Multiple systemic thromboembolism secondary to acute myocardial infarction in a young patient with coronavirus disease 2019 pneumonia: A case report.

Coronavirus disease 2019 (COVID-19) is associated with an increased risk of thromboembolic events. However, there are few reports on multiple thromboembolic events in young patients with COVID-19. Herein, we report a case of multiple visceral arterial embolisms secondary to acute myocardial infarction in a young patient with COVID-19. A 36-year-old male developed sudden chest pain after being diagnosed with COVID-19. Emergency coronary angiography revealed total occlusion of the right coronary artery, and the patient underwent a subsequent emergency percutaneous coronary intervention (PCI) which achieved successful recanalization. The patient was administered a loading dose and a subsequent maintenance dose of aspirin and prasugrel and a continuous intravenous infusion of unfractionated heparin at 10,000 units per day. Echocardiography detected a left ventricular apical thrombus 3 days after PCI; a loading dose of warfarin was administered and promptly reached the therapeutic range. However, the patient developed superior mesenteric artery embolism and renal infarction on the 12th day after PCI. COVID-19 was considered to play a role in the thromboembolic events observed in this patient. This case highlights the need for individualized antithrombotic regimens when managing patients with COVID-19 who develop acute myocardial infarction. Learning objective: Reportedly, coronavirus disease 2019 (COVID-19) is associated with an increased risk of venous and arterial thromboembolic events. However, few reports have described multiple thromboembolic events in younger patients with COVID-19. This case report describes arterial thromboembolism secondary to acute myocardial infection (AMI) in a patient with COVID-19. It highlights the need for individualized antithrombotic regimens when managing patients with COVID-19 who develop AMI.

Efficacy and safety of sheathless guiding catheter for distal radial approach.

OBJECTIVES: This study aimed to assess the efficacy and safety of a sheathless guiding system in patients who underwent percutaneous coronary intervention (PCI) with distal radial access (DRA). BACKGROUND: Hyperion™ Sheathless® guiding catheter (Asahi Intecc, Japan), one of the latest 6-Fr guiding systems for transradial PCI characterized by novel outer dilator, is considered to facilitate smooth insertion of the catheter to the artery and may contribute to further reduction of access site complications in DRA. METHODS: Between October 2018 and January 2023, 286 patients underwent PCI with a Hyperion™ Sheathless® guiding catheter with DRA at two Japanese hospitals. Procedural success, bleeding complications, and radial artery occlusion (RAO) detected by Doppler ultrasonography were assessed. RESULTS: Mean age of the patients was 72.7 years, and 236 patients (82.5 %) were male. The target lesions were located in the right coronary artery, left anterior descending artery, left circumflex artery, and left main trunk in 81, 44, 50 patients, and 18 patients respectively. Procedural success rate was 99.7 % with no patients requiring conversion to conventional radial access. Two patients presented with a forearm hematoma equivalent to an Early Discharge After Transradial Stenting of Coronary Arteries Study hematoma classification Grade II and 23 with Grade I. No patient presented minor or major bleeding according to the Thrombolysis in Myocardial Infarction bleeding classification. RAO at 30-day follow-up was observed in 6 out of 277 patients (2.2 %). CONCLUSIONS: 6-Fr sheathless guiding system for PCI via DRA is feasible and associated with a low incidence of access site complications.

Vascular Complications of Percutaneous Coronary Intervention Via Distal Radial Artery Approach in Patients With Acute Myocardial Infarction With and Without ST-Segment Elevation.

OBJECTIVES: Distal radial artery (DRA) access is a novel alternative to conventional radial artery access for coronary catheterization. This study investigated the incidence of vascular complications with percutaneous coronary intervention (PCI) from DRA access among patients with acute myocardial infarction (AMI) with and without ST-segment elevation. METHODS: Between April 2018 and October 2019, a total of 131 consecutive patients underwent primary PCI for AMI, among whom DRA access was used in 116 (88.5%), comprising 77 with ST-segment elevation myocardial infarction (STEMI) and 39 with non-ST-segment elevation myocardial infarction. The mean patient age was 70.4 ± 12.9 years and 71.6% were male. Right DRA was used in 110 patients (94.8%). A 5 or 6 Fr sheath was used in the PCI procedure. Patient backgrounds, procedural characteristics, and procedural complications were retrospectively analyzed. Patency of the radial artery was examined using Doppler ultrasound. RESULTS: Minor bleeding (Bleeding Academic Research Consortium [BARC] 2) was observed in 2 patients (1.7%) while no major bleedings (BARC 3a, 3b, 3c, and 5) were observed. On the Early Discharge After Transradial Stenting of Coronary Arteries Study (EASY) hematoma scale, a grade III hematoma (≥10 cm) was observed in 1 patient (0.9%), and no patients with hematoma were > grade IV. Doppler ultrasound of the radial artery was performed on 95 patients (81.9%). The incidence of radial artery occlusion was 1.1% (n = 1). The door-to-balloon time for STEMI patients was 40.0 ± 30.8 minutes. CONCLUSIONS: The current study demonstrated that DRA access was associated with a low incidence of access-site complications within optimal revascularization time among patients with AMI who underwent PCI.

Impact of the SARS-CoV-2 Pandemic on Primary Percutaneous Coronary Intervention for Patients with ST-Elevation Myocardial Infarction.

During the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, patients with ST-elevation myocardial infarction (STEMI) should be treated as possibly infected individuals. Therefore, more time is considered necessary to conduct primary percutaneous coronary intervention (PCI). In this study, we sought to evaluate the impact of the SARS-CoV-2 pandemic on primary PCI for STEMI. Between March 2019 and March 2021, 259 patients with STEMI underwent primary PCI. Patients were divided into 2 groups: the pre-pandemic group (March 2019-February 2020) and the pandemic group (March 2020-February 2021). The patient demographics, reperfusion time including onset-to-door time, door-to-balloon time (DTBT), computed tomography (CT), peak creatinine phosphokinase (CPK), and 30-day mortality rate were investigated. The mean age of the patients was 70.4 ± 12.9 years, and 71.6% were male. There were 117 patients before the pandemic and 142 during the pandemic. The median DTBT was 29 (21.25-41.25) minutes before the pandemic and 48 minutes (31-73 minutes) during the pandemic (P < 0.001). The median door-to-catheter-laboratory time was 13.5 (10-18.75) minutes before the pandemic and 29.5 (18-47.25) minutes during the pandemic (P < 0.001). CT evaluation was performed before PCI in 39 (33.3%) patients and 63 (44.4%) patients (P = 0.08); their peak CPK levels were 1480 (358-2737.5) IU and 1363 (621-2722.75) IU (P = 0.56), and the 30-day mortality rates were 4.3% and 2.1% (P = 0.48), respectively. The SARS-CoV-2 pandemic changed the diagnostic procedure in the emergency department and affected the DTBT in patients with STEMI. Nonetheless, no adverse effects on the 30-day mortality rate were observed.

Feasibility and safety of the successive use of distal transradial access for coronary angiography and intervention in the same arm.

Distal transradial access (dTRA) is a novel alternative to conventional radial artery access for coronary catheterization. However, the feasibility and safety of repeated use of dTRA have not been fully elucidated. This study aimed to evaluate the feasibility and safety of the repeated use of dTRA for coronary angiography and intervention in the same arm. A total of 1717 patients underwent angiography or angioplasty via dTRA. We retrospectively analyzed the catheterization records of patients who underwent repeated puncture of the distal radial artery in the same arm. The incidence of successive applications of dTRA and the reasons for dropout were retrospectively investigated. A total of 416 patients, including three who underwent coronary catheterization with the bilateral dTRA in the initial attempt were analyzed. A 3-, 4-, 5-, or 6-French sheath or sheathless guide catheter was used in the initial procedure. A maximum of four successive coronary catheterization procedures were performed. The second procedure with dTRA on the same arm was successfully performed in 395 cases (94.3%), with a successive rate of 89.6% for both the third and fourth dTRA procedures. Conversion to another approach site (n = 30) was attributed to radial artery occlusion (n = 9), narrowing of the distal radial artery (n = 19), and puncture failure (n = 2). The current data indicate that the repeated use of dTRA is safe and feasible, and this approach may become a standard approach site in the future.

Evaluation of the Determinant Factors and Clinical Implications of Self-Care Agency Among Patients with Acute Myocardial Infarction.

In patients with acute myocardial infarction treated with percutaneous coronary intervention (PCI), effective post-hospital care, partially determined by self-care agency, is critical for long-term prognosis. However, the relationship between agency and sociodemographic characteristics requires elucidation. One hundred and six outpatients participated in our study. Self-care agency was assessed with the Self-care Agency Questionnaire (SCAQ). We evaluated its correlation with patients' sociodemographic characteristics and morale on the Ikigai-9 Questionnaire. Mean SCAQ scores were higher in those who were younger, male, living with someone, and more educated compared to their counterparts. Furthermore, SCAQ scores were correlated with Ikigai-9 scores. Multivariate logistic regression analyses indicated that social participation, employment status, and morale were independent predictors of high SCAQ scores. A comprehensive approach utilizing medical professionals, families, and the local community is needed to promote self-care agency in patients receiving primary PCI.

Efficacy and safety of the distal transradial approach in coronary angiography and percutaneous coronary intervention: a Japanese multicenter experience.

The novel distal transradial approach (dTRA) is expected to further build upon the advantages of transradial access. However, the incidence of radial artery occlusion (RAO) and hemorrhagic events with the dTRA has not been fully elucidated. The objective of this study was to investigate the effects of using the dTRA on RAO and postprocedural hemorrhage. From April 2018 to July 2018, 228 consecutive patients who underwent coronary angiography or intervention through the dTRA at two hospitals were analyzed. The RAO rate, change in the forearm and distal radial artery diameter and cross-section area after the dTRA (at 1 day and 1 month) on vascular ultrasonography, and incidence of hemorrhagic complications were investigated. Forearm and distal RAO occurred in 1 (0.4%) and 8 (3.1%) patients at 1 month, respectively. No forearm hematomas occurred. Ultrasonographic findings indicated that the radial artery diameter and cross-section area were significantly larger after the dTRA (2.9 ± 0.5 mm vs. 2.7 ± 0.5 mm, p < 0.001 and 6.5 ± 2.4 mm2 vs. 5.6 ± 2.0 mm2, p < 0.001, respectively). The distal radial artery diameter and cross-section area in the anatomical snuffbox were also significantly larger after the dTRA (2.5 ± 0.5 mm vs. 2.3 ± 0.4 mm, p < 0.001 and 4.7 ± 2.0 mm2 vs. 4.2 ± 1.6 mm2, p < 0.001, respectively). The DTRA was associated with a low incidence of RAO at both the puncture site and the forearm, postprocedural dilatation of the radial artery, and no bleeding complications extending to the forearm.

Impact of living alone on the care and outcomes of patients with ST-elevation myocardial infarction.

BACKGROUND: This study aimed to investigate the association between living alone at home and the care and outcomes of patients with ST-segment elevation myocardial infarction (STEMI) who underwent primary percutaneous coronary intervention (pPCI). METHODS: In total, 557 patients with STEMI underwent pPCI between January 2008 and September 2017. Among them, we included 208 patients who were transferred directly by emergency medical services from their home to the hospital. RESULTS: Patients were classified into two groups, namely living alone (n = 45) and living with others (n = 163). There were no significant differences in age, sex, and cardiovascular risk factors between the two groups. The onset-to-door (OTD) and onset-to-balloon times were significantly shorter in patients living with others than in those living alone (106.4 vs. 190.8 min, p < 0.01 and 152.3 vs. 236.9 min; p < 0.01, respectively). The left ventricular ejection fraction after pPCI was significantly lower in patients living alone than in those living with others (48.7 % vs. 54.9 %, p < 0.01). Multivariate logistic regression analysis indicated that living alone and the incidence of congestive heart failure were independent predictors of a longer OTD time. CONCLUSIONS: Patients living alone were less likely to arrive early at the hospital than those living with others. A greater understanding of the inter-relationships among living alone, access to acute cardiac care, and outcomes is essential.

Pseudoaneurysm Formation After Cardiac Catheterization Using the Distal Transradial Approach.

This is the first case report of pseudoaneurysm formation after cardiac catheterization through the distal radial artery, which was easily treated by external compression.

The impact of tissue characterization for in-stent restenosis with optical coherence tomography during excimer laser coronary angioplasty.

We aimed to evaluate the impact of tissue characterization for in-stent restenosis (ISR) with optical computed tomography (OCT) during excimer laser coronary angioplasty (ELCA) in the drug-eluting stent (DES) era. The effect of ELCA for ISR according to differences in tissue characteristics is unclear. Fifty-three ISR lesions (7 bare metal stents and 46 drug-eluting stents) were treated with an ELCA catheter. After ELCA, balloon dilatation with either the scoring or non-compliant balloons was conducted. The procedure was completed by applying a drug-coated balloon. Tissue characterization and lumen measurement with OCT were performed thrice: (1) before percutaneous coronary intervention (PCI), (2) after ELCA, and (3) and after the procedure. Lesions were categorized into the homogenous, layered, and mixed groups. Follow-up angiograms were conducted 6-12 months after PCI. No significant differences in minimal lumen area (MLA) were observed before PCI. A significant difference was observed in MLA after ELCA among the three groups (homogeneous group: 1.75 ± 0.84 mm2, layered group: 1.72 ± 0.45 mm2, mixed group: 2.24 ± 0.70 mm2, P = 0.048). Final MLA was larger in the mixed group than in the homogeneous group (P = 0.028). No significant difference was observed in binary restenosis in the follow-up angiogram (homogeneous group 55.5%, layered group 33.3%, mixed group 33.3%; P = 0.311) and the target lesion revascularization rate (homogeneous 30.0%, layered 23.8%, mixed 25.0%; P = 0.923). Tissue characterization by OCT may predict the efficacy of ELCA and balloon angioplasty for ISR during the acute phase.

Impact of shorter door-to-balloon time on prognosis of patients with STEMI-single-center analysis with a large proportion of the patients treated within 30 min.

Several recent studies suggested that the door-to-balloon time (DTBT) for patients with ST-segment elevation myocardial infarction (STEMI) should be as short as possible, despite the existing guideline for STEMI. This study aimed to evaluate the clinical outcomes of the STEMI patient cohort having the highest proportion of patients treated with a DTBT of ≤ 30 min ever reported. We evaluated 527 consecutive patients with STEMI who underwent percutaneous coronary intervention between 2007 and 2015. The mean age was 68.0 ± 12.7 years, and the mean DTBT was 44.4 ± 33.1 min. The patients were classified into four groups according to the DTBT, and the relationship between the DTBT and clinical outcome was investigated. DTBTs were ≤ 30 min in 146 patients (27.7%), 31-60 min in 297 patients (56.4%), 61-90 min in 60 patients (11.4%), and > 90 min in 24 patients (4.6%). In-hospital mortality rates were 0.7, 5.0, 11.7, and 12.5% for DTBTs of ≤ 30, 31-60, 61-90, and > 90 min, respectively. In multivariate analysis, a DTBT ≤ 30 min (odds ratio [OR] 0.11, 95% confidence interval [CI] 0.01-0.91, p = 0.041), shock on arrival (OR 2.74, 95% CI 1.02-7.37, p = 0.046), and blood transfusion (OR 49.60, 95% CI 13.90-177.00, p < 0.001) were the independent predictors of in-hospital mortality. Patients with STEMI treated with a DTBT ≤ 30 min showed significantly better clinical outcomes than those treated with a DTBT > 30 min.

Successful treatment of out-of-hospital cardiopulmonary arrest due to streptococcal toxic shock syndrome - effectiveness of extracorporeal membrane oxygenation and the rapid antigen group A streptococcus test: a case report.

BACKGROUND: Streptococcal toxic shock syndrome caused by Streptococcus pyogenes, a group A streptococcus, infection is a rare condition that rapidly progresses to multiple organ failure, shock, and death. It is thus important to promptly establish a diagnosis, provide hemodynamic support, and initiate appropriate antibiotics therapy. CASE PRESENTATION: A 70-year-old Asian man presented with ventricular fibrillation. Extracorporeal membrane oxygenation was initiated 20 minutes after admission after unsuccessful conventional cardiopulmonary resuscitation including five attempts of electrical cardioversion. On the sixth attempt, a sinus rhythm was obtained. A physical examination revealed a large abscess in his right gluteal region, and computed tomography showed a large low-density area in the right gluteus maximus. Blood examination revealed elevated levels of inflammatory markers, hepatic enzymes, creatinine, and creatinine kinase. Transthoracic echocardiography demonstrated diffuse hypokinesis with an ejection fraction of 25%. A subsequent coronary angiography revealed normal findings. Therefore, we diagnosed our patient as having septic shock and conducted surgical drainage. A rapid antigen group A streptococcus test yielded positive results, which necessitated treatment comprising benzylpenicillin and clindamycin. He was successfully weaned from extracorporeal membrane oxygenation and continuous hemodiafiltration 4 days later and ventilation 9 days later; he was later transferred to another hospital to receive a skin graft. CONCLUSIONS: Our case report is the first to demonstrate the successful treatment of cardiac arrest caused by streptococcal toxic shock syndrome via extracorporeal membrane oxygenation and prompt initiation of antibiotic therapy. The rapid antigen group A streptococcus test may be an effective approach to promptly diagnose streptococcal toxic shock syndrome caused by group A streptococcus infection.

Usefulness of the twin guidewire method during retrieval of the broken tip of a microcatheter entrapped in a heavily calcified coronary artery.

During percutaneous coronary intervention performed for a stenotic lesion with heavy calcification in the left coronary artery, the microcatheter tip became transected in the vessel. The fragment was successfully retrieved using the twin guidewire method after negotiating to cross a chronic total occlusion-dedicated guidewire outside the retained tip.

Examination of the appropriate timing of reperfusion therapy for recent myocardial infarction: a Japanese single-center retrospective study.

BACKGROUND: The various guidelines clearly mention the treatment strategies for in patient of acute myocardial infarction (MI) presenting more than 24h from symptom onset (recent myocardial infarction, RMI). However, the appropriate timing of reperfusion for RMI is unclear. METHODS: We retrospectively evaluated 525 consecutive MI patients who underwent percutaneous coronary intervention (PCI) in our hospital between January 2008 and December 2012. RESULTS: Sixty RMI patients were more frequently associated with cardiac complications such as myocardial rupture (3.3% vs. 0%; p<0.01), ventricular septal rupture (3.3% vs. 0.4%; p<0.05), and congestive heart failure (15% vs. 2.6%; p<0.001) than 272 consecutive ST-elevation myocardial infarction (STEMI) patients. Of the 60 RMI patients, 33 (55.0%) underwent PCI within 7days (early-PCI group) and 27 (45.0%) underwent PCI after 7days (late-PCI group). Left ventricular ejection fraction measured by echocardiography at second hospital day was similar between the groups. The early-PCI group was more significantly associated with cardiogenic shock and heart failure and more frequently required intra-aortic balloon pumping (24.2% vs. 3.7%; p<0.05) than the late-PCI group. There were no significant differences in 30-day mortality, cardiac complications, and major cardiac events during long-term follow-up (12-36 months) between the groups. CONCLUSION: RMI patients had a higher incidence of cardiac complications than AMI patients. Clinical outcomes were similar between patients undergoing early revascularization and those undergoing late revascularization, although the former group included a higher proportion of patients with severe cardiac failure.

Spontaneous rotation of the monorail-type guide extension support catheter during advancement of a curved guiding catheter: the potential hazard of twisting with the coronary guidewire.

The extension support guiding catheter has been used to perform complex percutaneous coronary intervention to increase back-up support for the guiding catheter or to ensure deep intubation for device delivery. However, because of its monorail design, advancement of the stent into the distal extension tubing segment is sometimes problematic. Although this problem is considered due to simple collision of the stent, operators have observed tangling between a monorail extension catheter and coronary guidewire in some patients. To examine movement of the collar of the extension guide catheter during advancement of the guiding catheter, we set up an in vitro model in which the guiding catheter had two curves. Rotation of the extension guide catheter was examined by both fluoroscopic imaging and movement of the hub of the proximal end of the catheter. During advancement in the first curve, the collar moved toward the outer side of the curve of the guiding catheter as the operator pushed the shaft of the extension guiding catheter, which overrode the guidewire. After crossing the first curve, the collar moved again to the outer side of the second curve (the inner side of the first curve) of the mother catheter, and then, another clockwise rotation was observed in the proximal hub. Consequently, the collar and tubing portion of the extension guide catheter rotated 360° around the coronary guidewire, and the monorail extension catheter and guidewire became tangled. There is a potential risk of unintentional twisting with the guidewire during advancement into the curved guiding catheter because of its monorail design.

Severe catheter kinking and entrapment during transbrachial angiography: percutaneous retrieval with a slender approach.

A 74-year-old man previously treated with bilateral femoro-popliteal bypass was referred to our hospital for the treatment of a severely tangled 4-Fr diagnostic catheter in the right brachial artery. We inserted a 5-Fr sheath introducer from the proximal right femoral artery and advanced a 5-Fr JR catheter to the right brachial artery. A Sion coronary guidewire was then advanced for the tip of the tangled catheter, and a 4-mm gooseneck snare catheter was inserted through the guidewire. The tip of the catheter was caught and successfully removed after clockwise untwisting. The patient was discharged the next day without any complications.

Successful treatment of a nonagenarian patient with acute coronary syndrome complicated with chronic total occlusion of the left main coronary artery.

Although chronic total occlusion of the left main coronary artery (LMCA) is considered very rare, this condition could be fatal if it becomes complicated with an acute coronary syndrome lesion in the right coronary artery (RCA) which is usually the only remaining coronary artery for the myocardium. We reported a successfully treated case of a nonagenarian patient with ST-segment elevation myocardial infarction, who had subtotal occlusion of the RCA and total occlusion of the LMCA with Rentrop grade 2 collateral coronary artery supply from the RCA.

Onset-to-device time of patients who arrive at off-hours: Importance of prehospital management and public awareness for patients with ST-segment elevation myocardial infarction.

AIM: The influence of the time of arrival at the hospital on the door-to-device (DTD) time has been investigated; however, the influence on the onset-to-device (OTD) time is unclear in ST-segment elevation myocardial infarction (STEMI) patients. The aim of this study was to investigate the relationship between the time of arrival at the hospital and the OTD time in STEMI patients. METHODS: We evaluated 377 STEMI patients who underwent primary percutaneous coronary intervention (pPCI) between January 2008 and December 2014. RESULTS: During the study period, 222 patients arrived at our hospital between 9 AM and 9 PM (on-hours group) and 155 patients arrived between 9 PM and 9 AM (off-hours group). The DTD time was longer in the off-hours group than in the on-hours group (50.4 vs 39.3 minutes; P<.001), while the OTD time was longer in the on-hours group than in the off-hours group (285.7 vs 184.5 minutes, P<.001). The 30-day mortality and peak creatinine kinase levels were similar between the groups. Transfer from a non-pPCI-capable facility to our hospital was more common in the on-hours group than in the off-hours group (49.1% vs 15.5%, P<.001). The OTD time was shorter in patients who directly visited our hospital than in those who were transferred (172.9 vs 338.5 minutes, P<.001). CONCLUSIONS: The OTD time might be markedly longer in STEMI patients who arrive at the hospital during on-hours than in those who arrive at the hospital during off-hours because of the underuse of emergency medical services at STEMI onset.