Association of PC and AT levels in the early phase of STEMI treated with pPCI with LV systolic function and 6-month MACE.

OBJECTIVES: To examine a relationship between protein C (PC) and antithrombin III (AT III) activities with ejection fraction of left ventricle (EFLV), in the early phase of acute ST-elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (pPCI), and to investigate whether PC and AT III are associated with major adverse cardiovascular events (MACE) within 6 months following from pPCI. PATIENTS AND METHODS: The research had a prospective character and included 357 patients who had, following the diagnosis of the STEMI, undergone pPCI at the Clinic of Cardiology and Emergency Internal Medicine, Military Medical Academy, Belgrade, Serbia, from January 2010 until April 2019. RESULTS: The EFLV positively correlated with PC values (rho = 0.229). There was a statistically significant increase in the PC values between patients with MACE compared with those without MACE at 6 months' follow-up evaluation (p < 0.0001). Also, significant difference in PC values between patients who died in hospital and those who were alive at 6 months' follow-up (p < 0.01) was observed. PC values were different across different EFLV groups (p < 0.001), increasing from the 1st to the 4th EFLV quartiles: the median and the interquartile values for the 1st, 2nd, 3rd and 4th quartiles were 1.0400IU/l ± 0.15, 1.1400IU/l ± 0.15, 1.1350IU/l ± 0.16 and 1.2200IU/l ± 0.14, respectively. CONCLUSION: Increased PC activity in the early phase of STEMI is associated with higher EFLV 5 days after the pPCI as well as with MACE at 6 months after the pPCI.

Lower plasma protein C activity is associated with early myocardial necrosis and no-reflow phenomenon in patients with ST elevation myocardial infarction.

Background: Activity of protein C has important role in the development of early necrosis and no-reflow phenomenon in patients with ST-segment elevation myocardial infarction (STEMI) after successful primary percutaneous coronary intervention (pPCI). Methods: We examined association between plasma activity of protein C, antithrombin, coagulation factors II, VII, VIII and fibrinogen to early formation of new Q-waves (myocardial necrosis) before pPCI and early ST-segment resolution (microcirculatory reperfusion) after pPCI in patients with acute STEMI. According to ischaemic time, patients were considered as early or late presenters. 12-lead ECG was analysed for the presence of new Q-wave at admission and for significant ST-segment resolution 60 minutes after primary PCI. Results: In early presenters' group, protein C activity was significantly lower in patients who did not achieve significant ST-segment resolution after pPCI compared to patients who did (1.11 IU/L vs. 0.99 IU/L, p = .006) and in patients who had new Q-waves compared to group who had not (1.04 UI/l vs. 1.11 IU/L, p = .038). There was significant negative correlation between protein C activity and maximal CK-MB levels (R2 = 0.06, p = .009) and BNP levels (R2 = 0.109, p = .003) and significant positive correlation between protein C activity with LVEF (R2 = 0.065, constant = 33.940, b = 11.968, p = .007) in early STEMI presenters. There were no differences between the activity of other examined haemostasis factors. Conclusion: Therefore we concluded that STEMI patients with early myocardial necrosis and no-reflow phenomenon after pPCI have lower activity of plasma protein C levels.

Diagnostic significance of three-dimensional echocardiography in asymptomatic unicuspid aortic valve.

Unicuspid aortic valve (UAV) is a rare congenital anomaly of aorta associated with a faster progress of valvular dysfunction, aortic dilatation and with necessity for more frequent controls and precise evaluation Asymptomatic 35 year old man had abnormal systolic diastolic murmur on aortic valve during routine examination. Initial diagnostic with transthoracic echocardiography (TTE) supposed bicuspid aortic valve, while three-dimensional transesophageal echocardiography (3D TEE) and multidetector computed tomography defined unicuspid, unicomissural aortic valve with moderate aortic stenosis and regurgitation. This case report confirmed that 3D TEE gives us opportunity for early, improved and precise diagnosis of UAV.

Iatrogenic dissection of the left main coronary artery during elective diagnostic procedures--A report on three cases.

UNLABELLED: INTRODUCTION. Left main coronary artery dissection is a rare and potentially life-threatening complication of coronary angiography and angioplasty which requests urgent revascularization. CASE REPORT: During the period between 2010 and November 2014 at single healthcare center we did totally 8,884 coronary procedures, out of which 2333 were percutaneous coronary interventions (PCI). In this period we had a total of 3 (0.03%) left main coronary artery dissections, and all of them were successfully treated by PCI. We presented three cases with iatrogenic dissection of the left main coronary artery, occurred during elective diagnostic procedures, successfully treated with PCI with different techniques. CONCLUSION: PCI could be fast and life-saving approach in iatrogenic dissections of the left main coronary artery.

Successful primary percutaneous coronary interventions in a patient with two consecutive ST-segment elevation myocardial infarctions and dual left anterior descending artery (type IV).

INTRODUCTION: Dual left anterior descending (LAD) artery is a very rare inherited anomaly. It can be incidentally revealed during primary percutaneous coronary intervention (pPCI) and may produce difficulties in detecting and treating the culprit lesion. CASE REPORT: We presented a 52-year-old male patient with ST-segment elevation myocardial infarction (STEM1) of inferior wall, in whom dual LAD anomaly was revealed during pPCI: a short LAD artery originated from the left main coronary artery and a long LAD artery originated from the proximal part of the right coronary artery (RCA). A bare metal stent was successfully implanted in the place of the culprit lesion in RCA and ST-segment resolution was achieved in ECG. After two hours, the patient was referred again to the catheter lab due to new STEMI of anteroseptal wall. Another bare metal stent was implanted in new infarction related artery, this time it was proximal part of the short LAD. CONCLUSION: Careful and correct interpretation of ECG is very helpful in detection and treatment of the culprit lesion in cases with dual LAD.

Very late stent thrombosis of bare-metal coronary stent nine years after primary percutaneous coronary intervention.

Introduction: Stent thrombosis (ST) in clinical practice can be classified according to time of onset as early (0­30 days after stent implantation), which is further divided into acute (< 24 hours) and subacute (1­30 days), late (> 30 days) and very late (> 12 months). Myocardial reinfaction due to very late ST in a patient receiving antithrombotic therapy is very rare, and potentially fatal. The procedure alone and related mechanical factors seem to be associated with acute/subacute ST. On the other hand, in-stent neoathero-sclerosis, inflammation, premature cessation of antiplatelet therapy, as well as stent fracture, stent malapposition, un-covered stent struts may play role in late/very late ST. Some findings implicate that the etiology of very late ST of bare-metal stent (BMS) is quite different from those following drug-eluting stent (DES) implantation. Case report: We presented a 56-year old male with acute inferoposterior ST segment elevation myocardial infarction (STEMI) related to very late stent thrombosis, 9 years after BMS implantation, despite antithrombotic therapy. Thrombus aspiration was successfully performed followed by percutaneous coronary intervention (PCI) with implantation of DES into the pre-viously implanted two stents to solve the in-stent restenosis. Conclusion: Very late stent thrombosis, although fortu-nately very rare, not completely understood, might cause myocardial reinfaction, but could be successfully treated with thrombus aspiration followed by primary PCI. Very late ST in the presented patient might be connected with neointimal plaque rupture, followed by thrombotic events.

Psoriasis is the independent factor for early atherosclerosis: A prospective study of cardiometabolic risk profile.

Background/Aim: Psoriasis as multisystemic inflammatory dis-ease is related with an increased cardiometabolic risk. The aim of the study was to analyze risk biomarkers, peripheral and renal arteries ultrasonography and echocardiography for subclinical atherosclerosis and metabolic disease in 106 subjects (66 psoriasis patients and 40 controls, 20 eczema patients and 20 healthy volunteers). Methods: In all exameenes following parameters were analyzed: body mass index (BMI), C-reactive protein, D-dimer, serum amyloid A (SAA), apolipoprotein (Apo) A1, ApoB, ApoB/Apo A1 index, fasting glucose, C-peptide, fasting insulinemia, homeostatic model assessment-insulin resistance (HOMA-IR), HOMA-ß-cell, lipid profile, serum uric acid concentration (SUAC), 24-h proteinuria and microalbuminuria. Carotid, brachial, femoral and renal arteries ultrasonography, as well as echocardiography was also performed. Results: Five of 66 (7.6%) psoriasis patients had metabolic syndrome (not present in both control groups). The following variables were increased in patients with psoriasis compared to both control groups: BMI (p = 0.012), insulinemia (p < 0.001), HOMA-IR (p = 0.003), HOMA-ß cell (p < 0.001), SUAC (p = 0.006), ApoB/ApoA1 ra-tio (p = 0.006) and microalbuminuria (p < 0.001). Also, increased C-peptide (p = 0.034), D-dimer (p = 0.029), triglycerides (p = 0.044), SAA (p = 0.005) and decreased ApoA1 (p = 0.014) were found in the psoriasis patients compared to healthy controls. HDL cholesterol was decreased in the psoriasis patients compared to the control group of eczema patients (p = 0.004). Common carotid (CIMT) and femoral artery intima-media thickness (FIMT) was significantly greater (p < 0.001) and the maximal flow speed (cm/s) in brachial artery significantly de-creased (p = 0.017) in the patients with psoriasis in comparison to both control groups. In multivariate logistic regression analysis, after the adjustment for confounding variables, the most important predictor of CIMT and FIMT was the diagnosis of psoriasis (p < 0.001).. Conclusion: Cardiometabolic risk biomarkers and ultrasonographic signs of early atherosclerosis are correlated with the diagnosis of psoriasis, and not to generalized eczema. Psoriasis was found to be an independent risk factor for subclinical atherosclerosis

Women have right ventricular infarction more frequently than men.

OBJECTIVE: The objective of the study was to determine whether women significantly have more frequently right ventricular infarction than men. METHODS: The study population consisted of consecutive patients with ST-segment elevation myocardial infarction (STEMI) who underwent primary percutaneous intervention. The following criteria were used for the diagnosis of right ventricular infarction: ST-segment elevation in one of the right precordial leads V4R-V6R for equal or more than 1 mm together with ST-segment elevation in at least two contiguous inferior leads. The odds ratio for the diagnosis was calculated according to gender. Searching PubMed, nine more relevant studies that used the same criteria for the diagnosis of right ventricular infarction were identified and a metanalysis was conducted. RESULTS: In our group of 517 consecutive patients with STEMI, 32 (23.5%) of 136 women and 42 (11.0%) of 381 men had RVI (odds ratio (OR) = 2.48, 95% confidence interval (CI): 1.49-4.13; P = 0.001). Two hundred and seventy-five patients had inferior STEMI and among them 32 (42.7%) of 75 women and 42 (23.1%) of 182 men, had a right ventricular infarction (OR = 2.48, 95%CI: 1.40-4.40; P= 0.002). In a meta-analysis, a total number of 4,326 patients with inferior STEMI were included. Four hundred and thirty-seven (41.4%) out of 1,056 women and 1,221 (37.3%) out of 3,270 men, had been diagnosed with RVI (OR = 1.27, 95% CI: 1.09-1.48; P = 0.021). CONCLUSION: Right ventricular infarctions occur more frequently in women than in men.

Does thrombolytic therapy harm or help in ST elevation myocardial infarction (STEMI) caused by the spontaneous coronary dissection?

INTRODUCTION: Spontaneous coronary artery dissection (SCAD) is a very rare disease with poor prognosis. It mainly affects young women free of risk factors for coronary artery disease (CAD) and women during the peripartum period. The prognosis for myocardial infarction caused by SCAD is poor, management is often difficult and guidelines still missing. CASE REPORT: We presented a woman with acute myocardial infarction of anterior wall of the left ventricle, caused by spontaneous dissection of medial segment of the left anterior descending coronary artery. We treated the patient with thrombolytic therapy and performed coronary angiography after that. Finally we decided to do nothing more. Two years later we performed coronary angiography again and founded the coronary artery normal. We also analyzed 19 cases publiched from 1996 to 2012 when coronary artery dissection had been treated with thrombolytic agent Analysis revealed only one case of 19, with complication after treating SCAD with thrombolysis. CONCLUSION: Sometimes, regarding myocardial infarction in young women with no risk factors for CAD, especially in young women in peripartum, we should think about SCAD. The presented case, like eight others, demonstrates that good clinical outcomes can be achieved with thrombolysis. In spite of all this, we still need more data to verify that thrombolysis does not have to harm the therapy for SCAD. For the time being thrombolytic therapy could be an option.

The additive diagnostic role of coronary flow reserve in noninvasive evaluation of coronary stenosis on left descending artery previously detected by multislice computed tomography.

PURPOSE: Multislice computed coronary angiography (MSCT) provides valuable morphological information about coronary artery disease, but precise quantification of coronary stenosis remains difficult. Transthoracic color Doppler echocardiography (TDE) gives a new insight into the functional significance of coronary luminal narrowing. We have tried to assess the additive value of coronary flow reserve (CFR) determined by TDE over MSCT in prediction of a significant stenosis on the left anterior descending artery (LAD) using the invasive coronary angiography (ICA) as a reference method. METHODS: This prospective study included 63 patients in stable cardiac status with previously detected atherosclerotic lesions on LAD by MSCT. CFR assessment by TDE with adenosine infusion was obtained to all patients (feasibility was 96.92%). CFR was determined as ratio between the peak diastolic flow velocity during adenosine infusion and at basal condition, a cutoff value indicating significant stenosis was <2. ICA was preformed to all patients 24-48 hours after CFR. RESULTS: MSCT had sensitivity of 86.36%, specificity 53.66%, positive predictive value 50.00%, negative predictive value 88.00%, and diagnostic accuracy of 65.07% in detection of significant LAD stenosis. CFR had sensitivity 81.81%, specificity 97.06%, positive predictive value 94.74%, negative predictive value 89.19%, and diagnostic accuracy of 91.07%. When the results of both methods were agreed diagnostic accuracy was improved to 92.72%. CONCLUSION: Additional assessment of CFR by TDE increase diagnostic accuracy of MSCT angiography in detection of significant coronary artery lesions.

Successful implantation of a permanent pacemaker through a persistent left superior vena cava by using a right subclavian approach.

INTRODUCTION: Persistent left superior vena cava, a rare congenital abnormality, can complicate placement of pacemaker leads through the subclavian vein. A left-sided approach is usually preferable in such cases. CASE REPORT: We reported a case in which we began a single-chamber pacemaker implantation procedure via a right subclavian approach (because of scarring beneath the left clavicle) and then discovered intraoperatively that the patient had a persistent left superior vena cava. After a few attempts, we succeeded in placing the head of the electrode in the septum, near the top of the right ventricle, and the rest of the procedure was completed without complication. CONCLUSION: To our knowledge, this is the first reported case of pacemaker implantation, with passive electrode, through a persistent left superior vena cava via the right subclavian vein. This case demonstrates that such an approach, when necessary, can be used successfully.

TandemHeart as a rescue therapy for patients with critical aortic valve stenosis.

BACKGROUND: We analyzed our use of the TandemHeart Percutaneous Ventricular Assist Device (Cardiac Assist Inc, Pittsburgh, PA) as a rescue therapy for patients with cardiac arrest or severe refractory cardiogenic shock (SRCS) before or after aortic valve replacement (AVR) for critical aortic valve stenosis. METHODS: We reviewed the records of 10 patients (6 men; 4 women), aged 62 +/- 12 years, who presented with cardiac arrest or SRCS. Eight patients, 5 undergoing cardiopulmonary resuscitation (CPR) and 3 with SRCS, received TandemHeart support in the catheterization laboratory and had AVR after undergoing hemodynamic stabilization. The other 2 patients went directly to the operating room while undergoing CPR, for emergency AVR and received the device for postcardiotomy cardiogenic shock. All 10 patients were intubated, on maximal vasopressor support, and 7 had an intraaortic balloon pump. The preoperative Society of Thoracic Surgeons mortality risk was 74.9% +/- 24.5%. RESULTS: The 8 patients who received the TandemHeart in the catheterization laboratory were supported for 6.4 +/- 3.8 days and had significantly improved renal function before AVR. One patient died of sepsis 34 days after AVR, The other 7 were discharged home (ejection fraction, 0.42 +/- 0.14) and were alive 2 to 43 months later. The 2 patients who received the device in the operating room after AVR died on days 8 and 21, respectively. CONCLUSIONS: Prompt placement of the TandemHeart in these critically ill patients yields the shortest "emergency department door to left ventricular unloading time," improves end-organ function, and allows AVR to be performed electively.