A long-term complication of coronary artery perforation developed during primary percutaneous coronary intervention: Coronary arteriovenous fistula

Abstract Background Despite the implementation in the use of primary percutaneous coronary intervention (pPCI) and in secondary preventive measures, the risk of recurrence of myocardial infarction (MI) in patients who underwent ST-elevation myocardial infarction (STEMI) remains high. The prognostic role of old and emerging cardiovascular risk factors for MI recurrence, such as Lipoprotein(a) [Lp(a)] levels, in this very high-risk population is still not fully understood. Purpose To identify the baseline predictors of MI recurrence in a cohort of patients admitted for STEMI and treated with pPCI. Methods Single-center, observational, retrospective analysis of consecutive patients admitted for STEMI who underwent pPCI from February 2013 to April 2019 at our Insitution. Baseline demographic, clinical, echocardiographic and laboratory data were prospectively collected. Only patients with available Lp(a) values were included in the analysis. The study outcome was the recurrence of MI at three years follow-up. Univariable and multivariable Cox regression analysis was performed to identify the baseline variables correlated to the study outcome. Results The study population included 560 patients (mean age = 60.6±13.7 years; 79.5% males). Hypertension was observed in 351 patients (62.7%), diabetes in 134 (23.9%), dyslipidemia in 266 (47.5%), smoking status in 316 (56.4%), history of coronary artery disease (CAD) in 76 (13.6%), prior MI in 69 (12.3%), prior PCI in 62 (11.1%). Multivessel disease (MVD) was reported in 211 (37.7%) cases. The infarct-related artery was the left anterior descending in 310 patients (55.4%), the right coronary artery in 179 (32.0%), the left circumflex 60 (10.7%) and the left main in 11 (2.0%). Total cholesterol mean value was 187.7±48.8 mg/dl; LDL cholesterol was 112.2±41.3 mg/dl and Lp(a) was 26.5±27.2 mg/dl. At three-year follow-up, MI occurred in 58 (10.4%) patients. At multivariable analysis, Lp(a) (HR 1.015 95% CI: 1.008–1.022 p<0.001) and MVD (HR 1.994; 95% CI 1.179–3.372 p=0.010) emerged as the only two independent predictors of MI recurrence up to three years. The Kaplan-Meier analysis showed a significantly lower survival free from MI in patients with Lp(a) ≥50 mg/dl as compared to the subgroups with levels ≥30 and <50 mg/dL, or <30 mg/dL (Log-Rank=0.001). Also, MVD was able to identify patients with significantly lower survival free from MI for up to three years (Log-Rank=0.004). The Kaplan-Meier analysis combining these two parameters identified patients with both MVD and Lp(a) ≥50 mg/dl as the highest risk cohort for MI recurrence up to three years (MI incidence rate=22.2%; Log-Rank=0.002). Conclusions Among patients with STEMI who underwent pPCI, high Lp(a) level and MVD predict the recurrence of MI at long-term follow-up. Funding Acknowledgement Type of funding source: None

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Clinical characteristics and long-term mortality of patients with midrange ejection fraction undergoing primary percutaneous coronary intervention for ST-elevation myocardial infarction

European Heart Journal ◽

10.1093/ehjci/ehaa946.0941 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

J Vratonjic ◽

D Milasinovic ◽

M Asanin ◽

V Vukcevic ◽

S Zaharijev ◽

...

Keyword(s):

Myocardial Infarction ◽

Percutaneous Coronary Intervention ◽

Ejection Fraction ◽

Primary Percutaneous Coronary Intervention ◽

Coronary Intervention ◽

Primary Pci ◽

Percutaneous Coronary ◽

St Elevation ◽

Long Term Mortality

Abstract Background Previous studies associated midrange ejection fraction (mrEF) with impaired prognosis in patients with ST-elevation myocardial infarction (STEMI). Purpose Our aim was to assess clinical profile and short- and long-term mortality of patients with mrEF after STEMI treated with primary percutaneous coronary intervention (PCI). Methods This analysis included 8148 patients admitted for primary PCI during 2009–2019, from a high-volume tertiary center, for whom echocardiographic parameters obtained during index hospitalization were available. Midrange EF was defined as 40–49%. Adjusted Cox regression models were used to assess 30-day and 5-year mortality hazard of mrEF, with the reference category being preserved EF (>50%). Results mrEF was present in 29.8% (n=2 427), whereas low ejection fraction (EF<40%) was documented in 24.7% of patients (n=2 016). mrEF was associated with a higher baseline risk as compared with preserved EF patients, but lower when compared with EF<40%, in terms of prior MI (14.5% in mrEF vs. 9.9% in preserved EF vs. 24.2% in low EF, p<0.001), history of diabetes (26.5% vs. 21.2% vs. 30.0%, p<0.001), presence of Killip 2–4 on admission (15.7% vs. 6.9% vs. 26.5%, p<0.001) and median age (61 vs. 59 vs. 64 years, p<0.001). At 30 days, mortality was comparable in mrEF vs. preserved EF group, while it was significantly higher in the low EF group (2.7% vs. 1.6% vs. 9.4%, respectively, p<0.001). At 5 years, mrEF patients had higher crude mortality rate as compared with preserved EF, but lower in comparison with low EF (25.1% vs. 17.0% vs. 48.7%, p<0.001) (Figure). After adjusting for the observed baseline differences mrEF was independently associated with increased mortality at 5 years (HR 1.283, 95% CI: 1.093–1.505, p=0.002), but not at 30 days (HR 1.444, 95% CI: 0.961–2.171, p<0.001). Conclusion Patients with mrEF after primary PCI for STEMI have a distinct baseline clinical risk profile, as compared with patients with reduced (<40%) and preserved (≥50%) EF. Importantly, mrEF did not have a significant impact on short-term mortality following STEMI, but it did independently predict the risk of 5-year mortality. Funding Acknowledgement Type of funding source: None

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Isolated right ventricular myocardial infarction: a case report

European Heart Journal - Case Reports ◽

10.1093/ehjcr/ytaa494 ◽

2020 ◽

Author(s):

Adeogo Akinwale Olusan ◽

Paul Francis Brennan ◽

Paul Weir Johnston

Keyword(s):

Myocardial Infarction ◽

Computed Tomography ◽

Percutaneous Coronary Intervention ◽

Coronary Artery ◽

Right Ventricular ◽

Primary Percutaneous Coronary Intervention ◽

Coronary Intervention ◽

Left Circumflex Artery ◽

Right Ventricular Myocardial Infarction ◽

Percutaneous Coronary

Abstract Background Isolated right ventricular myocardial infarction (RVMI) due to a recessive right coronary artery (RCA) occlusion is a rare presentation. It is typically caused by right ventricle (RV) branch occlusion complicating percutaneous coronary intervention. We report a case of an isolated RVMI due to flush RCA occlusion presenting via our primary percutaneous coronary intervention ST-elevation myocardial infarction pathway. Case summary A 61-year-old female smoker with a history of hypercholesterolaemia presented via the primary percutaneous coronary intervention pathway with sudden onset of shortness of breath, dizziness, and chest pain while walking. Transradial coronary angiography revealed a normal left main coronary artery, large left anterior descending artery that wrapped around the apex and dominant left circumflex artery with the non-obstructive disease. The RCA was not selectively entered despite multiple attempts. The left ventriculogram showed normal left ventricle (LV) systolic function. She was in cardiogenic shock with a persistent ectopic atrial rhythm with retrograde p-waves and stabilized with intravenous dobutamine thus avoiding the need for a transcutaneous venous pacing system. A computed tomography pulmonary angiogram demonstrated no evidence of pulmonary embolism while an urgent cardiac gated computed tomography revealed a recessive RCA with ostial occlusive lesion. A cardiac magnetic resonance imaging confirmed RV free wall infarction. She was managed conservatively and discharged to her local district general hospital after 5th day of hospitalization at the tertiary centre. Discussion This case describes a relatively rare myocardial infarction presentation that can present with many disease mimics which can require as in this case, a multi-modality imaging approach to establish the diagnosis.

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