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.

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

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.

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.

A 78-year-old diabetic male with multivessel coronary artery disease and history of nonrevascularized anterior myocardial infarction (15 years prior), evolved with severe left ventricle systolic dysfunction and apical aneurysm at the time.He had a single-chamber, apical, cardioverter-defibrillator implanted soon after as a primary prevention strategy.He presented with a two-week history of fatigue, weight loss and fever.At admission he was hemodynamically stable, febrile, with elevated inflammatory markers.Chest X-ray showed mild left pleural effusion (Supplementary Figure S1) and the electrocardiogram revealed sinus

INTRODUCTION:Ticagrelor might reduce infarct size by exerting a more potent antiplatelet effect or by promoting a potential conditioning stimulus in ST-elevation myocardial infarction (STEMI) patients. Pre-infarction angina (PIA) is an effective preconditioning stimulus that reduces ischemia-reperfusion injury. Because little is known on the interaction of PIA in STEMI-patients loaded with ticagrelor, we sought to determine if patients loaded with ticagrelor had improved clinical outcomes as compared to clopidogrel and to study if it is modulated by the presence of PIA.METHODS:From 1272 STEMI patients submitted to primary percutaneous coronary intervention and treated with clopidogrel or ticagrelor from January 2008 to December 2018, 826 were analyzed after propensity score matching. Infarct size was estimated using peak creatine kinase (CK) and troponin T (TnT), and clinical impact was evaluated through cumulative major cardiac and cerebrovascular events (MACCE) at 1-year follow-up. Matched patients and their interaction with PIA were analyzed.RESULTS:Patients loaded with ticagrelor had lower peak CK [1405.50 U/L (730.25-2491.00), P < .001] and TnT [3.58 ng/mL (1.73-6.59), P < .001)], regardless of PIA. The presence of PIA was associated with lower CK (P = .030), but not TnT (P = .097). There was no interaction between ticagrelor loading and PIA (P = .788 for TnT and P = .555 for CK). There was no difference in MACCE incidence between clopidogrel or ticagrelor loading (P = .129). Cumulative survival was also similar between clopidogrel or ticagrelor, regardless of PIA (P = .103).CONCLUSION:Ticagrelor reduced infarct sizes independently and without a synergic effect with PIA. Despite reducing infarct size, clinical outcomes were similar across both groups.

Myocardial bridging (MB) is a congenital coronary anomaly, which is defined as cardiac muscle overlying a portion of a coronary artery. Although traditionally considered benign in nature, increasing attention is being given to specific subsets of MB. Sports medicine recognizes MB as a cause of sudden death among young athletes. We present a case of a 30-year-old man who suddenly collapsed during a marathon running. Diagnostic workup with coronary computed tomography angiography revealed the presence of three simultaneous myocardial bridges in this patient, possibly explaining the exercise-induced syncope. The other diagnostic tests excluded seizures, cranioencephalic lesions, ionic or metabolic disturbances, acute coronary syndromes, cardiomyopathies, myocarditis, or conduction disturbances. Exertional syncope is a high-risk complaint in the marathon runner. In the context of intense physical activity, the increased sympathetic tone leading to tachycardia and increased myocardial contractility facilitates MB ischemia. In this illustrative case, the patient's syncope might probably be associated with an ischemia-induced arrhythmia secondary to MB and potentiated by dehydration in the context of prolonged stress (marathon running). In conclusion, this case highlights that MB may be associated with dangerous complications (myocardial ischemia and life-threatening ventricular arrhythmias), particularly during intense physical activity and in the presence of a long myocardial bridge.

The clinical benefits of right ventricular septal (RVS) pacing compared to those of right ventricular apical (RVA) pacing are still in debate. We aimed to compare the incidence of heart failure (HF) and all-cause mortality in patients submitted to RVS and RVA pacing during a longer follow-up. This a single-center, retrospective study analysis of consecutive patients submitted to pacemaker implantation. The primary outcome was defined as the occurrence of HF during follow-up. The secondary outcome was all-cause death. A total of 251 patients were included, 47 (18.7%) with RVS pacing. RVS pacing was associated to younger age, male gender, lower body mass index, ischemic heart disease, and atrial fibrillation. During a follow-up period of 5.2 years, the primary outcome occurred in 89 (37.1%) patients. RVS pacing was independently associated with a 3-fold lower risk of HF, after adjustment. The secondary outcome occurred in 83 (34.2%) patients, and pacemaker lead position was not a predictor. Fluoroscopy time and rate of complications (rarely life-threatening) were similar in both groups. Our study points to a potential clinical benefit of RVS positioning, with a 3.3-fold lower risk of HF, without accompanying increase in procedure complexity nor complication rate.

Abstract A 38-year-old woman with a 32-week gestation was admitted in the emergency department complaining of acute lower limb pain. She had history of smoking, 1 voluntary interruption of pregnancy, 1 miscarriage at age 34, and family history of antiphospholipid syndrome (APS). At admission, bilateral acute limb ischemia and foetal death were diagnosed. CT angiography revealed acute bilateral thrombotic occlusion of the iliac arteries, left renal artery thrombosis with extension to the distal abdominal aorta, deep vein thrombosis (DVT) of the left iliac vein and distal inferior vena cava, and bilateral pulmonary embolism. The patient started on anticoagulation and underwent caesarean section and axillobifemoral bypass. Plasmapheresis and rituximab were attempted due to high clinical suspicion of catastrophic APS. Immunological and neoplastic study were repeatedly negative. The patient was ultimately discharged on vitamin K antagonist (VKA). Further investigation revealed a patent foramen ovale (PFO) with spontaneous right-to-left shunt. Given the risk of paradoxical embolism in this thrombophilic setting of unclear cause, she was referred for percutaneous PFO closure using a GORE® CARDIOFORM 25 mm device. Post-procedure maintenance of antithrombotic therapy with VKA was decided by a multidisciplinary team. Since the event, she had no recurrence of thromboembolic events and continues under investigation in autoimmune disease outpatient clinic. Although simultaneous arterial and venous thrombosis cannot be ruled out, we suspect of left paradoxical embolism following DVT. PFO closure in this setting might be useful for reduction of paradoxical arterial embolism risk on top of systemic anticoagulation. Figure 1Panels A and B show the presence of patent foramen ovale (PFO). Panels C and D show the final result after percutaneous PFO closure using a GORE® CARDIOFORM 25 mm device.

Introduction Platypnoea orthodeoxia syndrome (POS) is an uncommon condition characterised by dyspnoea and arterial desaturation induced by an upright position and relieved in the supine position, usually due to a patent foramen ovale (PFO). Percutaneous closure of a PFO is the preferred treatment to cure POS. This study aimed to evaluate the clinical and gasometrical characteristics and to describe the long-term outcomes of percutaneous PFO closure in a group of patients with POS. Methods Patients with POS and a PFO treated by percutaneous intervention from 2010-2020 were reviewed. The primary efficacy outcome was the arterial oxygen pressure to fraction of inspired oxygen (PaO2/FiO2) ratio before and 24 hours after the procedure. Total clinical success was considered if the arterial oxygen saturation measured by pulse oximetry (SpO(2)) improved to.94% in the supine and sitting positions without supplemental oxygen, while partial success was considered if SpO(2) improved from baseline but still required oxygen to achieve.94%. Secondary outcomes were an absolute improvement in SpO(2) and sense of dyspnoea, without significant residual shunt on transthoracic echocardiography (TTE) at follow-up. Results Of 168 patients undergoing PFO or atrial septal defect closure, 14 had POS (8.3%). Percutaneous PFO closure was successfully performed in all patients with a single device. Twelve of 14 patients had total clinical success (86%) and one patient had partial success. The PaO2/FiO(2) ratio increased from 155.9650.6 to 318.3673.4 after PFO closure (p=0.002). All patients with total clinical success had a successful secondary efficacy outcome with an absolute improvement in SpO(2) and complete resolution of dyspnoea, which was maintained at follow-up (37620 months; range, 11 months to 6 years). None had a significant residual shunt between 12 and 24 months of follow-up. Conclusion The PFO percutaneous closure was a successful, durable and safe method for patients presenting with POS; it achieved major improvements in both gasometrical parameters and quality of life.

Abstract Case report A 40-year-old obese man with hypertension and history of femoro-popliteal deep vein thrombosis (DVT), presented to the emergency department with right lower limb (RLL) ischemia associated with exertional dyspnoea for the past three weeks. Physical examination revealed a cold RLL without peripheral pulses and mild respiratory failure. Angio-CT revealed bilateral acute pulmonary embolism (APE), thrombosis of the right common iliac artery and left renal infarct (Figure 1A). Transthoracic echocardiogram revealed signs of pulmonary hypertension (PH), dilated right ventricle and a suspected patent foramen ovale (PFO) with spontaneous high volume right-to-left shunt. A diagnosis of intermediate-low risk APE with concomitant RLL acute ischemia was made. The patient underwent iliac thrombectomy, local fibrinolysis and started anticoagulation. Immunological study was positive for antiphospholipid syndrome. He recovered well and was discharged on Vitamin-K antagonists. Six months later, transoesophageal echocardiogram confirmed the PFO with persistence of right-to-left shunt with a bubble test, and recovery of the right ventricle function without signs of PH (Figure 1B). Due to the suspected paradoxical embolic event, resolution of the PH and shunt persistence, the patient underwent percutaneous PFO closure with Amplatzer PFO Occluder (25mm) [Abbott®] (Figure 1C). He has had no recurrence of thrombotic events ever since. Conclusion Concomitant arterial and venous thrombosis should prompt screening for an intracardiac shunt. Despite unclear evidence, PFO closure might reduce the risk for paradoxical embolism recurrence in a thrombophilic setting on top of oral anticoagulation.

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