ABSTRACT
Clinical Information Patient Initials or Identifier Number: BGS 22/0371940 Relevant Clinical History and Physical Exam: We present a case of an 80-year-old man with coronary risk factors diabetes, hypertension, dyslipidemia and familiarity without previous history of cardiac disease and known nephrolithiasis and urethral stenosis. He came to our observation during the second COVID wave pandemic within the emergency department for chest discomfort during hypertensive crisis and evidence of not known complete left bundle branch block and minimal elevation of TnI-HS levels. Relevant Test Results Prior to Catheterization: Echocardiography demonstrated septal dyskinesia with ejection fraction of 53%, no relevant valvular disease. The patient was hospitalized with the diagnosis NSTEMI for early coronary angiography within 24 hours and therapy according to the ESC 2020 NSTEMI Guidelines was initiated: acetylsalicylic acid 100 mg SID (no P2Y12 receptor inhibitors in unknown coronary anatomy), low molecular weight heparin atorvastatin 80 mg, ace-inhibitor, beta-blocker, rapid insulin and adequate hydration. Relevant Catheterization Findings: Angiography shoed critical mid RCA and ostial, LM (Medina 1.1.1) mid LAD and LCx stenosis (Fig.1). The patients definitively refused surgical revascularization choosing percutaneous one. At this point the mid (Fig.2.a.) and ostial RCA (Fig.2.b.) stenosis were fixed with DES with optimal angiographic and IVUS (Fig.2.c-d.) results. The left coronary system was studied with IVUS demonstrating significant LM/LAD/LCx stenosis and presence of circumferential calcification (Fig.3.a-b). [Formula presented] [Formula presented] Interventional Management Procedural Step: As a first step we performed rotational atherectomy on the axis LM-LAD (Fig. 3.c.) and LM-LCx (Fig. 3.d.) with 1,75 mm burr and after rewiring LAD (Renato) and LCx (Sion Blu) we repeated IVUS evaluation. Predilatation with non-compliant balloons of mid LAD and LCx and LM-LAD and LM-LCx (Fig.4.) was performed and then a bifurcation dedicated stent BIOSS was places on the axis LM-LCx (Fig. 5.a-b). The procedure continued with placing of a second DES in the mid LCx (Fig.5.c-d) and third DES in the mid LAD (Fig.6.a-b.). Then we placed a fourth DES (Fig.6.c-d.) in the axis LM-LAD (culottes with the just placed BIOSS on LM-LCx). Procedure was ended with DOT, POT, kissing balloon and final POT. Optimal result with IVUS (Fig.7.a-d) and angiography (Fig.7.e-f.) was achieved. The patient was discharged after 48 hours on DAPT and clinical follow-up was scheduled for 1st and 3rd month and angiography control after 6 months. [Formula presented] [Formula presented] [Formula presented] Conclusions: Adopting the common rules and guidelines in the everyday practice as in our case with NSTEMI patient rule-in/rule-out, early coronary angiography in less than 24 hours from admission, all vessels revascularization during index hospitalization, imaging in the left main treatment, stent like preparation of vessels before stenting and in some cases using of dedicated bifurcation stent can increase the success rate and reduce the complication rate.
ABSTRACT
Clinical Information Patient Initials or Identifier Number: CE 16/04/1941 Relevant Clinical History and Physical Exam: An 80 years of age lady without any previous disease were conducted to our emergency department due to dyspnoea lasting several hours. At arrival in our emergency department, the patient was still dyspnoeic. Her ECG demonstrated diffuse ischemic changes without certain site definite ischemia. Her chest X-ray showed thickening of the interlobular septa, peri-bronchial cuffing, thickening of the fissures, increased vascular marking, bilateral pleural effusions, cardiomegaly and aortic calcifications. [Formula presented] Relevant Test Results Prior to Catheterization: Her laboratory data revealed increase in myocardial necrosis markers as her TnI-HS was 3450 ng/ml and relatively normal values of other parameters. At echocardiography flash we found severe aortic valve calcification causing stenosis with peak gradient 48 mmHg, mean gradient 28 mmHg and diffuse segmental hypokinesis of left ventricle with global systolic function about 30%. The DAPT was started, and the patient was planned for coronary angiography within 24 hours of admission. [Formula presented] [Formula presented] Relevant Catheterization Findings: Coronary angiography performed through the right radial artery shoed ostial and mid RCA stenosis, severe calcific distal left main (Medina 1.1.1.), mid LAD and mid Lcx stenosis (Fig. 3). At the time of COVID any transfer to any surgical center was extremely difficult so after discussion with the patient and the family we fixed the RCA with one in the mid segment and one ostial DES. Then after aortic valvuloplasty (Valver 20 mm) for Impella 2,5 placement in the left ventricle was done. [Formula presented] [Formula presented] [Formula presented] Interventional Management Procedural Step: Through right radial artery access, the right coronary artery was fixed with stenting. Then aortic balloon valvuloplasty (Valve 20 mm). The Impella device was advanced and after crossing the dilated aortic valve the tip was placed in the left ventricle. Sequential predilatations of LM-LAD and LM-LCx with semi-compliant, non-compliant and scoring balloons were performed. For persisting of unacceptable for stenting result we continued the preparation of LM bifurcation with predilatation using intravascular lithotripsy (IVL) with Shockwave balloon on LM-LAD and LM-CX. Then we implanted one bifurcation dedicated stent Bioss Lim on the axis LM-LCx. After predilatation of mid LAD we placed one drug eluting stent from LM to LAD proximal through the Bioss stent (short culotte stenting). The procedure was ended with drug coated balloon on LAD mid and with drug coated balloon inflation on LCx mid. Then, Impella was removed, and vascular closure was achieved with Manta closing device. In the ICCU, the patient complained of intensive pain in the left lumbar and iliac region, nausea and severe hypotension (80/40 mmHg blood pressure). Contralateral injection demonstrated common femoral artery injury with large amount of blood passage in the pelvic cavity. A self-expandable covered stent 8 x 60 mm was introduced and placed at the site of artery rupture. The control angiography evidenced complete closure of the artery wall with no blood passage. [Formula presented] [Formula presented] [Formula presented] Conclusions: In time of pandemic restrictions, decision of treatment must be done using available in-hospital facilities. The presence of aortic valve stenosis and multi-vessel disease and low ejection fraction requires contemporary preparation of aortic valve for haemodynamic support during coronary angioplasty. Vessel preparation can be achieved with new devices as intravascular lithotripsy (IVL) to reduce the risk of complication. DCB are valid alternative to DES particularly in small vessels with long atherosclerotic disease. Vascular access site dramatic complications in the experienced hands and well-organized catheterization laboratory can be managed within the cath lab percutaneously.
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Objectives: COVID-19 is a viral-induced illness whose outcomeseems to be determined by a cytokine storm that produces damage to tissues and organs such as ARDS, pneumonia, MODS. Inthis study we report the effects of steroids at low dosage and continuos infusion in patient with progressive Respiratory failure dueto SARS-COV2.Patients and Methods: This is a case series of patients with severe pneumonia or ARDS due to SARS COV2 treated with infusionof methylprednisolone. Patients were also treated with anticoagulant therapy with enoxaparin 6000 IU/day or 100 IU/kg/bid inpatients with documented pulmonary embolism via subcutaneousinjection, hydroxychloroquine 800 mg/day as loading dose for the1st day, than 400 mg/day, azithromycin 500 mg/ day, and oxygensupplementation.Results: We treated eleven COVID-19 patients with severe pneumonia or ARDS. All patients showed clinical improvement after anaverage of 5 days. Mean ferritin decreased from 669,475 ng/mlto 400,425 ng/ml and the mean duration illness was 27 days.Conclusions: The early use of corticosteroids at the onset of therespiratory failure in patients with SARS COV 2 infection seems toblock the cytokine storms and may reduce mortality. Cliniciansshould pay close attention to the impact immune inflammatoryfactor release.
ABSTRACT
Background and Aim of the study: We report the data of a studywhose aim was to evaluate the discriminative ability of differentmarkers to identification patients destined to serious/fatal formsof COVID-19. Materials and Methods: We studied 67 patients of our COVIDCenter with a Pneumonia by SARS Cov-2. Based on clinical severity patients were divided into 2 groups;for each, data and clinicalinformation were analyzed, with a comparison between resultsand groups, subsequently highlighting their characteristics anddifferences. Results: Of many markers evaluated, a significant increase of serumferritin (FER) was detected in severe (33/52) and fatal (11/33)disease;the high values (652-5,841 ng/mL) were found to be proportional to clinical severity, to interstitial damage and to the use ofmechanical ventilation. In the patients with fatal disease extremelyhigh values were found (944-2,535 ng/mL). Other markers werealso found to be related to severe forms, but not as FER. The samestudy also found that a value >650 ng/mL corresponded to a persistent positivity to NP swab;this finding guided us in the timing forthe discharge of patients. Ferritin increase in COVID seems to be related to cell damage (activation of the RE system).Conclusions: In our study FER dosed proved to be the most reli able and sensitive marker in patient monitoring, in the evaluationof virus persistence and in recognition of potentially fatal forms. Further studies are needed to understand the application of itsuse in SARS Cov-2 infection, but FER appears to be a reliablemarker if associated with the clinical practice and in combinationwith other tests.