TIMI Flow Research Articles

Baseline predictors of final infarct size in patients with ST elevation myocardial infarction undergoing primary PCI

Abstract Background In patients with coronary artery disease, the presence and extent of myocardial scar determined from cardiac magnetic resonance (CMR) imaging have recognized associations with major adverse cardiac events. Therefore, in patients presenting with ST elevation myocardial infarction (STEMI), early prediction of final infarct size (IS) has important prognostic and therapeutic implications. Purpose We sought to determine the predictors of final IS from baseline clinical, laboratory, and CMR imaging variables in patients presenting with STEMI and undergoing successful primary PCI (pPCI). Methods After successful pPCI, 76 STEMI patients underwent baseline (within 48-hours) and 3-months follow-up CMR imaging. The baseline CMR study was used to measure left ventricular (LV) volumes, ejection fraction (EF), and global longitudinal strain (GLS), the latter calculated using feature tracking from cine images. Final IS was measured in the 3-months follow up study using signal intensity quantification by the full width at half maximum method from late gadolinium enhancement images and expressed as a percentage of the total LV mass. Serum ST2 was drawn within 48 hours of STEMI presentation. Maximum values of ECG ST elevation prior to pPCI and serum Troponin I during index hospitalization were measured. Non-collinear baseline variables deemed significantly associated with the final IS on univariable linear regression and captured in all patients were entered into a multivariable model, adjusting for age and sex. Results Mean age was 54.1±10.9 years, 64 patients (78%) being males. Mean LV EF was 43.5±9.8%. Univariable predictors of final IS included hypertension, baseline maximum troponin, ST2, maximum ST elevation, LV volumes and EF, GLS, total angiographic procedure time, the presence of multi-vessel CAD, use of thrombectomy, TIMI flow and myocardial blush grades at baseline and after wiring, and prescription of loop diuretics and potassium-sparing diuretics on discharge (Table 1). A final multivariable linear model was constructed including age, sex, maximum troponin, maximum ST elevation, ST2, LV EF and GLS. In this model, baseline LV EF, maximum troponin, and maximum ST elevation remained independently associated with the final IS. Respective beta coefficients [95% CI] were -0.63 [-1- (-0.26)], 0.22 [0.11-0.33], and 0.90 [0.22-1.58]; p=0.001, <0.001, and 0.01) (Table 2; adjusted R2=0.6, p<0.001). ST2 and GLS were no longer associated with the IS. Conclusion After successful pPCI, baseline LV EF, maximum troponin I, and maximum ST elevation were independent predictors of final IS. These simple markers can identify patients at high risk of final IS who might benefit from advanced therapeutics. Future studies are warranted to confirm the prognostic value of risk scores incorporating these markers. Advanced laboratory (ST2) and imaging (strain) markers were not independently associated with IS.

Pretreatment with parenteral anticoagulation in patients with ST-segment elevation myocardial infarction: a systematic review and meta-analysis

Abstract Background and Aim According to ESC guidelines, parenteral anticoagulation is recommended for all patients presenting with ST-segment elevation myocardial infarction (STEMI) during primary percutaneous coronary intervention (PPCI). However, no specific recommendations are made regarding the timing of administration. In fact, whether upstream anticoagulation improves clinical outcomes in STEMI patients is not well established. We conducted a systematic review and meta-analysis of current evidence on parenteral anticoagulation timing for patients presenting with STEMI. Methods We performed a systematic search of electronic databases (PubMed, CENTRAL and Scopus) until December 2022. Studies were considered eligible if they a) compared upstream anticoagulation with administration at the catheterization lab; and b) enrolled patients with STEMI undergoing PPCI. Studies comparing different anticoagulants were excluded from the analysis. Random-effects meta-analyses were performed. Efficacy outcomes included TIMI flow-grade pre- and post-PPCI, in-hospital cardiogenic shock (CS) and 30-day all-cause mortality. Safety outcome was defined as major in-hospital bleeding events. Results Overall, 9 studies were included (all non-randomized), with a total of 69,571 patients (30,693 in the pretreatment arm). In all but one, anticoagulation strategy was exclusively based on unfractionated heparin. Pretreatment was associated with a significant reduction in the incidence of 30-day all-cause mortality (OR 0.61; 95% CI 0.47-0.80; p<0.001) and in-hospital CS (OR 0.69; 95% CI 0.59-0.81; p<0.001). Upstream anticoagulation was also associated with a significant increase of spontaneous reperfusion of the culprit artery before PPCI (pre-PPCI TIMI > 0: OR 1.47; 95% CI 1.35-1.60; p<0.001) and TIMI flow ≥ 2 after coronary intervention (OR 1.28; 95% CI 1.05-1.56; p=0.016). Regarding safety outcomes, pretreatment was not associated with an increase of in-hospital major bleeding (OR 1.01; 95% CI 0.70-1.44; p=0.970). Multiple sensitivity analyses, including propensity-matched populations, showed consistent results. Conclusions Upstream anticoagulation was associated with a significant lower risk of 30-day all-cause mortality, incidence of in-hospital cardiogenic shock and improved reperfusion of culprit artery. These benefits were not accompanied by an increased risk of major bleeding, suggesting an overall clinical benefit of early anticoagulation in patients presenting with STEMI. These results require confirmation in a randomized clinical trial.

Predictive value of STEP-HF risk score in patients with ST-segment elevation myocardial infarction (Killip I) treated by primary percutaneous coronary intervention

Abstract Background New-onset heart failure (HF) during the first hospitalization was considered as an earlier indicator for poor prognosis in acute ST-segment elevation myocardial infarction (STEMI) without overt HF (Killip I). Purpose This study aims to develop a practical risk score to predict the in-hospital occurrence of new-onset HF and to evaluate its ability for prognosis. Methods The Chinese STEMI pPCI Registry is registered with ClinicalTrials.gov (NCT04996901). Within 24 h of symptom onset, 2940 STEMI patients with Killip class I on admission were treated by pPCI from five hospitals between January 2015 and January 2021; 1869 patients from three of the hospitals served as a derivation cohort, and 1071 from the other two hospitals constituted the external validation cohort. In-hospital HF was defined as Killip class ≥II at the first hospital presentation (8.7% in the derivation cohort vs. 14.3% in the validation cohort). Multivariable logistic regression was used to develop the in-hospital HF score. For 2-year following-up, all-cause mortality rate was estimated using the Cox regression analysis. Results Eight variables were independently associated with the development of in-hospital HF: age >65 years, previous atrial fibrillation, triple vessel lesion, anterior myocardial infarction, symptom onset-to-balloon time > 5 h, TIMI flow grade 0 before pPCI, neutrophil-to-lymphocyte ratio > 6.3 and aspartate aminotransferase > 65U/L on admission. STEP-HF score was created based on these 8 variables, and classified patients into three risk categories: low (0-3), intermediate (4-7), and high (≥8). Observed in-hospital HF rates were 3.47% (3.5%), 12.35% (8.34%), and 30.8% (17.05%) across the three risk categories, respectively in derivation (validation) cohort. The STEP-HF score demonstrated high discrimination (c-statistic of 0.705 in the derivation cohort, 0.656 in the validation cohort) and adequate calibration (Hosmer-Lemeshow goodness-of-fit test P values > 0.05) in both cohorts. After two-year follow up, 202 patients were lost to follow-up and finally a total of 2738 patients were included. 30-day all-cause mortality occurred in 0.13%, 0.66% and 1.71% of patients in low, intermediate and high risk group, respectively (p = 0.041). The association persisted during 1 year and 2 years of follow-up. Two-year all-cause mortality were 8 (1.03%), 32 (2.33%), and 37 (6.32%) for the low, intermediate, and high score groups, respectively (p<0.001). Receiver operating characteristic (ROC) analysis demonstrated the STEP-HF score can effectively predict all-cause mortality as compared with GRACE score for 30d, 1 year, and 2 years, respectively (STEP-HF: AUC 0.76, 0.71,0.68 vs. GRACE: AUC 0.75, 0.67, 0.67, p = 0.923, 0.202, 0.619, respectively). Conclusion The STEP-HF score can be used to predict prognosis in STEMI (Killip I) with pPCI. Higher scores are associated with higher in-hospital HF at first admission and all-cause mortality for long-term following up.

Improved detection of echocardiographically occult left ventricular thrombi following ST-elevation myocardial infarction

Abstract Background and Aims Patients with STEMI are at significant risk for developing left ventricular thrombi (LVT). However, this complication often (up to 65%) remains undetected by using transthoracic echocardiography (TTE), referred to as TTE-occult LVT. The aim of this study was to investigate predictors of TTE-occult LVT and to propose a clinical model for improved detection of TTE-occult LVT post ST-elevation myocardial infarction (STEMI). Methods In total, 870 STEMI patients underwent TTE and cardiac magnetic resonance (CMR), the reference method for LVT detection, 3 days after infarction. Clinical and echocardiographic predictors were analyzed. Primary endpoint was the presence of TTE-occult LVT identified by CMR-Imaging. Results From the overall cohort, 37 patients (4%) showed an LVT by CMR. Of these thrombi, 25 (68%) were not identified by TTE. TTE-occult thrombi did not significantly differ in volume (1.4 vs. 2.74cm3), diameter (19.0 vs. 23.3mm), number of fragments or shape compared with TTE-apparent LVT (all p>0.05). For predicting these TTE-occult LVT, apical wall motion score using the 16-segment model (AWMS16Seg) showed highest validity (AUC:0.91 [95%CI:0.89-0.93];p<0.001), with an association independent of ejection fraction and AWMS17Seg (OR:1.68 [95%CI:1.43-1.97];p<0.001), clinical (body mass index, peak troponin) and angiographic (culprit lesion, post-interventional TIMI flow) associates of TTE-occult LVT (all p<0.05). Dichotomization at AWMS16Seg≥8 (n=260, 30%) allowed for a detection of all TTE-occult LVT (sensitivity:100%), with a corresponding specificity of 77%. Conclusions After acute STEMI, AWMS16Segserved as simple and very robust predictor of TTE-occult LVT. An AWMS16Seg-based algorithm to identify patients for additional CMR-imaging offers great potential to optimize detection of TTE-occult LVT following STEMI.Key IllustrationProposed Algorithm

Pathogenetic role of neutrophil extracellular traps in coronary flow impairment following percutaneous coronary intervention in acute myocardial infarction patients -A multicenter study-

Abstract Background A suicidal function of neutrophils to ensnare and kill microbes by expelling neutrophil extracellular traps (NETs) via histone citrullination and chromatin decondensation has emerged as it enhances local inflammation and thrombogenicity at the culprit lesion of acute myocardial infarction (AMI). Purpose This multicenter study was aimed to examine 1) the histopathological feature of coronary thrombus with the NETs formation in AMI patients, and 2) the association of NETs with impaired coronary flow after percutaneous coronary intervention (PCI) for AMI patients. Methods Coronary thrombi were obtained from 44 patients with AMI [male; 77%, age; 69±12(SD) y-o)]who underwent PCI within 24 hours from the onset. Aspirated thrombi were immediately bisected and frozen, and 5-µm thickness unstained sections were processed for polarized light microscopy (PLM) imaging and immunofluorescence staining. NETs were immunohistochemically defined when objects were co-stained with anti-myeloperoxidase and anti-citrullinated histone H3 antibodies (Figure A,B). Adjacent sections were stained with Masson’s trichrome to measure the whole thrombus area. The ImageJ1 software was utilized for the automatic segmentation on the digitized histology images. Segmented NETs area was divided by the thrombus area as a measure of NETs. Clinical characteristics, including AMI subset, post PCI final TIMI flow grade and TIMI frame count, were collected. Results All aspirated thrombi exhibited NETs (Figure A), and then subjects were split into 2 groups with a median value of NETs (62.8 x10-4 um2/um2); high-NETs and low-NETs groups. Patient characteristics were all comparable between the 2 groups. PLM results showed that birefringent crystals, suggestive of cholesterol crystals, were more frequently noted in the thrombi with high-NETs compared with those with low-NETs (50.0% vs. 13.6%, P=0.010). In the immunofluorescence, NETs were seen in the proximity of the crystals (Figure B). The multivariable analysis with covariates of age, sex, major coronary risk factors, MI related to left anterior descending artery and the onset to aspiration time revealed that the presence of birefringent crystals remained an independent predictor for high-NETs formation [OR=5.78, 95%CI=1.13-29.66, P=0.035]. In the high-NETs group, the prevalence of the final TIMI flow grade 3 was significantly lower than the low-NETs group (63.6% vs. 90.9 %, P=0.031). Likewise, there was a significant positive correlation between NETs area and TIMI frame count, defined as the number of cineframes required for contrast to reach a standardized distal coronary landmark (R=0.681, P<0.001). Conclusion The present study demonstrated that NETs were highly expressed in coronary thrombus aspirated from AMI patients in association with crystalline components, relating to coronary flow impairment following PCI in AMI patients.

Aggressive CTO PCI strategy improved the success rate but not clinical outcomes for coronary chronic total occlusion patients : Korean single center experience

Abstract Background Successful coronary chronic total occlusion (CTO) recanalization was well associated with lesion characteristics, technique and devices development. Indeed, the operators’ experience and new device usage are also associated with success rate. There is few data whether this technical advancement and/or new therapeutic strategy adoption influence the procedural success rate between Japan and Korea. Purpose This study sought to compare the success rate and its clinical outcome between aggressive strategy (joint PCI with Japanese CTO experts, never give up strategy) who adopted new devices and technology and conventional strategy in a Korean single center. Methods A total of 670 target lesions underwent PCI at a single center between September 1999 and February 2020, divided into conventional strategy (control group, n = 508) and aggressive strategy (Joint-PCI group, n = 162) before COVID pandemic period. Primary endpoint was procedural success rate, defined as <20% residual stenosis with TIMI flow grade ≥2 by visual estimation of the angiograms. We also observed the incidence of periprocedural complication, and MACCE (cardiac death, non-fatal MI, TLR/TVR, and stroke) during 3-year clinical follow-up period. To reduce the effect of potential confounding factors in an observational study, we used the propensity score matching (PSM). Results In comparison to conventional strategy, aggressive strategy group had no difference of male (76.2% vs 82.1%), but had a significantly difference of age (63.0 vs 60.9). For the primary endpoint, aggressive strategy group had a significantly difference in procedural success rate (79.5% vs. 92.5%)during 2015-2020, compared to conventional strategy. There was no difference in MACCE rate, 64 patients (12.6%) in conventional strategy group versus 21 (13.0%) in aggressive strategy group (p = 0.903) in Chi-square test. In PSM data, there was also no difference in MACCE rate (conventional strategy, 11.9% versus aggressive strategy, 11.0%). Conclusions Aggressive strategy with Japanese CTO experts, who adopted new devices and technology early, resulted in a higher success rate in CTO PCI. However, there were no differences in clinical outcomes during 3 year follow-up. Figure 1. Success rate Table 1. Clinical outcomes

Single stent versus two stent strategy in primary PCI for unprotected LM occlusion

Abstract Background Acute MI due to left main coronary artery (LMCA) occlusion carry the highest anatomical risk for morbidity and mortality during primary PCI. Although several clinical trials compared different PCI techniques and strategies for LMCA, still special populations and different clinical scenarios have lack of evidence about ideal approaches. Purpose We aim to compare provisional stenting versus two stent upfront technique in acute MI due to LMCA occlusion regarding short term clinical outcomes. Methods This was a prospective observational study from three large centers within the period from February 2019 to Feb 2023. Patients with acute STEMI due to LMCA occlusion who are candidates for primary PCI were included and was assigned to two groups according to operator discretion. Group I (provisional stenting) versus group II (upfront two stent strategy). Our primary outcome was MACE within 30 days and secondary Outcomes were angiographic outcomes after intervention including TIMI flow, CTFC and myocardial blush. Results A total of 62 patients met our inclusion criteria, mean age (62.64±8.61), 24.6% women. Thirty-eight patients in group I undergone provisional stenting and twenty-four patients in group II undergone two stent strategy. MACE was significantly higher in the two-stent strategy group (61.62% vs 40.34%, P<0.001] compared with provisional stenting group. the IV epinephrine group. Angiographic outcomes were significantly better in provisional stenting group by the end of the procedure. There was marked increase in patients who achieved postprocedural TIMI III and TMPG III in group I by 22% and 18% respectively in comparison with two stent strategy group. Conclusion Our observational study concluded that provisional stenting carries better short-term outcomes in acute MI intervention due to unprotected LMCA occlusion. Clinical studies are needy in this specific population.Study flow chartFigure I

Abstract 13759: Impact of Shock Network Protocols on Reducing Cardiogenic Shock Death in STEMI Cases: A Middle Eastern Study

Introduction: The optimal use of mechanical circulatory support (MCS) in managing acute myocardial infarction with cardiogenic shock (AMICS) treated with percutaneous coronary intervention (PCI) remains a complex clinical challenge. In response to this, our study seeks to explore the implementation of a systematic Shock Protocol that integrates pre-PCI MCS in patients presenting with STEMI and SCAI class C and above. Hypothesis: Utilizing a prospective, multi-centre STEMI database, our study aimed to assess the impact of the Shock Protocol on survival at hospital discharge. Methods: From January 2022 to February 2023, five participating sites within our STEMI network committed to the study, adhering to a standardized protocol for AMICS treatment. The selection criteria mirrored those of the "SHOCK" trial. The survival rate at hospital discharge for this cohort was compared to pre-protocol implementation (October 2020-December 2021). Results: Of 745 STEMI cases, 418 and 327 were treated before and after protocol implementation. AMICS diagnoses were in 10.5% and 10.7% in the BSP and ASP groups, respectively. The mean ages were 53 (BSP) and 51 (ASP), with 90% males. Approximately 83% and 85% of BSP and ASP patients, respectively, were on vasopressors or inotropes at Cath-Lab arrival. Pre-Cath-Lab cardiac arrests (CA) occurred in 20% (BSP) and 33% (ASP), while post-arrival CA incidence was 30% (BSP) and 12% (ASP). MCS was used in 27% (BSP) and 87% (ASP). In ASP, 85% of devices were implanted pre-PCI. Median FMC-to-balloon times were 104 ±28.2 (BSP) and 77 ±41.6 (ASP) minutes. Discharge survival rates were 77% (BSP) and 82% (ASP). Mortality predictors: TIMI flow <3 post-PCI, post-Cath-Lab CA, and SCAI class D/E. In SCAI class D/E patients, protocol implementation enhanced survival at hospital discharge. Conclusions: In our STEMI network, upfront MCS use in AMICS patients improved post-discharge survival.

Abstract 12177: Quantitative Flow Ratio is a Great Predictor of Microvascular Obstruction in ST-Segment Elevation Myocardial Infarction After Percutaneous Coronary Intervention

Backgrounds: Compare the predictive effects of ST-segment resolution (STR) and quantitative flow ratio (QFR) in the detection of MVO in STEMI patients after PCI. Research Questions: To investigate the efficacy of STR/QFR in the evaluation of MVO detected by CMR in STEMI after PCI. Methods: A prospective cohort study enrolled 208 consecutive patients with STEMI. The degree of STR post procedure and predischarge after reperfusion was calculated. QFR were measured according to the angiography, CMR was performed within median time 5 days after revascularization to determine MVO. Clinical factors were enrolled to predict the incidence of MVO. Results: The MVO/LV mass is 1.42±2.28 in 126 patients with MVO according to CMR, and the area under ROC curves (AUC) identified QFR is the best predictor (AUC: 0.784, P <0.001). Factors including QFR, STR, TIMI flow, CK-MB, cTnI, WBC, and HsCRP showed good predictive effects for the incidence of MVO ( P <0.05). Except for peak cTnI, QFR (%) was the best predictor (AUC: 0.784, P <0.001) ( Figure 1 ). A nomogram for predicting MVO was done (c-index: 0.894) ( Figure 2 ). A significant correlation was observed between STR and various parameters ( P <0.05), except for the correlation between predischarge STR and MVO/LV mass at 6 months. Predischarge STR has the best correlation with infarct size after the 6-month follow-up ( r =-0.509, P <0.001) ( Figure 3 ). Regression analysis indicated that postoperative STR (β=-0.248, P =0.007) was a significant predictor of MVO/LV mass ( Figure 3 ). Figure 4 further analyzed heart function from in-hospital CMR between different postoperative STR levels, and from 6 months CMR between predischarge STR subgroups. Higher STR predicted less cardiac injury and more ideal index of cardiac remodeling. Conclusions: In STEMI patients after PPCI, QFR demonstrated better predictive effect of the incidence of MVO than STR. Predischarge STR is closely related to infarct size and ejection fraction after 6-month follow-up.

Abstract 14974: Spontaneous Coronary Dissection: A Challenging Case of Young Weightlifter

A 26-year-old weightlifter with no significant past medical history presented with chest pain while performing his routine exercise. ECG showed anterior ST elevation myocardial infarction with subsequent angiography revealing 99% occlusion in the proximal LAD with extensive thrombus burden along with a 100% occluded distal RCA with left to right collaterals present, indicating an RCA subacute/chronic lesion (see image). An intra-aortic balloon pump was inserted, and the patient was transferred to UC Davis Medical Center. Repeat angiography revealed thrombus and dissection in the proximal LAD and RCA, stabilized with heparin drip and Gp2b3a inhibitor. Transthoracic echocardiogram showed a severely reduced ejection fraction of 15%. After heart team discussion, the patient was deemed high risk for surgery, so he underwent percutaneous coronary intervention with balloon angioplasty and deployment of drug eluting stents to the LAD and RCA with resulting TIMI-3 flow. He was initiated on guideline directed medical therapy and discharged home with LifeVest. Unfortunately, he presented with ventricular tachycardia (VT) after LifeVest shock on the following day. Repeat angiogram did not show any in-stent restenosis or thrombus. Implantable cardioverter-defibrillator (ICD) was implanted, and the patient was started on amiodarone. The patient continued to have recurrent VT. Lidocaine was added and MRI was done, which showed a large scar burden. Left ventricular assist device Impella 5.5 was placed, and the patient eventually underwent successful cardiac transplant. This case report highlights weightlifting causing spontaneous coronary dissection. It is rare but has devastating complications with limited options for acute management. Revascularization options have limited success in a patient with such an extensive scar burden and a severely reduced ejection fraction.

ROLE OF ST SEGMENT RESOLUTION ALONE AND IN COMBINATION WITH THROMBOLYSIS IN MYOCARDIAL INFARCTION (TIMI) FLOW IN PRIMARY PERCUTANEOUS CORONARY INTERVENTION FOR ST SEGMENT ELEVATION MYOCARDIAL INFARCTION

This study aimed to assess the effect of ST-segment resolution (STR) alone and in combination with TIMI flow after primary percutaneous coronary intervention (PPCI) for ST-segment elevation myocardial infarction (STEMI). The study was conducted at the Department of Cardiology, Peshawar Institute of Cardiology, Hayatabad Peshawar, KPK, from August 2022 to July 2023. Ninety patients with acute myocardial infarction were enrolled, and STR was considered successful if it reached 50% or complete STR (ST-segment back to the equipotential line). TIMI flow was evaluated after PPCI, and the primary outcome was two-year all-cause mortality. Results showed that each STR <50%, STR ≥50%, and complete STR occurred in 33.3% of the patients. Successful STR was the only independent predictor of 2-year death among all clinical factors. Combining TIMI flow and STR showed different 2-year mortality rates in subgroups; the lowest was seen in successful STR and TIMI 3 flow, the middle when either of these measures was decreased, and the greatest when both were abnormal. The study concluded that analyzing both STR and TIMI flow provides additional prognostic information beyond what either measure could provide. Therefore, it can be used as a reliable and convenient surrogate endpoint for determining successful PPCI. Additionally, the study found that post-PPCI STR is a strong long-term prognosticator for ST-segment elevation myocardial infarction.

Syphilitic ostial coronary artery occlusion treated with percutaneous coronary intervention: Case series and literature review

IntroductionNon-atherosclerotic causes of acute coronary syndrome (ACS) are important contributors to a substantial number of acute ischemic coronary events. Syphilitic aortitis is a rare complication of tertiary cardiovascular syphilis that may result in ostial coronary artery stenosis, aortic insufficiency, and ascending aortic aneurysm. MethodsIn this manuscript, we present two Case Reports of patients with bilateral syphilitic coronary artery ostial occlusion, and we review the associated literature. The immunofluorescent test was positive for syphilis in both patients. ResultsDiagnostic coronary angiography revealed bilateral occlusions of the left main coronary artery (LMCA) and right coronary artery (RCA), which were successfully treated with percutaneous coronary intervention (PCI) with bare metal stents (BMS). After deployment of the stents, arterial blood flow was re-established with TIMI flow grade 3. DiscussionThe angiographic finding of bilateral coronary ostial lesions in young patients should raise the suspicion of cardiovascular syphilis. Options for revascularization should be discussed amongst the patient and the Heart Team. PCI may be an option for treatment of isolated syphilitic coronary stenosis in the setting of acute hemodynamic instability or chronic inflammation.

Relationship between the Fibrinogen/Albumin Ratio and Microvascular Perfusion in Patients Undergoing Primary Percutaneous Coronary Intervention for ST-Elevated Myocardial Infarction: A Prospective Study.

Correct TIMI frame count (CTFC), myocardial blush grade (MBG), and ST-segment resolution (STR) are parameters used to evaluate reperfusion at the microvascular level in patients that have undergone primary percutaneous coronary intervention (pPCI). Fibrinogen-to-albumin ratio (FAR) has been associated with thrombotic events in patients with ST-elevation myocardial infarction (STEMI) and chronic venous insufficiency. To investigate the relationship of FAR with CTFC, MBG, and STR. Methods: The study included 167 consecutive patients who underwent successful pPCI for STEMI and achieved TIMI-3 flow. The cases were divided into two groups, high (>0.0765) and low FAR (≤0.0765), according to the cut-off value of this parameter in the receiver operator characteristic analysis (ROC). STR, CTFC, and MBG were used to evaluate myocardial reperfusion. P values<0.05 were considered statistically significant. CTFC value, SYNTAX score, neutrophil/lymphocyte ratio, low-density lipoprotein, glucose, and peak cTnT were significantly higher, whereas STR, MBG, and LVEF were lower in the high FAR group. Spearman's correlation analysis revealed a significant relationship between the FAR and STR (r=-0.666, p<0.001), MBG (-0.523, p<0.001), and CTFC (r=0.731, p≤0.001). According to the logistic regression analysis, FAR, glucose, peak cTnT, and pain to balloon time were the most important independent predictors of MBG 0/1, CTFC>28, and STR<50%).ROC analysis revealed that the cut-off value of FAR≥0.0765 was a predictor of incomplete STR with a sensitivity of 71.9 % and a specificity of 69.8 %, MBG0/1 with a sensitivity of 72.6 % and a specificity of 68.6 %, and CTFC >28 with a sensitivity of 76 % and a specificity of 65.8 %. FAR is an important independent predictor of microvascular perfusion in patients undergoing pPCI for STEMI.

Impact of symptom-to-reperfusion-time on transmural infarct extent and left ventricular strain in patients with ST-segment elevation myocardial infarction: a 3D view on the wavefront phenomenon.

We examined the association between the symptom-to-reperfusion-time and cardiovascular magnetic resonance (CMR)-derived global strain parameters and transmural infarct extent in ST-segment elevation myocardial infarction (STEMI) patients. The study included 108 STEMI patients who underwent successful primary percutaneous coronary intervention (PPCI). Patients were categorized according to the median symptom-to-reperfusion-time: shorter (<160 min, n = 54) and longer times (>160 min, n = 54). CMR was performed 2-7 days after PPCI and at 1 month. CMR cine imaging was performed for functional assessment and late gadolinium enhancement to evaluate transmural infarct extent. Myocardial feature-tracking was used for strain analysis. Groups were comparable in relation to incidence of LAD disease and pre- and post-PPCI thrombolysis in myocardial infarction (TIMI) flow grades. The mean transmural extent score at follow-up was lower in patients with shorter reperfusion time (P < 0.01). Both baseline and follow-up maximum transmural extent scores were smaller in patients with shorter reperfusion time (P = 0.03 for both). Patients with shorter reperfusion time had more favourable global left ventricular (LV) circumferential strain (baseline, P = 0.049; follow-up, P = 0.01) and radial strain (baseline, P = 0.047; follow-up, P < 0.01), whilst LV longitudinal strain appeared comparable for both baseline and follow-up (P > 0.05 for both). In multi-variable regression analysis including all three strain directions, baseline LV circumferential strain was independently associated with the mean transmural extent score at follow-up (β=1.89, P < 0.001). In STEMI patients, time-to-reperfusion was significantly associated with smaller transmural extent of infarction and better LV circumferential and radial strain. Moreover, infarct transmurality and residual LV circumferential strain are closely linked.

Effect of optimized thrombus aspiration on myocardial perfusion and prognosis in acute ST-segment elevation myocardial infarction patients with primary percutaneous coronary intervention.

To investigate the impact of optimized thrombus aspiration on myocardial perfusion, prognosis, and safety in patients with acute ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention(primary PCI). A total of 129 patients with STEMI were randomly allocated into control group (Subgroup A and B) and experimental group(Subgroup C and D). Control group received percutaneous transluminal coronary angioplasty (PTCA),thrombus aspiration and primary PCI. Experimental group received optimized thrombus aspiration and primary PCI. The number of thrombus aspiration was less than 4 times in Subgroup A and C. The number of thrombus aspiration was performed more than 4 times in Subgroups B and D. The classification of thrombi extracted, the TIMI flow grade, the incidence of no-reflow and slow flow, cTFC, TPI and CK-MB at 12 h and 24 h after stenting, ST segment resolution of ECG after stenting, NT-proBNP, LVEFat 24 h, 30 days and 180 days after stenting were compared between groups. The incidence of intraoperative and postoperative bleeding complications, stroke events and major cardiovascular events (MACE) were recorded and compared between groups. The classification of thrombi extracted in the experimental group was higher than that in the control group. The TIMI flow grade of the experimental group was better than the control group after thrombus aspiration. After stenting, the advantage still existed, but the difference was not statistically significant. On cTFC, the experimental group was lower than the control group, but the difference was not statistically significant; After stenting the experimental group was significantly lower than the control group. The CK-MB at 12 h and 24 h of the experimental group was lower than the control group. After thrombus aspiration the incidence of no-reflow in the experimental group was significantly lower than that in the control group; after stenting the incidence of no-reflow in the experimental group was still lower than the control group, but no statistically difference. After thrombus aspiration and stenting the incidence of slow flow in the experimental group were lower than that in the control group. After stenting, NT-proBNP at 24 h was lower in the experimental group than that in the control group, However, there was no statistical difference; after stenting, The NT-proBNP in the experimental group was lower than that in the control group at 30 days and 180 days. After stenting, LVEF of the experimental group was significantly higher than the control group at 24 h and 30 days; superiority remained after 180 days but no statistical difference. There was no statistical difference between two groups for intraoperative and postoperative bleeding complications, stroke events, and MACE events. In Subgroup analysis,there was no significant difference in the classification of thrombi extracted, TIMI flow grade, cTFC, CK-MB,NT-proBNP and LVEF between group C and D, but group A was better than group B. Analysis of variance showed that the optimal number of suction was 4-5 times. Optimized thrombus aspiration can significantly improve myocardial perfusion and short-term and medium-term prognosis of STEMI patients after PCI, and reduce the incidence of slow flow and no-reflow. The optimal suction times were 4-5 times. Traditional aspiration method with more aspiration times is harmful to cardiac prognosis. Thrombus aspiration does not increase the incidence of stroke events and is safe.Clinical Trial Registration: identifier, ChiCTR2300073410.

CHA2DS2 VASc score and its correlation with TIMI flow count in patients with STEMI Undergoing primary PCI

CHA2DS2 VASc score and its correlation with TIMI flow count in patients with STEMI Undergoing primary PCI

Left Ventricular End-Diastolic Pressure and Extent of Coronary Artery Disease in Patients Undergoing Primary Percutaneous Coronary Intervention

Objectives: This study aimed to assess the association of left ventricular end-diastolic pressure (LVEDP) with the extent and severity of coronary artery diseases (CAD) in individuals undergoing primary percutaneous coronary intervention (PCI) at a tertiary care cardiac center in Karachi, Pakistan. Methodology: This descriptive cross-sectional study included consecutive patients undergoing primary PCI. LVEDP was assessed with the help of a multipurpose catheter. The Association of LVEDP with the extent and severity of CAD was assessed. Results: LVEDP was stratified as ≤15 mmHg, 15-25 mmHg, and &gt;25 mmHg. Out of 498 patients included in this study, 76.3% (380) were male, and mean age was 53.7±11.7 years. Mean LVEDP was 19.35±6.17 mmHg. Burden of diseases was found to be significantly associated with LVEDP level (p&lt;0.001) with mean LVEDP of 18.5±5.6 mmHg, 19.5±6 mmHg, and 21.4±7.2 mmHg among patients with single, two and three-vessel disease respectively. Proportion of three-vessel diseases was 15.5% (37/239), 22.5% (47/209), and 36% (18/50) at LVEDP ≤15 mmHg, 15-25 mmHg, and &gt;25 mmHg, respectively. Conclusion: There was a strong inverse relationship between LVEDP and initial TIMI flow grade (p=0.013) and a positive relationship between LVEDP and total length of the lesion (p=0.002). In conclusion, increased LVEDP was found to be associated with increased burden and extent of coronary artery disease, poor initial TIMI flow grade, and longer length of lesion.

A SURVIVAL STORY OF 47 YEARS OLD MALE WITH ACUTE TOTAL OCCLUSION OF LEFT MAIN AND COEXISTING OSTIAL RIGHT CORONARY ARTERY LESION

Left main coronary artery (LMCA) thrombus occlusion causing acute coronary syndrome is an uncommon event and associated with severe life-threatening presentations. The clinical outcome depends on the age of the patients, presence of cardiogenic shock and the presence of dominant Right Coronary Artery (RCA) Early reperfusion is associated with improved outcomes. A 47-years man presented with sudden substernal burning sensation and dry cough for 1 hour. Coronary angiography revealed an acute totally occlusion of ostial left main (LM) with TIMI flow grade 0 and dominant RCA with ostial 80% stenosis having TIMI flow grade 3 and Grade 1 contralateral collaterals from RCA to left system. Emergency percutaneous coronary intervention (PCI) was performed to ostial LMCA toward the proximal LAD to cover the whole LMCA and stage PCI was performed to ostial RCA. Patient was discharge on 7th day with good general condition. An electrocardiographic pattern is associated with collateral filling territories in unprotected left main (ULM) occlusion. In our case diagnosis was completely made after diagnostic coronary angiogram. Acute total occlusion of LMCA is associated with arrhythmias, cardiogenic shock and sudden death. However, Patient was hemodynamically stable that showed indubitably the importance of dominant RCA with TIMI 3 flow and Grade 1 contralateral collaterals to left coronary circulation. We perform successful primary PCI of acute total occluded LMCA which shortened the ischemic time to salvage the ischemic myocardium.

Association of soluble suppression of tumorigenicity 2 protein with new-onset atrial fibrillation in patients with acute ST-segment elevation myocardial infarction undergoing primary PCI.

Previous studies have indicated that the soluble suppression of tumorigenicity 2 protein (sST2) is associated with new-onset atrial fibrillation (NOAF) in patients diagnosed with coronary artery disease (CAD). However, the predictive value of sST2 in patients with acute ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI) has not been well studied. A total of 580 patients with STEMI undergoing primary PCI were consecutively recruited between January 2021 and January 2023. These patients were then categorized into two groups: the NOAF group and the no NOAF groups based on the presence of NOAF during admission. The concentration of sST2 in blood samples was measured in all patients. The clinical data from the two groups were prospectively analyzed to investigate the predictive factors of NOAF in patients with STEMI undergoing primary PCI. A total of 41 (7.1%) patients developed NOAF. The presence of NOAF has been found to be associated with various factors, including age, diabetes mellitus, hypertension, the left atrial (LA) diameter, N-terminal pro-brain natriuretic peptide, C-reactive protein (CRP), sST2, a Killip class of ≥2, and a final TIMI flow grade of <3. After including multiple factors, it was observed that LA diameter, CRP, sST2, a Killip class of ≥2, and a final TIMI flow grade of <3 remained significant risk factors for developing NOAF. The receiver operating characteristic (ROC) curve showed the following findings: (1) when the LA diameter exceeded 38.5 mm, the sensitivity and specificity values were observed to be 67.2% and 68.2%, respectively, and the area under the ROC curve (AUC) was 0.683 [95% confidence interval (CI): 0.545-0.732; p = 0.003]; (2) when the CRP level exceeded 8.59, the sensitivity and specificity values were observed to be 68.6% and 69.2%, respectively, and the AUC was 0.713 (95% CI: 0.621-0.778; p < 0.001); and (3) when the sST2 value exceeded 53.3, the sensitivity and specificity values were 79.2% and 68.7%, respectively, and the AUC was 0.799 (95% CI: 0.675-0.865; p < 0.001). sST2 has been identified as an independent predictor of NOAF in patients with STEMI undergoing PCI.

Long-term clinical outcomes of drug-coated balloon for the management of chronic total occlusions.

This study aims to compare the clinical outcomes of patients with de novo chronic total occlusion (CTO) lesions treated by hybrid strategy and drug-coated balloons (DCB)-only strategy. DCBs have been used as an alternative to or in combination with drug-eluting stents in CTO lesions. However, the clinical impact of DCB treatment on CTO lesion remains uncertain. We retrospectively enrolled 154 patients with de novo CTO lesions treated by DCB, including 57 cases in hybrid group and 97 cases in DCB-only group. The lesions in hybrid group were more complicated than those in DCB-only group as shown by higher J-CTO score, and therefore higher percentage of retrograde approach, more IVUS guidance, more CTO guidewires, and longer procedural time were demonstrated. Although the percentage of non-flow-limiting dissection and residual stenosis of more than 30% were lower in hybrid group, TIMI flow grade, satisfactory and acceptable recanalization rate were not significantly different between two groups. During a median follow-up was 470 days, the incidence of target lesion revascularization (TLR), myocardial infarction and cardiac death was 11.0%, 1.3% and 1.9%, respectively. The long-term TLR-free survival was comparable between hybrid and DCB-only groups. By multivariate analysis, DCB length and age were predictors of TLR. DCB treatment appears effective and safe in selected de novo CTO lesions during long-term follow up. The recanalization results and long-term outcomes are comparable between hybrid and DCB-only group despite more complicated lesions in hybrid group.