Postpartum Coronary Artery Embolism

Background Acute coronary syndrome (ACS) is rare in post-partum women. Prompt diagnosis of ACS and its etiology in postpartum women is crucial to guide the management of these complicated cases. Case summary In this case, a 37-year-old woman presented with acute chest pain. Transthoracic echocardiography revealed a large left ventricular apical thrombus. The patient underwent coronary angiography in the setting of ST segment elevation on the electrocardiogram (ECG) and troponin elevation. Coronary angiography showed a large thrombus in the proximal left anterior descending artery (LAD) with embolization to the distal (LAD) artery and distal second diagonal branch. Thrombophilia workup was unremarkable. The patient was managed with anticoagulation. Conclusion This case demonstrates an example of acute coronary syndrome in the postpartum period due to coronary artery thrombosis.

Multiple coronary artery perforation following global pericardial tamponade in a patient with prior coronary artery bypass graft surgery: a case report

Background Patients who undergo coronary artery bypass graft surgery rarely develop global pericardial tamponade due to pericardial adhesions. There are no reports of multiple coronary artery perforations following global pericardial tamponade during percutaneous coronary intervention in these patients. Case Summary A 52-year-old male who underwent coronary artery bypass graft surgery developed effort angina pectoris. Coronary angiography demonstrated chronic total occlusion of the first diagonal branch with severe stenosis of the second diagonal branch. Because his chest pain did not improve with medical therapy and ischemia of the left ventricular anterolateral wall was confirmed by myocardial scintigraphy, percutaneous coronary intervention was performed. The second diagonal branch stenosis was passed anterogradely by a 0.014-inch coronary angioplasty guidewire, while the first diagonal branch chronic total occlusion was recanalized by side-branch intravascular ultrasonography-guided parallel wiring. After stent deployment, coronary artery perforation at the distal end of the second diagonal branch was detected via contrast injection. We immediately performed intravascular hemostasis, leading to the disappearance of contrast. However, multiple bleeding sites were visualized by angiography at different sites of coronary arteries, including the circumflex artery. Although intravascular hemostasis is a standard procedure, we could not control rebleeding. Despite intensive care, the patient died. Discussion Increased tissue pressure due to bleeding possibly led to global pericardial tamponade with multiple coronary artery perforations. We report a rare case of a patient with multiple coronary artery perforations during coronary intervention.

Five-year outcomes of implantation of Absorb biodegradable stents using the bifurcation stenting technique: a case report

The presented case report describes a five-year outcomes of bifurcation stenting of the left anterior descending artery and large diagonal branch with Absorb bioabsorbable vascular stent (BVS) according to selective coronary angiography and optical coherence tomography. The example demonstrates not only the successful implantation of biodegradable stents into the bifurcation area, but also the complete restoration of the arterial wall with the formation of neocarina. Optical coherence tomography made it possible to study in detail all stages of vascular wall alterations from the inside. This case report prompts a fresh look at the biodegradable BVS Absorb stents and does not rule out the potential of returning these stents to clinical practice in the future. Currently, the production and use of Absorb BVSs has been suspended, but they have filled a certain niche in the endovascular treatment of patients with coronary artery disease.

Role of IVUS in the rectification of angiographically judged ramus intermedius and its clinical significance

Background Due to the technical limitations of coronary artery angiography (CAG), ramus intermedius (RI) is sometimes difficult to distinguish from a high-origin obtuse marginal branch or a high-origin diagonal branch. This study sought to investigate the role of intravascular ultrasonography (IVUS) in the rectification of angiographically judged RI. Methods This study retrospectively analyzed 165 patients who were reported to have an RI based on CAG and underwent IVUS implementation from 02/01/2009 to 31/12/2019 in Zhongshan Hospital, Fudan University. Taking IVUS as the gold standard, we calculated the accuracy of RI identification by CAG and evaluated the impact of RI on revascularization strategy. Results Among the 165 patients, 89 patients (54%) were demonstrated to have an RI on IVUS (IVUS-RI), 32 patients (19%) were identified to have a high-origin diagonal branch on IVUS (IVUS-h-D), and 44 patients (27%) had an actual high-origin obtuse marginal artery on IVUS (IVUS-h-OM). Among 84 patients who underwent one-stent crossover stenting because of left main furcation lesions (48 patients in the IVUS-RI group, 12 patients in the IVUS-h-D group, and 24 in the IVUS-h-OM group), 14.6% of patients in the IVUS-RI group, 33.3% in the IVUS-h-D group and 0% in the IVUS-h-OM group had CAG-RI compromise (P = 0.02), which was defined as severe stenosis of the RI ostium (> 75%) or significant RI flow impairment (TIMI < 3). Conclusions Only 54% of CAG-RIs were confirmed by IVUS, which indicates the necessity of preintervention IVUS to distinguish real RIs from other branches in LM furcation lesions.

Implementation of electrocardiography from the coronary sinus in interventional treatment of coronary arteries: two-year experience of clinical application of the method

The aim of this study was to summarize, systematize, and extend analysis of data of two-year clinical use of intracardiac ECG (ECG-CS) in patients with coronary artery disease.Material and methods. 131 patients with coronary artery disease who underwent a planned coronary stenting were included in a prospective study from 2018 till 2020 . Ischemia was monitored with the use of electrophysiological recording system with the following settings: combining electrodes into fi ve cathode-anode pairs with a frequency range of 30–500 Hz, signal cut-off of 1 cm, and an amplitude of 0.3 mV/cm.Results. According to the ROC-analysis, the sensitivity of the ECG-СS method in case of ST segment depression was 79.5%, the specifi city was 100%; with ST segment elevation — 83% with a specifi city of 100%, according to data obtained in 88 patients with single-vessel disease of the coronary arteries (CA). Out of 43 patients with coronary artery disease, compromise of the diagonal branch and signifi cant ischemic dynamics (p < 0.05) in the intracardiac lead CS 3–4 after stent placement in the ADA according to ECG-CS was observed in 11 (25.6%) patients, in 9 (20.9%) of which successful provisional stenting was performed, and 2 (4 .6%) patients required implantation of the second stent.Conclusion. ECG-CS is a promising method for detecting myocardial ischemia in patients with coronary artery disease and allows to optimize intervention in the area of coronary artery bifurcation.

Lateral ST-elevation myocardial infarction after donation of COVID-19 convalescent plasma in a naïve donor

A 34-year-old man presented with central chest pain heralded by bilateral arm numbness, tingling and pain soon after donation of 1000 mL of COVID-19 convalescent plasma (CP). ECG showed ST-elevation in lateral leads and coronary angiogram showed large thrombus in diagonal branch of the left anterior descending artery. The patient underwent successful thrombus aspiration and percutaneous coronary intervention of diagonal branch. In this report, we describe a case of coronary thrombosis leading to ST-elevation myocardial infarction in a naïve plasma donor after donation of COVID-19 CP.

Revascularization of Coronary Artery Chronic Total Occlusion by Active Antegrade Reverse Wire Technique

Objectives. To assess the effectiveness and safety of ARW for vascular recanalization in CTO patients. Background. Chronic total occlusion (CTO) of coronary artery accompanied with large branch distal to the occluded segment (<2 mm) is one of the challenges physicians are facing during the coronary intervention. In cases where the antegrade wire passed the occluded segment reaching the branch vessel, but could not access the main vessel through various adjustments, application of active antegrade reverse wire technique (ARW) could be considered. Patients and Methods. A total of 301 consecutive CTO patients who received the antegrade percutaneous coronary intervention (PCI) between December 2015 and December 2019 at our institution were included, of whom 11 were treated with ARW (10 successfully) for vascular recanalization. The applicability and safety of ARW were assessed. Results. Among the 301 CTO patients who received antegrade vascular recanalization, 11 were treated with ARW. ARW was successful in 10 patients as follows: from the diagonal branch (D) to anterior descending branch (LAD) in 4 patients; from the septal branch (S) to LAD in 1 patient; from D to S and LAD in 1 patient; from the circumflex branch (LCX) to obtuse marginal branch (OM) in 1 patient; from OM to LCX in 1 patient; from a posterior descending artery (PDA) to the posterior lateral vein (PLV) in 2 patients. Yet, ARW in patient with RCAm CTO failed, while the consequent retrograde PCI succeeded. The mean J-CTO score of the 11 patients was 2.7 ± 0.65, among whom eight were accompanied with calcifications. Sion Black and Fielder XTR reverse wires were used in 9 and 2 patients, respectively. No loss of side branches or severe procedure-related complications occurred in 11 patients. Conclusion. Therefore, ARW can improve procedural efficiency and should be popularized for further application.

High Density Intramural Mapping of Post-Infarct Premature Ventricular Contractions.

Background: Spontaneous ventricular premature contractions (PVCs) in the post infarct milieu is assumed to be due to automaticity. However, the mechanism has not been studied with appropriate mapping tools. Objective: To study the mechanism of spontaneous PVCs with high density intramural mapping in a canine model, to test the hypothesis that post-infarct PVCs are due to re-entry rather than automaticity. Methods: In 15 anesthetized dogs, using 768 intramural unipolar electrograms, simultaneous recordings were made. After 30 mins of stabilization, recordings were made during the first 10 minutes of ischemia, and activation maps were constructed of individual beats. Acute ischemia was produced by clamping the left anterior descending coronary artery proximal to the first diagonal branch. The analysis was limited to the activation pattern of spontaneous ventricular beats. Results: In all experiments ST-T alternans occurred. In 8 of 15 dogs spontaneous ventricular beats occurred. In all 8 of these experiment earliest, ectopic activity occurred in the endocardium, well within the ischemic zone. From there, activity spread rapidly along the subendocardium, with endo-to epicardial spread along the non ischemic myocardium. Epicardial breakthrough always occurred at the border of the ischemic myocardium. In 3 dogs, delayed potentials were observed, which were earliest at the ischemic epicardium and extended transmurally with increasing delay towards the endocardium, where they culminated in a premature beat. Conclusion: Graded responses that occur with each sinus beat intramurally, when able to propagate from epicardium to endocardium is the mechanism by which PVCs are generated in post-infarct myocardium.