DOUBLE-TROUBLE: TAKOTSUBO AND ACUTE CORONARY SYNDROME IN A YOUNG WOMAN

Background: The original case series of patients with Takotsubo Syndrome (TTS) reported no significant epicardial coronary artery disease during angiography. However, recent evidence suggests an increasing overlap between the two diseases. We report a case of a 48-year old woman who had untreated generalized anxiety disorder and presented with angina. Case: A 48-year old woman with untreated general anxiety disorder presented with a 5 hour history of angina. An electrocardiogram demonstrated a prolonged QTc, no ST segment changes and new T-wave inversions in the anterolateral leads. High-sensitivity troponin was 4,336 ng/L and her InterTAK score was 91 with a 99.6% probability of TTS. Decision-making: Due to her persistent chest pain and EKG changes the patient underwent emergent left heart catheterization which showed critical occlusion of the 1st diagonal and 71% stenosis of the distal left circumflex. She underwent a primary PCI of both lesions. Her chest pain resolved after 6 hours of a nitrolgycerin infusion postoperatively and a transthoracic echocardiogram showed hypokinesis of the mid-distal apical, periapical, septal, lateral, inferior and anterior wall with an ejection fraction of 30-35%. The distribution of hypokinesia was out of proportion to the territory supplied by the culprit artery, suggesting a possibility of the apical type of Takotsubo syndrome. She was started on guideline-directed medical therapy for heart failure with reduced ejection fraction and dual antiplatelet therapy Conclusion: Patients with TTS may have coexistent significant epicardial CAD. Prolonged QTc and lack of ST-segment elevation in patients with CAD may help identify an additional diagnosis of TTS

Incidence and prognosis of vascular complications after percutaneous placement of left ventricular assist device

OBJECTIVE: Mechanical assist devices have found an increasingly important role in high-risk interventional cardiac procedures. The Impella (Abiomed Inc, Danvers, Mass) is a percutaneous left ventricular assist device inserted through the femoral artery under fluoroscopic guidance and positioned in the left ventricular cavity. This study was undertaken to assess the incidence of vascular complications and associated morbidity and mortality that can occur with Impella placement. METHODS: We used a prospective database to review patients who underwent placement of an Impella left ventricular assist device in our tertiary referral center from July 2010 to December 2013. Patient demographics, comorbidities, interventional complications, and 30-day mortality were recorded. RESULTS: The study included 90 patients (60% male). Mean age was 66 years (range, 17-97 years). Hypertension was found in 69% of the patients, 37% were diabetic, 57% had a history of tobacco abuse, and 65% had chronic renal insufficiency. The median preprocedure cardiac ejection fraction was 30%. Most (87%) had undergone coronary artery intervention. Cardiogenic shock was documented in 67 patients (74%). The Impella was placed for an average of 1 day (range, 0-5 days). At least one vascular complication occurred in 15 patients (17%). Acute limb ischemia occurred in 12 patients; of whom four required an amputation and six required open or endovascular surgery. Other complications included groin hematomas and one pseudoaneurysm. All-patient 30-day mortality was 50%, which was not significantly associated with vascular complications. Female sex and cardiogenic shock at the time of insertion were associated with vascular complications (P = .043 and P = .018, respectfully). CONCLUSIONS: Vascular complications are common with placement of the Impella percutaneous left ventricular assist device (17%) and are related to emergency procedures. Vascular complications in this high-risk patient population frequently lead to withdrawal of care. These data provide quality improvement targets for left ventricular assist device programs

TCT-175 Safety and Complications Associated With the Use of Protamine in Percutaneous Coronary Intervention

Background: There is a paucity of data on the use of protamine after percutaneous coronary intervention (PCI). Methods: We conducted a retrospective analysis of 168 patients who underwent PCI from 2015 to 2021. All patients received protamine intra- or immediately after index PCI. We evaluated baseline characteristics, intraprocedural characteristics including heparin dosing and protamine dosing, and complications such as acute stent thrombosis (ST), dissection, perforation, and access-site bleeding. The primary outcome was the incidence of acute ST, subacute ST, and other thrombotic complications. Secondary outcomes included mortality within 24 hours and within 28 days of the index procedure. Results: One hundred sixty-eight patients were included. The mean age of patients was 72 ± 12.1 years, and 36% were women. The majority of patients received antiplatelet therapy prior to the index procedure (90%), and the average ejection fraction (EF) was 50% ± 14.3%. Of the 33 insulin-dependent patients (20%), only 1 (0.5%) used neutral protamine Hagedorn insulin. One hundred fifteen of the procedures (68%) were elective, and the average procedure time was 3 hours 21 minutes (SD 1 hour 43 minutes). Fifty-nine patients underwent rotational, orbital, or laser atherectomy (27, 23, and 9 patients, respectively). An average of 2.59 ± 1.38 stents were deployed, and intravascular ultrasound was used in 96 patients (57%). An average protamine dose of 32 mg was administered. Seventy-three patients (43%) had coronary perforations, and 19 (11%) had pericardial effusions requiring pericardiocentesis. Twenty-one patients (13%) had coronary dissections following PCI, and 6 (4%) had access-site bleeding requiring transfusion. Three patients (2%) underwent urgent cardiac surgery. Eight (5%) died within 24 hours of PCI, and 6 (3.5%) died within 28 days of PCI. Four patients (2%) had acute ST, no patients experienced subacute ST, and 1 patient (0.5%) developed arterial thrombosis (common femoral artery). Conclusions: Use protamine in PCI typically occurred because of intraprocedural complications. In our series, protamine was tolerated well in the majority of patients, but 3% of patients experienced coronary or arterial thrombosis, warranting caution when using protamine in these challenging scenarios. Categories: CORONARY: Stents: Drug-Elutin

Effects of Impella on Coronary Perfusion in Patients With Critical Coronary Artery Stenosis

BACKGROUND: Mechanical circulatory support devices are used to maintain hemodynamic stability during high-risk percutaneous coronary interventions. Little is known on the effects of such devices on coronary hemodynamics in patients with significant coronary stenosis. We sought to investigate whether mechanical circulatory support in the form of Impella (Abiomed Inc, Danvers, MA) can improve coronary hemodynamics in the presence of a critical coronary stenosis. METHODS AND RESULTS: We examined coronary perfusion pressures and coronary pressure distal to a critical stenosis using a coronary pressure wire in 11 patients (12 coronary lesions) undergoing high-risk percutaneous coronary interventions with the use of mechanical circulatory support. Systemic, ventricular, and coronary hemodynamics were obtained at both minimum and maximum support levels before high-risk percutaneous coronary interventions. All patients had obstructive lesions with angiographically estimated diameter stenosis between 70% and 99% and distal coronary artery pressure to aortic pressure ratios between 0.44 and 0.88. When compared with minimum support, maximum support resulted in a decrease in the left ventricular end-diastolic pressure (27.3±8.6 versus 21.5±5.2 mm Hg; CONCLUSIONS: Mechanical circulatory support with Impella can improve distal coronary pressure and coronary perfusion pressures in the presence of critical coronary stenosis

Effects of mechanical circulatory support on coronary pressure in patients with critical coronary stenosis

Background: Mechanical circulatory support (MCS) devices are frequently used in high-risk percutaneous coronaryinterventions (HR-PCI) due to their improved effects onsystemic hemodynamics. Little is known on the effects ofsuch devices on coronary hemodynamics in patients withcritical coronary stenosis. Prior studies using intra-aortic balloon pump have failed to demonstrate significant improvements in coronary hemodynamic in patients withcritical coronary stenosis. We therefore sought to investigate if more robust forms of MCS would improve coronary hemodynamics in critical coronary stenosis. Methods: From November 2015 to November 2016 we examined coronary perfusion pressures and distal coronarypressures, using a pressure wire (Volcano Corp. San Diego, CA), in 7 patient undergoing HRPCI with the use of MCS devices. Baseline hemodynamic were obtained after delivery of MCS. MCS was adjusted to a low output state and a high output state according to device specific recommendations and measurements were made prior to PCI. Results: Mean patient age was 79±10 years, 71% were male, and 42% had a left ventricular ejection fractio

A Visual Depiction of Left Ventricular Unloading in Veno-Arterial ExtraCorporeal Membrane Oxygenation With Impella

Left ventricular (LV) unloading has been associated with improved survival in patients treated with venoarterial extracorporeal membrane oxygenation. This case describes a patient with a COVID-19 infection who subsequently developed non-ischemic cardiomyopathy with an LV ejection fraction of 10% to 15% (baseline echocardiography). He did poorly in the outpatient setting and was admitted to an outside hospital with heart failure symptoms and was subsequently transferred to our hospital for escalation of care and consideration of advanced heart failure therapies. This clinical image and related video series help to visually demonstrate the effect of LV unloading in a 30-year-old male with a history of COVID-19 myocarditis