Cardiogenic shock remains the leading cause of death in patients hospitalized for acute myocardial infarction, despite many advances encountered in the last years in reperfusion, mechanical, and pharmacological therapies addressed to stabilization of the hemodynamic condition of these critical patients. Such patients require immediate initiation of the most effective therapy, as well as a continuous monitoring in the Coronary Care Unit. Novel biomarkers have been shown to improve diagnosis and risk stratification in patients with cardiogenic shock, and their proper use may be especially important for the identification of the critical condition, leading to prompt therapeutic interventions. The aim of this review was to evaluate the current literature data on complex biomarker assessment and monitoring of patients with acute myocardial infarction complicated with cardiogenic shock in the Coronary Care Unit.
Introduction: 64 multislice CT angiography is a recently introduced imaging technique, increasingly being used as a tool to show the coronary arteries in three-dimensional visualization. One of the advantages of this method is the ability to estimate the degree of calcification of atheromatous plaques via coronary calcium score calculation, which correlates with the severity score of ateromatous systemic burden. The aim of this study was to evaluate the relationship between the severity of coronary calcification, expressed by calcium score, and the left ventricular ejection fraction (LVEF). Material and methods: This retrospective study included 81 patients with symptoms of angina and ECG modifications (at rest or during exercise). Echocardiography and 64 multislice CT angiography were performed in all patients to assess the LVEF and Ca scoring. Results: Calcium score was lower than 100 in 62 patients (50.22%), between 100 and 400 in 11 patients (8.91%), and higher than 400 in 8 patients (6.48%). Mean LVEF was 53.52%, 17 patients having an LVEF of less than 50%. In patients with calcium score less than 100, the corresponding ejection fraction was normal: 55.29%, while in coronary arteries with extensive calcifications (calcium score > 400), the LVEF was significantly lower, 50.5% (p = 0.004). Conclusions: High Calcium score is positively correlated with LVEF reduction, and a high value for calcium score indicates an increased probability of reduced left ventricular ejection fraction
Introduction: The association between a high calcium score at the level of the unstable coronary lesions and the different characteristic of culprit lesions which result in an acute coronary syndrome (ACS) has not been described yet. We aimed to study the correlation between the accumulation of calcium within the vessel wall of a coronary artery and the plaque burden of culprit lesions that develop an acute coronary event. Material and methods: A total of 45 patients with ACS (22 unstable angina, 23 nonST elevation myocardial infarction) underwent 64-slice CCTA. In all patients a complex CT analysis of the culprit plaques was performed and the calcium score for each coronary artery was computed. Results: We found a significant correlation between a calcium score higher than 100 and the plaque volume (r = 0.85. p = 0.01). Selecting a cut-off value of 100 HU for regional calcium score at the level of the coronary artery, we found that those arteries with Ca score higher than 100 presented significantly larger plaque volumes than the ones with calcium score below 100 (110.8 ml vs 82.4 ml, p <0.0001 for left anterior descending artery, 111.09 ml vs 82.5 ml, p = 0.0005 for circumflex artery, and 132.78 ml vs 76.23 ml for right coronary artery). Conclusion: Our data shows that in ACS, the severity of the culprit lesions correlates with regional accumulation of calcium within the vessel wall.
Introduction: Coronary calcium score, as determined by Angio CT multislice, has been proved to represent a reliable parameter which reflects the global cardiovascular risk. We aimed to study the characteristics of culprit lesions in Acute Coronary Syndrome (ACS) patients with low versus high calcium score. Material and methods: A total of 45 patients with ACS underwent 64-slice CCTA. Group 1 - 19 patients with Ca score below 400HU, Group 2 - 26 patients with calcium score >400HU. In all patients a complex CT analysis of the culprit plaque was performed. Results: There were no significant differences between the groups at baseline as regard to age, gender, cardiovascular risk factors (p>0.2). In patients with high calcium score, culprit lesions presented a significantly larger amount of plaque burden than in patients with low calcium score (82.8ml versus 131.81ml, p <0.0001). This was also true when assessing in a subanalysis different cut-off points for definition of relatively higher calcium score (89.66ml versus 137.93ml, p <0.0001, for calcium score cut off 600HU, 97.88ml versus 137.57ml, p<0.0001 for calcium score cut-off of 1000HU). Conclusion: Our data shows that patients with high calcium score who develop an acute coronary syndrome present larger atheromatous plaque than those with low calcium scores, and theseverity of the culprit lesions correlates with global cardiovascular risk as expressed by a high calcium score
Background: Coronary arteriovenous malformation is a rare congenital disease consisting mainly in a direct communication between a coronary artery and any one of the four cardiac chambers, coronary sinus, pulmonary arteries or veins. This disease can lead to various cardiovascular events, their severity depending on the degree of the malformation. Case report: We present the case of a 56-year-old male patient, who was admitted to our institution with dyspnea, palpitation and chest pain, having a history of hypertension and hyperlipidemia, and an abnormal electrocardiogram. Physical examination did not reveal any alterations and the cardiac enzymes were in normal ranges. Cardiac computed tomography was performed before any other invasive studies, with a 64-row scanner (Somatom Sensation multislice 64 equipment, Siemens) after intravenous administration of non-ionic contrast material. CT scan revealed a large (2-2.5 mm) coronary fistula originating from the LAD to the main pulmonary artery, and multiple significant atherosclerotic coronary lesions. Coronary angiography confirmed the arteriovenous malformation between LAD and pulmonary artery, associated with three vascular coronary artery disease. Conclusions: Cardiac computed tomography angiography can help for a non-invasive diagnosis of the coronary artery malformations, in the same time revealing anatomic details which can be particulary useful for choosing the appropriate management strategy (surgical planning, interventional treatment or optimum medical treatment)
Truncus arteriosus (TA) or common arterial trunk is a rare malformation, accounting for 0.21 to 0.34% of congenital heart diseases, which, if left untreated, leads to increased mortality rates. The condition is characterized by the presence of a unique arterial trunk that overrides the interventricular septum. Despite an overall poor outcome, few subjects present in emergency settings with signs suggestive for pulmonary arterial hypoplasia and associated heart failure. We report the case of a 31-year-old female patient who had been previously diagnosed with pulmonary atresia and severe scoliosis as an infant, presenting in the emergency department with clinical sings of decompensated heart failure which were demonstrated to be attributable to the severe cyanogenic heart malformation and were reversible after initiation of appropriate therapeutic measures.
Introduction: The term “myocardial bridging” is used to describe an anatomic variant where a band of cardiac muscle overlies a segment of an epicardial coronary artery. It is a highly debated topic, because it can cause conditions such as acute coronary syndrome. Myocardial bridging (MB) can be diagnosed using invasive procedures, but also non-invasive ones, such as Multislice Computed Tomography Angiography (MSCTA).
Objectives: A comparative analysis was performed on the patients who were admitted to the clinic with typical angina, ischemic ECG changes and muscular bridging shown on MSCTA, and patients with the same symptoms, but without MB. A sub-study was also undertaken in which the MB site and ischemia revealed by thickening of the myocardial muscle, using 3D Polar Mapping, were compared.
Materials and methods: A retrospective study assessed 59 patients with typical angina pectoris, shortness of breath and clinical appearance of an acute coronary syndrome, and for whom MSCTA was carried out. Patients were divided into two groups: Group 1 — patients with MB, and Group 2 — patients without MB. Thirty patients in Group 1 had 3D polar mapping to evaluate the thickness of the myocardial muscle.
Results: The mean age of our patients with muscular bridging was 55.51 ± 11.4 years, CI 51.57–59.45 years. Patients without MB had a mean age of 59.17 ± 9.6 years, CI 54.98–63.6 years, p = 0.211. 24.32% of the patients with MB were females and 60.86% from the patients without MB were males, p = 0.040. 40.54% of patients presented with MB in the first segment of the LAD and 15.62% had an MB in the second segment of LAD. In patients with an ischemic site smaller than 2 cm of the MB, the ischemic myocardial area was more pronounced compared to the patients with higher length MB (21.85 ± 6.123% vs. 17.62 ± 5.856%).
Conclusions: MSCTA is an important procedure that contributes to the clinical investigations of patients with typical angina and suspected acute coronary syndrome. There is a good positive correlation between the location of the MB and the ischemic segments as shown on 3D CT-based polar maps.
Introduction: In-stent restenosis (ISR) is traditionally associated with neointimal hyperplasia. However, recent studies have suggested that an underlying progression of the atherosclerotic process called neoatherosclerosis, different from intimal proliferation, could be involved in ISR development. In this study the aim was to compare the characteristics of the neoatheromatous plaque evidenced by Multislice Angio Computed Tomography, Optical Coherence Tomography (OCT) and Virtual Histology Intravascular Ultrasound (VH-IVUS) with the characteristics of de-novo lesions in native coronary vessels of patients with ISR. Material and methods: This is a prospective single-center pilot study in which patients presenting with acute chest pain and having at least one symptomatic bare-metal stent (BMS) restenosis at six months to one year after BMS implantation, were enrolled. The characteristics of the neointimal tissue developed within the implanted stents using Acio CT, OCT and VH-IVUS were studied. Results: In total, 27 patients with 38 coronary BMS were included in the study, in whom 27 ISR lesions and 43 lesions in native coronary vessels were identified. Angio CT examination revealed that atheromatous plaques responsible for ISR tend to have a larger volume compared with native lesions located in the same coronary vessel (plaque volume 91.2 mm3 for ISR vs. 60.4 mm3 for native vessels, p <0.0001). Additionally, they show more low density plaques compared to native coronary lesions located in the same coronary vessel (33.9 mm3 vs. 18.2 mm3 for the volume of the plaque with density <30 HU, p <0.0001). Plaques responsible for ISR exhibit a higher lipid content than native ones (41.1% vs. 22.9%, p = 0.05). OCT analysis indicated an irregular shaped vascular lumen in 44.4% of ISR lesions compared to 25.6% of de-novo lesions (p = 0.1). Conclusions: Neoatherosclerosis within the implanted coronary stents is associated with signs of plaque vulnerability to a significantly higher extent than the atheromatous plaques in native coronary arteries in patients with ISR presenting with an acute coronary syndrome.
Despite of numerous treatment strategies developed in the last years, ischemic heart disease remains the leading cause of death around the world. Acute myocardial infarction (MI) causes irreversible destruction to the myocardial tissue, which is replaced by fibroblast cells, leading to the formation of a dense, collagenous scar, a non-contractile tissue, and often to heart failure. Stem cell therapy seems to represent the next therapeutic method for the treatment of heart failure caused by myocardial infarction. Several international trials proved the beneficial outcome of the intracoronary infusion of bone marrow-derived stem cells, improving left ventricular systolic function and clinical symptomatology. Many noninvasive imaging procedures are available to evaluate the beneficial properties of stem cell therapy. Most studies have demonstrated the role of multislice computed tomography (MSCT) in evaluating left ventricular parameters such as end-diastolic and end-systolic volumes and ejection fraction, or to quantify myocardial scar tissue. In this review we will discuss the usefulness of MSCT for the assessment of coronary arteries, new tissue regeneration, and evaluation of tissue changes and their functional consequences in subjects undergoing stem cell treatment following MI.