Atrial coronary artery occlusion during elective percutaneous coronary angioplasty

Coronary Angiography-Derived Index of Microcirculatory Resistance Associated With New-Onset Atrial Fibrillation in Patients With STEMI

BACKGROUND

Coronary angiography-derived index of microcirculatory resistance (caIMR) can effectively assess coronary microvascular dysfunction in patients with ST-segment elevation myocardial infarction (STEMI). This study aimed to explore the role of caIMR in the occurrence of new-onset atrial fibrillation (NOAF) in patients with STEMI.

METHODS

This was a single-centre retrospective clinical observational study. Patients diagnosed with STEMI from September 2019 to December 2022 were included. caIMR was calculated using computational flow and pressure simulations. During admission, suspicious heart rhythm was recorded by electrocardiographic (ECG) monitoring, and NOAF was confirmed by an immediate 12-lead ECG.

RESULTS

A total of 739 patients were enrolled, including 57 (7.7) with NOAF. caIMR was significantly correlated with microvascular obstruction (R = 0.604; P < 0.001) and infarct size (R = 0.514; P < 0.001). After adjusting for potential confounding factors, the results showed that caIMR (odds ratio 1.058, 95% confidence interval 1.035-1.083; P < 0.001) was an independent risk factor for NOAF in patients with STEMI. Receiver operating characteristic analysis showed that the area under the curve of caIMR for predicting NOAF was 0.716. Compared with the caIMR < 27.35 U group, the caIMR ≥ 27.35 U group had higher high-sensitivity troponin T and N-terminal pro-B-type natriuretic peptide levels. When caIMR was added to the model, the reclassification and discriminant abilities improved significantly.

CONCLUSIONS

Higher caIMR was an independent risk factor for NOAF in patients with STEMI. The caIMR had high specificity and sensitivity for predicting NOAF in patients with STEMI. The integration of caIMR into clinical risk factors showed significantly increased predictability for NOAF in patients with STEMI.

Sinus Node Dysfunction due to Occlusion of the Sinus Node Artery during Percutaneous Coronary Intervention

Background

Sinus node artery occlusion (SNO) is a rare complication of percutaneous coronary intervention (PCI). We analyze both the short- and long-term consequences of SNO.

Methods

We retrospectively reviewed 1379 consecutive PCI's involving RCA and Cx arteries performed in our heart institute from 2016 to 2019. Median follow-up was 44 ± 5 months.

Results

Among the 4844 PCIs performed during the study period, 284 involved the RCA and the circumflex's proximal segment. Periprocedural SNO was estimated by angiography observed in 15 patients (5.3%), all originated from RCA. The majority of SNO occurred during urgent and primary PCIs following acute coronary syndrome (ACS). Sinus node dysfunction (SND) appeared in 12 (80%) of patients. Four (26.6%) patients had sinus bradycardia, which resolved spontaneously, and 8 (53.3%) patients had sinus arrest with an escaped nodal rhythm, which mostly responded to medical treatment during the first 24 hours. There was no association between PCI technique and outcome. Three patients (20%) required urgent temporary ventricular pacing. One patient had permanent pacemaker implantation. Pacemaker interrogation during follow-up revealed a recovery of the sinus node function after one month.

Conclusion

SNO is rare and seen mostly during angioplasty to the proximal segment of the RCA during ACS. The risk of developing sinus node dysfunction following SNO is high. SND usually appears during the first 24 h of PCI. The majority of SND patients responded to medical treatment, and only in rare cases were permanent pacemakers required.

Association Between Flow Impairment in Dominant Coronary Atrial Branches and Atrial Arrhythmias in Patients With ST-Segment Elevation Myocardial Infarction

OBJECTIVES

The impact of atrial ischemia in the occurrence of atrial arrhythmias may vary based on the amount of jeopardized myocardium. We sought to determine the association between coronary flow impairment in dominant coronary atrial branches (CAB) and atrial arrhythmias at 1-year follow-up in ST-segment elevation myocardial infarction (STEMI) patients.

METHODS

Patients with STEMI involving the right or circumflex coronary artery were included. Dominant CAB was defined as the most developed CAB. Patients were followed-up during 1 year, including 24-h Holter ECG at 3 and 6 months. Atrial arrhythmias were defined as atrial fibrillation/flutter, atrial tachycardia (≥3 consecutive supraventricular ectopic beats) and excessive supraventricular ectopic activity (>30 supraventricular beats/h or runs ≥20 beats).

RESULTS

A dominant CAB was identified in 897 of 900 patients STEMI (age 61 ± 12 years, 79% male). TIMI flow < 3 at the dominant CAB was present in 69 (8%) patients. Compared to those with dominant CAB preserved flow, patients with dominant CAB flow impairment presented with higher levels of troponin T (3.9 [2.2-8.2] vs. 3.1 [1.3-5.8], P = 0.008)and higher rates of atrial tachycardia at 3 months (68% vs. 37%, P = 0.007) and more supraventricular ectopic beats both at 3 months (58 [21-235] vs. 33 [12-119], P = 0.02) and at 6 months (62 [24-156] vs. 32 [12-115]; P = 0.04) on 24-h Holter ECG. Age and an impaired coronary flow at the dominant CAB were independently related to a higher risk of developing atrial arrhythmias at 1-year follow-up.

CONCLUSION

Dominant CAB flow impairment is infrequent and is associated with the occurrence of atrial arrhythmias, in the form atrial tachycardia and supraventricular ectopic beats, at follow-up.

Changes in Local Atrial Electrograms and Surface ECG Induced by Acute Atrial Myocardial Infarction

Background

Atrial coronary branch occlusion is a hardly recognizable clinical entity that can promote atrial fibrillation. The low diagnostic accuracy of the ECG could deal with the characteristics of the ischemia-induced changes in local atrial electrograms, but these have not been described.

Objectives

We analyzed the effects of selective acute atrial branch occlusion on local myocardial structure, atrial electrograms, and surface ECG in an experimental model close to human cardiac anatomy and electrophysiology.

Methods

Six anesthetized open-chest anesthetized pigs underwent surgical occlusion of an atrial coronary branch arising from the right coronary artery during 4 h. Atrial electrograms and ECG were simultaneously recorded. One additional pig acted as sham control. In all cases, the hearts were processed for anatomopathological analysis.

Results

Atrial branch occlusion induced patchy atrial necrosis with sharp border zone. During the first 30 min of occlusion, atrial electrograms showed progressive R wave enlargement (1.8 ± 0.6 mV vs. 2.5 ± 1.1 mV, p < 0.01), delayed local activation times (28.5 ± 8.9 ms vs. 36.1 ± 16.4 ms, p < 0.01), ST segment elevation (-0.3 ± 0.3 mV vs. 1.0 ± 1.0 mV, p < 0.01), and presence of monophasic potentials. Atrial ST segment elevation decreased after 2 h of occlusion. The electrical border zone was ∼1 mm and expanded over time. After 2 h of occlusion, the ECG showed a decrease in P wave amplitude (from 0.09 ± 0.04 mV to 0.05 ± 0.04 mV after 165 min occlusion, p < 0.05) and duration (64.4 ± 8.0 ms vs. 80.9 ± 12.6 ms, p < 0.01).

Conclusion

Selective atrial branch occlusion induces patchy atrial infarction and characteristic changes in atrial activation, R/S wave, and ST segment that are not discernible at the ECG. Only indirect changes in P wave amplitude and duration were appreciated in advanced stages of acute coronary occlusion.

Procedural-related coronary atrial branch occlusion during primary percutaneous coronary intervention for ST-segment elevation myocardial infarction and atrial arrhythmias at follow-up

OBJECTIVES

To evaluate the frequency of procedural-related atrial branch occlusion in ST-segment elevation myocardial infarction (STEMI) patients and its association with atrial arrhythmias at 1-year follow-up.

BACKGROUND

Atrial ischemia due to procedural-related coronary atrial branch occlusion in elective percutaneous coronary intervention (PCI) has been associated with atrial arrhythmias. Its role in a STEMI scenario is unknown.

METHODS

STEMI patients treated with primary PCI were classified according to the loss or patency of an atrial branch at the end of the procedure. The occurrence of atrial arrhythmias was documented on 24-hr Holter-ECG at 3 and 6 months or on ECG during 1-year follow-up visits.

RESULTS

Of 900 patients, 355 (age 61 ± 12 years, 79% male) underwent primary PCI involving the origin of an atrial branch. Procedural-related coronary atrial branch occlusion was observed in 18 (5%) individuals). During 1-year follow-up, 33% of patients with procedural-related atrial branch occlusion presented atrial arrhythmias, as compared with 55% in those with a patent atrial branch (p = .088). Age, no previous history of myocardial infarction, and a reduced flow in the culprit vessel were the only independent correlates of atrial arrhythmias.

CONCLUSIONS

The frequency of procedural-related atrial branch occlusion during primary PCI is low (5%) and is not associated with increased frequency of atrial arrhythmias at 1-year follow-up.

Electrophysiological Effects of Selective Atrial Coronary Artery Occlusion in Humans

BACKGROUND

The arrhythmogenesis of ventricular myocardial ischemia has been extensively studied, but models of atrial ischemia in humans are lacking. This study aimed at describing the electrophysiological alterations induced by acute atrial ischemia secondary to atrial coronary branch occlusion during elective coronary angioplasty.

METHODS AND RESULTS

Clinical data, 12-lead ECG, 12-hour Holter recordings, coronary angiography, and serial plasma levels of high-sensitivity troponin T and midregional proatrial natriuretic peptide were prospectively analyzed in 109 patients undergoing elective angioplasty of right or circumflex coronary arteries. Atrial coronary branches were identified and after the procedure patients were allocated into two groups: atrial branch occlusion (ABO, n=17) and atrial branch patency (non-ABO, n=92). In comparison with the non-ABO, patients with ABO showed: (1) higher incidence of periprocedural myocardial infarction (20% versus 53%, P=0.01); (2) more frequent intra-atrial conduction delay (19% versus 46%, P=0.03); (3) more marked PR segment deviation in the Holter recordings; and (4) higher incidence of atrial tachycardia (15% versus 41%, P=0.02) and atrial fibrillation (0% versus 12%, P=0.03). After adjustment by a propensity score, ABO was an independent predictor of periprocedural infarction (odds ratio, 3.4; 95% confidence interval, 1.01-11.6, P<0.05) and atrial arrhythmias (odds ratio, 5.1; 95% confidence interval, 1.2-20.5, P=0.02).

CONCLUSIONS

Selective atrial coronary artery occlusion during elective percutaneous transluminal coronary angioplasty is associated with myocardial ischemic damage, atrial arrhythmias, and intra-atrial conduction delay. Our data suggest that atrial ischemic episodes might be considered as a potential cause of atrial fibrillation in patients with chronic coronary artery disease.