Successful removal of a paradoxical coronary embolus using an aspiration catheter

Congenital heart disease: types, pathophysiology, diagnosis, and treatment options

Congenital heart disease (CHD) is a structural abnormality of the heart and/or great vessels and patients with CHD are at an increased risks of various morbidities throughout their lives and reduced long-term survival. Eventually, CHD may result in various complications including heart failure, arrhythmias, stroke, pneumonia, and sudden death. Unfortunately, the exact etiology and pathophysiology of some CHD remain unclear. Although the quality of life and prognosis of patients with CHD have significantly improved following technological advancement, the influence of CHD is lifelong, especially in patients with complicated CHD. Thus, the management of CHD remains a challenge due to its high prevalence. Finally, there are some disagreements on CHD among international guidelines. In this review, we provide an update of the pathophysiology, diagnosis, and treatment in most common type of CHD, including patent foramen ovale, atrial septal defect, ventricular septal defect, atrioventricular septal defect, patent ductus arteriosus, coarctation of the aorta, transposition of the great arteries, congenitally corrected transposition of the great arteries, coronary anomalies, left and right ventricular outflow tract obstruction, tetralogy of Fallot and Ebstein anomaly. In particular, we focus on what is known and what is unknown in these areas, aiming to improve the current understanding of various types of CHD.

[Uncommon cause of acute coronary syndrome : Paradoxical embolism]

Coronary artery embolism is an uncommon cause of myocardial infarction (MI). Among several etiologies of coronary embolism, we mention a very rare cause which is the paradoxical embolism via patent foramen ovale (PFO). It interests generally youngest people without cardiac risk factors. We report three cases who presented ST-elevation MI (STEMI) due to paradoxical embolism with high risk PFO that can justify embolic infarction. The aim of this article is to define the high risk PFO, to establish causal link between PFO and embolic events and to guide therapeutic management.

Coronary Embolism and Myocardial Infarction: A Scoping Study

Coronary embolism is a cause of acute myocardial infarction (AMI)in which obstructive foci enter the coronary circulation, block normal blood flow and precipitate ischemia. Precise studies focusing on patient population affected, pathophysiological mechanisms, and treatment strategies are scanty, in spite of a reported prevalence estimated at 2.9%. As the understanding of myocardial infarction without evidence of coronary artery disease continues to grow, an in-depth review of this previously seldomly reported subtype of coronary ischemia was in order. Patients suffering coronary embolism are 15 to 20 years younger than traditional AMI patients with a slight predominance towards male sex, which resembles the gender data of the populations affected by non-traditional myocardial infarction in published reports. While the expected prevalence rate of cardiovascular disease risk factors such as hypertension and hyperlipidemia are present, this population also has a relatively high prevalence of atrial fibrillation and valve pathology, especially endocarditis. Initial presentation is indistinguishable from other causes of myocardial infarction however fever is commonly present, when endocarditis with valvular involvement is the primary cause of the coronary embolism. Mechanical thrombectomy is the mainstay of treatment, followed by percutaneous coronary intervention. Mortality is the highest in patients who do not receive targeted treatment for the coronary embolism, particularly if only antimicrobial agents or anticoagulation without thrombolytic agents are employed. The unique features of coronary embolism highlighted in this historical study justify further examination in contemporary patient populations.

ST-segment elevation in V1-V4 in acute pulmonary embolism: a case presentation and review of literature

INTRODUCTION

Electrocardiographic (ECG) abnormalities are seen in 70%-80% of patients with acute pulmonary embolism (APE). Rarely, APE presents with ST-segment elevation (STE) in leads V1-V4, mimicking ST-segment elevation myocardial infarction (STEMI). Herein, we describe a case of APE presenting with STE in V1-V3, along with a comprehensive review of the literature.

METHODS

We reviewed Pubmed/Medline indexed articles from 1950 to 2014 reporting cases of APE presenting with STE in V1-V3 or V4 (V1-V3/V4). Cases were analyzed with specific reference to patient demographics, clinical, laboratory, and radiological data, treatment, and outcome.

RESULTS

A total of 12 cases were identified comprising seven males and five females aged between 31 and 64 years. Five cases met the American College of Cardiology/American Heart Association criteria for massive APE due to sustained hemodynamic instability or requirement for inotropic support, and seven met criteria for submassive PE due to right ventricular (RV) dysfunction or elevated troponin in absence of systemic hypotension. Among the notable clinical features in this cohort is the high incidence of syncope, in 66.7% of the cases, high incidence of concomitant deep venous thrombosis (DVT) in 90% of cases that reported venous Doppler results (eight proximal and one distal DVT), and the presence of a dilated RV in 90% of the cases that reported echocardiographic results. In all but one case the initial working diagnosis was STEMI and emergent cardiac catheterization was planned. In the 90% of cases who eventually had a coronary angiography, the angiogram was performed prior to diagnosing APE, and the lack of occlusive disease prompted further workup that confirmed the diagnosis of APE. In-hospital mortality rate in the studied population was 16.7%.

CONCLUSION

STE in leads V1-V3/V4 in cases with APE identifies a subset of patients who are an intermediate to high risk category. In cases presenting with right precordial lead STE and clinical features that are more suggestive of APE rather than STEMI, a computed tomography pulmonary angiogram is warranted for earlier diagnosis of suspected APE, which allow for immediate-rather than delayed-initiation of therapeutic anticoagulant therapy if the diagnosis is confirmed and may avert the need for coronary angiography.

Paradoxical coronary artery embolism - a rare cause of myocardial infarction

Paradoxical coronary artery embolism is a rare, but often an underdiagnosed cause of acute myocardial infarction. It should be considered in patient who presents with chest pain and otherwise having a low risk profile for atherosclerosis coronary artery disease. We describe a case of paradoxical coronary artery embolism causing ST segment elevation myocardial infarction in a patient with upper extremity venous thrombosis. Echocardiography demonstrated a patent foramen ovale (PFO) with bidirectional shunt. In addition to treatment of acute coronary event closure of the PFO should be considered to prevent a recurrence.

Paradoxical cardiac and cerebral arterial gas embolus during percutaneous lead extraction in a patient with a patent foramen ovale

A 42 year-old man presented for elective percutaneous lead extraction for pacemaker redundancy. The procedure was performed supine under general anaesthesia via the right femoral vein and was complicated by acute inferior ST elevation and hypotension. Urgent transoesophageal echocardiogram showed inferior left ventricular hypokinesis, right ventricular impairment, a patent foramen ovale and air in the left ventricle. Coronary angiography demonstrated normal coronary arteries, the ST changes resolved and the leads were subsequently removed intact. Post-operatively the patient displayed nystagmus, was managed with hyperbaric oxygen therapy, and had complete resolution of his symptoms. An MRI brain confirmed an acute left cerebellar infarction, and a diagnosis of paradoxical air embolus to the coronary and cerebral circulations was made. This case illustrates the risks associated with paradoxical embolism in patients with PFOs undertaking percutaneous lead extractions. It also highlights the need for further consideration into techniques to avoid this complication in all high-risk percutaneous procedures.

Paradoxical Thromboembolism/ST-Elevation Myocardial Infarction via a Patent Foramen Ovale in Sub-Massive Pulmonary Embolism Following an Upper Extremity Deep Venous Thrombosis: Is It Time for a Change in the Standard of Care?

The objective of this case study is to discuss a rare case of proven paradoxical thromboembolism captured in-transit. A 23-year-old female with a diagnosis of right internal jugular deep vein thrombus who developed acute onset chest pain, dyspnea and hypotension, was selected for the study. Sub-massive PE and STEMI were diagnosed. Transthoracic echocardiogram revealed a left ventricular (LV) mass moving across the aortic valve. Soon after, the patient developed numbness of right extremities with non-palpable pulses. A transesophageal echocardiogram revealed absent LV mass, PFO, left atrial mass entering through the PFO and emboli in bilateral pulmonary arteries. We report a case of sub-massive PE and paradoxical proven coronary and upper extremity embolism, captured in-transit, following destabilization of an UEDVT in a patient with PFO.

Acute right ventricular failure caused by concomitant coronary and pulmonary embolism: successful treatment with endovascular coronary and pulmonary thrombectomy

Patent foramen ovale (PFO) is present in approximately 25% of the general population. PFO is characterized by intermittent shunting of blood from the right to the left atrium, especially in the context of increased right-sided filling pressures, with risk of paradoxical embolism. We describe a 69-year-old woman presenting with acute chest pain, severe dyspnoea, and acute inferolateral ST-segment elevation on the electrocardiogram. The patient was diagnosed with myocardial infarction and failure of the right cardiac ventricle, which was considered to be secondary to extensive pulmonary embolism leading to increased filling pressures and paradoxical coronary embolism. The patient underwent emergent percutaneous interventions with coronary thrombus extraction and pulmonary thrombus fragmentation and local thrombolysis. The patient was free of symptoms at follow up 6 months later and echocardiography showed substantially improved right ventricular function. We discuss issues related to the diagnosis, treatment, and secondary prevention for patients with concomitant pulmonary and coronary arterial thrombosis.

Electrocardiogram patterns during hemodynamic instability in patients with acute pulmonary embolism

BACKGROUND

We have previously described new electrocardiogram (ECG) findings for massive pulmonary embolism, namely ST-segment elevation in lead aVR with ST-segment depression in leads I and V4 -V6 . However, the ECG patterns of patients with acute pulmonary embolism during hemodynamic instability are not fully described.

METHODS

We compared the differences between the ECG at baseline and after deterioration during hemodynamic instability in twenty patients with acute pulmonary embolism.

RESULTS

Compared with the ECG at baseline, three ischemic ECG patterns were found during clinical deterioration with hemodynamic instability: ST-segment elevation in lead aVR with concomitant ST-segment depression in leads I and V4 -V6 , ST-segment elevation in leads V1 -V3 /V4 , and ST-segment elevation in leads III and/or V1 /V2 with concomitant ST-segment depression in leads V4 /V5 -V6 . Ischemic ECG patterns with concomitant S1Q3 and/or abnormal QRS morphology in lead V1 were more common (90%) during hemodynamic instability than at baseline (5%) (P = 0.001).

CONCLUSIONS

Hemodynamic instability in acute pulmonary embolism is reflected by signs of myocardial ischemia combined with the right ventricular strain pattern in the 12-lead ECG.

Primary percutaneous thrombus aspiration alone as definitive intervention for left main coronary artery occlusion presenting as acute anterior wall ST elevation myocardial infarction

Primary angioplasty and stenting remains the standard of care for patients presenting with acute ST-segment elevation myocardial infarction. Recently, thrombus aspiration has been shown to improve the myocardial perfusion and outcomes in STEMI. In a subset of patients thrombus aspiration may result in optimal perfusion and minimal residual stenosis. These patients may be managed without additional stenting. Three patients with anterior wall STEMI were successfully managed with thrombus aspiration alone without additional stenting. All three are doing well at 30 day follow up with significant improvement in left ventricular ejection fraction.