Background: The presence of ST-segment elevation in lead III exceeding that in lead II when combined with ST-segment depression in lead I, aVL or both, was proposed as a powerful predictor of occlusion of the right coronary artery with sensitivity/specificity values of 90%/71% in patients with acute inferior ST-segment elevation myocardial infarction (STEMI). The present study was performed to investigate the reliability of this ECG-algorithm in clinical practice.
Methods: ECGs of all consecutive patients who presented to our hospital with acute inferior STEMI and underwent emergency coronary angiography/primary percutaneous coronary intervention between January 2006 and December 2013 were analyzed retrospectively by 2 independent cardiologists according to the criteria mentioned above. The results were then compared with the angiographic findings and 28-day mortality data were collected.
Results: A total of 356 patients with acute inferior STEMI were included in the present study. The right coronary artery was the infarct-related artery in 272 (76.4%) patients and the left circumflex coronary artery in 76 (21.4%) patients, whereas inferior STEMI was caused by distal occlusion of a large left anterior descending coronary artery in 4 (1.1%) and of the Ramus intermedius in 4 (1.1%) patients. In our population the sensitivity/specificity values of the proposed ECG-algorithm to correctly identify the right coronary artery were 78%/49%. There was a non-significant trend towards a higher 28-day mortality in patients with a positive ECG-algorithm (3.5% vs. 1.0% ; p=0.186).
Conclusions: In the present study we could not reproduce the excellent diagnostic accuracy of an ECG-algorithm for predicting the infarct-related artery in acute inferior STEMI reported in the literature. Thus, given its suboptimal diagnostic reliability and the lack of therapeutic consequences in patients with acute inferior STEMI and a clear indication for immediate reperfusion therapy, the clinical relevance of the proposed ECG-algorithm is questionable.
Composite graft replacement is an established surgical procedure that radically treats pathologies of the aortic root, especially when the aortic valve cannot be spared. We analyzed the intraoperative details and the short-term outcome of a large consecutive series of patients operated in a teaching tertiary institution.
Out of 877 patients that received a composite graft during a 13-years period, we excluded all those patients who were operated as an emergency because of a type A acute aortic dissection, those who received this procedure as a redo-surgery and those who presented with a destructive endocarditis of the aortic root. Finally 622 patients with a mean age of was 59.5 ± 12.5 years (range between 16 and 85 years) were analyzed. 423 patients (68%) were male, mean body mass index was 27.8 ± 4.3 (18.4 to 37.3). Anulo-aortic dilatation with or without aortic valve dysfunction was the most frequent indication (n=448), bicuspid valve with aortic root and/or ascending aortic dilatation was found in 107 patients and typical aortic root dilatation in the presence of Marfan/Loeys-Dietz syndrome was found in 33 patients. A large majority of patients presented with moderate or severe aortic regurgitation (n=409, 65%), while aortic stenosis was present in 164 patients (26.5%).
Early mortality occurred in 9 patients (1.4%). Causes of death were: low output syndrome in 3, severe cerebrovascular complication in 4 patients and respiratory, respectively multiorgan failure in one patient each. Multivariate logistic regression analysis showed that a severly reduced LV function (LV-EF < 0.35) (OR 4.9, 95% CI 1.7-12.2), aortic regurgitation grade IV (OR 6.35, 95% CI 1.8-17.8), NYHA functional class III or IV (OR 2.94 (95% CI 1.5-7.4) and need for additional CABG surgery (OR 4,25, 95% CI 1.6-11.3) were the independent risk factors for mortality as well as for early morbidity.
Composite graft replacement is a standard procedure to treat different pathologies of the aortic root and is associated with a low perioperative risk. This justify liberal indications in case of moderately dilated aortic root (4.5 to 5 cm) in younger patients (<60 years) and in those with a particular cardiovascular risk profile.
