Right coronary occlusion following transcatheter aortic valve implantation： two case reports

This paper discusses two male patients with severe aortic stenosis, whose right coronary arteries （RCA） were completely occluded during transcatheter aortic valve implantation （TAVI）, leading to fatal hemodynamic disorder. Occlusions of RCA complicated by TAVI are rare. In addition, emergency cardiopulmonary bypass （CPB） played a critical role in rescuing our second patient. Both patients were admitted for ＂severe aortic stenosis,＂ and TAVIs were performed. The first patient＇s blood pressure immediately dropped to 70/40 mmHg after the balloon expansion and did not increase much after the administration of aramine or fluid therapy. He did not receive emergency surgery and died after 1.5 h of resuscitation. The second patient＇s blood pressure fluctuated greatly for several minutes after the valve implantation, ranging from 170/100 mmHg to 60/40 mmHg. Angiography revealed a total occlusion of RCA. Thoracic surgery with CPB was performed, and the patient survived.

Chest pain showing precordial ST-segment elevation in a 96-year-old woman with right coronary artery occlusion:A case report

BACKGROUND Typically,right coronary artery(RCA)occlusion causes ST-segment elevation in inferior leads.However,it is rarely observed that RCA occlusion causes STsegment elevation only in precordial leads.In general,an electrocardiogram is considered to be the most important method for determining the infarct-related artery,and recognizing this is helpful for timely discrimination of the culprit artery for reperfusion therapy.In this case,an elderly woman presented with chest pain showing dynamic changes in precordial ST-segment elevation with RCA occlusion.CASE SUMMARY A 96-year-old woman presented with acute chest pain showing precordial STsegment elevation with dynamic changes.Myocardial injury markers became positive.Coronary angiography indicated acute total occlusion of the proximal nondominant RCA,mild atherosclerosis of left anterior descending artery and 75%stenosis in the left circumflex coronary artery.Percutaneous coronary intervention was conducted for the RCA.Repeated manual thrombus aspiration was performed,and fresh thrombus was aspirated.A 2 mm×15 mm balloon was used to dilate the RCA with an acceptable angiographic result.The patient’s chest pain was relieved immediately.A postprocedural electrocardiogram showed alleviation of precordial ST-segment elevation.The diagnosis of acute isolated right ventricular infarction caused by proximal nondominant RCA occlusion was confirmed.Echocardiography indicated normal motion of the left ventricular anterior wall and interventricular septum(ejection fraction of 54%),and the right ventricle was slightly dilated.The patient was asymptomatic during the 9-mo follow-up period.CONCLUSION Cardiologists should be conscious that precordial ST-segment elevation may be caused by occlusion of the nondominant RCA.

Effects of Tirofiban and Nicorandil on Effective Reperfusion and the Levels of IL-4 and sICAM-1 After PCI for Chronic Coronary Total Occlusion

Aim:The effects of tirofiban combined with nicorandil on effective reperfusion,and the levels of interleukin-4(IL-4)and soluble intercellular adhesion molecule-1(sICAM-1)after percutaneous coronary intervention(PCI)for chronic coronary total occlusion(CTO)were investigated.Method:From January 1,2017,to June 31,2019,a total of 40 patients with CTO receiving PCI in Shandong Qian-foshan Hospital were randomly divided into a control group(treated with single tirofiban)and a cocktail group(treated with nicorandil combined with tirofiban).Effective reperfusion was compared between groups.In addition,differences in coronary serum IL-4 and sICAM-1 levels before and 10 min after the operation were compared between groups,and the incidence rates of adverse reactions were observed.Finally,patient follow-up occurred at 1 month and 6 months,and the total incidence rates of adverse cardiac events in both groups were assessed.Results:The levels of IL-4 and sICAM-1 in the cocktail group significantly decreased after the operation(P<0.05).In addition,after the operation,significantly greater decreases in the IL-4 and sICAM-1 levels were observed in the cocktail group than the control group(P<0.05).The Seattle Angina Scale(SAQ)score of the cocktail group,compared with the control group,showed a significant improvement after vessel opening in the patients with CTO.At the 1-month follow-up,the SAQ score of the cocktail group,compared with the control group,indicated further improvements in terms of angina attack frequency.No significant differences were observed in the incidence rates of adverse reactions between groups(P>0.05).Conclusion:The treatment of patients with CTO undergoing PCI with nicorandil and tirofiban alleviated the inflam-matory response,improved the SAQ scores,and decreased the occurrence of angina pectoris in patients.Moreover,this treatment is safe and reliable,and has important clinical significance.

Stenting versus non-stenting after revascularization of chronic total coronary artery occlusion: short and long-term clinical and angiographic results

Objective To investigate the short and long term clinicam and angiographic outcome of stenting or angioplasty for chronic total coronary artery occlusion Methods A total of 95 patients with successful percutaneous transluminal coronary angioplasty (PTCA) for total occlusion coronary artery were identified out of 358 patients undergoing PTCA for chronic total occlusion Patients were classified into two groups: Group A had selective stenting after successful PTCA and Group B only had PTCA Clinical cardiac events including acute myocardial infarction (AMI) angina, death, repeat revascularization and angiographic variables were followed and analyzed Results A total of 85 of 95 patients (89%) completed clinical and angiographic follow up In group A (n=42), 1 patient experienced an AMI while in group B, 2 patients experienced AMI and 1 died In group A, the restenosis rate was 29%, reocclusion rate was 12% and recanularization rate was 19%, as compared to 58%, 22% and 45% respectively in group B ( P <0 001, P <0 05 and P <0 001, respectively) Conclusions Selective stent improves short and long term clinical and angiographic outcomes and is recommended in cases of chronic total occlusion independent of the primary PTCA results

Impact of Coronary Chronic Total Occlusion on Long-term Clinical Outcome in Patients with Unprotected Left Main Disease Undergoing Percutaneous Coronary Intervention

Objectives:Reported data regarding the prevalence,prognostic impact,and safety and efficacy of revascularization of coronary chronic total occlusion(CTO)in patients with left main coronary artery(LMCA)disease who undergo percutaneous coronary intervention(PCI)are scarce.The aim of the present study was to compare clinical outcomes among patients with LMCA disease undergoing PCI.Outcomes were compared between those with and without coronary CTO and between those with CTO who had successful and unsuccessful CTO recanalization procedures.Methods:All consecutive patients with significant LMCA disease(>50%stenosis at coronary angiography)who underwent PCI between July 2014 and December 2018 were retrospectively included in our study.The primary endpoint of the study was long-term mortality.Secondary endpoints included the incidence of myocardial infarction,repeat percutaneous or surgical revascularization,stroke,and stent thrombosis.Results:Between July 2014 and December 2018,578 patients underwent PCI for LMCA disease at Pederzoli Hospital and University of Turin were enrolled.They were divided into 3 groups:group A:374(65%)patients without CTO,group B:108(19%)patients with untreated or unsuccessfully treated CTO,and group C:96(17%)patients with successfully treated CTO.At a median follow-up of(1090±279)days,there were no statistically significant differences between the groups in terms of the primary and secondary endpoints.However,there was a trend towards higher mortality in patients with untreated or unsuccessfully treated CTO(13%vs.19%vs.14%in groups A,B,and C,respectively;P=0.12).The primary and secondary endpoints were further analyzed based on the presence or absence of myocardial viability:subgroup C1:54(56%)patients with successful percutaneous transluminal coronary angioplasty(PTCA)having viability,and subgroup C2:42(44%)patients with successful PTCA not having viability.There was a trend toward a statistically significant higher rate of death among patients in group B,who underwent unsuccessful recanalization with viable myocardium(19%vs.9%vs.19%in groups B,C1,and C2,respectively,P=0.05).On multivariable analysis,the propensity for successful revascularization of CTO was associated with a reduced risk of death(P=0.01;odds ratio,0.75;95%confidence interval:0.62-0.87).Conclusions:Among patients with LMCA disease undergoing PCI,CTO represents a common finding associated with worse prognosis.Successful revascularization of CTO in patients with viable myocardium appears to significantly improve prognosis.

Comparison of long-term clinical outcomes after percutaneous coronary intervention between in-stent restenosis and de novo chronic total occlusion

Background The occurrence of in-stent restenosis(ISR)coronary chronic total occlusion(CTO)is presently increasing. However,there were few data related to the long-term clinical outcomes after percutaneous coronary intervention(PCI)between ISR CTO and de novo CTO. Methods A total of 435 CTO patients who had attempted PCI between Jan 2013 and November 2017 were screened for inclusion in this study. The Kaplan-Meier method was applied to estimate event-free survival and the log-rank test to compare long-term outcome. Cox regression analysis was used to identify associations between adverse events and risk factors. Results There were84 ISR CTO cases and 351 de novo CTO cases in this study. Successful revascularization was achieved similar between ISR CTO group and de novo CTO group(84.5% vs. 87.2%,P=0.592). The prevalence of MACE[17.9% vs. 9.1%;hazard ratio(HR):2.323;95% confidence interval(CI)1.233-4.37;P=0.004]and TLR(8.3% vs. 3.4%;HR:2.627;95% CI 1.05-6.53;P<0.016)were higher in the ISR CTO group,during the 2-year follow-up. Conclusions The procedural success rate of ISR CTO achieved was comparable to that of de novo CTO in the contemporary practice. But the long-term clinical outcome was significantly worse in term of major adverse cardiac events and target lesion revascularization.