Intracoronary electrocardiogram detects coronary microvascular dysfunction and ischemia in patients with no obstructive coronary arteries disease.

BACKGROUND: Coronary microvascular dysfunction (CMD) is the leading cause of ischemia with no obstructive coronary arteries disease (INOCA) disease. Diagnosis of CMD relies on surrogate physiological indices without objective proof of ischemia. OBJECTIVES: Intracoronary electrocardiogram (icECG) derived hyperemic indices may accurately and objectively detect CMD and reversible ischemia in related territory. METHODS: INOCA patients with proven ischemia by myocardial perfusion scan (MPS) and completely normal coronary arteries underwent simultaneous intracoronary electrophysiological (icECG) and physiological (intracoronary Doppler) assessment in all 3 coronary arteries during rest and under adenosine induced hyperemia. RESULTS: Sixty vessels in 21 patients were included in the final analysis. All patients had at least one vessel with abnormal CFR. 41 vessels had CMD (CFR < 2.5), of which 26 had increased microvascular resistance (structural CMD, HMR > 1.9 mmHg.cm-1.s) and 15 vessels had CMD (CFR < 2.5) with normal microvascular resistance (functional CMD, HMR <= 1.9 mmHg.cm-1.s). Only one-third of the patients (n = 7) had impaired CFR < 2.5 in all 3 epicardial arteries. Absolute ST shift between hyperemia and rest (∆ST) has shown the best diagnostic performance for ischemia (cut-off 0.10 mV, sensitivity: 95%, specificity: 72%, accuracy: 80%, AUC: 0.860) outperforming physiological indices (CFR: 0.623 and HMR: 0.653 DeLong's test P = .0002). CONCLUSIONS: In INOCA patients, CMD involves coronary artery territories heterogeneously. icECG can accurately detect CMD causing perfusion abnormalities in patients with INOCA outperforming physiological CMD markers, by demonstrating actual ischemia instead of predicting the likelihood of inducible ischemia based on violated surrogate thresholds of blunted flow reserve or increased minimum microvascular resistance. CONDENSED ABSTRACT: In 21 INOCA patients with coronary microvascular dysfunction (CMD) and myocardial perfusion scan proved ischemia, hyperemic indices of intracoronary electrocardiogram (icECG) have accurately detected vessel-specific CMD and resulting perfusion abnormalities & ischemia, outperforming invasive hemodynamic indices. Absolute ST shift between hyperemia and rest (∆ST) has shown the best classification performance for ischemia in no Obstructive Coronary Arteries (AUC: 0.860) outperforming Doppler derived CMD indices (CFR: 0.623 and HMR: 0.653 DeLong's test P = .0002).icECG can be used to diagnose CMD causing perfusion defects by demonstrating actual reversible ischemia at vessel-level during the initial CAG session, obviating the need for further costly ischemia tests. CLINICALTRIALS: GOV: NCT05471739.

Intracardiac masses: Single center experience within 12 years: I-MASS Study.

Objective: The aim of this cross-sectional, retrospective, descriptive study was to review and classify cardiac masses systematically and to determine their frequencies. Methods: The medical records of 64,862 consecutive patients were investigated within 12 years. Every patient with a cardiac mass imaged by transthoracic echocardiography (TTE) and confirmed with an advanced imaging modality such as transesophageal echocardiography (TEE), computed tomography (CT) and/or cardiac magnetic resonance imaging (CMR) was included. Acute coronary syndromes triggering thrombus formation, vegetations, intracardiac device and catheter related thrombi were excluded. Results: Data demonstrated 127 (0.195%) intracardiac masses consisting of 33 (0.050%) primary benign, 3 (0.004%) primary malignant, 20 (0.030%) secondary tumors, 3 (0.004%) hydatid cysts and 68 (0.104%) thrombi respectively. The majority of primary cardiac tumors were benign (91.67%), predominantly myxomas (78.79%), and the less malignant (8.33%). Secondary cardiac tumors were common than the primary malignant tumors (20:3), with male dominancy (55%), lymphoma and lung cancers were the most frequent. Intracardiac thrombi was the majority of the cardiac masses, thrombi accompanying malignancies were in the first range (n = 17, 25%), followed by autoimmune diseases (n = 13, 19.12%) and ischemic heart disease with low ejection fraction (n = 12, 17.65%). Conclusions: This retrospective analysis identified 127 patients with cardiac masses. The majority of benign tumors were myxoma, the most common tumors that metastasized to the heart were lymphoma and lung cancers, and the thrombi associated with malignancies and autoimmune diseases were the most frequent.

Echocardiographic diagnosis of a giant thrombus passing through a patent foramen ovale from right atrium to the left atrium.

Pulmonary embolus sourced by right atrial thrombus trapped in a patent foramen ovale is an unusual, rare condition. Thus in suspicion of massive pulmonary thromboembolus, echocardiographic examination carries great importance evaluate right ventricular functions and diagnose right sided intracardiac thrombus. We report a 76-year-old female with massive pulmonary embolism caused by a gigantic thrombus trapped in a patent foramen ovale. The echocardiography was the diagnostic procedure to display the source of the thromboembolism and urgent cardiac surgery was successful and life-saving treatment in this case.

Acute anterior myocardial infarction after chemotherapy for testicular seminoma in a young patient.

Testicular cancer is the most common solid tumor among young men aged 15 to 35 years. Combination chemotherapy with cisplatin, etoposide, and bleomycin remains the mainstay of treatment. We present a 27-year-old man who presented with an acute anterior myocardial infarction during the second course of chemotherapy for seminoma. Because the patient had no significant risk factors for coronary heart disease, the infarction was likely caused by the chemotherapy regimen.

Association of haematological indices with the degree of microvascular injury in patients with acute anterior wall myocardial infarction treated with primary percutaneous coronary intervention.

BACKGROUND: In acute myocardial infarction (AMI), increased neutrophil count has been associated with more severe coronary artery disease and larger infarct size. Increased mean platelet volume (MPV) is also associated with poor clinical outcome and impaired angiographic reperfusion in patients with AMI. However, the associations of neutrophil count and MPV with the indices of tissue level reperfusion were not fully elucidated. AIM: To elucidate the relationship between baseline neutrophil count and MPV on presentation and microvascular injury in patients with anterior AMI treated with primary percutaneous coronary intervention (pPCI). METHODS: 41 patients with anterior wall AMI treated successfully with pPCI were included. The leucocyte count, neutrophil count and MPV were obtained on admission, and the percentage of neutrophils was calculated. After PCI thrombolysis in myocardial infarction, grade 3 flow was established in all patients. The coronary flow velocity pattern (diastolic deceleration time (DDT)) was examined with transthoracic echocardiography and measured intracoronary pressures with fibreoptic pressure-temperature sensor-tipped guidewire in the left anterior descending artery within 48 h after pPCI. Thermodilution-derived coronary flow reserve (CFR) was calculated. Index of microvascular resistance (IMR) was defined as simultaneously measured distal coronary pressure divided by the inverse of the thermodilution-derived hyperaemic mean transit time. Subsequently, a short compliant balloon was placed in the stented segment and inflated to measure coronary wedge pressure (CWP). RESULTS: Higher neutrophil counts were strongly associated with higher IMR (r = 0.86, p<0.001), lower CFR (r = -0.60, p<0.001), shorter DDT (r = -0.73, p<0.001) and higher CWP (r = 0.73, p<0.001). Likewise, there were significant correlations among the percentage of neutrophils and CFR (r = -0.34, p = 0.02), IMR (r = 0.46, p = 0.002), DDT (r = -0.36, p = 0.01) and CWP (r = 0.49, p = 0.001). Relationships among leucocyte count and IMR (r = 0.38, p = 0.01), CFR (r = -0.33, p = 0.03), DDT (r = -0.36, p = 0.01) and CWP (r = 0.32, p = 0.026) were slightly significant. Higher neutrophil count remained independently associated with indices of microvascular perfusion in multivariable models controlling for age, smoking habits and time to treatment. Also, higher MPV on admission was strongly associated with higher IMR (r = 0.89, p<0.001), steeper DDT (r = -0.64, p<0.001), lower CFR (r = -0.43, p = 0.004) and higher CWP (r = 0.77, p<0.001). CONCLUSION: Absolute and relative neutrophilia and higher MPV on admission were independently associated with impaired microvascular perfusion in patients with anterior AMI treated with pPCI. It is possible that neutrophilia and high MPV are simple surrogate markers of worse microvascular injury in patients with AMI.

A potential evidence to explain the reason behind the devastating prognosis of coronary artery disease in uraemic patients: renal insufficiency is associated with poor coronary collateral vessel development.

The potential of individuals to develop coronary collateral circulation is often neglected but is of potential major importance in myocardial vulnerability. Likewise, the effect of chronic kidney disease (CKD) on collateral vessel development is not known. The purpose of this study was to evaluate the effect of CKD on collateral development in patients with advanced coronary artery disease. A total of 171 uraemic patients (serum creatinine > or = 1.5 mg/dl, creatinine clearance < 80 mL)/min) who underwent coronary angiography were evaluated in this study. A total of 134 patients met the criteria for the uraemic group and 134 consecutive non-uraemic patients who constituted the control group. The collateral score (CS) was graded according to the Rentrop classification and the collateral score was calculated by summing the Rentrop numbers of every patient. Collateral vessels have also been categorized according to their anatomic locations and collateral connection grades (CC). CC2 collaterals were observed less frequently in the uraemic patients than in the control subjects (11% versus 26%, p=0.03) and CC0 more frequently (31% versus 22%, p<0.05). Epicardial pathway was detected more frequently in the control subjects than in the uraemic patients (31% versus 12%, p=0.03) and septal pathway less frequently (37% versus 54%). There was a significant negative correlation between CS and creatinine (r=-0.68, p<0.01). The mean CS in the uraemic group was significantly lower than the non-uraemic group (1.29+/-0.88 versus 2.18+/-1.3, p<0.001). These results altogether showed that besides the quantity, quality (functional, haemodynamic and anatomic features) of the uraemic collaterals and a network that they constitute is also impaired and different from the collaterals of the patient with normal renal function.

Multiple coronary thrombosis and stent implantation to the subtotally occluded right renal artery in a patient with essential thrombocytosis: a case report with review.

Essential thrombocytosis is a myeloproliferative disorder of unknown etiology manifested clinically by the overproduction of platelets in the absence of a definable cause. Platelet dysfunction in essential thrombocytosis results in both hemorrhage and thrombosis. It is one of the rare causes of ischemic cardiovascular events. Fewer than 20 cases of essential thrombocytosis with involvement of coronary arteries leading to acute coronary syndromes or myocardial infarction have been reported. We report a case of multiple coronary thrombosis involving the left anterior descending artery and circumflex artery and stent implantation to the subtotally stenotic right renal artery in a women with unstable angina pectoris, essential thrombocytosis and previous history of renal artery trombosis.

[Reduced coronary collateral vessel recruitment capacity in diabetes mellitus: an evidence for defective ischaemic tolerance]. / Diyabetes mellitus'ta azalmis koroner kollateral damar açilma kapasitesi: defektif iskemik tolerans için bir kanit.

OBJECTIVE: Collateral channel opening is one of the components of the ischemic tolerance developing during subsequent coronary balloon occlusions. The effect of diabetes mellitus (DM) on coronary collateral recruitment (CR) is still not known. We therefore sought the effect of DM on CR in patients with stable angina pectoris (SAP) by using intracoronary pressure measurement technique. METHODS: Study material consisted of 44 patients (21 diabetic) with SAP. All of the patients had single vessel disease with more than 70% vessel narrowing and all of them underwent stent implantation to this vessel. After angiography, fiber-optic pressure monitoring guidewire was advanced distal to the stenosis to be dilated. Myocardial fractional flow reserve (FFRmyo) was determined under adenosine hyperemia by the ratio of simultaneously measured mean distal pressure to mean aortic pressure. During subsequent two 1 minute balloon occlusions, distal pressures were recorded as coronary wedge pressure (CWP). Collateral flow index was determined by the ratio of simultaneously measured CWP to mean aortic pressure. Percentage of the improvement in the coronary flow index (CFI) (first to second occlusion) between two occlusions was determined for each patient. RESULTS: There was no difference between two groups in terms of pre-intervention FFRmyo (0.54 +/- 0.12 in DM group and 0.50 +/- 0.11 in non-DM group). The baseline CFI was significantly higher in non-DM group (0.26 +/- 0.09 versus 0.17 +/- 0.08, p<0.03). Beyond this finding, mean CFI increased by 17% (from 0.17 +/- 0.08 to 0.20 +/- 0.09) in DM group and by 30% (from 0.26 +/- 0.09 to 0.34 +/- 0.10) in non- DM group. There was statistically significant difference between these two groups in terms of improvement in CFI during subsequent balloon occlusions (p<0.01). CONCLUSION: In addition to poor collateral vessels seen in patients with DM, CR is also impaired. This finding suggests that DM abolishes ischemic tolerance in terms of CR as well.

The relationship between corrected TIMI frame count and myocardial fractional flow reserve.

UNLABELLED: Thrombolysis in myocardial infarction (TIMI) frame count (TFC) is a reproducible, objective and quantitative index of coronary flow that allows standardization of TIMI flow grades. After myocardial infarction (MI), hyperemic and basal flows decrease in the infarct region due to residual stenosis and increased resistance in the microvasculature subtended by this infarct-related artery (IRA). Myocardial fractional flow reserve (FFRmyo) is a lesion-specific index for epicardial stenosis. FFRmyo can also be used as a criterion for assessing the success of revascularization therapy. The aim of this study was to investigate the relationship between improvement of the corrected TFC (CTFC) and change in FFRmyo, which were determined in the IRA in patients with recent MI who underwent mechanical revascularization. METHODS: Forty-one patients (28 male; age, 58.3 +/- 12.3 years) early after MI with > 60% narrowing in the IRA who underwent stent implantation for this residual stenosis were included in this study. After angiography, a fiber-optic pressure monitoring guidewire was positioned distal to the stenosis to be dilated. Means of aortic (Pa) and distal (Pd) pressures were recorded simultaneously under baseline and hyperemic conditions. FFRmyo (Pd/Pa) was determined under adenosine hyperemia before and after stent implantation, as was TFC. Percentage of the improvement in the CTFC and FFRmyo was calculated for each lesion. The first frame used for TFC was defined by a column of contrast extending across > 70% of the arterial lumen and last frame counted was that in which contrast first appeared in the distal, pre-defined landmark branches for each vessel. CTFC was calculated for the LAD by dividing TFC of the LAD by a factor of 1.7. RESULTS: Eighteen patients had LAD, 10 had CX and 13 had RCA lesions. After stent implantation, the CTFC improved by 41% (from 32.3 +/- 3.4 to 19.2 +/- 2.1; p < 0.0001) and FFRmyo improved by 69% (from 0.53 +/- 0.11 to 0.90 +/- 0.15; p < 0.0001). There was a statistically significant correlation between the change in FFRmyo and improvement in the TFC (r = 0.85). CONCLUSION: Improvement in CTFC is associated with change in FFRmyo in the IRA undergoing mechanical revascularization. After mechanical revascularization, CTFC decreases proportionally to improvement of the FFRmyo. These two parameters support each other in terms of successful revascularization and this relationship shows the recruitability of CTFC in terms of FFRmyo as well.