Is Low Serum Klotho Level Associated with Alterations in Coronary Flow Reserve?

BACKGROUND: The Klotho gene, described as an "aging suppressor" gene, encodes a single-pass transmembrane protein. The extracellular part of Klotho is cleaved and released into the circulation where it may function as a vasculoprotective hormone. Coronary flow reserve (CFR) is accepted as a marker of coronary microvascular dysfunction when epicardial coronary stenosis is absent. There are no data regarding the relationship between serum Klotho levels and disorders in coronary microcirculation in healthy adults. We aimed to investigate the association between serum Klotho levels and alterations in coronary microcirculation in healthy adults using echocardiographic measurements of CFR. METHODS: Thirty-four healthy volunteers (median age: 34 [27-39], 14 males) were enrolled in this study. The study population was divided into two subgroups according to the median value of serum Klotho levels: a high Klotho (HK) group (n = 17, median age: 34 [30-38]; 6 males) and a low Klotho (LK) group (n = 17, median age: 32 [26-39]; 8 males). The analysis of coronary flow velocities was performed by transthoracic Doppler echocardiography. RESULTS: Hyperemic diastolic peak flow velocities and CFR were significantly higher in the HK group than in the LK group (70 [66-92] versus 61 [47-66], P = 0.003 and 3.0 [2.6-3.8] versus 2.2 [1.7-2.8], respectively, P = 0.001). Serum Klotho levels were positively correlated with CFR (P < 0.001). CONCLUSION: Serum Klotho levels correlate with CFR in a healthy population. Low serum Klotho levels may potentially identify patients with impaired CFR.

Low Serum Level of Klotho Is an Early Predictor of Atherosclerosis.

The Klotho gene, identified as an 'aging suppressor' gene, encodes a single-pass transmembrane protein. The extracellular domain of Klotho is cleaved and released in the blood stream, where it may function as a vasculoprotective hormone. Carotid artery intima-media thickness (CIMT), flow-mediated dilation (FMD) of the brachial artery and epicardial fat thickness (EFT) have been reported as early predictors of atherosclerosis. We aimed to investigate the relationship between serum Klotho levels and early atherosclerotic predictors, including EFT, FMD and CIMT in healthy adults. Fifty healthy volunteers were enrolled in this study, consisting of 21 males and 29 females with median age of 32 years. They were free of known risk factors for cardiovascular diseases. Serum Klotho levels were determined by the ELISA method. The study population was divided into two groups (n = 25 for each) according to the median serum Klotho level (459.4 pg/mL): higher Klotho (HK) group (613.6 pg/mL; ranges of 501.2-772.6 pg/mL) and lower Klotho (LK) group (338.7 pg/mL; ranges of 278.8-430.3 pg/mL). EFT was measured by transthoracic echocardiography, and CIMT and FMD were measured with standard procedures. The LK group showed lower values of FMD (p = 0.012) and larger values of EFT (p = 0.01) and CIMT (p < 0.001), compared to the HK group. Thus, the low serum Klotho levels were associated with increased EFT and CIMT and with the decreased FMD in the study population. We propose that the lower serum Klotho level is a newly identified predictor of atherosclerosis.

Retrobulbar blood flow and carotid intima-media thickness alteration may relate to subclinic atherosclerosis in patients with chronic inflammatory diseases.

OBJECTIVE: AA amyloidosis occurs in the setting of longstanding inflammation. An increased incidence of coronary artery disease (CAD) was noted in patients with chronic inflammatory disease (CID). Retrobulbar blood flow predicts future macrovascular events including CAD. Increase in carotid artery intima-media thickness is regarded as a marker for early atherosclerosis. The relationship between chronic inflammation and atherosclerosis is well known; however, the connection between amyloidosis-advanced CIDs and retrobulbar microvascular function and carotid intima-media thickness (CIMT) is unidentified. We aimed to investigate whether retrobulbar microcirculation and CIMT were impaired or not in amyloidosis-advanced CID patients compared to normal subjects. METHODS: Fourteen patients with renal AA amyloidosis and a group of healthy volunteers were included in the study. Measurement of CIMT and retrobulbar blood flow velocities was performed with ultrasound scanner and color Doppler ultrasonography. RESULTS: The CIMT of patients with renal amyloidosis was significantly thicker than that of the normal population (p < 0.001). The resistivity index of the ophthalmic artery (OA) of patients with renal amyloidosis was significantly higher than the study group (p < 0.001). CONCLUSION: This study demonstrates that accelerated atherosclerosis which can be shown by increased OA resistivity index and CIMT are found in amyloidal-related CID patients.

Effect of mitral valve repair versus replacement on left ventricular rotational deformation: a study with speckle tracking echocardiography.

BACKGROUND AND AIM OF THE STUDY: Radial and longitudinal movements of the heart do not fully reflect cardiac hemodynamics and physiology. Twist deformation of the heart is essential for adequate cardiac filling and stroke volume. The study aim was to examine the effects of mitral valve replacement or repair on left ventricular rotational parameters, evaluated by speckle tracking echocardiography, in patients with severe mitral regurgitation (MR). METHODS: A total of 51 patients (22 males, 29 females; mean age 45.7 +/- 13.5 years) with severe MR, sinus rhythm and left ventricular ejection fraction (LVEF) > 50% was included in the study. Mitral valve repair was performed in 29 patients (group A), and mitral valve replacement in 22 patients (group B). Rotational parameters (basal rotation, apical rotation, twist and untwist), LVEF and left ventricular diameters and volumes were compared before and after surgery. The postoperative percentage change in twist was calculated as follows: (preoperative twist - postoperative twist)/preoperative twist x 100. RESULTS: Rotational parameters of basal rotation were significantly decreased in both groups (group A: -5.6 +/- 3.1 degrees versus -4.0 +/- 3.0 degrees; p = 0.035; group B: -6.7 +/- 3.0 degrees versus -3.4 +/- 2.6 degrees; p < 0.001). However, apical rotation (group A: 11.4 +/- 6.6 degrees versus 9.7 +/- 8.3 degrees; p = 0.4; group B: 10.9 +/- 5 degrees versus 7.2 +/- 6.8 degrees; p = 0.009), twist (group A: 16.9 +/- 8.4 degrees versus 13.4 +/- 8.4 degrees; p = 0.1); group B: 17.1 +/- 5.7 degrees versus 10.1 +/- 8.7 degrees; p < 0.001) and untwist (group A: -109.2 +/- 57.8 degrees versus -104.6 +/- 56.0 degrees; p = 0.69; group B: -120.4 +/- 47.8 degrees versus -79.2 +/- 39.5 degrees; p = 0.002) were decreased significantly in the replacement group, but the decreases were not statistically significant in the repair group. The change in twist was observed to be significantly higher in the replacement group compared to the repair group (43.2 +/- 34.7% versus 9.4 +/- 54.1%; p = 0009; overall twist change 24 +/- 49.3%). To identify independent predictors of change in twist, a multivariate regression analysis was performed, whereby the left ventricular end-diastolic volume and type of operation were identified as independent predictors of change in twist. CONCLUSION: Compared to mitral valve replacement, mitral valve repair results in better rotational deformation parameters. Maintaining the mitral apparatus and enabling valvular-ventricular interaction contributes to a preservation of left ventricular twist and untwist. However, the prognostic and clinical impact of preserved rotational deformation parameters need to be determined.

Left atrial longitudinal strain parameters predict postoperative persistent atrial fibrillation following mitral valve surgery: a speckle tracking echocardiography study.

Postoperative atrial fibrillation (POAF) is common after cardiac surgery and is associated with increased morbidity, mortality, and prolonged hospital stay. Speckle tracking echocardiography (STE) has been applied recently for evaluation of LA function. The purpose of this study was to examine whether left atrial longitudinal strain measured by STE is a predictor for the development of POAF following mitral valve surgery for severe mitral regurgitation. We studied 53 patients undergoing mitral valve surgery in sinus rhythm at the time of surgery. Echocardiography with evaluation of LA strain by STE was performed. Detection of POAF was based on documentation of AF episodes by continuous telemetry throughout hospitalization. Patients who did not develop POAF were taken as group 1 and those who had POAF constituted group 2. The echocardiographic and clinical predictors of POAF were investigated. POAF occurred in 28.3% of subjects. Mean age, LAVi and BNP were found higher in group 2 while peak atrial longitudinal strain (PALS) (13.9 ± 3.8% vs. 24.8 ± 7.3%; P < 0.001), peak atrial contraction strain (PACS) (7.6 ± 1.95% vs. 11.3 ± 3.5%; P < 0.001) were significantly lower. By multivariate logistic regression analysis, PALS and LAVi were independent predictor of POAF development. LA longitudinal strain was found to predict POAF in patients undergoing mitral valve surgery. It could be used to better identify patients at greater risk of developing POAF, and thus to guide in risk stratification and to take appropriate intensive prophylactic therapy.

Left atrial deformation parameters predict left atrial appendage function and thrombus in patients in sinus rhythm with suspected cardioembolic stroke: a speckle tracking and transesophageal echocardiography study.

The aim of this study was to evaluate left atrial deformations using speckle tracking echocardiography for predicting left atrial appendage (LAA) thrombus in patients with suspected cardioembolic stroke who were in normal sinus rhythm. A total of 153 ischemic stroke patients (89 males, 64 females) in sinus rhythm who were suspected of having cardioembolism were included in the study. The patients underwent conventional two-dimensional (2D) echocardiogram and 2D speckle tracking echocardiogram of the left atrium. Left atrial peak strain (LA-4C-RES) and left atrial precontraction strain (LA-4C-PUMP) were measured. Patients were divided into 2 groups according to the presence of thrombus in the LAA in transesophageal echocardiography. Both LA-4C-RES and LA-4C-PUMP values were found to be significantly lower in patients with LAA thrombus (11.8 ± 1.4% vs. 33 ± 12%, P < 0.001 and 5.8 ± 1.3% vs. 14.2 ± 5.3%, P < 0.001, respectively). A good inverse correlation was present between LA-4C-RES values and LAA morphologic parameters (with LAA area: r = -0.70, P < 0.001, with LAA length: r = -0.60, P < 0.001), and a good positive correlation was present with LAA emptying velocity with pulse Doppler (r = 0.74, P < 0.001). The area under the receiver-operating characteristic curve of the LA-4C-RES was 0.94 (0.90-0.98, P < 0.001), for the LA-4C-PUMP, the area was 0.92 (0.87-0.96, P < 0.001) to predict LAA thrombus. Left atrial deformation parameters measured by 2D speckle tracking method was found to predict impaired LAA functions and the presence of LAA thrombus in ischemic stroke patients with suspected cardioembolism, but who are in sinus rhythm.

A successful percutaneous retrieval of a fractured pacemaker lead from a segmental pulmonary artery.

A rarely reported complication of pacemaker lead extraction is embolization of the pulmonary vasculature by a fragmented lead tip. The tip fractured and migrated to the right pulmonary artery during the extraction, and it was successfully retrieved percutaneously. Percutaneous retrieval is an important treatment option of an embolized fragmented lead tip as it could sometimes lead to disastrous complications.

Long-term exposure to biomass fuel and its relation to systolic and diastolic biventricular performance in addition to obstructive and restrictive lung diseases.

BACKGROUND: Previous studies have demonstrated an increased risk for cardiovascular events and pulmonary disease in patients with biomass fuel exposure (BFE). However, biventricular heart function has yet to be investigated in these patients. Left ventricular (LV) myocardial performance index (LVMPI), which is an index of global ventricular function, incorporates ejection, isovolumic relaxation, and contraction times. In this study, pulmonary function and biventricular heart function were investigated in nonsmoking female patients with BFE. METHODS: Our study population consisted of 46 female patients with BFE (group 1) and 31 control subjects (group 2). Pulmonary function tests and transthoracic echocardiographic examination were performed. Right ventricular myocardial performance index (RVMPI) and LVMPI were obtained by tissue Doppler imaging echocardiography (TDI). RESULTS: BFE caused obstructive and restrictive spirometric impairments. RVMPI was higher in group 1 (0.55 ± 0.07) than group 2 (0.46 ± 0.06) (P = 0.042) and LVMPI was higher in group 1 (0.54 ± 0.08) than group 2 (0.47 ± 0.05) (P = 0.032). Also, pulmonary artery systolic pressure was higher in group 1 than group 2 (P = 0.02). CONCLUSIONS: BFE causes both obstructive and/or restrictive lung disease and systolic and diastolic biventricular dysfunction. Nonetheless, long-term studies are needed to understand on BFE-related ventricular dysfunctions and to document subsequent cardiovascular events.

Unusual left atrial mass: inverted left atrial appendage caused by massive pericardial effusion.

Left atrial appendage inversion is a very rare cause of left atrial mass that usually occur after cardiac surgery. Its echocardiographic appearance often misleads clinicians to the diagnosis of thrombus or cardiac neoplasms. Unfortunately, misdiagnosed patients often undergo unnecessary anticoagulation or surgical treatment. We are presenting a case of left atrial appendage inversion caused by massive pericardial effusion in a patient with no previous history of cardiac surgery together with demonstrative images of transesophageal echocardiography and magnetic resonance imaging.

Dynamic circle image in left ventricle outflow tract.

A 46-year-old man presented with a complaint of effort dyspnea. On transthoracic echocardiography a circle appeared in LVOT. It was seen freely floating, disappearing in every systole and appearing again in diastole. Turbulence was seen inside the circle with color Doppler. Transesophageal echocardiography showed aortic cusps and their coaptation to be normal. Aortic root diameters were normal at the annulus, sinus of Valsalva, and sinotubular junction. There were no signs of dissection, infective endocarditis or abscess. But as the probe was advanced, left sinus of Valsalva was found to be prolapsed, and ruptured into LVOT.

Assessment of atrial conduction time in patients with essential hypertension.

BACKGROUND: We aimed to assess atrial conduction time in patients with essential hypertension. METHODS: A total of 80 patients with hypertension (51 males/29 females, 53 ± 12.5 years) and 80 controls (50 males/30 females, 50 ± 12 years) were included. Atrial electromechanical coupling (time interval from the onset of P wave on surface electrocardiogram [ECG] to the beginning of A wave interval with tissue Doppler echocardiography [PA]), intraatrial and interatrial electromechanical delay (intra and inter atrial electromechanical delay [AEMD]), and P-wave dispersion (Pd) were measured (Appelton, C.P., Hatle, L., Popp, R.L., Relation of transmitral flow velocity patterns to left ventricular diastolic function: new insights from combined hemodynamic and Doppler echocardiographic study. J Am Coll Cardiol. 1988; 12: 426-440). RESULTS: Atrial electromechanical coupling at the left lateral mitral annulus (PA lateral) and septal mitral annulus were longer in patients with hypertension (63.0 ± 8.0 vs 50.2 ± 4.3, P < .001, and 53.3 ± 6.2 vs 40.1 ± 5.5, P < .001). Interatrial (PA lateral-PA tricuspid) and intraatrial electromechanical delay (PA septum-PA tricuspid) were longer in patients with hypertension (24.8 ± 7.2 vs 12.4 ± 4.3, P < .001, and 14.1 ± 4.5 vs 2.3 ± 1.6, P < .001, respectively). Maximum P-wave duration and Pd were higher in patients with hypertension compared with controls (95.6 ± 8.0 vs 90.1 ± 9.5, P = .01, and 41.3 ± 7.1 vs 33.5 ± 6.1 P < .001, respectively). In correlation analysis, a positive correlation was detected between interatrial electromechanical delay and Pd (r = 0.72, P < .001). There was a moderate correlation between left ventricular mass index and PA lateral (r = 0.48, P < .001). CONCLUSION: Our results revealed that interatrial electromechanical delay and Pd were prolonged in patients with hypertension. Our results also showed a correlation between interatrial electromechanical delay and Pd. Prolonged electromechanical delay and Pd found in hypertensive patients could be related with increased incidence of atrial fibrillation in these patients. Prospective studies are needed to document the association between intraatrial and interatrial electromechanical delays and the development of atrial fibrillation.

The importance of the conus artery in patients with obstructive coronary artery disease.

It is well-known that collateral circulation is important in preserving ventricular functions, especially in coronary artery disease with total occlusion. The conus branch is distinct in having notable capacity of angiogenesis and arteriogenesis. We intend to emphasize the clinical importance of the conus branch by presenting two cases in which it supplied the distal regions of total occlusion.

A hammock in the left atrium.

Shone's anomaly describes a complex involving multiple left sided cardiac obstructions, namely, parachute deformity of the mitral valve, supravalvular ring of the left atrium, subaortic stenosis and aortic coarctation. We are reporting a case of Shone's anomaly characterised by aortic recoarctation, mitral supravalvular membrane, bicuspid aortic valve, complicated complete atrioventricular block and bradycardia-induced nonsustained polymorphic ventricular tachycardia. We revealed mitral supravalvular membrane by 3D transoesophageal echocardiography.

The relationship between echocardiographic parameters and brain natriuretic peptide levels in acute and chronic mitral regurgitation.

OBJECTIVES: Plasma brain natriuretic peptide (BNP) level increases with symptoms and severity of mitral regurgitation (MR). We aimed to determine the relationship between plasma BNP levels and echocardiographic parameters in patients with acute and chronic MR. STUDY DESIGN: The study included 55 patients (31 males, 24 females) with isolated moderate-to-severe MR. Of these, 31 patients had acute MR, and 24 patients had chronic MR. All the patients were assessed by transthoracic, transesophageal and Doppler echocardiography and plasma BNP levels were determined. RESULTS: Clinical characteristics and functional capacity were similar in the two groups. Patients with acute MR had significantly higher left ventricular (LV) ejection fraction (EF) (p=0.001), and significantly lower LV end-systolic diameter (p=0.016), end-systolic volume (p=0.027), end-diastolic diameter (p=0.011), left atrial volume (LAV) (p=0.003), and plasma BNP levels (p=0.036). Effective regurgitation orifice area was also significantly higher in patients with acute MR (p=0.038). In multiple linear regression analysis, the natural logarithm of BNP was significantly correlated with E/Ea ratio (ß=0.50, p=0.002) and LAV (ß=0.38, p=0.015) in patients with acute MR, and with systolic pulmonary artery pressure (ß=0.60, p=0.002) and EF (ß=-0.36, p=0.039) in patients with chronic MR. CONCLUSION: Although the echocardiographic degree of MR was more pronounced in patients with acute MR, serum BNP levels tended to be lower in this group. Correlation of serum BNP with E/Ea and LAV in this group may be an important finding.

Implementation of a neonatal hepatitis B immunization program in rural Karenni State, Myanmar: A mixed-methods study.

BACKGROUND: Hepatitis B infection is a major health concern in Myanmar. Hepatitis B birth dose vaccination to prevent mother-to-child transmission is not universal, especially in births outside of health care facilities. Little is documented about delivery of immunization programs in rural Myanmar or in conflict-affected regions. To address this gap, this study describes the implementation of a novel community delivered neonatal hepatitis B immunization program in rural Karenni State, Myanmar. METHODS: A mixed-methods study assessed the effectiveness and feasibility of hepatitis B birth dose immunization program. 1000 pregnant women were screened for hepatitis B virus (HBV) infection using point of care testing. Neonates of HBV positive mothers were immunized with a three dose HBV vaccine schedule at birth, 1, and 6 months of age. HBV testing was completed for children at 9 months to assess for infection. Descriptive statistics were collected including demographic data of mothers, neonatal vaccination schedule completion, and child HBV positivity at 9 months. Qualitative data examining barriers to implementation were collected through semi-structured interviews, participant-observation, and analysis of program documents. Themes were codified and mapped onto the Consolidated Framework for Implementation Research. RESULTS: 46 pregnant women tested HBV positive leading to 40 live births. 39 women-child dyads were followed until the 9-month age mark. With the exception of two neonates who received their birth dose past 24 hours, all children received their vaccines on time. None of the 39 children tested positive for HBV at nine months. Themes regarding barriers included adaptability of the program to the rural setting, friction with other stakeholders and not meeting all needs of the community. Identified strengths included good communication and leadership within the implementing ethnic health organization. CONCLUSION: A community delivered neonatal HBV vaccination program by ethnic health organizations is feasible and effective in rural Myanmar.

BNP levels in patients with long-term exposure to biomass fuel and its relation to right ventricular function.

UNLABELLED: Previous studies have demonstrated a consistent increased risk for cardiovascular events and pulmonary disease in patients with biomass fuel exposure (BFE). However right ventricular (RV) function have not been investigated yet in these patients. In this study, pulmonary function, right ventricular function and their relations with Brain Natriuretic Peptide (BNP) were investigated in non-smoking female patients with BFE. METHODS: Our study population consisted of 39 female patients with BFE (group 1) and, 31 control subjects (group 2). Pulmonary function tests and transthoracic echocardiographic examination were performed. Right ventricular volumes, diameters and tissue velocities were obtained by tissue Doppler echocardiography. BNP levels were measured and correlated to right ventricular measurements and pulmonary artery pressure. RESULTS: In BFE group, obstructive and restrictive spirometric findings were found. RV diameters, volumes and pulmonary artery pressure were higher in group 1 than group 2. BNP levels were well correlated with right ventricular end diastolic diameter and pulmonary artery pressure. A suspicion is also arised that toxic chemicals in biomass fuel may play a role in RV dysfunction. CONCLUSION: Biomass fuel exposure not only cause obstructive and/or restrictive lung disease but also leads to systolic and diastolic right ventricular dysfunction. BNP levels may be used to monitor pulmonary artery pressure and right ventricular enlargement in these patients.

Measuring individual-level needle and syringe coverage among people who inject drugs in Myanmar.

BACKGROUND: Myanmar has prioritised people who inject drugs (PWID) as a key population for HIV mitigation efforts, with targets for needle and syringe distribution set at a population level. However, individual-level coverage, defined as the percentage of an individual's injecting episodes covered by a sterile syringe, is a more sensitive measure of intervention coverage. We sought to examine individual-level coverage in a sample of PWID in Myanmar. METHODS: We recruited 512 PWID through urban drop-in-centres in Yangon, Mandalay and Pyin Oo Lwin. Participants were administered a quantitative questionnaire covering five domains: demographics, drug use, treatment and coverage, and injecting risk behaviour. We calculated past fortnight individual-level syringe coverage, estimating levels of sufficient (≥100% of injecting episodes covered by a sterile syringe) and insufficient (<100%) coverage, and examined associations between key variables and insufficient coverage via logistic regression. RESULTS: Our sample was predominately male (97%), employed (76%), and living in stable accommodation (96%), with a median age of 27. All participants reported heroin as the drug most frequently injected, and injected a median of 27 times in the past two weeks. Nineteen per cent of participants had insufficient coverage in the two weeks before interview. Insufficient coverage was positively associated with syringe re-use (AOR: 5.19, 95% CIs: 2.57, 10.48) and acquiring sterile syringes from a location other than a formal drop-in-centre (AOR: 2.04, 95% CIs: 1.08, 3.82). Participants recruited in Mandalay (AOR: 0.30, 95% CIs: 0.11, 0.80) and Pyin Oo Lwin (AOR: 0.39, 95% CIs: 0.18, 0.87) had lower odds of insufficient coverage than those recruited in Yangon. CONCLUSION: Our study shows coverage in selected areas of Myanmar was comparable with studies in other countries. Our results inform the delivery of harm reduction services for PWID, specifically by encouraging the use of formal drop-in-centres, over other sources of syringe distribution, such as pharmacies.

Predictors and clinical significance of angiographically detected distal embolization after primary percutaneous coronary interventions.

OBJECTIVES: The aim of this study was to investigate clinical, angiographic and procedural predictors of distal embolization (DE) on angiography after primary percutaneous coronary intervention (PCI). The impact of DE on outcome in the first 30 days was also assessed. METHODS: Between January 2004 and April 2006, primary PCI was performed in 212 consecutive patients with acute myocardial infarction (AMI) of < or = 12-h duration. RESULTS: Distal embolization was present in 27 patients (12.7%) and more often observed in female sex (27.5 vs. 10.4%, P=0.01), in patients with right coronary artery involvement (52 vs. 28%, P=0.02), prerevascularization thrombolysis in myocardial infarction flow < or = 1 (89 vs. 69%, P=0.03), in the presence of high thrombus burden (92.6 vs. 39.5%, P=0.0009), and a long target lesion in the infarct-related artery (>14.5 mm, 74 vs. 29%, P<0.0001). By multiple stepwise logistic regression analysis, only the presence of high thrombus burden before the PCI procedure [odds ratio (OR)=5.2, 95% confidence interval (CI)=1.09-24.97, P=0.03)] and target lesion length (>14.5 mm, OR=3.9, 95% CI=1.45-10.60, P=0.007) were found independent predictors of DE. Patients with DE had an increased risk of target vessel revascularization (26 vs. 5%, P=0.001) and short-term mortality (29.6 vs. 7.5%, P=0.002) when compared with patients without angiographic signs of embolization. CONCLUSIONS: In patients who undergo primary PCI, high thrombus burden on angiography before PCI and/or a long target lesion in the infarct-related artery increase the risk of DE and subsequent short-term mortality.

Acute anterior myocardial infarction due to aortosaphenous vein graft occlusion with very large thrombus burden.

A 75-year-old man, with a previous history of myocardial infarction and three-vessel coronary artery bypass grafting, presented with an acute anterior ST-elevation myocardial infarction. The vein graft to the left anterior descending artery was occluded with heavy thrombus burden, and the other grafts were patent. After administering a bolus dose of tirofiban and then undergoing percutaneous coronary intervention without stenting to the left anterior descending artery saphenous vein graft, intracoronary thrombolytic infusion was performed to maintain the patency of the vein graft. The patient was asymptomatic after medical follow-up. This may be an effective treatment option in patients with large thrombus burden and requires further investigation through large-scale trials.