SummaryA 27-year old female i.v. drug user presented to our institution with chest pain. She had a history of bicuspid aortic valve endocarditis with aortic root abscess repaired with bioprosthetic ...aortic valve replacement and pericardial patch reconstruction of the left ventricular outflow tract and non-coronary sinus 6 weeks previously.Echocardiographic and cardiac CT imaging confirmed three foci of breakdown of the pericardial patch repair with active bleeding into a large posterior pseudoaneurysm (92 mm diameter) compressing the left atrium and pulmonary artery. Following multidisciplinary discussion, the consensus was to attempt urgent percutaneous closure of the defect, given the prohibitive surgical risks.The procedure was performed under fluoroscopic and 3D-transoesophageal guidance. TOE demonstrated the pericardial patch breaches and active bleeding into the large pseudoaneurysm (Figs 1 and 2). Initial deployment of an Amplatzer atrial septal defect occluder resulted in significant flow reduction, but there remained two small peri-device leaks (Fig. 3).During an attempt to implant an additional smaller Amplatzer vascular plug (AVP-2) to rectify this, the initial device dislodged and embolised into the pseudoaneurysm. This was felt irretrievable and unlikely to be clinically significant given its containment. The embolised device freely floated within the pseudoaneurysm, uniquely akin to a satellite orbiting in space (Video 1). The secondary device was removed and initial breach was satisfactorily closed with a 15-mm-sized Amplatzer atrial septal defect occluder (third device). This was confirmed to be well-seated on real-time 3D imaging (Video 2), with negligible residual leak on TOE (Fig. 4). This is the first published case of percutaneous cardiac device embolization into a pseudoaneurysm cavity that we are aware of.
Background Microvascular obstruction (MVO) predicts short- and longer-term outcomes following primary percutaneous coronary intervention (PPCI) treatment of ST-elevation myocardial infarction ...(STEMI). The evidence base supporting the role of adenosine and sodium nitroprusside (SNP), the most evaluated adjunctive therapies aimed at attenuating MVO and infarct size, remains weak as the trials involved have had variable end points and used differing drug doses and modes of delivery. Objective To determine whether intracoronary administration of adenosine or SNP following thrombus aspiration reduces infarct size and/or MVO measured by cardiac magnetic resonance (CMR) imaging in patients undergoing PPCI within 6 hours of onset of STEMI. Design Multicentre, prospective, parallel, randomised controlled and open-label trial with blinded end point analysis. Setting Four high-volume UK PPCI centres. Participants Patients with STEMI undergoing PPCI with Thrombolysis in Myocardial Infarction (TIMI) flow grade 0/1 in the infarct-related artery and no significant bystander coronary artery disease on angiography. Interventions Participants were anticoagulated with bivalirudin and allocated by an automated 24-hour telephone randomisation service to one of three groups: (1) standard PPCI (control), (2) PPCI with adjunctive adenosine 1–2 mg or (3) PPCI with adjunctive SNP 250 µg. The study drugs were delivered intracoronary immediately following thrombus aspiration and again following successful stenting. Main outcome measures The primary outcome was infarct size (% total left ventricular end-diastolic mass; %LVM) measured by CMR imaging undertaken 48–96 hours post PPCI. Secondary outcome measures included MVO (hypoenhancement within the infarct core) on CMR imaging, electrocardiographic and angiographic markers of microvascular perfusion and major adverse cardiac events (MACEs) during a median of 6 months’ follow-up. The study aimed to recruit 240 patients (powered at 80% to detect a 5% absolute reduction in infarct size). Results The trial completed recruitment in April 2014 having randomised 247 patients (standard PPCI group, n = 86; PPCI + adenosine group, n = 82; PPCI + SNP group, n = 79). In total, 79% of participants were male and the mean ± standard deviation age of participants was 59.3 ± 12.3 years. CMR imaging was completed in 197 (80%) patients (standard PPCI, n = 65; PPCI + adenosine, n = 63; PPCI + SNP, n = 69) for the primary outcome. There was no significant difference in infarct size %LVM, median, interquartile range (IQR) between the adenosine group (10.1, 4.7–16.2), the SNP group (10.0, 4.2–15.8) and the control group (8.3, 1.9–14.0) ( p = 0.062 and p = 0.160 vs. control, respectively). MVO (%LVM, median, IQR) was similar across the groups 1.0, 0.0–3.7 ( p = 0.205) and 0.6, 0.0–2.4 ( p = 0.244) for adenosine and SNP, respectively, vs. 0.3, 0.0–2.8 for the control. Using per-protocol analysis, infarct size (%LVM) was increased in adenosine-treated patients compared with control patients (12.0 vs. 8.3; p = 0.031). Increased left ventricular volume and reduced left ventricular ejection fraction were also observed in the adenosine arm. There was a significant increase in MACEs in patients undergoing adenosine-facilitated PPCI compared with control patients, driven by heart failure, at 30 days hazard ratio (HR) 5.39, 95% confidence interval (CI) 1.18 to 24.60; p = 0.04 and 6 months (HR 6.53, 95% CI 1.46 to 29.2; p = 0.01) post randomisation. Conclusions High-dose intracoronary adenosine and SNP during PPCI did not reduce infarct size or MVO measured by CMR imaging. Furthermore, adenosine may adversely affect mid-term clinical outcome and should not be used during PPCI to prevent reperfusion injury. Trial registration ClinicalTrials.gov NCT01747174 and EudraCT 2010–023211–34. Funding This project was funded by the Efficacy and Mechanism Evaluation (EME) programme, a MRC and NIHR partnership.
Abstract Percutaneous occlusion techniques of secundum type atrial septal defects have recently become the treatment of choice, delivering excellent results and being associated with a low rate of ...early and late complications. The investigators report an unusually delayed presentation of acute right heart failure due to Amplatzer septal device embolisation into the main pulmonary artery, 2 years after implantation.
Cardiac tamponade is a well-recognized early complication (ie, within 15 days) of cardiac surgery usually a result of the development of a pericardial effusion postoperatively. However, left ...ventricular diastolic collapse as a result of the presence of a large pleural effusion, but in the absence of any pericardial effusion, is rare, particularly late (ie, after 15 days) after cardiac surgery. We present the echocardiographic findings of a man presenting with recurrent exertional breathlessness, after elective tissue aortic valve replacement, and demonstrate, by echocardiography, the mechanism of left ventricular diastolic collapse and late regional cardiac tamponade, after cardiac surgery, as a result of the effects of a large pleural effusion but in the absence of any pericardial effusion. We discuss and review the literature on this phenomenon.
Microvascular obstruction (MVO) following primary percutaneous coronary intervention (PPCI) treatment of ST-segment elevation myocardial infarction (STEMI) contributes to infarct expansion, left ...ventricular (LV) remodelling, and worse clinical outcomes. The REFLO-STEMI trial tested whether intra-coronary (IC) high-dose adenosine or sodium nitroprusside (SNP) reduce infarct size and/or MVO determined by cardiac magnetic resonance (CMR).
REFLO-STEMI, a prospective, open-label, multi-centre trial with blinded endpoints, randomized (1:1:1) 247 STEMI patients with single vessel disease presenting within 6 h of symptom onset to IC adenosine (2-3 mg total) or SNP (500 μg total) immediately following thrombectomy and again following stenting, or to standard PPCI. The primary endpoint was infarct size % LV mass (%LVM) on CMR undertaken 24-96 h after PPCI (n = 197). Clinical follow-up was to 6 months. There was no significant difference in infarct size (%LVM, median, interquartile range, IQR) between adenosine (10.1, 4.7-16.2), SNP (10.0, 4.2-15.8), and control (8.3, 1.9-14.0), P = 0.062 and P = 0.160, respectively, vs.
MVO (% LVM, median, IQR) was similar across groups (1.0, 0.0-3.7, P = 0.205 and 0.6, 0.0-2.4, P = 0.244 for adenosine and SNP, respectively, vs. control 0.3, 0.0-2.8). On per-protocol analysis, infarct size (%LV mass, 12.0 vs. 8.3, P = 0.031), major adverse cardiac events (hazard ratio, HR, 5.39 1.18-24.60, P = 0.04) at 30 days and 6 months (HR 6.53 1.46-29.2, P = 0.01) were increased and ejection fraction reduced (42.5 ± 7.2% vs. 45.7 ± 8.0%, P = 0.027) in adenosine-treated patients compared with control.
High-dose IC adenosine and SNP during PPCI did not reduce infarct size or MVO measured by CMR. Furthermore, adenosine may adversely affect mid-term clinical outcome.
ClinicalTrials.gov Identifier: NCT01747174; https://clinicaltrials.gov/ct2/show/NCT01747174.
BACKGROUND—Postinfarction ventricular septal defect carries a grim prognosis. Surgical repair offers reasonable outcomes in patients who survive a healing phase. Percutaneous device implantation ...represents a potentially attractive early alternative.
METHODS AND RESULTS—Postinfarction ventricular septal defect closure was attempted in 53 patients from 11 centers (1997–2012; aged 72±11 years; 42% female). Nineteen percent had previous surgical closure. Myocardial infarction was anterior (66%) or inferior (34%). Time from myocardial infarction to closure procedure was 13 (first and third quartiles, 5–54) days. Devices were successfully implanted in 89% of patients. Major immediate complications included procedural death (3.8%) and emergency cardiac surgery (7.5%). Immediate shunt reduction was graded as complete (23%), partial (62%), or none (15%). Median length of stay after the procedure was 5.0 (2.0–9.0) days. Fifty-eight percent survived to discharge and were followed up for 395 (63–1522) days, during which time 4 additional patients died (7.5%). Factors associated with death after postinfarction ventricular septal defect closure included the followingage (hazard ratio HR=1.04; P=0.039), female sex (HR=2.33; P=0.043), New York Heart Association class IV (HR=4.42; P=0.002), cardiogenic shock (HR=3.75; P=0.003), creatinine (HR=1.007; P=0.003), defect size (HR=1.09; P=0.026), inotropes (HR=4.18; P=0.005), and absence of revascularization therapy for presenting myocardial infarction (HR=3.28; P=0.009). Prior surgical closure (HR=0.12; P=0.040) and immediate shunt reduction (HR=0.49; P=0.037) were associated with survival.
CONCLUSIONS—Percutaneous closure of postinfarction ventricular septal defect is a reasonably effective treatment for these extremely high-risk patients. Mortality remains high, but patients who survive to discharge do well in the longer term.
To investigate whether a very early invasive strategy (IS)±revascularisation improves clinical outcomes compared with standard care IS in higher risk patients with non-ST-elevation acute coronary ...syndrome (NSTE-ACS).
Multicentre, randomised, controlled, pragmatic strategy trial of higher risk patients with NSTE-ACS, defined by Global Registry of Acute Coronary Events 2.0 score of ≥118, or ≥90 with at least one additional high-risk feature. Participants were randomly assigned to very early IS±revascularisation (<90 min from randomisation) or standard care IS±revascularisation (<72 hours). The primary outcome was a composite of all-cause mortality, new myocardial infarction or hospitalisation for heart failure at 12 months.
The trial was discontinued early by the funder due to slow recruitment during the COVID-19 pandemic. 425 patients were randomised, of whom 413 underwent an IS: 204 to very early IS (median time from randomisation: 1.5 hours (IQR: 0.9-2.0)) and 209 to standard care IS (median: 44.0 hours (IQR: 22.9-72.6)). At 12 months, there was no significant difference in the primary outcome between the early IS (5.9%) and standard IS (6.7%) groups (OR 0.93, 95% CI 0.42 to 2.09; p=0.86). The incidence of stroke and major bleeding was similar. The length of hospital stay was reduced with a very early IS (3.9 days (SD 6.5) vs 6.3 days (SD 7.6), p<0.01).
A strategy of very early IS did not improve clinical outcomes compared with a standard care IS in higher risk patients with NSTE-ACS. However, the primary outcome rate was low and the trial was underpowered to detect such a difference.
NCT03707314.
Abstract
Background
Myocardial infarction with non-obstructive coronary arteries (MINOCA) is a recently described phenomenon where no flow-limiting lesions are noted on coronary angiography in a ...patient with electrocardiogram changes, elevated cardiac biomarkers, and symptoms suggesting acute myocardial infarction. Patients with MINOCA can also potentially develop structural cardiac defects through ischaemic injury. Therefore, the absence of a flow-limiting lesion on angiography coupled with structural defects (e.g. apical ballooning) can very easily result in a diagnosis of Takotsubo cardiomyopathy (TTC). This can lead to potentially serious consequences since treatment options between TTC and MINOCA are different.
Case summary
We report a case of a patient presenting with features suggestive of TTC but where the final diagnosis was of a MINOCA that induced an apical ventricular septal defect (VSD). Reaching the correct diagnosis proved challenging given that there is no gold standard diagnostic modality for diagnosing MINOCA.
Conclusion
Imaging adjuncts played a vital role in both diagnosing the underlying MINOCA as well as revealing and planning closure of the resultant VSD. Cardiovascular magnetic resonance imaging played an instrumental role in establishing the patient’s primary pathology and in planning a remediation of the structural defect. Structural myocardial defects in a patient with a diagnosis of TTC should prompt clinicians to further investigate whether there is an underlying infarct aetiology (MINOCA).
Pseudoaneurysm of the aorta is a rare and high-risk complication of native aortic valve endocarditis and can develop following cardiac surgery for aortic valve and root disease. If left untreated, ...there is a significant risk of aortic wall rupture and fatality. Given the high risk of mortality associated with traditional open surgical repair of aortic pseudoaneurysms, endovascular approach is a potentially favourable alternative. We describe a unique case of a young woman with a large and complex paraprosthetic pseudoaneurysm with multiple communicating fistulae which was successfully percutaneously treated with two occluder devices. In this technically challenging case, a minor but unique procedural complication is also illustrated.
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