Right atrial thrombus in constrictive pericarditis.

We describe right atrial thrombus complicated by tricuspid valve obstruction in a patient with constrictive pericarditis. This report highlights the role of surgical thrombectomy, and the investigation of constrictive pericarditis to exclude intra-cardiac thrombus.

Percutaneous coronary intervention for diffuse coronary artery disease.

Patients with diffuse coronary artery disease present a significant management problem. It has been proposed that diffuse coronary disease is unsuitable for balloon angioplasty and surgical treatment is not ideal either. We review the evidence that coronary balloon angioplasty is not a suitable treatment for diffuse coronary disease and examine the role of alternative interventional techniques. New techniques including long angioplasty balloon catheters and atherectomy devices have shown promise. If this is confirmed by prospective randomized trials then coronary angioplasty may yet prove an attractive treatment for diffuse coronary disease.

First clinical experience with a new flexible low profile metallic stent and delivery system.

We report the first clinical use of a new, flexible, low profile, balloon-expandable metallic stent and delivery system (ACS Multi-Link). The stent, designed in an effort to overcome the shortcoming of existing stents, has a low metal mass, superior scaffolding properties and favourable rheological characteristics. It also allows side branch access and is delivered via an innovative stent catheter. Ten stents were used to treat 10 patients with threatened abrupt closure after balloon angioplasty. All were successfully deployed, with a satisfactory angiographic result in nine. The patient with an unsatisfactory angiographic result proceeded to uneventful coronary bypass surgery. There were no other procedural or in-hospital complications. One patient developed restenosis and one had an intra-cerebral bleed following a fall. This new stent thus appears safe and effective when used to treat threatened abrupt closure. Due to its favourable characteristics, it may be well suited for reduction of restenosis. A multi-centre European registry (WEST) for primary implantation in 100 consecutive patients has now been completed.

Self expanding stents for the management of aorto-ostial stenoses in saphenous vein bypass grafts.

OBJECTIVE: To assess the early and follow up results of implantation of a self expanding stent in aorto-ostial stenoses of vein grafts. DESIGN: Prospective, non-randomised, observational study. SETTING: Tertiary referral centre for cardiac diseases. PATIENTS: Nineteen patients with ostial stenoses of saphenous vein grafts. MAIN OUTCOME MEASURES AND RESULTS: Stents were successfully deployed in all 19 patients with satisfactory angiographic results. In one patient this required two attempts. There were no deaths and no major procedural complications related to ostial stenting. Before discharge two (11%) patients had thrombosis of the ostial stent; one patient had a Q wave myocardial infarction. Femoral artery bleeding occurred in three (16%) patients. Angiographic follow up was performed in 18 patients at a mean of seven months. Restenosis within the ostial stent was detected in three (16%) patients. Twelve (63%) patients had an improved functional status at a mean follow up of nine months. One patient died suddenly at three months. Three (16%) patients required additional revascularisation procedures because of symptoms caused by restenosis within the ostial stent during follow up. CONCLUSIONS: Intracoronary stenting is an attractive treatment for the management of patients with vein graft ostial stenoses.

Experience with flecainide for the treatment of cardiac arrhythmias in children.

We treated 22 children, aged 3 days to 16 years 6 months (median 11 years 1 month), with flecainide for a variety of arrhythmias where a Class I agent was indicated. In 16, conventional antiarrhythmic treatment had failed. Structural heart disease was present in nine. The arrhythmia was paroxysmal re-entry atrioventricular tachycardia in nine; paroxysmal atrial tachycardia, flutter or fibrillation in five; paroxysmal ventricular tachycardia in five and frequent ventricular extrasystoles (with couplets) in three. Sinus rhythm was achieved in all four children who received flecainide during tachycardia (three received intravenous flecainide, one oral). During follow-up of 3-24 months (median 12 months), arrhythmia control was obtained in 13 children (59%). Combination therapy was used in seven of these; with digoxin in four and a beta blocker in three. Flecainide doses used in this study ranged from 1-11 mg kg-1 day-1 (median 4 mg kg-1 day-1), 25-297 mg m-2 day-1 (median 113 mg m-2 day-1). The median, pre-dose flecainide concentration in those responding to therapy was 225 micrograms l-1 and in those failing to respond was 417 micrograms l-1. An arrhythmogenic effect occurred in one child.