Symptomatic Myocardial Bridging in D-Transposition of the Great Arteries Post-Arterial Switch

We present Stanford's experience with patients post-arterial switch operation presenting with chest pain found to have hemodynamically significant myocardial bridging. The evaluation of symptomatic patients post-arterial switch should not only include assessment for coronary ostial patency but also for nonobstructive coronary conditions such as myocardial bridging. (Level of Difficulty: Advanced.).

Multi-vessel giant coronary artery aneurysms: An unusual cause of chest pain

We describe an unusual case of multi-vessel giant coronary artery aneurysms complicated by acute coronary syndrome despite escalation of therapy. A 65-year-old man with hypertension and hypercholesterolemia presented to clinic with atypical chest pain over 4 months. Outpatient computed tomography coronary angiography (CTCA) demonstrated giant coronary aneurysms involving all 3 major coronary arteries. Outpatient coronary angiogram findings were in concordance with the CTCA with no definite obstructive coronary disease. Myocardial perfusion imaging was normal. He was commenced on dual antiplatelet therapy (DAPT). At 6 months, he presented with chest pain and non-ST-elevation myocardial infarction. Repeat coronary angiogram demonstrated occluded first septal LAD branch which previously had aneurysmal dilatation. DAPT was changed to long-term oral anticoagulation. He remains well at 18 months. This case highlights the importance of multi-modality imaging in the diagnosis and workup of coronary artery aneurysms and challenges in management; an individualized approach is required.

A novel transit-time flow metric, diastolic resistance index, detects subcritical anastomotic stenosis in coronary artery bypass grafting

Objective

Transit time flow measurement (TTFM) can detect critical anastomotic stenosis during coronary artery bypass grafting. However, the identification of subcritical stenosis remains challenging. We hypothesized that diastolic resistance index (DRI), a novel TTFM metric, is more effective in evaluating subcritical stenosis than the currently available TTFM metrics. DRI is used to measure changes in the diastolic versus systolic resistance of distal anastomosis.

Methods

A total of 123 coronary bypass anastomoses in 35 patients were prospectively analyzed. During coronary artery bypass grafting, the mean graft flow (Q_mean), pulsatility index, and diastolic filling were obtained. DRI was calculated using the intraoperative recordings of TTFM and arterial pressure. Postoperatively, stenosis of anastomoses was categorized into successful (<50%), subcritical (50%-74%), and critical (≥75%) via multidetector computed tomography scan.

Results

In total, 93 (76%), 13 (10%), and 17 (14%) anastomoses were graded as successful, subcritical, and critical, respectively. DRI and diastolic filling could distinguish subcritical from successful anastomoses (P < .01 and < .01, respectively), whereas Q_mean and pulsatility index could not (P = .12 and .39, respectively). The receiver operating characteristic curves were established to evaluate the diagnostic ability for detecting ≥50% stenosis. In left anterior descending artery grafting (n = 55), DRI had the highest area under the curve (0.91), followed by diastolic filling (0.87), Q_mean (0.74), and pulsatility index (0.65).

Conclusions

DRI and diastolic filling had a reliable diagnostic ability for detecting ≥50% stenosis during coronary artery bypass grafting. In left anterior descending artery grafting, DRI had a more satisfactory detection capability than other TTFM metrics.

2 Cases of Spontaneous Coronary Artery Dissection in Neonates

Spontaneous coronary artery dissection in infants is a rare phenomenon. We present 2 neonates with severe ventricular dysfunction due to coronary artery dissection. Neither patient had evidence of extracardiac fibromuscular dysplasia or other comorbidities that would explain the presentation. (Level of Difficulty: Advanced.).

Ventricular Rupture at the Site of a Septic Myocardial Abscess After Acute Myocardial Infarction

Mechanical complications after acute myocardial infarction are well-described yet catastrophic complications of acute coronary syndromes. Uniquely, we describe a rare case of left ventricular free wall rupture at the site of a septic myocardial abscess after an anterior wall myocardial infarction. (Level of Difficulty: Advanced.).

1-Year Patency of Biorestorative Polymeric Coronary Artery Bypass Grafts in an Ovine Model

Many attempts have been made to inhibit or counteract saphenous vein graft (SVG) failure modes; however, only external support for SVGs has gained momentum in clinical utility. This study revealed the feasibility of implantation, and showed good patency out to 12 months of the novel biorestorative graft, in a challenging ovine coronary artery bypass graft model. This finding could trigger the first-in-man trial of using the novel material instead of SVG. We believe that, eventually, this novel biorestorative bypass graft can be one of the options for coronary artery bypass graft patients who have difficulty harvesting SVG.

Transvascular Balloon Occlusion: A Novel Bailout Strategy in Large Left Main Perforations

Several complications have been reported in rotational atherectomy, and these complications are closely associated with cardiac tamponade, emergent surgery, and death. Here we describe a case of left main coronary artery, bullet-like perforation treated with a novel approach-transvascular balloon occlusion. (Level of Difficulty: Advanced.).

Stentless percutaneous coronary intervention with directional coronary atherectomy and drug-coated balloon angioplasty in worsening angina patients with metal allergies

Metal allergy is a concern in percutaneous coronary intervention (PCI) with stent implantation because of its potential association with poor cardiovascular outcomes, such as stent thrombosis and recurrent in-stent restenosis requiring revascularization. Although stentless PCI with drug-coated balloon (DCB) angioplasty is theoretically useful for patients with metal allergies, DCB angioplasty alone for huge plaques in large vessels may yield inadequate luminal enlargement and coronary deep dissection, leading to insufficient results. Directional coronary atherectomy (DCA) is effective to reduce plaque volume. However, the efficacy of DCA followed by DCB (DCA/DCB) angioplasty in patients with metal allergies has never been described. We present two cases wherein stentless PCI with DCA/DCB angioplasty was an alternative revascularization strategy for patients with metal allergy and concomitant worsening angina pectoris involving proximal left anterior descending artery stenoses. Preoperative evaluation using coronary computed tomography angiography in Case 1 and intravascular ultrasound in Case 2 was useful to determine the possible use of the DCA/DCB procedure for huge plaques in large vessels.

Learning objective

Revascularization for patients with metal allergy with worsening angina pectoris due to stenoses of the proximal main arteries is often challenging because of the necessity to avoid stent implantation. As stentless percutaneous coronary intervention (PCI) is theoretically useful in such settings, PCI with directional coronary atherectomy (DCA)/drug-coated balloon angioplasty can be one of the treatable strategies. Preoperative evaluation of plaque morphology for the suitability of DCA procedure is important.

ECGs in Critical Care Cardiology: Do Not Miss That Myocardial Infarction

This paper provides clinical cases of acute myocardial infarction that do not show ST-segment elevation on 12-lead electrocardiogram, but should be clinically treated as ST-segment elevation myocardial infarction with early diagnostic coronary angiogram followed by appropriate strategy of revascularization. (Level of Difficulty: Beginner.).

Successful Surgical Treatment for Ruptured Aneurysm of Coronary-Pulmonary Artery Fistula Complicated With Cardiac Tamponade

A 74-year-old woman with no past medical history showed cardiac tamponade caused by rupture of a coronary-pulmonary artery fistula-related aneurysm. Preoperative pericardial puncture and multidetector computed tomography imaging enabled patient condition optimization and accurate morphologic evaluation of fistula and aneurysm, leading to complete surgical resection of the aneurysm. (Level of Difficulty: Advanced.).

Robotic advanced hybrid coronary revascularization: Outcomes with two internal thoracic artery grafts and stents

Objective

Advanced hybrid coronary revascularization is the integration of sternal-sparing multivessel coronary artery bypass grafting and percutaneous coronary intervention in patients with multivessel coronary artery disease. We sought to review our advanced hybrid coronary revascularization experience over an 8.5-year period using robotic totally endoscopic coronary artery bypass with bilateral internal thoracic artery grafts and percutaneous coronary intervention.

Methods

From August 2013 to February 2022, 664 patients underwent robotic totally endoscopic coronary artery bypass at our institution. Of the 293 patients who underwent totally endoscopic coronary artery bypass assigned to a hybrid revascularization strategy, 156 patients received bilateral internal thoracic artery grafts and are the subject of this review. Patients underwent percutaneous coronary intervention with drug-eluting stents before or after totally endoscopic coronary artery bypass. We reviewed early and midterm outcomes (up to 8 years) in this cohort of patients with intent-to-treat advanced hybrid coronary revascularization.

Results

The mean age of patients was 65 ± 10 years. The mean Society of Thoracic Surgeons predicted risk of mortality was 1.26 ± 1.56. Triple-vessel disease occurred in 94% of patients, and 17% of patients had 70% or more left-main disease. The mean operative time was 311 ± 54 minutes, and the mean hospital length of stay was 2.7 ± 1.1 days. All patients had bilateral internal thoracic artery grafts; the total number of grafts was 334. Eight seven percentage of patients had totally endoscopic coronary artery bypass ×2, and 13% of patients had totally endoscopic coronary artery bypass ×3. One patient received totally endoscopic coronary artery bypass ×4. The mean number of grafts per patient was 2.14 ± 0.4, and the mean number of vessels stented was 1.23 ± 0.5. There were no conversions, perioperative stroke, or myocardial infarction. Early mortality occurred in 2 patients. Early graft patency was 98% (209/214 grafts); left internal thoracic artery to left anterior descending patency was 100% (66/66 grafts). At 8-year follow-up in 155 patients (mean 39 ± 26 months), all-cause and cardiac-related mortality were 11.6% and 3.9%, respectively. Freedom from major adverse cardiac/cerebrovascular events including repeat revascularization was 94%.

Conclusions

In patients with multivessel coronary artery disease, integrating robotic totally endoscopic coronary artery bypass with bilateral internal thoracic artery and percutaneous coronary intervention resulted in excellent early and midterm outcomes. Further studies are warranted.

Topography of immune cell infiltration in different stages of coronary atherosclerosis revealed by multiplex immunohistochemistry

Background

Aim of this study was to investigate immune cells and subsets in different stages of human coronary artery disease with a novel multiplex immunohistochemistry (mIHC) technique.

Methods

Human left anterior descending coronary artery specimens were analyzed: eccentric intimal thickening (N = 11), pathological intimal thickening (N = 10), fibroatheroma (N = 9), and fibrous plaque (N = 9). Eccentric intimal thickening was considered normal, and pathological intimal thickening, fibroatheroma, and fibrous plaque were considered diseased coronary arteries. Two mIHC panels, consisting of six and five primary antibodies, autofluoresence, and DAPI, were used to detect adaptive and innate immune cells. Via semi-automated analysis, (sub)types of immune cells in whole plaques and specific plaque regions were quantified.

Results

Increased numbers of CD3⁺ T cells (P < 0.001), CD20⁺ B cells (P = 0.013), CD68⁺ macrophages (P = 0.003), CD15⁺ neutrophils (P = 0.017), and CD31⁺ endothelial cells (P = 0.024) were identified in intimas of diseased coronary arteries compared to normal. Subset analyses of T cells and macrophages showed that diseased coronary arteries contained an abundance of CD3⁺CD8^- non-cytotoxic T cells and CD68⁺CD206^- non-M2-like macrophages. Proportions of CD3⁺CD45RO⁺ memory T cells were similar to normal coronary arteries. Among pathological intimal thickening, fibroatheroma, and fibrous plaque, all immune cell numbers and subsets were similar.

Conclusions

The type of immune response does not differ substantially between different stages of plaque development and may provide context for mechanistic research into immune cell function in atherosclerosis. We provide the first comprehensive map of immune cell subtypes across plaque types in coronary arteries demonstrating the potential of mIHC for vascular research.

A Ruptured Coronary Artery Aneurysm Secondary to Kawasaki Disease

Coronary artery aneurysm occurs in 0.3%-0.8% of patients with Kawasaki disease, and cases of rupture are extremely rare. Only 2 cases have been reported in which the patients survived. We report a case of ruptured coronary artery aneurysm that was treated with coronary artery bypass grafting and extracorporeal membrane oxygenation. (Level of Difficulty: Advanced.).

Lithoplasty-Facilitated Proximal Cap Penetration of a Calcified Chronic Total Occlusion Coronary Lesion

We present a case of calcified chronic total occlusion of the left anterior descending coronary artery with ambiguous cap at the bifurcation with a large diagonal branch, in which intravascular lithoplasty balloon was used to modify the calcified proximal cap and facilitate wire crossing. (Level of Difficulty: Advanced.)

Rescue transventricular off-pump mitral valve repair with artificial neochords for acute mitral regurgitation due to postinfarction papillary muscle rupture

Background

We report 3 cases of rescue transventricular off-pump mitral valve (MV) repair in high-risk patients with acute mitral regurgitation (MR) due to post–myocardial infarction (MI) papillary muscle rupture (PMR).

Methods

The 3 patients presented with acute inferior ST elevation myocardial infarction, cardiogenic shock, and pulmonary edema. Their preoperative peak troponin I levels were 1909 ng/L, 16,963 ng/L, and 8299 ng/L. All 3 patients underwent successful percutaneous intervention to the culprit coronary artery, and antiplatelet therapy was initiated. All patients required inotropic support and had an intra-aortic balloon pump inserted preoperatively. Transesophageal echocardiography (TEE) demonstrated severe eccentric MR due to the leaflet prolapse secondary to PMR. The patients’ estimated EuroSCORE II scores were 16.03%, 16.68%, and 7.81%, and their Society of Thoracic Surgeons scores were 14.77%, 18.24%, and 9.8%, respectively. All 3 patients underwent urgent transventricular off-pump MV repair using artificial chords, with 2 or 3 three neochords implanted. The duration of operation was <2 hours, and intraoperative and postoperative drainage was minimal in all cases. MV function was assessed by qualitative and semiquantitative TEE.

Results

Intraoperative MR reduction to a mild level was achieved in all 3 patients. All patients had moderate MR at discharge, likely due to left ventricular remodeling. Severe MR recurred in all patients, at 5, 4, and 2 months of follow-up, respectively. All 3 patients underwent an elective MV reoperation via conventional approach.

Conclusions

Off-pump transventricular MV repair may offer a safe and feasible alternative to stabilize high-risk patients with acute MR due to post-MI PMR. Although early MR recurrence is concerning, urgent transventricular MV repair may serve as a bridge to conventional surgery in such unstable patients.

Cardiac Strangulation Due to Partial Pericardial Defect Presenting as Acute Myocardial Infarction

A 79-year-old man with chest pain and dyspnea underwent emergency percutaneous coronary intervention for acute myocardial infarction. However, he died 17 days later due to refractory heart failure. An autopsy revealed cardiac strangulation caused by herniation of the apical heart through a pericardial defect due to partial absence of the pericardium. (Level of Difficulty: Advanced.).

Acute Coronary Syndrome Requiring Coronary Artery Bypass Grafting in a Patient With Sotos Syndrome

Sotos syndrome, characterized by cerebral gigantism with neurologic disorders, is an overgrowth syndrome caused by mutations of the NSD1 gene, with an estimated prevalence of 1:10,000-1:50,000. We herein describe the first case of Sotos syndrome complicated by acute coronary syndrome, for which emergency coronary artery bypass grafting was performed. (Level of Difficulty: Intermediate.)

Impaction of a Percutaneous Heart Pump in Iliac Artery and Its Removal Using Snare

In the process of forceful pulling out of an entangled placement guidewire, the percutaneous heart pump catheter folded in on itself and, on withdrawal farther down in the aorta, became impacted in the right common iliac artery. We describe the removal of this impacted catheter with the help of snare. (Level of Difficulty: Advanced.)

Dynamic Changes in Coronary Flow Pattern During Transcatheter Aortic Valve Replacement in Severe Aortic Stenosis

Coronary flow reserve in patients with severe aortic stenosis decreases even in the absence of coronary stenosis. In this case, the dynamic changes in the coronary flow pattern around transcatheter aortic valve replacement were observed by periprocedural transesophageal echocardiography. (Level of Difficulty: Intermediate.).

Chest Pain and Hemodynamic Instability in a Young Woman

We report the case of an 18-year-old female admitted to the hospital for severe hemodynamic instability and fatal outcome within 6 hours following admission. Significant electrocardiographic modifications were noted and are presented with diagnostic options. (Level of Difficulty: Intermediate.)

Past, Present, and Future of Radiation-Induced Cardiotoxicity: Refinements in Targeting, Surveillance, and Risk Stratification

Radiation therapy is an important component of cancer therapy for many malignancies. With improvements in cardiac-sparing techniques, radiation-induced cardiac dysfunction has decreased but remains a continued concern. In this review, we provide an overview of the evolution of radiotherapy techniques in thoracic cancers and associated reductions in cardiac risk. We also highlight data demonstrating that in some cases radiation doses to specific cardiac substructures correlate with cardiac toxicities and/or survival beyond mean heart dose alone. Advanced cardiac imaging, cardiovascular risk assessment, and potentially even biomarkers can help guide post-radiotherapy patient care. In addition, treatment of ventricular arrhythmias with the use of ablative radiotherapy may inform knowledge of radiation-induced cardiac dysfunction. Future efforts should explore further personalization of radiotherapy to minimize cardiac dysfunction by coupling knowledge derived from enhanced dosimetry to cardiac substructures, post-radiation regional dysfunction seen on advanced cardiac imaging, and more complete cardiac toxicity data.

Acute Coronary and Cerebral Emboli From a Pedunculated Ascending Aorta Thrombus

Hyperprolactinemia is a risk factor for thrombus formation. We present a rare case of a mobile ascending aorta thrombus leading to acute myocardial infarction and cerebral infarction in a patient with idiopathic hyperprolactinemia. (Level of Difficulty: Beginner.).

Coexistence of Spontaneous Coronary Artery Dissection, Takotsubo Cardiomyopathy, and Myocardial Bridge

We report a case of spontaneous coronary artery dissection located next to a myocardial bridge in a patient with concomitant takotsubo cardiomyopathy. A fusion image with multidetector-row computed tomography and single-photon emission computed tomography played an important role in the diagnosis of these lesions. (Level of Difficulty: Advanced.)

Dynamic Takotsubo Syndrome: When SCAD Hides in a Pot

Both Takotsubo cardiomyopathy and spontaneous coronary artery dissection (SCAD) of the distal portion of the left anterior descending artery affect the apical myocardium. It is important to distinguish between both diseases, because therapy and follow-up differ. Revascularization may be lifesaving in SCAD, whereas heart failure management is vital in Takotsubo cardiomyopathy. (Level of Difficulty: Intermediate.)

Multiple Coronary Fistulas After Several Penetrating Chest Wounds: A Rare Case of Refractory Heart Failure

Coronary artery fistulas are rare coronary abnormalities. Most of these fistulas have a congenital origin, and only a few are acquired. We report the case of a patient with late-acquired multiple coronary fistulas secondary to a stab wound, diagnosed in the setting of ischemic heart failure secondary to coronary steal syndrome. (Level of Difficulty: Intermediate.)

Siblings With Familial Dwarfism Presenting With Acute Myocardial Infarction at Adolescence

We encountered siblings with familial Majewski osteodysplastic primordial dwarfism type II (MOPD II) with acute myocardial infarction in adolescence and in their early 20s. We successfully performed percutaneous and surgical coronary interventions. From these cases, we were able to better understand coronary artery disease of MOPD II and provide better management. (Level of Difficulty: Intermediate.)

A Continuous Murmur as the Only Clinical Sign for Complex Coronary Artery Fistulas Diagnosis

An asymptomatic patient presented at our hospital exhibiting a Brugada electrocardiography pattern with coronary artery fistulas. Coronary artery fistula is a congenital or acquired rare abnormal condition with increased symptoms and complications over time. In the absence of the therapeutic consensus, we discuss the association and management for this condition. (Level of Difficulty: Advanced.).

Conduits' Biology Regulates the Outcomes of Coronary Artery Bypass Grafting

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Accelerated atherosclerosis is common when SVGs, but not arterial grafts, are used for myocardial revascularization during CABG.

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This review will provide an overview of the available data on the most commonly used conduits in CABG, highlighting the differences in their cellular biology, mechanical, biochemical, and vasoconstrictive properties.

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Clinical and scientific evidence support the use of arterial grafts over venous conduits at the time of CABG. These arterial conduits seem to be more protected toward the development of atherosclerosis. Exploring the molecular and cellular mechanisms, of the various cell populations within these conduits, will help unveil the pathways responsible for these protective effects.

Coronary artery bypass graft (CABG) is the gold standard for coronary surgical revascularization. Retrospective, prospective, and meta-analysis studies looking into long-term outcomes of using different conduits have pointed to the superiority of arterial grafts over veins and have placed the internal mammary artery as the standard conduit of choice for CABG. The superiority of the internal mammary artery over other conduits could be attributable to its intrinsic characteristics; however, little is known regarding the features that render some conduits atherosclerosis-prone and others atherosclerosis-resistant. Here, an overview is provided of the available data on the most commonly used conduits in CABG (internal mammary artery, saphenous vein, radial artery, gastroepiploic artery), highlighting the differences in their cellular biology, mechanical, biochemical, and vasoconstrictive properties. This information should help in furthering our understanding of the clinical outcomes observed for each of these conduits.

Ventricular Fibrillation Due to Aortocoronary Vein Graft Spasm During Angiography: Case Report and Literature Review

A 69-year-old man underwent coronary angiography 7 years after coronary artery bypass. Saphenous vein graft spasm was observed during contrast injection, resulting in ventricular fibrillation. Angiography 6 years later showed graft patency. Vein graft spasm after coronary artery bypass grafting is rarely described. Further investigation is needed regarding incidence, mechanism, and clinical outcomes. (Level of Difficulty: Beginner.).

Surgical Repair of Congenital Atresia of the Left Coronary Ostium

Congenital left main coronary artery atresia is an exceedingly rare condition with potentially fatal consequences if not diagnosed in a timely fashion. We present a case series in children and adolescents, including surgical repair and outcomes. We describe the presenting symptoms and subsequent management of each patient, including surgical repair and outcomes. (Level of Difficulty: Advanced.).

Coronary Artery Embolism Caused by BioGlue Surgical Adhesive After Type A Acute Aortic Dissection Repair

Coronary artery embolism due to BioGlue surgical adhesive after repair of type A acute aortic dissection is a rare condition. We report a case of BioGlue coronary artery embolism after type A acute aortic dissection repair confirmed using intravascular ultrasound imaging and pathological examination. It was successfully treated with percutaneous coronary intervention. (Level of Difficulty: Advanced.)

Quantification of epicardial fat using non contrast cardiac CT in an HIV population: Reproducibility and association with other body fat indices

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Assessment of epicardial fat volume is highly reproducible.

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Epicardial fat volume and epicardial fat area have a good correlation to BMI.

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Epicardial fat volume correlates best with DEXA-derived total body fat and trunk fat.

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Epicardial fat volume should be considered over other CT assessment methods when quantifying epicardial fat in HIV patients.

Purpose

To assess the reproducibility of different epicardial fat measurement and their association with other adiposity measurements in HIV-infected and non-HIV-infected patients.

Methods and materials

In this cross-sectional study, 167 HIV-infected and 58 non-HIV-infected consecutive participants (200 males; mean age 56 years) with low/intermediate cardiovascular risk were recruited between 2012 and 2017 from a large prospective cohort and underwent non-contrast cardiac CT. Two independent observers measured epicardial fat volume, area and thickness in all participants. For intra-observer agreement, one observer did a second assessment in a subset of 40 patients. Agreement was assessed with the intraclass correlation coefficient (ICC). Pearson's correlation was estimated to assess the association between epicardial fat, body-mass index (BMI) and dual-energy x-ray absorptiometry (DEXA) derived percentage of body fat.

Results

Inter-observer agreement was excellent for epicardial fat volume (ICC 0.75) and area (ICC 0.95) and good for epicardial fat thickness (ICC near the left anterior descending artery (LAD) 0.64, ICC near right coronary artery (RCA) 0.64). Intra-observer agreement was excellent for epicardial fat volume (ICC 0.97), area (ICC 0.99), thickness at LAD (ICC 0.71) and good for epicardial fat thickness at RCA (ICC 0.68). Epicardial fat volume had a better correlation to total body fat (r = 0.28, p < 0.001) and trunk fat (r = 0.37, p < 0.001), in comparison to other epicardial fat indices.

Conclusion

Assessment of epicardial fat volume is highly reproducible in both HIV-infected and non-HIV-infected patients and shows a superior correlation with DEXA-based body and trunk fat measurements. Epicardial fat volume should be considered over other CT assessment methods when quantifying epicardial fat in HIV patients.

Ultra-Low Contrast Percutaneous Coronary Intervention Guided by Optical Coherence Tomography Complicated by Coronary Perforation

Percutaneous coronary intervention (PCI) in patients with chronic kidney disease is associated with a high-risk of contrast-induced nephropathy. We describe a case of ultra-low contrast PCI guided using optical coherence tomography using normal saline for clearance complicated by distal wire perforation treated with embolization. (Level of Difficulty: Intermediate.).

A Unique Case of STEMI STEALing the Flow

We report a case of a 55-year-old woman with previous coronary artery bypass grafting. She presented with acute ST-segment elevation myocardial infarction secondary to occlusion of the proximal left subclavian artery causing reduced flow in the left internal mammary artery to left anterior descending artery graft. (Level of Difficulty: Intermediate.)

Ventricular Septal Rupture Complicating Delayed Acute Myocardial Infarction Presentation During the COVID-19 Pandemic

The rate of mechanical complications of acute myocardial infarction has declined. Recent publications raised concerns over the reduction in cardiac catheterization laboratory activation for ST-segment myocardial infarction (STEMI) during the coronavirus disease-2019 (COVID-19) pandemic. We present 2 recent cases of ventricular septal rupture in patients who presented to our institution with delayed STEMI. (Level of Difficulty: Intermediate.).

A Challenging Case of Extensive Spontaneous Coronary Artery Dissection

The detection of spontaneous coronary artery dissection (SCAD) causing myocardial infarction is integral in pursuing the appropriate management. Our case posed a diagnostic challenge, with Takotsubo cardiomyopathy and coronary embolism among the potential differential diagnoses upon the initial presentation. Extensive propagation of spontaneous coronary artery dissection subsequently resulted in a significant challenge to management requiring surgical revascularization. (Level of Difficulty: Intermediate.).

Multimodal Imaging of Post-Stenting Mycotic Coronary Pseudoaneurysm Complicated by Device Fracture and Myocardial Abscess

Mycotic coronary aneurysm and pseudoaneurysm are rare infective complications of percutaneous coronary interventions, associated with poor prognosis. Multimodality imaging is recommended to achieve a correct diagnosis. We present a case of post-stenting mycotic coronary pseudoaneurysm complicated by myocardial abscess in which we used different imaging tools, each carrying additional information. (Level of Difficulty: Advanced.)

Acute Myocardial Infarction With Cardiogenic Shock Due to Pericardial Constriction and Multivessel Coronary Obstruction

We present a rare case of cardiogenic shock and multivessel coronary compression due to focal pericardial inflammation and constriction. The patient was treated in the acute phase with coronary stenting and temporary mechanical support. Multimodality imaging was essential in elucidating the diagnosis. (Level of Difficulty: Beginner.)

Intracoronary Lithoplasty in Percutaneous Treatment of Challenging Calcified Coronary Lesions

Unexpanded stents in calcified coronary stenosis is a problem where intravascular lithotripsy could be effectively employed. In these 2 cases, we report possible issues associated with the use of this technology. (Level of Difficulty: Intermediate.)

Cardiac Sarcoidosis Causing Ventricular Tachycardia After Myocardial Infarction: A Shocking Diagnosis

Scar-mediated ventricular tachycardia (VT) commonly results from ischemic heart disease. We present a case of recurrent VT, which was initially attributed to ischemic disease; however, the scar location pointed to an alternate pathology. This case demonstrates the utility of multimodality imaging in diagnosing sarcoidosis as a cause of VT. (Level of Difficulty: Intermediate.)

Constrictive Pericarditis After Lung Transplantation

As a rare complication after lung transplant, cardiac constriction should not be missed. Physical exam, echocardiography, and catheterization are essential for diagnosis A 65-year-old man with previous coronary artery disease and idiopathic pulmonary fibrosis underwent bilateral lung transplant and subsequently presented for progressive dyspnea and volume overload. Cardiac imaging and cardiac catheterization confirmed constriction, and complete pericardiectomy was performed. The patient had rapid resolution of heart failure symptoms. Pericardial constriction is a rare complication following lung transplant, and we provide a review of the literature and discussion of potential contributing factors. (Level of Difficulty: Intermediate.)

Eosinophilic Granulomatosis With Polyangiitis Presenting as an Acute Coronary Syndrome

Eosinophilic granulomatosis with polyangiitis, formerly Churg-Strauss Syndrome, is an uncommon disorder that carries a high mortality when coronary artery disease develops. Early recognition and treatment is crucial. We highlight an unusual presentation of acute coronary syndrome not associated with atherosclerotic coronary disease. (Level of Difficulty: Intermediate.)

Effect of Pressure-controlled intermittent Coronary Sinus Occlusion (PiCSO) on infarct size in anterior STEMI: PiCSO in ACS study

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STEMI patients treated with PiCSO were propensity matched to INFUSE-AMI controls.

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Infarct size at day 5 was significantly lower in the PiCSO group.

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There were no major adverse cardiac events (MACE) related to the PiCSO.

Background

The aim of this clinical research was to investigate the effects of Pressure-controlled intermittent Coronary Sinus Occlusion (PiCSO) on infarct size at 5 days after primary percutaneous coronary intervention (pPCI) in patients with ST-segment elevation myocardial infarction (STEMI).

Methods and results

This comparative study was carried out in four UK hospitals. Forty-five patients with anterior STEMI presenting within 12 h of symptom onset received pPCI plus PiCSO (initiated after reperfusion; n = 45) and were compared with a propensity score-matched control cohort from INFUSE-AMI (n = 80). Infarct size (% of LV mass, median [interquartile range]) measured by cardiac magnetic resonance (CMR) at day 5 was significantly lower in the PiCSO group (14.3% [95% CI 9.2–19.4%] vs. 21.2% [95% CI 18.0–24.4%]; p = 0.023). There were no major adverse cardiac events (MACE) related to the PiCSO intervention.

Conclusions

PiCSO, as an adjunct to pPCI, was associated with a lower infarct size at 5 days after anterior STEMI in a propensity score-matched population.

Collateral Damage: Medical Care Avoidance Behavior Among Patients With Myocardial Infarction During the COVID-19 Pandemic

The coronavirus disease-2019 (COVID-19) pandemic has caused an enormous strain on healthcare systems and society on a global scale. We report a new phenomenon of medical care avoidance among patients with acute coronary syndrome, which is due to concerns about contracting severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) infection during hospital stay, ultimately leading to dire clinical outcomes. (Level of Difficulty: Beginner.)

Coronary Microvascular Spasm as the Underlying Cause of the Angiographic Slow Flow Phenomenon

Slow coronary flow is frequently seen during angiography in patients with angina and unobstructed coronary arteries. However, the pathophysiology of this finding remains largely unclear. We report a case of a 52-year-old woman with slow coronary flow caused by acetylcholine-induced microvascular spasm, as confirmed by intracoronary flow measurements. (Level of Difficulty: Beginner.).

Ping-Pong Guide Catheters to Facilitate Real-Time Intravascular Ultrasound-Guided Recanalization of Stumpless Chronic Total Occlusion

Stumpless chronic total occlusion is associated with a higher failure rate of recanalization. Intravascular ultrasound (IVUS) is useful for identifying the entry point; however, 8-F guide catheters are necessary for real-time IVUS-guided wiring. This case reports the novel use of the "ping-pong" guide catheter technique to facilitate real-time IVUS-guided wiring for a stumpless chronic total occlusion. (Level of Difficulty: Advanced.).

Spontaneous Internal Mammary Artery Graft Dissection Triggered by Emotional Stress

Internal mammary artery graft dissection is a rare condition and is usually caused by iatrogenic complications or mechanical stress. We experienced a case of acute myocardial infarction due to spontaneous internal mammary artery graft dissection that was triggered by emotional stress and was successfully treated by percutaneous intervention using drug-eluting stents. (Level of Difficulty: Beginner.).

Collaborative Cardiac Care: A Comprehensive Heart Team Approach to Multiple Severe Vascular Conditions

Left main artery coronary disease represents the highest risk lesion of ischemic heart disease. Revascularization can be accomplished by surgery or percutaneous interventions. This study highlights the case of a patient with severe multiple peripheral vascular conditions and complex coronary anatomy treated with percutaneous coronary intervention using mechanical circulatory support. (Level of Difficulty: Intermediate.)

Cardiotoxicity of mediastinal radiotherapy

Aim

To explore available recent literature related to cardiotoxicity following mediastinal radiation.

Background

Radiotherapy-related heart injury is well documented, with no apparent safety threshold dose. The number of long-term cancer survivors exposed to mediastinal radiotherapy at some point of their treatment is increasing. Heart dosimetric parameters are of great importance in developing a treatment plan, but few data are available regarding radiosensitivity and dose-volume constraints for specific heart structures.

Materials and Methods

In October 2018, we identified articles published after 1990 through a PubMed/MEDLINE database search. The authors examined rough search results and manuscripts not relevant for the topic were excluded. We extracted clinical outcomes following mediastinal radiotherapy of childhood cancers, lymphoma, medulloblastoma, thymic cancers and hematopoietic cell transplantation survivors and evaluated treatment planning data, whenever available.

Results

A total of 1311 manuscripts were identified in our first-round search. Of these manuscripts, only 115 articles, matching our selection criteria, were included.

Conclusions

Studies uniformly show a linear radiation dose-response relationship between mean absorbed dose to the heart (heart-D_mean) and the risk of dying as a result of cardiac disease, particularly when heart-D_mean exceeds 5 Gy. Limited data are available regarding dose-volume predictors for heart substructures and the risk of subsequent cardiac toxicity. An individual patient's cardiotoxicity risk can be modified with advanced treatment planning techniques, including deep inspiration breath hold. Proton therapy is currently showing advantages in improving treatment planning parameters when compared to advanced photon techniques in lymphoma, thymic malignancies, malignant mesothelioma and craniospinal irradiation.