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      Urgent Pericardiocentesis Is More Frequently Needed After Left Circumflex Coronary Artery Perforation


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          Background: Coronary artery perforation (CAP) is a rare but potentially life-threatening complication of percutaneous coronary interventions (PCIs) due to the risk of cardiac tamponade. Strikingly, in contrast to numerous analyses of CAP predictors, only few studies were focused on the predictors of tamponade after PCI, once iatrogenic CAP has occurred. Our aim was to search for clinical and periprocedural characteristics, including the coronary artery involved, associated with the development of acute cardiac tamponade among patients experiencing CAP. Methods: From the medical records of nine centers of invasive cardiology in southern Poland, we retrospectively selected 81 patients (80% with acute myocardial infarction) who had iatrogenic CAP with a visible extravasation jet during angiography (corresponding to type III CAP by the Ellis classification, CAP III) over a 15-year period (2005–2019). Clinical, angiographic and periprocedural characteristics were compared between the patients who developed acute cardiac tamponade requiring urgent pericardiocentesis in the cathlab (n = 21) and those with CAP III and without tamponade (n = 60). Results: CAP III were situated in the left anterior descending artery (LAD) or its diagonal branches (51%, n = 41), right coronary artery (RCA) (24%, n = 19), left circumflex coronary artery (LCx) (16%, n = 13), its obtuse marginal branches (7%, n = 6) and left main coronary artery (2%, n = 2). Acute cardiac tamponade occurred in 24% (10 of 41), 21% (4 of 19) and 37% (7 of 19) patients who experienced CAP III in the territory of LAD, RCA and LCx, respectively. There were no significant differences in the need for urgent pericardiocentesis (37%) in patients with CAP III in LCx territory (i.e., the LCx or its obtuse marginal branches) compared to CAP III in the remaining coronary arteries (23%) ( p = 0.24). However, when CAP III in the LCx were separated from CAP III in obtuse marginal branches, urgent pericardiocentesis was more frequently performed in patients with CAP III in the LCx (54%, 7 of 13) compared to subjects with CAP III in an artery other than the LCx (21%, 14 of 68) ( p = 0.03). The direction of this tendency remained consistent regardless of CAP management: prolonged balloon inflation only (n = 26, 67% vs. 13%, p = 0.08) or balloon inflation with subsequent stent implantation (n = 55, 50% vs. 24%, p = 0.13). Besides LCx involvement, no significant differences in other characteristics were observed between patients according to the need of urgent pericardiocentesis. Conclusions: CAP III in the LCx appears to lead to a higher risk of acute cardiac tamponade compared to perforations involving other coronary arteries. This association may possibly be linked to distinct features of LCx anatomy and/or well-recognized delays in diagnosis and management of LCx-related acute coronary syndromes.

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          Most cited references 23

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          Coronary artery spatial distribution of acute myocardial infarction occlusions.

          Acute coronary occlusions leading to ST-segment elevation myocardial infarctions (STEMIs) are due primarily to rupture of atherosclerotic plaques. Present "vulnerable plaque" detection technology focuses on identifying individual plaques with no clear therapeutic plan beyond conventional risk factor reduction. We developed a spatial map of the distribution of acute coronary occlusions to test our hypothesis that plaque ruptures do not occur uniformly throughout the coronary tree. We analyzed 208 consecutive patients who presented to the Brigham and Women's Hospital with STEMI and mapped the location of the acute coronary occlusion. These occlusions were not uniformly distributed throughout each of the major epicardial coronary arteries but tended to cluster within the proximal third of each of the vessels (right coronary artery, P=0.001; left anterior descending artery, P=0.003; left circumflex artery, P=0.001). Furthermore, Poisson regression showed that for each 10-mm increase in distance from the ostium, the risk of an acute coronary occlusion was significantly decreased by 13% in the right coronary artery, 30% in the left anterior descending artery, and 26% in the left circumflex artery. Acute coronary occlusions leading to STEMI tend to cluster in predictable "hot spots" within the proximal third of the coronary arteries. Identification of these high-risk zones for acute coronary occlusions will lead to future advances in vulnerable plaque detection technology and potentially locally directed preventive strategies.
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              Incidence, risk factors, management and outcomes of coronary artery perforation during percutaneous coronary intervention.

              Coronary artery perforation (CP) is a rare, sometimes lethal complication of percutaneous coronary intervention. There are limited controlled contemporary data regarding its predictors, incidence, and outcomes. The aim of this study was to define the incidence, associated factors, and outcomes of CP in the current era of coronary intervention. All patients who had CP during percutaneous coronary intervention at a large tertiary center from January 2001 to December 2008 were identified. Demographic, clinical, and procedural data and outcome variables were obtained. Patients with CP were compared with a randomly assigned control group. Fifty-seven patients with CP were identified among 9,568 interventions performed during the study period (0.59%); these patients were compared with 171 who underwent percutaneous coronary intervention without CP. Vessels were perforated by wires (52.6%), balloons (26.3%), and stents (21.1%). Perforations were classified using the Ellis classification. CP was associated with mortality and tamponade rates of 7% and 16%, respectively, but all these serious complications occurred with grade III perforations. Most grade I and II perforations were managed conservatively. Multivariate analysis identified the treatment of chronic total occlusion as the strongest independent predictor of CP; other independent variables included calcium in the coronary artery that was the site of intervention and non-ST elevation myocardial infarction.

                Author and article information

                J Clin Med
                J Clin Med
                Journal of Clinical Medicine
                21 September 2020
                September 2020
                : 9
                : 9
                [1 ]Students’ Scientific Group at the Second Department of Cardiology, Jagiellonian University Medical College, 30-688 Cracow, Poland; msurdacki1997@ 123456gmail.com (M.A.S.); marcin.major@ 123456student.uj.edu.pl (M.M.)
                [2 ]Second Department of Cardiology, Institute of Cardiology, Jagiellonian University Medical College, 30-688 Cracow, Poland; michal.chyrchel@ 123456uj.edu.pl (M.C.); mcrakows@ 123456cyf-kr.edu.pl (T.R.); l_bryniarski@ 123456poczta.fm (L.B.); surdacki.andreas@ 123456gmx.net (A.S.); mbbartus@ 123456cyfronet.pl (S.B.)
                [3 ]Department of Cardiology and Cardiovascular Interventions, University Hospital, 30-688 Cracow, Poland
                [4 ]Laboratory of Hemodynamics and Invasive Cardiology, District Hospital, 97-500 Radomsko, Poland
                [5 ]Department of Interventional Cardiology, Institute of Cardiology, Jagiellonian University Medical College, 31-202 Cracow, Poland; kleczu@ 123456interia.pl (P.K.); jacek.legutko@ 123456uj.edu.pl (J.L.)
                [6 ]Subcarpathian Cardiovascular Intervention Center, 38-500 Sanok, Poland; wisniewskiandrzej@ 123456yahoo.com
                [7 ]Center for Invasive Cardiology, Electrotherapy and Angiology, 38-400 Krosno, Poland; m.nosal@ 123456intercard.net.pl
                [8 ]Interventional Cardiology Department, District Hospital, 37-450 Stalowa Wola, Poland; mujda@ 123456poczta.onet.pl
                [9 ]Center for Invasive Cardiology, Electrotherapy and Angiology, 33-300 Nowy Sącz, Poland; r.korpak-wysocka@ 123456intercard.net.pl
                [10 ]Center for Invasive Cardiology, Electrotherapy and Angiology, 32-600 Oświęcim, Poland; witowz@ 123456gmail.com
                [11 ]Invasive Cardiology, Electrotherapy and Angiology Center, 27-400 Ostrowiec Świętokrzyski, Poland; mmaliszewski@ 123456gvmcarint.eu
                [12 ]Department of Cardiology, District Hospital, 42-300 Myszków, Poland; marcin.rzeszutko@ 123456uj.edu.pl
                [13 ]Department of Angiology, Jagiellonian University Medical College, 30-688 Cracow, Poland
                Author notes
                [* ]Correspondence: lukasz.rzeszutko@ 123456uj.edu.pl ; Tel.: +48-12-400-2250
                © 2020 by the authors.

                Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license ( http://creativecommons.org/licenses/by/4.0/).



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