Background and Aims: The DanGer shock trial showed a survival benefit of Impella in highly selected patients with ST-elevation myocardial infarction-related cardiogenic shock (STEMI-CS). In real-world settings, however, Impella is often used in broader populations not meeting trial criteria. This study aimed to assess the distribution and outcomes of DanGer shock-eligible and -ineligible acute myocardial infarction-related cardiogenic shock (AMI-CS) patients in a nationwide Japanese registry. Methods: A total of 3975 AMI-CS patients treated with Impella between 2020 and 2023 were identified from the J-PVAD registry. Patients were stratified into five groups: eligible STEMI-CS, non-eligible STEMI-CS, out-of-hospital cardiac arrest (OHCA), mechanical complications (MCs), and non-STEMI-CS (NSTEMI-CS). Eligible STEMI-CS was defined as STEMI-CS fulfilling all of the following: lactate ≥ 2.5 mmol/L, systolic blood pressure <100 mmHg or catecholamine use, left ventricular ejection fraction <45%, and shock onset to first Impella support ≤24 h. Thirty-day mortality, associated risk factors, and complications were examined across the five groups. Results: Eligible STEMI-CS accounted for 35.6% of all AMI-CS cases, with a 30-day mortality of 37.6%. Non-eligible STEMI-CS patients had lower mortality (27.6%), but it increased significantly with advanced age, renal dysfunction, veno-arterial extracorporeal membrane oxygenation use, ventricular arrhythmia, or sepsis. Thirty-day mortality was 51.3% in OHCA (63.4% without return of spontaneous circulation), 39.8% in MC, and 33.3% in NSTEMI-CS groups. Conclusions: In this nationwide registry, one-third of AMI-CS patients treated with Impella met DanGer shock criteria. Outcomes in non-eligible subgroups were heterogeneous, highlighting the importance of individualized risk assessment in guiding Impella use in real-world practice.

The relationship between myocardial bridging (MB) and coronary spasms during spasm provocation testing (SPT) remains unclear. We aimed to investigate whether MB was correlated with the SPT by ergonovine (ER) injections in a retrospective observational study. Of the 3340 patients who underwent a first coronary angiography, 166 underwent SPT using ER injections and were divided into 2 groups: MB(+) (n = 23), and MB(−) (n = 143). MB was defined as an angiographic reduction in the diameter of the coronary artery during systole. The patients who had severe organic stenosis in the left anterior descending coronary artery were excluded. The MB(+) group more frequently had diabetes mellitus and chronic kidney disease, and a thicker interventricular septum thickness. The rate of SPT-positivity was higher in the MB(+) group than MB(−) group (56.5% vs. 22.4%, P = 0.001). A multivariate regression analysis showed that the presence of MB was independently associated with SPT-positivity (odds ratio 5.587, 95% confidence interval 2.061–15.149, P = 0.001). In conclusion, coronary spasms during provocation tests with ER independently correlated with the MB. MB may predict coronary spasms.

Background: Nonobstructive general angioscopy (NOGA) can identify vulnerable plaques in the aortic lumen that serve as potential risk factors for cardiovascular events such as embolism. However, the association between computed tomography (CT) images and vulnerable plaques detected on NOGA remains unknown. Methods and Results: We investigated 101 patients (67±11 years; women, 13.8%) who underwent NOGA and contrast‐enhanced CT before or after 90 days in our hospital. On CT images, the aortic wall thickness, aortic wall area (AWA), and AWA in the vascular area were measured at the thickest point from the 6th to the 12th thoracic vertebral levels. Furthermore, the association between these measurements and the presence or absence of NOGA‐derived aortic plaque ruptures (PRs) at the same vertebral level was assessed. NOGA detected aortic PRs in the aortic lumens at 145 (22.1%) of the 656 vertebral levels. The presence of PRs was significantly associated with greater aortic wall thickness (3.3±1.7 mm versus 2.1±1.2 mm), AWA (1.33±0.68 cm ² versus 0.89±0.49 cm ² ), and AWA in the vascular area (23.2%±9.3% versus 17.2%±7.6%) ( P <0.001 for all) on the CT scans compared with the absence of PRs. The frequency of PRs significantly increased as the aortic wall thickness increased. Notably, a few NOGA‐derived PRs were detected on CT in near‐normal intima. Conclusions: The presence of NOGA‐derived PRs was strongly associated with increased aortic wall thickness, AWA, and AWA in the vascular area, measured using CT. NOGA can detect PRs in the intima that appear almost normal on CT scans.

A 76-year-old man suffering from chest pain was admitted to our hospital with a suspected acute myocardial infarction (AMI). Emergent coronary angiography revealed a totally occluded proximal left circumflex artery (LCX). During primary percutaneous coronary intervention, his blood pressure suddenly fell within seconds, and he developed pulseless electrical activity (PEA). Surprisingly, the 12-lead electrocardiogram (ECG) findings including the heart rate remained unchanged before and after the PEA, but a heart rate reduction and asystole occurred a few minutes after developing PEA. After tracheal intubation and mechanical assistance by venoarterial extracorporeal membrane oxygenation (VA-ECMO), the sudden onset of PEA appeared to be caused by cardiac tamponade due to a blowout-type left ventricular free wall rupture (BO-LVFWR) diagnosed by transthoracic echocardiography. While pericardiocentesis was performed and the drained blood was directly continuously perfused intravenously to keep the VA-ECMO flow, the patient was moved to the operation room. The surgical findings revealed a solitary BO-LVFWR due to a lateral AMI, and a direct closure was performed. Successful perioperative management, oral medication administration, and rehabilitation lead to the patient being transferred to a rehabilitation hospital without any serious cerebral damage. This case report suggested the detailed onset pattern of a BO-LVFWR followed by a rapid diagnosis by echocardiography and lifesaving treatment.

Ventricular septal rupture (VSR) is one of the fatal complications of myocardial infarction in the percutaneous coronary intervention era. A rapid diagnosis, medical and mechanical support, and surgical intervention are required for recovery and survival. In such a situation, the risk of complications associated with surgery is very high, especially in very elderly patients, in which any therapeutic strategy should be carefully discussed by the heart team. Herein, we describe two cases of VSRs after recent myocardial infarction (RMI) in very elderly patients that required debate regarding whether to perform surgery. The patients included a 93-year-old man and 89-year-old man, both of which were not highly frail before the RMI occurred. In the former case, a conservative strategy was adopted because the risk of surgery was considered, but he did not survive. On the other hand, the latter patient underwent surgery and his life was ultimately saved. Based on these two cases, we concluded that even if the patients are very old, if possible, surgical intervention should be fully considered.