Prevalence and prognosis of isolated posterior ST-segment elevation acute myocardial infarction using synthesized-V7-9 lead.

Limited data exist on the prevalence and prognosis of isolated posterior ST-segment elevation acute myocardial infarction (STEMI), revealed with a posterior chest lead. Furthermore, the utility of a synthesized-V7-9 lead in the diagnosis of STEMI is unclear; therefore, we aimed to evaluate its usefulness. We enrolled 142 consecutive patients with STEMI with the culprit lesion on the left circumflex artery (STEMI-LCx) undergoing percutaneous coronary intervention (PCI) between January 2009 and December 2019. We retrospectively checked the ST-segment change of both standard 12-lead and synthesized-V7-9 lead in all patients with STEMI-LCx. Based on electrocardiogram (ECG) findings, isolated posterior STEMI that was only revealed in synthesized-V7-9 lead was classified as "STEMI-LCx-synV7-9" and the remaining as "STEMI-LCx-12ECG." The prevalence of STEMI-LCx-synV7-9 in patients with STEMI-LCx was assessed. The incidence of all-cause death, cardiac death, and mechanical complications within 30 days, 3 months, and 1 year was also assessed according to each STEMI-LCx. STEMI-LCx-synV7-9 and STEMI-LCx-12ECG occurred in 10 (7.0%) and 132 (93.0%) patients, respectively. No significant difference was found in patients' characteristics between the two groups. The patients with STEMI-LCx-synV7-9 had significantly higher incidences of cardiac death within 3 months and 1 year (30.0% vs. 6.1%, P = 0.031, 30.0% vs. 7.6%, P = 0.050, respectively) and mechanical complications in each follow-up period (20.0% vs. 1.5%, P = 0.025) than those with STEMI-LCx-12ECG. STEMI-LCx-synV7-9 was observed in 7.0% of the patients with STEMI-LCx. Our findings suggest that the synthesized-V7-9 lead helps diagnose isolated posterior STEMI and might improve prognosis in patients with STEMI-LCx.

Myocardial salvage after ST-segment-elevation myocardial infarction: comparison between prasugrel and clopidogrel in the presence or absence of high-residual platelet reactivity.

BACKGROUND: The effect of prasugrel over clopidogrel on myocardial salvage in ST-segment-elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (p-PCI) is not fully elucidated. METHODS: Among 854 consecutive STEMI patients who underwent p-PCI, 446 patients were evaluated by two-phase (7 days and 3 months) single-photo emission computed tomography (SPECT). Patients were divided into two groups based on the loading P2Y12 inhibitor. The clopidogrel group was further divided based on the result of platelet function testing. Thus, the prasugrel group included 227 patients; the clopidogrel without high-residual platelet reactivity (HRPR) group, 109 patients; and the clopidogrel with HRPR group, 107 patients. The primary endpoint was the Myocardial Salvage Index (MSI), determined by SPECT. RESULTS: The incidence of final TIMI 0/1 and TIMI myocardial perfusion grade 0/1 was higher in the clopidogrel with HRPR group (0.9%, 1.8%, and 7.5%, P =  .002; 19.8%, 29.4%, and 41.1%, P = .0002, in the prasugrel, clopidogrel without HRPR, and clopidogrel with HRPR groups, respectively). The MSI was significantly lower in the clopidogrel with HRPR group (48% [27-66], 44% [30-72], and 36% [15-55], P =  .006, respectively). CONCLUSIONS: Prasugrel in STEMI patients was associated with an increased MSI compared with clopidogrel in the presence of HRPR.

Three-dimensional visualization of the left atrium by intracardiac echocardiography facilitates trans-septal catheterization and atrial fibrillation catheter ablation in cor triatriatum sinister: A case report and literature review.

A key to the success of catheter ablation in complex congenital heart disease is an accurate delineation of the anatomy. Here we describe the efficiency of intracardiac echocardiogram in guiding the catheter ablation of persistent atrial fibrillation in a 55-year-old Japanese male with cor triatriatum sinister. Echo imaging provided a detailed three-dimensional anatomy of the whole left atrium and identified an ideal trans-septal puncture site that allowed catheter access to both the accessory and main chambers of the left atrium. We review similar cases from the literature. .

Rotational Atherectomy for Severely Calcified Lesions in Patients With Left Ventricular Systolic Dysfunction: One-Year Outcomes From aSingle-Center Registry Analysis.

BACKGROUND: High-risk percutaneous coronary intervention (PCI) in patients with left ventricular (LV) systolic dysfunction has been proven to induce reverse LV remodeling. However, the impact of high-risk PCI focusing on rotational atherectomy (RA) in patients with severe LV systolic dysfunction has not been completely addressed. METHODS: Among 4339 consecutive patients who underwent PCI, 178 patients with 192 lesions were treated with RA. The reduced ejection fraction (EF) group (LVEF ≤35%) included 25 patients, the mid-range EF group (LVEF 36-50%) included 44 patients, and the preserved EF group (LVEF >50%) included 109 patients. The primary outcome was a composite of cardiac death, non-fatal myocardial infarction, target-vessel revascularization, and ischemic stroke. RESULTS: The cumulative 1-year incidence of the primary outcome was similar among the three groups (reduced EF, 29%; mid-range EF, 25%; preserved EF, 26%; p = 0.95). After adjusting for confounding factors, the incidence of the primary outcome in the reduced EF group (hazard ratio [HR], 1.07; 95% confidence interval [CI], 0.43-2.37; p = 0.87) and the mid-range EF group (HR, 0.99; 95% CI, 0.47-1.94; p = 0.97) was similar to that in the preserved EF group. LVEF was significantly improved in the reduced EF and mid-range EF groups compared with the preserved EF group (absolute change in LVEF: 13.6 ± 11.3%, 9.0 ± 10.1%, and -0.7 ± 7.8%, respectively; p < 0.0001). CONCLUSIONS: Reduced EF was not associated with increase in the primary outcome in patients undergoing RA. This seemed to result from the improved LV function after PCI. SUMMARY FOR ANNOTATED TABLE OF CONTENTS: This single center analysis study investigated 1-year composite outcome of cardiac death, non-fatal myocardial infarction, target-vessel revascularization, and ischemic stroke in patients with severe LV systolic dysfunction undergoing RA compared with that in patients with preserved LV function. The cumulative 1-year incidence of the composite outcome was similar among the three groups (reduced EF, 29%; mid-range EF, 25%; preserved EF, 26%; p = 0.95). LVEF was significantly improved in the reduced EF and mid-range EF groups compared with the preserved EF group (absolute change in LVEF: 13.6 ± 11.3%, 9.0 ± 10.1%, and -0.7 ± 7.8%, respectively; p < 0.0001).

Predicting long-term freedom from atrial fibrillation after catheter ablation by a machine learning algorithm: Validation of the CAAP-AF score.

BACKGROUND: Preprocedural clinical predictors of the successful maintenance of sinus rhythm may contribute to optimal treatment strategies for atrial fibrillation (AF). The CAAP-AF score, a novel simple tool scored as 0-13 points (including six independent variables) has been proposed to predict long-term freedom from AF after catheter ablation. To clarify its reproducibility, we examined the CAAP-AF score's predictive performance and then created subgroups to best predict AF recurrence by using a machine learning algorithm. METHODS: We studied 583 consecutive patients who underwent initial AF catheter ablation at our institute (median CAAP-AF score, 5; age, 66 ± 10 years old; female, 28.3%; coronary artery disease, 10.8%; left atrial diameter, 39.9 ± 6.6 mm; number of antiarrhythmic drugs failed, 0.4 ± 0.6; nonparoxysmal AF, 45.3%). All were systematically followed up with an endpoint of atrial tachyarrhythmia recurrence after the last ablation procedure. RESULTS: During the 1.8 ± 1.2-year follow-up, 157 patients had atrial tachyarrhythmia recurrence. Repeated procedures were performed (n = 115). Arrhythmia recurrence after the last session occurred in 69 patients. We created Kaplan-Meier curves for freedom from AF after final AF ablation for ranges of CAAP-AF scores; these confirmed the original study results. The machine learning using Classification and Regression Trees divided the patients into three categories by the risk score: low (score ≤5), intermediate (score 6-8), and high (score ≥9). CONCLUSIONS: The CAAP-AF score was useful to stratify the atrial tachyarrhythmia recurrence risk in AF patients undergoing catheter ablation into three categories. The score should be considered when deciding whether to perform AF ablation in clinical practice.

Usefulness of excimer laser in acute coronary syndrome with left main coronary artery: a case series.

BACKGROUND: Acute coronary syndrome caused by unprotected left main coronary artery (ACS-ULMCA) occlusion has a high mortality due to the formation of plaques and rich thrombi. Although excimer laser coronary angioplasty (ELCA) is effective in debulking and ablation of plaque burden and rich thrombi, its effectiveness in ACS-ULMCA remains unknown. CASE SUMMARY: We conducted percutaneous coronary intervention (PCI) using ELCA for six patients with ACS-ULMCA from February 2016 to May 2019. This case series includes a 65-year-old man who presented with sudden-onset chest pain. Angiography revealed subtotal occlusion of the left main coronary artery (LMCA). The use of a 0.9-mm ELCA catheter advanced from LMCA to the left anterior descending artery markedly improved coronary blood flow, and intravascular ultrasound revealed debulking of the plaque and thrombus. Another 79-year-old man presented with chest pain. Angiography revealed total occlusion of LMCA. Use of a 0.9-mm ELCA catheter improved coronary blood flow. Subsequent kissing balloon technique led to satisfactory results. All cases needed mechanical support (such as intra-aortic balloon pumping or percutaneous cardiopulmonary support) prior to PCI. Five patients survived finally, and one died 34 days after primary PCI. DISCUSSION: After stabilizing haemodynamics by mechanical support, ELCA could be a good option to improve coronary blood flow in patients with ACS-ULMCA.

The impact of the excimer laser on myocardial salvage in ST-elevation acute myocardial infarction via nuclear scintigraphy.

Data on the efficacy of excimer laser coronary atherectomy (ELCA) for patients with ST-elevation myocardial infarction (STEMI) are limited. Therefore, we sought to evaluate the impact of ELCA on myocardial salvage using nuclear scintigraphy in patients with STEMI. Between September 2014 and April 2017, we retrospectively enrolled 316 consecutive patients undergoing primary PCI (p-PCI) after their first STEMI in our institute. Of those, 72 patients with STEMI, an initial thrombolysis in myocardial infarction (TIMI) flow-0/1, and an onset to balloon time (OBT) < 6 h were included (ELCA, n = 32; non-ELCA, n = 40). The endpoint was the myocardial salvage index (MSI) based on a 17-segment model with a 5-point scoring system. MSI was calculated as: MSI = (∑123I-BMIPP defect score at 3-7 days after p-PCI - ∑99mTc-tetrofosmin defect score at 3-6 months after p-PCI)/∑123I-BMIPP defect score × 100 (%) at 3-7 days after p-PCI. The groups were compatible except in age (ELCA: 62.9 ± 12.4 years vs. non-ELCA: 69.8 ± 11.0 years) and loading antiplatelet drug (prasugrel: 100% vs. 40.0%). Direct implantation of shorter stents more frequently occurred in the ELCA group than in the non-ELCA group. MSI seemed to be better in the ELCA group compared with the non-ELCA group (57.6% vs. 45.6%, p = 0.09). This trend was emphasized when the final TIMI-3 flow was achieved (67.1% vs. 45.7%, p = 0.01). The nuclear scintigraphy results showed that ELCA can potentially improve myocardial salvage in patients with STEMI with OBT < 6 h and initial TIMI flow-0/1.

Prognostic impact of recanalizing chronic total occlusion in non-infarct related arteries on long-term clinical outcomes in acute myocardial infarction patients undergoing primary percutaneous coronary intervention.

Although chronic total occlusion (CTO) in non-infarct-related arteries (non-IRAs) negatively affects long-term mortality in patients with acute myocardial infarction (AMI) who are undergoing primary percutaneous coronary intervention (PCI), the prognostic impact of successful CTO-PCI has not been completely addressed. Among 1855 consecutive patients with AMI who underwent primary PCI, those who were treated for CTO with either PCI or medical therapy were included. We evaluated the association between recanalization of CTO and long-term cardiac mortality. Of the 172 included patients, 88 underwent CTO-PCI, and the procedures were successful in 65 patients. Thus, the successfully recanalized CTO (SR-CTO) group included 65 patients; and the no recanalized CTO (NR-CTO) group, 107 patients. During the follow-up, 72 patients died, and of whom 56 (77.8%) died because of cardiac causes. The cumulative 10-year, 30-day, and 30-day to 10-year incidences of cardiac mortality were lower in the SR-CTO group than in the NR-CTO group (19.0% vs. 51.9% p = 0.004; 4.6% vs. 14.0%, p = 0.05; 15.0% vs. 44.1%, p = 0.003, respectively). After adjusting for confounding factors, the benefits of SR-CTO for the 10-year cardiac mortality remained significant compared with those of NR-CTO (hazard ratio 0.37; 95% confidence interval 0.17-0.75; p = 0.004). In conclusion, patients with SR-CTO in non-IRAs after AMI was associated with reduced long-term cardiac mortality compared with those with NR-CTO.

Coronary vasospasm caused by intravenous infusion of dexmedetomidine: Unrecognized pitfall of catheter ablation procedures of atrial fibrillation.

Coronary vasospasm is an emerging potentially lethal complication of catheter ablation for atrial fibrillation (AF), however, its mechanism in this setting has not been well elucidated. A 55-year-old man with symptomatic paroxysmal AF underwent pulmonary vein isolation under sedation with propofol. The procedure was completed without any complications. Fifteen months later, a repeated session was performed because of AF recurrence. Initially, a high-dose infusion of dexmedetomidine instead of propofol was administered to introduce sedation. Then, an ST-segment elevation developed in the inferior leads and the diagnosis of coronary vasospasm was made by urgent coronary angiography. A comparison of the procedural details between the first and second sessions identified dexmedetomidine, an α-2 adrenergic agonist with a short distribution half-life, as a potential cause of coronary vasospasm seen only in the second session in the same individual. Since it has been shown that α-2 adrenoreceptor-mediated vasoconstriction can involve the coronary circulation, it is thus possible that a stimulation of α-2 adrenergic receptors induced by dexmedetomidine caused a coronary vasospasm. The present case provides new insights into dexmedetomidine-induced vasospasm. Physicians should be aware of this potentially lethal side effect of dexmedetomidine which is increasingly used in the current AF ablation practice. .

Early versus delayed invasive strategy in patients with non-ST-elevation acute coronary syndrome and concomitant congestive heart failure.

BACKGROUND: Although there are guidelines that recommend an early invasive strategy in patients with non-ST-elevation acute coronary syndrome (NSTE-ACS) and concomitant congestive heart failure (CHF), optimal timing of the invasive strategy remains controversial. METHODS: Among 2045 patients who were admitted owing to NSTE-ACS or CHF, 300 presented with NSTE-ACS and concomitant CHF. Of the 300 patients, we enrolled 160 patients for whom coronary angiography (CAG) during their hospital stay was planned at the time of admission; 64 of these patients were classified into the early invasive group (<24h) and 96 were classified to the delayed invasive group (≥24h). We evaluated the primary outcome which was defined as a composite of cardiac mortality, life-threatening arrhythmia, and non-fatal myocardial infarction (MI). RESULTS: The median time between presentation and CAG was 2h in the early invasive group and 240h in the delayed group. During follow-up, the primary outcome was significantly lower in the early invasive group [hazard ratio (HR), 0.52; 95% confidence interval (CI), 0.30-0.87; p=0.01]. After the adjustment of confounding factors, the primary outcome was significantly less frequent (HR, 0.44; 95% CI, 0.23-0.78; p=0.004) in the early invasive group compared to the delayed invasive group. CONCLUSIONS: The early invasive strategy was associated with a lower risk of the composite primary outcome in the long-term follow-up of patients with NSTE-ACS and concomitant CHF.

Impact of Postdischarge Bleeding on Long-Term Mortality in Percutaneous Coronary Intervention Patients Taking Oral Anticoagulants.

Although postdischarge bleeding (PDB) is known to negatively affect long-term outcome in patients undergoing percutaneous coronary intervention (PCI) with antiplatelet therapy (APT), the prognostic importance of PDB in patients who require both oral anticoagulants (OACs) and APT has not been fully elucidated. Among 3718 consecutive patients who underwent PCI, 302 patients were treated with both OACs and APT. We evaluated the association between PDB and 3-year all-cause mortality, as estimated by a time-updated Cox proportional hazard regression model. We performed nearest-neighbor matching on the propensity score to adjust the differences in baseline characteristics. Among 302 patients treated with OACs and APT, PDB was observed in 98 patients at a median time of 239 days. Patients experienced PDB had significantly higher incidence of 3-year all-cause mortality in the overall cohort and 94 propensity-score-matched pairs (hazard ratio 6.21, 95% confidence interval 3.29-11.72, P < 0.0001; and hazard ratio 6.13, 95% confidence interval 2.68-14.02, P < 0.0001, respectively). The risk of subsequent mortality was the highest within 180 days after PDB (58.3% within 180 days and 75.0% within 1 year). In conclusion, PDB was significantly associated with long-term mortality in patients taking both OACs and APT after PCI.

A survival case of a young adult patient with ST-elevated myocardial infarction with high levels of lipoprotein(a).

A 23-year-old Japanese man presented to a nearby hospital with a complaint of chest pain. In terms of the risk factors for cardiovascular events, there were no abnormal findings in past medical examinations and no smoking history. The 12-lead　electrocardiogram revealed ST-elevation in V1-V6, I, and aVL, and he was diagnosed with acute myocardial infarction. Emergency coronary angiography findings revealed total occlusion of the left main trunk and collateral vessels from the right coronary artery to the left anterior descending artery. He underwent emergency percutaneous coronary intervention and placement of drug-eluting stent under the support of venoarterial-extracorporeal membrane oxygenator (VA-ECMO). On day 8 after the onset, transthoracic echocardiography revealed that cardiac function improved with left ventricular ejection fraction from 10% to 20% and VA-ECMO was successfully removed. Alternatively, laboratory findings revealed abnormally high levels of serum lipoprotein(a) [Lp(a), 74 mg/dL] despite the normal levels of low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, and triglyceride. In addition, computed tomography angiography revealed atherosclerosis and stenosis of internal and external carotid arteries, subclavian artery, and renal artery. The abnormally high levels of serum Lp(a) could influence systemic atherosclerosis as well as the onset of myocardial infarction in our young adult patient. .

Impact of the clinical frailty scale on mid-term mortality in patients with ST-elevated myocardial infarction.

BACKGROUND: "Frailty" is associated with poor prognosis in ST-elevated myocardial infarction (STEMI). However, there is little data regarding the impact of the Canadian Study of Health and Aging Clinical Frailty Scale (CFS), a simple and semiquantitative tool for assessing frailty, on mid-term mortality in STEMI patients. METHODS: A total of 354 consecutive STEMI patients (mean age 69.8 ±â€¯12.4 years; male 76.6%) who underwent percutaneous intervention between July 2014 and March 2017 were retrospectively reviewed. The study endpoint was mid-term mortality according to the CFS classification. Furthermore, in order to clarify the impact of CFS upon admission on mid-term mortality, the independent predictors of all-cause death were evaluated. RESULTS: Patients were categorized into three groups (CFS 1-3, n = 281; CFS 4-5, n = 62; and CFS 6-7, n = 11). During the study period (median 474 days), all-cause death was observed in 39 patients. After multivariate Cox regression analysis, higher CFS (adjusted hazard ratio [HR] 2.34, 95% confidence interval [CI] 1.43-3.85, p < 0.001), higher Killip score (adjusted HR 2.46, 95%CI 1.30-5.78, p = 0.002), and lower serum albumin level (adjusted HR 4.29, 95%CI 2.16-8.51, p < 0.001) were significantly associated with an increased risk of all-cause death. CONCLUSION: In conclusion, severe frailty was associated with mid-term mortality in STEMI patients who underwent PCI.

The Early Initiation of Extracorporeal Life Support May Improve the Neurological Outcome in Adults with Cardiac Arrest due to Cardiac Events.

Objective Extracorporeal life support (ECLS) is effective for improving the survival rate of patients with refractory cardiac arrest (rCA). As little data are available regarding the impact of ECLS on a favorable neurological outcome, the predictors of a favorable neurological outcome were evaluated in this study. Methods Between January 2007 and August 2016, we retrospectively recruited patients with rCA caused by cardiac events treated with ECLS in our institute. A favorable neurological outcome was defined as a Glasgow-Pittsburgh cerebral performance category score 1 at discharge. The study endpoint was the clinical outcomes and predictors of favorable neurologic patients at discharge. Results During the study period, 67 patients with CA caused by cardiac events (acute coronary syndrome, 57 patients; idiopathic ventricular fibrillation, 10 patients) were included. Of these, 20 patients (29.9%) were classified into the favorable neurological group. No marked difference was observed in the patient characteristics between those with and without a favorable outcome except for in the time from CA to starting ECLS (ECLS initiation time). A short ECLS initiation time resulted in a favorable outcome (37.8±28.1 minutes vs. 53.6±30.7 minutes, p=0.05). The cut-off time of ECLS initiation was 46 minutes, which was prolonged by the temporary return of spontaneous circulation before ECLS [odds ratio (OR), 3.69; 95% confidence interval (CI), 1.34-10.19; p=0.01] and transfer to the angiographic room (OR, 4.07; 95% CI, 1.44-11.53, p=0.008). Conclusion The early initiation of ECLS (within 46 minutes) might be associated with a favorable neurological outcome for patients with rCA caused by cardiac events.

Performance of HAS-BLED, ORBIT, PRECISE-DAPT, and PARIS risk score for predicting long-term bleeding events in patients taking an oral anticoagulant undergoing percutaneous coronary intervention.

BACKGROUND: No standardized tool exists for weighting bleeding risk before selecting an antithrombotic regimen in patients undergoing percutaneous coronary intervention (PCI) who require both oral anticoagulant (OAC) and antiplatelet agents. METHODS: We performed PCI in 3718 consecutive patients between April 2011 and March 2017, 302 of whom were treated with both OAC and antiplatelet agents. We retrospectively evaluated the predictive performance of four major bleeding risk scores (HAS-BLED, ORBIT, PRECISE-DAPT, and PARIS score). Patients were followed for up to 3 years for bleeding events, defined as a composite of major and minor bleeding according to the Thrombolysis in Myocardial Infarction (TIMI) criteria and the Bleeding Academic Research Consortium (BARC) criteria. RESULTS: TIMI significant bleedings (major, minor, and requiring medical attention) were seen in 90 patients (29.8%); whereas the BARC class ≥3 bleedings were seen in 53 patients (17.5%). Regarding TIMI significant bleedings, HAS-BLED, ORBIT, and PRECISE-DAPT scores equally categorized high-risk patients, but the PARIS score could not [high-risk versus non-high-risk: hazard ratio (HR), 1.74; 95% confidence interval (CI), 1.15-2.64; p=0.01; HR, 1.63; 95% CI, 1.08-2.48; p=0.02; HR, 1.62; 95% CI, 1.06-2.51; p=0.03; HR, 1.05; 95% CI, 0.70-1.63; p=0.79, respectively); regarding BARC class ≥3 bleeding, all four scores could stratify high-risk patients (high-risk versus non-high-risk: HR, 2.23; 95% CI, 1.30-3.88; p=0.004; HR, 2.25; 95% CI, 1.31-3.96; p=0.003; HR, 3.87; 95% CI, 2.06-7.91; p<0.0001; HR, 1.85; 95% CI, 1.04-3.47; p=0.04, respectively). CONCLUSIONS: In patients taking an OAC undergoing PCI, HAS-BLED, ORBIT, and PRECISE-DAPT scores predicted TIMI significant bleeding events better than the PARIS score; whereas all four scores could predict BARC class ≥3 bleeding events.

Coil embolization of pseudoaneurysm as a complication of excimer laser coronary angioplasty: insights from intravascular ultrasound and optical coherence tomography findings.

The occurrence of pseudoaneurysm in the coronary artery is rare and can develop after percutaneous coronary interventions. To date, the optimal therapy, including conservative, surgical, and endovascular therapies, for pseudoaneurysm in the coronary artery remains unclear. Here, we report a case of pseudoaneurysm arising as a complication of excimer laser coronary angioplasty, which was successfully treated with stent-assisted coil embolization, after which optical coherence tomography revealed complete healing of the pseudoaneurysm. This report highlights the feasibility of stent-assisted coil embolization for coronary pseudoaneurysms involving bifurcation.