The epicardial delivery of cardiosphere derived cells or their extracellular vesicles is safe but of limited value in experimental infarction

The epicardial administration of therapeutics via the pericardial sac offers an attractive route, since it is minimally invasive and carries no risks of coronary embolization. The aim of this study was to assess viability, safety and effectiveness of cardiosphere-derived cells (CDCs), their extracellular vesicles (EVs) or placebo administered via a mini-thoracotomy 72 h after experimental infarction in swine. The epicardial administration was completed successfully in all cases in a surgery time (knife-to-skin) below 30 min. No significant differences between groups were found in cardiac function parameters evaluated using magnetic resonance imaging before therapy and at the end of the study, despite a trend towards improved function in CDC-treated animals. Moreover, infarct size at 10 weeks was smaller in treated animals, albeit not significantly. Arrhythmia inducibility did not differ between groups. Pathological examination showed no differences, nor were there any pericardial adhesions evidenced in any case 10 weeks after surgery. These results show that the epicardial delivery of CDCs or their EVs is safe and technically easy 3 days after experimental myocardial infarction in swine, but it does not appear to have any beneficial effect on cardiac function. Our results do not support clinical translation of these therapies as implemented in this work.

Dual coronary embolization associated with atrial fibrillation: a case report

Background: Thrombotic occlusion of the coronary artery, which succeeds the atherosclerotic plaquerupture or erosion, gives rise to a major portion of acute myocardial infarction (AMI) incidences.Nevertheless, coronary embolism is gaining increasing recognition as another important factor contributingto AMI. Case presentation: A 72-year-old woman with atrial fibrillation (AF) and diabetes mellitus histories,presented with chest pain radiating to the left arm and shoulder that began 6 hours prior to admission.Electrocardiogram revealed AF plus ST-segment elevation in the anterior leads.Intervention: Patient was first treated with anti-platelet agents (aspirin plus ticagrelor) and atorvastatin.Emergency coronary angiography depicted multi-site coronary embolization of the left circumflex artery(LCX) and the left anterior descending artery (LAD). Blood flow was not restored after intracoronaryinjection of 600 ug tirofiban. 40 mg recombinant human prourokinase was then administered via aspirationthrombectomy catheter. Outcome: Two weeks later, coronary angiography showed no residual obstructive lesion in the LCX andLAD with TIMI (thrombolysis in myocardial infarction) 3 flow. Conclusion: Primary percutaneous coronary intervention is the most effective measure. In the case offailed blood flow restoration, thrombolytic treatment in both intravenous and intracoronary route should beconsidered.

Myocardial Infarction or Takotsubo Cardiomyopathy? A Case Report of a Rare Clinical Dilemma in the Setting of Atrial Myxoma

Background Acute myocardial infarction (AMI) secondary to coronary embolization is one of the rare complications of atrial myxoma. Takotsubo cardiomyopathy (TCM), a close mimic of AMI, is extremely rare in the setting of atrial myxoma. We report a patient with atrial myxoma presenting with features leading to a clinical dilemma between these two entities. Case summary A 60-year-old woman presented with acute chest pain with ST segment elevation. Echocardiogram revealed left ventricular (LV) apical ballooning which is typical of TCM, coexisting with a fragile left atrial mass. Emergency coronary angiogram showed a hazy lesion in the circumflex ostium and an intermediate lesion in ramus without any obstruction. Surgical excision of the tumor was done due to features of recurrent coronary embolism. The histopathology examination confirmed it as a myxoma. Regional wall motion abnormalities reversed within a month and LV function normalized. Cardiac magnetic resonance (CMR) imaging at follow-up suggested myocardial infarction. Discussion TCM can occur very rarely in the setting of atrial myxoma. In a patient with atrial myxoma presenting with features of TCM, differentiating it from coronary embolization is important.

Epicardial Delivery of Cardiosphere Derived Cells or Their Extracellular Vesicles in a Relevant Infarcted Swine Model: Safe, Easy but of Limited Effectiveness.

The epicardial administration of therapeutics via the pericardial sac offers an attractive route, since it is minimally invasive and carries no risks of coronary embolization. The aim of this study was to assess viability, safety and effectiveness of Cardiosphere-Derived Cells (CDCs), their extracellular vesicles (EVs) or placebo administered via a mini-thoracotomy 72h after experimental infarction in swine. The epicardial administration was completed successfully in all cases in a surgery time (knife-to-skin) below 30 minutes. No significant differences between groups were found in cardiac function parameters evaluated using magnetic resonance imaging before therapy and at the end of the study, despite a trend towards improved function in CDC-treated animals. Moreover, infarct size at 10 weeks was smaller in treated animals, albeit not significantly. Arrhythmia inducibility did not differ between groups. Pathological examination showed no differences, nor were there any pericardial adhesions evidenced in any case 10 weeks after surgery. These results show that the epicardial delivery of CDCs or their EVs is safe and technically easy 3 days after experimental myocardial infarction in swine, but it does not appear to have any beneficial effect on cardiac function. Our results do not support clinical translation of these therapies as implemented in this work.

Acute coronary syndrome, a rare manifestation of infective endocarditis: a case report

Systemic embolization in infective endocarditis is common, occurring in 45-65% of cases. However, the septic coronary embolization is a complication rarely described as a cause of acute myocardial infarction (AMI). The presentation of chest pain as the first manifestation of endocarditis is associated with a poor prognosis. Mitral valve endocarditis with embolization to the left anterior descending coronary is the most common situation described in the literature. We present a case of a young male patient with typical angina caused by acute myocardial infarction, who had an obstructive lesion to the marginal branch of the circumflex artery in the angiography, and was later diagnosed with aortic valve endocarditis. Key words: infective endocarditis; embolism; coronary artery; acute myocardial infarction

ST segment elevation caused by ostial right coronary artery obstruction in infective endocarditis: a case report

Background Acute coronary syndrome (ACS) is a rare, but serious complication of infective endocarditis, and diagnosis can be challenging given clinical overlap with other syndromes. A rare cause of ACS in infective endocarditis is mechanical obstruction of the coronary artery. We present the case of a patient with infective endocarditis who developed ST segment myocardial infarction due to occlusion of the right coronary artery ostium by a vegetation. Case presentation A 53-year-old female with no prior history of coronary artery disease was transferred to our tertiary care facility for evaluation and treatment of suspected myopericarditis. After transfer she developed inferior ST segment elevations on ECG along with fever and positive blood cultures for methicillin susceptible Staphylococcus aureus (MSSA). A transesophageal echocardiogram revealed a vegetation on the aortic valve that intermittently prolapsed into the right coronary ostium. She decompensated from a hemorrhagic brain infarct and subsequently transferred to the intensive care unit. She underwent surgical aortic valve debridement without prior cardiac catheterization given the danger of septic coronary embolization. After a prolonged hospital course with multiple complications, she was able to discharge home, with no neurologic deficits on follow-up. Conclusions ACS presents a diagnostic and therapeutic challenge in the setting of infective endocarditis. Careful attention to the history, physical exam and testing can help differentiate infective endocarditis from other conditions sharing similar symptoms. Traditional atherosclerotic ACS management may cause great harm when treating patients with infective endocarditis. The presence of a multidisciplinary endocarditis team is ideal to provide the best clinical outcomes for this population.

Myocardial infarction with non-obstructive coronary arteries: what is the prognosis?

Myocardial infarction in the absence of obstructive coronary stenosis (MINOCA) is a syndrome with several causes, characterized by clinical evidence of myocardial infarction and coronary angiographically normal or almost normal (stenosis ≤50%). MINOCAs represent about 10% of acute coronary syndromes. The causes of MINOCA are manifold and can be classified on the basis of the mechanism in epicardial (unstable plaque not manifested by angiography, epicardial spasm and coronary dissection) or microvascular. The latter in turn can be divided into intrinsic (microvascular spasm, Takotsubo syndrome and coronary embolization) and extrinsic (myocarditis). In the former, the dysfunctional microcirculation causes myocardial necrosis due to reduction of the lumen due to vasoconstriction and / or obstruction, while in the latter, the compression of the lumen occurs ab extrinsic due to myocardial edema. Note that the prognosis of MINOCA is extremely variable and depends on the underlying cause with high risk clinical subsets. A correct diagnostic procedure includes first level tests (clinical / anamnestic examination, ECG, myocardial necrosis enzyme dosage, trans-thoracic echocardiogram, coronary angiography, ventriculogram) and second level tests (intracoronary imaging, coronary vasomotor test, cardiac nuclear magnetic resonance and trans-esophageal or contrast ultrasound). Through this process, it is possible to identify the cause of MINOCA, fundamental for targeting therapy on the disease mechanism, thus constituting a typical example of precision medicine.

P651 Left intraventricular mass. An exceptional finding

74-year-old woman without cardiovascular risk factors. Se came to the out-paint clinic due to chest pain. Normal ECG. Spherical, pedunculated, mobile, slightly hyper-echogenic mass at the level of the posterior papillary muscle by transthoracic echocardiography. Cardiac MR (CMR) was performed for further evaluation: mobile mass of 4 x 5mm, located in the mitral subvalvular apparatus was confirmed, with similar intensity to the myocardium in the SSFP sequences. In T2 TSE sequences, the mass was hyperintense and in the perfusion sequences marked hypoperfusion was found. In early late gad enhancement the mass was hypointense and in the late phase, hyper-intense. According to these findings papillary fibroelastoma was our first diagnostic choice. The coronary angio showed a significant RCA stenosis. The tumor was surgically removed and aorto-coronary bypass was perfomed. Pathological anatomy confirmed the suspected diagnosis. Papillary fibroelastoma is the second most frequent benign primary cardiac tumor, originated mainly in the valvular endocardium. The most frequent localization of these tumors is in the aortic valve. The vast majority are asymptomatic and their diagnosis is usually incidental (as in the case described), although severe symptoms may appear secondary to embolic phenomena such as cerebrovascular event, acute myocardial infarction or even sudden death by coronary embolization. The initial diagnosis is usually made by echocardiography. CMR is a reference diagnostic technique in the study of cardiac tumors: provides a better location and tissue characterization. Regarding the treatment, it is recommended the exeresis, in symptomatic patients with embolic phenomenon or in asymptomatic patients with a high risk of embolization (tumors> 1cm or very mobile). This case is of special interest since the location of a fibroelastoma in the mitral subvalvular apparatus is exceptional (there are very few cases described in the literature). In addition, although in the study of cardiac tumors pathological anatomy remains the reference diagnostic method, this case shows how cardio-MRI can correctly guide diagnosis even in small and mobile tumors. Abstract P651 Figure. A.3D TOE B.Surgical image C.CMR D. PA