Atypical de Winter Presentation of Critical Left Anterior Descending Coronary Artery Occlusion

A 69-year-old male presented with substernal chest pain that started a few hours earlier. On arrival, the patient was hemodynamically stable, and the physical examination was unrevealing. Laboratory workup revealed an elevated high-sensitivity troponin, and an initial electrocardiogram (ECG) revealed tall, symmetric T-waves with preceding minor concave ST-segment elevations less than 1 mm in the precordial leads (V1-V6) and 0.5 mm ST elevation in the aVR. Due to concerning ECG changes, the patient was treated for a possible non-ST-segment elevation myocardial infarction. A loading dose of aspirin and clopidogrel was given and a heparin drip was initiated. However, the patient's chest pain persisted requiring multiple sublingual nitroglycerin tablets. Later, on further review of the ECGs, the presence of de Winter T-waves was noted and led to activation of the catheterization laboratory, and an urgent left heart catheterization (LHC) was done. LHC revealed a critical 90% occlusion of the left anterior descending artery, and a drug-eluting stent was placed. The patient had a good recovery thereafter. This case emphasizes the rarity of the case and lack of awareness about the atypical de Winter pattern that is considered to be an ST-segment elevation myocardial infarction equivalent. Failure to recognize this can potentially lead to delayed intervention.

A Systemwide Approach for Navigating the Dilemma of Oral Factor Xa Inhibitor Interference With Unfractionated Heparin Anti-Factor Xa Concentrations

BACKGROUND

Oral factor Xa inhibitors are known to significantly increase heparin anti-Xa concentrations, which leads to inaccuracies when monitoring intravenous unfractionated heparin (IV UFH). Guidance for managing this laboratory interference is lacking, creating substantial uncertainty in clinical practice.

OBJECTIVE

To describe a strategy used by a large academic institution for managing the controversy of laboratory interference in the setting of oral factor Xa inhibitor use and provide effectiveness and safety data for this approach.

METHODS

In December 2016, a new Heparin IV Direct Oral Anticoagulant (DOAC) Interference PowerPlan (a comprehensive order set) was made available in the electronic health record (Cerner, North Kansas City, MO) throughout the health system. We retrospectively examined 169 patients with events reported in the error reporting system, RISKMASTER, and evaluated reports with and without the use of the PowerPlan. Effectiveness was determined through evaluation of thrombosis. The Naranjo criteria for causality were applied to assess thrombotic events.

RESULTS

Of 56 events that were reported with apixaban when the PowerPlan was not ordered, 4 (7%) thrombotic events occurred within 7 days of UFH initiation. One out of the 4 events (25%) that occurred when the PowerPlan was not appropriately initiated was considered probable using the Naranjo Scale. Three additional events (75%) were possible using the Naranjo Scale.

CONCLUSION AND RELEVANCE

The Heparin IV DOAC Interference PowerPlan appears to be conducive to positive patient outcomes when evaluating voluntary reported events and may assist clinicians with managing the therapeutic dilemma of this laboratory interference.

Embolization of intracranial aneurysms with second-generation Matrix-2 detachable coils: mid-term and long-term results

BACKGROUND

Bioactive polyglycolic/polylactic acid (PGLA)-coated Matrix detachable coils were reported to incite intra-aneurysmal inflammation and fibrosis. Multiple large case series with Matrix-1 coils have shown no advantage with respect to aneurysm recurrence. Second-generation Matrix-2 coils were designed with improved platinum support and reduced copolymer friction. We assessed the safety and efficacy of Matrix-2 coil embolization.

METHODS

84 aneurysms were embolized primarily with Matrix-2 coils. Anatomic results were evaluated using a modified Raymond scale with progressive occlusion or recanalization/recurrence strictly defined as any interval change in intra-aneurysmal opacification.

RESULTS

Mid-term (8.9 ± 3.4 months) and long-term (23.0 ± 7.4 months) follow-up was available for 65 aneurysms. At mid-term, 55 (85%) aneurysms remained stable (or progressed to occlusion) versus 10 (15%) recurrent aneurysms, 7 (11%) requiring retreatment. At long term, 49 (75%) aneurysms remained stable versus 16 (25%) recurrent aneurysms, 12 (18%) requiring retreatment. Statistically significant factors affecting recanalization included ruptured aneurysms 9/20 (45%), large aneurysms 5/8 (71%), post-procedure residual aneurysms 6/12 (50%) and differential coil packing density of recurrent (21%) versus stable (28%) aneurysms. Patient morbidity (5%) was limited to thromboembolic complications (n=4) or aneurysm rerupture (n=1). Patient mortality (5%) was secondary to subarachnoid hemorrhage complications (n=4) with no procedure-related deaths (0%).

CONCLUSION

Coil embolization with Matrix-2 coils is safe and effective, preventing recanalization in small aneurysms at mid-term. Although these aneurysm recurrence rates initially appeared lower than previous reports with Matrix-1 or platinum coils, significant late recanalization was observed on long-term follow-up. We postulate that any derived benefit from Matrix-2 coils is directly dependent on post-procedure outcomes and coil packing density.