Mechanical thrombectomy as a bailout reperfusion strategy for ST-segment elevation myocardial infarction with refractory huge thrombus burden: a case report
Ontology highlight
ABSTRACT:
SUBMITTER:
PROVIDER: S-EPMC10083689 | biostudies-literature | 2023 Mar
REPOSITORIES: biostudies-literature
Similar Datasets
Project description:ST-segment elevation myocardial infarction (STEMI) occurs as a result of acute occlusion of the coronary artery. Despite successful reperfusion using primary percutaneous coronary intervention (PPCI), a large percentage of myocardial cells die after reperfusion, which is recognized as ischemia/reperfusion injury (I/R). There are rapid changes in plasma lipidome during myocardial reperfusion injury. However, the impact of coronary artery reperfusion on plasma oxylipins is unknown. This study aimed to investigate alterations in the oxylipin profiles of STEMI patients during ischemia and at various reperfusion time points following PPCI. Blood samples were collected from patients presenting with STEMI prior to PPCI (Isch, n = 45) and subsequently 2 h following successful reperfusion by PPCI (R-2 h, n = 42), after 24 h (R-24 h, n = 44), after 48 h (R-48 h, n = 43), and then 30 days post PPCI (R-30 d, n = 29). As controls, blood samples were collected from age- and sex-matched patients with non-obstructive coronary artery disease after diagnostic coronary angiography. High-performance liquid chromatography-mass spectrometry (HPLC-MS/MS) using deuterated standards was used to identify and quantify oxylipins. In patients presenting with STEMI prior to reperfusion (Isch group), the levels of docosahexaenoic acid (DHA)-derived oxylipins were significantly higher when compared with controls. Their levels were also significantly correlated with the peak levels of creatine kinase (CK) and troponin T(TnT) before reperfusion (CK: r = 0.33, p = 0.046, TnT: r = 0.50, p = 1.00 × 10-3). The total concentrations of oxylipins directly produced by 5-lipoxygenase (5-LOX) were also significantly elevated in the Isch group compared with controls. The ratio of epoxides (generated through epoxygenase) to diols (generated by soluble epoxide hydrolysis (sEH)) was significantly lower in the Isch group compared with the controls. Following reperfusion, there was an overall reduction in plasma oxylipins in STEMI patients starting at 24 h post PPCI until 30 days. Univariate receiver operating characteristic (ROC) curve analysis also showed that an elevated ratio of epoxides to diols during ischemia is a predictor of smaller infarct size in patients with STEMI. This study revealed a large alteration in plasma oxylipins in patients presenting with STEMI when compared with controls. Total oxylipin levels rapidly reduced post reperfusion with stable levels reached 24 h post reperfusion and maintained for up to 30 days post infarct. Given the shifts in plasma oxylipins following coronary artery reperfusion, further research is needed to delineate their clinical impact in STEMI patients.
| S-EPMC10821107 | biostudies-literature
Project description:BackgroundIn patients with ST-segment elevation myocardial infarction (STEMI), it is unknown how patient delay modulates the beneficial effects of timely reperfusion.AimsTo assess the prognostic significance of a contact-to-balloon time of less than 90 min on in-hospital mortality in different categories of symptom-onset-to-first-medical-contact (S2C) times.MethodsA total of 20 005 consecutive patients from the Feedback Intervention and Treatment Times in ST-segment Elevation Myocardial Infarction (FITT-STEMI) programme treated with primary percutaneous coronary intervention (PCI) were included.ResultsThere were 1554 deaths (7.8%) with a J-shaped relationship between mortality and S2C time. Mortality was 10.0% in patients presenting within 1 hour, and 4.9%, 6.0% and 7.3% in patient groups with longer S2C intervals of 1-2 hours, 2-6 hours and 6-24 hours, respectively. Patients with a short S2C interval of less than 1 hour (S2C<60 min) had the highest survival benefit from timely reperfusion with PCI within 90 min (OR 0.27, 95% CI 0.23 to 0.31, p<0.0001) as compared with the three groups with longer S2C intervals of 1 hour<S2C≤2 hours (OR 0.44, 95% CI 0.33 to 0.59, p<0.0001), 2 hours<S2C≤6 hours (OR 0.49, 95% CI 0.38 to 0.64, p<0.0001) and 6 hours<S2C≤24 hours (OR 0.42, 95% CI 0.30 to 0.58, p<0.0001).ConclusionsTimely reperfusion with a contact-to-balloon time of less than 90 min is most effective in patients presenting with short S2C intervals of less than 1 hour, but has also beneficial effects in patients with S2C intervals of up to 24 hours.Trial registration numberNCT00794001.
| S-EPMC8103948 | biostudies-literature
Project description:A 42-year-old male patient presented with recurrent inferior ST-segment elevation myocardial infarction with minimal atherosclerotic disease on intracoronary imaging. Transesophageal echocardiogram and computed tomography aortogram revealed the underlying cause to be a mobile aortic thrombus in the right coronary cusp, prolapsing into and out of the right coronary ostium. (Level of Difficulty: Beginner.).
| S-EPMC8299257 | biostudies-literature
Project description: Not available
| S-EPMC5381598 | biostudies-literature
Project description:BackgroundEarly spontaneous reperfusion (ESR) is not an uncommon phenomenon in clinical settings.AimsThe aim of this study was to detect potential mechanisms of ESR in patients with STEMI.MethodsThis prospective study enrolled a total of 241 consecutive patients with STEMI undergoing optical coherence tomography (OCT) from July 2016 to August 2019. Forty-five patients (18.7%) met angiographic ESR criteria (TIMI 3 flow on the initial angiogram). Among those without ESR (TIMI 0 flow on initial angiogram), 45 patients were assigned to the control group according to propensity score matching with the ESR group.ResultsAlthough the baseline characteristics of the groups were comparable, non-ruptured plaque (62.2% vs 35.6%) predominated and plaque rupture (37.8% vs 64.4%) was less common in the ESR group (p=0.011). Red thrombus (44.4% vs 77.8%) was also less common in the ESR group (p=0.001). Lastly, compared to the control group, the ESR group underwent fewer emergent stent placements (68.9% vs 91.1%, p=0.008).ConclusionsRelief of coronary occlusion induced by a non-ruptured plaque may contribute to ESR in patients with STEMI.
| S-EPMC9724883 | biostudies-literature
Project description:It is assumed that platelets in diseased conditions share similar properties to platelets in healthy conditions, although this has never been examined in detail for myocardial infarction (MI). We examined platelets from patients with ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation myocardial infarction (NSTEMI) compared with platelets from healthy volunteers to evaluate for differences in platelet phenotype and function. Platelet activation was examined and postreceptor signal transduction pathways were assessed. Platelet-derived plasma biomarkers were evaluated by receiver operator characteristic curve analysis. Maximum platelet activation through the thromboxane receptor was greater in STEMI than in NSTEMI but less through protease-activated receptor 1. Extracellular-signal related-kinase 5 activation, which can activate platelets, was increased in platelets from subjects with STEMI and especially in platelets from patients with NSTEMI. Matrix metalloproteinase 9 (MMP9) protein content and enzymatic activity were several-fold greater in platelets with MI than in control. Mean plasma MMP9 concentration in patients with MI distinguished between STEMI and NSTEMI (area under curve [AUC] 75% [confidence interval (CI) 60-91], P = 0.006) which was superior to troponin T (AUC 66% [CI 48-85, P = 0.08), predicting STEMI with 80% sensitivity (95% CI 56-94), 90% specificity (CI 68-99), 70% AUC (CI 54-86, P < 0.0001), and NSTEMI with 50% sensitivity (CI 27-70), 90% specificity (CI 68-99), 70% AUC (CI 54-86, P = 0.03). Platelets from patients with STEMI and NSTEMI show differences in platelet surface receptor activation and postreceptor signal transduction, suggesting the healthy platelet phenotype in which antiplatelet agents are often evaluated in preclinical studies is different from platelets in patients with MI.
| S-EPMC5898983 | biostudies-literature
Project description:Background We systematically reviewed trials comparing different reperfusion strategies for ST-segment-elevation myocardial infarction and used multivariate network meta-analysis to compare outcomes across these strategies. Methods and Results We identified 31 contemporary trials in which patients with ST-segment-elevation myocardial infarction were randomized to ≥2 of the following strategies: fibrinolytic therapy (n=4212), primary percutaneous coronary intervention (PCI) (n=6139), or fibrinolysis followed by routine early PCI (n=5006). We categorized the last approach as "facilitated PCI" when the median time interval between fibrinolysis to PCI was <2 hours (n=2259) and as a "pharmacoinvasive approach" when this interval was ≥2 hours (n=2747). We evaluated outcomes of death, nonfatal reinfarction, stroke, and major bleeding using a multivariate network meta-analysis and a Bayesian analysis. Among the strategies evaluated, primary PCI was associated with the lowest risk of mortality, nonfatal reinfarction, and stroke. For mortality, primary PCI had an odds ratio of 0.73 (95% CI, 0.61-0.89) when compared with fibrinolytic therapy. Of the remaining strategies, the pharmacoinvasive approach was the next most favorable with an odds ratio for death of 0.79 (95% CI, 0.59-1.08) compared with fibrinolytic therapy. The Bayesian model indicated that when the 2 strategies examining routine early invasive therapy following fibrinolysis were directly compared, the probability of adverse outcomes was lower for the pharmacoinvasive approach relative to facilitated PCI. Conclusions A pharmacoinvasive approach is safer and more effective than facilitated PCI and fibrinolytic therapy alone. This has significant implications for ST-segment-elevation myocardial infarction care in settings where timely access to primary PCI, the preferred treatment for ST-segment-elevation myocardial infarction, is not available.
| S-EPMC7429064 | biostudies-literature
Project description:ObjectiveThe aim of this study was to synthesize evidence by examining the effects of manual thrombus aspiration on clinical outcomes in patients with ST-segment elevation myocardial infarction (STEMI).Methods and resultsA total of 26 randomized controlled trials (RCTs), enrolling 11,780 patients, with 5,869 patients randomized to manual thrombus aspiration and 5,911 patients randomized to conventional percutaneous coronary intervention (PCI), were included in the meta-analysis. Separate clinical outcome analyses were based on different follow-up periods. There were no statistically reductions in the incidences of mortality (risk ratio [RR], 0.86 [95% confidence interval [CI]: 0.73 to 1.02]), reinfarction (RR, 0.62 [CI, 0.31 to 1.32]) or target vessel revascularization (RR, 0.89 [CI, 0.75 to 1.05]) in the manual thrombus aspiration arm at 12 to 24 months of follow-up. The composite major adverse cardiac events (MACEs) outcomes were significantly lower in the manual thrombus aspiration arm over the long-term follow-up (RR, 0.76 [CI, 0.63 to 0.91]). A lower incidence of reinfarction was observed in the hospital to 30 days (RR, 0.59 [CI, 0.37 to 0.92]).ConclusionThe present meta-analysis suggested that there was no evidence that using manual thrombus aspiration in patients with STEMI could provide distinct benefits in long-term clinical outcomes.
| S-EPMC4236171 | biostudies-literature
Project description:Angiographic microvascular resistance (AMR) serves as an effective metric for assessing coronary microvascular status. The aim of this study was to investigate the predictive value of AMR for left ventricular thrombus (LVT) in ST-segment elevation myocardial infarction. This study enrolled 401 consecutive patients with anterior STEMI who underwent primary percutaneous coronary intervention (PPCI) between May 2019 and July 2023. AMR was measured immediately after PPCI via coronary angiography. LVT was identified during hospitalization through cardiac magnetic resonance imaging (CMR) or transthoracic echocardiography (TTE). Major adverse cardiac and cerebrovascular events (MACCEs) were recorded over 36 months follow-up. The predictive value of AMR was evaluated by logistic regression and receiver operating characteristic (ROC) analysis. Kaplan-Meier analysis was performed to estimate event-free rates for MACCEs. LVT was identified in 38 out of 401 anterior STEMI patients (9.5%). After adjusting for confounders through multivariable analysis, AMR was found to be an independent predictor of LVT (odds ratio [OR] 1.240 per 0.1 mmHg·s/cm, 95% confidence interval [CI]: 1.131-1.359, P < 0.001). ROC analysis demonstrated an area under the curve (AUC) of 0.742. For LVT, AMR provided modest incremental predictive value over established risk factors (continuous net reclassification improvement, 0.826 [95% CI: 0.523-1.129]; P < 0.001). Furthermore, Kaplan-Meier analysis revealed MACCEs for anterior STEMI patients with AMR ≥ 2.82 (log-rank P < 0.001). AMR is an independent predictor of LVT in anterior STEMI, providing incremental predictive value beyond traditional risk factors, and may be utilized to identify patients at risk for LVT.
| S-EPMC11880151 | biostudies-literature
Project description:Background Intramyocardial edema and hemorrhage are key pathological mechanisms in the development of reperfusion-related microvascular damage in ST-segment-elevation myocardial infarction. These processes may be facilitated by abrupt restoration of intracoronary pressure and flow triggered by primary percutaneous coronary intervention. We investigated whether pressure-controlled reperfusion via gradual reopening of the infarct-related artery may limit microvascular injury in patients undergoing primary percutaneous coronary intervention. Methods and Results A total of 83 patients with ST-segment-elevation myocardial infarction were assessed for eligibility and 53 who did not meet inclusion criteria were excluded. The remaining 30 patients with totally occluded infarct-related artery were randomized to the pressure-controlled reperfusion with delayed stenting (PCRDS) group (n=15) or standard primary percutaneous coronary intervention with immediate stenting (IS) group (n=15) (intention-to-treat population). Data from 5 patients in each arm were unsuitable to be included in the final analysis. Finally, 20 patients undergoing primary percutaneous coronary intervention who were randomly assigned to either IS (n=10) or PCRDS (n=10) were included. In the PCRDS arm, a 1.5-mm balloon was used to achieve initial reperfusion with thrombolysis in myocardial infarction grade 3 flow and, subsequently, to control distal intracoronary pressure over a 30-minute monitoring period (MP) until stenting was performed. In both study groups, continuous assessment of coronary hemodynamics with intracoronary pressure and Doppler flow velocity was performed, with a final measurement of zero flow pressure (primary end point of the study) at the end of a 60-minute MP. There were no complications associated with IS or PCRDS. PCRDS effectively led to lower distal intracoronary pressures than IS over 30 minutes after reperfusion (71.2±9.37 mm Hg versus 90.13±12.09 mm Hg, P=0.001). Significant differences were noted between study arms in the microcirculatory response over MP. Microvascular perfusion progressively deteriorated in the IS group and at the end of MP, and hyperemic microvascular resistance was significantly higher in the IS arm as compared with the PCDRS arm (2.83±0.56 mm Hg.s.cm-1 versus 1.83±0.53 mm Hg.s.cm-1, P=0.001). The primary end point (zero flow pressure) was significantly lower in the PCRDS group than in the IS group (41.46±17.85 mm Hg versus 76.87±21.34 mm Hg, P=0.001). In the whole study group (n=20), reperfusion pressures measured at predefined stages in the early reperfusion period showed robust associations with zero flow pressure values measured at the end of the 1-hour MP (immediately after reperfusion: r=0.782, P<0.001; at the 10th minute: r=0.796, P<0.001; and at the 20th minute: r=0.702, P=0.001) and peak creatine kinase MB level (immediately after reperfusion: r=0.653, P=0.002; at the 10th minute: r=0.597, P=0.007; and at the 20th minute: r=0.538, P=0.017). Enzymatic myocardial infarction size was lower in the PCRDS group than in the IS group with peak troponin T (5395±2991 ng/mL versus 8874±1927 ng/mL, P=0.006) and creatine kinase MB (163.6±93.4 IU/L versus 542.2±227.4 IU/L, P<0.001). Conclusions In patients with ST-segment-elevation myocardial infarction, pressure-controlled reperfusion of the culprit vessel by means of gradual reopening of the occluded infarct-related artery (PCRDS) led to better-preserved coronary microvascular integrity and smaller myocardial infarction size, without an increase in procedural complications, compared with IS. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02732080.
| S-EPMC9238546 | biostudies-literature