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INTRODUCTION: Regionalisation and organised pathways of care using specialist centre hospitals can improve outcomes for critically ill patients. Cardiac arrest centre hospitals (CAC) may optimise the delivery of post-resuscitation care. The International Liaison Committee on Resuscitation (ILCOR) has called for a review of the current evidence base. AIM: This systematic review aimed to assess the effect of cardiac arrest centres for patients with non-traumatic cardiac arrest. METHODS: Articles were included if they met the prospectively registered (PROSPERO) inclusion criteria. These followed the PICOST framework for ILCOR systematic reviews. A strict definition for a CAC was used, reflecting current position statements and clinical practice. MEDLINE, Embase and the Cochrane Library were searched using pre-determined criteria from inception to 31 December 2023. Risk of bias was assessed using Cochrane's Risk of Bias tool and ROBINS-I. The certainty of evidence for each outcome was assessed using the GRADE approach. Substantial heterogeneity precluded meta-analysis and a narrative synthesis with visualisation of effect estimates in forest plots was performed. RESULTS: Sixteen studies met eligibility criteria, including data on over 145,000 patients. One was a randomised controlled trial (RCT) at low risk of bias and the remainder were observational studies, all at moderate or serious risk of bias. All studies included adults with out-of-hospital cardiac arrest. One study used initial shockable rhythm as an inclusion criterion and most studies (n = 12) included patients regardless of prehospital ROSC status. Two studies, including the RCT, excluded patients with ST elevation. Survival to hospital discharge with a favourable neurological outcome was reported by 11 studies and favoured CAC care in all observational studies, but the RCT showed no difference. Survival to 30 days with a favourable neurological outcome was reported by two observational studies and favoured CAC care in both. Survival to hospital discharge was reported by 13 observational studies and generally favoured CAC care. Survival to 30 days was reported by two studies, where the observational study favoured CAC care, but the RCT showed no difference. CONCLUSION: This review supports a weak recommendation that adults with out-of-hospital cardiac arrest are cared for at CACs based on very low certainty of evidence. Randomised evidence has not confirmed the benefits of CACs found in observational studies, however this RCT was a single trial in a very specific setting and a population without ST elevation on post-ROSC ECG. The role of CACs in shockable and non-shockable subgroups, direct versus secondary transfer, as well as the impact of increased transport time and bypassing local hospitals remains unclear.
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INTRODUCTION: Inflammation and oxidative stress are related to congestive heart failure in patients with coronary heart disease. OBJECTIVE: Chronic congestive heart failure is a serious stage of coronary artery disease and is mainly a disease of elderly people over the age of 65. Elderly heart failure patients are characterized by myocardial ischemia, and post-ischemic myocardial dysfunction. Oxidative Stress, inflammation, and immune response play important roles in the development of heart failure. We tried to examine the mutual triggering of oxidative stress (malondialdehyde), inflammatory cytokines (tumor necrosis factor-α and soluble tumor necrosis factor receptor-1/2), immune response (toll-like receptors 2,3,4), and high sensitivity C-reactive protein expression in elderly patients with recurrent congestive heart failure after coronary stenting and investigated the effect of interplay of these changes on onset and progression of recurrent congestive heart failure in elderly patients underwent coronary stent implantation. METHODS: A total of 726 patients were enrolled in this study. We determined the levels of malondialdehyde (MDA), high sensitivity C-reactive protein (hs-CRP), tumor necrosis factor-α (TNF- α), soluble tumor necrosis factor receptor-1 and 2 (sTNFR-1/2) and toll-like receptor 2,3,4 (TLR2/3/4) in elderly patients with recurrent congestive heart failure after coronary artery stent implantation. RESULTS: Levels of MDA, hs-CRP, TNF-α, sTNFR-1, sTNFR-2, TLR2, TLR3 and TLR4 were remarkably increased (p<0.01) in elderly patients with recurrent congestive heart failure after coronary artery stenting. The results indicated that these markers were closely correlated to each other and showed that these markers were associated with increased New York Heart Association functional classification and low left ventricular ejection fractions. Further analysis confirmed that the independent clinical risk factors for recurrent congestive heart failure were MDA, hs-CRP, TNF-α, sTNFR-1, sTNFR-2, TLR2, TLR3 and TLR4. The interplay of oxidative stress, inflammatory cytokines and toll-like receptors, and hs-CRP expression levels was an important factor involved in recurrent congestive heart failure of elderly patients after coronary stenting. CONCLUSION: High levels of MDA, hs-CRP, TNF-α, sTNFR-1, sTNFR-2, TLR2, TLR3 and TLR4 had an important implication for recurrent heart failure with increased New York Heart Association functional classification and low left ventricular ejection fractions. These eight factors amplified each other's positive effects and this interaction may be a key element of their roles in recurrent heart failure. The eight risk factors were inter-dependent and occurred simultaneously, and exerted detrimental effects forming a vicious circle. MDA may trigger the over-expressions of pro-inflammatory risk factors (hs-CRP, TNF-α, sTNFR-1, sTNFR-2) through the activation of TLRs as risk factors (TLR2, TLR3 and TLR4) contributing to the dysfunction of myocardial mitochondria, cardiomyocyte hypertrophy, maladaptive myocardial remodeling, myocardial interstitial fibrosis, cardiac systolic decrease and recurrent heart failure. These eight risk factors were the basis of the mechanisms of recurrent heart failure. Therefore, the mutual triggering of oxidative stress, inflammatory and toll-like receptor signaling pathways, and hs-CRP expression could play key roles in the development of recurrent congestive heart failure in elderly patients after coronary stenting.
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This review discusses the new recommendations in the 2023 European Society of Cardiology guidelines on the management of acute coronary syndrome and provides a perspective on topics specific to clinical practice in the Netherlands, including pre-treatment, antiplatelet agent strategies, the use of risk scores and logistical considerations with regard to the timing of coronary angiography.
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Primary Percutaneous Coronary Intervention (PCI) has significantly contributed to reducing the mortality of patients with ST-segment elevation myocardial infarction (STEMI) even in cardiogenic shock and is now the standard of care in most of Japanese institutions. The Task Force on Primary PCI of the Japanese Association of Cardiovascular Intervention and Therapeutics (CVIT) proposed an expert consensus document for the management of acute myocardial infarction (AMI) focusing on procedural aspects of primary PCI in 2018 and updated in 2022. Recently, the European Society of Cardiology (ESC) published the guidelines for the management of acute coronary syndrome in 2023. Major new updates in the 2023 ESC guideline include: (1) intravascular imaging should be considered to guide PCI (Class IIa); (2) timing of complete revascularization; (3) antiplatelet therapy in patient with high-bleeding risk. Reflecting rapid advances in the field, the Task Force on Primary PCI of the CVIT group has now proposed an updated expert consensus document for the management of ACS focusing on procedural aspects of primary PCI in 2024 version.
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OBJECTIVE: This study aims to elucidate the association between serum levels of circular RNAs circ_0001879 and circ_0004104 and the occurrence of coronary microcirculation disorders along with post-PCI prognosis in individuals with stable coronary heart disease. METHODS: A cohort of 92 patients diagnosed with stable coronary heart disease and subjected to PCI between June 2020 and June 2022 at our institution was assembled. Patients were categorized into an exposed group (nâ¯=â¯60) and a non-exposed group (nâ¯=â¯32), predicated on the coronary angiography-derived microcirculation resistance index (caIMR). RESULTS: Comparative analysis revealed significantly elevated levels of circ_0001879 and circ_0004104 in the serum of the exposed group compared to the non-exposed group, with statistical significance (Pâ¯<â¯0.05). Post-PCI, both caFFR and caIMR values demonstrated a marked increase in comparison to pre-surgical measurements within both groups, with the exposed group exhibiting lower indices post-surgery relative to the non-exposed group, indicative of superior microcirculatory outcomes (Pâ¯<â¯0.05). Furthermore, serum levels of circ_0001879 and circ_0004104 were inversely correlated with favorable prognosis, with lower levels observed in patients with positive outcomes (Pâ¯<â¯0.05). The predictive accuracy for poor prognosis, as indicated by the area under the curve (AUC), was enhanced when circ_0001879 and circ_0004104 were considered in tandem (AUCâ¯=â¯0.934), surpassing the predictive power of individual assessments (Z combination vs circ_0001879â¯=â¯2.439, Z combination vs circ_0004104â¯=â¯2.317, Pâ¯<â¯0.05). CONCLUSION: Elevated serum levels of circ_0001879 and circ_0004104 are observed in stable coronary heart disease patients and are significantly associated with the presence of coronary microcirculation disorders and post-PCI prognosis, underscoring their potential as prognostic biomarkers.
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Patients with lower socioeconomic status (SES) have poorer outcomes following acute myocardial infarction (AMI) than patients with higher SES; however, how sex modifies socioeconomic differences is unclear. Using the United Kingdom (UK) Myocardial Ischaemia National Audit Project (MINAP) registry, alongside Office of National Statistics (ONS) mortality data, we analyzed 736,420 AMI patients between 2005 and 2018, stratified by Index of Multiple Deprivation (IMD) score Quintiles (most affluent [Q1] to most deprived [Q5]). There was no significant difference in probability of in-hospital mortality in our adjusted model according to sex. The probability of 30-day mortality in our adjusted model was similar between men and women throughout Quintiles, ((Q5; Men 7.6%; 95% CI 7.3-7.8% (P < .001), Women; 7.0%; 95% CI 6.8-7.3%, P < .001)) ((Q1; Men 7.1%; 95% CI 6.8-7.4%, P < .001, Women; 6.9%; 95% CI 6.6-7.1%, P < .001)). The probability of one-year mortality in our adjusted model was higher in men throughout all Quintiles (Q1; Men 15.0%; 95% CI 14.8-15.6%), P < .001, Women; 14.5%; 95% CI 14.2-14.9%, P < .001) (Q5; Men 16.9%; 95% CI 16.5-17.3%, P < .001, Women; 15.5%; 95% CI 15.1-15.9 by %, P < .001). Overall, female sex did not significantly influence the effect of deprivation on AMI processes of care and outcomes.
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BACKGROUND: Fractional flow reserve (FFR) has emerged as the invasive gold standard for assessing vessel-specific ischemia. However, FFR measurements are influenced by the hydrostatic effect, which might adversely impact the assessment of ischemia. AIMS: This study aimed to investigate the impact of hydrostatic pressure on FFR measurements by correcting for the height and comparing FFR with [15O]H2O positron emission tomography (PET)-derived relative flow reserve (RFR). METHODS: The 206 patients were included in this analysis. Patients underwent coronary computed tomography angiography (CCTA), [15O]H2O PET, and invasive coronary angiography with routine FFR in every epicardial artery. Height differences between the aortic guiding catheter and distal pressure sensor were quantified on CCTA images. An FFR ≤ 0.80 was considered significant. RESULTS: The study found a reclassification in 7% of the coronary arteries. Notably, 11% of left anterior descending (LAD) arteries were reclassified from hemodynamically significant to nonsignificant. Conversely, 6% of left circumflex (Cx) arteries were reclassified from nonsignificant to significant. After correcting for the hydrostatic pressure effect, the correlation between FFR and PET-derived RFR increased significantly from r = 0.720 to r = 0.786 (p = 0.009). The average magnitude of correction was +0.05 FFR units in the LAD, -0.03 in the Cx, and -0.02 in the right coronary artery. CONCLUSION: Hydrostatic pressure has a small but clinically relevant influence on FFR measurements obtained with a pressure wire. Correcting for this hydrostatic error significantly enhances the correlation between FFR and PET-derived RFR.
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Background and Aims: For patients with high-risk non-ST elevation myocardial infarction (NSTEMI), current guidelines recommend an early invasive strategy within 24 h. New-onset acute ischemic stroke (NAIS) is a rare but fatal complication of percutaneous coronary intervention (PCI). However, the effect of the timing of PCI and the risk of NAIS in NSTEMI is poorly defined. Methods: Patients with NSTEMI who underwent PCI were queried from the National Inpatient Sample Database (2016-2019) and stratified into three groups: early (<24 h), medium (24-72 h), and late (>72 h) PCI. Multivariate logistic regression models were used to determine the association between timing of PCI and NAIS. Results: Among 633,115 weighted hospitalizations, patients in the late PCI group had a higher incidence of NAIS (1.3%) than those in the early (0.67%) and medium (0.71%) PCI groups. Patients undergoing late PCI were older, more likely to be female, and had a greater incidence of comorbidities (e.g., diabetes mellitus, chronic pulmonary and renal illness, and atrial fibrillation) than those undergoing early or medium PCI. After adjustment, only late PCI was significantly associated with a 54% increased NAIS risk (adjusted odds ratio: 1.54 [95% confidence interval: 1.29-1.84]). Additionally, there was heterogeneity in the magnitude of risk by age and sex. Younger people (<65 years) (p for interaction <0.001) and men (interaction-value p = 0.040) were more likely to encounter NAIS. Conclusion: Late PCI was associated with a higher risk of NAIS than early PCI, particularly among men and those aged <65 years.
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BACKGROUND: Optimal lesion preparation for coronary lesions has been reappraised in the interventional community, given the increasing use of drug-coated balloons for de novo lesions; however, whether multiple ballooning could achieve more favorable angiographic results compared with single ballooning remains unknown. We aimed to investigate the incremental effect of multiple ballooning on de novo coronary lesions over single ballooning as assessed by optical coherence tomography (OCT) and intravascular ultrasound (IVUS) among patients undergoing percutaneous coronary intervention (PCI). METHODS: Patients with chronic coronary syndrome (CCS) undergoing PCI were enrolled. Ballooning before stent implantation was repeatedly performed for three times using the same semi-compliant balloon. OCT and IVUS were performed after each balloon dilatation. Primary outcome measure was the difference in the mean lumen area between post-1st ballooning (1B) and post-3rd ballooning (3B) as assessed by OCT. RESULTS: A total of 32 lesions in 30 patients undergoing PCI between May 2021 and August 2022 were analyzed. Major plaque types of the lesions were fibrous (68.8%) and lipid (28.1%). Mean lumen area by OCT was significantly increased from 1B to 3B (5.9 ± 2.9 mm2 vs. 6.0 ± 2.9 mm2, difference: 0.2 ± 0.4 mm2, p = 0.040). There were significant increases from 1B to 3B in minimum lumen area by OCT (3.1 ± 1.5 mm2 vs. 3.6 ± 1.7 mm2, difference: 0.5 ± 0.6 mm2, p < 0.001) and mean dissection angle by OCT (65.6 ± 24.9° vs. 95.2 ± 34.0°, difference: 29.6 ± 25.5°, p < 0.001). Additionally, mean plaque area by IVUS was significantly decreased (8.0 ± 4.2 mm2 vs. 7.8 ± 4.1 mm2, difference: -0.2 ± 0.2 mm2, p < 0.001). CONCLUSIONS: Among CCS patients with mainly non-calcified lesions, multiple ballooning significantly increased the lumen area and dissection angle compared with single ballooning.
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Background: Mechanical circulatory support may facilitate high-risk percutaneous coronary intervention (PCI). This study aimed to assess the feasibility, safety and effectiveness of high-risk PCI under the support of venoarterial extracorporeal membrane oxygenation (VA-ECMO) combined with intra-aortic balloon pump (IABP). Methods: We enrolled patients who received VA-ECMO plus IABP-assisted PCI procedures at our center from April 2012 to June 2018. Major adverse cardiac events (MACEs) included all-cause death, myocardial infarction, and target vessel revascularization. Results: A total of 10 patients were included, with a mean age of 71 years, EuroSCORE II of 19.9%, and SYNTAX score of 39.8. Procedural success was achieved in nine (90%) patients. The mean duration of ECMO support was 1.5 hours, and 2.6 stents were implanted per patient. Major complications included contrast-induced nephropathy needing hemodialysis in one (10%) patient, significant hemoglobin drop requiring blood transfusion in two (20%) patients, pulmonary infection in one (10%) patient, and local surgical incision infection in one (10%) patient. The accumulative mortality rates for the nine patients with procedural success were 0, 22.2%, and 44.4% at 1, 3, and 5 years follow-up, respectively. However, cardiac death occurred in only one (11.1%) patient. In addition, two patients received repeat PCI or coronary artery bypass grafting within two years following the index procedure. The overall incidence rates of MACEs were 11.1%, 44.4%, and 66.7% at 1, 3, and 5 years follow-up, respectively. Conclusions: VA-ECMO plus IABP-assisted high-risk PCI was feasible in patients with complex coronary disease, with a high procedural success rate and acceptable mid-term clinical outcomes.
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BACKGROUND: In this study, we aimed to construct a robust diagnostic model that can predict the early onset of heart failure in patients with ST-elevation myocardial infarction (STEMI) following a primary percutaneous coronary intervention (PCI). This diagnostic model can facilitate the early stratification of high-risk patients, thereby optimizing therapeutic management. METHODS: We performed a retrospective analysis of 664 patients with STEMI who underwent their inaugural PCI. We performed logistic regression along with optimal subset regression and identified important risk factors associated with the early onset of heart failure during the time of admission. Based on these determinants, we constructed a predictive model and confirmed its diagnostic precision using a receiver operating characteristic (ROC) curve. RESULTS: The logistic and optimal subset regression analyses revealed the following three salient risk factors crucial for the early onset of heart failure: the Killip classification, the presence of renal insufficiency, and increased troponin T levels. The constructed prognostic model exhibited excellent discriminative ability, which was indicated by an area under the curve value of 0.847. The model's 95% confidence interval following 200 Bootstrap iterations was found to be between 0.767 and 0.925. The Hosmer-Lemeshow test revealed a chi-square value of 3.553 and a p-value of 0.938. Notably, the calibration of the model remained stable even after 500 Bootstrap evaluations. Furthermore, decision curve analysis revealed a substantial net benefit of the model. CONCLUSION: We have successfully constructed a diagnostic prediction model to predict the incipient stages of heart failure in patients with STEMI following primary PCI. This diagnostic model can revolutionize patient care, allowing clinicians to quickly identify and create individualized interventions for patients at a higher risk.
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Delays in initiation of targeted temperature management (TTM) have been observed in randomized trials evaluating immediate or delayed coronary angiography among survivors of ventricular tachycardia (VT) or ventricular fibrillation (VF) out-of-hospital cardiac arrest (OHCA), but whether delays are associated with adverse clinical outcomes is unknown. Resuscitated survivors of VT/VF OHCA who received TTM between April 2011 and June 2015 were identified and time to TTM initiation was described. The association between TTM initiation <2 versus ≥2 hours, neurologically favorable, and overall survival to hospital discharge was assessed. In a propensity-weighted analysis of 2954 patients, a significantly larger proportion of patients undergoing percutaneous coronary intervention (PCI) had TTM initiation ≥2 hours (48.6%) as compared to patients undergoing angiography (41.4%) or those who did not undergo a procedure (33.0%; p < 0.001 for all comparisons). In this cohort, the odds of neurologically favorable survival (odds ratios [OR]: 0.88, 95% confidence intervals [CI] = 0.75-1.02) and overall survival (OR: 0.92, 95% CI = 0.83-1.03) to hospital discharge were similar among ST-elevation myocardial infarction (STEMI) patients who underwent PCI with TTM initiation <2 versus ≥2 hours. Patients without STEMI who underwent PCI with TTM initiation ≥2 hours and did not have a "do not resuscitate" order or withdrawal of life-sustaining care had decreased odds of neurologically favorable survival to hospital discharge (OR: 0.45, 95% CI = 0.22-0.93) compared to TTM initiation <2 hours. PCI was associated with delays in TTM initiation ≥2 hours among resuscitated survivors of VT/VF OHCA. Delays in TTM initiation ≥2 hours were associated with decreased odds of neurologically favorable survival among patients without STEMI who underwent PCI.
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BACKGROUND: Thrombus aspiration (TA) is used to decrease large thrombus burden (LTB), but it can cause distal embolization. OBJECTIVES: The aim of this study was to investigate the impact of TA failure on defective myocardial perfusion in patients with ST-segment elevation myocardial infarction (STEMI) and LTB. METHODS: In total, 812 consecutive patients with STEMI and LTB (thrombus grade ≥3) were enrolled, who underwent manual TA during the primary percutaneous coronary intervention. TA failure was defined as the absence of thrombus retrieval, presence of prestenting thrombus residue, or distal embolization. The final TIMI (Thrombolysis In Myocardial Infarction) flow grades and other myocardial perfusion parameters of the failed TA group were matched with those of the successful TA group. RESULTS: The proportion of final TIMI flow grade 3 was lower (74.6% vs 82.2%; P = 0.011) in the failed TA group (n = 279 [34.4%]) than in the successful TA group (n = 533 [65.6%]). The failed TA group also had lower myocardial blush grade, lower ST-segment resolution, and a higher incidence of microvascular obstruction than the successful TA group. TA failure was independently associated with low final TIMI flow grade (risk ratio: 1.525; 95% CI: 1.048-2.218; P = 0.027). Old age, Killip class ≥III, vessel tortuosity, calcification, and a culprit vessel other than the left anterior descending coronary artery were associated with TA failure. CONCLUSIONS: TA failure is associated with reduced myocardial perfusion in patients with STEMI and LTB. Advanced age, hemodynamic instability, hostile coronary anatomy such as tortuosity or calcification, and non-left anterior descending coronary artery status might attenuate TA performance. (Gangwon PCI Prospective Registry [GWPCI]; NCT02038127).
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There is great heterogeneity in lengths of stay in interventional cardiology but the number of outpatient procedures is increasing. The expected benefits of an outpatient procedure are numerous and non-inferiority of this strategy has been demonstrated. Proper selection of patients eligible for this treatment is essential to minimize the risks of unplanned hospitalization and early complications. It is based on clinical, medico-social and organizational criteria. Perfect management of the care pathway based on an organizational unit and a geographical unit is essential.
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Objective: The research was carried out to determine and compare the efficiency of completely transradial access (cTRA) and transfemoral access (TFA) in retrograde chronic total occlusion (CTO) percutaneous coronary intervention (PCI). Background: The cases of retrograde chronic total occlusion (CTO) percutaneous coronary intervention usually need the dual access. The transradial method is now used more frequently in CTO PCI, and improves the safety of CTO PCI. Methods: This retrospective, observational study was carried out in a single center. Participants were patients who underwent dual-access retrograde CTO PCI from January 2017 to October 2023, categorized into two groups: cTRA (biradial access) and TFA (bifemoral, or combined radial and femoral access). All patients in the cTRA group received conventional radial access. All punctures of the femoral artery were performed without fluoroscopic or ultrasound guidance. None of the patients in the TFA group accepted any arterial closure devices. Clinical, angiographic and procedural characteristics and the occurrence of in-hospital major adverse cardiovascular events (MACE) of the cTRA and TFA procedures were recorded. Results: This research involved 187 CTO PCI procedures with dual access, of which 88 were done using cTRA and the rest (99) were carried out through TFA. The J-CTO (Multicenter Chronic Total Occlusion Registry of Japan) score was lower in the cTRA group than TFA group (2.1± 0.6 vs 3.0± 0.8; P <0.001). The technical success (84.1% vs 82.8%; P= 0.817), procedural success (80.7% vs 79.8%; P= 0.906) and in-hospital MACE rates (5.7% vs 4.0%; P= 0.510) were the same for both groups. For a J-CTO score of 3 or higher, technical success rate was significantly lower in the cTRA group than the TFA group (58.1% vs 74.2%; P < 0.001). Conclusion: In the retrograde CTO PCI, the percentages of success and in-hospital MACE were similar for both cTRA and TFA. Meanwhile, cTRA may be used for simpler lesions (J-CTO score < 3) as compared to TFA.
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Background: Percutaneous coronary intervention (PCI), also known as coronary angioplasty, is the preferred strategy for treating obstructive coronary artery disease. Existing literature suggests the worsening of clinical outcomes in patients with previous coronary artery bypass grafting (CABG) history. In light of this, a comprehensive systematic review and meta-analysis was performed. Methods: Databases including PubMed, Cochrane Library, and ScienceDirect were utilized for the inclusive systematic search dating from inception to September 01, 2023. The risk of bias assessment was performed using the Newcastle-Ottawa scale for cohort studies, and the Cochrane Risk of Bias Tool for randomized controlled trials. Results: Ultimately, there were 16 eligible studies pooled together, involving a total of 250 684 patients, including 231 552 CABG-naïve patients, and 19 132 patients with a prior history of CABG. Overall, patients with CABG history were associated with significantly greater short-term mortality (P = .004), long-term mortality (P = .005), myocardial infarction (P < .00001), major adverse cardiovascular events (P = .0001), and procedural perforation (P < .00001). Contrastingly, CABG-naïve patients were associated with significantly greater risk of cardiac tamponade (P = .02) and repeat CABG (P = .03). No significant differences in stroke, bleeding, revascularization, or repeat PCI were observed. Conclusion: Comparatively worsened clinical outcomes were observed, as patients with prior CABG history typically exhibit complex coronary anatomy, and have higher rates of comorbidities in comparison to their CABG-naïve counterparts. The refinement of current procedural and surgical techniques, in conjunction with continued research endeavors, are needed in order to effectively address this trend.
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BACKGROUND: With the development of percutaneous coronary intervention (PCI), the number of interventional procedures without implantation, such as bioresorbable stents (BRS) and drug-coated balloons, has increased annually. Metal drug-eluting stent unloading is one of the most common clinical complications. Comparatively, BRS detachment is more concealed and harmful, but has yet to be reported in clinical research. In this study, we report a case of BRS unloading and successful rescue. CASE SUMMARY: This is a case of a 59-year-old male with the following medical history: "Type 2 diabetes mellitus" for 2 years, maintained with metformin extended-release tablets, 1 g PO BID; "hypertension" for 20 years, with long-term use of metoprolol sustained-release tablets, 47.5 mg PO QD; "hyperlipidemia" for 20 years, without regular medication. He was admitted to the emergency department of our hospital due to intermittent chest pain lasting 18 hours, on February 20, 2022 at 15: 35. Electrocardiogram results showed sinus rhythm, ST-segment elevation in leads I and avL, and poor R-wave progression in leads V1-3. High-sensitivity troponin I level was 4.59 ng/mL, indicating an acute high lateral wall myocardial infarction. The patient's family requested treatment with BRS, without implantation. During PCI, the BRS became unloaded but was successfully rescued. The patient was followed up for 2 years; he had no episodes of angina pectoris and was in generally good condition. CONCLUSION: We describe a case of a 59-year-old male experienced BRS unloading and successful rescue. By analyzing images, the causes of BRS unloading and the treatment plan are discussed to provide insights for BRS release operations. We discuss preventive measures for BRS unloading.
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We report the clinical case of a patient with acute myocardial infarction due to coronary stent compression as first manifestation of a large thymoma. The patient underwent a coronarography and thrombus aspiration + plain old balloon angioplasty restoring the stent patency. The mass resection was performed through left robotic-assisted thoracic surgery (RATS), resulting in a type A thymoma pT1a, IIb Masaoka-Koga. An uncommon presentation led to early diagnosis and treatment of a thymoma with both oncological and functional significance.
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BACKGROUND: Non-eruptive calcium nodules (CNs) are commonly seen in heavily calcified coronary artery disease. They are the most difficult subset for modification, and may result in stent damage, malapposition and under-expansion. There are only limited options available for non-eruptive CN modification. Intravascular lithotripsy (IVL) is being explored as a potentially safe and effective modality in these lesions. AIMS: This study aimed to investigate the safety and efficacy of the use of IVL for the modification of non-eruptive CNs. The study also explored the OCT features of calcium nodule modification by IVL. METHODS: This is a single-center, prospective, observational study in which patients with angiographic heavy calcification and non-eruptive CN on OCT and undergoing PCI were enrolled. The primary safety endpoint was freedom from perforation, no-reflow/slow flow, flow-limiting dissection after IVL therapy, and major adverse cardiac events (MACE) during hospitalization and at 30 days. MACE was defined as a composite of cardiac death, myocardial infarction (MI), and ischemia-driven target lesion revascularization (TLR). The primary efficacy endpoint was procedural success, defined as residual diameter stenosis of <30% on angiography and stent expansion of more than 80% as assessed by OCT. RESULTS: A total of 21 patients with 54 non-eruptive CNs undergoing PCI were prospectively enrolled in the study. Before IVL, OCT revealed a mean calcium score of 3.7 ± 0.5 and a mean MLA at CN of 3.9 ± 2.1 mm2. Following IVL, OCT revealed calcium fractures in 40 out of 54 (74.1%) CNs with an average of 1.05 ± 0.72 fractures per CN. Fractures were predominantly observed at the base of the CN (80%). Post IVL, the mean MLA at CN increased to 4.9 ± 2.3 mm2. After PCI, the mean MSA at the CN was 7.9 ± 2.5 mm2. Optimal stent expansion (stent expansion >80%) at the CN was achieved in 85.71% of patients. All patients remained free from MACE during hospitalization and at the 30-day follow-up. At 1-year follow-up, all-cause death had occurred in 3 (14.3%) patients. CONCLUSIONS: This single-arm study demonstrated the safety, efficacy, and utility of the IVL in a subset of patients with non-eruptive calcified nodules. In this study, minimal procedural complications, excellent lesion modifications, and favorable 30-day and 1-year outcomes were observed.