Thrombus burden significantly increases risk of no-reflow and microvascular obstruction and subsequently impacts outcomes in acute myocardial infarction(AMI).While initial studies suggested benefits of thrombus aspira...Thrombus burden significantly increases risk of no-reflow and microvascular obstruction and subsequently impacts outcomes in acute myocardial infarction(AMI).While initial studies suggested benefits of thrombus aspiration(TA),recent large trials have questioned its routine use.This review examines the role of thr-ombectomy in the management of AMI,focusing on its potential to improve my-ocardial perfusion and mitigate no-reflow risk.Attention should be focused on recognising high thrombus burden and its effect on major adverse cardiovascular events and impaired myocardial reperfusion.Similarly,standardising TA techn-iques and ensuring appropriate patients’selection may also improve enhance our understanding of the role of thrombectomy in AMI.Emerging technologies such as stent retrievals and mechanical thrombectomy may overcome the limitations of manual thrombectomy devices.展开更多
A 54-year-old black African woman, 22 years human immunodeficiency virus(HIV)-positive, presented with an acute coronary syndrome. She was taking two nucleoside reverse transcriptase inhibitors and two protease inhibi...A 54-year-old black African woman, 22 years human immunodeficiency virus(HIV)-positive, presented with an acute coronary syndrome. She was taking two nucleoside reverse transcriptase inhibitors and two protease inhibitors. Viral load and CD4 count were stable. Angiography revealed a right coronary artery lesion, which was treated with everolimus eluting stent. She also underwent balloon angioplasty to the first diagonal. She re-presented on three different occasions and technically successful coronary intervention was performed. The patient has reported satisfactory compliance with dual anti platelet therapy throughout. She was successfully treated with surgical revascularisation. The patient did not experience any clinical recurrence on follow up. This case demonstrates exceptionally aggressive multifocal and recurrent instent restenosis in a patient treated for HIV infection, raising the possibility of an association with HIV infection or potentially components of retro viral therapy.展开更多
Statins have been shown to be effective in reducing cardiovascular events.Their magnitude of benefits has been proportionate to the reduction in low-density lipoprotein cholesterol(LDL-c).Intensive lipid-lowering ther...Statins have been shown to be effective in reducing cardiovascular events.Their magnitude of benefits has been proportionate to the reduction in low-density lipoprotein cholesterol(LDL-c).Intensive lipid-lowering therapies using ezetimibe and more recently proprotein convertase subtilisin kexin 9 inhibitors have further improved clinical outcomes.Unselective application of these treatments is undesirable and unaffordable and,therefore,has been guided by LDL-c level.Nonetheless,the residual risk in the post-statin era is markedly heterogeneous,including thrombosis and inflammation risks.Moreover,the lipoprotein related risk is increasingly recognised to be related to other non-LDL-c markers such as Lp(a).Emerging data show that intensive lipid-lowering therapy produce larger absolute risk reduction in patients with polyvascular disease,post coronary artery bypass graft and diabetes.Notably,these clinical entities share similar phenotype of large burden of atherosclerotic plaques.Novel plaque imaging may aid decision making by identifying patients with propensity to develop lipid rich plagues at multi-vascular sites.Those patients may be suitable candidates for intensive lipid lowering treatment.展开更多
BACKGROUND High-speed rotational atherectomy (HSRA) is most commonly used to modify calcified coronary artery lesions to facilitate stent deployment and expansion. The use of HSRA as an emergency rescue technique to r...BACKGROUND High-speed rotational atherectomy (HSRA) is most commonly used to modify calcified coronary artery lesions to facilitate stent deployment and expansion. The use of HSRA as an emergency rescue technique to release a fractured microcatheter has not been described. We report the use of HSRA in a case of a fracture trapped corsair tip that was impeding coronary flow causing a ST elevation myocardial infarct. CASE SUMMARY A 79 years old male was scheduled for elective percutaneous coronary intervention (PCI) to his left anterior descending artery (LAD). Given its calcific nature, a decision was made for upfront rotablation. During procedural preparations, the tip of an employed micro-catheter was separated from the shaft resulting in obstructing coronary flow and ST-segment elevation. The consensus was for an attempt bail out PCI strategy. A rotafloppy wire was advanced to the distal LAD using a corsair micro-catheter which was placed proximal to the occlusion site. Modification of the mid LAD segment was performed, resulting in mobilising the corsair tip, and deflecting it to a small diagonal branch. Following serial predilation, the procedure was completed using two overlapping drug eluting stents, jailing the corsair tip in the diagonal branch. The patient made uneventful recovery and was clinically stable at one year follow up. CONCLUSION HSRA may be offered as a bailed-out strategy to rescue fractured and jailed micro-catheter tip in high risk surgical cases.展开更多
BACKGROUND Coexistent coronary artery disease is commonly seen in patients undergoing transcatheter aortic valve implantation(TAVI).Previous studies showed that pre-TAVI coronary revascularisation was not associated w...BACKGROUND Coexistent coronary artery disease is commonly seen in patients undergoing transcatheter aortic valve implantation(TAVI).Previous studies showed that pre-TAVI coronary revascularisation was not associated with improved outcomes,challenging the clinical value of routine coronary angiogram(CA).AIM To assess whether a selective approach to perform pre-TAVI CA is safe and feasible.METHODS This was a retrospective non-randomised single-centre analysis of consecutive patients undergoing TAVI.A selective approach for performing CA tailored to patient clinical need was developed.Clinical outcomes were compared based on whether patients underwent CA.The primary endpoint was a composite of allcause mortality,myocardial infraction,repeat CA,and re-admission with heart failure.RESULTS Of 348 patients(average age 81±7 and 57%male)were included with a median follow up of 19(9-31)mo.One hundred and fifty-four(44%)patients,underwent CA before TAVI procedure.Patients who underwent CA were more likely to have previous myocardial infarction(MI)and previous percutaneous revascularisation.The primary endpoint was comparable between the two group(22.6%vs 22.2%;hazard ratio 1.05,95%CI:0.67-1.64,P=0.82).Patients who had CA were less likely to be readmitted with heart failure(P=0.022),but more likely to have repeat CA(P=0.002)and MI(P=0.007).In those who underwent CA,the presence of flow limiting lesions did not affect the incidence of primary endpoint,or its components,except for increased rate of repeat CA.CONCLUSION Selective CA is a feasible and safe approach.The clinical value of routine CA should be challenged in future randomised trials.展开更多
文摘Thrombus burden significantly increases risk of no-reflow and microvascular obstruction and subsequently impacts outcomes in acute myocardial infarction(AMI).While initial studies suggested benefits of thrombus aspiration(TA),recent large trials have questioned its routine use.This review examines the role of thr-ombectomy in the management of AMI,focusing on its potential to improve my-ocardial perfusion and mitigate no-reflow risk.Attention should be focused on recognising high thrombus burden and its effect on major adverse cardiovascular events and impaired myocardial reperfusion.Similarly,standardising TA techn-iques and ensuring appropriate patients’selection may also improve enhance our understanding of the role of thrombectomy in AMI.Emerging technologies such as stent retrievals and mechanical thrombectomy may overcome the limitations of manual thrombectomy devices.
文摘A 54-year-old black African woman, 22 years human immunodeficiency virus(HIV)-positive, presented with an acute coronary syndrome. She was taking two nucleoside reverse transcriptase inhibitors and two protease inhibitors. Viral load and CD4 count were stable. Angiography revealed a right coronary artery lesion, which was treated with everolimus eluting stent. She also underwent balloon angioplasty to the first diagonal. She re-presented on three different occasions and technically successful coronary intervention was performed. The patient has reported satisfactory compliance with dual anti platelet therapy throughout. She was successfully treated with surgical revascularisation. The patient did not experience any clinical recurrence on follow up. This case demonstrates exceptionally aggressive multifocal and recurrent instent restenosis in a patient treated for HIV infection, raising the possibility of an association with HIV infection or potentially components of retro viral therapy.
文摘Statins have been shown to be effective in reducing cardiovascular events.Their magnitude of benefits has been proportionate to the reduction in low-density lipoprotein cholesterol(LDL-c).Intensive lipid-lowering therapies using ezetimibe and more recently proprotein convertase subtilisin kexin 9 inhibitors have further improved clinical outcomes.Unselective application of these treatments is undesirable and unaffordable and,therefore,has been guided by LDL-c level.Nonetheless,the residual risk in the post-statin era is markedly heterogeneous,including thrombosis and inflammation risks.Moreover,the lipoprotein related risk is increasingly recognised to be related to other non-LDL-c markers such as Lp(a).Emerging data show that intensive lipid-lowering therapy produce larger absolute risk reduction in patients with polyvascular disease,post coronary artery bypass graft and diabetes.Notably,these clinical entities share similar phenotype of large burden of atherosclerotic plaques.Novel plaque imaging may aid decision making by identifying patients with propensity to develop lipid rich plagues at multi-vascular sites.Those patients may be suitable candidates for intensive lipid lowering treatment.
文摘BACKGROUND High-speed rotational atherectomy (HSRA) is most commonly used to modify calcified coronary artery lesions to facilitate stent deployment and expansion. The use of HSRA as an emergency rescue technique to release a fractured microcatheter has not been described. We report the use of HSRA in a case of a fracture trapped corsair tip that was impeding coronary flow causing a ST elevation myocardial infarct. CASE SUMMARY A 79 years old male was scheduled for elective percutaneous coronary intervention (PCI) to his left anterior descending artery (LAD). Given its calcific nature, a decision was made for upfront rotablation. During procedural preparations, the tip of an employed micro-catheter was separated from the shaft resulting in obstructing coronary flow and ST-segment elevation. The consensus was for an attempt bail out PCI strategy. A rotafloppy wire was advanced to the distal LAD using a corsair micro-catheter which was placed proximal to the occlusion site. Modification of the mid LAD segment was performed, resulting in mobilising the corsair tip, and deflecting it to a small diagonal branch. Following serial predilation, the procedure was completed using two overlapping drug eluting stents, jailing the corsair tip in the diagonal branch. The patient made uneventful recovery and was clinically stable at one year follow up. CONCLUSION HSRA may be offered as a bailed-out strategy to rescue fractured and jailed micro-catheter tip in high risk surgical cases.
文摘BACKGROUND Coexistent coronary artery disease is commonly seen in patients undergoing transcatheter aortic valve implantation(TAVI).Previous studies showed that pre-TAVI coronary revascularisation was not associated with improved outcomes,challenging the clinical value of routine coronary angiogram(CA).AIM To assess whether a selective approach to perform pre-TAVI CA is safe and feasible.METHODS This was a retrospective non-randomised single-centre analysis of consecutive patients undergoing TAVI.A selective approach for performing CA tailored to patient clinical need was developed.Clinical outcomes were compared based on whether patients underwent CA.The primary endpoint was a composite of allcause mortality,myocardial infraction,repeat CA,and re-admission with heart failure.RESULTS Of 348 patients(average age 81±7 and 57%male)were included with a median follow up of 19(9-31)mo.One hundred and fifty-four(44%)patients,underwent CA before TAVI procedure.Patients who underwent CA were more likely to have previous myocardial infarction(MI)and previous percutaneous revascularisation.The primary endpoint was comparable between the two group(22.6%vs 22.2%;hazard ratio 1.05,95%CI:0.67-1.64,P=0.82).Patients who had CA were less likely to be readmitted with heart failure(P=0.022),but more likely to have repeat CA(P=0.002)and MI(P=0.007).In those who underwent CA,the presence of flow limiting lesions did not affect the incidence of primary endpoint,or its components,except for increased rate of repeat CA.CONCLUSION Selective CA is a feasible and safe approach.The clinical value of routine CA should be challenged in future randomised trials.
