An 80-Year-Old Man with Inferior Wall Myocardial Infarction and Cardiogenic Shock: Case Report.

We report a case of ruptured head of posteromedial papillary muscle and prolapse of anterior mitral valve leaflet that caused severe mitral regurgitation (MR) and cardiogenic shock as a complication of inferior wall myocardial infarction in an 80-year-old man. Emergency coronary angiogram revealed thrombotic occlusion at proximal right coronary artery. Transesophageal echocardiogram revealed ruptured head of posteromedial papillary muscle and prolapse of anterior mitral valve leaflet causing severe MR. After percutaneous coronary intervention with bare metal stent, the patient underwent mitral valve repair with saphenous vein graft to the posterolateral branch of the right coronary artery. The patient was discharged from hospital on day 14 of admission.

One-year clinical outcomes of ST segment elevation myocardial infarction patients treated with emergent percutaneous coronary intervention: the impact of thrombus burden.

OBJECTIVE: To investigate the impact of thrombus burden on 1-year clinical outcomes in patients who underwent emergent percutaneous coronary intervention (PCI) for ST segment elevation myocardial infarction (STEMI). MATERIAL AND METHOD: Angiographic evidence of intracoronary thrombus adversely affects the outcome of PCI in STEMI. Large thrombus burden (> or = 2 times vessel diameter) has been shown to be a significant predictor of major adverse cardiac events (MACE). The impact of thrombus burden in Asian patients who undergo PCI in STEMI has not been described. This is an observational cohort of patients with STEMI from June 1, 2008 through May 31, 2011, who underwent emergent PCI (primary or rescue). The patients were categorized into two groups according to the angiographic thrombus burden, large thrombus burden (> or = 2X vessel diameter size, LTB) and small thrombus burden (< 2X vessel diameter size, STB). MACE was defined as the composite of death, repeat myocardial infarction, target vessel revascularization and stent thrombosis. RESULTS: 202 patients were enrolled, 72% were male and the mean age was 60 years old. 134 patients (66%) presented with an occluded infarct related artery. Primary PCI was performed in 90.6% of the patients and the remainder underwent rescue PCI. One hundred eleven (55%) patients were categorized into the STB group and 91 patients (45%) into the LTB group. The use of aspiration thrombectomy was significant higher in the LTB group (LTB 80.2% vs. STB 60.44%, p = 0.002). A higher proportion of patients in the STB group underwent direct stenting strategy (STB 32.4% vs. LTB 18.7%, p = 0.027). There were no significant differences in final TIMI grade 3 flows and procedural success between the groups. Overall, in hospital, mortality was 13.4% and there were no significant differences among the groups. At 1-year follow-up, there was no significant difference in cumulative MACE-free survival in the LTB vs. STB group (82.4% vs. 79.3%, 95% confidence interval for the difference: -8.0% to 13.8%, p = 0.59). CONCLUSION: In the current study, large thrombus burden is not an independent predictor of 1-year cumulative MACE in STEMI patients who were treated with emergent PCI.

Predicting factors for a false positive treadmill exercise stress test.

BACKGROUND: The present study was conducted to determine whether the exaggerated blood pressure (BP) response as well as other factors during exercise stress test (EST) is associated with false positive treadmill EST. MATERIAL AND METHOD: This is a retrospective (case-control) study. Patient upon whom EST was performed at Her Majesty Cardiac Center (HMCC), Siriraj Hospital, Mahidol University and for whom the result revealed positive EST and underwent coronary angiogram (CAG) during October 2007-July 2011. RESULTS: 272 patients were included. 61% was male gender There were 65 false positive cases (23.9%). Most patients are female (60%). No significant difference in baseline systolic blood pressure (SBP), diastolic blood pressure (DBP) and heart rate (HR) was noted between true and false positive group. Using Multiple logistic regression analysis to determining the independent predictors of false positive EST, exaggerated BP response did not result in false positive EST and factors that were associated with the occurrence of false positive EST are female (OR 2.604, 95% CI 1.109-5.952, p = 0.018), the use of statin (OR 0.402, 95% CI 0.194-0.835, p = 0.015), the difference between the peak and the baseline HR (OR 1.049, 95% CI 1.028-1.071, p < 0.001) and time from abnormal to baseline ECG (OR 0.725, 95% CI 0.641-0.820, p < 0.001). CONCLUSION: The present study did not demonstrate that the exaggerated BP response during EST is associated with false positive EST

Current recommendations for revascularization of non-infarct-related artery in patients presenting with ST-segment elevation myocardial infarction and multivessel disease.

ST-segment elevation myocardial infarction (STEMI) is a leading cause of morbidity and mortality worldwide. Immediate reperfusion therapy of the infarct-related artery (IRA) is the mainstay of treatment, either via primary percutaneous coronary intervention (PPCI) or thrombolytic therapy when PPCI is not feasible. Several studies have reported the incidence of multivessel disease (MVD) to be about 50% of total STEMI cases. This means that after successful PPCI of the IRA, residual lesion(s) of the non-IRA may persist. Unlike the atherosclerotic plaque of stable coronary artery disease, the residual obstructive lesion of the non-IRA contains a significantly higher prevalence of vulnerable plaques. Since these lesions are a strong predictor of acute coronary syndrome, if left untreated they are a possible cause of future adverse cardiovascular events. Percutaneous coronary intervention (PCI) of the obstructive lesion of the non-IRA to achieve complete revascularization (CR) is therefore preferable. Several major randomized controlled trials (RCTs) and meta-analyses demonstrated the clinical benefits of the CR strategy in the setting of STEMI with MVD, not only for enhancing survival but also for reducing unplanned revascularization. The CR strategy is now supported by recently published clinical practice guidelines. Nevertheless, the benefit of revascularization must be weighed against the risks from additional procedures.

Current Perspectives on Antithrombotic Therapy for the Treatment of Acute Coronary Syndrome.

Acute coronary syndrome (ACS) is one of the leading causes of death worldwide. Percutaneous coronary intervention (PCI) is the treatment of choice for ACS as this procedure reduces the morbidity and mortality rates of patients in clinical trials and daily practice. However, patients with a history of prior ACS who undergo PCI are still at high risk for recurrent major adverse cardiac events (MACE). Because the antithrombotic drugs reduce the rate of MACE and minimize stent-related complications such as target vessel failure or stent thrombosis, the utilization of these agents is the cornerstone treatment for secondary prevention of ACS patients after PCI. Unfortunately, using the antithrombotic agents may be associated with bleeding complications, including major or fatal bleeding. Therefore, premature discontinuation of antithrombotic regimens regarding the hemorrhagic events is sometimes inevitable and possibly leads to fatal complications such as stent thrombosis. To minimize the bleeding issues, shorten antithrombotic regimens have been proposed, which theoretically offers improved safety. Nevertheless, inappropriate withdrawal of antithrombotic drugs may increase the rate of ischemic events. On the other hand, an unnecessary prolonged antithrombotic regimen may cause avoidable bleeding. Balancing the risk of bleeding against the benefits of using antithrombotic drugs is therefore challenging especially for the patients who contain both bleeding and ischemic risks such as ACS patients who are concomitant using the anticoagulants. Currently, the treatment paradigms are shifting from the "one size fits all approach" toward the "tailored approach". This means that the antithrombotic regimens can be adjustable individually. As a result, various clinical risk scoring systems have been established to help physicians with their decision-making. However, besides the development of these dedicated scoring tools, clinical judgment for balancing the safety versus the efficacy before deciding on the antithrombotic plan is still imperative.

Clinical Outcomes of Rotational Atherectomy in Heavily Calcified Lesions: Evidence From the Largest Cardiac Center in Thailand.

Background: Evidence regarding the clinical outcomes of rotational atherectomy (RA) in middle-income countries is limited. We analyzed the clinical outcomes of patients with heavily calcified coronary lesions who underwent RA-assisted percutaneous coronary intervention (PCI) and explored the risks for developing major adverse cardiovascular and cerebrovascular events (MACCE). Methods: This is a single-center, retrospective cohort analysis that enrolled consecutive patients who underwent RA-assisted PCI at the largest tertiary hospital in Thailand. The primary endpoint is the incidence of MACCE during the first-year follow-up. MACCE consists of cardiac death, ischemic stroke, definite stent thrombosis, target lesion revascularization, and target vessel revascularization. Results: From January 2015 to December 2018, 616 patients (663 lesions) were enrolled. The mean age was 72.8 ± 9.7 years, 292 (47.4%) patients were female and 523 (84.9%) completed one-year follow-up. Drug-eluting stents were deployed in 606 (91.4%) lesions. The RA success rate - defined as when the operator successfully passed the burr across the target lesion - was 99.4% and the angiographic success rate was 94.8%. 130 (21.4%) procedures developed periprocedural complications. The cumulative MACCE rate at 30-days was 1.5% and at 1-year was 6.3%. The in-hospital mortality rate was 1.1% and the cardiac death rate was 1.6%. Independent risk factors for developing MACCE included the use of an intra-aortic balloon pump (hazard ratio [HR] 3.96, 95% confidence interval [CI] 1.54-10.21; P = 0.004), a history coronary artery bypass graft (HR 2.30, 95% CI 1.01-5.25; P = 0.048), and increased serum creatinine (HR 1.16, 95% CI 1.04-1.30; P = 0.008). Conclusions: RA is an effective revascularization technique for heavily calcified lesions. This study demonstrates a high success rate and good short- to intermediate-term results of RA-assisted PCI in middle-income countries which are similar to high-income countries. Nevertheless, the rate of periprocedural complications remains high.

Intravascular Imaging Guidance Reduce 1-Year MACE in Patients Undergoing Rotablator Atherectomy-Assisted Drug-Eluting Stent Implantation.

Objectives: This study aimed to investigate the incidence of 1-year major adverse cardiac events (MACE) compared between intravascular imaging guidance and angiographic guidance in patients undergoing rotablator atherectomy (RA)-assisted percutaneous coronary intervention (PCI) with drug-eluting stent (DES) implantation. Methods: This retrospective analysis included 265 consecutive patients with heavy calcified lesion who underwent RA-assisted PCI with DES implantation at our institution during the January 2016-December 2018 study period. This study was approved by the Siriraj Institutional Review Board. Patients were divided into either the angiographic guidance PCI group or the imaging guidance PCI group, which was defined as intravascular ultrasound or optical coherence tomography. The primary endpoint was 1-year MACE. Results: Two hundred and sixty-five patients were enrolled, including 188 patients in the intravascular imaging guidance group, and 77 patients in the angiographic guidance group. One-year MACE was significantly lower in the imaging guidance group compared to the angiographic guidance group (4.3 vs. 28.9%, respectively; odds ratio (OR): 9.06, 95% CI: 3.82-21.52; p < 0.001). The 1-year rates of all-cause death (OR: 8.19, 95% CI: 2.15-31.18; p = 0.002), myocardial infarction (MI) (OR: 6.13, 95% CI: 2.05-18.3; p = 0.001), and target vessel revascularization (TVR) (OR: 3.67, 95% CI: 1.13-11.96; p = 0.031) were also significantly lower in the imaging guidance group compared with the angiographic guidance group. The rate of stroke was non-significantly different between groups. Conclusion: In patients with heavy calcified lesion undergoing RA-assisted DES implantation, the intravascular imaging guidance significantly reduced the incidence of 1-year MACE, all-cause death, MI, and TVR compared to the angiographic guidance.

Chronic Dissection of Left Sinus of Valsalva Obscuring Left Main Coronary Artery.

Coronary angiography in a 44-year-old woman shows chronic dissection of the left sinus of Valsalva, totally obscuring the LMCA, with good collaterals supplying the left coronary system from the right coronary artery.