Time to Reperfusion in ST-Segment Elevation Myocardial Infarction Patients With vs. Without Pre-Hospital Mobile Telemedicine 12-Lead Electrocardiogram Transmission.

BACKGROUND: Prehospital ECG improves survival following ST-segment elevation myocardial infarction (STEMI). Although a new International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations placed new emphasis on the role of prehospital ECG, this technology is not widely used in Japan. We developed a mobile telemedicine system (MTS) that continuously transmits real-time 12-lead ECG from ambulances in a prehospital setting. This study was designed to compare reperfusion delay between STEMI patients with different prehospital transfer pathways. METHODS AND RESULTS: Between 2008 and 2012, 393 consecutive STEMI patients were transferred by ambulance to hospital (PCI-capable center); 301 patients who underwent primary percutaneous coronary intervention (PCI) were enrolled prospectively. We compared time to reperfusion between patients transferred to PCI-capable hospital using the MTS (MTS group, n=37), patients directly transferred from the field to PCI-capable hospital without the MTS (field transfer group, n=125) and patients referred from a PCI-incapable hospital (interhospital transfer group, n=139). Times to reperfusion in the MTS group were significantly shorter than in the other groups, yielding substantial benefits in patients who arrived at a PCI-capable hospital within 6 h after symptom onset. On multivariate analysis, MTS use was an independent predictor of <90-min door-to-device interval (OR, 4.61; P=0.005). CONCLUSIONS: Reperfusion delay was shorter in patients using MTS than in patients without it. (Circ J 2016; 80: 1624-1633).

Rivero-Carvallo Sign in Bioprosthetic Tricuspid Valve Stenosis.

In a case with bioprosthetic tricuspid stenosis, simultaneous phonocardiogram and Doppler recordings revealed that the louder diastolic rumble in inspiration (Rivero-Carvallo sign) is related to increased tricuspid gradient caused by less prominent decrease of right atrial pressure compared with that of the right ventricle in inspiration caused by tricuspid stenosis. (Level of Difficulty: Intermediate.).

A Case of Transient Unilateral Right Leg Edema Caused by a Markedly Distended Bladder.

External compression of a vein is a relatively rare but important cause of unilateral leg edema. Here, we present a case of unilateral right leg edema caused by external compression of the right iliac vein due to a markedly distended urinary bladder, secondary to a neurogenic bladder. The patient initially had bilateral leg edema associated with chronic heart failure. However, the right-leg edema worsened and remained painful for several days. Lower extremity ultrasonography and computed tomography revealed an enlarged bladder. Based on these findings, venous angiography and intravascular ultrasound were performed. External compression is a significant cause of leg edema. It is important to consider the possibility of intra-abdominal/pelvic processes that may lead to external compression of the venous system in patients with unilateral and even bilateral lower extremity swelling.

Bypass failure of internal mammary artery caused by subclavian artery stenosis: its clinical characteristics and cardiovascular outcomes in patients receiving coronary artery bypass graft surgery.

Background: While internal mammary artery (IMA) has become a major conduit of coronary artery bypass graft (CABG) surgery, subclavian artery stenosis (SAS) could cause subsequent coronary events due to ischemia of myocardial territory supplied by IMA. Clinical characteristics and cardiovascular outcomes of SAS-related IMA failure (SAS-IMAF) remain to be fully determined yet. Therefore, the current study was designed to characterize SAS-IMAF in patients receiving CABG with IMA. Methods: This is a retrospective observational study which analyzed 380 patients who presented acute coronary syndrome/stable ischemic heart disease (ACS/SIHD) after CABG using IMA (2005.01.01-2020.10.31). SAS-IMAF was defined as the presence of myocardial ischemia/necrosis caused by SAS. Clinical characteristics and cardiovascular outcomes [major adverse cardiovascular events (MACE) = cardiac death + non-fatal myocardial infarction + non-fatal ischemic stroke], were compared in subjects with and without SAS-IMAF. Multivariate Cox proportional hazards model and propensity score-matched analyses were used to compare cardiovascular outcomes between those with and without SAS-IMAF. Results: SAS-IMAF was identified in 5.5% (21/380) of study subjects. Patients with SAS-IMAF are more likely had a history of hemodialysis (P<0.001), stroke (P<0.001) and lower extremity artery disease (P<0.001). Furthermore, SAS-IMAF patients more frequently presented ACS (P=0.002) and required mechanical support (P=0.02). Despite SAS as a culprit lesion causing ACS/SIHD, percutaneous coronary intervention was firstly selected in 47.6% (10/21) of them. Consequently, 33.3% (7/21) of SAS-IMAF patients required additional revascularization procedure (vs. 0.3%, P<0.001). During 4.9-year observational period, SAS-IMAF exhibited a 5.82-fold [95% confidence interval (CI): 2.31-14.65, P<0.001] increased risk of MACE. Multivariate Cox proportional hazards model [hazard ratio (HR) 4.04, 95% CI: 1.44-11.38, P=0.008] and propensity score-matched analyses (HR 2.67, 95% CI: 1.06-6.73, P=0.038) consistently demonstrated the association of SAS-IMAF with MACE. Conclusions: SAS-IMAF reflects a high-risk phenotype of polyvascular disease, underscoring meticulous evaluation of subclavian artery after CABG using IMA.

Sirolimus-eluting stent versus balloon angioplasty for sirolimus-eluting stent restenosis: Insights from the j-Cypher Registry.

BACKGROUND: Optimal treatment strategies for restenosis of sirolimus-eluting stents (SES) have not been adequately addressed yet. METHODS AND RESULTS: During the 3-year follow-up of 12 824 patients enrolled in the j-Cypher registry, 1456 lesions in 1298 patients underwent target-lesion revascularization (TLR). Excluding 362 lesions undergoing TLR for stent thrombosis or TLR using treatment modalities other than SES or balloon angioplasty (BA), 1094 lesions with SES-associated restenosis in 990 patients treated with either SES (537 lesions) or BA (557 lesions) constituted the study population for the analysis of recurrent TLR and stent thrombosis after the first TLR. Excluding 24 patients with both SES- and BA-treated lesions, 966 patients constituted the analysis set for the mortality outcome. Cumulative incidence of recurrent TLR in the SES-treated restenosis lesions was significantly lower than that in the BA-treated restenosis lesions (23.8% versus 37.7% at 2 years after the first TLR; P<0.0001). Among 33 baseline variables evaluated, only hemodialysis was identified to be the independent risk factor for recurrent TLR by a multivariable logistic regression analysis. After adjusting for confounders, repeated SES implantation was associated with a strong treatment effect in preventing recurrent TLR over BA (odds ratio, 0.44; 95% confidence interval, 0.32 to 0.61; P<0.0001). The 2-year mortality and stent thrombosis rates between the SES- and the BA-treated groups were 10.4% versus 10.8% (P=0.4) and 0.6% versus 0.6%, respectively. CONCLUSIONS: Repeated implantation of SES for SES-associated restenosis is more effective in preventing recurrent TLR than treatment with BA, without evidence of safety concerns.

Effect of pretreatment with pioglitazone on reperfusion injury in diabetic patients with acute myocardial infarction.

BACKGROUND: Pioglitazone (PIO) is a new class of anti-diabetic agent with an anti-inflammatory effect. In the experimental studies, pretreatment with PIO before ischemia/reperfusion reduced ischemia-reperfusion injury and myocardial infarct size. However, the clinical efficacy of this therapy in patients with acute myocardial infarction (AMI) remains unknown. METHODS AND RESULTS: Three hundred and nineteen diabetic patients with ST-segment elevation AMI, treated with bare metal stent within 24h from the onset of AMI were examined. Myocardial blush grade, ST-segment resolution, peak creatine kinase (CK) level, and left ventricular ejection fraction (LVEF) were compared between PIO group (pretreatment with PIO [+]; n=26) and non-PIO group (pretreatment with PIO [-]; n=293). The PIO group showed a significantly higher incidence of blush score ≥ 2 and complete ST-segment resolution (blush score ≥ 2; 38% vs. 71%, P=0.04, ST-segment resolution; 44% vs. 71%, P=0.04). Besides, slow flow/no-reflow phenomenon and reperfusion arrhythmia did not occur in this group. Better improvement of LVEF and lower peak CK level was observed in this group, although these were not statistically significant (LVEF 48% vs. 41%, P=0.10, peak CK level 2,041 vs. 3,207, P=0.06). CONCLUSIONS: Pretreatment with PIO in diabetic patients with AMI resulted in better myocardial perfusion with less reperfusion injury.

Efficacy of paclitaxel-eluting stent in patients with impaired glucose tolerance--comparison with sirolimus-eluting stent.

BACKGROUND: Experimental and clinical studies have shown that paclitaxel-eluting stent (PES) attenuates the effect of diabetes on re-stenosis after percutaneous coronary intervention. Although impaired glucose tolerance (IGT) is a pre-diabetic phase characterized as post-prandial hyperglycemia and hyperinsulinemia, the efficacy of PES in these pre-diabetic patients remains unknown. The purpose of the present study was therefore to compare the efficacy of PES in IGT patients with that of sirolimus-eluting stent (SES). METHODS AND RESULTS: A total of 370 IGT patients with coronary artery disease were examined (SES, n=229; PES, n=141). The incidence of major adverse cardiovascular events (MACE; all-cause death, non-fatal myocardial infarction or repeat revascularization) was compared between the 2 groups. The PES group had lower body mass index, total cholesterol and low-density lipoprotein cholesterol levels and higher prevalence of previous myocardial infarction than the SES group. The incidence of repeat revascularization in the PES group was similar to that in the SES group (22% vs. 19%, P=0.71). The incidence of hard cardiac events such as all-cause death and non-fatal myocardial infarction were also similar between the 2 groups. Finally, there were no significant differences in MACE between the SES and PES groups (23% vs. 21%, P=0.76). CONCLUSIONS: In patients with IGT, the efficacy of PES was similar to that of SES, and any advantage of PES over SES was not observed in these pre-diabetic patients.

A rare connection by newly formed conduit vessels between the left internal mammalian artery and radial artery bypass grafts after failure of grafts.

Neovascularization such as formation of collateral vessels following total occlusion of native coronary artery is common in coronary artery disease. This is a case report of a very rare connection by newly formed conduit vessels between the left internal mammalian artery and the radial artery establishing bypass, which occurred after failure of bypass grafts.

Prone position ventilation and femoro-femoral veno-venous extracorporeal membrane oxygenation for COVID-19 treatment.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which causes coronavirus disease 2019 (COVID-19), has resulted in significant morbidity and mortality worldwide. Approximately 5% of COVID-19 patients who suffer from pneumonia develop critical respiratory failure. Here, we report the case of a healthy 52-year-old man who had respiratory failure owing to SARS-CoV-2 infection and was treated using femoro-femoral veno-venous extracorporeal membrane oxygenation (VV-ECMO) and prone position ventilation (PPV). After this treatment, his blood oxygen levels, chest high-resolution computed tomography findings, and clinical parameters significantly improved. He was decannulated from VV-ECMO on day 6 and finally extubated on day 11. To our knowledge, this is the first reported case of SARS-CoV-2-associated acute respiratory distress syndrome that was successfully treated with a combination of femoro-femoral VV-ECMO and PPV.

Coronary Artery Embolism Caused by BioGlue Surgical Adhesive After Type A Acute Aortic Dissection Repair.

Coronary artery embolism due to BioGlue surgical adhesive after repair of type A acute aortic dissection is a rare condition. We report a case of BioGlue coronary artery embolism after type A acute aortic dissection repair confirmed using intravascular ultrasound imaging and pathological examination. It was successfully treated with percutaneous coronary intervention. (Level of Difficulty: Advanced.).

Unilateral Left Pulmonary Edema Caused by Contained Rupture of the Ascending Aortic Dissection.

Unilateral pulmonary edema (UPE) is a rare entity and is usually associated with severe mitral regurgitation and more frequently occurs in the right lung. We herein report a case of unilateral left pulmonary edema caused by external compression of the right pulmonary artery and left pulmonary vein caused by the presence of hematoma due to type A acute aortic dissection (AAD), resulting in asymmetrically increased inflow and decreased outflow in the left pulmonary circulation. Physicians caring for patients with UPE should be aware that AAD leading to the external compression of the heart may be a possible underlying mechanism.

Coronary vasospasm secondary to allergic reaction following food ingestion: a case of type I variant Kounis syndrome.

Coronary vasospasm can be induced by allergic reactions with some chemical mediators, and the angina and myocardial infarction secondary to allergy-induced coronary vasospasm are referred to as "Kounis syndrome." Only two cases of Kounis syndrome following food ingestion have been reported. However, they had pre-existing atheromatous coronary artery disease, and no provocation test to induce coronary vasospasm was done. We describe here another probable case of allergic vasospasm after food intake. To the best of our knowledge, this is the first documented report of a patient with food-induced allergic vasospasm subsequent to the provocation test with ergometrine maleate.

Clinical Predictors for Delayed or Inappropriate Initial Diagnosis of Type A Acute Aortic Dissection in the Emergency Room.

BACKGROUND: Initial diagnosis of acute aortic dissection (AAD) in the emergency room (ER) is sometimes difficult or delayed. The aim of this study is to define clinical predictors related to inappropriate or delayed diagnosis of Stanford type A AAD. METHODS: We conducted a retrospective analysis of 127 consecutive patients with type A AAD who presented to the ER within 12 h of symptom onset (age: 69.0 ± 15.4 years, male/female = 49/78). An inappropriate initial diagnosis (IID) was considered if AAD was not included in the differential diagnosis or if chest computed tomography or echocardiography was not performed as initial imaging tests. Clinical variables were compared between IID and appropriate diagnosis group. The time to final diagnosis (TFD) was also evaluated. Delayed diagnosis (DD) was defined as TFD > third quartile. Clinical factors predicting DD were evaluated in comparison with early diagnosis (defined as TFD within the third quartile). In addition, TFD was compared with respect to each clinical variable using a rank sum test. RESULTS: An IID was determined for 37% of patients. Walk-in (WI) visit to the ER [odds ratio (OR) 2.6, 95% confidence interval (CI) = 1.01-6.72, P = 0.048] and coronary malperfusion (CM, OR = 6.48, 95% CI = 1.14-36.82, P = 0.035) were predictors for IID. Overall, the median TFD was 1.5 h (first/third quartiles = 0.5/4.0 h). DD (>4.5 h) was observed in 27 cases (21.3%). TFD was significantly longer in WI patients (median and first/third quartiles = 1.0 and 0.5/2.85 h for the ambulance group vs. 3.0 and 1.0/8.0 h for the WI group, respectively; P = 0.003). Multivariate analysis revealed that WI visit was the only predictor for DD (OR = 3.72, 95% CI = 1.39-9.9, P = 0.009). TFD was significantly shorter for appropriate diagnoses than for IIDs (1.0 vs. 6.0 h, respectively; P < 0.0001). CONCLUSIONS: WI visit to the ER and CM were predictors for IID, and WI was the only predictor for DD in acute type A AAD in the community hospital.

Coronary steal due to ruptured right coronary aneurysm causing myocardial infarction in a patient with systemic lupus erythematosus.

A 34-year-old female with a history of systemic lupus erythematosus (SLE) developed an acute inferior myocardial infarction while hospitalized for methicillin-resistant Staphylococcus Aureus sepsis. An emergent coronary angiography revealed an ectatic proximal left coronary artery and a huge aneurysm (37 mm × 32 mm) in the mid-portion of the right coronary artery, which had ruptured into the right atrium. A "steal phenomenon" due to significant left to right shunt resulting from the ruptured aneurysm was the cause of the myocardial infarction. Infection of the wall of the aneurysm might have contributed to the growth and the rupture in the presence of a pre-existing coronary aneurysm.

A case of arrhythmogenic right ventricular cardiomyopathy presenting with progressive right ventricular failure and recurrent multifocal monomorphic ventricular tachycardia during 15 years of follow-up.

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a multigenic form of cardiomyopathy characterized by myocardial loss and fibrofatty replacement mainly in the right ventricle. Progressive right ventricular dysfunction, ventricular arrhythmias, and sudden cardiac death are the clinical picture of this disease. Despite its clinical importance as a cause of sudden death, ARVC is likely to be under-recognized. In case reports about ARVC, disease characteristics such as arrhythmias, images, and genes are described in fragments. Little is reported about the long-term course of ARVC in the same patient. In this report, we present a case of a 68-year-old male who was diagnosed with ARVC after his first episode of ventricular tachycardia. Both mechanical and electrical progression were seen during the 15 years of follow-up, requiring the modification of disease management. This report could help improve the understanding of this rare disease, and the way of its management. .

Left ventricular pseudoaneurysm as a complication of prosthetic mitral valve infective endocarditis.

We report a case of infective endocarditis complicated with left ventricular pseudoaneurysm originating from the posterior annulus of the prosthetic mitral valve in a 56-year-old woman. Despite prolonged antibiotic treatment, transesophageal echocardiography (TEE) showed partial detachment of the prosthesis from the posterior mitral annulus. Three-dimensional rotational computed tomography clearly demonstrated a pseudoaneurysm toward the posterolateral portion of the mitral prosthetic valve, which was not evident by TEE. Valve replacement and repair of the pseudoaneurysm were performed 83 days after initiation of antibiotic therapy. Left ventricular pseudoaneurysm is a rare but serious complication of mitral prosthetic valve endocarditis. It requires prompt diagnosis and early surgical intervention. .