Infarto agudo de miocardio sin enfermedad coronaria ateroesclerótica obstructiva: utilidad de las imágenes intravasculares y resonancia cardíaca en su diagnóstico

Background: Myocardial infarction with non-obstructive coronary artery disease (MINOCA) is common. Cardiac magnetic resonance (CMR) and intravascular imaging (IVI) may be useful for establishing its etiology. Aim: To describe a population with MINOCA and its multi-image assessment using IVI or CMR. Material and Methods: Review of medical records, imaging and functional studies of patients with MINOCA treated in three different clinical centers between 2015 and 2019. Results: Twenty-eight patients with MINOCA and IVI were included. Seventy eight percent were women, 46% had hypertension, 32% smoked and 32% had dyslipidemia. At wall motion assessment, 46% presented apical ballooning pattern. In 36% of patients IVI identified lesions that explained the cause of MINOCA, namely plaque disruption (PD) in 18%, spontaneous coronary dissection in 11% and a thrombus without PD in 7%. Forty-six percent of patients had uncomplicated atherosclerotic plaques, and 36% had no pathological findings. CMR was performed in 50% of patients, identifying in all a diagnostic pattern. In nine cases it was compatible with stress cardiomyopathy, three cases had a myocarditis and two cases had transmural infarctions. PD and transmural late gadolinium enhancement were observed in 23% of patients with apical ballooning. Patients with a pattern of myocarditis did not have acute pathological findings at IVI. After a mean follow-up of 16.4±11.4 months, 3 patients with PD died. Conclusions: Among patients with MINOCA, there was a predominance of female gender with low cardiovascular risk factor load. The multi-image assessment allowed greater precision for etiological diagnosis of MINOCA. Apical ballooning was not pathognomonic for stress cardiomyopathy. PD was associated with mortality.

[Myocardial infarction with non-obstructive coronary artery disease. Diagnostic value of intravascular imaging and cardiac resonance]. / Infarto agudo de miocardio sin enfermedad coronaria ateroesclerótica obstructiva: utilidad de las imágenes intravasculares y resonancia cardíaca en su diagnóstico.

BACKGROUND: Myocardial infarction with non-obstructive coronary artery disease (MINOCA) is common. Cardiac magnetic resonance (CMR) and intravascular imaging (IVI) may be useful for establishing its etiology. AIM: To describe a population with MINOCA and its multi-image assessment using IVI or CMR. MATERIAL AND METHODS: Review of medical records, imaging and functional studies of patients with MINOCA treated in three different clinical centers between 2015 and 2019. RESULTS: Twenty-eight patients with MINOCA and IVI were included. Seventy eight percent were women, 46% had hypertension, 32% smoked and 32% had dyslipidemia. At wall motion assessment, 46% presented apical ballooning pattern. In 36% of patients IVI identified lesions that explained the cause of MINOCA, namely plaque disruption (PD) in 18%, spontaneous coronary dissection in 11% and a thrombus without PD in 7%. Forty-six percent of patients had uncomplicated atherosclerotic plaques, and 36% had no pathological findings. CMR was performed in 50% of patients, identifying in all a diagnostic pattern. In nine cases it was compatible with stress cardiomyopathy, three cases had a myocarditis and two cases had transmural infarctions. PD and transmural late gadolinium enhancement were observed in 23% of patients with apical ballooning. Patients with a pattern of myocarditis did not have acute pathological findings at IVI. After a mean follow-up of 16.4±11.4 months, 3 patients with PD died. CONCLUSIONS: Among patients with MINOCA, there was a predominance of female gender with low cardiovascular risk factor load. The multi-image assessment allowed greater precision for etiological diagnosis of MINOCA. Apical ballooning was not pathognomonic for stress cardiomyopathy. PD was associated with mortality.

Percutaneous Intervention of Coronary Aneurysm.

The coronary artery aneurysm (CAA) is not a frequent condition in the catheterization laboratory. The management is uncertain. Most of the cases, the treatment is surgical with good results. In smaller aneurysm, the use of covered stents is an alternative. This is an anterograde approach CTO (chronic total occlusion) case of a middle segment RCA (right coronary artery) with a thrombosed coronary aneurysm. This was occluded due to thrombus as a result of a STEMI five months ago. In this case, we used a covered stent with good results in follow up to five months.

Amiloidosis cardíaca: a propósito de un caso / Case report: cardiac amyloidosis

La amiloidosis corresponde a un conjunto de enfermedades que tienen en común el depósito de amiloide en uno o más órganos. El hallazgo típico del compromiso cardíaco secundario a la amiloidosis es la presencia de insuficiencia cardíaca rápidamente progresiva. La historia natural de esta enfermedad en ausencia de tratamiento es de un rápido compromiso con alta mortalidad. Reportamos el caso de una paciente con esta enfermedad, describiendo su historia, manejo y seguimiento.

Cardiac amyloidosis refers to a set of diseases characterized by amyloid deposit in one or more organs. The typical finding of cardiac involvement secondary to amyloidosis is the presence of rapidly progressive heart failure. The natural story of this disease in the absence of treatment leads to rapid deterioration with a high mortality rate We report the case of a patient with amyloidosis and cardiac invol-vement, describing the clinical history, management and follow up.

Utilidad de la tromboaspiración manual de rutina durante la angioplastía primaria en la preservación del flujo microvascular / Routine thrombi aspiration during primary anngioplasty does not improve micro vascular flow compared to conventional angioplasty in ST elevation myocardial infarction

Antecedentes: La efectividad de la aspiración de trombos de rutina en una angioplastía primaria (AP) es controversial. Objetivo: Evaluar la efectividad de la aspiración de rutinaria de trombos durante la AP en la preservación del flujo microvascular final, estratificada por horas de presentación. Métodos: Realizamos un ensayo clínico prospectivo randomizado de 122 pacientes que se presentaron al Hospital Sótero del Río con infarto agudo al miocardio con upradesnivel del ST (IAM c/SDST) a AP + aspiración o sólo AP, evaluando el flujo microvascular final. Resultados: Se randomizaron 59 pacientes a AP + aspiración y 63 a sólo AP En el grupo de aspiración hubo menor empleo de pre-dilatación (46.4% vs 80.3 por ciento; p=0.01) y menor necesidad de realizar técnicas complejas de bifurcación (3.6 por ciento vs 15.2 por ciento; p=0.03). No observamos diferencias en el flujo microvascular final medido por conteo de cuadros TIMI (cTFC) (25.6 +/- 11.8 vs 24.8 +/- 10.9; p=0.12). No hubo diferencias en el flujo microvascular final, de acuerdo al tiempo de presentación: < 3 horas de IAM c/SDST (cTFC 22.3 +/- -9.1 vs 22.4 +/--8; p= 0.2) y > 3 horas de IAM c/SDST (cTFC 27.7 +/- 13.4 vs 25.9 +/- 11.6; p= 0.08). Conclusion: En nuestra experiencia, no hay mejoría del flujo microvascular final en la tromboaspiración manual de rutina durante la AP como tampoco en el subgrupo de presentación precoz. La menor predilatación y el menor uso de técnicas complejas de bifurcación, podría traducir una angioplastía técnicamente más fácil al aspirar el trombo y permitir una mejor visualización del vasoculpable.

Background. There is controversy regarding the effectiveness of thrombi aspiration during primary angioplasty for ST elevation myocardial Aim: to evaluate the effect of routine aspiration of thrombus upon micro vascular flow, both overall and according to the time from initial pain to intervention. Method: 122 patients admitted to a general hospital for acute ST elevation myocardial infarction were prospectively randomized to undergo coronary angioplasty (PTCA) with prior aspiration of thrombi or PTCA alone. The final micro vascular flow was compared between groups. A similar analysis compared patients presenting before or after 3 hours from de initial pain. Results: 59 patients underwent thrombi aspiration followed by PTCA (A+PTCA) and 63 PTCA alone (PTCA). Compared to the PTCA group, the A+PTCA group required less frequently balloon pre-dilation. (46.4 percent vs 80.3 percent; p=0.01) and a need for complex angioplasty of bifurcation lesions (3.6 percent vs 15.2 percent; p=0.03). No difference was observed in final micro vascular flow assessed by cTFC between corresponding groups (25.6 +/- 11.8 vs 24.8 +/- 10.9; p=0.12). Compared to Group A+PTCA, patients undergoing PTCA alone had no difference in final micro vascular flow, irrespective of time from initial pain to PTCA: cTFC 22.3 +/- -9.1 vs 22.4 +/--8 in those treated <3 hours from initial pain and 27.7 +/- 13.4 vs 25.9 +/- 11.6, in those treated >= 3 hr after initial pain, respectively. Conclusion: Manual thrombi aspiration before PTCA in patients with ST elevation myocardial infarction did not improve micro vascular flow, regardless of the time from initial pain to primary PTCA. The lesser need for complex angioplasty and balloon pre-dilatation in patients undergoing thrombi aspiration may reflect a better visualization of affected arteries during PTCA.