Temporary atrial septal defect balloon occlusion test as a must in the elderly.

BACKGROUND: Atrial septal defect (ASD) can often remain asymptomatic until adulthood. It still remains unclear whether large ASD closure in senior people should be performed or not. Temporary ASD balloon occlusion test has been suggested as a tool to assess the risk of acute left ventricular heart failure post-ASD closure, and it allows to better distinguish responders from non-responders. CASE PRESENTATION: An 83-year-old man with a long-standing uncorrected secundum ASD was admitted for recently decompensated right-sided heart failure. During hospitalization, this patient was studied with trans-esophageal echocardiography, cardiac magnetic resonance imaging, and right heart catheterization, showing high Qp:Qs ratio and favorable anatomical conditions for percutaneous closure. Because of patient's increasing need for intravenous diuretics and worsening renal function, it was considered that transcatheter ASD closure could improve symptoms, hence it was performed an attempt of percutaneous closure of the ASD with a fenestrated device. Unfortunately, irrespective of ASD being hemodynamically significant, it was found a very significant increase in pulmonary capillary wedge pressure during the temporary balloon occlusion test, supporting the existence of concealed left ventricular diastolic dysfunction. As a result, it was decided to abandon the procedure and not to close the ASD. CONCLUSION: This clinical case illustrates the value of temporary balloon occlusion test before permanent percutaneous closure of ASD in elderly patients, regardless of left ventricular (systolic or diastolic) dysfunction.

"(Pseudo)cavities inside the heart: What may they unfold?"

Subvalvular aortic stenosis manifesting as a subaortic membrane predisposes to bacterial endocarditis, which typically affects the aortic valve (AoV) or, less frequently, the left ventricular outflow tract (LVOT). We present the case of a 60-year-old woman expressing an odd form of a subvalvular aortic membrane in conjunction with a left Valsalva sinus pseudoaneurysm as a result of an endocarditis complication.

Platypnoea Orthodeoxia Syndrome and Patent Foramen Ovale Closure: Single-Centre Experience and Long-Term Follow-Up.

INTRODUCTION: Platypnoea orthodeoxia syndrome (POS) is an uncommon condition characterised by dyspnoea and arterial desaturation induced by an upright position and relieved in the supine position, usually due to a patent foramen ovale (PFO). Percutaneous closure of a PFO is the preferred treatment to cure POS. This study aimed to evaluate the clinical and gasometrical characteristics and to describe the long-term outcomes of percutaneous PFO closure in a group of patients with POS. METHODS: Patients with POS and a PFO treated by percutaneous intervention from 2010-2020 were reviewed. The primary efficacy outcome was the arterial oxygen pressure to fraction of inspired oxygen (PaO2/FiO2) ratio before and 24 hours after the procedure. Total clinical success was considered if the arterial oxygen saturation measured by pulse oximetry (SpO2) improved to >94% in the supine and sitting positions without supplemental oxygen, while partial success was considered if SpO2 improved from baseline but still required oxygen to achieve >94%. Secondary outcomes were an absolute improvement in SpO2 and sense of dyspnoea, without significant residual shunt on transthoracic echocardiography (TTE) at follow-up. RESULTS: Of 168 patients undergoing PFO or atrial septal defect closure, 14 had POS (8.3%). Percutaneous PFO closure was successfully performed in all patients with a single device. Twelve of 14 patients had total clinical success (86%) and one patient had partial success. The PaO2/FiO2 ratio increased from 155.9±50.6 to 318.3±73.4 after PFO closure (p=0.002). All patients with total clinical success had a successful secondary efficacy outcome with an absolute improvement in SpO2 and complete resolution of dyspnoea, which was maintained at follow-up (37±20 months; range, 11 months to 6 years). None had a significant residual shunt between 12 and 24 months of follow-up. CONCLUSION: The PFO percutaneous closure was a successful, durable and safe method for patients presenting with POS; it achieved major improvements in both gasometrical parameters and quality of life.

Manual thrombectomy efficiency in relationship to the area at risk in patients with myocardial infarction with TIMI 0-1 coronary flow: Insights from an all comers registry.

OBJECTIVES: To review the effectiveness of manual thrombectomy (MT) in a series of patients with ST-elevation myocardial infarction (STEMI) exclusively presenting with TIMI 0-1 flow undergoing percutaneous coronary intervention (PCI), in accordance to the angiographically estimated area at risk (AAR). Second, to assess major in-hospital clinical events, emphasizing neurological outcomes. BACKGROUND: The routine utilization of MT in STEMI is not recommended. However, in recent trials, a significant proportion of patients had neither large thrombus burden nor a totally occluded coronary segment, neutralizing the expected benefits of MT. In addition, the efficiency of MT to remove thrombus has rarely been addressed. Finally, MT diminished distal embolization, which has been related to mortality. RESULTS: In 850 consecutive STEMI-patients, MT was utilized in 525 (62%) and it was considered efficient (TIMI 2-3 flow after MT) in 445 (85%). We found a significant interaction between the AAR and the effectiveness of MT to reduce infarct size (P-interaction = 0.014). In patients having AAR ≥ 28% (n = 184), efficient MT conferred lesser infarct size compared to inefficient MT (Ln-transformed peak CK): 7.87 ± 0.86 versus 8.36 ± 0.41 IU/L, P = 0.005, with no impact for AAR <28%. Clinical outcomes including stroke between MT and PCI-only groups were not different. CONCLUSION: In comparison with the group where MT was inefficient, efficient MT may modestly reduce final infarct size without a significant clinical benefit. In comparison with PCI-only, no difference was found regarding stroke. © 2017 Wiley Periodicals, Inc.

Soluble TNF-related apoptosis induced ligand (sTRAIL) is augmented by Post-Conditioning and correlates to infarct size and left ventricle dysfunction in STEMI patients: a substudy from a randomized clinical trial.

Low levels of Soluble TNF-related apoptosis induced ligand (sTRAIL) seem to be related to worse prognosis after an acute coronary syndrome. PostConditioning (PostCond) may protect the heart from reperfusion injury. We sought to evaluate the impact of PostCond on sTRAIL in relationship to infarct size (area under the curve of Troponin T, AUCTnT) and left ventricle ejection fraction (LVEF) in a series of patients undergoing primary coronary intervention for ST-segment elevation myocardial infarction (STEMI). In a substudy of a randomized trial that tested the effects of PostCond in STEMI-patients, sTRAIL was measured 24 h after reperfusion (PostCond n = 39, Control n = 39). Correlations between sTRAIL and both AUCTnT and LVEF were studied for each study arm. At 24 h, sTRAIL was higher for PostCond vs Controls (46.4 ± 30.6 vs 32.9 ± 23.4, p = 0.031), was negatively related to AUCTnT [B = -0.09, 95 % CI (-0.15 to -0.30), p = 0.005] and was positively related to both in-hospital [B = 0.10, 95 % CI (0.02-0.17), p = 0.018], and follow-up LVEF [B = 0.21, 95 % (0.10-0.32), p = 0.001]. No significant relationship was found for Controls. On multivariate analysis, PostCond was an independent predictor for sTRAIL [B = 12.13 95 % CI (0.40-23.87), p = 0.043]. In conclusion, PostCond positively influenced sTRAIL, which was related to reduced infarct size and better LVEF. Further studies are needed to understand potential mechanisms elicited by PostCond in infarct size reduction.

Cardiac Rehabilitation after an Acute Coronary Syndrome: The Impact in Elderly Patients.

INTRODUCTION: Cardiac rehabilitation (CR) has been shown to decrease mortality and morbidity, improve the control of risk factors and the quality of life of patients with coronary artery disease. However, the elderly are underrepresented in most studies and in real-life CR programs. Our goal was to evaluate the impact of CR after an acute coronary syndrome in the elderly population. METHODS: A cutoff of 65 years was used to dichotomize age. Our main focus was on the effects of ambulatory supervised exercise training on several surrogate markers, namely total cholesterol, low- and high-density lipoprotein cholesterol, triglycerides, body mass index, fasting glucose, glycated hemoglobin, probrain natriuretic peptide, International Physical Activity Questionnaire score, maximal exercise capacity, chronotropic response index and heart rate recovery. We evaluated those variables at the beginning and at the end of phase II of the CR program (after 3 months) and repeated the treadmill test at 12 months. RESULTS: A total of 548 patients with a recent acute coronary syndrome were enrolled; 37% were 65 years old or older. Both age groups had a statistically significant improvement in all the evaluated parameters. Interestingly, at 12 months both groups maintained the improvement in functional capacity seen immediately after 3 months. CONCLUSIONS: The benefits of CR in terms of functional capacity, metabolic profile and other prognostic parameters were significant in both younger and older patients. Therefore, all eligible patients should be referred to CR programs, irrespective of age.

Twelve-year trends in unprotected left main coronary artery occlusion: insights from a real-world multicentre study.

AIMS: Acute myocardial infarction (AMI) resulting from unprotected left main coronary artery (LMCA) occlusion and subtotal occlusion is a life-threatening condition. Although AMI management has improved in the past two decades, there is limited information on recent trends in patient characteristics, management, and outcomes for acute unprotected LMCA-related AMI. This study aims to assess such trends over a 12 year period. METHODS AND RESULTS: This retrospective multicentre study includes patients with unprotected LMCA occlusion/subtotal occlusion admitted to three tertiary hospitals between 2008 and 2020. The patients were divided into two groups based on the chronology of presentation: a 'past group' (January 2008 to December 2014) and a 'contemporary group' (January 2015 to December 2020). The study compares clinical characteristics, management approaches, and outcomes between the two groups. The study includes 128 patients, with 51 (40%) in the 'past group' and 77 (60%) in the 'contemporary group'. Baseline risk factors did not show statistically significant differences between the two groups, except for hypertension (49% vs. 74%; P = 0.005). Chest pain was more frequent in the 'past group' (98% vs. 89%; P = 0.014), and a trend towards more cardiac arrests was observed in the 'contemporary group' (18% vs. 31%; P = 0.087). Revascularization type did not differ significantly (P = 0.419), but manual thrombectomy was less frequently used (41% vs. 23%; P = 0.032) and stent implantation showed a trend towards higher rates (66% vs. 78%; P = 0.150) in the 'contemporary cohort'. There was a gradual shift from bare-metal to drug-eluting stents, with a significantly higher percentage of ticagrelor/prasugrel loading in the 'contemporary cohort' (5% vs. 79%; P < 0.001). The use of mechanical circulatory support (MCS), although not statistically significant, was higher among patients in the 'past group' (67% vs. 51%; P = 0.073). The type of MCS differed significantly between groups, with a decrease in intra-aortic balloon pump use (67% vs. 42%; P = 0.005) and an increase in veno-arterial extracorporeal membrane oxygenation (4% vs. 22%; P = 0.005) and Impella system (0% vs. 3%) over time. Survival analysis showed no significant differences (P = 0.599; log-rank test) in all-cause mortality between the different time groups, with the long-term survival rate being approximately 30%. CONCLUSIONS: In our real-world population, despite the progressive use of newer drugs and more advanced devices over time, patients with unprotected LMCA occlusion/subtotal occlusion remain a subpopulation with poor prognosis.

Thyroid storm and arrhythmic storm: a potentially fatal combination.

Thyroid storm is a rare clinical emergency with a mortality rate between 20% and 30%. Cardiac arrhythmias associated with thyrotoxicosis are usually supraventricular. Ventricular arrhythmias are rarely associated with this entity and tend to occur in patients with intrinsic cardiac disease. We present a 35-year-old woman with Graves disease and a thyroid storm manifested with multiple malignant dysrhythmic episodes, without underlying cardiac disease. The mechanism for ventricular arrhythmia is not clear but seems to be due to the increased myocardial excitability directly caused by the thyroid hormones. The presence of myocarditis lesions may constitute an arrhythmogenic substratum and contribute further to this manifestation. This case emphasizes the importance of cardiac monitoring in patients with thyroid storm.

[Long-term effects of a cardiac rehabilitation program in the control of cardiovascular risk factors]. / Efeitos a longo prazo de um programa de reabilitação cardíaca no controlo dos fatores de risco cardiovasculares.

INTRODUCTION: Cardiac rehabilitation programs are designed to improve patients' functional capacity, as well as to educate them and to monitor their cardiovascular risk factors. AIM: The study aims to evaluate the effects of cardiac rehabilitation programs in patients with coronary disease over a 12-month follow-up period with regard to control of cardiovascular risk factors. METHODS: This was a prospective study of patients diagnosed with coronary disease who completed an exercise-based cardiac rehabilitation program between January 2008 and December 2009 and who were not lost to follow-up. Patients were evaluated at an early stage (first medical consultation in phase II of the program) and 3, 6 and 12 months later, the following parameters being assessed: weight and body mass index, waist circumference, lipid profile, HbA1c in diabetic patients, blood pressure, smoking status and physical activity (using the International Physical Activity Questionnaire). RESULTS: In the sample of 256 patients (76.2% male, mean age 67 years), dyslipidemia proved to be the most prevalent risk factor (74.2%), followed by overweight (71.5%). There was a statistically significant improvement (p<0,05) in all risk factors studied at the end of phase II of the program, which was maintained at 6 and 12 months of follow-up, with the exception of body mass index (loss of statistical significance at 6-month assessment, p=0,92). CONCLUSION: This study highlights the need for cardiac rehabilitation programs in the context of secondary prevention of cardiovascular disease and the importance of implementing strategies that promote long-term maintenance of their benefits.

Triple, simultaneous, very late coronary stent thrombosis.

Coronary artery stent thrombosis is an uncommon but potentially catastrophic complication. The risk of very late stent thrombosis (VLST) raises important safety issues regarding the first generation of drug-eluting stents (DES). Although several complex mechanisms for VLST have been suggested and various predictors have been described, its pathophysiology is not completely understood and it is not known whether longer-term dual antiplatelet therapy reduces the risk. We present a rare case of simultaneous very late DES thrombosis in the three vascular territories, following discontinuation of antiplatelet therapy seven years after stent placement, presenting as cardiogenic shock.

Coil Embolization for Management of Brachiocephalic Artery Perforation and Mediastinal Hematoma Following Percutaneous Coronary Intervention.

In this clinical image vignette, we illustrate the presentation and management of an extremely rare and lethal complica- tion of radial access percutaneous coronary intervention. We present a case of perforation of a small collateral branch of the brachiocephalic artery with subsequent mediastinal hematoma formation and stridor presentation. We suspect the perforation was probably caused by the hydrophilic-coated guidewire. After a multidisciplinary heart team discussion, a percutaneous approach was recommended. We performed the procedure with a single coil embolization of the collateral branch perforation, achieving complete resolution of the hemorrhage.

Amiodarone-Induced Electrical Storm: A Nightmare in the Emergency Room.

Drug-induced long QT syndrome (LQTS) is defined as prolonged corrected QT interval (QTc ≥460 ms) plus polymorphic ventricular arrhythmia fitting the description of torsades de pointes temporally associated with the administration of a drug or combination of drugs. Amiodarone therapy is a known uncommon cause of acquired QT interval prolongation that should not be underestimated. We present a case of an iatrogenic electrical storm with atrial fibrillation (AF) in which amiodarone was administered to attempt chemical cardioversion, resulting in an unnoticed prolongation of the QT interval, with subsequent repeated polymorphic ventricular tachycardia, managed with isoproterenol. Concomitant drugs and slight electrolyte disturbances potentiated this phenomenon. Given the widespread use of this drug in the emergency department, our case highlights a pertinent matter for all medical emergency practitioners. Additionally, it stresses the significance of potential precipitating factors, such as electrolyte imbalances, which are clinical conditions very frequent in the emergency context, along with the importance of recognizing drug interactions. Finally, this case also emphasizes the vital importance of closely monitoring the patient's receiving amiodarone.

ST-Segment Elevation: An Unexpected Culprit.

The clinical presentation of pulmonary embolism (PE) and acute coronary syndrome can be similar. We report a case of a patient presenting with antero-septal ST-segment elevation after cardiac arrest, found to have acute-PE-mimicking ST-segment elevation myocardial infarction (STEMI), treated with aspiration thrombectomy and catheter-directed thrombolysis (CDT). A 78-year-old man was admitted with dyspnea, chest pain and tachycardia. During evaluation, cardiac arrest in pulseless electrical activity was documented. Advanced life support was started immediately. ECG post-ROSC revealed ST-segment elevation in V1-V4 and aVR. Echocardiography showed normal left ventricular function but right ventricular (RV) dilation and severe dysfunction. The patient was in shock and was promptly referred to cardiac catheterization that excluded significant CAD. Due to the discordant ECG and echocardiogram findings, acute PE was suspected, and immediate invasive pulmonary angiography revealed bilateral massive pulmonary embolism. Successful aspiration thrombectomy was performed followed by local alteplase infusion. At the end of the procedure, mPAP was reduced and blood pressure normalized allowing withdrawal of vasopressor support. Twenty-four-hour echocardiographic reassessment showed normal-sized cardiac chambers with preserved biventricular systolic function. Bedside echocardiography in patients with ST-segment elevation post-ROSC is instrumental in raising the suspicion of acute PE. In the absence of a culprit coronary lesion, prompt pulmonary angiography should be considered if immediately feasible. In these cases, CDT and aspiration in high-risk acute PE seem safe and effective in relieving obstructive shock and restoring hemodynamics.

Ticagrelor Loading on ST-Elevation Myocardial Infarction: Interaction With Prodromal Angina on Infarct Size and Clinical Events.

INTRODUCTION: Ticagrelor might reduce infarct size by exerting a more potent antiplatelet effect or by promoting a potential conditioning stimulus in ST-elevation myocardial infarction (STEMI) patients. Pre-infarction angina (PIA) is an effective preconditioning stimulus that reduces ischemia-reperfusion injury. Because little is known on the interaction of PIA in STEMI-patients loaded with ticagrelor, we sought to determine if patients loaded with ticagrelor had improved clinical outcomes as compared to clopidogrel and to study if it is modulated by the presence of PIA. METHODS: From 1272 STEMI patients submitted to primary percutaneous coronary intervention and treated with clopidogrel or ticagrelor from January 2008 to December 2018, 826 were analyzed after propensity score matching. Infarct size was estimated using peak creatine kinase (CK) and troponin T (TnT), and clinical impact was evaluated through cumulative major cardiac and cerebrovascular events (MACCE) at 1-year follow-up. Matched patients and their interaction with PIA were analyzed. RESULTS: Patients loaded with ticagrelor had lower peak CK [1405.50 U/L (730.25-2491.00), P < .001] and TnT [3.58 ng/mL (1.73-6.59), P < .001)], regardless of PIA. The presence of PIA was associated with lower CK (P = .030), but not TnT (P = .097). There was no interaction between ticagrelor loading and PIA (P = .788 for TnT and P = .555 for CK). There was no difference in MACCE incidence between clopidogrel or ticagrelor loading (P = .129). Cumulative survival was also similar between clopidogrel or ticagrelor, regardless of PIA (P = .103). CONCLUSION: Ticagrelor reduced infarct sizes independently and without a synergic effect with PIA. Despite reducing infarct size, clinical outcomes were similar across both groups.

Complex ventricular septal rupture with dissection of the right ventricular wall in ischemic context.

A 72-year-old man was admitted to the local hospital with non-ST elevation myocardial infarction. In the first 24 hours, a new onset apical murmur was heard. Transthoracic and transesophageal echocardiography showed interventricular septal (IVS) rupture and dissection of the right ventricle (RV) wall forming an echolucent pseudocavity that partially occupied the RV and communicated with the true RV cavity. Multislice computed tomography characterized in detail the IVS and RV wall dissection, and further showed the right coronary artery in the outer border of the RV and pseudocavity, excluding pericardial fluid. Despite surgical correction, progression to cardiogenic shock and death occurred 33 days after admission.

[Anomalous origin of the right coronary artery and acute myocardial infarction: cause or coincidence?]. / Origem anómala da coronária direita e enfarte agudo do miocárdio: causa ou coincidência?

Congenital coronary artery anomalies are one of the causes of myocardial ischemia and sudden death in the young, mainly during sports. Origin of the right coronary artery from the left anterior descending artery is very rare, with a prevalence of 0.015%, corresponding to 1.2% of all coronary artery anomalies. The authors present the case of a 22-year-old man, with a history of cocaine use, admitted to hospital with a non-ST elevation acute myocardial infarction. Coronary angiography revealed the presence of this rare coronary anomaly and the absence of atherosclerotic luminal stenosis, and so it was assumed to be a type II infarction caused by cocaine-induced vasospasm of the anomalous vessel.

Successful Percutaneous Management of Iatrogenic Left Main Coronary Artery and Ascending Aorta Dissection.

Iatrogenic left main coronary artery and aortic root dissection is a rare but life-threatening complication of percutaneous coronary intervention. This is a case where this complication was induced by catheter manipulation. Prompt percutaneous closure of the dissection point of entry was effective in managing this complication. (Level of Difficulty: Advanced.).

Heart Failure Incidence Following ST-Elevation Myocardial Infarction.

ST-elevation myocardial infarction (STEMI) survivors have a heightened risk of developing heart failure (HF). The magnitude of this risk with the advent of primary percutaneous coronary intervention is less characterized. We aimed to examine the incidence and predictors of incident HF and all-cause mortality in a contemporary STEMI cohort. We performed a retrospective analysis of 700 consecutive patients with STEMI treated with primary percutaneous coronary intervention at a tertiary hospital. The primary outcome was the occurrence of HF during follow-up. HF was defined by HF hospitalization or the presence of congestion that led to de novo prescription or up-titration of diuretics in the outpatient clinic. The secondary outcome was defined by the occurrence of HF or all-cause mortality. During a median follow-up period of 43.6 months, HF events occurred in 110 patients (15.7%), 34 (4.8%) managed as outpatient and 76 (10.9%) requiring hospitalization. Left ventricular ejection fraction (LVEF) <50% was present in 76% of those who developed HF. Age (hazard ratio [HR] 1.03, 95% confidence interval [CI] 1.01 to 1.06), diabetes (HR 1.85, 95% CI 1.12 to 3.05), door-to-balloon time (HR 1.002, 95% CI 1.000 to 1.003), Killip-Kimball class ≥II (HR 2.24, 95% CI 1.32 to 3.80) and LVEF <50% (HR 1.71, 95% CI 1.01 to 2.92) were independent predictors. All-cause mortality incidence was 8.7%. HF was independently associated with a threefold increased risk of dying (HR 3.52, 95% CI 1.85 to 6.69, p <0.001). In conclusion, a substantial proportion of contemporary patients with STEMI develop HF, which triplicates the risk of dying. Older age, diabetes and LVEF <50% independently predicted the development of HF and all-cause death.