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Background: Essential thrombocythemia (ET) is a myeloproliferative neoplasm characterized by uninhibited platelet production. It can present with vasomotor symptoms, and less commonly, severe thrombotic events such as myocardial infarction. ST-segment elevation myocardial infarction (STEMI) secondary to the hypercoagulable state in ET is a diagnostic challenge as the complication is rare, especially outside the typical demographics affected by ET such as the female and elderly populations., Case Presentation: Here we report a case of a 32-year-old male found to have STEMI and a markedly elevated platelet count. Angiography revealed occlusion of the left anterior descending and left circumflex arteries, requiring percutaneous intervention and Impella support. The patient was later diagnosed with essential thrombocythemia, treated with hydroxyurea and antiplatelet therapy, and discharged with a wearable cardioverter defibrillator., Conclusions: This case illustrates the potential for severe thrombotic complications such as STEMI due to ET. Severe thrombotic complications are less common manifestations of ET in general, particularly in young males. Recognition and diagnosis of ET are critical for the institution of appropriate therapy and prevention of STEMI and cardiogenic shock among other complications., (© 2024. The Author(s).)

Background: Thrombus aspiration (TA) is used to decrease large thrombus burden (LTB), but it can cause distal embolization., Objectives: The aim of this study was to investigate the impact of TA failure on defective myocardial perfusion in patients with ST-segment elevation myocardial infarction (STEMI) and LTB., Methods: In total, 812 consecutive patients with STEMI and LTB (thrombus grade ≥3) were enrolled, who underwent manual TA during the primary percutaneous coronary intervention. TA failure was defined as the absence of thrombus retrieval, presence of prestenting thrombus residue, or distal embolization. The final TIMI flow grades and other myocardial perfusion parameters of the failed TA group were matched with those of the successful TA group., Results: The proportion of final TIMI flow grade 3 was lower (74.6% vs 82.2%; P = 0.011) in the failed TA group (n = 279 [34.4%]) than in the successful TA group (n = 533 [65.6%]). The failed TA group also had lower myocardial blush grade, lower ST-segment resolution, and a higher incidence of microvascular obstruction than the successful TA group. TA failure was independently associated with low final TIMI flow grade (risk ratio: 1.525; 95% CI: 1.048-2.218; P = 0.027). Old age, Killip class ≥III, vessel tortuosity, calcification, and a culprit vessel other than the left anterior descending coronary artery were associated with TA failure., Conclusions: TA failure is associated with reduced myocardial perfusion in patients with STEMI and LTB. Advanced age, hemodynamic instability, hostile coronary anatomy such as tortuosity or calcification, and non-left anterior descending coronary artery status might attenuate TA performance. (Gangwon PCI Prospective Registry [GWPCI]; NCT02038127)., Competing Interests: Funding Support and Author Disclosures The authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2024 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Woven coronary artery (WCA) is a rare and underdiagnosed congenital anomaly that involves multiple thin and tortuous epicardial arterial conduits reassembling distally into a single lumen. Recanalized thrombus may present as woven-like coronary arteries, appearing similar to WCA on angiographic images., Case Presentation: A 58-year-old female patient with intermittent chest pain for 5 years and polycythaemia vera (PV) for 8 years. The left anterior descending artery was presented like WCA on coronary angiography and finally confirmed as recanalized thrombus by optical coherence tomography(OCT), which might have been caused by PV. Given the patient's high thrombotic risk of PV and thrombotic changes in the left circumflex artery (LCX), we ultimately chose a conservative treatment without stenting., Conclusions: OCT would be needed for the diagnosis and differential diagnosis of woven-like coronary arteries. And physicians should take an appropriate treatment in a personalized way in patients with PV., (© 2024. The Author(s).)

Competing Interests: Funding Support and Author Disclosures Dr d’Entremont is a Canadian Institutes of Health Research Canada Graduate Scholarship Doctoral awardee. Dr Jolly has received institutional grants from Boston Scientific; and has received honoraria from Penumbra, Teleflex, Boston Scientific, Shockwave, and Abiomed. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Background: Patients with acute myocardial infarction (AMI) and large thrombus burden (LTB) still represent a challenge. Afflicted patients have a high morbidity and mortality. Aspiration thrombectomy is often ineffective in those cases. Mechanical thrombectomy devices (MTDs), which are effective for management of ischemic strokes, were recently CE-approved for treatment of thrombotic coronary lesions. Real-world data about their performance in AMI cases with LTB are scarce. This study sought to summarize our early experience with a novel MTD device in this context., Methods: We analyzed consecutive patients from the prospective OPTIMISER registry (NCT04988672), who have been managed with the NeVa™ MTD (Vesalio, USA) for AMI with LTB at a tertiary cardiology facility. Outcomes of interest included, among others, periprocedural complications, target lesion failure (TLF), target lesion revascularization (TLR) and target vessel myocardial infarction (TV-MI)., Results: Overall, 15 patients underwent thrombectomy with the NeVa™ device. Thrombectomy was successfully performed in 14 (93%) patients. Final TIMI 3 flow was achieved in 13 (87%) patients, while 2 (13%) patients had TIMI 2 flow. We encountered no relevant periprocedural complications, especially no stroke, stent thrombosis or vessel closure. After a mean follow-up time of 26 ± 2.9 months, 1 (7%) patient presented with TLR due to stent thrombosis (10 months after treatment with the MTD and stenting)., Conclusions: In AMI patients with LTB, the deployment of the novel NeVa™ MTD seems efficient and safe. Further randomized trials are warranted to assess whether the use of the NeVa™ device in cases with LTB improves procedural and clinical outcomes., (© 2024. The Author(s).)

Objectives: It is uncertain, if omitting post-dilatation and stent oversizing (stent optimization) is safe and may decrease the risk for distal thrombus embolization (DTE) in STEMI patients with large thrombus burden (LTB)., Background: In patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (pPCI) with stenting, (DTE) and flow deterioration are common and increase infarct size leading to worse outcomes., Methods: From a prospective registry, 74 consecutive STEMI patients with LTB undergoing pPCI with stenting and intentionally deferred stent optimization were analyzed. Imaging data and outcomes up to 2 years follow-up were analyzed., Results: Overall, 74 patients (18% females) underwent deferred stent optimization. Direct stenting was performed in 13 (18%) patients. No major complications occurred during pPCI. Staged stent optimization was performed after a median of 4 (interquartile range (IQR) 3; 7) days. On optical coherence tomography, under-expansion and residual thrombus were present in 59 (80%) and 27 (36%) cases, respectively. During deferred stent optimization, we encountered no case of flow deterioration (slow or no-reflow) or side branch occlusion. Minimal lumen area (mm 2 ) and stent expansion (%) were corrected from 4.87±1.86mm to 6.82±2.36mm (p<0.05) and from 69±18% to 91±12% (p<0.001), respectively. During follow-up, 1 patient (1.4%) required target lesion revascularization and 1 (1.4%) patient succumbed from cardiovascular death., Conclusions: Among STEMI patients with LTB, deferring stent optimization in the setting of pPCI appears safe and potentially mitigates the risk of DTE. The impact of this approach on infarct size and clinical outcomes warrants further investigation in a dedicated trial., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Manual Thrombus Aspiration (MTA) reduces thrombus burden and improves myocardial reperfusion markers in patients with ST-segment elevation myocardial infarction (STEMI), however its clinical benefit is controversial due to conflicting results from randomized clinical trials, which is why the benefit of its application during primary angioplasty (PA) remains uncertain. Reports such as that of Doo Sun Sim, et al. suggest that the impact of MTA may become clinically relevant in patients with a longer total ischemia time. 1 We present the case of an adult male, with multiple risk factors for coronary disease, with lower STEMI, due to occlusion of the right coronary artery with a heavy thrombus load and an ischemia time of 10 hours. It was successfully treated by MTA, removing abundant intracoronary thrombus and obtaining a TIMI III flow, without requiring stent implantation. The case, the evolution and the current knowledge regarding the use of AT are discussed. Our case report and review of five cases with similar characteristics in the literature illustrate the use of MTA in patients with STEMI, high thrombus burden, and prolonged ischemia time., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023. Published by Elsevier Inc.)

Background: Acute arterial embolism due to tumor embolus is a rare complication in cancer patients, even rarer is lung tumor embolization leading to acute myocardial infarction. We report a patient who had a diagnosis of acute myocardial infarction(AMI)which was brought on by a coronary artery embolism by a metastatic lung cancer tumor. Clinicians need to be aware that tumor embolism can result in AMI., Case Presentation: An 80-yeal-old male patient presented with persistent chest pain for 2 h and his electrocardiogram(ECG)showed anterior ST-segment elevation myocardial infarction. Instead of implanting a stent, thrombus aspiration was performed. Pathological examination of coronary artery thrombosis showed that a few sporadic atypical epithelial cells were scattered in the thrombus-like tissue. Combined with immune phenotype and clinical history, metastatic squamous cell carcinoma is more likely., Conclusions: We report a rare case of a patient who was diagnosed of AMI due to a coronary artery embolism by a metastatic mass from lung cancer. Since there is no evidence-based protocol available for the treatment of isolated coronary thrombosis, we used thrombus aspiration to treat thrombosis rather than implanting a stent., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Introduction and Objectives: Current guidelines do not recommend routine thrombus aspiration in acute myocardial infarction (AMI) because no benefits were observed in previous randomized trials. However, there are limited data in cardiogenic shock (CS) complicating AMI., Methods: We included 575 patients with AMI complicated by CS. The participants were stratified into the TA and no-TA groups based on use of TA. The primary outcome was a composite of 6-month all-cause death or heart failure rehospitalization. The efficacy of TA was additionally assessed based on thrombus burden (grade I-IV vs V)., Results: No significant difference was found in in-hospital death (28.9% vs 33.5%; P=.28), or 6-month death, or heart failure rehospitalization (32.4% vs 39.4%; HR adj : 0.80; 95%CI, 0.59-1.09; P=.16) between the TA and no-TA groups. However, in 368 patients with a higher thrombus burden (grade V), the TA group had a significantly lower risk of 6-month all-cause death or heart failure rehospitalization than the no-TA group (33.4% vs 46.3%; HR adj : 0.59; 95%CI, 0.41-0.85; P=.004), with significant interaction between thrombus burden and use of TA for primary outcome (adjusted P int =.03)., Conclusions: Routine use of TA did not reduce short- and mid-term adverse clinical outcomes in patients with AMI complicated by CS. However, in select patients with a high thrombus burden, the use of TA might be associated with improved clinical outcomes. The study was registered at ClinicalTrials.gov (Identifier: NCT02985008)., (Copyright © 2023 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.)

Background: ST-elevation myocardial infarction (STEMI) is typically caused by thrombotic occlusion of a coronary artery with subsequent hypoperfusion and myocardial necrosis. In approximately half of patients with STEMI, despite successful restoration of epicardial coronary patency, downstream myocardium perfusion remains impeded. Coronary microvascular injury is one of the key mechanisms behind suboptimal myocardial perfusion and it is primarily, yet not exclusively, related to distal embolization of atherothrombotic material following recanalization of the culprit artery. Routine manual thrombus-aspiration has failed to show clinical efficacy in this scenario. This could be related with limitations in technology adopted as well as patients' selection. To this end, we set out to explore the efficacy and safety of stent retriever-assisted thrombectomy based on clot-removal device routinely used in stroke intervention., Study Design and Objectives: The stent RETRIEVEr thrombectomy for thrombus burden reduction in patients with Acute Myocardial Infarction (RETRIEVE-AMI) study has been designed to establish whether stent retriever-based thrombectomy is safe and more efficacious in thrombus modification than the current standard of care: manual thrombus aspiration or stenting. The RETRIEVE-AMI trial will enrol 81 participants admitted for primary PCI for inferior STEMI. Participants will be 1:1:1 randomised to receive either standalone PCI, thrombus aspiration and PCI, or retriever-based thrombectomy and PCI. Change in thrombus burden will be assessed via optical coherence tomography imaging. A telephone follow-up at 6 months will be arranged., Conclusions: It is anticipated by the investigators that stent retriever thrombectomy will more effectively reduce the thrombotic burden compared to current standard of care whilst being clinically safe., Competing Interests: Declaration of competing interest Rafail A Kotronias reports grants from Medtronic and Terumo Inc. in relation to the submitted work during the conduct of the study. Prof. Banning reports grants from Boston Scientific, personal fees from Boston Scientific, personal fees from Abbott, personal fees from Medtronic, personal fees from Phillips, outside the submitted work. Dr. De Maria reports grants from Medtronic, grants from Terumo, during the conduct of the study in relation to the submitted work. Dr. De Maria reports grants, personal fees and speaker fees from Miracor Medical SA, speaker fees from Abbott, grants from Opsens, grants from Hexacath, grants from Medis, outside the submitted work., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: The diagnosis and management of myocardial infarction are increasingly complex, and establishing the presence of intracoronary thrombosis has major implications for both the classification and treatment of myocardial infarction., Objectives: The aim of this study was to investigate whether positron emission tomographic (PET) and computed tomographic (CT) imaging could noninvasively detect in vivo thrombus formation in human coronary arteries using a novel glycoprotein IIb/IIIa receptor antagonist-based radiotracer, 18 F-GP1., Methods: In a single-center observational case-control study, patients with or without acute myocardial infarction underwent coronary 18 F-GP1 PET/CT angiography. Coronary artery 18 F-GP1 uptake was assessed visually and quantified using maximum target-to-background ratios., Results: 18 F-GP1 PET/CT angiography was performed in 49 patients with and 50 patients without acute myocardial infarction (mean age: 61 ± 9 years, 75% men). Coronary 18 F-GP1 uptake was apparent in 39 of the 49 culprit lesions (80%) in patients with acute myocardial infarction. False negative results appeared to relate to time delays to scan performance and low thrombus burden in small-caliber distal arteries. On multivariable regression analysis, culprit vessel status was the only independent variable associated with higher 18 F-GP1 uptake. Extracoronary cardiac 18 F-GP1 findings included a high frequency of infarct-related intramyocardial uptake (35%) as well as left ventricular (8%) or left atrial (2%) thrombus., Conclusions: Coronary 18 F-GP1 PET/CT angiography is the first noninvasive selective technique to identify in vivo coronary thrombosis in patients with acute myocardial infarction. This novel approach can further define the role and location of thrombosis within the heart and has the potential to inform the diagnosis, management, and treatment of patients with acute myocardial infarction. (In-Vivo Thrombus Imaging With 18 F-GP1, a Novel Platelet PET Radiotracer [iThrombus]; NCT03943966)., Competing Interests: Funding Support and Author Disclosures The Edinburgh Clinical Research Facilities and Edinburgh Imaging facility is supported by the National Health Service Research Scotland through the National Health Service Lothian Health Board. This work was supported by several grant funding organizations. Drs Tzolos (FS/CRTF/20/24086), Williams (FS/ICRF/20/26002, FS/11/014, and CH/09/002), Newby (CH/09/002, RG/16/10/32375, and RE/18/5/34216), and Dweck (FS/14/78/31020) are supported by the British Heart Foundation. Dr Newby is the recipient of a Wellcome Trust Senior Investigator Award (WT103782AIA). Dr van Beek is supported by the Scottish Imaging Network: A Platform of Scientific Excellence. Dr Mills is supported by the British Heart Foundation through the award of Personal Chair and a Programme Grant (CH/F/21/90010 and RG/20/10/34966). Dr Dweck is supported by the Sir Jules Thorn Biomedical Research Award 2015 (15/JTA). Dr Slomka and FusionQuant analysis tools are supported by National Heart, Lung, and Blood Institute grant 5R01HL135557. Dr Dey and Autoplaque analysis tools are supported by National Heart, Lung, and Blood Institute grant 1R01HL148787-01A1. Drs Koglin and Stephens are employees of Life Molecular Imaging, which provided reagents for radiotracer production. Dr Williams is a member of the Speakers Bureau for Canon Medical Systems. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2023 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Cardiac computed tomography angiography (CCTA) is precise in noninvasive coronary atherosclerosis characterization but its value in the diagnosis of intracoronary thrombus remains unknown. Therefore, our aim was to evaluate CCTA for intracoronary thrombus and stenosis detection in patients with acute coronary syndromes with high thrombus burden selected for a deferred stenting strategy., Methods: We systematically performed a CCTA in consecutive patients following a deferred stenting strategy, 24 h before the scheduled repeated coronary angiography including optical coherence tomography (OCT) imaging. Intracoronary thrombus and residual stenosis were blindly and independently evaluated by both techniques. Agreement was determined per lesion using the weighted Kappa ( K ) coefficient and absolute intraclass correlation coefficient (ICC). A stratified analysis according to OCT-detected thrombus burden was also performed., Results: Thirty lesions in 28 consecutive patients were analyzed. Concordance between CCTA and repeated coronary angiography in thrombus detection was good ( K  = 0.554; P  < 0.001), but both showed poor agreement with OCT. CCTA needed >11.5% thrombus burden on OCT to obtain adequate diagnostic accuracy. The lesions detected by angiography were more frequently classified as red thrombus (76.5 vs. 33.3%; P  = 0.087) on OCT. CCTA showed an excellent concordance with coronary angiography in diameter measurement (ICC = 0.85; P  < 0.001) and was able to identify all the patients with severe residual stenosis., Conclusions: Although CCTA showed just a good concordance with angiography in intracoronary thrombus detection, the agreement in residual stenosis was excellent. Thus, in patients with a high-thrombus burden selected for a deferred stenting strategy CCTA may substitute repeat angiography., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

The identification of intracoronary thrombus and atherothrombosis is central to the diagnosis of acute myocardial infarction, with the differentiation between type 1 and type 2 myocardial infarction being crucial for immediate patient management. Invasive coronary angiography has remained the principal imaging modality used in the investigation of patients with myocardial infarction. More recently developed invasive intravascular imaging approaches, such as angioscopy, intravascular ultrasound and optical coherence tomography, can be used as adjunctive imaging modalities to provide more direct visualisation of coronary atheroma and the causes of myocardial infarction as well as to improve the sensitivity of thrombus detection. However, these invasive approaches have practical and logistic constraints that limit their widespread and routine application. Non-invasive angiographic techniques, such as CT and MRI, have become more widely available and have improved the non-invasive visualisation of coronary artery disease. Although they also have a limited ability to reliably identify intracoronary thrombus, this can be overcome by combining their anatomical and structural characterisation of coronary anatomy with positron emission tomography. Specific radiotracers which bind with high specificity and sensitivity to components of thrombus, such as activated platelets, fibrin and factor XIIIa, hold promise for the non-invasive detection of intracoronary thrombus. The development of these novel non-invasive approaches has the potential to inform clinical decision making and patient management as well as to provide a non-invasive technique to assess the efficacy of novel antithrombotic therapies or interventional strategies. However, these have yet to be realised in routine clinical practice., Competing Interests: Competing interests: MCW has given talks for Canon Medical Systems and Siemens Healthineers. MRD and DEN are on the Editorial Board for BMJ Heart., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Poor myocardial reperfusion due to distal embolization and microvascular obstruction after percutaneous coronary intervention is associated with increased risk of morbidity and mortality. Prior trials have not shown a clear benefit of routine manual aspiration thrombectomy. Sustained mechanical aspiration may mitigate this risk and improve outcomes. The objective of this study is to evaluate sustained mechanical aspiration thrombectomy before percutaneous coronary intervention in high thrombus burden acute coronary syndrome patients., Methods: This prospective study evaluated the Indigo CAT RX Aspiration System (Penumbra Inc, Alameda CA) for sustained mechanical aspiration thrombectomy before percutaneous coronary intervention at 25 hospitals across the USA. Adults presenting within 12 hours of symptom onset with high thrombus burden and target lesion(s) located in a native coronary artery were eligible. The primary end point was a composite of cardiovascular death, recurrent myocardial infarction, cardiogenic shock, or new or worsening New York Heart Association class IV heart failure within 30 days. Secondary end points included Thrombolysis in Myocardial Infarction thrombus grade, Thrombolysis in Myocardial Infarction flow, myocardial blush grade, stroke, and device-related serious adverse events., Results: From August 2019 through December 2020, a total of 400 patients were enrolled (mean age 60.4 years, 76.25% male). The primary composite end point rate was 3.60% (14/389 [95% CI, 2.0-6.0%]). Rate of stroke within 30 days was 0.77%. Final rates of Thrombolysis in Myocardial Infarction thrombus grade 0, Thrombolysis in Myocardial Infarction flow 3, and myocardial blush grade 3 were 99.50%, 97.50%, and 99.75%, respectively. No device-related serious adverse events occurred., Conclusions: Sustained mechanical aspiration before percutaneous coronary intervention in high thrombus burden acute coronary syndrome patients was safe and was associated with high rates of thrombus removal, flow restoration, and normal myocardial perfusion on final angiography.

Competing Interests: Funding Support and Author Disclosures Prof Valgimigli has received grants and/or personal fees from AstraZeneca, Terumo, Alvimedica/CID, Abbott Vascular, Daiichi Sankyo, Bayer, CoreFLOW, Idorsia Pharmaceuticals-Ltd, Universität Basel Department Klinische Forschung, Vifor, Bristol Myers Squibb SA, Biotronik, Boston Scientific, Medtronic, Vesalio, Novartis, Chiesi, and PhaseBio, outside the submitted work. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Objectives: Here we investigate the safety and efficacy of a continuous mechanical aspiration system when used before percutaneous coronary intervention (PCI) in patients with acute coronary syndrome (ACS)., Background: Historically, trials of routine manual aspiration thrombectomy in ACS patients have reported mixed results. This may be due to the technical limitations of manual aspiration, which suffers from decreasing vacuum power as aspiration is performed., Methods: This is a retrospective case series of all patients treated with continuous mechanical aspiration (Indigo CAT RX Aspiration System; Penumbra Inc.) before PCI between August 2017 and July 2020 at five centers in the United States. Data regarding angiographic assessments, procedure, and safety were examined., Results: Seventy-two patients (mean age 60 ± 12.5 years, 34.7% female) with ST Elevation Myocardial Infarction (STEMI) (80.6%) or Non-ST Elevation Myocardial Infarction (NSTEMI) (19.4%) were included. Target vessels were the right coronary (43.1%), left anterior descending (33.3%), and left circumflex (23.6%). Preprocedure, 94.4% had a high thrombus burden (thrombolysis in myocardial infarction [TIMI] thrombus grade ≥ 3). Median aspiration time was 35 s and median access-to-reperfusion time was 10 min. After CAT RX alone, 86.1% had complete perfusion (TIMI flow grade 3). After the procedure, 94.4% had TIMI thrombus grade <3% and 97.2% had TIMI flow grade 3. There were no cases of ischemic stroke. Cardiovascular mortality at 30 days was 1.4%., Conclusions: In our initial experience, aspirating thrombus from ACS patients using the Indigo CAT RX Aspiration System before PCI was safe and effective for reducing thrombus burden and restoring flow., (© 2022 Wiley Periodicals LLC.)

Background: Women have a worse prognosis after ST-segment elevation myocardial infarction (STEMI) than men. The prognostic role of thrombus burden (TB) in influencing the sex-related differences in clinical outcomes after STEMI has not been clearly investigated., Objectives: The aim of this study was to assess the sex-related differences in TB and its clinical implications in patients with STEMI., Methods: Individual patient data from the 3 major randomized clinical trials of manual thrombus aspiration were analyzed, encompassing a total of 19,047 patients with STEMI, of whom 13,885 (76.1%) were men and 4,371 (23.9%) were women. The primary outcome of interest was 1-year cardiovascular (CV) death. The secondary outcomes of interest were recurrent myocardial infarction, heart failure, all-cause mortality, stroke, stent thrombosis (ST), and target vessel revascularization at 1 year., Results: Patients with high TB (HTB) had worse 1-year outcomes compared with those presenting with low TB (adjusted HR for CV death: 1.52; 95% CI: 1.10-2.12; P = 0.01). In unadjusted analyses, female sex was associated with an increased risk for 1-year CV death regardless of TB. After adjustment, the risk for 1-year CV death was higher only in women with HTB (HR: 1.23; 95% CI: 1.18-1.28; P < 0.001), who also had an increased risk for all-cause death and ST than men., Conclusions: In patients with STEMI, angiographic evidence of HTB negatively affected prognosis. Among patients with HTB, women had an excess risk for ST, CV, and all-cause mortality than men. Further investigations are warranted to better understand the pathophysiological mechanisms leading to excess mortality in women with STEMI and HTB., Competing Interests: Funding Support and Author Disclosures Dr Manzi has received a research grant from the European Society of Cardiology during the conduct of this study. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Thrombus aspiration (TA) has been considered a procedure for controlling distal emboli and improving microvascular perfusion. However, current guidelines classify routine TA as class III recommendation, and it has been reported that the efficacy of TA is limited because of the relatively high incidence of failure in retrieval of thrombotic material. The aim of this study was to explore patient characteristics and procedural factors associated with successful TA in ST-elevation myocardial infarction (STEMI) and to assess the clinical impact of successful TA., Methods: This single-center retrospective study enrolled 158 STEMI patients who underwent TA as initial recanalization. Factors associated with successful TA, which was defined as retrieving any visible material by aspiration catheter, were explored, and angiographical and short-term outcomes were assessed., Results: In 146 cases (92.4%), the aspiration catheter reached the culprit lesion. Successful TA was achieved in 72 cases (45.6%). The single angiographical characteristic of successful TA was a higher Thrombolysis in Myocardial Infarction grade before TA. Among the procedural characteristics, the rate of successful TA was higher with a 7-French aspiration catheter compared with the rate with a 6-French catheter (57.1% vs. 29.9%, P  = 0.01). Thrombolysis in Myocardial Infarction grade 3 flow was more frequent in patients with successful TA immediately after TA (36.1% vs. 16.3%, P  = 0.006) and at final angiography (91.7% vs 79.1%, P  = 0.04) compared with the grade in patients without successful TA, respectively., Conclusions: The use of a larger aspiration catheter may be effective in retrieving visible thrombus material, and successful TA led to better angiographical results., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: This study investigated the relationship between coronary collateral circulation (CCC) and intracoronary thrombus burden in patients undergoing primary percutaneous coronary intervention for ST-segment elevation myocardial infarction (STEMI). CCC and thrombus burden are predictive of clinical outcomes in patients with STEMI., Methods: Patients with STEMI undergoing primary percutaneous coronary intervention were enrolled (n = 172). CCC was graded according to the Cohen-Rentrop classification. Patients were classified as insufficient (grade 0 or 1, n = 134) or well-developed (grade 2 or 3; n = 38) CCC. The Thrombolysis in Myocardial Infarction scale was used to evaluate intra-coronary thrombus burden. The low-thrombus-burden group comprised those with grades 0 to 2, and the high-thrombus-burden group comprised those with grades 3 or 4., Results: Right coronary artery infarcts had a 13.830-fold higher chance of having well-developed CCC than did left anterior descending artery infarcts (P &lt; .001). Circumflex artery infarcts had a 7.904-fold higher chance of well-developed CCC than did left anterior descending artery infarcts (P = .016). High thrombus burden was associated with a 4.393-fold higher chance for well-developed CCC than was low thrombus burden (P = .030). Low albumin levels were related to a greater chance of having well-developed CCC (P = .046)., Conclusion: Patients with well-developed CCC have higher thrombus burden than do those with insufficient CCC. Because well-developed CCC is an indicator of more severe underlying lesions, we speculate that patients with severe lesions are more prone to experience more complicated STEMI with high thrombus burden., (© 2022 by the Texas Heart® Institute, Houston.)

To increase confidence in the use of observational analyses when addressing effectiveness questions beyond those addressed by randomized trials, one can first benchmark the observational analyses against existing trial results. We used Swedish registry data to emulate a target trial similar to the Thrombus Aspiration in ST-Elevation Myocardial Infarction in Scandinavia (TASTE) randomized trial, which found no difference in the risk of death or myocardial infarction by 1 year with or without thrombus aspiration among individuals with ST-elevation myocardial infarction. We benchmarked the emulation against the trial at 1 year and then extended the emulation's follow-up to 3 years and estimated effects in subpopulations underrepresented in the trial. As in the TASTE trial, the observational analysis found no differences in risk of outcomes by 1 year between groups (risk difference = 0.7 (confidence interval, -0.7, 2.0) and -0.2 (confidence interval, -1.3, 1.0) for death and myocardial infarction, respectively), so benchmarking was considered successful. We additionally showed no difference in risk of death or myocardial infarction by 3 years, or within subpopulations by 1 year. Benchmarking against an index trial before using observational analyses to answer questions beyond those the trial could address allowed us to explore whether the observational data can be trusted to deliver valid estimates of treatment effects., (© The Author(s) 2022. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health.)

Aims:  The mechanisms of coronary thrombosis can influence prognosis after ST-elevation myocardial infarction (STEMI) and allow for different treatment groups to be identified; an association between neutrophil extracellular traps (NETs) and unfavorable clinical outcomes has been suggested. Our aim was to determine the role played by NETs in coronary thrombosis and their influence on prognosis. The role of other histological features in prognosis and the association between NETs and bacteria in the coronary thrombi were also explored., Methods and Results:  We studied 406 patients with STEMI in which coronary thrombi were consecutively obtained by aspiration during angioplasty between 2012 and 2018. Analysis of NETs in paraffin-embedded thrombi was based on the colocalization of specific NET components by means of confocal microscopy. Immunohistochemistry stains were used to identify plaque fragments. Fluorescence in situ hybridization was used to detect bacteria.NETs were detected in 51% of the thrombi (NET density, median [interquartile range]: 25% [17-38%]). The median follow-up was 47 months (95% confidence interval [CI] 43-51); 105 (26%) patients experienced major adverse cardiac events (MACE). A significant association was found between the presence of NETs in coronary aspirates and the occurrence of MACE in the first 30 days after infarction (hazard ratio 2.82; 95% CI 1.26-6.35, p  = 0.012), mainly due to cardiac deaths and stent thrombosis., Conclusion:  The presence of NETs in coronary thrombi was associated with a worse prognosis soon after STEMI. In some patients, NETs could be a treatment target and a feasible way to prevent reinfarction., Competing Interests: None declared., (Thieme. All rights reserved.)

COVID-19 has been associated with cardiovascular events. This case demonstrates severe left main coronary artery thrombosis with distal embolisation in a young male patient admitted with COVID-19 who developed ST-elevation myocardial infarction. The patient was treated with thrombus aspiration combined with aggressive anticoagulant treatment, which yielded complete resolution of the thrombus. Left main thrombus represents a life-threatening coronary event and is most often associated with atherosclerotic plaque rupture. In this case, however, we suspect that COVID-19-related intimal inflammation and hypercoagulopathy might be the causal mechanism of thrombus formation. Revascularisation with coronary artery bypass grafting or percutaneous coronary intervention is the standard treatment of left main thrombosis. However, due to the patient's young age and lack of significant atherosclerotic disease burden, we used a conservative medical treatment strategy using potent antithrombotic therapy., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: The impact of adjunctive manual thrombus aspiration (TA) in patients with stent thrombosis (ST) treated with percutaneous intervention has not been evaluated in the current era of potent P2Y12 agents and new-generation drug-eluting stents. We sought to assess the effect of TA using data from a large contemporary registry., Methods: The study population was derived from the Essex ST Investigation Registry (ESTHIR), which contains all consecutive cases of angiographically determined definite ST undergoing interventional treatment in a tertiary cardiac centre between November 2015 and June 2018. Propensity score matching was performed to match patients who underwent TA (TA group) to those who did not (n-TA group). The study endpoints were final TIMI flow and survival free of cardiovascular death (CD) or target lesion revascularisation (TLR)., Results: A total of 128 ST patients were included in the present analysis. The mean age was 65 ± 11 years, and 84% were male. About 90% of the patients presented with STEMI, and 85% had very late ST. Seventy-two patients (56%) underwent TA. After propensity score matching, 30 patients were included in each study group. A higher rate of final TIMI III flow was observed in the TA group (TA vs n-TA group, 100% vs 83%), but this difference did not reach statistical significance (p = 0.052). At 1000 days of follow-up, survival free of CD or TLR was not different between the two groups (p = 0.8)., Conclusion: In a propensity-matched population of ST patients undergoing PCI in a contemporary setting, TA was not associated with improved final TIMI flow or long-term cardiovascular outcomes., (Copyright © 2022 Hellenic Society of Cardiology. Published by Elsevier B.V. All rights reserved.)

We assessed the effect of thrombus aspiration (TA) during percutaneous coronary intervention (PCI) on in-hospital and 3-year mortality in consecutive non-ST segment elevation myocardial infarction (n = 189) and unstable angina pectoris (n = 148) patients (n = 337) between 2011 and 2016. In total, 153 patients (45.4%) underwent TA. The number of patients with postoperative thrombolysis in terms of myocardial infarction grade 3 blood flow ( P < .001) and myocardial blush grade 3 ( P < .001) were significantly higher in all TA groups. At 6-, 12- and 24-month post-PCI, the mean left ventricular ejection fraction was significantly higher in the all TA groups versus the stand alone PCI group ( P < .001). Thrombus aspiration was associated with a significant improvement both in epicardial flow, myocardial perfusion and left ventricular ejection fraction. Thrombus aspiration during PCI in all acute coronary syndrome (except ST segment elevation) patients was associated with better survival compared with stand alone PCI group at 3-year follow-up ( P = .019).

Background: Simultaneous thrombosis in more than one coronary artery is an uncommon angiographic finding in patients with acute ST-segment elevation myocardial infarction. It is difficult to identify using 12-lead electrocardiography and usually leads to cardiogenic shock and fatal outcomes, including sudden cardiac death. Therefore, immediate revascularization and adequate mechanical circulatory support are required., Case Presentation: We report the case of a 58-year-old man who presented with vomiting and chest pain complicated by cardiogenic shock and complete atrioventricular block. Electrocardiography revealed ST-segment elevation in leads II, III, aVF, and V1-V6. Emergency coronary angiography revealed total occlusion of the proximal left anterior descending artery and right coronary artery. The patient successfully underwent primary percutaneous coronary intervention with ballooning and stenting for both arteries. An Impella CP was inserted during the procedure. Fifty-seven days after admission, he had New York Heart Association class II heart failure and was transferred to a rehabilitation hospital., Conclusions: Acute double-vessel coronary thrombosis, a serious event with a high mortality rate, requires prompt diagnosis and management to prevent complications such as cardiogenic shock and ventricular arrhythmias. A combination of judicious medical treatment, efficient primary percutaneous coronary intervention, and early mechanical support device insertion is crucial to improve the survival rate of patients with this disease., (© 2022. The Author(s).)

Background: It is unclear whether more effective forms of thrombus removal than current aspiration catheters would lead to improved outcomes. We sought to evaluate the prognostic role of residual thrombus burden (rTB), after manual thrombectomy, in patients undergoing primary percutaneous coronary intervention with routine manual thrombectomy in the TOTAL trial (Thrombectomy Versus PCI Alone)., Methods: This is a single-arm analysis of patients from the TOTAL trial who underwent routine manual aspiration thrombectomy. The rTB was quantified by an angiographic core laboratory using the Thrombolysis in Myocardial Infarction criteria and validated using existing optical coherent tomography data. Large rTB was defined as grade ≥3. The primary outcome was death from cardiovascular causes, recurrent myocardial infarction, cardiogenic shock, or new or worsening heart failure within 180 days., Results: Of 5033 patients randomized to routine thrombectomy, 2869 patients had quantifiable rTB (1014 [35%] had large rTB). Patients with large rTB were more likely to have hypertension, previous percutaneous coronary intervention, myocardial infarction, or Killip class III on presentation but less likely to have Killip class I. The primary outcome occurred more frequently in patients with large rTB, even after adjustment for known risk predictors (8.6% versus 4.6%; adjusted hazard ratio, 1.83 [95% CI, 1.34-2.48]). These patients also had a higher risk of cardiovascular death (adjusted hazard ratio, 1.83 [95% CI, 1.13-2.95]), cardiogenic shock (adjusted hazard ratio, 2.02 [95% CI, 1.08-3.76]), and heart failure (adjusted hazard ratio, 1.74 [95% CI, 1.02-2.96]) but not myocardial infarction or stroke., Conclusions: Large rTB is a common finding in primary percutaneous coronary intervention and is associated with increased risk of adverse cardiovascular outcomes, including cardiovascular death. Future technologies offering better thrombus removal than current devices may decrease or even eliminate the risk associated with rTB. This, potentially, can turn into a strategic option to be studied in clinical trials., Registration: URL: https://www., Clinicaltrials: gov; Unique identifier: NCT01149044.

Background: Neonatal myocardial infarction is rare and is associated with a high mortality of 40% to 50%. We report our experience with neonatal myocardial infarction, including presentation, management, outcomes, and our current patient management algorithm., Methods: We reviewed all infants admitted with a diagnosis of coronary artery thrombosis, coronary ischemia, or myocardial infarction between January 2015 and May 2021., Results: We identified 21 patients (median age, 1 [interquartile range (IQR), 0.25-9.00] day; weight, 3.2 [IQR, 2.9-3.7] kg). Presentation included respiratory distress (16), shock (3), and murmur (2). Regional wall motion abnormalities by echocardiogram were a key criterion for diagnosis and were present in all 21 with varying degrees of depressed left ventricular function (severe [8], moderate [6], mild [2], and low normal [5]). Ejection fraction ranged from 20% to 54% (median, 43% [IQR, 34%-51%]). Mitral regurgitation was present in 19 (90%), left atrial dilation in 15 (71%), and pulmonary hypertension in 18 (86%). ECG was abnormal in 19 (90%). Median troponin I was 0.18 (IQR, 0.12-0.56) ng/mL. Median BNP (B-type natriuretic peptide) was 2100 (IQR, 924-2325) pg/mL. Seventeen had documented coronary thrombosis by cardiac catheterization. Seventeen (81%) were treated with intracoronary tPA (tissue-type plasminogen activator) followed by systemic heparin, AT (antithrombin), and intravenous nitroglycerin, and 4 (19%) were treated with systemic heparin, AT, and intravenous nitroglycerin alone. Nineteen of 21 recovered. One died (also had infradiaphragmatic total anomalous pulmonary venous return). One patient required a ventricular assist device and later underwent heart transplant; this patient was diagnosed late at 5 weeks of age and did not respond to tPA. Nineteen of 21 (90%) regained normal left ventricular function (ejection fraction, 60%-74%; mean, 65% [IQR, 61%-67%]) at latest follow-up (median, 6.8 [IQR, 3.58-14.72] months). Two of 21 (10%) had residual trivial mitral regurgitation. After analysis of these results, we present our current algorithm, which developed and matured over time, to manage neonatal myocardial infarction., Conclusions: We experienced a lower mortality rate for infants with neonatal infarction than that reported in the literature. We propose a post hoc algorithm that may lead to improvement in patient outcomes following coronary artery thrombus.

Thrombotic coronary artery occlusions usually manifest as acute coronary syndrome with cardiogenic shock, acute pulmonary edema, cardiac arrest, fatal arrhythmias, or sudden cardiac death. Although it usually occurs based on atherosclerosis, it can also occur without atherosclerosis. There is no predictor of coronary artery thrombosis clinically and no consensus regarding the optimal treatment. In the current literature, treatment options include emergency coronary artery bypass grafting, entrapment of thrombus in vessel wall with stent implantation, intracoronary thrombolysis, glycoprotein IIb/IIIa inhibitors, anticoagulation with heparin, and thrombus aspiration as reperfusion strategies. Here, we reviewed a new treatment strategy based on the literature, and a case series with successful results in hemodynamically stable patients with low-dose slow infusion tissue plasminogen activator (tPA) for thrombotic coronary artery occlusions that allow coronary flow was reported. Prospective randomized studies and common consensus are needed on low-dose, slow-infusion tissue plasminogen activator treatment regimen and optimal treatment management for thrombotic coronary artery occlusions.

Competing Interests: Funding Support and Author Disclosures The authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Since the start of the COVID-19 pandemic, several cases have reported extensive multivessel coronary thrombosis as a cardiovascular manifestation of SARS-CoV-2 infection. This case describes a patient who developed non-ST elevation myocardial infarction during hospitalization for acute hypoxic respiratory failure due to COVID-19. We review the immediate and delayed revascularisation strategies of culprit and non-culprit lesions in the setting of high intracoronary thrombus burden induced by SARS-CoV-2. Successful percutaneous intervention and stenting of a culprit lesion and resolution of an intracoronary thrombus using a delayed strategy of lesion passivation with adjuvant pharmacotherapy are demonstrated on index and follow-up angiography., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Intra coronary thrombus is  frequently encountered during acute coronary syndromes revascularisation procedures. It can also be encountered during angioplasty procedures in a stable angina context, although at a much lesser frequency.In both situations, it harbors a risk of poor angiographic result and poor prognosis. Intracoronnary thrombus may cause coronary occlusion at the angioplasty site or distal embolic  flow obstruction. Per procedure thrombus prevention rests on an prior optimal anti thrombotic treatment and in some circumstances the choice to defer the revascularisation procedure in the complex high risk setting. Treating the initiated thrombus remains controversial concerning thrombectomy and GPIIBIIIa inhibitors which are still in use in common practice. No reflow phenomenon is a particularly complex setting during cornary angioplasties, partially but not solely related to a thrombotic complication. It's treatment remains unclear in the absence of related oriented studies.The current mechanical and pharmacological antithrombotic therapies must remain common practice and used appropriately as of the clinical and angiographic setting, until further scientific outbrakes., (Copyright © 2021 Elsevier Masson SAS. All rights reserved.)

A coronary artery aneurysm (CAA) is an uncommon clinical finding with an incidence of <5% in adults. The presence of a large intracoronary thrombus within an aneurysmal coronary artery and normal coronary flow is usually a very challenging case scenario. Here, we present a case of a patient presenting with typical chest pain symptoms, high-risk findings on a pharmacological nuclear stress test and coronary angiogram showing severe multivessel coronary artery disease, including a large aneurysmal segment within the proximal left anterior descending artery with a large thrombus that did not affect intracoronary flow. Today, there are no published guidelines for the management of CAA with a normal intracoronary flow. The approach used in this case was initial antithrombotic therapy followed by a successful staged percutaneous coronary intervention. Here, we present a case supporting the use of combined intravenous anticoagulant and antiplatelet therapy for 48 hours, followed by successful percutaneous intervention guided by intravascular ultrasound., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

A 58-year-old man was admitted to our center with an inferior ST-segment elevation myocardial infarction. A coronary angiogram showed an ectatic right coronary artery (RCA) occluded at mid vessel by a significant clot burden quantified by micro-computed tomography. Guide catheter-directed intracoronary thrombolysis with low-dose tenekteplase resulted in regaining RCA flow, when numerous efforts of manual and 'mother-child' thrombectomy had failed to achieve. A stentless strategy was followed with final thrombolysis in myocardial infarction 3 flow and angiographically insignificant stenosis remaining in the RCA. The combination of intracoronary thrombolysis and a stentless strategy is a safe and effective treatment in ST-segment elevation myocardial infarction patients with ectatic arteries and large thrombus burden when repeat manual aspiration thrombectomy fails.