Transcatheter aortic valve implantation in patients with anomalous coronary artery.

OBJECTIVES: The aim of this review was to analyze literature and provide systematic algorithm to guide decision making during TAVI procedure. BACKGROUND: Transcatheter aortic valve implantation (TAVI) is growing in popularity and expanding to younger patients with lower risk profiles. Currently, there is no concise guideline on the management strategy during TAVI in patients with anomalous coronary artery (ACA) anatomy undergoing this procedure. METHODS: A systematic search was conducted for relevant case reports of TAVI in patients who had confirmed ACA anatomy. Twenty-four case reports, that met the criteria for this review, were identified and included in the final study size. RESULTS: TAVI was successful in 23 out of 24 cases. Half of the cases (12) described performing balloon aortic valvuloplasty (BAV) before TAVI. The majority (15) reported using angiogram Postimplantation. Only one-third of cases (8) reported performing coronary protection (with either wire, wire and stent or wire and balloon). Two-third of case reports (16/24, 67%) mentioned using Edwards SAPIEN balloon expandable transcatheter heart valves (THV). CONCLUSIONS: Preprocedural diagnostic imaging tests play important role in determining the ACA anatomy and its relation to the aortic valve. BAV with simultaneous coronary arteries angiography or aortography should be performed before implantation of THV, as it could potentially predict whether the ACA would be compressed. Using at least a coronary wire for ACA protection is recommended in case there is high risk of ACA obstruction. Management strategy should be individualized when performing TAVI in patients with ACA.

Case report: A rare manifestation of vasospasm induced myocardial infarction with ST-segment elevation in a young male patient.

Background: Minority of acute myocardial infarctions (MI) are caused by a non-atherosclerotic occlusion of the coronary artery. We present a case report, where MI with ST-segment elevation was provoked by a vasospasm, which is a rare aetiological finding. Case presentation: 27-year-old male patient presented to the emergency department because of a sudden onset chest pain radiating to the left arm. The patient underwent percutaneous coronary intervention (PCI) to the right coronary artery (RCA) 3 months ago due to inferior wall MI, however, chest pain episodes kept on recurring at night throughout the whole period after the intervention. During current admission, initial electrocardiogram (ECG) demonstrated ST-segment elevation in leads II, III and aVF. Coronary angiogram revealed diffuse severe narrowing of the right coronary artery, which was relieved with intracoronary administration of nitrates and verapamil. After coronary angiogram patient was given oral long-acting nitrates and verapamil, however, during the following days nocturnal chest pain episodes reoccurred. It was decided to swap verapamil to diltiazem, which led to complete cessation of angina episodes. The patient was discharged in stable condition and symptom free. It was suspected that the first MI was of vasospastic origin, which likely led to unnecessary stenting. Conclusions: This clinical case has demonstrated the challenges clinician could face in order to correctly diagnose vasospasm-induced MI because of its rare occurrence and highly variable presentation. We strongly suggest using intracoronary nitroglycerine during coronary angiography as a standard practice to avoid a potential diagnostic error and unnecessary stenting. Although, in some cases the reason behind coronary artery spasm (CAS) remains unclear, medical treatment can be very effective for CAS prevention.

Increase of Myocardial Ischemia Time and Short-Term Prognosis of Patients with Acute Myocardial Infarction during the First COVID-19 Pandemic Wave.

Background and objectives: early reports showed a decrease in admission rates and an increase in mortality of patients with acute myocardial infarction (AMI) during the first wave of COVID-19 pandemic. We sought to investigate whether the COVID-19 pandemic and associated lockdown had an impact on the ischemia time and prognosis of patients suffering from AMI in the settings of low COVID-19 burden. Materials and Methods: we conducted a retrospective data analysis from a tertiary center in Lithuania of 818 patients with AMI. Data were collected from 1 March to 30 June in 2020 during the peri-lockdown period (2020 group; n = 278) and compared to the same period last year (2019 group; n = 326). The primary study endpoint was all-cause mortality during 3 months of follow-up. Secondary endpoints were heart failure severity (Killip class) on admission and ischemia time in patients with acute ST segment elevation myocardial infarction (STEMI). Results: there was a reduction of 14.7% in admission rate for acute myocardial infarction (AMI) during the peri-lockdown period. The 3-month mortality rate did not differ significantly (6.9% in 2020 vs. 10.5% in 2019, p = 0.341 for STEMI patients; 5.3% in 2020 vs. 2.6% in 2019, p = 0.374 for patients with acute myocardial infarction without ST segment elevation (NSTEMI)). More STEMI patients presented with Killip IV class in 2019 (13.5% vs. 5.5%, p = 0.043, respectively). There was an increase of door-to-PCI time (54.0 [42.0-86.0] in 2019; 63.5 [48.3-97.5] in 2020, p = 0.018) and first medical contact (FMC)-to-PCI time (101.0 [82.5-120.8] in 2019; 115 [97.0-154.5] in 2020, p = 0.01) during the pandemic period. Conclusions: There was a 14.7% reduction of admissions for AMI during the first wave of COVID-19. FMC-to-PCI time increased during the peri-lockdown period, however, it did not translate into worse survival during follow-up.