Excimer laser technology in percutaneous coronary interventions: Cardiovascular laser society's position paper.

Excimer Laser Coronary Atherectomy (ELCA) is a well-established therapy that emerged for the treatment of peripheral vascular atherosclerosis in the late 1980s, at a time when catheters and materials were rudimentary and associated with the most serious complications. Refinements in catheter technology and the introduction of improved laser techniques have led to their effective use for the treatment of a wide spectrum of complex coronary lesions, such as thrombotic lesions, severe calcific lesions, non-crossable or non-expandable lesions, chronic occlusions, and stent under-expansion. The gradual introduction of high-energy strategies combined with the contrast infusion technique has enabled us to treat an increasing number of complex cases with a low rate of periprocedural complications. Currently, the use of the ELCA has also been demonstrated to be effective in acute coronary syndrome (ACS), especially in the context of large thrombotic lesions.

Aerobic exercise and Orexin A: role of sympathetic activity and redox system.

Aerobic exercise is associated with the sympathetic activation evoking adaptive responses to sustain muscle engagement. Physical exercise can cause alterations in the cardiovascular activity and cellular stress may occur which could be marked by either heart rate (HR), or galvanic skin response (GSR). Moderate plasma levels of reactive oxygen species (ROS) are considered as health markers, absolving to important roles such as adaptive cellular responses to exercise. Orexin A, a hypothalamic peptide, causes a widespread stimulation of the sympathetic nervous system, playing a role in many physiological functions.

Reduction of coronary flow reserve non-invasively determined by transthoracic Doppler echocardiography as a predictor of left anterior descending coronary artery stenosis.

BACKGROUND: The aim of this study was to evaluate if a reduced coronary flow reserve determined by transthoracic echocardiography alone or combined with contrast agents may represent a predictive index of significant left anterior descending coronary artery (LAD) stenosis. METHODS: Thirty-four patients (mean age 59+/-9 years) undergoing coronary angiography for coronary artery disease were studied. Coronary stenosis was classified (according to visually determined percent narrowing) as severe (> 75%), moderate (40 to 75%) and mild (< 40%). Coronary blood flow velocities were recorded in each patient at baseline and after low-dose dipyridamole administration by use of a 3.5 MHz transducer with a machine equipped with second harmonic capability and nondirectional color Doppler software. Coronary flow reserve was defined as the ratio of hyperemic to basal diastolic peak velocity. RESULTS: Adequate Doppler recordings in the LAD were obtained by transthoracic echocardiography in 26/34 patients (76%); the infusion of Levovist allowed for the visualization of LAD flow in a further 7 patients, with an overall feasibility of 97%. Coronary flow reserve was significantly higher in the group of patients with mild coronary lesions (2.3+/-0.3) than in patients with moderate (1.68+/-0.29, p = 0.0004) or severe (1.49+/-0.39, p = 0.0005) LAD stenosis. CONCLUSIONS: By use of transthoracic echocardiography combined with contrast agents it is possible to visualize blood flow velocities in the LAD and to evaluate coronary flow reserve after dipyridamole infusion with a non-invasive approach. Combined with angiographic findings, this diagnostic approach could be useful in giving additional information to assess the functional significance of a stenotic coronary lesion.

Chronic lymphocytic leukaemia and neuroendocrine cancer.

We report a unique association between neuroendocrine cancer and chronic lymphocytic leukaemia (CLL) in a 63-year-old man. Neuroendocrine cancer was resistant to various conventional treatments and following locoregional progression we treated the patient with hypoxic pelvic perfusion of cisplatin 100 mg/m2 plus mitomycin 40 mg/m2, using the stopflow method, for three cycles: a dramatic and surprising reduction of > 75% in the evaluable lesions was observed. The cumulative effect of treatment produced a complete response from CLL. At cytogenetic examination the neuroendocrine cells were diploid, whereas CLL cells showed trisomy 12. Moreover, deletion of the short arm of chromosome 3 was found in both neoplastic populations. Whether the abnormality seen on chromosome 3 in the two diseases represents a critical event is not known.

Giant congenital nevus and chronic progressive ascending hemiparesis (Mills syndrome). Report of a case.

We describe the case of a 20 year old boy with a giant congenital nevus who developed a chronic progressive ascending hemiparesis. The association of the pigmented lesion with a focal neurological deficit is pathognomonic for neurocutaneous melanosis complicated by a leptomeningeal melanoma. MR imaging at 1.5 tesla ruled out such a possibility and showed a small aspecific pontine lesion along the route of the corticospinal tract. We discuss possible etiologies.

Total lymphoid irradiation in chronic progressive multiple sclerosis.

6 patients with severe chronic progressive multiple sclerosis were subjected to total lymphoid irradiation (TLI) to assess clinical efficacy and side effects. During a 4 year follow-up the disability progression was continuous. Side effects during TLI were well tolerated; side effects after TLI brought about a worsening of the quality of life. One patient died of pneumonia. In this preliminary study TLI did not reduce the worsening of disability in MS patients.

Short-lasting unilateral neuralgiform headache attacks with tearing and conjunctival injection: the first "symptomatic" case?

A 36-year-old man was suffering from brief, unilateral and short-lasting pain attacks always associated with marked homolateral tearing and conjunctival injection, both presenting in a cluster fashion. An arteriovenous malformation was subsequently discovered in the homolateral cerebellopontine angle. The clinical picture shares similarities with both cluster headache and trigeminal neuralgia, although it can not be accurately placed with either of these forms. Patients with similar symptoms have previously been described in detail, and on the basis of these few descriptions a new syndrome "short-lasting" unilateral neuralgiform headache attacks with conjunctival injection, tearing, sweating, and rhinorrhoea has been postulated. Assuming the validity of this syndrome as an entity, this case is in all probability its first "symptomatic" example. Careful evaluation of the varieties of cluster headache and trigeminal neuralgia, and the reporting of similar new cases as they arise are necessary to establish the nosologic boundaries of this syndrome.

Stroke due to paradoxical embolism.

We present a case of stroke in a young girl, preceded by a deep vein thrombosis and pulmonary embolism, both clinically asymptomatic, and accompanied by upper limb acute ischemia. Diagnosis of paradoxical embolism through a patent foramen ovale was made on clinical grounds and with contrast echocardiography. We discuss the main points leading to diagnosis, stressing the importance of contrast echocardiography. We also suggest that paradoxical embolism could be a more frequent cause of stroke than usually suspected.

Insomnia and perceptual disturbances during flunarizine treatment.

We report two cases of sleep disturbances and perceptual disorder appearing in close temporal relationship with initiation of flunarizine therapy for migraine prophylaxis: these side effects disappeared after therapy interruption; resumption of the drug in one case was associated with symptom recurrence.

Disulfiram neuropathy: a review (1971-1988) and report of a case.

Neuropathy is one of the most severe side effects of disulfiram therapy. We report the case of a young man who developed a neuropathy following disulfiram administration, with a virtually complete recovery in 14 months. We then discuss 37 cases of disulfiram neuropathy reported since 1971. Evidence is given that: (1) there is no numerical sex prevalence, although the incidence of the disease in women is probably disproportionately high; (2) symptom onset latency is dose-dependent, being longer at 250 mg/day or less; (3) neurological deficits are also dose-dependent, being milder at 250 mg/day or less; (4) the two previous findings and single observations suggest that disulfiram neuropathy is a dose-dependent phenomenon; (5) recovery probably follows a course which depends primarily on the initial degree of impairment; (6) the genetic mechanism probably involves carbon disulfide and a hypothesis as to the possible biochemical mechanism is proposed; (7) chloral hydrate can bear a potentiation effect on neuropathy, and the association with disulfiram is best avoided. Further, we give guidelines for the differentiation between alcoholic and disulfiram neuropathy, advise prescribing the drug at 250 mg daily or less, if possible, and stress the utmost importance of an early diagnosis.

The automatic implantable cardioverter/defibrillator: transesophageal atrial pacing discloses the potential for erroneous discharges.

We report the occurrence of erroneous discharge from an implanted automatic cardioverter/defibrillator during transesophageal atrial pacing. Transesophageal pacing was performed as part of a study protocol on the inducibility of ventricular tachycardia from the atrium in patients with ischemic heart disease. At an induced heart rate of 166 beats per minute (a value just above the cut-off rate of the device), the cardioverter/defibrillator was triggered. This observation suggests that transesophageal atrial pacing could be utilized to disclose the potential for spurious discharges in the event of fast atrial rhythms in patients with the automatic implantable cardioverter/defibrillator.

Transvenous catheter ablation of the His bundle in ventricular tachycardia.

The usefulness of transvenous catheter ablation of the His bundle in three patients with recurrent ventricular tachycardia (VT), in which the initiating mechanism was recognized during a rapid atrial rhythm, is reported. Tachycardia was refractory to conventional treatment and required transthoracic direct-current shocks in all patients. In patient No. 1 double tachycardia (atrial flutter and VT) was documented and VT was easily induced by rapid atrial pacing. In patients Nos. 2 and 3 initiation of VT during junctional reciprocating and atrial tachycardia, respectively, was observed. Interruption of the His bundle was performed by means of fulguration. Stable atrioventricular (AV) block was observed in patient No. 1 after the ablative procedure; patient No. 2 showed anterograde conduction over a posterior septal accessory pathway with no evidence of conduction over the normal conduction system in both the anterograde and retrograde directions. In patient No. 3, transient AV block was observed; AV conduction resumed 2 days later and the cardiac rhythm showed persistent ectopic atrial tachycardia with second-degree AV block. Patients Nos. 1 and 2 underwent pacemaker implantation, but patient No. 2 was not pacemaker dependent. After the procedure, VT no longer occurred in any of the patients (follow-up: 2 years, 5 months, and 6 months).

Catheter ablation of accessory pathway in the permanent form of junctional reciprocating tachycardia.

Successful transvenous catheter ablation of accessory pathway (AP) in a patient (pt) with the permanent form of junctional reciprocating tachycardia is reported. A concealed AP with long conduction time comprised the retrograde limb of tachycardia circuit. The atrial end of the AP was near the coronary sinus (CS) orifice. Catheter ablative technique was performed after assessment of its feasibility and safety by using a canine model. During an electrophysiologic study CS mapping was obtained; the earliest retrograde activity was recorded 1-2 cm inside the orifice of the CS. Two unipolar shocks of 120 J were delivered on the sites exhibiting the earliest retrograde atrial activity. After the procedure, the AP was no longer conducting in both anterograde and retrograde direction. During a follow-up period of 13 months, the pt remained free of tachycardia on no antiarrhythmic medication.