Acute coronary occlusion with vs. without ST elevation: impact on procedural outcomes and long-term all-cause mortality.

BACKGROUND: Acute total occlusion (ATO) is diagnosed in a substantial proportion of patients with non-ST-elevation myocardial infarction (NSTEMI). We compared procedural outcomes and long-term mortality in patients with STEMI with NSTEMI with vs. without ATO. METHODS AND RESULTS: We included patients with acute myocardial infarction (AMI) undergoing invasive coronary angiography between 2004 and 2019 at our centre. Acute total occlusion was defined as thrombolysis in myocardial infarction (TIMI) 0-1 flow in the infarct-related artery or TIMI 2-3 flow with highly elevated peak troponin (>100-folds the upper reference limit). Association between presentation and long-term mortality was evaluated using multivariable adjusted Cox regression analysis. From 2269 AMI patients (mean age 66 ± 13.2 years, 74% male), 664 patients with STEMI and 1605 patients with NSTEMI (471 [29.3%] with ATO) were included. ATO(+)NSTEMI patients had a higher frequency of cardiogenic shock and no reflow than ATO(-)NSTEMI with similar rates compared with STEMI patients (cardiogenic shock: 2.76 vs. 0.27 vs. 2.86%, P < 0.0001, P = 1; no reflow: 4.03 vs. 0.18 vs. 3.17%, P < 0.0001, P = 0.54). ATO(+)NSTEMI and STEMI were associated with 60 and 55% increased incident mortality, respectively, as compared with ATO(-)NSTEMI (ATO(+)NSTEMI: 1.60 [1.27-2.02], P < 0.0001, STEMI: 1.55 [1.24-1.94], P < 0.0001). Likewise, left ventricular ejection fraction (48.5 ± 12.7 vs. 49.1±11 vs. 50.6 ± 11.8%, P = 0.5, P = 0.018) and global longitudinal strain (-15.2 ± -5.74 vs. -15.5 ± -4.84 vs. -16.3 ± -5.30%, P = 0.48, P = 0.016) in ATO(+)NSTEMI were comparable to STEMI but significantly worse than in ATO(-)NSTEMI. CONCLUSION: Non-ST-elevation myocardial infarction patients with ATO have unfavourable procedural outcomes, resulting in increased long-term mortality, resembling STEMI. Our findings suggest that the occlusion perspective provides a more appropriate classification of AMI than differentiation into STEMI vs. NSTEMI.

Permanent His bundle pacing and atrioventricular node ablation in a case with drug-refractory atrial fibrillation.

Permanent His bundle pacing (HBP) activates the ventricles through the normal conduction system and has become a useful technique for patients with a high ventricular pacing rate. Presently described is a case of drug-refractory atrial fibrillation (AF) with a high ventricular rate that was treated with atrioventricular (AV) node ablation and permanent HBP. A 62-year-old woman with persistent AF and a drug-refractory high ventricular response was referred for exercise intolerance and palpitation. She had a history of failed catheter ablation attempts and amiodarone toxicity. Permanent HBP and AV node ablation was planned to achieve rate control with a stepwise approach. Initially, implantation of a permanent pacemaker was performed. The His lead and right ventricular back-up leads were implanted successfully, in the manner described previously. The His lead was connected to the atrial channel of the pacemaker battery and programmed to AAI pacing mode. The AV node was ablated successfully 3 weeks later without any threshold changes in the His lead. No His lead threshold changes were observed during or after AV node ablation and the patient was subsequently asymptomatic with twice daily apixaban 5 mg. Permanent HBP after AV node ablation can be a beneficial treatment option to prevent pacing-induced ventricular dyssynchrony and heart failure in patients who are not eligible for cardiac resynchronization therapy.

A Rare Access Site Complication after Transcatheter Aortic Valve Implantation.

In the majority of patients undergoing transcatheter aortic valve implantation, the transfemoral access is the suggested approach due to its less invasive nature and feasibility in patients with suitable vascular anatomy. The complications of the transfemoral access site are generally vascular; however, we herein present a rare case of colon perforation following the transfemoral procedure owing to prior abdominal surgery. A transfemoral aortic valve was inserted on account of severe aortic stenosis and a high probability of surgical mortality. The patient developed acute abdomen following the procedure. Hemicolectomy was performed because of colonic perforation caused by femoral catheterization. The patient was well at 3 months' follow-up.