Surgical management of a giant pulmonary artery aneurysm in a patient with ischaemic heart disease - a case report

Association of Pulmonary Artery Aneurysm with Ischemic Heart Disease is uncommon, and its surgical management has been rarely described in the literature. Surgical intervention should be individualised according to the coexisting diseases and comorbidities to achieve optimal outcome. We report a case of a 76-year-old man with background history of coronary artery stenting due to ischaemic heart disease. The patient presented with features of coronary compression due to giant pulmonary artery aneurysm. He was operated with replacement of aneurysmal pulmonary trunk with 25 mm Hancock conduit.

Acute non-ST segment elevation myocardial infarction as the first manifestation of Takayasu arteritis in a 16-year-old female patient: a case report and literature review

Takayasu arteritis (TA) is now recognized worldwide and is a disease that mainly affects the aorta and its main branches. TA rarely involves the small or medium-sized vessels. Certain vascular lesions, such as arterial stenosis, occlusion, and aneurysm are common with TA. However, patients with new-onset TA who present with left main trunk acute non-ST segment elevation myocardial infarction are extremely rare. We report a 16-year-old female patient with non-ST segment elevation myocardial infarction due to severe stenosis of the left main coronary artery that was caused by TA. She was eventually diagnosed with TA and underwent successful coronary artery stenting combined with glucocorticoids and folate reductase inhibitor therapy. Over the 1-year follow-up, she experienced two episodes of chest pain and was admitted to the hospital. During the second hospitalization, coronary angiography (CAG) revealed 90% stenosis of the original left main trunk (LM) stent. Following percutaneous coronary angiography (PTCA), drug-coated balloon (DCB) angioplasty was performed. Fortunately, a clear diagnosis of TA was made, and treatment was initiated with an interleukin-6 (IL-6) receptor inhibitor. Early diagnosis and therapy for TA are emphasized.

The association between the MELD-XI score and heart failure in patients with acute myocardial infarction after coronary artery stenting-a retrospective study

Background

The model for end-stage liver disease (MELD) score is a marker used to evaluate end-stage liver disease in patients with liver failure and is suggested to be valuable in evaluating heart diseases such as heart failure. Because patients with heart failure and myocardial infarction often use anticoagulants, there is an impact on the international normalized ratio (INR). Therefore, removing the INR from MELD score to form MELD-XI score may help to more accurately evaluate the cardiac function in patients with heart failure. This study was conducted to examine the predictive value of MELD-XI score in patients with acute myocardial infarction after coronary artery stenting, as there is a lack of literature in this area.

Methods

The data of 318 patients with acute myocardial infarction admitted to The People's Hospital of Dazu from January 2018 to January 2021 was retrospectively collected. According to the MELD-XI score on admission, the patients were divided into a high-MELD-XI score group (n=159) and a low-MELD-XI score group (n=159). The patients were followed up for 1 year after surgery to observe the long-term prognosis and the long-term prognosis of the 2 groups was compared.

Results

Compared with that in the low-MELD-XI score group, the left ventricular ejection fraction in the high-MELD-XI score group was significantly reduced (51.61%±7.66% vs. 60.48%±5.94%; P<0.001), while the level of N-terminal pro-B-type natriuretic peptide (NT-proBNP) increased significantly (821.58±461.81 vs. 723.51±335.16 ng; P=0.031). The MELD-XI score had a certain predictive value for heart failure in patients with acute myocardial infarction after coronary artery stenting, and the area under the curve was 0.730 (95% CI: 0.670-0.791; P<0.001). The MELD-XI score had a predictive value for death in patients with acute myocardial infarction after coronary artery stenting, and the area under the curve was 0.704 (95% CI: 0.564-0.843; P=0.022). MELD-XI score was significantly negatively correlated with left ventricular ejection fraction in patients with acute myocardial infarction after coronary artery stenting (r=-0.444; P<0.001).

Conclusions

MELD-XI could evaluate the cardiac function of patients with acute myocardial infarction after coronary artery stenting, which was valuable in predicting the prognosis.

Coronary Artery Restenosis in Women by History of Preeclampsia

Background A history of preeclampsia is associated with increased risk of coronary artery disease and experimental evidence suggests that a history of preeclampsia also increases the risk of restenosis. However, the extent to which a history of preeclampsia is associated with risk of restenosis after percutaneous coronary intervention in women is unknown. Methods and Results We included 6065 parous women aged ≤65 years with first percutaneous coronary intervention on 9452 segments 2006 to 2017, linking nationwide data on percutaneous coronary intervention and delivery history in Sweden. Main outcomes were clinical restenosis and target lesion revascularization within 2 years. We accounted for segment-, procedure-, and patient-related potential predictors of restenosis in proportional hazards regression models. Restenosis occurred in 345 segments (3.7%) and target lesion revascularization was performed on 383 patients (6.3%). A history of preeclampsia was neither significantly associated with risk of restenosis (predictor-accounted hazard ratio [HR], 0.71 [95% CI, 0.41-1.23]) nor target lesion revascularization (0.74 [95% CI, 0.51-1.07]) compared with a normotensive pregnancy history. When term and preterm preeclampsia were investigated separately, segments in women with a history of term preeclampsia had a lower risk of restenosis (predictor-accounted HR, 0.45 [95% CI, 0.21-0.94]). A history of preeclampsia was not significantly associated with death by any cause within 2 years of the index procedure (predictor-accounted HR 1.06, [95% CI, 0.62-1.80]). Conclusions A history of preeclampsia was not associated with increased risk of restenosis but instead some evidence pointed to a decreased risk. To facilitate future studies and allow for replication, concomitant collection of data on pregnancy complication history and percutaneous coronary intervention outcomes in women is warranted.

[The effect of low-frequency electrostatic therapy on immunoinflammatory reactions in patients with acute myocardial infarction after endovascular myocardial revascularization at the inpatient stage of medical rehabilitation]

PURPOSE OF THE STUDY

To study the effect of complex rehabilitation with the inclusion of low-frequency electrostatic therapy on the dynamics of immune status in patients with myocardial infarction (MI) after endovascular myocardial revascularization.

MATERIAL AND METHODS

The state of the immune status was studied in 68 patients with MI after percutaneous coronary intervention (PCI) - coronary angioplasty with stenting, admitted to the inpatient stage of medical rehabilitation.

RESULTS

The study proved the involvement of the immune system in a complex set of reactions occurring in patients with myocardial infarction after PCI. Significant correlations between biochemical and immunological markers of inflammation and risk factors for cardiovascular diseases have been established. Carrying out complex rehabilitation measures using low-frequency electrostatic therapy at the stationary stage of medical rehabilitation helps to reduce the activity of the inflammatory process and eliminate the immunological imbalance in MI patients after endovascular myocardial revascularization.

CONCLUSION

The inclusion of low-frequency electrostatic therapy in the medical rehabilitation complex has a significant immunocorrective effect on the parameters of cellular and humoral immunity, the ratio of pro- and anti-inflammatory cytokines, which justifies the prospects for its use in the rehabilitation of patients with myocardial infarction.

Pro-inflammatory Mediators and Oxidative Stress: Therapeutic Markers for Recurrent Angina Pectoris after Coronary Artery Stenting in Elderly Patients

BACKGROUND

Pro-inflammatory mediators and oxidative stress are related to severity of angina pectoris in patients with coronary heart disease.

OBJECTIVE

We evaluated the effects of pro-inflammatory mediators and oxidative stress on recurrent angina pectoris after coronary artery stenting in elderly patients.

METHODS

We determined the expression levels of malondialdehyde (MDA), acrolein (ACR), tumour necrosis factor-α (TNF-α), toll-like receptor 4 (TLR4), superoxide dismutase 3 (SOD3), paraoxonase-1 (PON-1), stromal cell-derived factor-1α (SDF-1α) and endothelial progenitor cells (EPCs) in elderly patients with recurrent angina pectoris after coronary artery stenting.

RESULTS

Levels of MDA, ACR, TNF-α and TLR4 were significantly increased (p<0.001), and levels of SOD3, PON-1, SDF-1α and EPCs were significantly decreased (p<0.001) in the elderly patients with recurrent angina pectoris after coronary artery stenting. MDA, ACR, TNF-α and TLR4 as markers of oxidative stress and pro-inflammatory mediators may have suppressed SOD3, PON-1, SDF-1α and EPCs as markers of anti-oxidative stress/anti-inflammatory responses. Oxidative stress and pro-inflammatory mediators were important factors involved in recurrent angina pectoris of elderly patients after coronary artery stenting.

CONCLUSION

Oxidative stress and pro-inflammatory mediators could be considered as potential non-invasive prognostic, predictive and therapeutic biomarkers for stable recurrent angina and recurrent unstable angina in the elderly patients after coronary artery stenting.

Structural and Hemodynamic Analyses of Different Stent Structures in Curved and Stenotic Coronary Artery

Coronary artery stenting is commonly used for the treatment of coronary stenosis, and different stent structures indeed have various impacts on the stress distribution within the plaque and artery as well as the local hemodynamic environment. This study aims to evaluate the performance of different stent structures by characterizing the mechanical parameters after coronary stenting. Six stent structures including three commercially-shaped stents (Palmaz-Schatz-shaped, Xience Prime-shaped, and Cypher-shaped) and three author-developed stents (C-Rlink, C-Rcrown, and C-Astrut) implanted into a curved stenotic coronary artery were investigated. Structural analyses of the balloon-stent-plaque-artery system were first performed, and then followed by hemodynamic analyses. The results showed that among the three commercially-shaped stents, the Palmaz-Schatz-shaped had the least stent dogboning and recoiling, corresponding to the greatest maximum plastic strain and the largest diameter change, nevertheless, it induced the highest maximum von Mises stress on plaque, arterial intima and media. From the viewpoint of hemodynamics, the Palmaz-Schatz-shaped displayed smaller areas of adverse low wall shear stress (<0.5 Pa), low time-averaged wall shear stress (<0.5 Pa), and high oscillating shear index (>0.1). Compared to the Cypher-shaped, the C-Rcrown and C-Astrut had smaller recoiling, greater maximum plastic stain and larger diameter change, which indicated the improved mechanical performance of the Cypher-shaped stent. Moreover, both C-Rcrown and C-Astrut exhibited smaller areas of adverse low wall shear stress, and low time-averaged wall shear stress, but only the C-Rcrown displayed a smaller area of adverse high oscillating shear index. The present study evaluated and compared the performance of six different stents deployed inside a curved artery, and could be potentially utilized as a guide for the selection of suitable commercially-shaped stent for clinical application, and to provide an approach to improve the performance of the commercial stents.

Evolving role of platelet function testing in coronary artery interventions

The substantial reduction in ischemic events provided by the dual antiplatelet regimen with aspirin and clopidogrel is well documented in patients with acute coronary syndrome and patients undergoing percutaneous coronary intervention. Recently the variable response to the antiplatelet agents has received considerable attention after several “boxed warnings” on clopidogrel. This led to intense controversy on pharmacokinetic, pharmacodynamic, and pharmacogenomic issues of antiplatelet drugs, especially clopidogrel. Research use of platelet function testing has been successfully validated in identifying new antiplatelet drugs like prasugrel and ticagrelor. These platelet function assays are no longer regarded just as a laboratory phenomenon but rather as tools that have been shown to predict mortality in several clinical trials. It is believed that suboptimal response to an antiplatelet regimen (pharmacodynamic effect) may be associated with cardiovascular, cerebrovascular, and peripheral arterial events. There has been intense controversy about this variable response of antiplatelet drugs and the role of platelet function testing to guide antiplatelet therapy. While the importance of routine platelet function testing may be uncertain, it may be useful in high-risk patients such as those with diabetes mellitus, diffuse three vessels coronary artery disease, left main stenosis, diffuse atherosclerotic disease, and those with chronic renal failure undergoing percutaneous coronary intervention. It could also be useful in patients with suspected pharmacodynamic interaction with other drugs to assure the adequacy of platelet inhibition. While we wait for definitive trials, a predictive prognostic algorithm is necessary to individualize antiplatelet therapy with P2Y12 inhibitors based on platelet function assays and genetic testing.

Aspirin and clopidogrel hyporesponsiveness and nonresponsiveness in patients with coronary artery stenting

Patients undergoing coronary artery stenting receive an antiplatelet regimen to reduce the risk of antithrombotic complications. Current guidelines recommend the use of acetyl salicylic acid (aspirin) and clopidogrel as evidenced by large clinical trials. There has been a concern about variable responses of patients to aspirin and clopidogrel which may predispose them to subacute stent thrombosis or late stent thrombosis. Up to 25% of patients with acute myocardial infarction (AMI) undergoing percutaneous coronary intervention (PCI) were found to have hyporesponsiveness or resistance to clopidogrel which may predispose them to recurrent events. Dual antiplatelet regimen is a standard therapy in these patients and there is always a concern about variable responses to aspirin and clopidogrel predisposing them to acute coronary syndrome (ACS). Prevalence of this hyporesponsiveness or resistance may be due to noncompliance, genetic mutations, co-morbid situations and concomitant use of other drugs. This issue is of considerable importance in the era of coronary drug eluting stents when a long-term dual antiplatelet regimen is needed. This paper is a review for clinicians taking care of such patients with hyporesponsiveness or nonresponsiveness to dual antiplatelet regimen.