Myocardial ischemia in the setting of extrinsic coronary compression: two case reports.

Background: Myocardial ischemia occurs in the setting of inadequate or complete cessation of blood supply to the myocardium. While atherosclerosis is the most common cause; other causes have been identified. Rare cases can be caused by extrinsic compression of the coronaries by a dilated pulmonary artery (PA) or by mechanical obstruction from nearby chest tubes or drains. We present two cases of myocardial ischemia-driven malignant arrhythmia leading to cardiac arrest caused by obstruction of the coronary blood flow from external compression. Case Description: In the first case, venous bypass graft compression from a chest tube postoperatively was noted and in the second case left main coronary artery (LMCA) compression from a dilated PA secondary to pulmonary artery hypertension (PAH) was seen. Diagnosis of these two cases was made via emergent coronary angiogram and intravascular ultrasound (IVUS) and treated by placing a drug eluting stent (DES) in LMCA compression and by adjusting the chest tube and placing a DES in the venous bypass graft with the restoration of flow. We also review the available literature regarding the incidence, diagnosis, and management of this rare entity. Conclusions: Overall, extrinsic compression of the coronaries is rare, therefore clinicians need to be aware of this infrequent process, to allow for appropriate diagnosis, management, and to prevent excess morbidity and mortality from this rare complication.

ECPELLA: Beyond a Left Ventricular Venting Strategy When to Unload the Left Ventricle and How to Decide.

Left ventricular (LV) unloading has been shown to improve survival for patients requiring veno-arterial extracorporeal membrane oxygenation (VA ECMO) support for cardiogenic shock. A mortality benefit has been shown for ECMO and concomitant placement of a transcatheter unloading LV pump such as an Impella device (colloquially referred to as ECPELLA or ECMELLA) for patients resuscitated with VA ECMO after a short period of cardiac arrest. Despite the described benefit of LV unloading with VA ECMO for cardiopulmonary resuscitation, it remains unclear as to what criteria should be used and what other diagnostic and therapeutic adjuncts may be useful. We describe here the successful utilization of concomitant VA ECMO and Impella in a 43 year old male with acute heart failure and cardiac arrest. Distinguishing itself from the currently reported methods, our methodology incorporates transesophageal echocardiography (TEE) in the emergency department for rapid decision-making in addition to an automatic chest compression device, the Lund University Cardiac Assist System (LUCAS) device (Stryker, Portage, MI) as a bridge to LV unloading in a hybrid operating suite.

Choice of Steerable Sheath Impacts Contact Force Stability During Pulmonary Vein Isolation.

A stable contact force (CF) is correlated with more effective radiofrequency (RF) ablation (RFA) lesions and long-term procedural outcomes. Efforts to improve catheter stability include jet ventilation, pacing, steerable sheaths, and CF-sensing ablation catheters. This study compares CF stability and effective RF lesions between two commercially available steerable sheaths. Thirty patients underwent first-time RFA at a single center using the Agilis™ NxT (Abbott, Chicago, IL, USA) or SureFlex™ (Baylis Medical, Montreal, Canada) steerable sheath. High-power short-duration RFA was utilized, targeting a 10-Ω drop. Sheath performance was assessed for the entire procedure and around each pulmonary vein (PV) in terms of mean CF, CF variability, RF time per lesion, and inefficient contact lesions (defined as lesions with a CF of less than 5 g for at least 10% of the RF delivery time). The operator-targeted mean CF was achieved using both sheaths; however, the overall CF variability was 12.8% lower when using the SureFlex™ sheath (p = 0.08). The CF variability was generally 16% greater in the right PVs than the left PVs (p = 0.001) but trended lower with the SureFlex™ sheath. There were 8% more inefficient contact lesions created when using the Agilis™ sheath as compared to the SureFlex™ sheath (p = 0.035), especially in the right inferior PV (p = 0.009). The RF time per lesion was, on average, 12% (1.4 seconds) shorter when using the SureFlex™ sheath than the Agilis™ sheath (p < 0.05). The choice of steerable sheath may affect both catheter stability and lesion quality, especially in the right PVs.

Clostridium paraputrificum: An atypical and rare case of septic arthritis mimicking an acute sickle cell crisis.

Clostridium paraputrificum is an extremely rare species and constitutes only 1% of all clostridium infections in literature. Septic arthritis from Clostridium paraputrificum is even less documented, and currently there is only one known case report. Specifically, patients with sickle cell disease have a well-documented and increased susceptibility to infections with Salmonella, Streptococcus pneumoniae, Hemophilius influenzae, and Enterobacter-klebsiella. Clostridium infection in sickle cell patients has been less studied and described. Here we present a case of septic arthritis from Clostridium paraputrificum in a sickle cell disease patient likely provoked by underlying avascular necrosis of the right shoulder.

Dermatologic Conundrum: A Cardiac Condition Masqueraded as a Dermatologic Distraction.

A 38-year-old male presented to the emergency department (ED) complaining of extreme pain and a petechial rash on the left ankle for two weeks associated with generalized fatigue, intermittent fevers, and weight loss. He was discharged home from the ED on pain medications. He returned a few days later with a progressive rash that involved the entire left lower extremity to the level of the knee. He was diagnosed with herpes zoster (shingles) and was prescribed acyclovir and steroids. After several days, the patient presented for the third time to the ED. He developed a right lower extremity discomfort this time. The pain in bilateral lower extremities had become unbearable. His cardiac examination revealed a systolic murmur at the apex and a faint diastolic murmur at the left sternal border. Ultimately, he had an echocardiogram that demonstrated both a bicuspid aortic valve and large vegetation on the anterior leaflet of the mitral valve, and his blood culture grew Streptococcus mitis and Streptococcus oralis. The patient was subsequently diagnosed with subacute bacterial endocarditis thought to be sourced from his poor dentition. The diagnosis of infective endocarditis is often delayed due to its nonspecific clinical presentations. Our case displays an unusual skin manifestation of IE that may be present in the absence of other signs and symptoms of the disease.

The safety and efficacy of electroanatomical mapping (EAM)-guided device implantation.

BACKGROUND: The conventional method of device implantation requires fluoroscopic guidance. With the guidance of three-dimensional (3-D) navigation systems, devices can be implanted with minimal use of fluoroscopy. To date, this technique has been reported in several case reports in young, pregnant patients. However, this technique has not been widely utilized by electrophysiologists, despite offering several benefits, including reduced radiation exposure for the patient and the operator. METHODS: In this study, we evaluated 18 patients who successfully underwent device implantation with limited use of fluoroscopy under the guidance of the EnSite Precision 3-D mapping navigation system (Abbott, St. Paul, MN, USA). In most of the patients, the total fluoroscopy time was 1 s, accounted by a single postprocedural frame to insure appropriate lead placement. RESULTS: A total of 19 leads were implanted in 18 patients (14 male, four female) using the electroanatomical mapping (EAM)-guided technique. A total of 19 leads were implanted in 15 patients (10 male, five female) using the conventional method. The average length of stay was 1.20 days in the EAM group compared to 1.47 days in the conventional group (P = .10). Majority of the devices implanted in both groups were single-chamber implantable cardiac defibrillators (VVI ICD, Abbott) implanted for cardiomyopathy with left ventricular ejection fraction persistently below 35%, including 88% (16/18) in the EAM group compared to 73% (11/15) in the conventional group. No periprocedural or immediate postprocedure complications were reported in either group. Device parameters, including impedance, capture time, and capture voltage, showed no significant difference in either group. Total radiation time and radiation dose were markedly lower in the EAM-guided implantation group. CONCLUSIONS: In patients who meet appropriate criteria for device implantation, the use of EAM system offers a safe, practical, efficacious alternative method to device implantation, with significant reduction in radiation time and dose.

Is symptom to balloon time a better predictor of outcomes in acute ST-segment elevation myocardial infarction than door to balloon time?

INTRODUCTION: Current guidelines for the treatment of ST-segment elevation myocardial infarction (STEMI) recommend early revascularization with a door-to-balloon (D2B) time of 90 minutes or less in patients undergoing primary percutaneous coronary intervention (PPCI). The focus of most studies has been D2B time. Because of the large variability in the time between symptom onset and presentation, we sought to determine the effect of symptom-to-balloon (S2B) time on presentation and outcomes as a potentially more clinically relevant parameter. METHODS: We conducted a retrospective study of 106 patients who were diagnosed with an acute STEMI, had a documented S2B time and who underwent a PPCI at a tertiary hospital from the period of January 2014 to December 2014. S2B time was defined as the time interval beginning from the episode of chest pain that led the patient to present to the emergency department to the time of the first balloon inflation. We categorized our patients into 2 main groups depending on whether S2B time was greater or less than 240 minutes. They were further subdivided into 2 groups depending on the site of the culprit lesion (left anterior descending LAD vs. non-LAD). RESULTS: There was no difference between the two main groups in regard to the left ventricular ejection fraction (EF) on presentation, length of stay, and readmission with heart failure or chest pain. However, when S2B time was greater than 240 min, there was a statistically significant difference in left ventricular ejection fraction (EF) between LAD and non-LAD stenosis with a mean of 38.4% and 49.3% respectively (P=0.01). No relationship was found between S2B time and gender or age. CONCLUSION: Although D2B time is a well-established clinical parameter, S2B time may be expected to be a more accurate predictor of outcomes. However, in our study, S2B time of >240 minutes only predicted a significant worse EF (and presumably mortality) when the culprit vessel was the LAD. Further studies are needed to better elucidate the relation of S2B time to clinical outcomes.

Primary Angiitis of the Center Nervous System: A Clinical Challenge Diagnosed Postmortem.

Primary angiitis of the central nervous system (PACNS) is a rare vasculitis involving medium and small blood vessels of the brain, spinal cord, and meninges, without systemic involvement. The diffuse and patchy nature of its pathology is reflected by a wide spectrum of nonspecific clinical symptoms. Diagnosis is challenging due to lack of defined clinical criteria or specific imaging findings. Specific workup should be done only after exclusion of other etiologies, including infectious, neoplastic, toxic, and other vascular etiologies including systemic vasculitis. Given the fact that it is a patchy disease with 25% of the biopsies being falsely negative, treating physician should have a high index of suspicion despite negative initial neurovascular imaging and biopsy results. Once diagnosed, early treatment with immunosuppressive therapy is essential to avoid permanent neurologic damage. Herein, we are reporting a case of 66-year-old female patient who presented with insidious onset right-sided frontal headache. Her hospital course progressively worsened and family decision based on her wishes was to refer her to hospice and comfort care. Despite an extensive workup with advanced imaging techniques, no diagnosis was established until postmortem autopsy and histopathology confirmed primary angiitis of the central nervous system.