delivery and optimal expansion. In this case, we have successfully used the hybrid approach called ‘Rotatripsy’, which combines RA and IVL, in order to avoid more aggressive RA, which would have required the use of 7-Fr guiding catheter setting and may have increased the risk of complications.

The de Winter Pattern as Pre-Anterior ST-Elevation-Myocardial-Infarction. “An Evolution Sequence”: A Case Report

Introduction: The de Winter pattern (dWP) was first described by de Winter and colleagues in 2008 as static pattern associated with anterior myocardial infarction. A recent study showed the evolution sequence of this pattern into typical ST-elevation myocardial infarction (STEMI). This case discussed dWP who present as pre-anterior STEMI.&#x0D; Case Illustration: A-56-year old Male arrived in the emergency room complained chest pain about 3 hours. The patient also complained of diaphoresis, nausea, and fatigue. The patient has a previous history of hypertension. The vital signs were stable with an unremarkable physical examination. The initial electrocardiogram (ECG) revealed sinus rhythm with j-point depression followed by prominent T wave in precordial leads, slight ST-segment elevation in aVR, and loss of precordial R-wave progression. The initial-troponin-T was 31 pg/mL. Follow-up 1-hour after initial ECG showed typical ST-segment-elevation in V1-V4. The patient undergoing thrombolytic, followed by angiography that showed subtotal occlusion in the proximal left anterior descending (LAD) artery, occlusion in the proximal circumflex artery and stenosis in proximal right coronary artery, echocardiography revealed regional wall motion abnormality in the septal and anterior segments and preserved ejection fraction 58%, the patient was discharged after 8-days treated in intensive cardiac care unit.&#x0D; Conclusion: dWP has been shown as static and dynamic pattern in some conditions and associated with acute LAD occlusion. In this case, we showed dWP as early anterior STEMI, recognition of this pattern lead to early reperfusion and better myocardial salvage as anterior STEMI has a poor outcome.

A broad complex tachycardia suggesting global ischemia or repolarization abnormalities.

Our case presents a ​cavotricuspid isthmus (CTI​)-dependent atrial flutter (AFL) with 1:1 atrioventricular conduction and pronounced ST-segment elevation in aVR, previously described as a "shark fin phenomenon," mimicking a broad complex tachycardia with a ventricular origin.