High-risk coronary plaque of sudden cardiac death victims: postmortem CT angiographic features and histopathologic findings.

High-risk coronary plaques (HRP) are characterized in clinical radiological imaging by the presence of low plaque attenuation, a napkin-ring sign (NRS), spotty calcifications (SC) and a positive remodeling index (RI). To evaluate if these signs are detectable in postmortem imaging by a multi-phase postmortem CT angiography (MPMCTA), a retrospective study of a series of autopsy well-documented coronary plaques related to sudden cardiac death (SCD) was performed. Then correlations between histological and radiological findings were described. Fourty SCD cases due to acute coronary syndrome based on clinical history and confirmed at autopsy were selected (28 men and 12 women, age 53.3 ± 10.9). The culprit lesion was mainly situated in the proximal segments of coronary arteries, in the right coronary artery in 23 cases (57.5%), the left anterior descending artery in 13 cases (32.5%), the circumflex artery in 3 cases (7.5%) and in one case in the left main stem. MPMCTA showed a positive RI (≥ 1.1) in 75% of cases with a mean RI 1.39 ± 0.71. RI values were lower in cases with fibrotic plaques. NRS was observed in 40% of cases, low attenuation plaque in 46.3%, and SC in 48.7% of cases. There were significant correlations of the radiological presence of NRS for fibrolipid composition of the plaque (p-value 0.007), severe intraplaque inflammation (p-value 0.017), severe adventitial inflammation (p-value 0.021) and an increased vasa vasorum (p-value 0.012). A significant correlation (p-value 0.002) was observed between the presence of SC at radiological examination and the presence of punctuate/fragmented calcification at histology. In addition, in 58.3% of cases, plaque enhancement was observed, which correlated with plaque inflammation and the fibrolipid composition of the plaque. The coronary artery calcium score was 314 (± 455). There was a poor agreement between stenosis of the lumen at histology versus radiology. Our study shows that the various radiological signs of HRP can be detected in all plaques by MPMCTA, but individually only to a variable extent; plaque enhancement appeared as a new sign of vulnerability. In the postmortem approach, these radiological markers of HRP, should always be applied in combination, which can be useful for developing a predictive model for diagnosing coronary SCD.

Acute coronary thrombosis due to heparin-induced thrombocytopenia following improved COVID-19 pneumonia: A case report.

A 45-year-old male with anteroseptal myocardial infarction was referred to our hospital. The patient was previously admitted to another hospital with coronavirus disease-2019 pneumonia for 2 weeks; he was discharged 2 weeks before presentation to our institution. He received conventional treatment for coronavirus disease-2019, including administration of heparin. A moderate decrease in platelet count was observed on admission, and emergent angiography was performed under a definitive diagnosis of acute coronary syndrome. The angiography revealed occlusion of the left anterior descending artery. Percutaneous coronary intervention was performed; however, the occlusion did not improve owing to persistent thrombosis in the distal left anterior descending artery. Therefore, we induced intra-aortic balloon pumping to improve coronary blood flow and obtained Thrombolysis in Myocardial Infarction grade 2 flow. Following percutaneous coronary intervention, we detected a further decrease in platelets and positivity for heparin-induced thrombocytopenia antibody, leading to the diagnosis of heparin-induced thrombocytopenia. Subsequently, oral anticoagulation was introduced, and the symptoms did not recur. Learning objective: Treatment with heparin is indicated for patients with coronavirus disease-2019 (COVID-19) because of derangement of the coagulation system. However, this approach contributes to the development of heparin-induced thrombocytopenia (HIT). We report a case of acute coronary syndrome due to HIT with COVID-19. HIT is commonly reported in patients with COVID-19. Thus, attentive monitoring of the platelet count and considering the possibility of HIT are indispensable when treating acute coronary syndrome in patients with previous history of COVID-19.

Severe COVID-19 post pregnancy complicated by acute thromboemboli resulting in ST-elevation myocardial infarction - A case report.

Introduction: It has been shown that pregnancy can cause alterations in the severity of COVID-19 infection. We demonstrate an immediate post-partum patient diagnosed with severe COVID-19 and subsequently developed acute thrombosis of coronary artery.Case Summary: 35-year-old female unvaccinated for COVID-19 presented in labor and delivered on the same day. Several hours later, she was found to be in respiratory distress and tested positive for COVID-19. On day 7, computerized tomography (CT) of chest revealed bilateral pneumonia and pneumomediastinum. On day 8, she developed chest pain with electrocardiogram (EKG) showing inferior STelevations with troponin I of 0.6 ng/mL. She was intubated for airway protection and emergent diagnostic angiogram revealed thrombus occlusion of the third right posterolateral segment that resulted in thrombolysis in myocardial infarction (TIMI) 0 flow without evidence of underlying atherosclerotic disease in the remaining vessels. Intracoronary IIb/IIIa inhibitor was administered. Arterial blood gas in the lab revealed profound hypoxia despite being on 100% inspired oxygen. Multidisciplinary decision was made to cannulate patient for venovenous extracorporeal membrane oxygenation (ECMO) to treat severe COVID-19 pneumonia. She was finally decannulated from ECMO on day 65. After prolonged hospital stay, she eventually recovered and was discharged to rehabilitation.Conclusions: The center for disease control (CDC) surveillance has reported that pregnant patients with COVID-19 are more likely to require invasive ventilation and ECMO, and die given the immunological changes during pregnancy. Hypercoagulable state caused by combination of pregnancy and COVID-19 resulting in coronary thrombosis is rarely described in literature, our case demonstrated the paucity of this phenomenon.

A Fatal Case of Acute Thrombotic Occlusion in More Than 3 Epicardial Coronary Arteries Associated with the Yasmin Oral Contraceptive.

We report a case of a myocardial infarction (MI) due to multiple culprit vessels in a young woman. MI caused by more than 1 culprit vessel is very rare. Oral contraceptives (OCSs) are used for birth control. Despite a few case reports, the association between the new-generation OCS use and the MI risk remains controversial. A 53-year-old woman who had been consuming combined OCS-Yasmin (30 µg of ethinyl estradiol and 3 mg of drospirenone) for 2 years was admitted to our hospital with chest pain. Her past medical history revealed no coronary risk factors except for smoking. No hemodynamic instability was noted at admission. The admission electrocardiogram revealed slight ST elevations in D1 and aVL leads. An urgent coronary angiography showed distal occlusions in the right coronary, left anterior descending, first diagonal, and left circumflex coronary arteries. Unfractionated heparin and abciximab were administered during the procedure, with the latter continued for 12 hours after the procedure. During the hospital course, the patient complained of recurrent anginal attacks. A repeat coronary angiography demonstrated the persistence of thrombotic occlusions. After 24 hours, she experienced chest pain, and her electrocardiogram revealed diffuse ST elevations with a blood pressure of 60/40 mm Hg. She was urgently transferred to the catheterization laboratory. Multiple balloon inflations with intracoronary alteplase (10 mg over 5-10 min) injections failed to restore coronary flow, and she developed cardiovascular collapse. Despite maximal mechanic and mechanical support, she passed away.

Unusual cause of myocardial infarction following transcatheter aortic valve replacement.

Key Clinical Message: Left coronary artery embolism from aortic valve leaflet tissue mass is a rare but potentially life-threatening complication following transcatheter aortic valve replacement. It is important for interventional cardiologists to be aware of this rare complication for rapid identification and prompt treatment which is the key to a successful outcome. Abstract: An 81-year-old female presented for elective transcatheter aortic valve replacement (TAVR) for severe low-flow low-gradient aortic stenosis. Immediately post-procedure, she developed unexplained, persistent hypotension. There was no bleeding. There was no aortic injury. Activated clotting time was in therapeutic range. Coronary angiography revealed hazy filling defects in left anterior descending and left circumflex. Intravascular ultrasound showed heterogeneous, hypoechoic mass with mild calcification consistent with embolized valve leaflet tissue. This was treated with emergent percutaneous coronary intervention with excellent results. Left coronary artery embolism from aortic valve leaflet tissue is a rare, but potentially life-threatening complication following TAVR. Prompt recognition is key to a successful outcome.

Life long surveillance is warranted as coronary artery remodels variably after treatment of adult patients with anomalous left coronary artery origin from pulmonary artery.

Anomalous left coronary artery origin from pulmonary artery causes heart failure in infancy from ischemia and secondary mitral regurgitation. Rich intramyocardial collateralization may permit survival to adult age, where coronaries become tortuous and aneurysmally dilated. Surgery in adults involves left coronary ligation and providing a bypass graft to the left system, unlike coronary translocation adopted in infants. Unfavorable coronary remodeling in operated adults may lead to late coronary thrombotic occlusions. Two adults with markedly dilated tortuous coronary arteries showed variable remodeling after corrective intervention that impacted outcomes on follow-up. We stress the need for lifelong angiographic surveillance in older patients.

Eficacia de la tromboaspiración en pacientes con shock cardiogénico secundario a infarto agudo de miocardio y alta carga trombótica / Efficacy of thrombus aspiration in cardiogenic shock complicating acute myocardial infarction and high thrombus burden

Introducción y objetivos: Las guías actuales no recomiendan la aspiración sistemática de trombos (TA) en el infarto agudo de miocardio (IAM) debido a la falta de beneficio observada en ensayos aleatorizados previos. Sin embargo, los datos en el shock cardiogénico (SC) que complica un IAM son limitados. Métodos: Se incluyó a 575 pacientes con IAM complicado por SC, que se estratificaron en 2 grupos según el uso o no uso de la tromboaspiración. El objetivo primario del estudio fue un combinado de muerte por cualquier causa o rehospitalización por insuficiencia cardiaca a los 6 meses. La eficacia de la tromboaspiración se evaluó en función de la carga de trombo (grado I-IV frente a V). Resultados: No se encontraron diferencias significativas en la muerte intrahospitalaria (28,9% frente a 33,5%; p=0,28), ni en la muerte o rehospitalización por insuficiencia cardiaca a los 6 meses (32,4 frente a 39,4%; HRadj: 0,80; IC95%, 0,59-1,09; p=0,16) entre los grupos con y sin tromboaspiración. Sin embargo, en 368 pacientes con mayor carga trombótica (grado V), el grupo de tromboaspiración tuvo un riesgo significativamente menor de muerte por todas las causas o rehospitalización por insuficiencia cardiaca a los 6 meses comparado con el grupo sin tromboaspiración (33,4 frente a 46,3%, HR ajustada: 0,59; IC95%, 0,41-0,85; p=0,004), con una interacción significativa entre la carga de trombo y el uso de tromboaspiración para el resultado primario (pint ajustado=0,03). Conclusiones: El uso rutinario de TA no redujo los resultados clínicos adversos a corto y medio plazo en pacientes con IAM complicado con SC. Sin embargo, en pacientes seleccionados con una elevada carga trombótica, el uso de tromboaspiración podría asociarse a una mejora de los resultados clínicos. El estudio se registró en ClinicalTrials.gov (Identifier: NCT02985008).(AU)

Introduction and objectives: Current guidelines do not recommend routine thrombus aspiration in acute myocardial infarction (AMI) because no benefits were observed in previous randomized trials. However, there are limited data in cardiogenic shock (CS) complicating AMI. Methods: We included 575 patients with AMI complicated by CS. The participants were stratified into the TA and no-TA groups based on use of TA. The primary outcome was a composite of 6-month all-cause death or heart failure rehospitalization. The efficacy of TA was additionally assessed based on thrombus burden (grade I-IV vs V). Results: No significant difference was found in in-hospital death (28.9% vs 33.5%; P=.28), or 6-month death, or heart failure rehospitalization (32.4% vs 39.4%; HRadj: 0.80; 95%CI, 0.59-1.09; P=.16) between the TA and no-TA groups. However, in 368 patients with a higher thrombus burden (grade V), the TA group had a significantly lower risk of 6-month all-cause death or heart failure rehospitalization than the no-TA group (33.4% vs 46.3%; HRadj: 0.59; 95%CI, 0.41-0.85; P=.004), with significant interaction between thrombus burden and use of TA for primary outcome (adjusted Pint=.03). Conclusions: Routine use of TA did not reduce short- and mid-term adverse clinical outcomes in patients with AMI complicated by CS. However, in select patients with a high thrombus burden, the use of TA might be associated with improved clinical outcomes. The study was registered at ClinicalTrials.gov (Identifier: NCT02985008).(AU)

COVID-19 as an independent predictor of aspiration thrombectomy in STEMI. National data from the ORPKI register in the years 2020-2022.

Introduction: Coronavirus disease 2019 (COVID-19) exacerbates intravascular thrombosis that occurs in the coronary artery in ST-elevation myocardial infarction (STEMI). Aim: To analyze the impact of COVID-19 on the application and effect of thrombectomy in STEMI patients. Material and methods: 29915 STEMI patients were analyzed, of whom 3139 (10.5%) underwent thrombectomy. COVID-19 (+) was reported in 311 (10.8%). The clinical characteristics and management of STEMI in COVID-19 (+) and COVID-19 (-) patients were compared. A multivariable logistic regression analysis was performed in search of factors influencing thrombectomy. Results: COVID-19 (+) patients had higher Killip class (IV class; n = 33 (12.31%) vs. n = 138 (5.84%); p < 0.0001) and cardiac arrest at baseline was more frequent in this group (n = 25 (8.04%) vs. n = 137 (4.84%); p = 0.016). Thrombolysis in myocardial infarction (TIMI) 3 after percutaneous coronary intervention was less frequent (n = 248 (80.52%) vs. n = 2388 (87.19%); p = 0.001) in the COVID-19 (-) group. Periprocedural mortality was similar in both groups (n = 28 (0.99%) vs. n = 4 (1.29%); p = 0.622). In multivariable regression analysis COVID-19 increased the risk of thrombectomy (OR = 1.23; 97.5% CI: 1.05-1.43; p = 0.001). Conclusions: STEMI patients undergoing aspiration thrombectomy who were COVID-19 (+) were more likely to be in a severe clinical condition (higher Killip class, more frequent cardiac arrest before the procedure) than COVID-19 (-) patients. Despite more intensive antiplatelet and anticoagulant treatment, PCI procedures were less likely to result in an optimal TIMI 3 effect. COVID-19 is an independent strong predictor of patient qualification for aspiration thrombectomy in STEMI.

Acute myocardial infarction after inactivated COVID-19 vaccination: a case report and literature review.

A number of vaccines have been developed and deployed globally to restrain the spreading of the coronavirus disease 2019 (COVID-19). The adverse effect following vaccination is an important consideration. Acute myocardial infarction (AMI) is a kind of rare adverse event after COVID-19 vaccination. Herein, we present a case of an 83-year-old male who suffered cold sweat ten minutes after the first inactivated COVID-19 vaccination and AMI one day later. The emergency coronary angiography showed coronary thrombosis and underlying stenosis in his coronary artery. Type II Kounis syndrome might be a potential mechanism, which is manifested as coronary thrombosis secondary to allergic reactions in patients with underlying asymptomatic coronary heart disease. We also summarize the reported AMI cases post COVID-19 vaccination, as well as overview and discuss the proposed mechanisms of AMI after COVID-19 vaccination, thus providing insights for clinicians to be aware of the possibility of AMI following COVID-19 vaccination and potential underlying mechanisms.

Congenital analbuminemia associated with compound heterozygous novel nucleotide variations in a young adult with coronary thrombosis.

Congenital analbuminemia (CAA) is a very rare genetic disorder characterized by a significant reduced or even complete absence of human serum albumin. Our data describe the clinical features and laboratory results of a case confirmed by mutation analysis of the albumin gene in a 35-year-old man presenting recurrent acute coronary syndrome. To the best of our knowledge, only two cases of coronary artery disease have been reported worldwide without recurrence. Our findings contribute to shed light on the clinical characteristics and biochemical parameters of this disease and confirm that cardiovascular complications must be taken seriously in this pathology. Mutational screening disclosed two novel compound heterozygous nucleotide variations located in intron 12 and in 3'UTR. The prediction of the functional and structural impact of the reported variations using different bioinformatics tools demonstrates that these genetics variations affect RNA transcription and mRNA folding.

Acute Myocardial Infarction Following the Consumption of Energy Drink in a 28-Year-Old Male: A Case Report.

Excessive intake of energy drinks is increasingly realized to have a detrimental effect on platelet and endothelial functions with resultant hypercoagulable state and consequently increased risk of thrombosis. A 28-year-old man of African origin presented to the emergency department with an 8-hour history of retrosternal chest pain. His symptoms started 4 hours after consuming 5 cans (1250 cc) of an energy drink whose principal ingredients are caffeine, taurine, sugar, and glucuronolactone. His past medical and surgical history was unremarkable, and he had no apparent cardiovascular risk factor. Physical examination was unremarkable; however, electrocardiogram and echocardiogram showed features of anterolateral myocardial infarction (STEMI). Catheterization confirmed a 100% thrombotic occlusion of the proximal left anterior descending (LAD) artery and revascularization with a drug-eluting stent was successful. In conclusion, sudden onset of chest pain following energy drink consumption should raise an index of suspicion for acute coronary syndrome. With the preponderance of data suggesting increased incidence of energy drink-associated coronary events, it is prudent to advocate a limited consumption of such beverages.

Acute Myocardial Infarction in a Young Male With COVID-19 Infection.

Coronavirus disease 2019 (COVID-19) infection is a global health crisis resulting in significant morbidity and mortality. The presentation of COVID-19 infection is variable, ranging from an asymptomatic carrier state to multi-organ failure. While cases of COVID-related myocarditis and myocardial dysfunction are well reported, only a few cases of coronary artery thrombosis resulting in myocardial infarction are noted on literature review. However, the previously reported cases were in patients with high risk for coronary artery disease. We hereby report a case of a young man with no significant past medical history or cardiovascular risk factors who presented with severe chest pain and was diagnosed with acute myocardial infarction in the setting of COVID-19 infection requiring intervention. We want to report this case to improve awareness in the community about COVID-related arterial thrombosis and have a high index of suspicion for this regardless of the person's risk factors for cardiovascular diseases.

Administration of a new nano delivery system coated with Tirofiban to prevent early thrombosis of vein graft.

OBJECTIVE: To verify the administration of a new nano delivery system coated with Tirofiban on preventing early thrombosis in vein graft. METHODS: Forty New Zealand white rabbits were randomly divided into five groups with eight rabbits in each group. The rabbits of all groups underwent jugular vein transplantation, except group I with only neck opening and closing operation. Vein grafts of group II were preprocessed by intravenous injection of normal saline; group III were preprocessed by tirofiban alone; group IV were preprocessed by unloaded nanoparticles of PLGA-PEG; group V were preprocessed by PLGA-PEG coated with tirofiban. Coagulation and platelet function of peripheral and vein graft blood were detected at 1, 2, 4, 12 h and 1, 3, 7, 10, 14 days after operation. Patency rate of vein graft and blood flow index were measured by vascular ultrasound at third, seventh, 10th, and 14th days after operation; two rabbits in each group were randomly sacrificed at the corresponding time of detection. Pathological differences of vein grafts were observed by HE stainin. RESULTS: The patency rate of vein grafts in group V was significantly higher than that in group II to IV. The platelet and platelet aggregation rate in group V were inhibited in vein graft blood significantly. The post-operative PT and APTT in vein graft blood in group V were increased obviously while the FBG, D-dimer and FDP were significantly inhibited. Except group I, the lumen loss rate of vein grafts in group V was significantly lower than that in other groups, and vein graft blood in group V had a significant lower expression of platelet P-selectin and GP IIb/IIIa receptor than that in other groups. CONCLUSION: This study proves that PEG-PLGA coated with tirofiban can effectively prevent early vein graft stenosis from thrombosis by inhibition of platelet function, coagulation function.

Efficacy of thrombus aspiration in cardiogenic shock complicating acute myocardial infarction and high thrombus burden.

INTRODUCTION AND OBJECTIVES: Current guidelines do not recommend routine thrombus aspiration in acute myocardial infarction (AMI) because no benefits were observed in previous randomized trials. However, there are limited data in cardiogenic shock (CS) complicating AMI. METHODS: We included 575 patients with AMI complicated by CS. The participants were stratified into the TA and no-TA groups based on use of TA. The primary outcome was a composite of 6-month all-cause death or heart failure rehospitalization. The efficacy of TA was additionally assessed based on thrombus burden (grade I-IV vs V). RESULTS: No significant difference was found in in-hospital death (28.9% vs 33.5%; P=.28), or 6-month death, or heart failure rehospitalization (32.4% vs 39.4%; HRadj: 0.80; 95%CI, 0.59-1.09; P=.16) between the TA and no-TA groups. However, in 368 patients with a higher thrombus burden (grade V), the TA group had a significantly lower risk of 6-month all-cause death or heart failure rehospitalization than the no-TA group (33.4% vs 46.3%; HRadj: 0.59; 95%CI, 0.41-0.85; P=.004), with significant interaction between thrombus burden and use of TA for primary outcome (adjusted Pint=.03). CONCLUSIONS: Routine use of TA did not reduce short- and mid-term adverse clinical outcomes in patients with AMI complicated by CS. However, in select patients with a high thrombus burden, the use of TA might be associated with improved clinical outcomes. The study was registered at ClinicalTrials.gov (Identifier: NCT02985008).

Simultaneous Double-Vessel Coronary Thrombosis with Sudden Cardiac Arrest as the First Manifestation of COVID-19.

The relationship between coronavirus disease 2019 (COVID-19) and myocardial injury was established at the onset of the COVID-19 pandemic. An increase in the incidence of out-of-hospital cardiac arrest was also observed. This case report aims to point to the prothrombotic and proinflammatory nature of coronavirus infection, leading to simultaneous coronary vessel thrombosis and subsequently to out-of-hospital cardiac arrest. During the COVID-19 pandemic, a 46-year-old male patient with no comorbidities suffered out-of-hospital cardiac arrest (OHCA) with ventricular fibrillation as the first recorded rhythm. The applied cardiopulmonary resuscitation (CPR) measures initiated by bystanders and continued by emergency medical service (EMS) resulted in the return of spontaneous circulation. The stabilized patient was transferred to the tertiary university center. Electrocardiogram (ECG) revealed "lambda-like" ST-segment elevation in DI and aVL leads, necessitating an immediate coronary angiography, which demonstrated simultaneous occlusion of the left anterior descending (LAD) and right coronary artery (RCA). Primary percutaneous coronary intervention (PCI) with the implantation of one drug-eluting stent (DES) in LAD and two DES in RCA was done. Due to the presence of cardiogenic shock (SCAI C), an intra-aortic balloon pump (IABP) was implanted during the procedure, and due to the comatose state and shockable cardiac arrest, targeted temperature management was initiated. The baseline chest X-ray revealed bilateral interstitial infiltrates, followed by increased proinflammatory markers and a positive polymerase chain reaction (PCR) test for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) demasking underlying COVID-19-related pneumonia. Within the following 48 h, the patient was hemodynamically stable, which enabled weaning from IABP and vasopressor discontinuation. However, due to the worsening of COVID-19 pneumonia, prolonged mechanical ventilation, together with antibiotics and other supportive measures, was needed. The applied therapy resulted in clinical improvement, and the patient was extubated and finally discharged on Day 26, with no neurological sequelae and with mildly reduced left ventricle ejection fraction.

The Association between Vitamin D Levels and Thrombus Burden in Patients with ST-Elevation Myocardial Infarction.

Background: In current practice, establishing the potential predictors of high thrombus burden (HTB) before primary percutaneous coronary intervention (PCI) is crucial for its management. In this research, we aimed to investigate the association between vitamin D levels and HTB in patients with ST-elevation myocardial infarction (STEMI). Methods: This prospective, observational study was conducted on 257 STEMI patients undergoing primary PCI in Van Education and Research Hospital between March 2020 and March 2021. The thrombus burden grade was determined for each subject. The study population was divided into 2 groups: patients with HTB and those with low thrombus burden (LTB) based on the thrombus burden grade. Demographic, laboratory, and angiographic features were compared between the groups. Results: In total, 154 patients (mean age±SD=63.42±11.53 y, 65.6% male) had HTB and 103 patients had LTB (mean age±SD=61.50±10.23 y, 70.9% male). The patients stratified into the HTB group had lower vitamin D levels than those in the LTB group (8.0 ng/mL vs 17.9 ng/mL, respectively; P<0.001). The patients with HTB and low vitamin D levels had lower post-PCI thrombolysis in myocardial infarction (TIMI) flow, TIMI myocardial perfusion grade, and post-PCI ST resolution. In a multivariable analysis, vitamin D was an independent predictor of HTB among the STEMI patients (OR: 0.76, 95%CI: 0.70-0.82; P<0.001). The ideal value of vitamin D to predict HTB was >17.6 ng/mL with a sensitivity of 81.8% and a specificity of 90.3%. Conclusion: The study results showed that vitamin D levels were an independent predictor of HTB in STEMI patients treated by primary PCI.

Dilated Cardiomyopathy With Multiple Left Ventricular Thrombi and Embolic Stroke After Mild COVID-19.

COVID-19 is a novel disease with multisystem involvement, but most patients have pulmonary and cardiovascular involvement in the acute stages. The cardiovascular impact of acute COVID-19 is well recognized and ranges from myocarditis, arrhythmias, and thrombotic occlusion of coronary arteries to spontaneous coronary artery dissection and microthrombi in small coronary vessels on autopsy. We report a case of a 37-year-old man who recovered from mild COVID-19 only to present a few weeks later with devastating cardiovascular involvement that included severe left ventricular impairment resulting from nonischemic cardiomyopathy, multiple left ventricular thrombi, and embolic stroke.

Coronary thrombosis after European adder bite in a patient on dual antiplatelet therapy: A case report.

INTRODUCTION: Until now very few cases of an adverse cardiovascular event have been described following European viper envenomation (Aravanis et al., 1982) (Aravanis et al., 1982) (Aravanis et al., 1982) (Aravanis et al., 1982). In fact, cardiac toxicity following snake bite is rare and primary reported from tropical and subtropical areas with only twenty-one cases of myocardial infarction reported in literature. Herein, we report a case of European viper envenomation associated with coronary artery thrombosis complicated by acute myocardial infarction and cardiac arrest. CASE REPORT: A 62-year-old man, with a history of cardiovascular disease, on dual antiplatelet therapy with ticagrelor and acetylsalicylic acid, was admitted to the Emergency Department, after a bite, on the right hand, from a snake recognized by a herpetologist as a Vipera aspis francisciredi. At ED presentation, 2 hours after the bite, he manifested with vomiting, hypotension (90/60 mmHg) and mild oedema at the bite site. Standard electrocardiogram and troponin were normal at admission. One hour after the admission the patient developed cardiocirculatory arrest (ACC) with return of spontaneous circulation (ROSC) after cardiopolmunary resuscitation. Post ROSC-ECG showed an ST-elevation on anteroseptal and lateral leads and 1-vial of Viper Venom Antitoxin (Biomed®) was i.v. administered. During the next 3 hours three other episodes of ACC occurred, always with restoration of spontaneous circulation. Percutaneous transluminal coronary angiography showed a thrombus on the bifurcation of anterior descending coronary artery and diagonal 1 without an underlined atherosclerotic plaque. Neurologic clinical manifestations also occurred 12 hours after the bite: bilateral ptosis and facial paresthesia and a second vial of the same viper antivenom administered. The patient was discharged after 9 days of hospitalization without sequelae. CONCLUSIONS: Our case show that cardiotoxicity is a rare but possible event after snake envenomation in Europe, even if with mechanisms remains to be studied. Vipera aspis has been known to cause primarily neurotoxic manifestations, but a coagulation factor X activator have also been isolated from its venom. Moreover, a specific serine peptidase that can target both PAR1 and PAR3, that are responsible for alternate pathways of platelet aggregation, have been characterized in the venom of a viper. Coronary thrombosis in our case could thus be secondary to a combination of prothrombotic systemic state and platelets dysfunction, in a patient with predisposing factors. Antivenom specific antidotal therapy role in preventing cardiotoxicity still need to be elucidated, but it remains the mainstay of treatment together with coronary angiography if necessary.