Effect of an Internet-based Intervention on Motor Behavior in Patients after Percutaneous Coronary Intervention

Background During the containment of COVID-19，the traditional face-to-face interventions conducted at the rehabilitation center were plagued by many limitations，while internet-based interventions can overcome the limitations of geographic location，working hours and transportation，with less medical costs. Objective To examine the effects of internet-based interventions on knowledge，attitude/belief and practice（KAP） toward rehabilitation exercises，physical activity（PA）level，and exercise compliance inpatients after PCI. Methods The subjects were 76 patients who received their first PCI in Department of Cardiology，Tangshan Gongren Hospital from November 2021 to June 2022. They were randomly and equally divided into two groups to receive either internet-based intervention with routine nursing（experimental group） or routine nursing （control group）. Before and three months after the intervention，the Rehabilitation Exercise Knowledge-Belief-Practice Scale for Patients with Coronary Heart Disease（REKBPCHD），the International Physical Activity Questionnaire-Short Form （IPAQ-SF），and Patients' Exercise Log were used to assess the KAP level，PA level，and exercise adherence，respectively. The impact of network intervention on exercise adherence in patients after PCI by univariate Logistic regression analysis. Results After 3 months of intervention，a significant increase was found in the average total score of REKBPCHD，and the average scores of the knowledge dimension，attitude dimension and practice dimension of the scale in the experimental group（P<0.05），and the increase was more notable than that in the control group（P<0.05）. Moreover，both post-intervention low PA level and total PA level in the experimental group were higher than those in the control group（P<0.05）. Both post-intervention low PA level and total PA level were higher than the baseline levels in the experimental group（P<0.05）. The post-intervention exercise compliance of experimental group were higher than that in the control group（P=0.003）. Univariate Logistic regression analysis showed that the risk of non-adherence to exercise in the experimental group was relatively lower than that in the control group 〔OR=0.143，95%CI（0.034，0.594），P=0.007〕. Conclusion Theinternet-based intervention can effectively improve the KAP level toward rehabilitation，PA level，and exercise adherence in patients after PCI. © 2023 Chinese General Practice. All rights reserved.

Acute Coronary Syndrome during the Pandemic New Coronavirus Infection.

The experience of managing patients with COVID-19 around the world has shown that, although respiratory symptoms predominate during the manifestation of infection, then many patients can develop serious damage to the cardiovascular system. However, coronary artery disease (CHD) remains the leading cause of death worldwide. The purpose of the review is to clarify the possible pathogenetic links between COVID-19 and acute coronary syndrome (ACS), taking into account which will help to optimize the management of patients with comorbid pathology. Among the body's responses to SARS-CoV-2 infection, which increase the likelihood of developing ACS, the role of systemic inflammation, the quintessence of which is a "cytokine storm" that can destabilize an atherosclerotic plaque is discussed. Coagulopathy, typical for patients with Covid-19, is based on immunothrombosis, caused by a complex interaction between neutrophilic extracellular traps and von Willebrandt factor in conditions of systemic inflammation. The implementation of a modern strategy for managing patients with ACS, focused on the priority of percutaneous interventions (PCI), during a pandemic is experiencing great difficulties due to the formation of time delays before the start of invasive procedures due to the epidemiological situation. Despite this, the current European, American and Russian recommendations for the management of infected patients with ACS confirm the inviolability of the position of PCI as the first choice for treating patients with ACS and the undesirability of replacing invasive treatment with thrombolysis.Copyright © 2023 Stolichnaya Izdatelskaya Kompaniya. All rights reserved.

Surgical treatment of left atrial dissection caused by percutaneous coronary intervention.

Left atrial dissection (LatD), also known as left atrial intramural haematoma, is a rare condition that requires rapid diagnosis and frequently calls for timely surgical intervention. Diagnosis can be challenging because of a lack of definitive clinical criteria, and a patient's situation can be complicated by co-morbidities, including unstable haemodynamics. We surgically repaired a case of LatD related to percutaneous coronary intervention (PCI). The operation went smoothly, and the patient was discharged one week after the operation. For LatD patients with co-morbidities, especially haemodynamic disorders, active surgical intervention is recommended.

Case Report of a Transfusion-Associated Circulatory Overload Leading to Cardiac Arrest in a COVID-19 Positive Patient

Although case reports have been made regarding adverse transfusion reactions, few have been made regarding blood transfusions leading to cardiac arrest. Today, we present a case of a COVID-19 positive Bahraini male, triple vaccinated, transfused with packed red blood cell (pRBC) after finding out he has low haemoglobin levels (64 g/dl) after routine laboratory investigations. During the blood transfusion, he developed hypertension, tachycardia and tachypnoea. The patient went into cardiac arrest within a few minutes of this presentation. Return of spontaneous circulation was achieved, and the patient was managed as transfusion-associated circulatory overload (TACO) with a good overall outcome.Copyright © 2023, Bahrain Medical Bulletin. All rights reserved.

Coronary artery bypass grafting after iatrogenic coronary artery dissection: A single center eight years' experience

Background: Iatrogenic coronary artery dissection during diagnostic or therapeutic catheterization is a rare and mortal complication that may result in a newly developed myocardial infarction. In this study, we aimed to share the results of CABG treatment of patients with iatrogenic coronary artery dissection after coronary angiography (CAG) in our clinic. Method(s): All patients who underwent CAG or percutaneous coronary intervention (PCI) in our hospital between January 2014 and December 2021 were analyzed retrospectively and patients who underwent CABG after iatrogenic coronary artery dissection were included in the study. The dissection classification was achived according to the National Heart, Lung and Blood Institute (NHLBI) classification. Result(s): During the eight years, CAG was applied to 20,398 patients and PCI to 9583 patients. Needed to treat CABG in iatrogenic coronary artery dissection developed in 17 of the patients (0.06%). LMCA was dissected in 6 (35.3%) patients and LAD in 6 (35.3%), CX in 2 (11.8%) and RCA dissection in 3 (17.6%). 3 patients (17.6%) had an intubation time longer than 48 hours. One of them has recently had a COVID infection. Another was suffering from pulmonary edema. The other patient died on the 4th postoperative day due to low cardiac output. The length of stay in the intensive care unit was 2 (min: 1 - max: 13) days. The hospital stay was 6 (min: 4 - max: 20) days. Conclusion(s): The development of a critical clinical condition prior to surgery is strongly associated with a higher probability of early and late postoperative death. For this reason, it is clear that the treatments applied at every stage of the pre-, per-, and postoperative period are the most important determinants of the results.Copyright © 2023, CKS.

Impact of COVID-19 outbreak on patients with ST-segment elevated myocardial infarction undergoing primary percutaneous coronary intervention in a regional emergency center in Seoul, Korea

The corona virus disease 2019 (COVID-19) outbreak may have delayed the treatment of patients with ST-segment elevated myocardial infarction (STEMI) in the emergency department (ED). This study aimed to determine the causes for treatment delay and evaluate the outcomes of such delays in STEMI patients undergoing primary percutaneous coronary intervention. This was a single-center retrospective observational study. Hospital records of STEMI patients who received primary percutaneous coronary intervention from 01 January 2019, to 31 December 2020, were assessed. The preCOVID-19 period was set before 01 January 2020, and the COVID-19 period was set after 01 January 2020, following which the data between these two periods were compared. During the COVID-19 period, there was a decrease in the reported incidence of STEMI patients compared with during the pre-COVID-19 period (incidence rate ratio, 0.74;95% confidence interval, 0.55–0.99;p = 0.04). After arrival at ED, the time from door to balloon significantly differed between the pre-COVID-19 and COVID-19 period (78.0 min vs. 102.0 min, p < 0.001). Also, the time to alert a cardiologist (16 min vs. 9 min), puncture time after cardiologist arrival (57 min vs. 42 min), and puncture to balloon time (19 min vs. 14 min) were significantly longer during the COVID period. However, the time from alert to cardiologist arrival was similar. Compared to the pre-COVID 19 period, more patients suffered from major adverse cardiac events during the COVID-19 period (n = 20 (25.3%) vs. n = 12 (11.2%), p = 0.012). In both periods, the number of patients admitted to the intensive care unit and died (106 vs. 79, 9 vs. 10, respectively) and the number of days spent in the ICU were similar. Early recognition of critically ill patients and appropriate response in the ED can lower misdiagnosis rates and increase prompt and correct treatments, thereby improving patient prognosis. [ FROM AUTHOR] Copyright of Signa Vitae is the property of Pharmamed Mado Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)

Acute Coronary Syndrome during the Pandemic New Coronavirus Infection.

The experience of managing patients with COVID-19 around the world has shown that, although respiratory symptoms predominate during the manifestation of infection, then many patients can develop serious damage to the cardiovascular system. However, coronary artery disease (CHD) remains the leading cause of death worldwide. The purpose of the review is to clarify the possible pathogenetic links between COVID-19 and acute coronary syndrome (ACS), taking into account which will help to optimize the management of patients with comorbid pathology. Among the body's responses to SARS-CoV-2 infection, which increase the likelihood of developing ACS, the role of systemic inflammation, the quintessence of which is a "cytokine storm" that can destabilize an atherosclerotic plaque is discussed. Coagulopathy, typical for patients with Covid-19, is based on immunothrombosis, caused by a complex interaction between neutrophilic extracellular traps and von Willebrandt factor in conditions of systemic inflammation. The implementation of a modern strategy for managing patients with ACS, focused on the priority of percutaneous interventions (PCI), during a pandemic is experiencing great difficulties due to the formation of time delays before the start of invasive procedures due to the epidemiological situation. Despite this, the current European, American and Russian recommendations for the management of infected patients with ACS confirm the inviolability of the position of PCI as the first choice for treating patients with ACS and the undesirability of replacing invasive treatment with thrombolysis.Copyright © 2023 Stolichnaya Izdatelskaya Kompaniya. All rights reserved.

Impact of COVID-19 pandemic early response measures on myocardial infarctions and acute cardiac care in Singapore.

The COVID -19 pandemic impacted acute myocardial infarction (AMI) attendances, ST-elevation myocardial infarction (STEMI) treatments, and outcomes. We collated data from majority of primary percutaneous coronary intervention (PPCI)-capable public healthcare centres in Singapore to understand the initial impact COVID-19 had on essential time-critical emergency services. We present data comparisons from 'Before Disease Outbreak Response System Condition (DORSCON) Orange', 'DORSCON Orange to start of circuit breaker (CB)', and during the first month of 'CB'. We collected aggregate numbers of weekly elective PCI from four centres and AMI admissions, PPCI, and in-hospital mortality from five centres. Exact door-to-balloon (DTB) times were recorded for one centre; another two reported proportions of DTB times exceeding targets. Median weekly elective PCI cases significantly decreased from 'Before DORSCON Orange' to 'DORSCON Orange to start of CB' (34 vs 22.5, P = 0.013). Median weekly STEMI admissions and PPCI did not change significantly. In contrast, the median weekly non-STEMI (NSTEMI) admissions decreased significantly from 'Before DORSCON Orange' to 'DORSCON Orange to start of CB' (59 vs 48, P = 0.005) and were sustained during CB (39 cases). Exact DTB times reported by one centre showed no significant change in the median. Out of three centres, two reported significant increases in the proportion that exceeded DTB targets. In-hospital mortality rates remained static. In Singapore, STEMI and PPCI rates remained stable, while NSTEMI rates decreased during DORSCON Orange and CB. The severe acute respiratory syndrome (SARS) experience may have helped prepare us to maintain essential services such as PPCI during periods of acute healthcare resource strain. However, data must be monitored and increased pandemic preparedness measures must be explored to ensure that AMI care is not adversely affected by continued COVID fluctuations and future pandemics.

Challenges and Burdens in the Coronary Artery Disease Care Pathway for Patients Undergoing Percutaneous Coronary Intervention: A Contemporary Narrative Review.

Clinical and economic burdens exist within the coronary artery disease (CAD) care pathway despite advances in diagnosis and treatment and the increasing utilization of percutaneous coronary intervention (PCI). However, research presenting a comprehensive assessment of the challenges across this pathway is scarce. This contemporary review identifies relevant studies related to inefficiencies in the diagnosis, treatment, and management of CAD, including clinician, patient, and economic burdens. Studies demonstrating the benefits of integration and automation within the catheterization laboratory and across the CAD care pathway were also included. Most studies were published in the last 5-10 years and focused on North America and Europe. The review demonstrated multiple potentially avoidable inefficiencies, with a focus on access, appropriate use, conduct, and follow-up related to PCI. Inefficiencies included misdiagnosis, delays in emergency care, suboptimal testing, longer procedure times, risk of recurrent cardiac events, incomplete treatment, and challenges accessing and adhering to post-acute care. Across the CAD pathway, this review revealed that high clinician burnout, complex technologies, radiation, and contrast media exposure, amongst others, negatively impact workflow and patient care. Potential solutions include greater integration and interoperability between technologies and systems, improved standardization, and increased automation to reduce burdens in CAD and improve patient outcomes.

Remote Clinical Quality Management of Endovascular Care

To assess the effectiveness of remote clinical quality management of endovascular Aim care. The system of clinical quality management of medical care in myocardial infarction (MI) including the quality of remote control of endovascular care was developed and introduced into the health care system of the Moscow Region as a part of the comprehensive study in 2008-2020. The number of people under the study was 8375. The ground for assessing the effectiveness of remote clinical management in 2019-2020 was the health care system of megapolis. Based on the analysis of 2966 endovascular procedures protocols, the treatment tactics effectiveness of intraoperative decisions was studied after an emergency coronary angiography (ECA) had been performed by interventional cardiologists. The Methods system of remote clinical quality management of endovascular care included a complex of audiovisual communications, computer system processes, mentoring and the algorithm for making an intraoperative decision. The effectiveness of remote clinical quality management of endovascular care was investigated on the number of percutaneous coronary interventions (PCI) in MI, mortality of patients with MI in the Regional vascular center in 2019-2020. The T-criteria was used to assess the reliability. The material statistical processing was carried out in the Statistica 6.0 package calculating adequate statistical indicators and their reliability at p<=0.005. Ratio PCI/ECA in 2019, January-March 2020 counted up to 48.95%. In April-December 2020 it increased up to 71.6% (p<0.001). The frequency of performing Results PCI increased by 1.46 times (p<0.001). Hospital mortality from MI decreased during the following period 2019, April-December 2020 from 9.7% to 8.2% (p = 0.005). Remote clinical management based on telemedicine and mentoring process Conclusion technologies contributes to improving the quality of endovascular care in MI.Copyright © 2021 Angles. All rights reserved.

Comparison of thrombus burden in patients with COVID-19 presenting with ST-segment elevation myocardial infarction across the three waves of outbreak in the United Kingdom

Background: It has been previously reported during the first COVID outbreak that patients presenting with ST-Segment Elevation Myocardial Infarction (STEMI) and concurrent COVID-19 infection have increased thrombus burden and poorer outcomes [1]. Subsequently, there have been multiple further waves of the pandemic with the emergence of at least two new COVID-19 variants and the emergence of vaccinations. To-date, there have been no reports comparing the outcomes of COVID-19-positive STEMI patients across all waves of the pandemic. Purpose(s): The purpose of this study was to compare the baseline demographic, procedural and angiographic characteristics alongside the clinical outcomes of patients presenting with STEMI and concurrent COVID-19 infection across the COVID-19 pandemic in the UK. Method(s): This was a single-centre, observational study of 1250 consecutive patients admitted with confirmed STEMI treated with primary percutaneous coronary intervention (PCI) at Barts Heart Centre between 01/03/2020 and 10/03/2022. COVID +ve patients were split into 3 groups based upon the time course of the pandemic (Wave 1: March 2020-June 2020, Wave 2: Sept 2020-March 2021, Wave 3: October 2021-March 2022). Comparison was made between waves and with a control group of COVID-ve patients treated during the same timeframe. Result(s): A total of 135 COVID +ive patients with STEMI (1st Wave: 39 patients, 2nd Wave: 60 patients, 3rd wave 35 pts) were included in the present analysis;and compared with 1115 COVID negative patients. Significant changes in the baseline characteristics, angiographic features and clinical outcomes of COVID +ive patients occurred over time. Early during the pandemic (Wave 1 2020), STEMI patients presenting with concurrent COVID-19 infection had high rates of cardiac arrest, evidence of increased thrombus burden (higher rates of multi-vessel thrombosis, stent thrombosis, higher modified thrombus grade higher use of GP IIb/IIIa inhibitors and thrombus aspiration, coagulability (more heparin for therapeutic ACT), bigger infarcts (lower myocardial blush grade and left ventricular function) and worse outcomes (mortality). However, by wave 3 (late 2021/2022), no differences existed in clinical characteristics, thrombus burden, infarct size or outcomes between COVID +ive patients and those without concurrent COVID-19 infection with significant differences compared to earlier COVID +ve patients. Poor outcomes later in the study period were predominantly in unvaccinated individuals. Conclusion(s): Significant changes have occurred in the clinical characteristics, angiographic features and outcomes of STEMI patients with COVID- 19 infection treated by primary PCI during the course of the pandemic. Importantly it appears that angiographic features and outcomes of recent waves are no different to a non-COVID-19 population.

An Eventful Rotational Atherectomy Over the Left Main Stem and Left Anterior Descending Artery in an Elderly Male

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

Optical Coherence Tomography Guided Percutaneous Coronary Intervention of Spontaneous Recanalized Coronary Thrombus

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

Occlusive Explosion

Clinical Information Patient Initials or Identifier Number: A Relevant Clinical History and Physical Exam: 47yr old man, suffered a blast injury at the workplace after an O2 tank exploded while he was transferring liquid gas into a tank for welding purposes. The impact has caused him to temporary loss of consciousness. Upon awakening, he had severe chest pain associated with shortness of breath. On examination, superficial partial thickness injury on the chest wall, and lungs: reduced breath sound bi-basally, no murmur heard. BP:106/77mmHg, HR:100/min, SPO2 100% on HFM 15L/min. [Formula presented] [Formula presented] [Formula presented] Relevant Test Results Prior to Catheterization: Serial ECGs were done and showed dynamic changes in the anterior leads Bedside echo before invasive coronary angiograms shows mild LVSD, normal valves, and no pericardial effusion [Formula presented] [Formula presented] Relevant Catheterization Findings: Right radial approach 6F system Opitorque catheter for diagnostic angiogram LMS: smooth LAD: ATO mid LAD, DG1 prox ATO LCx: smooth RCA: smooth Impression: ATO to LAD and Diagonal 1 ( Dual ATO) [Formula presented] [Formula presented] [Formula presented] Interventional Management Procedural Step: Right radial coronary angiogram via 6F system EBU 3.0 engaged with good support Sion blue wired into LAD, export catheter delivered, and aspirated red thrombus Pre-dilated with Sapphire 3 SC 2.5x15mm @ 6-10ATM Flow established in LAD, however, decided to interrogate DG1 as it shows ATO BMW wired into the DG1 and pre-dilated with Sapphire 3 SC 2.0x15mm Noted nonflow limiting dissection and decided to stent DG1 with 2.25x34mm@12ATM, dissection sealed and TIMI III flow established Stented mid LAD with 2.5x30mm @12ATM just before LAD/DG1 bifurcation, then stented proximal LAD with 2.5x 26mm@ 12ATM. Post-dilated LAD with 2.75x15mm@ 14-20ATM TIMI II-III flow IV Tirofiban has been given a loading dose due to a high thrombus burden and sluggish flow [Formula presented] [Formula presented] [Formula presented] Conclusion(s): Myocardial infarction is a rare complication of blunt chest trauma. This case demonstrates how blast shock waves result in the dissection of the coronary vessel leading to total occlusion of the two vessels. It also promotes red thrombus within the coronary vessels. Percutaneous coronary intervention is the most suitable way to treat this condition. Intravascular imaging such as IVUS or OCT would be beneficial to demonstrate the physiology behind this MI and would also be helpful in planning and optimizing the lesions. Unfortunately, intravascular imaging was not used for this patient to reduce procedural time as he was treated during the height of the COVID pandemic.Copyright © 2023

COVID-19 and Spontaneous Coronary Artery Dissection: Association or Causality

Clinical Information Patient Initials or Identifier Number: JS Relevant Clinical History and Physical Exam: A 55-year old woman was brought to emergency department complaining of sudden onset squeezing chest pain radiating to her arm and jaw and associated with giddiness. She had flu like illness a day prior to her presentation associated with malaise, arthralgia and dry cough. She had history of hypertension. Physical examination revealed dual heart sounds and clear lung fields to auscultation. Relevant Test Results Prior to Catheterization: Electrocardiogram (ECG) showed normal sinus rhythm and the cardiac enzymes were elevated;high sensitivity troponin-I, 23000 ng/L (range0-10 ng/L). RNA PCR was positive for SARS-CoV-2 (COVID-19). D-Dimer was 303microgram/L (normal <500). Transthoracic echocardiogram showed severe hypokinesis of the mid inferolateral wall with left ventricular ejection fraction (LVEF) 52%. Chest X-ray showed no focal consolidation. [Formula presented] [Formula presented] Relevant Catheterization Findings: Invasive coronary angiogram showed tortuous coronary arteries with abrupt narrowing of mid- distal Ramus Intermiedius and discrete lesion of mid PDA. SCAD (spontaneous Coronary dissection) of Ramus Intermedius and mid PDA (posterior descending artery) was suspected, and patient was treated conservatively. Repeat coronary angiography, few months later showed complete resolution of SCAD with normal appearance of affected vessels. [Formula presented] [Formula presented] [Formula presented] Interventional Management Procedural Step: After obtaining an informed consent right Radial access was achieved with 6F Terumo sheath using over the wire technique. 1% lignocaine was used as local anaesthetic. 5F JL 3.5 (Judkin's) and JR 4 catheters were used to engage left main stem (LMS) and right coronary artery (RCA) and selective coronary angiography was performed. No percutaneous coronary intervention was performed. After the procedure hemoband (TR band) was applied to access site. Patient remained hemodyanamically stable throughout the procedure. [Formula presented] [Formula presented] [Formula presented] Conclusion(s): SCAD is a potential cause of type II myocardial infarction in patients with COVID-19, but more studies are needed to establish causality. Infection-related SCAD may occur at any time during index events and could be difficult to diagnose. Conservative management seems like a safe strategy.Copyright © 2023

Pharmacoinvasive Therapy in Treating Acute STEMI Patients in COVID-19 Era-Thrombolysis by Tenecteplase (TNK) / Streptokinase (STK) Followed by Rescue PCI of the Culprit Vessel

Background: Treating acute STEMI patients by primary PCI has dramatically fallen globally in covid era as there is chances of potential threat of spreading Covid among the non-Covid patient. Thereby, thrombolysis of acute STEMI patient either by Streptokinase (STK) or Tenecteplase (TNK) in grey zone till Covid RT PCR report to come, was the mode of treatment of acute myocardial infarction patient in our hospital. Post thrombolysis, Covid positive cases were managed conservatively in a Covid dedicated unit. Covid negative cases were treated by rescue PCI of the culprit lesion. Exact data on benefit of thrombolysis either by TNK or STK of STEMI patients in Covid era, is not well addressed in our patient population. Thereby, we have carried out this prospective observational study to see the outcomes of thrombolysis and subsequent intervention. Method(s): STEMI Patient who represented to our ER with chest pain and ECG and hs-TROP-I evidenced acute ST segment elevated myocardial infarction (STEMI), were enrolled in the study. Total 139 patients enrolled (Male:120, Female :19);average age for Male: 54yrs., female was: 56yrs. All patients were admitted in the grey zone of CCU where thrombolysis done either by TNK or STK. Positive for COVID-19, were patients excluded from intervention and managed conservatively in Covid-19 dedicated ward. Covid Negative patients were kept transferred to CCU green zone. Result(s): COVID-19 test was carried out on all studied patients. Among them, Covid-19 positive were 7.9% (11) patients and managed conservatively in dedicated Covid ward, Covid-19 negative were 92.1% (128). Primary PCI was performed in 5.03% (7). Rest was managed by Pharmacoinvasive therapy either by TNK or STK. Thrombolysis by Tenecteplase in 64% (89), Streptokinase in 17.9% (25) patient, 12.9% (18) patient did not receive any thrombolysis due to late presentation and primary PCI done in 5.4% (7). On average 2.1 days after Fibrinolysis, elective PCI carried out. Data analysis from 48 patients;chest pain duration (3.71 +/-2.8 hr., Chest pain to contact time 3.3+/-2.8hr., Chest pain to needle time 7.2 +/-12.7hr., thrombolysis to balloon time 117.5+/-314.8hr., as many of the patient develop LVF post thrombolysis. More than 50% stenosis resolution observed in 41.6% (20) patients, chest pain resolution with one hour of thrombolysis observed in 43.8% (21) patients and development of LVF in 20.8% (10) patients. Door to needle time was 30 min. At presentation of STEMI;Ant Wall MI 46.8% (65), Inferior Wall MI 52.5% (73) and high Lateral 0.7% (1). Average Serum hs Trop-I was 16656 for male and 12109 for female. LVEF were 41% for male and 48% for female. HbA1C were in Male 8.34%: Female 8.05%, SBP for Male 120mmHg: Female 128 mmHg. Total, 88 stents were deployed in 83 territories. CABG recommended for 5.03% (7) patients, PCI in 58.3% (81), remaining were kept on medical management. Stented territory was LAD 45.7% (37) and RCA 39.5% (32) and LCX 14.8% (12). Common stent used;Everolimus 61.4% (54), Sirolimus 25% (22), Progenitor cell with sirolimus 2.3%(2) and Zotarolimus 11.4% (10) Conclusion(s): In the era of COVID-19, in this prospective cohort study, on acute STEMI patient management, we found that Pharmaco therapy by Tenecteplase and Streptokinase, reduced patient symptom and ST resolution partially. Therefore, coronary angiogram and subsequent Rescue PCI by Drug Eluting Stents (DES) are key goals of complete revascularization.Copyright © 2023

Specific characteristics of STEMI in COVID-19 patients and their practical implications: A systematic review

Introduction: STEMI is one of the cardiac emergencies whose management has been mostly challenged by the COVID-19 pandemic. Patients presenting with the "lethal combo" of STEMI and concomitant SARS-CoV- 2 infection have faced dramatic issues related to need for self-isolation, systemic inflammation with multi-organ disease, and difficulties to obtain timely diagnosis and treatment. Method(s):We performed a systematic search of three electronic databases from February 1st 2020 to January 31st 2022. We included all studies reporting crude rates of in-hospital outcomes of STEMI patients with concomitant COVID-19. Result(s): A total of 9 observational studies were identified, mainly conducted during the first wave of the pandemic. STEMI patients with COVID -19 were more likely Afro-American and displayed higher rates of hypertension and diabetes with lower smoking prevalence. Associated comorbidities, including coronary artery disease, prior stroke and chronic kidney disease were also more common in those with SARS-CoV-2 infection. At coronary angiography, a higher thrombus burden in COVID-19 positive STEMI patients was highlighted, with up to 10-fold higher rates of stent thrombosis and greater need for glycoprotein IIb/IIa inhibitors and aspiration thrombectomy;this was not always associated with prolonged times from symptom onset to hospital admission and door-to-balloon. COVID-19 positive STEMI patients were less likely to receive coronary angiography and primary PCI, and more likely to be treated with fibrinolytics only. At the same time, patients with Covid-19 were more prone to present MINOCA. In-hospital mortality ranged from 15% to 40%, with consistent variability across different studies and subjects who tested positive for SARS-CoV- 2 did also present higher rates of cardiogenic shock, cardiac arrest, prolonged ICU stay, mechanical ventilation, major bleeding, and stroke. Conclusion(s): The coexistence of STEMI and COVID-19 was associated with increased in-hospital mortality and poor short-term prognosis. This was not entirely attributable to logistic issues determining delayed coronary revascularization, since patients' specific clinical and angiographic characteristics, including higher burden of cardiovascular risk factors and greater coronary thrombogenicity might have substantially contributed to this trend. (Figure Presented).

The Clot Thickens: COVID-19-Related ST-Elevation Myocardial Infarction in the Setting of Recent Boosters.

The coronavirus disease of 2019 (COVID-19) has an array of pathological effects that continue to be discovered. Vaccines against COVID-19 have quickly emerged as our main tool. However, the thrombotic risk of both the virus and the vaccine is yet to be established, let alone together. In this case report, we present a case involving a recently diagnosed COVID-19 patient who developed an ST-elevated myocardial infarction (STEMI) after receiving his booster shot. Our aim is to highlight the standard of treatment outcomes in COVID-19-associated clots, familiarize ourselves with the complexity of the clot burden in a COVID-19-associated STEMI, and illustrate the potential role of the cumulative pro-thrombotic effects of a recent COVID-19 booster with a concomitant symptomatic COVID-19 infection.