ST-Segment Elevation: An Unexpected Culprit

The clinical presentation of pulmonary embolism (PE) and acute coronary syndrome can be similar. We report a case of a patient presenting with antero-septal ST-segment elevation after cardiac arrest, found to have acute-PE-mimicking ST-segment elevation myocardial infarction (STEMI), treated with aspiration thrombectomy and catheter-directed thrombolysis (CDT). A 78-year-old man was admitted with dyspnea, chest pain and tachycardia. During evaluation, cardiac arrest in pulseless electrical activity was documented. Advanced life support was started immediately. ECG post-ROSC revealed ST-segment elevation in V1-V4 and aVR. Echocardiography showed normal left ventricular function but right ventricular (RV) dilation and severe dysfunction. The patient was in shock and was promptly referred to cardiac catheterization that excluded significant CAD. Due to the discordant ECG and echocardiogram findings, acute PE was suspected, and immediate invasive pulmonary angiography revealed bilateral massive pulmonary embolism. Successful aspiration thrombectomy was performed followed by local alteplase infusion. At the end of the procedure, mPAP was reduced and blood pressure normalized allowing withdrawal of vasopressor support. Twenty-four-hour echocardiographic reassessment showed normal-sized cardiac chambers with preserved biventricular systolic function. Bedside echocardiography in patients with ST-segment elevation post-ROSC is instrumental in raising the suspicion of acute PE. In the absence of a culprit coronary lesion, prompt pulmonary angiography should be considered if immediately feasible. In these cases, CDT and aspiration in high-risk acute PE seem safe and effective in relieving obstructive shock and restoring hemodynamics.

"(Pseudo)cavities inside the heart: What may they unfold?"

Subvalvular aortic stenosis manifesting as a subaortic membrane predisposes to bacterial endocarditis, which typically affects the aortic valve (AoV) or, less frequently, the left ventricular outflow tract (LVOT). We present the case of a 60-year-old woman expressing an odd form of a subvalvular aortic membrane in conjunction with a left Valsalva sinus pseudoaneurysm as a result of an endocarditis complication.

Ticagrelor Loading on ST-Elevation Myocardial Infarction: Interaction With Prodromal Angina on Infarct Size and Clinical Events

INTRODUCTION

Ticagrelor might reduce infarct size by exerting a more potent antiplatelet effect or by promoting a potential conditioning stimulus in ST-elevation myocardial infarction (STEMI) patients. Pre-infarction angina (PIA) is an effective preconditioning stimulus that reduces ischemia-reperfusion injury. Because little is known on the interaction of PIA in STEMI-patients loaded with ticagrelor, we sought to determine if patients loaded with ticagrelor had improved clinical outcomes as compared to clopidogrel and to study if it is modulated by the presence of PIA.

METHODS

From 1272 STEMI patients submitted to primary percutaneous coronary intervention and treated with clopidogrel or ticagrelor from January 2008 to December 2018, 826 were analyzed after propensity score matching. Infarct size was estimated using peak creatine kinase (CK) and troponin T (TnT), and clinical impact was evaluated through cumulative major cardiac and cerebrovascular events (MACCE) at 1-year follow-up. Matched patients and their interaction with PIA were analyzed.

RESULTS

Patients loaded with ticagrelor had lower peak CK [1405.50 U/L (730.25-2491.00), P < .001] and TnT [3.58 ng/mL (1.73-6.59), P < .001)], regardless of PIA. The presence of PIA was associated with lower CK (P = .030), but not TnT (P = .097). There was no interaction between ticagrelor loading and PIA (P = .788 for TnT and P = .555 for CK). There was no difference in MACCE incidence between clopidogrel or ticagrelor loading (P = .129). Cumulative survival was also similar between clopidogrel or ticagrelor, regardless of PIA (P = .103).

CONCLUSION

Ticagrelor reduced infarct sizes independently and without a synergic effect with PIA. Despite reducing infarct size, clinical outcomes were similar across both groups.

Clinical Case 04—Percutaneous patent foramen ovale closure after a thrombotic storm: a case report

A 38-year-old woman with a 32-week gestation was admitted in the emergency department complaining of acute lower limb pain. She had history of smoking, 1 voluntary interruption of pregnancy, 1 miscarriage at age 34, and family history of antiphospholipid syndrome (APS). At admission, bilateral acute limb ischemia and foetal death were diagnosed. CT angiography revealed acute bilateral thrombotic occlusion of the iliac arteries, left renal artery thrombosis with extension to the distal abdominal aorta, deep vein thrombosis (DVT) of the left iliac vein and distal inferior vena cava, and bilateral pulmonary embolism. The patient started on anticoagulation and underwent caesarean section and axillobifemoral bypass. Plasmapheresis and rituximab were attempted due to high clinical suspicion of catastrophic APS. Immunological and neoplastic study were repeatedly negative. The patient was ultimately discharged on vitamin K antagonist (VKA). Further investigation revealed a patent foramen ovale (PFO) with spontaneous right-to-left shunt. Given the risk of paradoxical embolism in this thrombophilic setting of unclear cause, she was referred for percutaneous PFO closure using a GORE® CARDIOFORM 25 mm device. Post-procedure maintenance of antithrombotic therapy with VKA was decided by a multidisciplinary team. Since the event, she had no recurrence of thromboembolic events and continues under investigation in autoimmune disease outpatient clinic. Although simultaneous arterial and venous thrombosis cannot be ruled out, we suspect of left paradoxical embolism following DVT. PFO closure in this setting might be useful for reduction of paradoxical arterial embolism risk on top of systemic anticoagulation. Figure 1Panels A and B show the presence of patent foramen ovale (PFO). Panels C and D show the final result after percutaneous PFO closure using a GORE® CARDIOFORM 25 mm device.

Clinical Case 09—Acute pulmonary embolism complicated by acute limb ischemia: a case report on the role of patent foramen ovale closure in thrombophilia

Case report

A 40-year-old obese man with hypertension and history of femoro-popliteal deep vein thrombosis (DVT), presented to the emergency department with right lower limb (RLL) ischemia associated with exertional dyspnoea for the past three weeks. Physical examination revealed a cold RLL without peripheral pulses and mild respiratory failure. Angio-CT revealed bilateral acute pulmonary embolism (APE), thrombosis of the right common iliac artery and left renal infarct (Figure 1A). Transthoracic echocardiogram revealed signs of pulmonary hypertension (PH), dilated right ventricle and a suspected patent foramen ovale (PFO) with spontaneous high volume right-to-left shunt. A diagnosis of intermediate-low risk APE with concomitant RLL acute ischemia was made. The patient underwent iliac thrombectomy, local fibrinolysis and started anticoagulation. Immunological study was positive for antiphospholipid syndrome. He recovered well and was discharged on Vitamin-K antagonists. Six months later, transoesophageal echocardiogram confirmed the PFO with persistence of right-to-left shunt with a bubble test, and recovery of the right ventricle function without signs of PH (Figure 1B). Due to the suspected paradoxical embolic event, resolution of the PH and shunt persistence, the patient underwent percutaneous PFO closure with Amplatzer PFO Occluder (25mm) [Abbott®] (Figure 1C). He has had no recurrence of thrombotic events ever since.

Conclusion

Concomitant arterial and venous thrombosis should prompt screening for an intracardiac shunt. Despite unclear evidence, PFO closure might reduce the risk for paradoxical embolism recurrence in a thrombophilic setting on top of oral anticoagulation.

Platypnea Orthodeoxia Syndrome and Patent Foramen Ovale Closure: Single-Centre Experience and Long-Term Follow-Up

INTRODUCTION

Platypnea orthodeoxia syndrome (POS) is an uncommon condition characterised by dyspnoea and arterial desaturation induced by an upright position and relieved in the supine position, usually due to a patent foramen ovale (PFO). Percutaneous closure of a PFO is the preferred treatment to cure POS. This study aimed to evaluate the clinical and gasometrical characteristics and to describe the long-term outcomes of percutaneous PFO closure in a group of patients with POS.

METHODS

Patients with POS and a PFO treated by percutaneous intervention from 2010-2020 were reviewed. The primary efficacy outcome was the arterial oxygen pressure to fraction of inspired oxygen (PaO2/FiO2) ratio before and 24 hours after the procedure. Total clinical success was considered if the arterial oxygen saturation measured by pulse oximetry (SpO2) improved to >94% in the supine and sitting positions without supplemental oxygen, while partial success was considered if SpO2 improved from baseline but still required oxygen to achieve >94%. Secondary outcomes were an absolute improvement in SpO2 and sense of dyspnoea, without significant residual shunt on transthoracic echocardiography (TTE) at follow-up.

RESULTS

Of 168 patients undergoing PFO or atrial septal defect closure, 14 had POS (8.3%). Percutaneous PFO closure was successfully performed in all patients with a single device. Twelve of 14 patients had total clinical success (86%) and one patient had partial success. The PaO2/FiO2 ratio increased from 155.9±50.6 to 318.3±73.4 after PFO closure (p=0.002). All patients with total clinical success had a successful secondary efficacy outcome with an absolute improvement in SpO2 and complete resolution of dyspnoea, which was maintained at follow-up (37±20 months; range, 11 months to 6 years). None had a significant residual shunt between 12 and 24 months of follow-up.

CONCLUSION

The PFO percutaneous closure was a successful, durable and safe method for patients presenting with POS; it achieved major improvements in both gasometrical parameters and quality of life.

[Suprapapilar puncture for biliary access to advanced cancer of the papilla and severe coagulopathy]

Biliary cannulation to perform endoscopic retrograde cholangiopancreatography (ERCP) may be difficult in patients with advanced papillary cancer, due to anatomical and technical reasons. Sphincterotomy may be contraindicated in severe coagulopathy. We report a recently described technique of suprapapillary puncture for biliary access with use of an Artifon's catheter for biliary access in a high-risk patient with coagulopathy and periampullary neoplasm.