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Objective: Is to find out which revascularization methods have less of risk factors and complications after the surgery and long-term period. Method(s): From January 2018 to December 2019 were operated 134 patients with LAD CTO. 48 of them underwent MIDCAB: 36 (75%) males and 12 (25%) females;aged 58.7 +/-8.7;7 (14.6%) with previous diabetes;10 (20.8%) with previous PCI of LAD with drug-eluting stent. In the PCI group there were 86 patients: 52 (60.5%) males and 34 (39.5%) females;aged 64.8 +/-8.3;23 (26.7%) with previous diabetes. Result(s): Hospital mortality was 0 (0%) in MIDCAB unlike 1 (1.2%) in PCI. Myocardial infarction was 0 (0%) in both the groups. In MIDCAB the number of conversions to onpump and sternotomy was 0 (0%), there were 6 (12.5%) pleuritis with pleural puncture and 3 (6.2%) with long wound-aches. The hospitalization period was 10.7+/-2.9 days for MIDCAB and 9.9 +/-3.9 days for PCI. In the PCI group 2.0 +/-1.0 drug-eluting stents were used. In-hospital costs were higher for PCI 3809 unlike 3258 for MIDCAB. After one year in MIDCAB group died 2 (4.2%) patients, from noncardiac causes. In PCI group died 3 (3.5%) patients, all from cardiac causes. Because of pandemic COVID-19 were checked only 48 patients by angiography and general clinical examination: 25 after MIDCAB and 23 after PCI. 5 patients have a graft failure, caused by surgical mistakes. 4 patients have stents restenosis and 1 has LAD's reocclusion. Conclusion(s): Both methods of revascularization for LAD CTO are demonstrated similar results. EuroSCORE II (P = 0.008) and glomerular filtrating rate (P = 0.004) are significant potential risk factors for mortality in both groups, age is potential risk factor for graft failure (P = 0.05). Dyslipidemia is significant risk factor for LAD restenosis in PCI group (P = 0.02). MIDCAB is associated with lower incidence of revascularization repeat and in-hospital mortality in the literature data and it costs lower than PCI for LAD CTO as our study has shown.
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INTRODUCTION. The aetiology of Kawasaki disease (KD) remains unknown. Changes in infectious exposure during the COVID-19 pandemic owing to infection prevention measures may have affected the incidence of KD, supporting the pathogenic role of an infectious trigger. The purpose of this study was to evaluate the incidence, phenotype and outcome of KD before and during the COVID-19 pandemic in Denmark. METHODS. This was a retrospective cohort study based on patients diagnosed with KD at a Danish paediatric tertiary referral centre from 1 January 2008 to 1 September 2021. RESULTS. A total of 74 patients met the KD criteria of whom ten were observed during the COVID-19 pandemic in Denmark. Alof these patients were negative for SARS-CoV-2 DNA and antibodies. A high KD incidence was observed during the first six months of the pandemic, but no patients were diagnosed during the following 12 months. Clinical KD criteria were equally met in both groups. The fraction of intravenous immunoglobulin (IVIG) non-responders was higher in the pandemic group (60%) than in the in the pre-pandemic group (28.3%), although the rate of timely administered IVIG treatment was the same in both groups (>= 80%). Coronary artery dilation was observed in 21.9% in the pre-pandemic group compared with 0% in KD patients diagnosed during the pandemic. CONCLUSION. Changes in KD incidence and phenotype were seen during the COVID-19 pandemic. Patients diagnosed with KD during the pandemic had complete KD, higher liver transaminases and significant IVIG resistance but no coronary artery involvement.Copyright © 2023, Almindelige Danske Laegeforening. All rights reserved.
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It is now widely known that COVID-19 can also cause various extrapulmonary manifestations. Possible mechanisms of cardiovascular damage include direct myocardial damage due to hypercoagulability caused by systemic inflammation, which may also lead to destabilisation of coronary plaques. We present a case of a 30-year-old young man following asymptomatic COVID-19 infection, who was admitted to the emergency room of the Grande Ospedale Metropolitano di Reggio Calabria, Italy, with typical chest pain. The patient had no cardiovascular disease, cardiovascular risk factors including no family history of cardiovascular disease. Urgent coronary angiography showed critical stenosis of the middle-proximal portion of the left anterior descending artery (80%) with ulcerated plaque appearance. Regardless of cardiovascular risk factors, our case report emphasises the need to determine COVID-19 status in all patients with acute myocardial infarction during this pandemic.Copyright © 2023, CKS.
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Calcium levels in the Coronary Artery are an indicative marker of the presence and extent of atherosclerosis. This serves as an additional prognostic indicator in addition to traditional risk factors. Moreover, the coronary calcium test is associated with a descriptor known as the calcium score or calcium score (Cs), which is primarily useful for stratifying the risk of asymptomatic patients, while for patients with acute or chronic chest pain, coronary axial computed tomography is generally required. A retrospective analysis of data was conducted in the radiology department of King Salman Specialist Hospital in Hail City, the kingdom of Saudi Arabia, between January and May 2022. A total of 40 patients were randomly selected, 25 males and 15 females. The study included all patients with or suspected of having a calcium deposit who underwent a CT scan using the Siemens SOMATOM definition MDC scan. Patients underwent a scan with the preparations and laboratory tests required for their coronary artery calcium scores. In this study, males were more likely to be affected by calcium deposits (64%), whereas females were 36%. Approximately 50 percent of the study populations were found to be normal (no identifiable calcium deposits) and 37.5% to have moderate calcium deposits. There is a significant association between CACS and moderate CVD risks based on age and gender in this study. Better control of cardiovascular system (CVS) risks is recommended in all primary care centers in the Kingdom of Saudi Arabia (KSA).Copyright © 2022 International Journal of Pharmaceutical Research and Allied Sciences. All rights reserved.
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Clinical Information Patient Initials or Identifier Number: SHS Relevant Clinical History and Physical Exam: Mr. SHS was admitted in August 2022 for acute decompensated heart failure secondary to NSTEMI, complicated with ventricular tachycardia (VT). CPR was performed for6 minutes on the day of admission and was subsequently transferred to the Cardiac Care Unit. His hospital stay was complicated with Covid-19 infection(category 2b) which he recovered well from. During admission, he developed recurrent episodes of angina. Physical examination was otherwise unremarkable. His ejection fraction was 45%. Relevant Catheterization Findings: Cardiac catheterization was performed, which revealed significant calcification of left and right coronary arteries. There was a left main stem bifurcation lesion (Medina 0,1,1) with subtotal occlusion over ostial the LAD, receiving collaterals from RCA and 90% stenosis over ostial LCx. RCA was dominant, heavily calcified with no significant stenosis. He was counselled for CABG (Syntex score26) but refused. As he was symptomatic, he was planned for PCI to the left coronary system. [Formula presented] [Formula presented] [Formula presented] Interventional Management Procedural Step: The left main was engaged with a 7F EBU 3.5guiding catheter via transradial approach. Sion Blue wired into LAD and LCx. IVUS catheter couldn't cross the LAD and LCx lesions, hence we decided for up front rotational atherectomy. Sion blue was exchanged to Rotawire with the assistance of Finecross microcatheter. A 1.5mm burr was used at 180000 rpm. After the first run of rotablation, patient developed chest pain and severe hypotension (BP ranging 50/30). 4 inotropes/vasopressors were commenced. The shock was refractory hence an intraarterial balloon pump was inserted. Symptoms and blood pressure improved. Another 2 runs of atherectomy done (patient developed hypotension after each run). IVUS examination then showed calcification of proximal to mid LAD with an IVUS Calcium score of 3. LAD was further predilated with Scoreflex balloon 3.0/20mm at 8-22ATM. LCx was predilated with Scoreflex balloon 2.0/15mm at 12-14ATM. DCB Sequent Please NEO2.0/30mm was deployed at 7ATM at ostial to proximal LCx. Proximal to mid LAD was stented with Promus ELITE 2.5/32mm at 11ATM, which was then post dilated with stent balloon at 11ATM. Ostial LM to proximal LAD (overlap) was stented with Promus ELITE 4.0/28mm at 11ATM. LMS POT was then done with NC Balloon 4.0/15mm at 24ATM. LCx was rewired and kissing balloon technique with NC balloon 4.0/15mm at 14ATM (LAD) and NC balloon 2.0/10mm at 12ATM (LCx) was done, followed by a final POT with NC balloon 4.0/15mm at 14ATM. Final IVUS showed good MSA. [Formula presented] [Formula presented] [Formula presented] Conclusion(s): This patient developed hemodynamic instability with each rotational atherectomy run, hence we decided not to perform rotablation to the circumflex artery. His hemodynamic condition improved with the use of intra aortic balloon pump. IABP use can reduce procedural event rate and potentially reduce long term mortality in appropriately selected patients who are at high risk of adverse events. He was followed up a month following the procedure and remained asymptomatic. For complex, calcified coronary lesions involving the left main stem, coronary artery bypass graft surgery is an alternative option.Copyright © 2023
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Clinical Information Patient Initials or Identifier Number: 56 years old woman Relevant Clinical History and Physical Exam: A 56-years-old woman with underlying history of hyperlipidemia without medical treatment. She experienced effort precordial tightness and shortness of breath for 8 months after COVID-19 vaccination. She received exercise TI 201 myocardial perfusion scan showed myocardial ischemia. EKG found old anterior wall myocardial infarction. Echocardiogram showed left ventricle anterior wall hypokinesia, LVEF 38%. [Formula presented] Relevant Test Results Prior to Catheterization: Coronary angiogram found left anterior descending artery from proximal to middle 70~80% long diffuse stenosis with spontaneous recanalized coronary thrombus. Also left anterior descending artery diagonal 2 branch bifurcation was 70% stenosis with spontaneous recanalized coronary thrombus (Medina 1.1.1) [Formula presented] [Formula presented] Relevant Catheterization Findings: Coronary angiogram found left coronary artery middle and diagonal branch braided apperance. OCT found recanalized thrombi, high backscattered septa that divided the lumen into multiple small cavities, created "lotus root" appearance. [Formula presented] [Formula presented] Interventional Management Procedural Step: Left main coronary artery was engaged with EBU3.5/7F guiding catheter. We advanced Runthrough to LAD-D and second wire Sion to LAD-DB2 but can't advance. Then we used with Sasuke double lumen catheter and successful advance Pilot 50 to LAD-DB2 distal. OCT found multiple channels with LAD-D and DB2 branch wires are at different channels, so we used cutting balloon 2.5 x 10mm as unconventional method. OCT was rechecked again and successfully destroyed to multiple channel of SRCT between LAD and Diagonal 2 branch. Long diffuse dissection found after POBA so we deployed to LAD-DB2 branch with DES Synergy 2.5 x 16mm and advanced LAD-M bifurcation to Pantera LEO 3.0 x 20mm and done Mini-Crush technique. Deployed for main vessel LAD-P to M long diffuse lesion with DES Xience 2.75 x 48mm at 14atm. Then we rewire Fielder XTR to DB2 branch with the support of Sasuke but difficult to deliver to Diagonal 2 branch. POT with Pantera LEO 3.0 x 20mm to LAD stent proximal site. Then successfully advance Fielder XTR to DB2 branch. Final kissing balloon technique with Pantera 2.75 x 12mm to LAD main vessel and MINI TREK 1.5 x15mm to LAD-DB2. [Formula presented] [Formula presented] [Formula presented] Conclusion(s): This is a case of SRCT (Spontaneous Recannalized Coronary Thrombus) that was confirmed with OCT. For secure side branch patency, main trunk & side branch wire must be in same channel. Due to relatively unstable hemodynamic, we chose to use unconventional method with 2.5 x 10mm Wolverine cutting balloon. Relatively large side-branch diagonal branch, possible dissection at ostial diagonal branch, we chose upfront 2 stents, bifurcation stenting technique we used Mini-crush stenting. Some difficult when rewire to side branch and initial POT to main branch stent proximal and then successfully delivered. If without guidewire recross, unrescuable side-branch occlusion can be occurred.Copyright © 2023
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Aim: Coronavirus disease 2019 (COVID-19) has caused thrombotic disease. In this study, we aimed to determine the demographic and clinical characteristics of acute coronary syndrome (ACS) patients infected with COVID-19 and to investigate whether they differ from patients with ACS without COVID-19 in terms of these characteristics. Material(s) and Method(s): The study was designed as a single-center retrospective study. Thirty-three COVID-19 infected ACS patients (Group 1) and 100 ACS patients without COVID-19 infection (Group 2) were included in the study. Result(s): The groups were compared in terms of coronary angiographic data. Twenty-eight (84.8%) patients in Group 1 and 74 (74%) patients in Group 2 were presented as non-ST elevation myocardial infarctus. Patients were compared in terms of baseline Thrombolysis in Myocardial Infarctus (TIMI) flow, thrombus stage, myocardial blush (end), using of thrombus aspiration catheter, stent thrombosis, and TIMI flow after percutaneous coronary intervention, and it was observed that there was no statistical difference between the groups (p> 0.05). Discussion(s): COVID-19 infection can cause plaque rupture, myocardial damage, coronary spasm and cytokine storm by triggering the coagulation and inflammation process. The fact is that we did not encounter an increased thrombus load in this study.Copyright © 2022, Derman Medical Publishing. All rights reserved.
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Background Coronary artery anomalies are rare with an incidence of 0.3 to 1.3%. Here we are describing an extremely rare anomaly of the left anterior descending artery (LAD) Case A 55-year-old female with covid-related chronic hypoxemic respiratory failure, pulmonary embolism on apixaban and IgG deficiency on IVIG therapy presented with dyspnea and increased oxygen requirement. EKG had no ischemic changes. Troponins were negative. CTPE was negative. TTE showed normal EF with no valvular or wall motion abnormalities. Right ventricular systolic pressure wasn't calculated due to insufficient TR. Decision-making Left and right heart catheterization was negative for coronary artery disease, bridging or pulmonary hypertension but revealed a dual LAD system and an interesting right coronary anatomy as seen below. These findings were confirmed with a coronary CT angiogram (done in the past that we reviewed again). Stress test was negative for ischemia of the apical anterior wall. The patient reported undergoing coronary angiograms multiple times at other institutions before for recurrent chest pains but has not been diagnosed with anomalous coronary artery until current admission. Conclusion This is a rare anomaly that has been not described before (upon our literature review). It is important to recognize dual LAD system as Inability to visualize the additional vessel, especially when the long LAD originates from the right coronary sinus, can be misinterpreted for mid-LAD occlusion. [Formula presented]Copyright © 2023 American College of Cardiology Foundation
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Case Report: Prolonged fever in children is a symptom that is seen in many different diseases, infections, malignancies, and autoimmune conditions. This can, at times, make the correct diagnosis challenging. A previously healthy 10-year-old male was transferred to our institution with one week history of fever, fatigue, abdominal pain, and vomiting. Laboratory studies demonstrated pancytopenia, transaminitis, electrolyte abnormalities, elevated pro-inflammatory markers & D-Dimer, and hypoalbuminemia. COVID-19 IgG was reactive. Due to the severity in presentation the patient was transferred to the ICU with a presumptive diagnosis of MIS-C. Hewas started on IVIG as well as a five-day course of high-dose methylprednisolone per protocol. Aspirin was added, but later discontinued, due to worsening thrombocytopenia. CT imaging with contrast showed small bilateral pleural effusions & periportal edema, mild splenomegaly, and echocardiogram showed diffuse dilation of the left main and left anterior descending arteries. Given the laboratory findings the differential diagnosis was expanded, Ehrlichia caffeensis serology was sent and empiric Doxycycline started. EBV Nuclear Antigen IgG antibody and EBV Viral Capsid Antigen IgM Antibody resulted as positive suggesting recent or reactivated infection. Respiratory viral PCR with COVID-19, Cytomegalovirus and Parvovirus PCR were negative. Despite initial treatment, the patient continued to have persistent fever, severe pancytopenia, and high ferritin up to 24 426 ng/mL, raising suspicion for Haemophagocytic Lymphohistiocytosis (HLH). Soluble interleukin-2 level was elevated & his presentation was then considered to be more consistent with HLH given that he met 6/8 criteria. Screening for primary HLH including CD107a, perforin and granzyme B, SAP, and XIAP resulted in the latter three being normal but CD107a was abnormal. Next generation sequencing for primary criteria was negative. E. Chaffeensis resulted positive: IgM 1:80, IgG 1:256. MIS-C and HLH have overlapping features but differ in some clinical manifestations. Timely recognition and management is paramount as the management differs. This case illustrates the importance of performing a broad search for potential causes, allowing for appropriate and timely treatment. COVID-19 serology alone should not be the basis for diagnosis of MIS-C in a patient with fever and inflammation. This is important as SARS-CoV2 becomes endemic. Infections such as EBV and Ehrlichiosis should be on the differential particularly in endemic areas and during seasons of higher prevalence for the latter, as these have been well documented to cause HLH. Copyright © 2023 Southern Society for Clinical Investigation.
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Air pollution and COVID-19 infection affect the pathogenesis of cardiovascular disease. The impact of these factors on the course of ACS treatment is not well defined. The purpose of this study was to evaluate the effects of air pollution, COVID-19 infection, and selected clinical factors on the occurrence of perioperative death in patients with acute coronary syndrome (ACS) by developing a neural network model. This retrospective study included 53,076 patients with ACS from the ORPKI registry (National Registry of Invasive Cardiology Procedures) including 2395 COVID-19 (+) patients and 34,547 COVID-19 (-) patients. The neural network model developed included 57 variables, had high performance in predicting perioperative patient death, and had an error risk of 0.03%. Based on the analysis of the effect of permutation on the variable, the variables with the greatest impact on the prediction of perioperative death were identified to be vascular access, critical stenosis of the left main coronary artery (LMCA) or left anterior descending coronary artery (LAD). Air pollutants and COVID-19 had weaker effects on end-point prediction. The neural network model developed has high performance in predicting the occurrence of perioperative death. Although COVID-19 and air pollutants affect the prediction of perioperative death, the key predictors remain vascular access and critical LMCA or LAD stenosis.
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Acute Coronary Syndrome , Air Pollutants , Air Pollution , COVID-19 , Coronary Stenosis , Humans , Coronary Stenosis/pathology , Coronary Stenosis/therapy , Acute Coronary Syndrome/epidemiology , Constriction, Pathologic , Retrospective Studies , Coronary Angiography , Air Pollution/adverse effectsABSTRACT
SESSION TITLE: Cardiovascular Complications in Patients with COVID-19 SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Spontaneous coronary artery dissection (SCAD) is a rare cardiac phenomenon associated with autoimmune and inflammatory conditions seen often in young women with few conventional atherosclerotic risk factors. The presentation is indistinguishable from acute coronary syndrome and can lead to acute myocardial infarction, arrhythmias, and sudden death. We share a thought-provoking case of SCAD in a COVID-19 positive patient. CASE PRESENTATION: 51-year-old physically fit female with BMI of 22.46kg/m2, non-diabetic with recent unremarkable lipid panel and history of anxiety, postpartum cardiomyopathy 15 years prior with recovered ejection fraction presented with complaints of midsternal chest pain at rest, 9/10 intensity, radiating to the right shoulder associated with dyspnea, lasting for 3 hours until relieved by nitroglycerine patch. Initial workup revealed troponin of 3.08 and EKG consistent with acute ischemic changes without STEMI. She was incidentally found positive for SARS-CoV-2. Echocardiogram showed dyskinetic apex with normal ejection fraction. The following day, while she was on aspirin and heparin drip, she developed chest discomfort with EKG revealing dynamic T wave inversions and troponin trending up to 14.79. The patient was taken for an emergent cardiac catheterization which revealed patent coronaries with concern for distal left anterior descending artery dissection. Subsequently, the patient was continued on a heparin drip with an improvement of her symptoms. Troponin declined to 7.97 with no other COVID-19 related concerns. She was deemed medically stable and discharged home after completing her isolation. Furthermore, she underwent a cardiac and coronary artery CT angiogram 2 weeks later, showing patent coronaries and a calcium score of 0 and no findings of coronary artery disease. DISCUSSION: SCAD is an emergent condition closely associated with inflammatory conditions, systemic arteriopathy, emotional stress triggers, fibromuscular dysplasia, and pregnancy. It is not iatrogenic, traumatic or associated with atherosclerosis. The mainstay of detection of SCAD is coronary angiography. In our patient, since it was a distal LAD disease, the echo findings of dyskinetic apex helped established the diagnosis of SCAD. Management is mainly supportive usually carrying a good prognosis. In our case report, the connecting factor to SCAD was the presence of SARS-CoV-2. Our patient was without traditional risk factors for coronary artery disease, which reinforced the likelihood of SCAD instead of acute coronary syndrome. CONCLUSIONS: Thus, as the manifestations, complications, and sequelae of COVID-19 continue to emerge, we believe SCAD needs to remain a top differential in COVID -19 positive patients presenting with symptoms of the acute coronary syndrome. To better elucidate the pathophysiology of SCAD in SARS-CoV-2 patients, we encourage further vigilance of this phenomenon. Reference #1: Hayes, S. N. et al (2018, February 22). Spontaneous coronary artery dissection: Current state of the science: A scientific statement from the American Heart Association. Circulation. Retrieved April 1, 2022, from https://www.ahajournals.org/doi/10.1161/cir.0000000000000564 Reference #2: Ahmed, T., Jeudy, J., & Srivastava, M. C. (2020). Imaging modalities to delineate sequelae of spontaneous coronary artery dissection managed with percutaneous coronary intervention. Cureus. https://doi.org/10.7759/cureus.7591 DISCLOSURES: No relevant relationships by Hareesh Lal No relevant relationships by Jennaire Lewars No relevant relationships by Avani Mohta
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SESSION TITLE: Cardiovascular Complications in Patients with COVID-19 SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: COVID-19 is associated with a hypercoagulable state and has been linked with Disseminated Intravascular Coagulation (DIC) [1]. DIC causes systemic thrombosis in micro- and macro- vasculature and in rare instances can involve coronary arteries [2]. In this case report, we present a patient who presented as an ST-segment elevation myocardial infarction (STEMI) and DIC in the setting of severe COVID-19 disease. CASE PRESENTATION: A 46-year-old lady with a history of hypertension presented with acute onset of typical chest pain. She tested positive for COVID-19 infection. Emergency room EKG showed anterior STEMI, and the patient underwent cardiac catheterization via a femoral approach which revealed a 99% stenosis in the proximal LAD, with filling defects consistent with a thrombus. Thrombectomy was performed and three drug-eluting stents were placed in the left anterior descending artery. Following stent placement, the patient went into ventricular fibrillation cardiac arrest followed by PEA. ROSC was attained after 3 rounds of CPR. Labs showed an acute drop in hemoglobin from 14 gm/dL to 5 gm/dL with CT evidence of extensive retroperitoneal bleed, extraperitoneal bleed, and large abdominal aorta thrombus proximal to the bifurcation. Labs were significant for prolonged INR (2.1), PT (23.4 seconds), PTT (106.7 seconds), elevated D-dimer (>4.0), decreased platelets (101K/μl), and increased fibrin split products (80uG/mL) consistent with DIC. The acute aortoiliac occlusive thrombus resulted in acute limb ischemia, rhabdomyolysis causing renal failure, and compartment syndrome requiring bedside fasciotomy. She was treated with triple therapy and demonstrated gradual clinical improvement. DISCUSSION: DIC was a possible precipitant of STEMI in this patient with evidence of thrombotic occlusion of LAD. DIC is a life-threatening coagulopathy characterized by mixed hypo- and hypercoagulation. This often leads to a systemic distribution of clots, evidenced by thrombi present in the coronary and aortoiliac arteries. Historically, bacterial sepsis was more strongly linked with DIC than viral causes;however, there has been an increasing amount of evidence linking COVID-19 with DIC, likely due to the severity of the illness. In this patient with recent stent placement, large aortic thrombus, and extensive retroperitoneal bleed, management was complicated by need for dual antiplatelet therapy for drug-eluting stents as well as anticoagulation for acute limb ischemia. Another diagnosis to keep in the differential includes heparin-induced thrombocytopenia, characterized by similar findings to DIC, but is associated with antibodies against platelet factor 4, which was not found in our patient. CONCLUSIONS: In this case, a young female patient without traditional cardiac risk factors was found to have an anterior STEMI, likely precipitated by DIC as a complication of COVID-19 infection. Reference #1: Asakura, Hidesaku, and Haruhiko Ogawa. "COVID-19-associated coagulopathy and disseminated intravascular coagulation.” International journal of hematology vol. 113,1 (2021): 45-57. doi:10.1007/s12185-020-03029-y Reference #2: M. Sugiura, K. Hiraoka, and S. Ohkawa, "A clinicopathological study on cardiac lesions in 64 cases of disseminated intravascular coagulation,” Japanese Heart Journal, vol. 18, no. 1, pp. 57–69, 1977. DISCLOSURES: No relevant relationships by radhika deshpande No relevant relationships by Shruti Hegde No relevant relationships by Robert Kropp No relevant relationships by Prashanth Singanallur
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Introduction: Coronary artery disease complicates 0.01% of pregnancies. In this case study, we illustrate the successful management strategy of a pregnancy with a cardiometabolic disorder who conceived after a ST-elevation myocardial infarction (STEMI). Case Description: A 41-year-old woman in her third pregnancy was referred to our maternal-fetal-medicine unit at 8 weeks of gestation. She had a history of an acute inferior myocardial infarction (MI) Killip 1 with 70% occlusion of the left anterior descending artery and ectatic vessels, which was successfully thrombolysed 1 year prior. On presentation, she had uncontrolled type 2 diabetes, chronic hypertension on treatment, and was morbidly obese with a BMI of 44 kg/m2. She had 2 previous lower segment caesarean sections and an umbilical hernia repair. A systematic effort involving a multidisciplinary team, both at tertiary and community level, was coordinated from the start, which successfully prevented any cardiac events during pregnancy. She recovered from Covid-19 category 4a at 28 weeks with no cardio-respiratory implications. She went on to have a lower segment caesarean section near term with tubal ligation. Post-operative recovery was uneventful, and she continued to see cardiologists and endocrinologists. Discussion: Specific risks such as MI recurrence, pre-eclampsia and low birth weight baby can be minimised through comprehensive antenatal and perinatal plans supported by patient compliance. Our case showed that pregnancy after MI results in good maternal-fetal outcome provided the pre-pregnancy cardiac performance status is good, early multidisciplinary management, patient-centred approach, close antenatal monitoring, adequate delivery preparation and patient compliance.
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As of December 2021, India has over 34.8 million cases of COVID 19, an infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). It has been a massive problem to society with variable manifestations in human, and there has been numerous reported cases of covid 19 patients presenting with broad spectrum of cardiovascular (CV) manifestations. This case presented 3 patients with CV complication of COVID 19 leading to vascular ischemia, cardiac tamponade and ST elevated myocardial infarction All patients presented with chief complaint of high grade fever and shortness of breath. The first patient was a healthy and young 24-year-old male having pain in the right thigh with swelling. Doppler ultrasound of limbs showed poor venous flow indicating vascular ischemia. 2nd patient was 60-year-old women with upper respiratory symptoms diagnosed with Covid 19 and had progressive dyspnoea. She was found to have a hemorrhagic pericardial effusion with echocardiographic signs of tamponade and grade 2 cardiomegaly. Third patient was a 59 years old diabetic male diagnosed with ST elevated myocardial infraction represented by elevated cardiac enzymes, raised troponin I, ST elevation in anterior and septal leads and akinesia in the region of left anterior descending coronary artery (LAD). Covid 19 infection has common respiratory foot prints identified by knowledge of clinical presentation however, it has also extra- pulmonary cardiac and Vascular Stigmas which can be of serious consequences.
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Introduction: Multisystem inflammatory syndrome in children (MIS-C) is a rare complication of SARS-CoV-2 infection, with an incidence of about 1:100'000 children. According to published case series, between 10% and 40% of MIS-C develop coronary artery modifications, mainly hyperechogenicity, with a lower incidence of aneurysm. Evolution and outcome of coronary artery aneurysm post MIS-C is unknown. Methods: We report the case of a 10-year old male with medium left anterior descending coronary artery (LAD) aneurysm (diameter of 6.2 mm, z-score +7.9) and small right coronary artery (RCA) aneurysm (z-score +2.9) detected one week after his hospital admission for hypotensif shock in the context of MIS-C and positive serologies for SARS-CoV-2. He didn't meet diagnosis criteria for Kawasaki disease. He was treated with 2 g/kg immunoglobulin (administered after coronary artery dilatation was observed, as the recognition and definition of MIS-C was contemporary with our case), corticosteroids and anakinra. He rapidly normalized his initial mild LV dysfunction and cardiac enzymes elevation. Results: Since discharge, the patient was treated with antiplatelet therapy (100 mg aspirin daily) and carefully followed up in outpatient cardiology. On echocardiography, coronary artery dimensions progressively regressed, prompting a control computed tomography (CT) 6 months after MIS-C episode. CT confirmed LAD and RCA dimension near-normalization, compared to the fusiform dilatations 6 months ago : LAD maximal diameter of 3.7 mm (z-score +2.3), RAD maximal diameter of 4 mm (zscore +1.8). Moreover, no coronary stenosis was observed. Conclusions: Coronary artery aneurysm in the context of MIS-C probably represents a post-infectious vasculitis. This case illustrates a regression of coronary artery dilatation after a few months. Further research is needed to assess if this finding reflects a generalisable outcome and to study the effect of medical treatment on the evolution of coronary artery dilatation post MIS-C.
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Background: Stent thrombosis (ST) is a dreaded complication of percutaneous coronary intervention (PCI), however incidence has been declining with improvement in stent design and pharmacological treatments. While ST can occur at any time after placement of a stent, the rate of ST declines as time from implantation progresses. Case: A 54 year-old man with a history of hypertension, hyperlipidemia, type two diabetes mellitus and coronary artery disease status PCI to the left anterior descending artery (LAD) six years prior presented with substernal chest discomfort for three hours. Vital signs were within normal limits, and his electrocardiogram showed two-to-three-millimeter ST elevation across the precordial leads with reciprocal ST depressions. He was brought emergently to the cardiac catheterization lab where coronary angiography revealed a large thrombus within the previously placed LAD stent. The patient underwent aspiration thrombectomy, balloon angioplasty and stenting of the LAD. The patient was discharged in good condition on dual-antiplatelet therapy three days after his presentation. Decision-making: Since the beginning of the COVID-19 pandemic, physicians on the front lines have been learning more and more about the virus including prevention and treatment. In a stunning collaboration of science and enterprise, several vaccines were created including the Johnson & Johnson/Janssen (J&J) single dose COVID-19 immunization. However, although effective at preventing serious COVID-19 infections, anecdotal evidence of thrombotic events has been reported. Given this patient's thrombotic event, a hypercoagulable workup was undertaken but unrevealing. Conclusion: We describe a case of very late ST of a six year-old drug eluting stent occurring three weeks after the patient received a J&J COVID-19 vaccine. While temporally the timing of the stent thrombosis is surprising and possibly related, this is yet another case to add to the body of evidence as we learn more about the 2019 Novel Coronavirus and the COVID-19 vaccines as we navigate this pandemic together.
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Background: Myocardial infarction with non-obstructive coronary arteries (MINOCA) is a complex and diagnostically challenging entity. Case: A 62-year-old female with recent COVID19 infection presented with chest pain. She was discharged just one week prior for NSTEMI, with mild non-obstructive CAD by left heart catheterization (LHC) and a normal transthoracic echocardiogram. This admission, Initial Troponin I peaked at 0.87 ng/mL and ECG without ischemic changes. Cardiac MRI (CMR) showed no myocarditis/pericarditis but moderate-severely hypokinetic apical cap, distal inferior and septal walls, with a small focus of subendocardial scar/infarction involving the distal septum (Fig.1A,B,C). LHC showed severe vasospasm in the right coronary artery and left anterior descending artery (Fig. 1D,E), which resolved after intracoronary nitroglycerin (Fig. 1F). With initiation of isosorbide mononitrate to manage coronary vasospasm, the patient’s symptoms improved. At 6-month follow-up, patient was doing well with no repeat hospitalizations. Decision-making: Even though initial workup did not identify a clear etiology, CMR was pivotal in prompting further evaluation that revealed severe coronary vasospasm. Given the transient nature of vasospasm, it is likely this had resolved prior to her initial LHC, but was caught on repeat imaging. Conclusion: CMR is a key diagnostic tool in preliminary investigation of MINOCA when a clear cause is not found, and can alter next steps in management. [Formula presented]
ABSTRACT
Background: Excimer Laser Coronary Atherectomy (ELCA) is a well-established adjunctive treatment modality that can be effectively used to reduce thrombus burden during percutaneous coronary intervention of coronary thrombosis. Case: A 34-year-old male with history of COVID-19 pneumonia one month prior, presented with non-ST elevation myocardial infarction. Coronary angiography revealed large thrombus burden involving the distal left main (LM) and ostial left anterior descending artery (LAD), as well as a distal LAD thrombotic occlusion (Figure 1A). Intravascular ultrasound showed distal LM plaque rupture with overlying thrombus (Figure 1C). Decision-making: Given the large thrombus burden and elevated risk of distal embolization, we proceeded with lesion passivation using adjunctive antiplatelet and antithrombotic treatment for 48 hours. ELCA was then used for thrombus debulking with a 1.7-mm catheter under distal embolic protection placed in mid LAD (Figure 1B). This was followed by aspiration thrombectomy, balloon dilation, and placement of a drug eluting stent in the distal LM and ostial LAD (Figure 1D). Conclusion: A strategy of using ELCA followed by stent implantation can be useful in selected patients with high intracoronary thrombus burden. ELCA can achieve effective thrombus removal, promotion of fibrinolysis, and platelet-stunning effects allowing plaque debulking and reduction of distal embolization. This case combines traditional tools to achieve the best possible outcome. [Formula presented]