A Case of Intraventricular Coronary Artery Perforation Following Percutaneous Coronary Intervention in the Setting of Myocardial Bridge of Left Anterior Descending Artery

Coronary artery perforation during percutaneous coronary intervention is a rare but potentially fatal complication. Intraventricular rupture is more commonly seen in setting of myocardial bridging where the epicardial coronary artery takes an intramuscular course. We describe a case of acute thrombotic in-stent restenosis of the intramyocardial (myocardial bridge) distal left anterior descending artery complicated by intraventricular perforation in the setting of an anterior ST elevation myocardial infarction managed by covered stenting.

Complex Coronary Intervention - When Time Is of Essence: Ping Pong Technique

Coronary artery disease (CAD) continues to be a significant cause of morbidity and mortality in the U.S. The prognosis and treatment of which is dependent on various factors including type, size, localization and extent of the coronary plaque and severity of the stenosis. Management of critical ostial left main CAD poses peculiar challenges. The present case report demonstrates a unique percutaneous coronary intervention technique helpful in the management of such complex left main coronary lesions.

Impact of Emergency Medical Service Provider Training and Institutional Volume Experience on ST-Elevation Myocardial Infarction Patient Outcomes in Rural Setting

INTRODUCTION

Rural sites provide management challenges for ST-elevation myocardial infarction (STEMI) patients. The impact of emergency medical service (EMS) training and institutional volume experience on STEMI outcomes was examined.

METHODS

All STEMI patients transferred to Sanford from 32 sites in rural South Dakota from 2010-2019 were analyzed. "Time to electrocardiogram (EKG)" (TEKG) and "Time from EKG to Thrombolytics" (TThrom) were calculated. Sites were compared based on EMS training (advanced life support (ALS) vs. basic life support (BLS)) and institutional volume experience (less than or equal to five vs. greater than five STEMI).

RESULTS

514 STEMI patients from 32 sites in South Dakota were analyzed. Average TEKG was 20 (±15) and 14 (±10) minutes for ALS and BLS trained services, respectively (p=0.25). More experienced sites had an average TEKG of 26 (±15) minutes, while sites with ≤ five STEMI patients had an average time of 15 (±13) minutes. TThrom did not differ significantly between sites based on our metrics.

CONCLUSION

The present study concludes that EMS provider training (BLS vs ALS) and institutional volume experience do not significantly impact patient-related outcomes when treating STEMI patients. This result is possibly attributed to increased educational efforts for rural health care providers in general and the establishment of the South Dakota statewide STEMI Network "Mission: Lifeline" which standardized STEMI care and improved connectivity between remote responders and the larger PCI-capable facilities.

Transcatheter tricuspid valve-in-valve implantation for very early bioprosthetic tricuspid stenosis secondary to pacemaker lead entrapment: a case report

Background

Tricuspid stenosis (native and prosthetic) is rare. Redo-sternotomy for isolated tricuspid replacement is associated with a higher risk. The efficacy and durability of transcatheter valve implantation for severe tricuspid stenosis are unclear.

Case summary

Successful tricuspid valve-in-valve implantation (Edwards 26 mm Ultra) was performed to exteriorize a retained, unextractable pacemaker lead causing very early surgical bioprosthetic valve dysfunction in a 66-year-old Caucasian woman. The original indication for surgical replacement was pacemaker lead-related severe tricuspid regurgitation. History of CABG and subsequent surgical replacement rendered the risk of a third sternotomy and open-heart surgery prohibitive.

Conclusion

Successful reduction in the severity of bioprosthetic tricuspid stenosis and improvement of right heart failure with transcatheter valve-in-valve implantation was observed. Percutaneous tricuspid valve implantation could be considered an alternative to redo-sternotomy for severe bioprosthetic tricuspid stenosis.

ST-Segment Elevation Myocardial Infarction Due to an Ectatic Infarct-Related Coronary Artery: Case Series and Review of the Literature

Coronary artery ectasia is an infrequent finding seen in a localized or diffuse fashion in patients undergoing coronary angiogram. This angiographic entity is attributed to coronary artery atherosclerosis. The ectatic coronary artery segment may be a culprit and perpetuate the thrombus formation in patients with acute myocardial infarction due to the altered normal laminar flow and deranged platelet and endothelial activation. Besides, it may lead to slow flow/no-reflow during the percutaneous coronary intervention and constitutes a significant management challenge. In this article, we report three patients with ST-segment elevation myocardial infarction from the culprit ectatic infarct-related artery and discuss the various management strategies.

Outcomes of remote pulmonary artery hemodynamic monitoring in heart failure patients with obstructive sleep apnea

Introduction

Obstructive sleep apnea (OSA) is often associated with heart failure (HF). Remote pulmonary artery (PA) hemodynamic monitoring has shown to decrease HF related readmissions. However, there is paucity of data regarding its efficacy and mortality in patients with OSA.

Purpose

Real-world analysis of outcomes of remote PA hemodynamic monitoring using CardioMEMS device in reducing HF hospitalization in patients with OSA [apnea–hypopnea index (AHI) ≥5].

Methods

Retrospective data was collected for patients with HF who had CardioMEMS device implanted based on FDA indications from April 2015 to August 2020. The number of hospitalizations, emergency department (ED) and HF clinic visits data was collected for 1-year pre and 1-year post device implantation. Mortality data was also collected at 1-year post-implantation. Patients who were diagnosed with OSA based on AHI ≥5 on sleep study at the time of implantation were included in the study. Analysis was done using Kruskal-Wallis test for comparison between heart failure patients with and without OSA. Mortality was compared with Pearson's chi-squared test.

Results

CardioMEMS device was implanted in 177 patients during the study period. Of this population, 108 (61%) patients had known OSA at the time of implantation. There was a statistically significant decrease in overall mean HF admissions from 1.80 (± 1.55) to 0.62 (± 1.07), 65.6%, p<0.001 and mean HF ED visits from 1.37 (± 1.50) to 0.5 (± 0.95), 63.5%, p<0.001 in 1-year pre- and post-implantation among OSA patients. When comparing outcomes between HF patients with and without OSA, there was no statistically significant difference observed between them in all-cause admissions, HF admissions, ED visits, ED HF visits, and HF clinic visits 1-year pre and post implantation. Also, no statistically significant difference was observed in mortality between the groups at 1-year post-implantation.

Conclusions

PA hemodynamic monitoring using CardioMEMS device had a net benefit in reducing HF admissions and HF ED visits in OSA patients which was similar in patients without OSA.

Funding Acknowledgement

Type of funding sources: None.

New and Emerging Technology in Cardiovascular Therapeutics

The last decade has seen the introduction of a number of important technological innovations in the management of advanced cardiovascular disease. These include transcatheter aortic valve replacement systems, a transcatheter mitral valve repair device, a left atrial appendage occluder device, coronary bioresorbable vascular scaffolds, leadless fully implantable pacemaker systems, wireless implantable pulmonary artery pressure monitors, transcatheter left ventricular assist pumping devices, drug-coated balloons, and robotic percutaneous coronary intervention devices. With the exception of drug coated balloon platforms, all have been utilized in our institution for patients from South Dakota and neighboring states. The objective of this study is to briefly describe these innovative devices, summarize the evidence for their benefit, and offer helpful pearls for the primary care providers who are key members of the care team for these patients.

Extremely Hyperdominant LAD Supplying the Anterior, Inferior, and Lateral Walls of the Left Ventricle

Hyperdominant left anterior descending artery (LAD) is a rare anomaly in which the LAD gives rise to the posterior descending artery. Our case report describes an extreme case of hyperdominant LAD supplying the anterior, inferior, and partially the lateral walls of the left ventricle. It is crucial that physicians be aware of the possibility of extreme LAD dominance. A proximal occlusion of such a vessel might have catastrophic consequences with atypical presentation on electrocardiogram.

Robotic-Assisted Percutaneous Coronary Intervention Through Transradial Approach: Experience in 4 Patients with Complex Lesions

Robotic-assisted percutaneous coronary intervention can reduce the exposure of interventional cardiologists to radiation and minimize the risk of occupational orthopedic injuries from wearing heavy protective aprons. The PRECISE (Percutaneous Robotically-Enhanced Coronary Intervention) study showed the efficacy and safety of robotic-assisted procedures for relatively low-risk lesions in single coronary arteries. Several reports have described robotic-assisted treatment of complex high-risk lesions, mostly through the transfemoral approach. We report 4 cases of patients in whom we used the transradial approach to treat complex lesions in the left anterior descending coronary artery with bifurcation balloon angioplasty reconstruction (2 cases), in the ostium of the first diagonal branch, and in the right coronary artery.

Triple-Guidewire Technique for Treating Stent Underexpansion in Severely Calcified Coronary Artery Lesions

Stent underexpansion, a potential complication of percutaneous coronary intervention in severely calcified and stenotic coronary arteries, may result in in-stent thrombosis and restenosis. Different balloon-based and atheroablative techniques have been proposed to reduce the risk of these complications. We describe a simple triple-guidewire technique that we used to treat stent underexpansion in 2 elderly men.

Orbital Atherectomy and Heavily Calcified Saphenous Vein Graft Intervention

Percutaneous coronary intervention in the diseased saphenous vein graft differs significantly from that in the diseased native coronary artery. After being exposed to arterial pressures over time, vein grafts have substantially different plaque characteristics, with more inflammatory cells, more diffuse disease, and less calcification. Severe calcification of saphenous vein grafts, although uncommon, poses a high risk of stent underexpansion. Orbital atherectomy for treatment of de novo calcified coronary lesions has been associated with better outcomes at 5-year follow-up. However, there are no published data on the use of orbital atherectomy to treat severely calcified saphenous vein graft lesions. We present the case of a 77-year-old woman with non-ST-segment-elevation myocardial infarction who underwent successful orbital atherectomy to prepare a severely calcified saphenous vein graft lesion for stent implantation.

Dietary Supplement Use in Patients with Cardiovascular Disease

IMPORTANCE AND OBJECTIVE

Dietary supplements and herbs (called naturoceuticals) are commonly used by Americans, but little is known about their use in cardiovascular disease patient populations. The objective was to evaluate naturoceutical use in a sample population of cardiovascular disease patients in the U.S.

DESIGN, SETTING AND PARTICIPANTS

A non-blinded, single medical center clinic open questionnaire was delivered to cardiovascular clinic patients with known cardiovascular diseases.

MAIN OUTCOMES AND MEASURES, AND RESULTS

Estimation of naturoceutical usage prevalence and frequency in the sample population of cardiovascular disease patients. A total of 163 patients (n = 99 males, 64 females) participated (mean age: males, 66 years; females, 64 years). Overall, 76.7 percent of participants reported using naturoceuticals. Of them, about 63.2 percent took more than one type, and 90.3 percent reported daily usage. Of the naturoceuticals reportedly being taken, multivitamins containing vitamin K were the most commonly consumed (32.3 percent male, 29.7 percent female), followed by vitamin D (23.2 percent male, 31.3 percent female) and fish oil (24.2 percent male, 15.6 percent female).

CONCLUSIONS AND RELEVANCE

The present study revealed that naturoceutical use was very popular in cardiovascular disease patients, largely due to the belief that they could reduce and/or prevent symptoms and disease in general. The benefits and hazards of those naturoceuticals being used concurrent with other prescription medications were discussed.

A prospective study of contrast preservation using ultra-low contrast delivery technique versus standard automated contrast injector system in coronary procedures

Background

We aimed to assess the decrease in contrast media volume (CMV) with ultra-low contrast delivery technique (ULCD) developed at our institution versus the usual automated contrast injector system (ACIS) contrast delivery in coronary procedures.

Methods

We analyzed the amount of contrast given in the consecutive 204 patients of the operators who use ULCD technique versus consecutive 200 patients of the other operators who use ACIS without ULCD technique for coronary angiograms and/or percutaneous coronary interventions (PCIs) from May 2017 to July 2018 at our center. We calculated the mean CMV between these groups.

Results

We observed a significant reduction in mean CMV with ULCD technique versus standard ACIS, respectively: angiogram 24.8 ± 15.8 mL (n = 194) vs 42.3 ± 25.1 mL (n = 200) (p < 0.0001); PCI 23.5 ± 19.7 mL (n = 52) vs 48.2 ± 30.8 mL (n = 16) (p < 0.0070); angiogram with ad hoc PCI 53.4 ± 32.1 mL (n = 23) vs 89.7 ± 35.6 mL (n = 16) (p < 0.0024); and overall angiogram and PCI 27.4 ± 20.5 mL (n = 204) vs 44.9 ± 28.0 mL (n = 181) (p < 0.0001).

Conclusion

Our study showed a highly significant reduction in CMV using ULCD technique compared to standard ACIS contrast delivery in coronary invasive procedures. Even in the standard ACIS arm, CMV was significantly lower than values reported in literature, possibly due to operators' bias toward contrast preservation.

Frequency Domain-optical Coherence Tomography of Coronary Arteries Using a Diluted Iodinated Contrast-saline Mix with 5-Fr Guide Catheters

Background

Optical coherence tomography (OCT) is currently mostly performed using 6-Fr coronary guide catheters via femoral access. Catheters with such large internal diameters are necessary to deliver viscous contrast media and achieve sufficient red blood cell washout. Currently, undiluted iodinated contrast media (15 mL/injection) is used to clear the coronary arteries of red blood cells (RBCs). This leads to an increase in the total amount of contrast used and often the need for femoral artery access. Our objective is to assess the feasibility of performance of OCT using a 5-Fr guide catheter via radial access using diluted iodinated contrast.

Methods

We present a case series of 11 patients where second-generation frequency domain (FD)-OCT was used to assess the coronary arteries using a novel 70:30 dilution mixture of iodinated contrast medium with heparinized normal saline. All procedures were performed with a 5-Fr coronary guide catheter via the radial artery approach.

Results

All procedures were successfully performed vial radial access with good quality imaging obtained. The target vessel was the left anterior descending artery in eight patients, the right coronary artery in two patients, and the left main coronary artery in one patient. OCT resulted in a change in management in 7/11 (64%) patients; no complications were reported with OCT. On average, 10 mL of contrast was used per injection.

Conclusions

The current study demonstrates the feasibility of FD-OCT using 5-Fr guide catheters and diluted iodinated contrast media. This approach lowers contrast exposure and potentially decreases vascular complications without sacrificing image quality.

Isolated Quadricuspid Aortic Valve as a Cause of Insufficiency-Predominant Aortic Valve Disease

Quadricuspid aortic valve is a rare cause of symptomatic aortic regurgitation. It tends to present earlier than degenerative native valve aortic regurgitation but with similar symptoms. The condition can occur in isolation or in association with other congenital cardiac abnormalities. Surgical intervention before the development of left ventricular failure is critical to improve long term survival. We describe a case of severe aortic regurgitation due to isolated quadricuspid valve morphology that was treated surgically.

Retained Coronary Balloon Requiring Emergent Open Surgical Retrieval: An Uncommon Complication Requiring Individualized Management Strategies

The entrapment of coronary intervention devices within the coronary vasculature is a rare but potentially devastating procedural complication. We report a case of an entrapped balloon and broken shaft that had to be retrieved by an open surgical approach. When device extraction is indicated and the use of snaring equipment is unsuccessful or inappropriate, a number of alternative percutaneous maneuvers can be attempted. These include (1) simple advancement and withdrawal of a trapped balloon, (2) use of a "buddy" wire to straighten the vessel and free the trapped device, (3) inflation of a buddy balloon adjacent to a trapped primary balloon to free the device, (4) partial inflation of a buddy balloon distal to a trapped device followed by gentle withdrawal, (5) use of an in-guide secondary balloon to trap the lost device, (6) advancement and twisting of guidewires to entwine the lost device, (7) saline dilution of trapped balloons, and (8) anchoring balloon and reverse-wire puncture of an undeflated and entrapped primary balloon. Careful consideration of various device retrieval strategies is indicated before resorting to open surgical retrieval in the rare instance of intracoronary device entrapment.

Post-Complex Myocardial Infarct Pseudoaneurysm Rupture and Subsequent Complications

Ventricular pseudoaneurysm is an uncommonly encountered complication of myocardial infarction (MI) in the era of percutaneous coronary intervention. Its presentation can be very non-specific, and diagnosis requires a high index of suspicion. Urgent surgical repair is generally warranted to prevent potentially catastrophic complications. We present a case of patient who presented several days after his index MI. He was ultimately diagnosed with a ruptured pseudoaneurysm, and despite best efforts had a complicated hospital course.

Prosthetic Aortic Valve Endocarditis Following Transcatheter Aortic Valve Implantation

Infective endocarditis after transcatheter aortic valve implantation is a life-threating complication, resulting in high in-hospital and one-year mortality. With the ongoing evolution of transcatheter aortic interventions, the proportion of endocarditis cases encountered by health care providers will continue to rise. Early diagnosis of infective endocarditis is of paramount importance to institute appropriate treatment with antibiotics and/or surgery to avoid negative clinical outcomes. In this review, we outline our experience with two cases of infective endocarditis following transcatheter aortic valve implantation and briefly review the literature on the incidence, microbiology, diagnosis, and management of this condition.

Coronary Artery Perforation Spilling into Right Ventricle: A Rare Complication of Percutaneous Coronary Intervention

Injury to the coronary circulation during percutaneous interventions is an existent risk. One of these is coronary artery perforation that can have grave consequences. Fortunately, this is rare and overall there is a declining incidence of complications due to technological advances and extensive experience over time. Predictors of coronary artery perforation include the administration of glycoprotein IIb/IIIa inhibitors, the use of hydrophilic guide wires, and the use of noncompliant high-pressure intracoronary balloons. Complex coronary lesions and the presence of total chronic occlusion are additional risk factors. In this paper, we present a rare class III coronary artery perforation with spilling into the right ventricle. Our case exemplifies all the aforementioned risk factors for perforation. The perforation was successfully sealed with a polytetrafluoroethylene covered stent and the patient remained hemodynamically stable.

The "Chimney Sweep Technique" and Recurrent Coronary Artery Dissections

We are reporting a case of a 65-year-old female who experienced three ST elevation myocardial infarctions (STEMI) during the course of 3 weeks. The first infarct was related to intramural coronary hematoma that propagated proximally after stenting, the second involved progression of this hematoma with obstruction of the vessel lumen, and the third caused subacute stent thrombosis that required "stent cleaning" using the inflated balloon technique.

Robotic-Assisted Percutaneous Coronary Intervention of a Saphenous Vein Graft Stenosis using a FilterWire EZ Embolic Protection

Robotic-assisted coronary angioplasty has been utilized to decrease radiation exposure to cardiologists, and to diminish risk of orthopedic and ergonomic injuries caused by wearing heavy lead during long procedures. The efficacy and safety of robotic-assisted percutaneous coronary intervention for relatively low-risk lesions was demonstrated in the PRECISE study. Successful percutaneous coronary interventions using robotic system for treatment of complex high-risk lesions have been reported in few case series so far. We describe a successful robotic-assisted coronary angioplasty for a complex lesion of saphenous vein graft using a FilterWire EZ embolic protection. This case illustrates the feasibility to use robotic-assisted angioplasty for complex cases.

Recurrent In-stent Restenosis in the Area of Previous Stent Fracture: A Management Dilemma

Drug eluting stents (DES) have been increasingly being used for treatment of coronary artery disease (CAD) and have been shown to be very effective in prevention of primary in-stent restenosis (ISR). However DES have been increasingly associated with acute to subacute risk of stent fractures (SF). There is also a paucity of data about different management strategies for SF, especially in the long term. We present a case of recurrent ISR in an area of previous acute SF at the touchdown of saphenous venous graft (SVG) to first diagonal artery (D1). In our knowledge this is the first case reported of recurrent ISR due to prior acute stent fracture in a saphenous venous graft. It presents an interesting management dilemma with multiple layers of stent in the area of recurrent ISR which was managed with balloon angioplasty with good results.

Clinical factors associated with physician choice of femoral versus radial access: A real-world experience from a single academic center

OBJECTIVES

To analyze clinical factors associated with operator's preference in selection of femoral versus radial access for angiography and percutaneous intervention (PCI) procedures.

BACKGROUND

There has been an increase in radial access in cardiac catheterization and PCI in the last few decades.

METHODS

Data from 11 226 consecutive cardiac catheterization procedures were collected from Sanford University Medical Center (University of South Dakota, Sanford School of Medicine) from 2011 to 2015.

RESULTS

In the overall cases, clinical factors that favored upfront femoral access include patients presenting as ST-elevation myocardial infarction (STEMI) or emergent, coronary artery bypass graft, body mass index (BMI) <30 kg/m² and age ≥70 years, whereas morbidly obese patients (BMI ≥35) and age <70 favored upfront radial access. Radial access in the overall group had lower fluoroscopy time (6.5 vs 8.4 min, P < 0.0001) and lower contrast use (68.8 vs 80.6 cc, P < 0.0001). In the PCI group, efficacy of upfront radial access is less evident with radial fluoroscopy time (10.1 vs 11.0 min, P < 0.0028) and contrast use being higher in radial group (113.8 vs 108.2 cc, P < 0.037). Interventional cardiologists were more efficient in diagnostic cases than non-interventional cardiologists.

CONCLUSION

STEMI or emergent cases and elderly patients favor upfront femoral access. As BMI increases and age decreases, radial access is progressively favored. In diagnostic cases, radial access appears to be superior to femoral access in efficacy, but the distinction is less obvious in PCI and STEMI or emergent cases.

A Case of an Acute Myocardial Infarction Post Thrombolytic Treatment of Ischemic Stroke - A Management Dilemma

Acute ischemic stroke and myocardial infarction are emergency clinical events that require prompt intervention. Concurrent occurrence of both events magnifies the complexity of the clinical management. We present a case of a patient who presented with acute ischemic stroke, complicated by acute myocardial infarction shortly after thrombolytic was administered. This case highlights the importance of individualization of management especially in complex cases where there are no clear specific guidelines to follow.

Abstract 143: Procedural Efficacy in Radial vs. Femoral Approach in Coronary Catheterization and Percutaneous Intervention in a Tertiary Care Teaching Hospital

Background: The practice of trans-radial artery (TRA) approach for coronary angiography and percutaneous coronary intervention (PCI) has been steadily increasing in the United States since 2007 from 1% to 16% in 2012. However, when compared to trans-femoral artery (TFA) approach the procedural efficacy for TRA was found to be worse in large studies. The aim of this study was to explore procedural efficacy of TRA vs TFA approach in a tertiary care teaching hospital.

Methods: We performed a retrospective review of data from 10,145 consecutive patients from our coronary catheterization lab database from 9/2011 to 5/2015 at University of South Dakota, Sanford Heart Hospital. Cases were analyzed for procedural efficacy as defined by duration of procedure, fluoroscopic time, and total contrast utilization.

Results: Overall, 7,581 (76%) patients underwent TRA approach and 2,564 (24%) patients underwent TFA approach. There was a shorter procedural duration for TRA approach vs TFR approach (60.1 minutes vs 78.3 minutes; p<0.0001), shorter fluoroscopic time for TRA approach vs TFR approach (6.06 minutes vs 9.01 minutes; p<0.0001), and less contrast utilization for TRA approach vs TFA approach (64.23 ml vs 72.15 ml; p<0.0001). The procedural duration trend over the past four years in quarterly increments is seen in Figure 1.

Conclusion: Contrary to what was seen in major trials; in our center, procedural efficacy was substantially better for TRA approach compared to TFA approach. Though procedural duration for TRA approach has remained the same over the past four years, there was also a general trend toward lengthening procedural duration for TFA approach.

Abstract 153: Rural Systems of Care: Real World Observations and Trends in ST Elevation Myocardial Infarction Patient Characteristics, and Correlations of Arrival Mode to Outcomes

Background: Minnesota, North Dakota and South Dakota have been enhancing statewide systems through infrastructure and clinical education regarding ST-elevation myocardial infarction (STEMI) since 2010 in an attempt to equalize access to timely reperfusion in rural areas. A trend in faster time to reperfusion has been observed for STEMI patients who transfer directly to Percutaneous Coronary Intervention (PCI) capable facilities via Emergency Medical Services (EMS) and receive a pre-hospital 12-lead ECG in comparison to those who first present to a non PCI capable facility. This improved time to STEMI recognition and reperfusion may be associated with improved outcomes.

Methods: Data was collected via ACTION Registry-GWTG from 2012-2015. The cohort was defined as STEMI patients who received PPCI with interfacility transfer (n=1010) and without (n=376) and who receive a pre-hospital 12-lead ECG (n=1078) and do not (n=308). The association between mode of transport, time to PPCI, and outcomes including LV function, in hospital clinical events, and in-hospital mortality were analyzed by unadjusted association. Multivariable adjustment was performed using covariates from the previously developed and validated ACTION mortality model to determine the independent association between arrival mode and outcomes.

Results: The direct transfer group demonstrated shorter cumulative times (79 vs. 145 min., p=<0.001) to coronary reperfusion as compared to the interfacility transfer group. The pre-hospital ECG group experienced a shorter time to transfer (40 vs. 55 min., p=<0.001) to a PPCI center consistent with earlier system recognition and activation for a STEMI patient. The direct transfer and pre-hospital ECG groups had a statistically significant less risk of in-hospital cardiogenic shock, congestive heart failure, cardiac arrest and death as a composite end-point, p=0.011 & <0.001 respectively. During the years of 2012 to 2015, the performance of pre-hospital ECGs has increased.

Conclusion: Implementation of Mission Lifeline programming was associated with significantly lower risk of in-hospital shock, congestive heart failure, cardiac arrest and death in STEMI patients presenting via EMS through increased utilization of pre hospital ECG, education, and hospital triage and procedural PPCI streamlining.