Irzal Hadžibegović

Complex, high risk and indicated patients in Croatia: are we ready?

2018;13(1-2):40. LITERATURE 1. Becher T, Baumann S, Eder F, Perschka S, Loßnitzer D, Fastner C, et al. Comparison of peri and post-procedural complications in patients undergoing revascularisation of coronary artery multivessel disease by coronary artery bypass grafting or protected percutaneous coronary intervention with the Impella 2.5 device. Eur Heart J Acute Cardiovasc Care. 2017 Jun 1:2048872617717687. https://doi.org/10.1177/2048872617717687 Complex, high risk and indicated patients (CHIP) for percutaneous coronary intervention have gained a lot of interest in the last several years, and revascularization strategies for complex multivessel and patients with chronic total occlusion (CTO) are being currently scrutinized beyond SYNTAX trial.1 It appears that in complex multivessel disease percutaneous coronary intervention (PCI), coronary artery bypass grafting or hybrid strategy selection does not matter if revascularization strategy is both indicated and total. CHIP group mostly comprises of patients selected for conservative treatment because of high risk after a heart team meeting, but it has been found that total revascularization of hemodynamically significant lesions improves survival in those patients. In fact, it seems that outside myocardial infarction, this subset of patients is the one where interventional cardiology treatment dramatically shows benefit in the terms of survival and quality of life. Interventional cardiology teams that plan to embark into CHIP have to be equipped, experienced, and educated in fractional flow reserve (FFR), intravascular ultrasound, CTO intervention techniques, plaque modification techniques, thrombus burden solutions and at last hemodynamic protection. However, results with the intra-aortic balloon pump or extracorporeal membrane oxygenation (ECMO) in CHIP subset did not prove beneficial. Currently, Impella 2.5 or Impella CP are temporary ventricular support devices preferred for protected PCI in hemodynamically stable high-risk patients, but it has not yet been used in our clinical setting.

Rapid progression of left main disease in a patient with anterior ST-segment elevation myocardial infarction

2. Liang JJ, Hodge DO, Mehta RA, Russo AM, Prasad A, Cha YM. Outcomes in patients with sustained ventricular tachyarrhythmias occurring within 48 h of acute myocardial infarction: when is ICD appropriate? Europace. 2014 Dec;16(12):1759-66. https://doi.org/10.1093/europace/euu138 Case report: 43-year old male patient, with a positive family history for coronary artery disease, was admitted to hospital in Jul 2017 with acute ST-segment elevation myocardial infarction presenting with rhythmic instability (VT/VF) and cardiogenic shock. Angiography revealed occlusion of the proximal left anterior descending artery as the culprit lesion and intermediate stenoses of the distal segment of the right coronary artery (RCA) and OM branch of the circumflex artery. Percutaneous coronary intervention (PCI) of the culprit lesion was performed with an optimal angiographic result. Echocardiography showed dilation of the left ventricle with significant reduction of ejection fraction (EFLV 35%) and mild mitral regurgitation. He was discharged with optimal medical therapy. In Oct 2017 repeat angiography was performed to evaluate the aforementioned residual coronary lesions. Intravascular ultrasonography showed nonsignificant lumen stenosis of the left main artery (MLA 8 cm2), RCA and OM branch. Medical therapy was modified with introduction of sacubitril/valsartan. In Dec 2017 the patient was admitted to hospital with rhythmic instability (VT/VF) and elevated cardiac biomarkers. Angiography revealed significant ostial stenosis of left main artery with ventriculization of blood pressure curves and fall in BP during catheterization. After stabilization, an implantable cardioverter defibrillator was implanted for secondary prevention followed by PCI of the left main with implantation of one everolimus-eluting stent. On follow up visits the patient remains symptom-free, without clinical signs of heart failure or evidence of malignant ventricular arrhythmias.