Myocardial contrast echocardiographic diagnosis and follow-up of interventricular septal hematoma after retrograde intervention for a chronic total occlusion of a right coronary artery: a case report

BACKGROUND

Chronic total occlusion percutaneous coronary interventions (CTO-PCI) can be highly complex and are associated with an increased risk of complications. Coronary perforation (CP) is one of the most feared complications of CTO-PCI. Awareness of the potential consequence, as well as meticulous attention to patient monitoring, can aid in rapid treatment if it happens. We present a unique case covering myocardial contrast echocardiography (MCE) characterization of interventricular septal hematoma secondary to CP associated with decompression of the hematoma into the left ventricle cavity and a favorable clinical outcome.

CASE DESCRIPTION

This is a case of a patient with no space-occupying effect in interventricular septum before CTO-PCI showed severe chest pain after PCI. Bedside echocardiography showed thickening of the interventricular septum with the anechoic area, and contrast-enhanced echocardiography suggested the presence of interventricular septal hematoma and coronary-ventricular fistula. It was considered that retrograde CTO-PCI led to CP, which developed into an interventricular septal hematoma. The hematoma obstructed the right ventricular outflow tract (RVOT) to a lesser amount; at the same time, the perforated coronary artery created a fistula with the left ventricle, resulting in perfusion damage and myocardial ischemia to some extent, although the patient's vital signs remained stable. Therefore, conservative treatment was carried out under close observation. The patient stayed stable. The hematoma was absorbed 7 days after the operation, and completely absorbed 1 month later.

CONCLUSIONS

Although most cases of myocardial hematoma caused by CP can be treated conservatively without causing acute hemodynamic damage, a myocardial hematoma can progress at any time. Closely monitoring the changes in patients' symptoms and vital signs; mastering the location of the perforated coronary artery, the size of the hematoma and the hemodynamic abnormalities can help clinicians quickly make further treatment plans. Echocardiography coupled with contrast-enhanced ultrasonography, which is non-invasive, safe, cost-effective, and bedside-operable may accurately indicate the location, size of the hematoma, whether there is a shunt, as well as observe the hemodynamic changes and myocardial perfusion in real-time.

The Usefulness of C-Reactive Protein to Albumin Ratio in the Prediction of Adverse Cardiovascular Events in Coronary Chronic Total Occlusion Undergoing Percutaneous Coronary Intervention

Inflammation and nutrition as main factors can affect the prognosis of patients with chronic total coronary occlusion (CTO) undergoing percutaneous coronary intervention (PCI). The C-reactive protein to albumin ratio (CAR) can clarify the inflammation and nutrition status, which are highly related to clinical outcomes. This study aims to investigate the association between CAR and adverse cardiovascular events in patients with CTO undergoing PCI. For this study, 664 patients were divided into three groups based on the tertiles of CAR. The primary endpoint was all-cause mortality and the secondary endpoint was major adverse cardiovascular events (MACE). Over a median follow-up of 33.7 months, the primary endpoint occurred in 64 patients (9.6%) and the secondary endpoint occurred in 170 patients (25.6%). The patients with higher CAR represented a worse prognosis with all-cause death and cardiovascular death after the adjustment for the baseline risk factors. Adding the CAR values raised the predictive value for the incidence of the all-cause death and cardiovascular death but not MACE. The capacity of prognosis prediction was improved after the addition of the CAR value to the traditional prediction model.

High Incidence of Cataracts in the Follow-Up of Patients Undergoing Percutaneous Coronary Intervention for Chronic Coronary Total Occlusion

Development of cataracts is a well-known adverse effect of ionizing radiation, but little information is available on their incidence in patients after other medical procedures, such as cardiac catheterizations. The study objective was to determine the incidence of cataracts in a cohort of patients undergoing percutaneous coronary intervention (PCI) for chronic coronary total occlusion (CTO) and its association with radiation dose. The study analyzed the incidence of cataracts during the follow-up of 126 patients who underwent chronic total coronary PCI, using Cox regression to identify predictive factors of cataract development. The study included 126 patients, 86.9% male, with a mean age of 60.5 years (range, 55.0-68.0 years). Twenty-three (18.2% n = 23) developed cataracts during a mean follow-up of 49.5 months (range 37.3-64.5 months). A higher incidence was observed in patients who received more than 5 Gy (29.0% vs. 14.7%, Hazard ratio (HR = 2.84 [1.19-6.77]). Multivariate analysis revealed a relationship between cataract development during the follow-up and a receipt of radiation dose >5 Gy (HR = 2.60, 95% confidence interval [CI 1.03-6.61]; p = 0.03), presence or history of predisposing eye disease (HR = 4.42, CI:1.57-12.40), diabetes (HR = 3.33 [1.22-9.24]), and older age, as in >57 (HR, 6.40 [1.81-22.61]). An elevated incidence of cataracts was observed in patients after PCI for CTO. The onset of cataracts is related to the radiation dose during catheterization, which is a potentially avoidable effect of which operators should be aware.

Radiation Exposure for Percutaneous Interventions of Chronic Total Coronary Occlusions in a Multicenter Registry: The Influence of Operator Variability and Technical Set-up

AIMS

Radiation exposure is a limiting factor for percutaneous coronary interventions (PCI) of chronic total coronary occlusion (CTO) lesions. This study was designed to analyze changes in patient radiation dose for CTO-PCI and parameters associated with radiation dose.

METHODS AND RESULTS

We analyzed a cohort of 12,136 procedures performed by 23 operators between 2012 and 2017 from the European Registry of CTO-PCI. Radiation exposure was recorded as air kerma (AK) and dose area product (DAP). A dose rate index (DRI) was calculated as AK per fluoroscopy time to normalize for individual differences in fluoroscopy time. The lesion complexity increased from Japanese-CTO (J-CTO) score of 2.19 ± 1.44 to 2.46 ± 1.28, with an increase of retrograde procedures from 31.1% to 40.7%; still, procedural success improved from 87.7% to 92.1%. Fluoroscopy time remained similar, but AK decreased by 14.9%, from 2.35 Gy (interquartile range [IQR], 1.29-4.14 Gy) to 2.00 Gy (IQR, 1.08-3.45 Gy) and DAP decreased by 21.5%, from 130 Gy•cm² (IQR, 70-241 Gy•cm²) to 102 Gy•cm² (IQR, 58-184 Gy•cm²). Radiation exposure was determined by the lesion complexity (J-CTO score) and procedural complexity (antegrade or retrograde). DRI was determined by fluoroscopy frame rate and type of equipment used, but the major influence remained interoperator differences.

CONCLUSIONS

Radiation exposure decreased during the observation period despite an increase in lesion and procedural complexity. While many operators already achieved a goal of low radiation exposure, there were considerable interoperator differences in radiation management, indicating further potential for improvement.

A prospective evaluation of a redefined version of the "minimalistic hybrid approach" algorithm for percutaneous coronary chronic total occlusion revascularization

OBJECTIVES

Aim of this study is to prospectively assess the feasibility of the "Minimalistic Hybrid Approach" (MHA) algorithm for chronic total occlusion (CTO) percutaneous coronary intervention (PCI).

BACKGROUND

We recently described the MHA, with focus on the classic hybrid strategies (antegrade wire escalation [AWE] or retrograde wire escalation [RWE], antegrade dissection-re-entry [ADR] or retrograde dissection-re-entry [RDR]), and also on access site (favoring "wrist" approach: radial, ulnar, and distal radial), introducer French size (favoring 6 French catheters) and nonroutine initial use of dual injection.

METHODS

The MHA was prospectively attempted in 56 consecutive CTO PCI in 54 patients. Technical success was defined as the achievement of TIMI 3 antegrade flow with residual stenosis <30%, procedural success was defined as technical success without in-hospital major adverse cardiovascular events.

RESULTS

Mean Japanese-CTO (J-CTO) score was 2.04 ± 0.95(J-CTO score ≥ 3 in 30.4%). The lesion-based technical and procedural success were 94.6%(53/56:three failures, two in the same patient) and 91.1%(51/56:three failures, one tamponade requiring pericardiocentesis and one periprocedural infarction), the patient-based successes were: technical 98.1%(53/54) and procedural 94.4%(51/54). In 34 procedures (60.7%), the approach was single catheter (always trans-wrist besides one femoral). Out of the 22(39.3%) lesions approached with dual catheters, one was bi-femoral, the rest was bi-wrist. In 29 cases (51.8%) AWE represented the successful technique, ADR in 5(8.9%) and retrograde in 19(33.9%); 3(5.4%) were failures.

CONCLUSIONS

The current study shows that the MHA algorithm is feasible in almost every CTO lesion and it can lead to extremely successful results once applied by operators well acquainted with the wrist approach and with established experience using the full spectrum of the hybrid algorithm techniques.