Transcatheter closure of ventricular septal rupture with prolonged support of intra-aortic balloon pump after primary PCI: a case report.

BACKGROUND: Ventricular septal rupture (VSR) is a rare but severe complication of acute myocardial infarction (AMI). For such cases, surgical repair is recommended by major guidelines, but not always possible for such cases. CASE PRESENTATION: A 72-year-old man presented to the emergency room. ECG showed the ST-segment was elevated by 2-3 mm in lead II, III, and aVF, with Q-waves. Coronary angiography (CAG) showed multi-vessel disease with a total occlusion of the right coronary artery (RCA) and severe stenosis of the left anterior descending artery (LAD). A diagnosis of acute inferior myocardial infarction was made. VSR occurred immediately after percutaneous coronary intervention (a 2.5 × 20 mm drug-eluting stent implanted in RCA), and the patient developed cardiogenic shock. An intra-aortic balloon pump (IABP) was used to stabilize the hemodynamics. Transthoracic echocardiography (TTE) revealed an 11.4-mm left-to-right shunt in the interventricular septum. An attempt was made to reduce the IABP augmentation ratio for weaning on day 12 but failed. Transcatheter closure was conducted using a 24-mm double-umbrella occluder on day 28. The patient was weaned from IABP on day 31 and underwent secondary PCI for LAD lesions on day 35. The patient was discharged on day 41. Upon the last follow-up 6 years later, CAG and TTE revealed no in-stent restenosis, no left-to-right shunt, and 51% left ventricular ejection fraction. CONCLUSIONS: Prolonged implementation of IABP can be a viable option to allow deferred closure of VSR in AMI patients, and transcatheter closure may be considered as a second choice for the selected senior and vulnerable patients, but the risk is still high.

de Winter syndrome or inferior STEMI?

BACKGROUND: The de Winter electrocardiography (ECG) pattern is associated with acute total or subtotal occlusion of the left anterior descending coronary artery (LAD) characterized by upsloping ST-segment depression at the J point in leads V1-V6 without ST-segment elevation. CASE PRESENTATION: We report an atypical style case of the de Winter ECG pattern accompanied by ST elevation in inferior leads. The patient underwent emergency coronary angiography, which revealed total occlusion of the proximal LAD with no observable stenosis in the right coronary artery. CONCLUSION: ECG-related changes in acute total LAD occlusion can present with the de Winter pattern and ST elevation in inferior leads. Recognizing this atypical ECG pattern is critical for immediate reperfusion therapy.

Tombstone Sign in an Inferior Wall Myocardial Infarction.

A 62-year-old white patient presents with markedly ischemic electrocardiogram, notable for Tombstone sign.

Longitudinal Evaluation of Mitral Valve Leaflet Remodeling After Acute Myocardial Infarction: Serial Quantitation of Valve Geometry Using Real-Time 3-Dimensional Echocardiography.

BACKGROUND: Recent animal studies have suggested that mitral valve (MV) leaflet remodeling can occur even without significant tethering force and that the postinfarct biological reaction would contribute to the histopathologic changes of the leaflet. We serially evaluated the MV remodeling in patients with anterior and inferior acute myocardial infarction (MI), by using 2- and 3-dimensional transthoracic echocardiography. Additional histopathologic examinations were performed to assess the leaflet pathology. METHODS: Sixty consecutive first-onset acute MI (anterior MI, n=30; inferior MI, n=30) patients who underwent successful primary percutaneous coronary intervention were examined (1) before primary percutaneous coronary intervention, (2) at 6-month follow-up, and (3) at follow-up 1 year or later after onset. MV complex geometry including MV leaflet area and thickness was analyzed using dedicated software. Additional histopathologic study compared 18 valves harvested during surgery for ischemic mitral regurgitation (MR). RESULTS: MV area and thickness incrementally increased during the follow-up period. MV leaflet area significantly increased (anterior MI: 5.59 [5.28-5.98] to 6.54 [6.20-7.26] cm2/m2, P<0.001; inferior MI: 5.60 [4.76-6.08] to 6.32 [5.90-6.90] cm2/m2, P<0.001), and leaflet thickness also increased (anterior MI: 1.09 [0.92-1.24] to 1.45 [1.28-1.60] mm/m2, P<0.001; inferior MI: 1.15 [1.03-1.25] to 1.44 [1.27-1.59] mm/m2, P<0.001); data represent onset versus ≥1 year. Larger annuls, larger tenting, and a reduced leaflet area/annular ratio with smaller coaptation index were observed in patients with persistent ischemic MR compared with those without significant ischemic MR. Histopathologic examinations revealed that MV thickness was significantly greater in chronic ischemic MR compared with acute ischemic MR (1432.6±490.5 versus 628.7±278.7 µm; P=0.001), with increased smooth muscle cells and fibrotic materials. CONCLUSIONS: MV leaflet remodeling progressed both in area and thickness after MI. This is the first clinical study to record the longitudinal course of MV leaflet remodeling by serial echocardiography.

Inferior ST-Elevation Myocardial Infarction Presenting When Urgent Primary Percutaneous Coronary Intervention Is Unavailable: Should We Adhere to Current Guidelines?

The pivotal studies that led to the recommendations for emergent reperfusion therapy for ST-elevation myocardial infarction (STEMI) were conducted for the most part over 25 years ago. At that time, contemporary standard treatments including aspirin, statin, and even anticoagulation were not commonly used. The 2013 American College of Cardiology Foundation (ACCF)/American Heart Association (AHA) guidelines and the 2017 European Society of Cardiology guidelines give a class I recommendation (with the level of evidence A) for primary percutaneous coronary intervention (pPCI) in patients with STEMI and ischemic symptoms of less than 12 h. However, if the patient presents to a hospital without pPCI capacity, and it is anticipated that pPCI cannot be performed within 120 min of first medical contact, fibrinolytic therapy is indicated (if there are no contraindications) (class I indication, level of evidence A). Our review of the pertinent literature shows that the current recommendation for inferior STEMI is based on the level of evidence lower than A. We can consider level B even C, supporting the recommendation for fibrinolytic therapy if pPCI is not available for inferior STEMI.

Does electrocardiogram help in identifying the culprit artery when angiogram shows both right and circumflex artery disease in inferior myocardial infarction?

OBJECTIVE: In a subgroup of patients with inferior myocardial infarction (MI), both the right coronary artery (RCA) and circumflex coronary artery (Cx) show potentially culprit lesions, and angiography may be insufficient to determine which artery is responsible for the clinical presentation. Although many electrocardiographic (ECG) algorithms have been proposed for identifying the infarct-related artery in patients with inferior MI, it is unclear whether the current algorithms have the discriminative power to identify the real culprit artery in these patients. METHODS: The patients with the diagnosis of acute inferior MI and underwent coronary angiography were enrolled in the study. The prediction of the infarct-related artery was attempted from the admission ECG using published algorithms and criteria. For the angiographic definition of the infarct-related artery, multiple criteria were used. RESULTS: Total 417 inferior MI cases were enrolled during the study period; the final patient population comprised of 318 patients. Forty-five patients (14.2%) had both RCA and Cx lesions on coronary angiography. Although several criteria and algorithms are able to identify the infarct-related artery in the general inferior MI population, they lose their strength in patients with both RCA and Cx lesions. Only the Aslanger-Bozbeyoglu criterion emerges as a more powerful diagnostic test with a sensitivity, specificity, and c-statistic of 80%, 48%, and 0.650, respectively for the whole population (p<0.001) and 81%, 58%, and 0.709, respectively, for patients with both RCA and Cx lesions (p=0.019). CONCLUSION: The Aslanger-Bozbeyoglu criterion is not only helpful in differentiating the infarct territory in combined inferior and anterior ST-segment elevation as previously shown, but also valuable in identifying the infarct-related artery in patients with inferior STEMI with critical lesions in both the RCA and the Cx. (Anatol J Cardiol 2020; 23: 318-23).

Effects of Myocardial Perfusion Defect on the Frontal QRS-T Angle in Anterior Versus Inferior Myocardial Infarction.

Objective The frontal QRS-T angle on a 12-lead electrocardiogram (ECG) has recently become accepted as a variable of ventricular repolarization. We compared the effects of myocardial perfusion defect (MPD) on the frontal QRS-T angle between anterior and inferior myocardial infarction (MI) using single-photon emission computed tomography. Methods The frontal QRS-T angle was defined as the absolute value of the difference between the frontal plane QRS axis and T-wave axis. A QRS-T angle more than 90° was considered abnormal. Patients Forty-two patients with anterior MI and 42 age- and sex-matched patients with inferior MI were enrolled. For controls, 42 age- and sex-matched patients with no MPD were selected. Results The mean frontal QRS-T angles in anterior MI, inferior MI and control subjects were 94.7±46.2°, 26.7±22.1° and 27.0±23.2°, respectively. Compared with controls, the frontal QRS-T angle was larger in anterior MI subjects (p<0.001), and similar in value to that in inferior MI subjects (p=0.69). An abnormal QRS-T angle was frequent in the anterior MI subjects than the inferior MI subjects (55% vs. 2%, p<0.001). In anterior MI subjects, MPD was significantly associated with the T-wave axis (ρ=0.46, p=0.002) and QRS-T angle (ρ=0.47, p=0.002), but was not with the QRS axis (ρ=0.07, p=0.66). In inferior MI subjects, there were no associations between MPD and the ECG variables. Conclusion Our data suggest that the frontal QRS-T angle in inferior MI subjects is not increased as evidently as that in anterior MI subjects.

Identification of the culprit artery in inferior myocardial infarction through the 12-lead ECG.

BACKGROUND: Identification of the culprit artery can be helpful in the management of inferior infarction with ST-segment elevation myocardial infarction. Some studies suggest that previously published algorithms intended to help identify the infarct-related artery are suboptimal. Our aim is to develop a better method to localise the culprit artery on the basis of the 12-lead ECG. PATIENTS AND METHODS: We analysed the ECG and coronary angiograms of two different cohorts of patients with inferior ST-segment elevation myocardial infarction. Patients from the first cohort were labelled the derivative cohort (group A), whereas patients in the second cohort were labelled the validation cohort (group B). ST-segment elevation was measured in each lead, and a multiple logistic regression analysis was carried out to determine the best equation to predict the culprit artery. A derived algorithm was then applied to the validation cohort. Next, our algorithm was applied to the total cohort of both groups and compared with four different previously published algorithms. We analysed differences in sensitivity, specificity and area under the curve (AUC). RESULTS: We included 252 patients in the derivative group and 90 in the validation group. The multiple models analysis concluded that the best model should include five leads. This model was validated by internal bootstrapping with 1000 repetitions in group A and externally in group B. The resultant algorithm was as follows: (ST-elevation in III + aVF + V3) - (ST-elevation in II + V6) less than 0.75 mm means that the culprit artery is the left circumflex artery (Cx). If the result is at least 0.75, the culprit artery is the right coronary artery. The total group of both cohorts comprised 342 patients, aged 61.2 ± 12.4 years, of whom 19.6% were female and 80.4% were male. The Cx was the culprit artery in 67 (19.6%) patients. Our algorithm had a sensitivity of 72.3, a specificity of 80.9 and an AUC of 0.766. The AUC value was better compared with the other algorithms. CONCLUSION: The best algorithm to localise the culprit artery includes ST-elevation in leads II and V6 related to Cx, and ST-elevation in leads III, aVF and V3 related to right coronary artery. Our algorithm has been validated internally and externally, and works better than other previously published algorithms.

Novel use of a stent graft for uncontrollable intraprocedural stent thrombosis in a patient with acute myocardial infarction.

We report the case of a patient who developed uncontrollable intraprocedural stent thrombosis (IPST) during an emergent percutaneous coronary intervention for acute myocardial infarction that was mitigated only by covering the culprit lesion with a stent graft. Although several factors can induce stent thrombosis, IPST was likely a result of intrastent plaque protrusion in this patient. This is the first case report on the use of stent graft implantation as an effective bailout procedure for uncontrolled IPST. The findings described in this case study warrant the adoption of stent grafts for the complete sealing of plaque protrusion in lesions.

Right Ventricular Dysfunction in Right Coronary Artery Infarction: A Primary PCI Registry Analysis.

Right ventricular involvement in inferior myocardial infarction (MI) was historically associated with a poor prognosis. However, few studies addressed the impact of right ventricular (RV) dysfunction in the primary percutaneous intervention (pPCI) era. Our aim was to assess the prognostic significance of RV dysfunction in right coronary artery (RCA) related MI treated with pPCI. METHODS: A total of 298 patients with a RCA related MI undergone pPCI between January 2011 and June 2015 were included. RV dysfunction was defined by a RV-FAC <35% at echocardiographic examination and further divided into mild (RV-FAC between 35 and 25%) and moderate-severe (RV-FAC <25%). RV function before discharge was reassessed in 95% of the study cohort. The primary endpoint was overall mortality. Median follow-up was 29 months. RESULTS: In RCA related MI, moderate-severe (HR 5.882, p = 0.002, 95% CI 1.882-18.385) but not mild RV dysfunction independently predicted lower survival at follow-up along with age (HR 1.104, p <0.001, CI 1.045-1.167). Importantly, patients recovering RV function at discharge showed a lower mortality (p = 0.001) vs patients with persistent moderate-severe RV dysfunction) that approached the risk of patients without RV dysfunction at presentation. CONCLUSION: In RCA related MI treated with pPCI, RV dysfunction was one of the strongest independent predictor of lower overall survival. However, patients with only transient RV dysfunction showed a better prognosis compared to patients who had persistent RV dysfunction. The focus on intensive support management of the RV in the first hours after pPCI may be important to overcome the acute phase and to promote RV recovery.

[Inferior myocardial infarction: first Moroccan study of 103 cases]. / Infarctus du myocarde inférieur: première série marocaine, à propos de 103 cas.

Myocardial infarction (MI) is a major cause of cardiovascular mortality. Inferior MI accounts for 30-50% of infarctions but it is associated with a favorable prognosis compared to anterior infarct. This study aimed to study the epidemiological, clinical, electrical, echocardiographic, angiographic features of inferior MI, as well as its complications and its therapeutic approaches. Over a period of 3 years, we admitted 720 patients with STEMI, of whom 103 with inferior STEMI, reflecting a rate of 14.3%. There was a clear male predominance, with an average age of 58 years (men) and 62 years (women). Smoking was the main risk factor for cardiovascular disease (57.28% of patients were smokers). Right ventricular infarction was found in 11.65% of cases. Half of these patients had hemodynamic instability. Third-degree atrioventricular block was diagnosed in 12.6% of patients. Therapeutic approach was based on thrombolysis (7 patients) and coronary angiogram (42 patients). Inferior MI was caused by right coronary lesion in 53% of cases and circumflex artery occlusion in 47% of cases. Right coronary is responsible for right ventricular infarction in 100% of cases. Coronary angioplasty was performed in 18 patients after coronary angiogram. Eleven patients underwent transluminal coronary angioplasty in the right coronary while 2 patients underwent transluminal coronary angioplasty in the circumflex artery. Early mortality at 30 days was 1.94%. In the right ventricular infarction group mortality rate was about 17%.

Salvage of Simultaneous Acute Coronary Closure and Retroperitoneal Bleeding Using Veno-Arterial Extracorporeal Membrane Oxygenation and Chronic Total Occlusion Percutaneous Coronary Intervention Techniques in a Patient with ST-Segment Elevation Myocardial Infarction.

Iatrogenic coronary artery dissection is a feared complication of percutaneous coronary intervention as it can potentially lead to severe myocardial ischemia, arrhythmias, shock, and death. Bailout-stenting or less often, emergent coronary artery bypass graft surgery may be needed for restoring antegrade flow. We describe a case of inferior ST-segment elevation acute myocardial infarction with preserved antegrade coronary flow. Percutaneous coronary intervention was complicated by acute right coronary artery closure during guide catheter engagement. Attempts for re-entry into the right coronary artery true lumen failed. Attempts to obtain right femoral arterial access resulted in retroperitoneal hematoma. The patient developed refractory ventricular fibrillation and could not be defibrillated. Veno-arterial extracorporeal membrane oxygenation was started using surgical right femoral cutdown for the venous cannula and the left common femoral artery for the arterial cannula. A dissection strategy with a knuckled guidewire was used around previously placed stents followed by successful re-entry into the distal right coronary artery using the Stingray system. The venous cannula was changed to the internal jugular vein and the right common femoral artery and vein were surgically repaired. The patient was decannulated two days later and was eventually discharged from the hospital neurologically intact.

Association between coronary dominance and acute inferior myocardial infarction: a matched, case-control study.

BACKGROUND: Previous studies have found a connection between left coronary artery dominance and worse prognoses in patient with acute coronary syndrome, which remains a predominant cause of morbidity and mortality globally. The aim of this study was to investigate whether coronary dominance is associated with the incidence of acute inferior myocardial infarction (MI). METHODS: Between January 2011 and November 2014, 265 patients with acute inferior MI and 530 age-matched and sex-matched controls were recruited for a case-control study in the Second Affiliated Hospital of Xi'an Jiaotong University in Xi'an, China. All participants underwent coronary angiography. The exclusion criteria included history of coronary artery bypass graft surgery, chronic or systemic diseases (including hepatic failure, kidney failure, hypothyroidism and Grave's disease), ventricular fibrillation, and known allergy to iodinated contrast agent. Patients with left- or co-dominant anatomies were placed into the LD group and those with right-dominant anatomy were included in the RD group. The association of acute inferior MI and coronary dominant anatomy were assessed using multivariable conditional logistic regression, and to estimate the odds ratio (OR) and 95% confidence interval (95%CI). RESULTS: Distributions of right dominance were significantly different between the acute inferior MI group and control group (94.0% vs. 87.9%, P = 0.018). Univariable conditional logistic regression revealed that right dominance may be a risk factor for the incident acute inferior MI (OR: 2.137; 95% CI: 1.210-3.776; P = 0.009). After adjusting for baseline systolic blood pressure, heart rate, smoking status, diabetes mellitus, hypertension, hyperlipidaemia, and family history of coronary artery disease, results of multivariate conditional logistic regression showed that right dominance was associated with the incidence of acute inferior MI (OR: 2.396; 95% CI: 1.328-4.321; P = 0.004). CONCLUSIONS: Right coronary dominance may play a disadvantageous role in the incidence of acute inferior MI. However, further studies are needed to verify our findings, especially with regard to the underlying mechanisms.

Disparate Impact of Ischemic Injury on Regional Wall Dysfunction in Acute Anterior vs Inferior Myocardial Infarction.

BACKGROUND: Acute transmural ischemia should induce similar magnitude of wall motion abnormality (WMA) in both anterior myocardial infarction (AMI) and inferior (IMI). However, patients with AMI generally suffer more severe hemodynamic compromise. METHODS: This retrospective study compared WMA's in ST segment elevation MI patients undergoing primary reperfusion and subsequent cardiac MRI. Regional systolic wall motion and thickening were assessed in all segments throughout the left ventricle (LV). RESULTS: We analyzed 37 patients (AMI = 24 vs IMI = 13). Reperfusion success was achieved in all and there were no differences between groups in door-to-balloon time (AMI median 77 vs IMI 119 min, p = 0.085). Compared to IMI, in AMI LV ejection fraction was more depressed (37 ±â€¯7.6% vs 51 ±â€¯10.3%, P = 0.0006) and regional WMA more severe (total regional WMA score = 2.63 ±â€¯0.53 vs IMI = 2.1 ±â€¯0.52, P = 0.007). Regional dyskinesis was commonly observed in AMI patients but was rare in IMI (79% vs 7% of cases). Similarly, AMI manifested systolic thinning, whereas thickening was depressed but still present in IMI patients. Strikingly, WMA severity differed downstream relative to the origin of the infarct artery: In all AMI cases, WMA worsened from proximal anterior toward the distal apical zone; in IMI the pattern was reverse, with WMA consistently most severe in the basal segment of the inferior-posterior wall with preservation toward the apical distribution of the infarct vessel. CONCLUSION: These results demonstrate a disparate impact of ischemic injury on mechanical performance of the anterior vs inferior-posterior walls. These findings may be attributable to differences between the walls in architecture, mechanics and coronary blood flow. These observations may have implications for myocardial salvage, remodeling and prognosis.

Acute inferior myocardial infarction with right ventricular involvement and several clinical-electrocardiographic markers of poor prognosis.

Right ventricular involvement in inferior myocardial infarction is a marker of poor prognosis. We present a case of a 62-year-old man with very recent onset of acute chest pain and cardiac shock with the triad of elevated jugular venous pressure, distension of the jugular veins on inspiration, and clear lung fields. In addition, the admission electrocardiogram showed a slurring J wave or lambda-like wave and conspicuous ST segment depression in several leads, predominantly in the lateral precordial (V4-V6), all clinical-electrocardiographic features of ominous prognosis.

The predictive value of aVR in determining the infarct related artery during primary percutaneous coronary intervention.

BACKGROUND: Isolation of infract related artery and timely revascularisation remains vital in the setting of primary percutaneous coronary intervention. OBJECTIVES: To analyse the predictive value of ST-T changes in lead aVR in inferior myocardial infarction in terms of prognosis and timely risk stratification. METHODS: We conducted a prospective analysis of acute inferior wall myocardial infarction patients. One hundred patients were categorised into two groups according to the culprit artery: group I, right coronary artery (RCA) and group II, left circumflex coronary artery (LCX), with 50 patients in each group. A comparative study was performed between the two groups, comprising the following data outputs: electrocardiogram (ECG) changes that could help determine the culprit artery, cardiac enzyme levels, echocardiographic findings, coronary angiography findings and in-hospital complications. The same patients were divided into two groups according to the presence or absence of 1 mm ST depression in lead aVR. A comparison analysis was performed between the two groups including: cardiac enzyme levels, echocardiographic findings, coronary angiography findings and in-hospital complications. RESULTS: ST depression in aVR ≥ 1 mm predicted the LCX as a culprit artery with sensitivity, specificity, positive predictive values (PPV) and negative predictive values (NPV) recorded at 66%, 84%, 80.5% and 71.2%, respectively. Also, patients with ST depression in aVR ≥ 1 mm showed significantly higher cardiac enzyme levels, indicating larger infarct size, with mean peak creatinine kinase (CK) = 1560 (1057-2375) IU/L versus 970 (613-1683) IU/L, (P value = 0.014), lower ejection fraction (Ef) with mean Ef = 47.93 ±â€¯8.04 versus 54.66 ±â€¯6.52, (P value < 0.001) and more significant mitral regurgitation: 17 (41.5%) patients versus 11 (18.6%) patients (P value = 0.012). Regarding in-hospital complications, there were no significant differences. CONCLUSIONS: ST depression of >1 mm in lead aVR predicts LCX as the infarct related artery and is a predictor of poor outcome in patients with inferior myocardial infarction.