Embolization of Patent Foramen Ovale Closure Device-Rare Complication and Unique Management Approach.

Percutaneous closure of the patent foramen ovale (PFO) is generally regarded as a safe and effective procedure, indicated in patients with a prior PFO-associated stroke. While it is highly safe, rarely, it could be accompanied by a migration of the device, mainly caused by the interplay of a specific PFO morphology and inappropriate device sizing. Herein, we outline a seldom-observed complication of an unintentional detachment of the PFO closure device during implantation, leading to its migration into the abdominal aorta, and a unique management approach. Due to the inability to recapture the occluder with a snare, which is considered to be a mainstay of endovascular retrieval methods, two coronary guidewires were maneuvered through the mesh of the occluder and then captured with a snare proximally to the occluder. This innovative dual-wire-snare system was carefully pulled to the common femoral artery, a position deemed suitable for surgical extraction via arteriotomy, which was achieved successfully.

Correction to: Pilot study of the multicentre DISCHARGE trial: image quality and protocol adherence results of computed tomography and invasive coronary angiography.

The original version of this article, published on 16 December 2019, unfortunately contained two mistakes.

Pilot study of the multicentre DISCHARGE Trial: image quality and protocol adherence results of computed tomography and invasive coronary angiography.

OBJECTIVE: To implement detailed EU cardiac computed tomography angiography (CCTA) quality criteria in the multicentre DISCHARGE trial (FP72007-2013, EC-GA 603266), we reviewed image quality and adherence to CCTA protocol and to the recommendations of invasive coronary angiography (ICA) in a pilot study. MATERIALS AND METHODS: From every clinical centre, imaging datasets of three patients per arm were assessed for adherence to the inclusion/exclusion criteria of the pilot study, predefined standards for the CCTA protocol and ICA recommendations, image quality and non-diagnostic (NDX) rate. These parameters were compared via multinomial regression and ANOVA. If a site did not reach the minimum quality level, additional datasets had to be sent before entering into the final accepted database (FADB). RESULTS: We analysed 226 cases (150 CCTA/76 ICA). The inclusion/exclusion criteria were not met by 6 of the 226 (2.7%) datasets. The predefined standard was not met by 13 of 76 ICA datasets (17.1%). This percentage decreased between the initial CCTA database and the FADB (multinomial regression, 53 of 70 vs 17 of 75 [76%] vs [23%]). The signal-to-noise ratio and contrast-to-noise ratio of the FADB did not improve significantly (ANOVA, p = 0.20; p = 0.09). The CTA NDX rate was reduced, but not significantly (initial CCTA database 15 of 70 [21.4%]) and FADB 9 of 75 [12%]; p = 0.13). CONCLUSION: We were able to increase conformity to the inclusion/exclusion criteria and CCTA protocol, improve image quality and decrease the CCTA NDX rate by implementing EU CCTA quality criteria and ICA recommendations. KEY POINTS: • Failure to meet protocol adherence in cardiac CTA was high in the pilot study (77.6%). • Image quality varies between sites and can be improved by feedback given by the core lab. • Conformance with new EU cardiac CT quality criteria might render cardiac CTA findings more consistent and comparable.

The Role of QRS Complex and ST-Segment in Major Adverse Cardiovascular Events Prediction in Patients with ST Elevated Myocardial Infarction: A 6-Year Follow-Up Study.

BACKGROUND: as a relatively high number of ST-segment elevation myocardial infarction (STEMI) patients develop major adverse cardiovascular events (MACE) following percutaneous coronary intervention (PCI), our aim was to determine the significance, and possible predictive value of QRS complex width and ST-segment elevation. METHODS: our patient sample included 200 PCI-treated STEMI patients, which were divided into two groups based on the following duration of symptoms: (I) less than 6 h, and (II) 6 to 12 h. For every patient, an ECG was performed at six different time points, patients were followed for up to six years for the occurrence of MACE. RESULTS: the mean age was 60.6 ± 11.39 years, and 142 (71%) were male. The 6-12 h group had significantly wider QRS complex, higher ST-segment elevation, lower prevalence of ST-segment resolution as well as MACE prevalence (p < 0.05). ECG parameters, QRS width, and magnitude of ST-segment elevation were proved to be independent significant predictors of MACE in all measured time points (p < 0.05). Even after controlling for biomarkers of myocardial injury, these ECG parameters remained statistically significant predictors of MACE (p < 0.05). CONCLUSION: our study highlights that wider QRS complex and a more pronounced ST-segment elevation are associated with longer total ischemic time and higher risk of long-term MACE.

Impact of COVID-19 on cardiac surgery outcomes.

AIM: This study aimed to assess the impact of COVID-19 infection on cardiac surgery outcomes in patients who contracted COVID-19 peri-operatively or had recently recovered from COVID-19. METHODS: The study prospectively enrolled 95 patients scheduled for cardiac surgery who had recently recovered from COVID-19. This formed the post-COVID-19 group. The other group consisted of 25 patients who contracted COVID-19 peri-operatively. Patients were followed for all-cause mortality as the primary endpoint and postoperative course complications as the secondary endpoint. Data were compared to a historical cohort of 280 non-COVID-19 patients. RESULTS: The peri-operative COVID-19 group exhibited a significantly higher prevalence of primary outcome all-cause mortality (28%), compared with 4.3% in the controls (p < 0.01), as well as the secondary composite endpoint (stroke, peri-operative myocardial infarction and pneumonia) (52 vs 13.9%, p < 0.01). The post-COVID-19 group had a higher incidence of acute pulmonary embolism (3.2 vs 0%, p < 0.01) and atrial fibrillation (23.4 vs 11.4%, p < 0.01). CONCLUSION: Patients who contracted COVID-19 peri-operatively had an increased rate of mortality and postoperative complications, while cardiac surgery in the recently recovered COVID-19 group was associated with a higher incidence of pulmonary embolism and atrial fibrillation.

Management and outcomes of spontaneous coronary artery dissection: a systematic review of the literature.

Background: Contemporary management of spontaneous coronary artery dissection (SCAD) is still controversial. This systematic review of the literature aims to explore outcomes in the patients treated with conservative management vs. invasive strategy. Methods: The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed when we extensively searched three electronic databases: PubMed, ScienceDirect, and Web of Science, for studies that compared conservative vs. invasive revascularization treatment outcomes for patients with SCAD from 2003 to 2023. The outcomes of interest were all-cause death and major adverse cardiovascular events (MACE), including acute coronary syndrome (ACS), heart failure (HF), need for additional revascularization, target vessel revascularization (TVR), SCAD recurrence, and stroke. Results: The systematic review included 13 observational studies evaluating 1,801 patients with SCAD. The overall mean age was 49.12 +/- 3.41, and 88% were females. The overall prevalence of arterial hypertension was 33.2%, hyperlipidemia, 26.9%, smoking, 17.8%, and diabetes, 3.9%. Approximately 48.5% of the patients were diagnosed with non-ST elevated myocardial infarction (NSTEMI), 36.8% with ST elevated myocardial infarction (STEMI), 3.41% with unstable angina, 0.56% with stable angina, and 0.11% were diagnosed with various types of arrhythmias. The left anterior descending artery (LAD) was the most common culprit lesion in 51% of the patients. There were initially 65.2% of conservatively treated patients vs. 33.4% that underwent percutaneous coronary intervention (PCI) or 1.28% that underwent coronary artery bypass graft (CABG). SCAD-PCI revascularization was associated with a variable range of PCI failure. The most common complications were hematoma extension and iatrogenic dissection. SCAD-PCI revascularization frequently required three or more stents and had residual areas of dissection. The overall reported in-hospital and follow-up mortality rates were 1.2% and 1.3%, respectively. The follow-up range across studies was 7.3-75.6 months. The authors reported variable prevalence of MACE, recurrent SCAD up to 31%, ACS up to 27.4%, TVR up to 30%, repeat revascularization up to 14.7%, UA up to 13.3%, HF up to 17.4%, and stroke up to 3%. Conclusion: Our results highlight that conservative treatment should be the preferred method of treatment in patients with SCAD. PCI revascularization is associated with a high prevalence of periprocedural complications. SCAD poses a considerable risk of MACE, mainly associated with TVR, ACS, and recurrent SCAD.

Prediction parameters of left ventricular diastolic dysfunction improvement in patients after acute coronary syndrome.

OBJECTIVES: The aim of this study was to examine the effects of comprehensive cardiac rehabilitation (CCR) in patients after acute coronary syndrome (ACS) resolved by percutaneous coronary intervention (PCI) on left ventricular diastolic dysfunction (LVDD) and to extract the parameters that have the greatest influence on LVDD improvement. METHODS: The study included 85 subjects who were divided into intervention (N = 56) and control (N = 29) groups depending on CCR attendance. Initially and after 12 weeks, patients of both groups were subjected to echocardiography to assess LVDD, as well as CPET to assess improvement in functional capacity. RESULTS: The study showed that 23 patients (27.1%) of both groups demonstrated the improvement of LVDD degree. The improvement of the LVDD degree in the intervention group was significant, whereas in the control group, it did not change (a one-degree improvement in 22 (39.3%) patients of the intervention group (p < 0.001) and only 1 (3.4%) (p > 0.05) in the control group). Multivariate binary logistic regression showed that key parameters in LVDD improvement were participation in the CCR, E/A ratio and haemoglobin value. We created a model, for prediction of LVDF improvement, with a cut-off value of 33 (area = 0.9, p < 0.0005), a sensitivity of 87.0% and a specificity of 85.5%. CONCLUSIONS: CCR can be used as an effective non-pharmacological measure to improve LVDD and functional capacity in patients after ACS. The statistical model may have practical application in prediction of clinical benefit in such a group of patients.

Takotsubo Cardiomyopathy Occurring Simultaneously with Acute Myocardial Infarction.

INTRODUCTION: Takotsubo cardiomyopathy (TCM) is a reversible form of cardiomyopathy characterized by transient regional systolic dysfunction of the left ventricle. CASE OUTLINE: A 78-year-old woman was admitted to the general hospital due to acute inferior STEMI late presentation. Two days after admission, the patient reported intense chest pain and an ECG registered diffuse ST-segment elevation in all leads with ST-segment denivelation in aVR. The patient also showed clinical signs of cardiogenic shock and was referred to a reference institution for further evaluation. Echocardiography revealed akinesia of all medioapical segments, dynamic obstruction of the left ventricular outflow tract (LVOT), moderate mitral regurgitation, and pericardial effusion. Coronary angiography showed the suboccluded right coronary artery, and a primary percutaneous coronary intervention was performed, which involved implanting a drug-eluting stent. The patient's condition worsened as pericardial effusion increased and led to tamponade. Pericardiocentesis was performed, resulting in the patient's stabilization. At this point, significant gradients at the LVOT and pericardial effusion were not registered. After eight days without symptoms and stable status, the patient was discharged. CONCLUSIONS: The simultaneous presence of AMI and TCM increases the risk of developing cardiogenic shock. The cardio-circulatory profile of these patients is different from those with AMI.

Invasive imaging modalities in a spontaneous coronary artery dissection: when "believing is seeing".

Spontaneous coronary artery dissection (SCAD) is a rare but increasingly recognized cause of acute coronary syndrome (ACS) with recent advancements in cardiac imaging facilitating its identification. However, SCAD is still often misdiagnosed due to the absence of angiographic hallmarks in a significant number of cases, highlighting the importance of meticulous interpretation of angiographic findings and, when necessary, additional usage of intravascular imaging to verify changes in arterial wall integrity and identify specific pathoanatomical features associated with SCAD. Accurate diagnosis of SCAD is crucial, as the optimal management strategies for patients with SCAD differ from those with atherosclerotic coronary disease. Current treatment strategies favor a conservative approach, wherein intervention is reserved for cases with persistent ischemia, patients with high-risk coronary anatomy, or patients with hemodynamic instability. In this paper, we provide a preview of invasive imaging modalities and classical angiographic and intravascular imaging hallmarks that may facilitate proper SCAD diagnosis.

An analysis of published cases of cutting balloon use in spontaneous coronary artery dissection.

Introduction: SCAD involves a sudden tear or separation within the layers of the coronary artery wall, resulting in blood flow obstruction and subsequent myocardial ischemia. Materials and methods: A comprehensive literature search was conducted to identify relevant published cases of cutting balloon use in patients diagnosed with spontaneous coronary artery dissection. Electronic databases including PubMed, MEDLINE, Embase, Cochrane Library and Google Scholar were systematically searched from inception until the present using terms "cutting balloon," "SCAD," "acute coronary syndrome," "intramural hematoma," and "angioplasty." Results: A total of 32 published cases of cutting balloon use in spontaneous coronary artery dissection were analyzed in this study. The majority of the patients included in the analysis were female without prior history of cardiovascular disease. The median age of the SCAD population was approximately 46 years. The most frequently affected artery in SCAD cases was the Left Anterior Descending artery. Intravascular ultrasound was utilized more frequently than other modalities of adjunctive imaging techniques. The most frequent complication was the distal propagation of hematoma. Despite the successful dilation achieved with the cutting balloon, in some cases stenting was required to provide additional support. Conclusion: The results of this analysis demonstrate that cutting balloon use in SCAD cases yields favorable outcomes.

Characteristics and Outcomes of Patients with Acute Coronary Syndrome and COVID-19.

Acute coronary syndrome (ACS) in patients with COVID-19 is triggered by various mechanisms and can significantly affect the patient's further treatment and prognosis. The study aimed to investigate the characteristics, major complications, and predictors of mortality in COVID-19 patients with ACS. All consecutive patients hospitalized from 5 July 2020 to 5 May 2021 for ACS with confirmed SARS-Co-2 were prospectively enrolled and tracked for mortality until 5 June 2021. Data from the electronic records for age and diagnosis, matched non-COVID-19 and COVID-19 ACS group, were extracted and compared. Overall, 83 COVID-19 ACS patients, when compared to 166 non-COVID ACS patients, had significantly more prevalent comorbidities, unfavorable clinical characteristics on admission (acute heart failure 21.7% vs. 6.6%, p < 0.01) and higher rates of major complications, 33.7% vs. 16.8%, p < 0.01, and intrahospital 30-day mortality, 6.7% vs. 26.5%, p < 0.01. The strongest predictors of mortality were aortic regurgitation, HR 9.98, 95% CI 1.88; 52.98, p < 0.01, serum creatinine levels, HR 1.03, 95% CI 1.01; 1.04, p < 0.01, and respiratory failure therapy, HR 13.05, 95% CI 3.62; 47.01, p < 0.01. Concomitant ACS and COVID-19 is linked to underlying comorbidities, adverse presenting features, and poor outcomes. Urgent strategies are needed to improve the outcomes of these patients.

Comparative effectiveness of initial computed tomography and invasive coronary angiography in women and men with stable chest pain and suspected coronary artery disease: multicentre randomised trial.

OBJECTIVE: To assess the comparative effectiveness of computed tomography and invasive coronary angiography in women and men with stable chest pain suspected to be caused by coronary artery disease. DESIGN: Prospective, multicentre, randomised pragmatic trial. SETTING: Hospitals at 26 sites in 16 European countries. PARTICIPANTS: 2002 (56.2%) women and 1559 (43.8%) men (total of 3561 patients) with suspected coronary artery disease referred for invasive coronary angiography on the basis of stable chest pain and a pre-test probability of obstructive coronary artery disease of 10-60%. INTERVENTION: Both women and men were randomised 1:1 (with stratification by gender and centre) to a strategy of either computed tomography or invasive coronary angiography as the initial diagnostic test (1019 and 983 women, and 789 and 770 men, respectively), and an intention-to-treat analysis was performed. Randomised allocation could not be blinded, but outcomes were assessed by investigators blinded to randomisation group. MAIN OUTCOME MEASURES: The primary endpoint was major adverse cardiovascular events (MACE; cardiovascular death, non-fatal myocardial infarction, or non-fatal stroke). Key secondary endpoints were an expanded MACE composite (cardiovascular death, non-fatal myocardial infarction, non-fatal stroke, transient ischaemic attack, or major procedure related complication) and major procedure related complications. RESULTS: Follow-up at a median of 3.5 years was available in 98.9% (1979/2002) of women and in 99.0% (1544/1559) of men. No statistically significant gender interaction was found for MACE (P=0.29), the expanded MACE composite (P=0.45), or major procedure related complications (P=0.11). In both genders, the rate of MACE did not differ between the computed tomography and invasive coronary angiography groups. In men, the expanded MACE composite endpoint occurred less frequently in the computed tomography group than in the invasive coronary angiography group (22 (2.8%) v 41 (5.3%); hazard ratio 0.52, 95% confidence interval 0.31 to 0.87). In women, the risk of having a major procedure related complication was lower in the computed tomography group than in the invasive coronary angiography group (3 (0.3%) v 21 (2.1%); hazard ratio 0.14, 0.04 to 0.46). CONCLUSION: This study found no evidence for a difference between women and men in the benefit of using computed tomography rather than invasive coronary angiography as the initial diagnostic test for the management of stable chest pain in patients with an intermediate pre-test probability of coronary artery disease. An initial computed tomography scan was associated with fewer major procedure related complications in women and a lower frequency of the expanded MACE composite in men. TRIAL REGISTRATION: NCT02400229ClinicalTrials.gov NCT02400229.

COOL AMI EU pilot trial: a multicentre, prospective, randomised controlled trial to assess cooling as an adjunctive therapy to percutaneous intervention in patients with acute myocardial infarction.

AIMS: We aimed to investigate the rapid induction of therapeutic hypothermia using the ZOLL Proteus Intravascular Temperature Management System in patients with anterior ST-elevation myocardial infarction (STEMI) without cardiac arrest. METHODS AND RESULTS: A total of 50 patients were randomised; 22 patients (88%; 95% confidence interval [CI]: 69-97%) in the hypothermia group and 23 patients (92%; 95% CI: 74-99) in the control group completed cardiac magnetic resonance imaging at four to six days and 30-day follow-up. Intravascular temperature at coronary guidewire crossing after 20.5 minutes of endovascular cooling decreased to 33.6°C (range 31.9-35.5°C). There was a 17-minute (95% CI: 4.6-29.8 min) cooling-related delay to reperfusion. In "per protocol" analysis, median infarct size/left ventricular mass was 16.7% in the hypothermia group versus 23.8% in the control group (absolute reduction 7.1%, relative reduction 30%; p=0.31) and median left ventricular ejection fraction (LVEF) was 42% in the hypothermia group and 40% in the control group (absolute reduction 2.4%, relative reduction 6%; p=0.36). Except for self-terminating paroxysmal atrial fibrillation (32% versus 8%; p=0.074), there was no excess of adverse events in the hypothermia group. CONCLUSIONS: We rapidly and safely cooled patients with anterior STEMI to 33.6°C at the time of coronary guidewire crossing. This is ≥1.1°C lower than in previous cooling studies. Except for self-terminating atrial fibrillation, there was no excess of adverse events and no clinically important cooling-related delay to reperfusion. A statistically non-significant numerical 7.1% absolute and 30% relative reduction in infarct size warrants a pivotal trial powered for efficacy.

Clinical use of optical coherence tomography and fractional flow reserve.

INTRODUCTION: The aim of each diagnostic method is to serve as a guide in deciding about the right patient treatment. During myocardial revascularization the decision to perform revascularization is usually not easy to make, especially in case of borderline stenosis. It has been proven that it is not enough to base morphological evaluation of coronary artery vessel stenosis solely on angiography. It is necessary to include additional modern diagnostic methods for functional analysis and detailed morphological analysis using fractional flow reserve (FFR) and optical coherence tomography (OCT), respectively. CASE REPORTS: In the first case report we showed the significance of morphological analysis using OCT and proved that it was not lumen stenosis. The second and the third case reports showed the complementarity between functional analysis (FFR) and morphological analysis (OCT) of stenosis in solving a complex coronary disease. The fourth case report showed the significance of OCT in dealing with the recurrent stent restenosis. CONCLUSION: By these short case reports we confirmed that percutaneous coronary intervention (PCI) guided by angiography is definitely not enough in deciding about myocardial revascularization especially in patients with a complex coronary disease. In certain cases FFR and OCT procedures can be complementary methods and improve quality of revascularization, particularly in case of recurrent in-stent restenosis.

FIRST APPLICATION OF AUTOMATED EXTERNAL DEFIBRILATOR IN SERBIA - CASE REPORT.

INTRODUCTION: Sudden cardiac death is an unexpected natural death from cardiac causes. It is the most common and first manifestation of coronary artery disease. It accounts for 50% of mortality from cardiovascular disease in the United States of America and other developed countries, so measures that can reduce it are an important medical task. CASE REPORT: A 55-year old man suddenly lost consciousness at the train station in Novi Sad. An eyewitness provided first aid and ventricular fibrillation was converted to sinus rhythm by means of the automated external defibrillator. Emergency Medical Service Novi Sad soon arrived, continued resuscitation procedure, and transported the patient to the Cardiac Care Unit, who was then diagnosed with acutedmyocardial infarction and primary percutaneous coronary intervention was performed. Resuscitative hypothermia was applied in acute phase to prevent further brain injury. During further hospitalization the patient was stable, woke up from coma and early rehabilitation measures were implemented. After six months the patient had normal physical activities and there was no left ventricular segmental hypokinesia on echo cardiography. CONCLUSION: The application of all four chains of survival is important in increasing the survival rate of patients with sudden cardiac arrest.

DATA MINING APPROACH FOR IN-HOSPITAL TREATMENT OUTCOME IN PATIENTS WITH ACUTE CORONARY SYNDROME.

INTRODUCTION: Risk stratification is nowadays crucial when estimating the patient's prognosis in terms of treatment outcome and it also helps in clinical decision making. Several risk assessment models have been developed to predict short-term outcomes in patients with acute coronary syndrome. This study was aimed at developing an outcome prediction model for patients with acute coronary syndrome submitted to percutaneus coronary intervention using data mining approach. MATERIAL AND METHODS: A total of 2030 patients hospitalized for acute coronary syndrome and treated with percutaneous coronary intervention from December 2008 to December 2011 were assigned to a derivation cohort. Demographic and anamnestic data, clinical characteristics on admission, biochemical analysis of blood parameters on admission, and left ventricular ejection fraction formed the basis ofthe study. A number of machine learning algorithms available within Waikato Environment for Knowledge Discovery had been evaluated and the most successful was chosen. The predictive model was subsequently validated in a different population of 931 patients (validation cohort), hospitalized during 2012. RESULTS: The best prediction results were achieved using Alternating Decision Tree classifier, which was able to predict in-hospital mortality with 89% accuracy, and preserved good performance on validation cohort with 87% accuracy. Alternating Decision Tree classifier identified a subset of 6 attributes most relevant to mortality prediction: systolic and diastolic blood pressure, heart rate, left ventricular ejection fraction, age, and troponin value. CONCLUSION: Data mining approach enabled the authors to develop a model capable of predicting the in-hospital outcome following percutaneous coronary intervention. The model showed excellent sensitivity and specificity during internal validation.