Heart International最新文献

In recent years, practice and guidelines for patients with ST-elevation myocardial infarction (STEMI) have evolved from a 'culprit-only approach' to complete revascularisation; however, several issues remain, particularly regarding assessment of non-culprit lesions and timing of their revascularisation. Complete revascularisation should be performed in patients presenting with STEMI; however, available studies often present contradictory results regarding the optimal timing of non-culprit lesion percutaneous coronary intervention (PCI). The aim of this review is to provide a practical approach for the assessment of patients presenting with STEMI and multivessel coronary artery disease by analysing randomised trials, meta-analyses and our clinical experience. We recommend multivessel revascularisation at the time of primary PCI for simple cases, while we suggest deferring treatment of complex lesions; the optimal timing of staged PCI should be individualised according to clinical judgement.

Background: The anomalous coronary arteries originating from the opposite sinus of Valsalva (ACAOS) constitutes one of the most clinically relevant coronary artery anomalies in adults. Exact pathophysiology and the impact of intramural (IM) course segment stenting in ACAOS with IM course (ACAOS-IM) has not been clarified. We aimed to elucidate the pathophysiology and impact of stenting applying biomechanical and computational fluid dynamics to computed tomography (CT) in patient-specific coronary vessel reconstruction.

Methods: We separated coronary artery (left or L-, right or R-) ACAOS-IM into segments (proximal, mid and distal), based on coronary angiography and coronary CT angiography features, in a series of patients at Rovigo General Hospital, Italy, between 1 January 2003 and 1 January 2018. Blood pressure gradient across the coronary circulation, calculated blood flow, vorticity magnitude, wall shear stress (WSS) and IM segment deformation were analysed by simulating exercise, before and after virtual stent implantation.

Results: In 21 symptomatic patients (13 males, mean age 46.1 ± 8.1 years, L-ACAOS-IM in 9 and R-ACAOS-IM in 12 patients), computational fluid dynamic analysis in both L- and R-ACAOS demonstrated higher basal WSS values in the IM course (9.5 ± 0.2 and 8.6 ± 0.2 Pa for R- and L-ACAOS, respectively), than in the rest of the vessels. These values decreased after stenting. Vorticity magnitude significantly decreased after stenting as well, compared with baseline. Biomechanical deformation analysis revealed not only compression, but also a twisting of the IM segment with a mean distal pressure drop of 32% and 35% in R- and L-ACAOS, respectively, which was corrected by stent implantation.

Conclusions: In both L- and R-ACAOS subtypes, the IM segment appeared to be phasically compressed and deformed with a degree of twisting that causes resting and exercise cross-sectional deformation and a drop in distal pressure. Stenting of the IM segment results in normalisation of the flow profile, correction of the IM segment deformation and reverses the drop in pressure, for both variants of ACAOS.

Spontaneously recanalized coronary thrombus (SRCT), also known as honeycomb, lotus root or Swiss-cheese lesion, is an increasingly recognised finding in patients undergoing coronary angiography. It is thought to arise from partial resorption of an initially occlusive thrombus. Most patients present with angina or exertional breathlessness. We describe a case of a 69-year-old patient who presented with ventricular tachycardia and was found to have SRCT in the left anterior descending artery on coronary angiography. Echocardiography and left ventricular (LV) angiography showed an akinetic, aneurysmal, thin-walled LV apex, diagnostic of an old anterior infarct. We highlight the role of optical coherence tomography in making the diagnosis and discuss the available management options of this condition.

Coronary artery calcium (CAC) scoring serves as a highly specific marker of coronary atherosclerosis. Based on the results of multiple large-scale, longitudinal population-based studies, CAC scoring has emerged as a reliable predictor of atherosclerotic cardiovascular disease (ASCVD) presence and risk assessment in asymptomatic patients across all age, sex and racial groups. Therefore, the measurement of CAC is useful in guiding clinical decision-making for primary prevention (e.g. use of statin and aspirin). This tool has already been incorporated into the clinical guidelines and is steadily being integrated into standard clinical practice. The adoption of CAC scoring will be important for curbing the progressive burden that ASCVD is exerting on our healthcare system. It has already been projected that CAC testing will decrease healthcare spending and will hopefully be shown to improve ASCVD outcomes. The purpose of this review is to summarise the evidence regarding calcium screening for atherosclerosis, particularly in asymptomatic individuals, including the pathophysiology, the prognostic power of CAC in the context of population-based studies, the progressive inclusion of CAC into clinical guidelines and the existing concerns of cost and radiation.

Introduction: Myocarditis is a rare presentation of drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome, traditionally associated with poor clinical outcomes. Prompt recognition and treatment are crucial. Case presentation: A 16-year-old patient presented with acute chest pain, hypotension, and pulmonary oedema 2 months after being diagnosed with trimethoprim/sulfamethoxazole-induced DRESS syndrome. Typical DRESS features were absent at onset of these symptoms. Echocardiography demonstrated biventricular systolic dysfunction, and electrocardiography (ECG) showed complete right bundle branch block and diffuse ST-segment elevation. The patient was admitted for high-dose inotropic support; however, his condition deteriorated. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and intra-aortic balloon pump were initiated on the third day of admission. Endomyocardial biopsy suggested the diagnosis of DRESS-associated myocarditis and a high-dose corticosteroid was commenced. While he was ECMO-dependent, the patient suffered multiple episodes of ventricular tachycardia on a background of cardioversion-resistant accelerated idioventricular rhythm. After 24 days of ECMO support, the ventricular function improved, and ECG reverted to sinus rhythm. His recovery allowed corticosteroid discontinuation 15 months after hospital discharge. Conclusion: Typical DRESS syndrome features may not accompany the onset of DRESS-associated myocarditis. Mechanical circulatory support and adequate immunosuppression could save patients with malignant arrhythmias and delayed myocardial recovery.

The complete and safe removal of a mediastinal mass requires cardiopulmonary bypass if the mass encroaches or compresses the heart and its great vessels. A 15-year-old male presented with a huge mediastinal mass with gradually worsening symptoms. Surgical removal of the tumour was planned under general anaesthesia and cardiopulmonary bypass based upon contrast-enhanced computed tomography of the chest, which suggested infiltration of the cardiac structures. Intraoperative transoesophageal echocardiography revealed a distinct separation of the tumour mass from the heart and its great vessels. The mass was excised en bloc without cardiopulmonary bypass.

Amongst the many challenges of the global pandemic, understanding the effects of coronavirus disease 2019 (COVID-19) on the cardiovascular system has emerged as a key priority. Emerging data indicate possible roles for cardiac biomarkers and cardiac imaging in the prognostic assessment of these patients, as well as implications of the vascular endothelium in the pathogenesis of the condition. From a therapeutic perspective, early data suggest that the provision of well-established treatments for cardiovascular disease, whether with angiotensin-converting enzyme inhibitors or primary angioplasty, is likely to be beneficial. These early data are of limited quality however, and robust studies are needed to address many of the key remaining questions.

The ISCHEMIA trial (International study of comparative health effectiveness with medical and invasive approaches; ClinicalTrials.gov Identifier: NCT01471522) has informed practice in patients with stable angina and confirms what other less definitive data have taught us, that in the absence of severe symptoms, significant left main disease or significant left ventricular dysfunction, there is no prognostic benefit of an early invasive/revascularisation strategy with optimal medical therapy (OMT) over OMT alone. Like all quality randomised trials, it has nuances: the invasive treatment group had much better relief of angina than the OMT alone group, and the rate of spontaneous myocardial infarction (MI) in follow-up was lower in the invasive group, although only after a prevalence of periprocedural MI. The clinical outcome consequence of the MI data, if indeed there is one, will only become clear at later follow-up. OMT is a powerful treatment, and reflex revascularisation in patients with little or no angina is not.

The coronary sinus reducer represents an emerging therapeutic option for patients suffering from chronic refractory angina. Current data indicate that the population suffering from angina symptoms despite maximal medical therapy and maximal achievable revascularisation - surgical or percutaneous - is constantly increasing. Also, the clinical outcome for these patients is strongly affected by the lack of adequate treatment, the occurrence of adverse events and the need for repeated hospitalisation. Growing evidence supports the clinical benefits of the coronary sinus reducer in relieving angina symptoms in this specific population, with emerging evidence of reduction in myocardial ischaemia following the implantation of the coronary sinus reducer. In this review, we provide an up-to-date description of the role of this relatively new device in the treatment of refractory angina, focusing not only on symptom relief but also on the increasing data that supports objective improvements in myocardial ischaemia.