Abstract Funding Acknowledgements None. Background Pre-infarct angina (PIA) has been demonstrated to reduce infarct size and improve prognosis in ST-elevation myocardial infarction (STEMI). However, the effects of ischemic preconditioning with aging are still controversial. Purpose We aimed at comparing the effect of pre-infarction angina (PIA) on infarct size between two age groups. Methods We retrospectively studied consecutive STEMI patients treated by primary percutaneous coronary intervention (PCI) from January 2008 to December 2017. PIA was diagnosed if a patient had arm, jaw, or chest pain in the preceding eight days. Peak creatine kinase (CK) concentration was used as a surrogate of infarct size. Patients were divided into two groups, based on the median age: ≤62 years and >62 years. Multiple linear regression was used to identify independent predictors for infarct size that included total ischemic time and classic cardiovascular risk factors (hypertension, diabetes, dyslipidaemia, and smoking). Interaction between age and PIA was evaluated by 2-way factorial ANOVA. Results From the 1131 patients included in the study, 590 (52,2%) had ≤62 years and 541 (47,8%) had >62 years. Older patients were more often women (17.2% vs 8.6%, p<0.001) and had longer total ischemic time [4.6(3.0-9.0) vs 3.5(2.3-6.0) hours, p<0.001]. They also had higher prevalence of hypertension (32.8% vs 22.8%, p<0.001), diabetes (30.7% vs 18.7%, p<0.001) and were less likely to be smokers (26.9% vs 71.4%, p<0.001). The prevalence of PIA was similar across age groups (≤62Y 31.2% vs >62Y 32.0%, p=0.668). In older patients, PIA was associated with smaller infarct size [1.29(0.72-2.33) vs. 1.76(0.97-2.91) U/Lx103, p<0.001]. This difference was not observed for younger patients [1.72(0.95-3.40) vs. 1.81(0.94-3.37) U/Lx103, p=0.392]. There was no significant interaction between the existence of PIA and age on peak CK (p=0.280 for interaction) (Figure 1). In multivariate analysis, overall, PIA was associated with reduced peak CK (β=-0,320, p=0.011). On subgroup group analysis, PIA was a predictor of infarct size only in the older patients (β=-0,459, p=0.005), but not in the younger group (β=-0,182, p=0.394). Conclusion Older patients with PIA had significantly lower infarct size compared to patients in the same age group without PIA. After adjustment for risk factors and total ischemic time, PIA was a predictor of lower infarct size only for the older patients. These results suggest that the effect of pre-ischemic conditioning is not blunted by age, indicating that older patients should not be excluded from clinical trials investigation of cardioprotective strategies in STEMI patients.

Abstract Funding Acknowledgements None. Background Women with ST-segment elevation myocardial infarction (STEMI) have been reported to have higher short-term mortality than men, especially in younger patients. However, data on long-term outcomes did not corroborate this association. Purpose We aimed to evaluate if sex was an independent predictor of major adverse cardio-cerebrovascular events (MACCE) at 1-year follow-up. A sub-analysis across different age subgroups was performed. Methods We retrospectively studied consecutive STEMI patients treated by primary percutaneous coronary intervention (PCI) from January 2008 to December 2017. Cox proportional hazard models were used to identify predictors of MACCE at 1-year follow-up (death, cerebrovascular accident, new myocardial infarction in any vessel, or target lesion revascularization). Patients were divided into four age groups, according to quartiles, for subgroup analysis (≤50, 51-60, 61-70, >71 years). Results Of the 1131 patients included in the study, 291 (25.7%) were women. Women were older [68.2 (±14.2) vs 60.6 (±12.2) years, p<0.001], more often non-smokers (21.5% vs 60.2%, p<0.001), and had a higher prevalence of diabetes (34,8% vs 20.9%, p<0.001) and hypertension (71.6% vs 50.2%, p<0.001). They also had lower haemoglobin [12.8 (±1.6) vs 14.5 (±1.7) g/dl, p<0.001] and lower creatinine clearance at admission [73.8 (±35.3) vs 92.6 (±35.2) ml/min, p<0.001], as well as longer door-to-balloon times [90 (60-166) vs 75(50-120) min, p=0.005]. However, total ischemic time was not significantly different between groups [250(175-480) vs 224(150-440) min, p=0.054]. Overall, women had a higher occurrence of MACCE (22.1% vs 15.4%; log-rank P = 0.008, Figure 1). On multivariate analysis, sex was not found to be an independent predictor of MACCE (HR 1.12; 95% CI, 0.77–1.65; P = 0.547). The risk of unfavourable outcomes was mainly driven by other comorbidities (namely, age, presence of peripheral arterial disease, lower haemoglobin concentration, lower systolic blood pressure on admission, a higher peak CK activity, and the utilization of a femoral approach). When MACCE was stratified by age, sex was not an independent predictor of MACCE in any age group (Figure 2). Conclusion Women with STEMI submitted to PCI had a higher rate of MACCE at 1-year follow-up compared with men, however, sex was not an independent predictor of these events on multivariate analysis, regardless of the age subgroups considered.

Calcified lesions are associated with higher rates of complications during percutaneous coronary intervention (PCI). Balloon shaft fracture and entrapment is a rare, but potentially severe complication of PCI. The resulting debris might lead to vessel occlusion and/or form a pro-thrombotic nidus, potentially leading to distal embolization, acute myocardial infarction, ventricular dysrhythmia, and even death. We report a case of balloon fracture and entrapment, where rotational atherectomy was essential in modifying the entrapped material, allowing the crossing of an otherwise uncrossable “balloon-lesion complex”, subsequently treated with crushing and jailing by stenting, with good angiographic result and outcome.

A tri-leaflet mitral valve (MV) is an extremely rare phenomenon, often associated with significant mitral regurgitation (MR). It may represent a phenotypic expression of hypertrophic obstructive cardiomyopathy (HOCM). We present the case of a 69-year-old woman with HOCM, a tri-leaflet MV, and systolic anterior motion (SAM)–induced severe MR. Despite receiving optimal medical therapy, her refractory symptoms and significant MR prompted surgical consideration. The patient underwent surgical myectomy, resulting in improvement of left ventricular outflow tract obstruction, SAM-induced MR, and symptomatic relief. This case illustrates a unique presentation of HOCM with a tri-leaflet MV and significant MR, successfully managed with a tailored surgical myectomy.

Abstract Funding Acknowledgements None. Background Differences in women’s prognosis have been described for both ST-segment elevation myocardial infarction (STEMI) and cardiogenic shock (CS). These might reflect asymmetries in clinical management, but also gender-specific comorbidities and pathologic mechanisms. Purpose We aimed to evaluate the risk of in-hospital complications and mid-term outcomes of women with CS following STEMI. Methods We retrospectively studied STEMI patients treated by primary percutaneous coronary intervention (PCI) from 2008 to 2017 in a tertiary care centre, presenting or evolving in Killip class IV (defined as cardiogenic shock or hypotension and organ hypoperfusion). Clinical and demographic characteristics, as well as complications and outcomes, were collected. Major adverse cardio-cerebrovascular events (MACCE) at 1-year follow-up was a composite of death, cerebrovascular accident, new myocardial infarction in any vessel, or target lesion revascularization. Results Among 1131 patients presenting with STEMI, our study included 117 (10.3%) patients in CS, of which 40 (34.2%) were women. Women were older [71.8(±13.4) vs 64.6(±11.72) years, p=0.002] and less frequently smokers (25.0% vs 50.7%, p=0.008). Prevalence of classic cardiovascular risk factors, namely diabetes (34,1% vs 39.2%, p=0.860), hypertension (71.5% vs 60.8%, p=0.212), and dyslipidaemia (47.5% vs 70.0%, p=0.799), was the same for both groups. Body mass index was also similar [26.6(±5.2) vs 26.1(±3.4) kg/m2, p=0.539]. Women had lower haemoglobin [12.4(±1.9) vs 13.8(±1.9) g/dl, p&lt;0.001] and lower creatinine clearance at admission [52.4(±30.6) vs 67.3(±29.4) ml/min, p=0.017]. Door-to-balloon times [80(59-180) vs 68(48-105) min, p=0.302], total ischemic time [210(120-360) vs 203(120-476) min, p=0.302] and prevalence of anterior STEMI (35.0% vs 50.0%, p=0.123) were not significantly different between sexes. The prevalence of in-hospital complications was generally similar for both sexes (Table 1), except for the risk of advanced atrioventricular (AV) block that was higher in women (32.5% vs 10.7%, p=0.004). Also, haemoglobin nadir was lower in women [10.6(±2.1) vs 11.7(±2.1) g/dl, p=0.023]. In a 1-year follow-up, the occurrence of MACCE was similar for both sexes (60.0% vs 59.7%, log-rank P 0.734) (Figure 1). Conclusion Women with STEMI complicated by CS submitted to PCI had a similar prevalence of in-hospital complications as men. Also, mid-term outcomes, assessed by MACCE at 1 year, did not differ between groups.

Introdução A cardite de Lyme (CL) é uma manifestação relativamente rara do estágio inicial disseminado da doença de Lyme. , A apresentação mais frequente da CL é o bloqueio atrioventricular (AV), caracterizado por rápidas flutuações no grau e que ocorre em aproximadamente 80-90% dos pacientes. , Outras possíveis manifestações clínicas da CL são miocardite, pericardite, cardiomiopatia dilatada e insuficiência cardíaca. , O curso clínico é geralmente leve, de curta duração e, na maioria dos casos, completamente reversível após tratamento antibiótico [...]

Patients with rheumatoid arthritis (RA) have an increased risk of cardiac dysfunction and heart failure (HF) due to a pro-inflammatory state. Detecting cardiac dysfunction in RA is challenging as these patients often present preserved ejection fraction (EF) but may have subclinical ventricular dysfunction. Echocardiographic strain analysis is a promising tool for early detection of subclinical left ventricular systolic dysfunction (LVSD). This study assesses the prognostic role of strain analysis in RA. Prospective study of 277 RA patients without known heart disease and preserved EF, categorized by left ventricular global longitudinal strain (GLS): normal GLS (≤ − 18

AbstractAimsAcute myocardial infarction (AMI) resulting from unprotected left main coronary artery (LMCA) occlusion and subtotal occlusion is a life‐threatening condition. Although AMI management has improved in the past two decades, there is limited information on recent trends in patient characteristics, management, and outcomes for acute unprotected LMCA‐related AMI. This study aims to assess such trends over a 12 year period.Methods and resultsThis retrospective multicentre study includes patients with unprotected LMCA occlusion/subtotal occlusion admitted to three tertiary hospitals between 2008 and 2020. The patients were divided into two groups based on the chronology of presentation: a ‘past group’ (January 2008 to December 2014) and a ‘contemporary group’ (January 2015 to December 2020). The study compares clinical characteristics, management approaches, and outcomes between the two groups. The study includes 128 patients, with 51 (40%) in the ‘past group’ and 77 (60%) in the ‘contemporary group’. Baseline risk factors did not show statistically significant differences between the two groups, except for hypertension (49% vs. 74%; P = 0.005). Chest pain was more frequent in the ‘past group’ (98% vs. 89%; P = 0.014), and a trend towards more cardiac arrests was observed in the ‘contemporary group’ (18% vs. 31%; P = 0.087). Revascularization type did not differ significantly (P = 0.419), but manual thrombectomy was less frequently used (41% vs. 23%; P = 0.032) and stent implantation showed a trend towards higher rates (66% vs. 78%; P = 0.150) in the ‘contemporary cohort’. There was a gradual shift from bare‐metal to drug‐eluting stents, with a significantly higher percentage of ticagrelor/prasugrel loading in the ‘contemporary cohort’ (5% vs. 79%; P < 0.001). The use of mechanical circulatory support (MCS), although not statistically significant, was higher among patients in the ‘past group’ (67% vs. 51%; P = 0.073). The type of MCS differed significantly between groups, with a decrease in intra‐aortic balloon pump use (67% vs. 42%; P = 0.005) and an increase in veno‐arterial extracorporeal membrane oxygenation (4% vs. 22%; P = 0.005) and Impella system (0% vs. 3%) over time. Survival analysis showed no significant differences (P = 0.599; log‐rank test) in all‐cause mortality between the different time groups, with the long‐term survival rate being approximately 30%.ConclusionsIn our real‐world population, despite the progressive use of newer drugs and more advanced devices over time, patients with unprotected LMCA occlusion/subtotal occlusion remain a subpopulation with poor prognosis.

Campinas, Andreia Filipa Oliveira; Brochado, Bruno F.; Santos, Raquel B.; Costa, Ricardo F.; de Frias, André D.; Alexandre, André M.; Couto, David S.; Gomes, Catarina P.; Luz, André C.; da Silveira, João B.; Torres, Severo B. Author Information

Background Atrial septal defect (ASD) can often remain asymptomatic until adulthood. It still remains unclear whether large ASD closure in senior people should be performed or not. Temporary ASD balloon occlusion test has been suggested as a tool to assess the risk of acute left ventricular heart failure post-ASD closure, and it allows to better distinguish responders from non-responders. Case presentation An 83-year-old man with a long-standing uncorrected secundum ASD was admitted for recently decompensated right-sided heart failure. During hospitalization, this patient was studied with trans-esophageal echocardiography, cardiac magnetic resonance imaging, and right heart catheterization, showing high Qp:Qs ratio and favorable anatomical conditions for percutaneous closure. Because of patient’s increasing need for intravenous diuretics and worsening renal function, it was considered that transcatheter ASD closure could improve symptoms, hence it was performed an attempt of percutaneous closure of the ASD with a fenestrated device. Unfortunately, irrespective of ASD being hemodynamically significant, it was found a very significant increase in pulmonary capillary wedge pressure during the temporary balloon occlusion test, supporting the existence of concealed left ventricular diastolic dysfunction. As a result, it was decided to abandon the procedure and not to close the ASD. Conclusion This clinical case illustrates the value of temporary balloon occlusion test before permanent percutaneous closure of ASD in elderly patients, regardless of left ventricular (systolic or diastolic) dysfunction.

Restrictive cardiomyopathy secondary to cardiac amyloidosis is an underdiagnosed cause of heart failure and it is associated with significant morbidity and mortality. The most common types of amyloidosis are light chain amyloidosis, transthyretin amyloidosis and secondary amyloidosis. We report the case of a 84 -year-old man that presented with new onset signs and symptoms of heart failure. Multimodality imaging with echocardiogram and bone tracer cardiac scintigraphy along with biomarkers, monoclonal proteins analysis and genetic test allowed to diagnosed a wild-type transthyretin amyloidosis. We discuss the clinical and diagnostic features and review the current literature about cardiac amyloidosis. This paper aims to increase clinicians' awareness of cardiac amyloidosis to promptly recognize, diagnose and treat it.

In this clinical image vignette, we illustrate the presentation and management of an extremely rare and lethal complica- tion of radial access percutaneous coronary intervention. We present a case of perforation of a small collateral branch of the brachiocephalic artery with subsequent mediastinal hematoma formation and stridor presentation. We suspect the perforation was probably caused by the hydrophilic-coated guidewire. After a multidisciplinary heart team discussion, a percutaneous approach was recommended. We performed the procedure with a single coil embolization of the collateral branch perforation, achieving complete resolution of the hemorrhage.

The clinical presentation of pulmonary embolism (PE) and acute coronary syndrome can be similar. We report a case of a patient presenting with antero-septal ST-segment elevation after cardiac arrest, found to have acute-PE-mimicking ST-segment elevation myocardial infarction (STEMI), treated with aspiration thrombectomy and catheter-directed thrombolysis (CDT). A 78-year-old man was admitted with dyspnea, chest pain and tachycardia. During evaluation, cardiac arrest in pulseless electrical activity was documented. Advanced life support was started immediately. ECG post-ROSC revealed ST-segment elevation in V1–V4 and aVR. Echocardiography showed normal left ventricular function but right ventricular (RV) dilation and severe dysfunction. The patient was in shock and was promptly referred to cardiac catheterization that excluded significant CAD. Due to the discordant ECG and echocardiogram findings, acute PE was suspected, and immediate invasive pulmonary angiography revealed bilateral massive pulmonary embolism. Successful aspiration thrombectomy was performed followed by local alteplase infusion. At the end of the procedure, mPAP was reduced and blood pressure normalized allowing withdrawal of vasopressor support. Twenty-four-hour echocardiographic reassessment showed normal-sized cardiac chambers with preserved biventricular systolic function. Bedside echocardiography in patients with ST-segment elevation post-ROSC is instrumental in raising the suspicion of acute PE. In the absence of a culprit coronary lesion, prompt pulmonary angiography should be considered if immediately feasible. In these cases, CDT and aspiration in high-risk acute PE seem safe and effective in relieving obstructive shock and restoring hemodynamics.

Um homem brasileiro de 33 anos foi admitido no departamento de emergência com início súbito de afasia global e hemiparesia direita. Uma angiotomografia de urgência das artérias cerebrais confirmou o diagnóstico de acidente vascular cerebral (AVC), mostrando uma oclusão da artéria carótida interna esquerda. O paciente foi submetido a trombólise sistêmica e trombectomia mecânica com posterior melhora neurológica. Considerando o diagnóstico de AVC em um adulto jovem provavelmente de origem cardioembólica, ele realizou uma avaliação diagnóstica completa. De realçar que [...]

Introduction and Objectives: Acute total occlusion of the unprotected left main coronary artery (LMCA) is a dramatic event. There are limited data regarding this population. We aimed to describe the clinical presentation and outcomes of patients and to determine predictors of in-hospital mortality.Methods: This retrospective study included patients presenting with acute (<12 h) myocardial infarction due to total occlusion of the LMCA (TIMI flow 0) between January 2008 and December 2020 in three tertiary hospitals.Results: During this period, 11 036 emergent coronary angiographies were performed, 59 (0.5%) of which revealed acute total occlusion of the LMCA. Patients' mean age was 61.2 (SD & PLUSMN; 12.2) years and 73% were male. No patients had left dominance. At presentation, 73% were in cardiogenic shock, aborted cardiac arrest occurred in 27% and 97% underwent myocardial revas-cularization. Primary percutaneous coronary intervention was performed in 90% of cases and angiographic success was achieved in 56% of procedures, while 7% of patients underwent surgi-cal revascularization. In-hospital mortality was 58%. Among survivors, 92% and 67% were alive after one and five years, respectively. After multivariate analysis, only cardiogenic shock and angiographic success were independent predictors of in-hospital mortality. Use of mechanical circulatory support and presence of well-developed collateral circulation were not predictive of short-term prognosis. Conclusion: Acute total occlusion of the LMCA is associated with a dismal prognosis. Cardiogenic shock and angiographic success play a major role in predicting the prognosis of these patients. The effect of mechanical circulatory support on patient prognosis remains to be determined.& COPY; 2023 Published by Elsevier Espan & SIM;a, S.L.U. on behalf of Sociedade Portuguesa de Cardiologia. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/ licenses/by-nc-nd/4.0/).

Abstract Funding Acknowledgements Type of funding sources: None. Background and purpose In ST-segment elevation myocardial infarction (STEMI) patients with multivessel coronary artery disease (MVCAD), remote-vessel percutaneous coronary intervention (PCI) has been associated with a reduction in the incidence of reinfarction when compared to a culprit-only revascularization strategy. Overall effects on long-term all-cause mortality are still unclear. Methods Between 2008 and 2013, a total of 584 consecutive patients were admitted with STEMI. 535 survived to discharge, from which 302 (56,5%) had MVCAD and were included in the analysis. We stratified the patients according to the revascularization strategy in two groups: culprit-lesion-only PCI and PCI of non-culprit vessels with angiographic significant stenosis. Patients were followed for 8 years. The primary endpoints were reinfarction in any vessel and all-cause death. Secondary endpoints included target vessel failure (TVF) (any repeat revascularization in the index culprit vessel), heart failure (HF) hospitalization and stroke. Results Of the 302 cases, 217 (74.2%) were men and the median age was 63 years. 150 (49.7%) had 2-vessel, 152 (50.3%) had 3-vessel disease and 104 (34.4%) underwent non-culprit vessel PCI. The mean follow-up time was 6.95 (± 2.29) years. Overall, the culprit-lesion-only group was older (median: 66 vs 59.5 years; p < 0.001) and had a lower proportion of smokers (41.9% vs 59.6%; p = 0.003). There were no significant differences between the groups’ other main comorbidities. The culprit-lesion-only group had a shorter hospital stay (median: 7.0 vs 7.5; p = 0.013), despite presenting at higher Killip class (24.4% vs 10.6% in Killip II-IV; p = 0.004). Regarding index PCI, no-reflow phenomenon was more common in the culprit-lesion-only group (7.1% vs 1.0%; p = 0.020), where the use of drug-eluted stents was more prevalent in the remote-vessel PCI group (69.2% vs 47.0%; p = 0.001). There was a higher risk of reinfarction (Adjusted hazard ratio (HR) 2.46; 95% CI [1.12 – 5.38]; p = 0.008) and TVF (Adjusted HR 2.37; 95% CI [1.02 – 5.48]; p = 0.044) in the culprit-lesion-only PCI group after relevant variable adjustment, with no significant differences in all-cause mortality. There were no significant differences in any of the remaining secondary outcomes. Conclusions Randomized trials and successive metanalysis have demonstrated benefit in complete revascularization after STEMI regarding the incidence of reinfarction and cardiovascular death. However, the long term impact on all-cause death is still unclear. This study corroborates the main findings in the literature, while suggesting lack of effect on overall mortality on a long-term follow-up.

Subvalvular aortic stenosis manifesting as a subaortic membrane predisposes to bacterial endocarditis, which typically affects the aortic valve (AoV) or, less frequently, the left ventricular outflow tract (LVOT). We present the case of a 60-year-old woman expressing an odd form of a subvalvular aortic membrane in conjunction with a left Valsalva sinus pseudoaneurysm as a result of an endocarditis complication.

Abstract Funding Acknowledgements Type of funding sources: None. Background and purpose Left anterior descending (LAD) coronary artery occlusion has been associated with worse short-term outcomes and overall worse prognosis, there is still unclear data about the long-term risk of reinfarction in relation to the index culprit vessel. Methods In this retrospective cohort study, between 2008 and 2013, a total of 584 patients were admitted with STEMI and were subject to emergent percutaneous coronary intervention (PCI). Of those, 535 (91.6%) were alive at hospital discharge, from which 532 were considered for the analysis, after excluding the missing cases. We stratified the individuals according to the culprit vessel in two groups: anterior myocardial infarction (MI) (LAD or left main stem (LM)), and non-anterior MI (circumflex (CX) or right coronary artery (RCA)). We followed the cases for a maximum of 8 years, censoring every event beyond. The primary endpoints were reinfarction and target vessel failure (TVF). Secondary endpoints included all-cause mortality, heart failure (HF) hospitalization and stroke. Mann-Whitney-U and Chi-square tests were used to compare baseline characteristics. Kaplan-Meyer survival analysis was used to obtain the survival curves. Univariate and multivariate analysis were done using Cox regression models. Results Of the 532 individuals included in the analysis, 395 (74.2%) were men and the median age was 61 (+/- 19.8) years. The most common culprit vessel was RCA (45.5%), followed by LAD (41.2%), CX (13.2%), and lastly LM (0.20%). The median follow-up time was 6.94 (+/- 2.38) years. Overall, the anterior MI group presented at a higher Killip class (20.0% vs 14.8% in Killip class II-IV; p = 0.046) and had higher peak plasma level of high-sensitivity troponin T (6.16 vs 3.66 ng/ml; p < 0.001), suggesting larger infarct area. Left ventricle ejection fraction (LVEF) at discharge was also lower in the anterior MI group (reduced in 78,3% vs 43.4%; p < 0.001). Multivessel disease was more common in the non-anterior MI group (49.5% vs 60.9%; p = 0.005), as was PCI of non-culprit vessels (15.5% vs 22.8%; p = 0.037) and the use of bare-metal stents (20.0 vs 51.6%; p < 0.001). There were no significant differences between the groups regarding the main comorbidities, except for peripheral artery disease, more common in the non-anterior MI group (4.10 vs 10.0%; p = 0.011). There was a higher risk of reinfarction in the non-anterior MI group which persisted after relevant variable adjustment (Adjusted hazard ratio 1.96; 95% CI [1.08 – 3.67]; p = 0.027) (Figure 1). There were no significant differences regarding the risk of TVF or any of the secondary outcomes. Conclusions Although LAD/LM occlusion is thought to carry a worse short-term prognosis, non-anterior STEMI appears to be associated with a higher long-term risk of reinfarction. Despite higher rates of reinfarction, non-anterior STEMI patients have not been shown to have an excess mortality of HF hospitalizations in this cohort.