Sinus node artery originating from the posterior part of the right coronary artery.

PURPOSE: The purpose of the study was to examine the anatomical variations of the sinus node artery (SNA). METHODS: Gross anatomical examination, angiographic evaluation and if necessary dissection were performed in 200 human hearts derived from victims of various accidents. RESULTS: The SNA was a branch of the right coronary artery in 118 [59%] cases, the left circumflex in 78 [39%] cases and both coronary arteries in 4 [2%] cases. In one subject, the SNA was found to arise from the distal part of the right coronary artery. CONCLUSIONS: In our case, the sinus node was perfused by a SNA arising from the mid-posterior segment of the right coronary artery. Knowledge of this anatomical variation is useful for anatomists and of clinical significance for the interventional cardiologists and mainly for the cardiac surgeons in planning the surgical procedures.

Arrhythmogenic right ventricular cardiomyopathy in an octogenarian presenting with ventricular tachycardia.

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is one of the major causes of sudden death. Myocardial atrophy with subsequent fibro-fatty replacement predominantly affects right ventricular myocardium and results in global and regional dysfunction as well as areas of slow conduction and dispersion of refractoriness, which are prerequisites for reentrant ventricular tachyarrhythmias. ARVC is commonly presented in patients <65 years old. However, few cases of elderly people suffering from this cardiomyopathy have been reported in the literature. We present a case of an 82-year-old woman with sustained ventricular tachycardia due to first diagnosed ARVC.

Electrophysiology Catheter-Facilitated coronary sinus cannulation and implantation of cardiac resynchronization therapy systems.

BACKGROUND: Cardiac resynchronization therapy (CRT) device implantation is hampered by difficult placement of the left ventricular (LV) lead. We have routinely used a steerable electrophysiology catheter to guide coronary sinus (CS) cannulation and facilitate LV lead positioning. The aim of this prospective study is to present our results with this approach in 138 consecutive patients receiving a CRT device over 10 years. METHODS: The study included 120 men and 18 women, aged 64.8±11.4 years, with coronary disease (n=63), cardiomyopathy (n=72), or other disease (n=3), and mean ejection fraction of 24.5±4.5%. Devices were implanted for refractory heart failure and dyssynchrony, all but 2 in the presence of left bundle branch block. Implanted devices included biventricular pacemakers (CRT-P) (n=33) and cardioverter defibrillators (CRT-D) (n=105). RESULTS: Using the electrophysiology catheter, the CS could be engaged in 134 (97.1%) patients. In 4 patients failing CS cannulation, a dual-chamber device was implanted in 2, and bifocal right ventricular pacing was effected in 2. Bifocal (n=2) or conventional (n=1) systems were implanted in another 3 patients, in whom the LV lead got dislodged (n=2) or removed because of local dissection (n=1). Thus, finally, a CRT system was successfully established in 131 (94.9%) patients. There were 3 patients with CS dissection, of whom 1 was complicated by cardiac tamponade managed with pericardiocentesis. There were no perioperative deaths. During follow-up (31.0±21.2 months), clinical improvement was reported by 108 (82.4%) patients. CONCLUSION: Routine use of an electrophysiology catheter greatly facilitated CS cannulation and successful LV lead placement in ∼95% of patients undergoing CRT system implantation.

Simplified percutaneous closure of patent foramen ovale and atrial septal defect with use of plain fluoroscopy: Single operator experience in 110 consecutive patients.

OBJECTIVE: Percutaneous closure of patent foramen ovale (PFO) and atrial septal defect (ASD) is routinely performed under general anesthesia or deep sedation and use of transesophageal (TEE) or intracardiac echocardiography, incurring longer duration and higher cost. We have used a simplified, economical, fluoroscopy-only guided approach with local anesthesia, and herein report our data. METHODS: The study includes 112 procedures in 110 patients with PFO (n=75) or ASD (n=35), with use of an Amplatzer occluder, heparin and prophylactic antibiotics. Balloon sizing guided ASD-device selection. All patients received aspirin and clopidogrel for 6 months, when they all underwent TEE. RESULTS: All PFOs but one (98.7%) and all (100%) ASDs were successfully closed with only one complication (local pseudoaneurysm). At the 6-month TEE, there was no residual shunt in PFO patients, but 2 ASD patients had residual shunts. During long-term (4.3-year) follow-up, no stroke recurrence in PFO patients, and no other problems were encountered. Among 54 patients suffering from migraine, symptom relief or resolution was reported by 45 (83.3%) patients. CONCLUSION: Percutaneous placement of an Amplatzer occluder was safe and effective with use of local anesthesia and fluoroscopy alone. There were no recurrent strokes over >4 years. Migraine relief was reported by >80% of patients.

"Real life" longevity of implantable cardioverter-defibrillator devices.

BACKGROUND: Manufacturers of implantable cardioverter-defibrillators (ICDs) promise a 5- to 9-year projected longevity; however, real-life data indicate otherwise. The aim of the present study was to assess ICD longevity among 685 consecutive patients over the last 20 years. HYPOTHESIS: Real-life longevity of ICDs may differ from that stated by the manufacturers. METHODS: The study included 601 men and 84 women (mean age, 63.1 ± 13.3 years). The underlying disease was coronary (n = 396) or valvular (n = 15) disease, cardiomyopathy (n = 220), or electrical disease (n = 54). The mean ejection fraction was 35%. Devices were implanted for secondary (n = 562) or primary (n = 123) prevention. Single- (n = 292) or dual-chamber (n = 269) or cardiac resynchronization therapy (CRT) devices (n = 124) were implanted in the abdomen (n = 17) or chest (n = 668). RESULTS: Over 20 years, ICD pulse generator replacements were performed in 238 patients (209 men; age 63.7 ± 13.9 years; ejection fraction, 37.7% ± 14.0%) who had an ICD for secondary (n = 210) or primary (n = 28) prevention. The mean ICD longevity was 58.3 ± 18.7 months. In 20 (8.4%) patients, devices exhibited premature battery depletion within 36 months. Most (94%) patients had none, minor, or modest use of ICD therapy. Longevity was longest for single-chamber devices and shortest for CRT devices. Latest-generation devices replaced over the second decade lasted longer compared with devices replaced during the first decade. When analyzed by manufacturer, Medtronic devices appeared to have longer longevity by 13 to 18 months. CONCLUSIONS: ICDs continue to have limited longevity of 4.9 ± 1.6 years, and 8% demonstrate premature battery depletion by 3 years. CRT devices have the shortest longevity (mean, 3.8 years) by 13 to 17 months, compared with other ICD devices. These findings have important implications, particularly in view of the high expense involved with this type of electrical therapy.

Cardiac implantable electronic device lead extraction using the lead-locking device system: keeping it simple, safe, and inexpensive with mechanical tools and local anesthesia.

OBJECTIVE: We have previously reported our successful approach for percutaneous cardiac implantable electronic device (CIED) lead extraction using inexpensive tools, which we have continued over the years. Herein we report the results of the systematic use of a unique stylet, the lead-locking device (LLD), which securely locks the entire lead lumen, aided with non-powered telescoping sheaths in 54 patients to extract 98 CIED leads. METHODS: This prospective observational clinical study included 38 men and 16 women aged 68.9±13.1 years undergoing lead extraction for device infection (n=46), lead malfunction (n=5), or prior to defibrillator implant (n=3). Leads were in place for 6.7±4.3 years. Infections were more commonly due to Staphylococcus species (n=40). There were 78 pacing (31 ventricular, 37 atrial, 4 VDD, and 6 coronary sinus leads) and 20 defibrillating leads. RESULTS: Using simple traction (6 leads) and the LLD stylets (92 leads) aided with telescoping sheaths (15 patients), 96 (98%) leads in 52 (96.3%) patients were successfully removed, with all but one leads removed using a subclavian approach; in 1 patient, the right femoral approach was also required. In 2 patients, distal fragments from one ventricular pacing and one defibrillating lead could not be removed. Finally, lead removal was completely (52/54) (96.3%) or partially (2/54) (3.7%) successful in 54 patients for 96 of 98 leads (98%) without major complications. CONCLUSION: Percutaneous lead extraction can be successful with mechanical tools using the LLD locking stylet aided with non-powered telescoping sheaths through a simplified, safe, and inexpensive procedure using local anesthesia.

Prognostic significance of microalbuminuria in non-diabetic patients with acute myocardial infarction.

BACKGROUND: The aim of this study was to examine whether the presence of microalbuminuria (20-200 microg/min) can predict in-hospital morbidity and mortality in non-diabetic patients with acute myocardial infarction. METHODS: Two hundred twenty-three (172 men and 51 women) non-diabetic patients with acute myocardial infarction were studied prospectively. The main outcome measures of the study were based on a comparison of in-hospital mortality and major non-fatal in-hospital events (pulmonary edema, post-infarction angina, infarct extension, mechanical complications, conduction disturbances and ventricular arrhythmias) between microalbuminuric and normoalbuminuric patients. RESULTS: A significant proportion of patients (33.6%) had microalbuminuria. Seventy-six patients (34%) developed an in-hospital event (fatal or non-fatal). Six patients (2.7%) with acute myocardial infarction died in the hospital. Patients with microalbuminuria had a higher mortality rate in comparison with normoalbuminuric patients (6.6% vs. 0.68%, p = 0.01). For non-fatal events, the incidence of pulmonary edema and ventricular arrhythmias was significantly higher in patients with microalbuminuria (14.6% vs. 3.4%, p < 0.001 and 12% vs. 3.4%, p = 0.01, respectively). The combined end-point of the total number of fatal and non-fatal events was significantly higher in patients with microalbuminuria (57.3% vs. 22.3%, p < 0.001). In multiple logistic regression analysis, microalbuminuria (p < 0.001) and ejection fraction (p = 0.01) were independently related to the occurrence of major in-hospital events. CONCLUSIONS: Microalbuminuria is a significant predictor of in-hospital morbidity and mortality in non-diabetic patients with acute myocardial infarction.

Simplified swift and safe vascular closure device deployment without a local arteriogram: Single center experience in 2074 consecutive patients.

OBJECTIVE: Vascular closure devices (VCDs), such as the Angio-Seal, a three-component hemostatic plug, have greatly facilitated the routine clinical practice in the catheterization laboratory. The manufacturer recommends a local angiogram before Angio-Seal deployment. However, from the outset, we employed a simplified routine of deploying this VCD, i.e. without use of local angiography. METHODS: The Angio-Seal was employed without a preceding femoral arteriogram over 8 years in 2074 consecutive patients, 72% presenting with acute coronary syndromes and subjected to coronary angiography (n=1032) or PCI n=1042) via a transfemoral approach with use of heparin and dual antiplatelet therapy. RESULTS: Deployment of the VCD was successful in 99.4%. Complete hemostasis was obtained in 98% of cases. In 14 patients, Angio-Seal deployment failed. Mean time for placement of Angio-Seal was <1min, to-hemostasis 1min, and to-mobilization 3h. Only 3 (0.15%) patients had a major complication with vessel occlusion that required emergent vascular surgery with a successful outcome. Two patients developed a local pseudoaneurysm treated with ultrasonography-guided compression. Six small and 4 large inguinal hematomas (one requiring blood transfusion) and 5 cases of retroperitoneal bleeding (one requiring blood transfusion) were recorded. CONCLUSION: Deployment of Angio-Seal without use of local angiography was efficacious and safe, characterized by a high success rate of deployment and hemostasis with few correctable complications in a large patient cohort undergoing transfemoral catheterization for PCI and non-PCI procedures under anticoagulation and antiplatelet drug therapy. VCD reduced the time-to-hemostasis and time-to-mobilization and minimized the incidence of complications.

Microalbuminuria: a strong predictor of 3-year adverse prognosis in nondiabetic patients with acute myocardial infarction.

BACKGROUND: The aim of this study is to evaluate the significance of microalbuminuria (MA) as a 3-year prognostic index in nondiabetic patients with acute myocardial infarction (AMI). METHODS: One hundred seventy-five patients with AMI were followed prospectively for 3 years. The study end point was cardiac death or rehospitalization for an acute coronary event. RESULTS: Forty-two patients (24%) developed a new cardiac event during the follow-up. Microalbuminuria (P < .001), pulmonary edema during initial hospitalization (P < .001) and postinfarction angina (P = .0364), advanced age (P = .001), severe atherosclerosis (high Gensini score) (P = .036), ejection fraction <50% (P = .0013), history of bypass surgery (P = .0265), and early conservative management (P = .0214) were all associated with adverse prognosis. Cox proportional hazards regression analysis showed that MA was an independent predictor of 3-year adverse prognosis in all the models tested, with an adjusted relative risk for the development of a cardiac event ranging from 2.1 to 4.3. CONCLUSIONS: In nondiabetic patients with AMI, MA is a strong and independent predictor of an adverse cardiac event within the next 3 years.

Comparison of the effects of ramipril versus telmisartan in reducing serum levels of high-sensitivity C-reactive protein and oxidized low-density lipoprotein cholesterol in patients with type 2 diabetes mellitus.

The effect of ramipril (an angiotensin [AT]-converting enzyme inhibitor), telmisartan (an AT-II type 1 receptor blocker), or their combination on inflammation and lipid peroxidation was assessed in 37 patients with type 2 diabetes who were free of coronary artery disease. All regimens were associated with a significant reduction of C-reactive protein and oxidized low-density lipoprotein cholesterol serum levels (p <0.001). These results further enlighten the mechanisms underlying the cardiovascular beneficial effect of renin-AT system inhibition.