Balloon assisted hematoma fenestration in spontaneous coronary artery dissection. Case presentation and literature review.

The management of spontaneous coronary artery dissection (SCAD) is lacking randomized data. This also holds for SCAD with ST-segment elevation myocardial infarction where stenting has been used to restore coronary flow. This approach can be associated with many drawbacks. Therefore, we present an alternative approach to stenting when coronary flow cannot be restored using cutting balloons alone.

Atypical Carcinoid Syndrome in a Patient Presenting With Pericarditis and Supraventricular Tachycardia: A Case Report.

Atypical carcinoids are more uncommon than typical carcinoids, and carcinoid syndrome in general is quite rare. Mediastinal atypical carcinoid is a rare neuroendocrine tumor (NET) that spreads aggressively and rapidly. Morphologically, neuroendocrine tumors are classified into typical carcinoid, atypical carcinoid, small cell carcinoma, and large cell neuroendocrine carcinoma, and the latter two are high-grade tumors. The incidence of atypical carcinoid is rare, and the prognosis is poor, which makes larger trials difficult. It may affect the liver, lungs, or mediastinum with or without metastasis. We present a case of a 47-year-old male patient who presented with chest pain and was found to be in supraventricular tachycardia (SVT) on initial presentation to the hospital. A repeat electrocardiogram (ECG) showed widespread ST-segment elevation. A bedside echocardiogram showed a moderate pericardial effusion, and the patient underwent a coronary angiogram, which showed normal coronary arteries. A computed tomography pulmonary angiogram (CTPA) showed a right mediastinal mass, and the patient was referred to oncology following a discussion in a multidisciplinary team (MDT) meeting. He was commenced on neoadjuvant chemotherapy and has been followed up since in the outpatient clinic. This case is unique due to the initial presentation of supraventricular tachycardia and pericardial effusion.

Tachycardia-Induced Cardiomyopathy in a Young Healthy Patient: A Case Report.

Tachycardia-induced cardiomyopathy (TIC) can result in both systolic and/or diastolic ventricular dysfunction as a result of the prolonged fast heart rate which is reversible upon controlling the fast heart rate or arrhythmia. The exact heart rate that can lead to this is not clear, however, a heart rate > 100 in general needs attention. Tachycardia-induced cardiomyopathy is a well-established cause of left ventricular dysfunction which usually happens due to an increased atrial or ventricular rate. The incidence of TIC is very low although the exact incidence is unclear. It should be considered in all patients with dilated cardiomyopathy or those with no obvious explanation for dilated cardiomyopathy and in presence of tachycardia or atrial fibrillation with a rapid ventricular response. Tachycardia-induced cardiomyopathy has also been labeled as arrhythmia-induced cardiomyopathy lately. We present a case of a 50-year-old patient who presented with a fever of 39oC, feeling generally unwell, had a sore throat, and collapsed at home after several episodes of vomiting after two days of intense exercise. He was diagnosed with suspected tonsillitis and was treated with co-amoxiclav. He was exercising over 10 hours weekly for the last two months in the gym for the Ironman triathlon in London. An echocardiogram showed severe left ventricular systolic dysfunction (LVSD) with a left ventricular ejection fraction (LVEF) of 25%. An electrocardiogram showed sinus tachycardia with a right bundle branch block (RBBB). Cardiac magnetic resonance imaging (CMR) showed normal biventricular function with an ejection fraction (EF) of 71% four months later. The patient was diagnosed with tachycardia-induced cardiomyopathy. This case is unique as the patient presented with transient severe LVSD after training for the ironman triathlon and spontaneous recovery.

Worsening Heart Failure and Atrial Flutter in a Patient Secondary to Cardiac Resynchronization Therapy Dyssynchrony: A Case Report.

Cardiac resynchronization therapy-defibrillator (CRT-D) and/or cardiac resynchronization therapy-pacemaker (CRT-P) play an important role in improving cardiac synchronization and reducing the risk of ventricular fibrillation arrest (VFA) in patients with severe left ventricular systolic dysfunction (LVSD). Patients with LVSD may notice worsening symptoms when CRT-D or CRT-P is in dyssynchrony. We present a case of 59-year-old patient who presented with worsening shortness of breath (SOB) and progressive exertional dyspnea for the past few weeks accompanied by pink, frothy sputum, occasional urinary incontinence and urge. He was known to have severe LVSD with an ejection fraction of 10% and had CRT-D in situ. Clinical examination revealed bilateral crepitation and normal heart sounds. A chest radiograph showed pulmonary oedema. An electrocardiogram (ECG) showed atrial fibrillation (AF)/flutter with wide QRS complexes. The patient was treated for acute pulmonary oedema and had CRT-D reprogrammed to achieve biventricular synchrony. He was treated with intravenous furosemide and alternate day metolazone initially. He showed significant subjective and objective improvement and was planned for outpatient synchronized intra-device cardioversion. This case is important because patients with severe LVSD with malfunctioning cardiac resynchronization therapy can result in worsening heart failure (HF) leading to higher morbidity and mortality.

COVID-19 Vaccine-Induced Thrombotic Thrombocytopaenia With Venous and Arterial Thrombosis: A Case Report.

Coronavirus disease 19 pandemic has put tremendous pressure on health systems and has caused significant morbidity and mortality throughout the world. Vaccination program against COVID-19 has been effective despite repeated outbreaks across the globe. It was however reported that COVID-19 vaccines in particular, the Oxford-AstraZeneca COVID-19 vaccine (AZD1222) was temporarily suspended by some European countries due to risk of thrombosis. COVID-19 is a prothrombotic condition and is associated with venous thromboembolism mainly. The condition can be challenging to diagnose due to its diagnostic variation. Cases of vaccine-induced thrombotic thrombocytopaenia has been reported in several countries. COVID-19 can also cause vaccine-induced thrombosis without thrombocytopaenia. The thrombotic events can affect different parts of the body including brain, heart, and peripheral vessels. We present a case of 54-year-old patient who presented with chest and abdominal pain for 12 hours and evidence of infero-lateral ST segment elevation on electrocardiogram. Patient received COVID-19 AstraZeneca vaccine 10 days prior to admission. Coronary angiography (CAG) showed occlusion of the proximal to mid part of the right coronary artery (RCA) distal to a large Right Ventricular branch with high thrombotic burden and multiple attempts at aspiration of the thrombus resulted in partial restoration of the flow to right coronary artery.

Can Tiger (TIG) Catheters Be a Solution to the Radial Artery Spasm (RAS) in Coronary Angioplasty? A Case-Based Report of Successful Reperfusion With the Use of 5-French (Fr) TIG Catheter and Literature Review.

Conventionally, during a primary percutaneous coronary intervention (PPCI), a diagnostic catheter is used to visualize the contralateral coronary system from the site of the acute occlusion. For that purpose, Judkins Right 4 (JR4) or Judkins Left 3.5 (JL3.5) diagnostic catheters are usually preferred, depending on the ECG findings. On the other hand, the use of a dedicated diagnostic catheter in the setting of PPCI is supported only by evidence extrapolated from coronary angiography on patients with stable coronary artery disease. We present a case of a 46-year-old patient who presented with ST-segment elevation myocardial infarction (STEMI) and underwent successful PPCI. A 6-French (Fr) radial sheath was placed in the right radial artery. Due to the presence of ST-segment elevation in both the inferior as well as in the anterior precordial leads, raising the possibility of a wrap-around left anterior descending (LAD) artery as the infarct-related artery, a 5-Fr Tiger (TIG) diagnostic catheter was initially used for cannulation of the left coronary system. The culprit lesion was identified in the proximal part of a small second right ventricular (RV) branch where it was 100% occluded with thrombus and the patient had a successful PPCI.

A Case Report of Large Bilateral Pulmonary Embolism in a Patient With Janus Kinase 2 (JAK2) Positive Mutation.

Venous thromboembolism may be the primary presentation in patients with polycythaemia vera (PV) and essential thrombocythemia. Most patients get diagnosed with polycythaemia vera after presenting with venous or arterial thromboembolism in the first place. Most patients tend to develop thrombosis just before or at the time of diagnosis, and this risk decreases over time. Patients aged >60 years with a history of previous thrombosis, elevated haematocrit, and leukocytosis are most at risk of thrombosis. We report a case of a 74-year-old patient presenting with shortness of breath for three days. A computerized tomography pulmonary angiogram showed bilateral pulmonary emboli with right heart strain. He underwent emergency EkoSonic™ endovascular system-directed thrombolysis (EKOS™, Boston Scientific, Marlborough, MA). The patient tested positive for the Janus kinase 2 gene mutation (JAK2), met two major and one minor criterion for PV, and was discharged home on oral anticoagulation. The Janus kinase 2 (JAK2V617F) mutation is quite common in patients with polycythaemia vera, thrombocythemia, and myelofibrosis, and these patients are at risk of both arterial and venous thrombosis, hence they require long-term follow-up.

An Unusual Presentation of Type B Aortic Dissection as Out-of-Hospital Cardiac Arrest Complicated by Spinal and Renal Ischaemia Along With Atrial Fibrillation, Stroke, and Severe Stenosis in Obtuse Marginal Branch: A Therapeutic Dilemma.

Aortic dissection (AD) is a catastrophic cardiovascular problem that can be challenging to diagnose sometimes. Despite diagnostic challenges, it requires a high degree of suspicion and prompt treatment is vital to its successful management. AD can be divided into type A aortic dissection (TAAD) and type B aortic dissection (TBAD). TAAD is characterised by dissection in the ascending aorta whereas TBAD does not have dissection in the ascending aorta. TBAD is usually managed conservatively, and patients receive medical therapy such as antihypertensive medications, analgesia, and rehabilitation. This, however, is complicated by malperfusion of certain organs, which can be life-threatening. Patients who have malperfusion of certain organs should be managed aggressively and endovascular aortic repair should be considered in such cases. We present a case of a 63-year-old patient who presented with out-of-hospital pulseless electrical activity cardiac arrest and was successfully resuscitated. An electrocardiogram showed new-onset atrial fibrillation with ST-segment depression and a coronary angiogram showed severe stenosis in the obtuse marginal branch of the left circumflex artery. A computed tomography scan of the thorax and abdomen showed TBAD with an occluded right renal artery and the patient was conservatively managed. The patient was discharged home after prolonged hospital admission and was conservatively managed for TBAD. This case was complicated by the fact that the patient had an out-of-hospital cardiac arrest and a coronary angiogram showed severe stenosis in the obtuse marginal branch of the left circumflex artery. The patient also had new-onset atrial fibrillation, which made his clinical management very challenging. It is important to avoid unnecessary coronary intervention that can create more challenges in managing such patients.

Intracoronary bolus of glycoprotein IIb/IIIa inhibitor as bridging or adjunctive strategy to oral P2Y12 inhibitor load in the modern setting of ST-elevation myocardial infarction.

BACKGROUND: In the acute management of ST-elevation myocardial infarction (STEMI), glycoprotein IIb/IIIa inhibitors (GPIs) bolus not followed by intravenous infusion is potentially advantageous given their fast onset and offset of action, but clinical evidence in a contemporary setting is limited. METHODS: We collected data from consecutive STEMI patients admitted to the cardiac catheterization laboratory of the IRCCS A. Gemelli University Polyclinic Foundation from October 2017 to September 2019. RESULTS: Out of 423 consecutive STEMI patients, 297 met the inclusion and exclusion criteria and were included in the study. Of them, 107/297 (36%) received an intracoronary GPI bolus-only during primary percutaneous coronary intervention (PPCI) not followed by intravenous infusion and 190/297 (64%) received standard antithrombotic therapy. Of the 107 GPI-treated, 22/107 (21%) had P2Y12 inhibitor pretreatment (adjunctive strategy) and 85/107 (79%) did not (bridging strategy). During hospital staying, there was no difference in the primary safety endpoint of TIMI major+minor bleeding (P=0.283), TIMI major (P=0.267) or TIMI minor (P=0.685) bleeding between groups. No stroke event occurred in the GPI group. Despite patients receiving GPI having a significantly higher intraprocedural ischemic burden, no significant differences were found in the efficacy outcomes between groups. Consistent findings were observed for patients receiving GPIs bolus before (bridging strategy) or after (adjunctive strategy) P2Y12 inhibitors, compared to those receiving standard therapy. Multivariate logistic regression analyses did not find any independent predictors significantly associated to the primary and secondary composite endpoints. CONCLUSIONS: In a contemporary real-world population of STEMI patients undergoing PPCI, the use of intracoronary GPIs bolus-only in selected patients at high ischemic risk is safe and could represent a useful antithrombotic strategy both in those pretreated and in those naïve to P2Y12 inhibitors.

Left Main Trifurcation and Its Percutaneous Treatment: What Is Known So Far?

In humans, the most common anatomic variation of the left main (LM) stem is represented by its distal division in 3 branches (LM trifurcation) instead of 2. LM trifurcation disease accounts for ≈10% to 15% of all LM diseases and is often managed by cardiac surgery. Over the last decades, due to the improvement of interventional material and techniques, percutaneous coronary intervention started gaining acceptance to treat patients with LM disease including those with trifurcated anatomy. Yet, LM trifurcation stenosis with its intrinsic anatomic complexity (3 branches, at least 4 angles, wide variability in branch size and disease) is recognized as a challenging lesion subset for percutaneous coronary intervention. In this review, we summarize available data about LM trifurcation anatomy, its influence on percutaneous coronary intervention feasibility, and the evidence collected regarding the different technical options (including trissing balloon inflation).