Dynamic left ventricular outflow tract obstruction in a patient with acute coronary syndrome and without the apical akinesia: Potential alternative mechanisms causing a dynamic left ventricular outflow tract obstruction other than a compensatory basal hyperkinesis.

The mechanism for dynamic left ventricular outflow tract obstruction (LVOTO) after acute coronary syndromes (ACS) is thought to be apical infarction with compensatory hyperkinesia of the residual normally perfused basal segments of the myocardium. However, herein, we report a patient with ACS and dynamic LVOTO (peak gradient of 250 mm Hg at rest) that could not be secondary to apical akinesia. We propose a potential alternative mechanism leading to dynamic LVOTO in ACS, namely, the interplay between sigmoid septum, basal hyperkinesis, and outflow tract narrowing induced by afterload reduction due to acute myocardial ischemia itself.

The Comparison of Clinical Outcomes Between Inferior ST-Elevation Myocardial Infarction with Right Ventricular Infarction Versus Without Right Ventricular Infarction.

Right ventricular infarction (RVI) is a complication following inferior ST-elevation myocardial infarction (STEMI). The aim of the present study was to investigate the clinical outcomes of RVI in the contemporary primary percutaneous coronary intervention (PCI) era. The primary endpoint was in-hospital death, and the secondary endpoint was major adverse cardiac events (MACE), defined as the composite of cardiovascular death, re-hospitalization for heart failure, and non-fatal acute myocardial infarction (AMI). Event-free survival curves for MACE were constructed using the Kaplan-Meier method, and statistical differences between curves were assessed using the log-lank test. A total of 1354 patients with AMI were screened from January 2010 to December 2016. The final study population involved 315 patients with STEMI whose infarct related artery (IRA) was the right coronary artery (RCA). We categorized these 315 patients into the RVI group (n = 85) and the non-RVI group (n = 230). Median follow-up duration was 358 (IQR: 208-987) days. In-hospital deaths were more frequently observed in the RVI group (9.4%) than in the non-RVI group (3.0%) (P = 0.018). However, the incidence of MACE was not different between the groups (P = 0.537). In conclusion, in-hospital clinical outcomes were poorer in the RVI group than in the non-RVI group. However, mid-term MACE was not different between the two groups, suggesting the importance of aggressive acute treatment for STEMI patients with RVI.

Novel Acute Myocardial Infarction Risk Stratification (nARS) System Reduces the Length of Hospitalization for Acute Myocardial Infarction.

BACKGROUND: The novel Acute Myocardial Infarction (AMI) Risk Stratification (nARS) system was recently developed based on original criteria. The use of nARS may reduce the length of hospitalization. Methods and Results: We allocated 560 AMI patients into the pre-nARS group (before adopting nARS) or the nARS group. Patients in the nARS group were subdivided into the low (L), intermediate (I), and high (H) risk groups, whereas patients in the pre-nARS group were subdivided into the equivalent L (eL), equivalent I (eI), or equivalent H (eH) risk groups based on the nARS criteria. Length of coronary care unit (CCU) stay was significantly shorter in the nARS group (2.8±3.5 days) compared with the pre-nARS group (4.4±5.4 days; P<0.001). Length of hospital stay was also shorter in the nARS group (9.4±8.9 days) compared with the pre-nARS group (13.4±12.8 days; P<0.001). Length of CCU stay was significantly shorter in the L (1.1±1.0 days), I (2.8±3.5 days), and H (5.0±4.8 days) risk groups compared with corresponding eL (2.2±1.1 days), eI (4.4±5.4 days), and eH (7.1±7.8 days) risk groups. CONCLUSIONS: Length of CCU and hospital stay were significantly shorter in the nARS group compared with the pre-nARS group. The use of nARS may save medical resources in the treatment of AMI in the regional health-care system.

Comparison of clinical outcomes between sufficient versus insufficient diagonal branch flow in anterior acute myocardial infarction.

In primary percutaneous coronary intervention (PCI), revascularization to the main branch is considered to be more important than that to the side branch. The purpose of the present study was to compare in-hospital clinical outcomes between sufficient and insufficient diagonal flow in patients with anterior ST-elevation acute myocardial infarction. A total of 229 left anterior descending artery (LAD)-AMI with final Thrombolysis in Myocardial Infarction (TIMI)-3 LAD flow were included, and divided into the sufficient diagonal flow group (TIMI-3 diagonal flow: n = 170) and the insufficient diagonal flow group (TIMI ≤ 2 diagonal flow: n = 59). The primary endpoint was the incidence of mechanical complication. The secondary endpoints were incidences of in-hospital death, heart failure at discharge, and left ventricular thrombus. There were no significant differences in the primary endpoint (the sufficient diagonal flow group: 1.2%, the insufficient diagonal flow group: 0%, P = 0.403). In-hospital death was more frequently observed in the insufficient diagonal flow group (8.5%) than the sufficient diagonal flow group (2.9%) without reaching statistical significance (P = 0.073). The incidence of heart failure at discharge, and thrombus in left ventricular were not different between the two groups. In conclusion, in-hospital outcomes were not significantly different between the sufficient and insufficient diagonal flow groups. We may not stick to the diagonal flow in LAD-STEMI, as long as the LAD flow is maintained by PCI.

Comparison of Clinical Outcomes between the Ostial Versus Non-Ostial Culprit in Proximal Left Anterior Descending Artery Acute Myocardial Infarction.

Percutaneous coronary interventions to the proximal left anterior descending artery (pLAD)-acute myocardial infarction (AMI) are still challenging, especially in the ostial pLAD. Clinical outcomes of the ostial pLAD-AMI were not well investigated. The aim of the present study was to compare clinical outcomes of the ostial pLAD-AMI with those of the non-ostial pLAD-AMI. The primary endpoint was the major cardiovascular events (MACE), defined as the composite of cardiac death, AMI, stent thrombosis (ST), target lesion revascularization (TLR), and target vessel revascularization (TVR). Between January 2009 and March 2016, a total of 401 pLAD-AMI were included as the study population and were divided into 78 ostial pLAD-AMI (the ostial pLAD group), and 323 non-ostial pLAD-AMI (the non-ostial pLAD group). The median follow-up duration was 414 days. The MACE tended to be higher in the ostial pLAD group (8.0% at 30 days, 19.9% at 400 days) than in the non-ostial pLAD group (4.4% at 30 days, 12.9% at 400 days) without reaching statistical significance (P = 0.087). The prevalence of cardiac death was significantly higher in the ostial pLAD group (6.6% at 30 days, 9.5% at 400 days) as compared with the non-ostial pLAD group (3.1% at 30 days, 4.5% at 400 days) (P = 0.034). There were no significant differences in ST, AMI, TLR, or TVR. We concluded that, as compared with the non-ostial pLAD-AMI, the clinical outcomes of the ostial pLAD-AMI, especially cardiac death, tended to be worse, requiring special attention to the ostial pLAD-AMI.

Important Clinical Features of Japanese Spotted Fever.

Japanese spotted fever (JSF) is a zoonosis transmitted by ticks carrying the pathogen Rickettsia japonica. The classic triad of JSF symptoms is high fever, erythema, and tick bite eschar. About 200 people in Japan develop the disease every year. Japanese spotted fever is also a potentially fatal disease. At Minami-Ise Municipal Hospital in Japan, 55 patients were diagnosed with JSF from 2007 to 2015, which was equivalent to 4.3% of the total JSF cases in Japan. In this retrospective study, we examined the medical records of these 55 JSF cases. Fever, erythema, eschar, and elevated C-reactive protein (CRP) are characteristic clinical features of the disease. We confirmed four of these in the reviewed cases; however, eschar was not present in occasional cases. We confirmed that eosinopenia appeared in nearly all cases. Using fever, erythema, elevated CRP, and eosinopenia in diagnostic screening, our positivity rate was 90.9%. In our clinical practice, including eosinopenia improves the initial diagnosis of JSF.

Clinical outcomes after acute myocardial infarction according to a novel stratification system linked to a rehabilitation program.

BACKGROUND: A risk classification of acute myocardial infarction (AMI) linked to a rehabilitation program has not been established. METHODS: We allocated 292 patients with AMI into the low- (L) (n=108), intermediate- (I) (n=72), and high- (H) (n=112) risk groups according to our original risk classification. The primary endpoint was major adverse cardiac events (MACE), defined as the composite of cardiac death, non-fatal AMI, stent thrombosis, and ischemia-driven target vessel revascularization. The mean follow-up period was 252 days. RESULTS: The length of coronary care unit (CCU) stay and hospital stay was shortest in the L-risk group (CCU stay, 1.0±1.0 days; hospital stay, 5.6±3.2 days), followed by the I-risk group (CCU stay, 2.3±1.8 days; hospital stay, 8.1±2.7 days), and longest in the H-risk group (CCU stay, 5.1±5.0 days; hospital stay, 14.6±12.6 days) (p<0.001). MACE were most frequently observed in the H-risk group (26.8%), followed by the I-risk group (5.6%), and least in the L-risk group (1.9%) (p<0.001). CONCLUSIONS: The lengths of hospital stay and CCU stay were significantly shortest in the L-risk group, followed by the I-risk group, and longest in the H-risk group. MACE were most frequently observed in the H-risk group, followed by the I-risk group, and least in the L-risk group. These results support the validity of our new classification system.

The comparison of clinical outcomes in patients with acute myocardial infarction and advanced chronic kidney disease on chronic hemodialysis versus off hemodialysis.

Acute myocardial infarction (AMI) is more frequently observed in patients with chronic kidney disease (CKD) than in patients without CKD. Initial treatment strategy for AMI includes primary percutaneous coronary intervention (PCI), which requires substantial amount of contrast media. We hypothesized that the clinical outcomes are comparable or worse in patients with AMI and advanced CKD off chronic hemodialysis as compared to patients with AMI and advanced CKD on chronic hemodialysis. The purpose of this study was to compare the clinical outcomes of patients with AMI and advanced CKD on hemodialysis versus off hemodialysis. A total of 148 patients with estimated glomerular filtration rate < 30 ml/min/1.73 m2 on admission were included and were divided into the HD group (n = 68) and non-HD group (n = 80). The length of hospitalization was significantly less in the HD group (15.7 ± 14.8 days) than in the non-HD group (22.4 ± 21.3 days) (P = 0.01). In-hospital death was significantly less in the HD group (10.3%) than in the non-HD group (25.0%) (P = 0.02). While the non-HD group was not significantly associated with in-hospital death after controlling clinical covariates, the non-HD group (odd ratio 2.89, 95% confidence interval 1.03-8.12, P = 0.04) was significantly associated with long hospitalization even after controlling clinical covariates. In conclusion, as compared to advanced CKD on chronic hemodialysis, advanced CKD off hemodialysis had higher morbidity and mortality in patients with AMI. Advanced CKD off hemodialysis was closely associated with long hospitalization even after controlling clinical factors.

In-hospital outcomes of acute myocardial infarction with cardiogenic shock caused by right coronary artery occlusion vs. left coronary artery occlusion.

In-hospital outcomes of acute myocardial infarction (AMI) with cardiogenic shock (CS) were still not satisfactory even in the primary percutaneous coronary intervention (PCI) era. The aim of this study was to compare in-hospital outcomes of AMI with CS caused by right coronary artery (RCA) occlusion vs. left coronary artery (LCA) occlusion. Consecutive 894 AMI patients from January 2010 to March 2015 were screened for inclusion. A total of 114 AMI patients with CS were included as the final study population, and were divided into the RCA group (n = 56) and LCA group (n = 58). The patient characteristics were compared between the two groups. Multivariate logistic regression analysis was performed to show whether the RCA group was associated with better outcomes even after controlling confounding factors. In-hospital mortality was significantly lower in the RCA group (8.9%) than in the LCA group (46.6%) (P < 0.001). The RCA group (vs. the LCA group) was inversely associated with in-hospital death (OR 0.08, 95% CI 0.02-0.21, P < 0.001) after controlling covariates. Aspartate transaminase value (per 50 U/L incremental: OR 1.22, 95% CI 1.03-1.45, P = 0.02), aging (per 10-year-old incremental: OR 2.14, 95% CI 1.26-3.63, P = 0.01) and using VA-ECMO (OR 22.13, 95% CI 5.22-93.90, P < 0.001) were also significantly associated with in-hospital death. In conclusion, among AMI patients with CS, IRA of RCA was significantly associated with the better in-hospital outcome.

Clinical outcomes of left main crossover stenting for ostial left anterior descending artery acute myocardial infarction.

Percutaneous coronary interventions to ostial left anterior descending artery (LAD)-acute myocardial infarction (AMI) were challenging, especially in crossover stenting from left main trunk (LMT) to LAD. The clinical outcomes of ostial LAD-AMI that needed crossover stenting were not well investigated. The objective of this study was to compare the clinical outcomes of LMT crossover stenting with those of ostial LAD just proximal (jp) stenting. Between January 2009 and March 2016, 1499 patients were diagnosed as AMI in our institution. Among them, 76 ostial LAD-AMIs were included in this study, and divided into 30 LMT crossover stenting (the crossover group) and 46 jp stenting (the jp stenting group). The primary endpoint was major cardiovascular events (MACE) defined as the composite of cardiac death, acute myocardial infarction (AMI), stent thrombosis (ST), target lesion revascularization (TLR) and target vessel revascularization (TVR). The frequency of MACE was comparable between the 2 groups (16.7% in the crossover group and 21.7% in the jp stenting group, P = 0.587). Similarly, the frequency of cardiac death was comparable between the 2 groups (6.7% in the crossover group and 13.0% in the jp stenting group, P = 0.376). The frequencies of TLR (6.7% in the crossover group and 6.5% in the jp stenting group, P = 0.980) and TVR (10.0% in the crossover group and 8.7% in the jp stenting group, P = 0.848) were not significantly different between the 2 groups. In conclusion, the clinical outcomes of the crossover stenting were comparable to the jp stenting in the stenting strategy for ostial LAD-AMI. LMT-LAD crossover stenting would be the acceptable strategy for ostial LAD-AMI.

Determinants of In-Hospital Death in Acute Myocardial Infarction With Triple Vessel Disease.

Compared to acute myocardial infarction (AMI) with single vessel disease (SVD) or double vessel disease (DVD), AMI with triple vessel disease (TVD) is associated with higher mortality. The aim of this study was to identify the determinants of in-hospital death in AMI with TVD. We identified AMI patients with TVD in our tertiary medical center between January 2009 and December 2014. Baseline patient characteristics including laboratory data, echocardiograms, and coronary angiograms were collected from our hospital records. We divided our study population into a survivor group and non-survivor group. Multivariate stepwise logistic regression analysis was performed to identify the determinants of in-hospital death. A total of 138 AMI patients with TVD were identified and included as the final study population. Fifteen patients died during the hospitalization (mortality rate, 10.9%). Mean systolic blood pressure (134 ± 27 mmHg) was significantly greater in the survivor group compared with the non-survivor group (114 ± 31 mmHg) (P = 0.02). The prevalence of shock on admission was significantly less in the survivor group (15.4%) than in the non-survivor group (66.7%) (P < 0.001). Multivariate stepwise logistic regression analysis revealed that shock status on admission (OR 11.50, 95% CI 3.21-41.14, P < 0.001), the left anterior descending artery (LAD) as the infarct related artery (IRA) (OR 3.83, 95% CI 1.04-14.09, P = 0.04), and serum albumin on admission (OR 0.26, 95% CI 0.08-0.84, P = 0.02) were significantly associated with in-hospital death. In conclusion, shock status on admission, the LAD as the IRA, and a low serum albumin level were the determinants of in-hospital death in AMI patients with TVD.

Coronary thrombus aspiration revealed tumorous embolism of myxofibrosarcoma from the left atrium.

Thrombus aspiration is currently the standard strategy for primary PCI. Thrombus can be aspirated via aspiration catheters, restoring coronary blood flow. However, there are a limited number of reports regarding thrombus aspiration toward tumor embolized occlusion. We present a case of 90-year-old male with AMI caused by the metastatic tumor embolism. Emergent coronary angiography revealed total occlusion in three epicardial vessels. Histopathological examination of the aspirated specimen revealed the mixture of thrombus and metastatic tumor cells. Thrombus aspiration was partially effective for restoring coronary blood flow; however, it was very helpful for the final diagnosis of tumor embolism.