Rotablation for Octogenarians in a Modern Cathlab: Short- and Intermediate-Term Results.

Background: There are limited reports on the treatment of complex calcified lesions using rotational atherectomy (RA) in octogenarians, particularly in high-risk patients. Objective: To evaluate procedural and clinical outcomes of RA in octogenarians. Methods: Consecutive RA patients from 2010 to 2018 were selected from our catheterization laboratory database, stratified into two groups (≥ or < 80 years old), and analyzed. Results: A total of 411 patients (269 males and 142 females) with a mean age of 73.8 ± 11.3 years were enrolled, of whom 153 were ≥ 80 years old and 258 were < 80 years old. Most of the patients displayed high-risk features. The baseline Syntax scores were high in both groups, and most lesions were heavily calcified (96.1% vs. 97.3%, p = 0.969, respectively). The use of hemodynamic support intra-aortic balloon pump was more frequent in the octogenarians (21.6% vs. 11.6%, p = 0.007), but the RA completion rate was similarly high (95.9% vs. 99.1%, p = 0.842). There was no difference in acute complications. The total/cardiovascular (CV) death rate within one year was higher in the octogenarians, along with higher major adverse cardiovascular event (MACE)/CV MACE rates in the first month. Cox regression analysis showed that age ≥ 80 years, acute coronary syndrome, ischemic cardiomyopathy/shock, multi-vessel disease and serum creatinine were all predictors of MACE, and that these factors plus peripheral artery disease were predictors of all-cause mortality in these patients. Conclusions: RA is feasible with a very high success rate in high-risk octogenarians with complex anatomies, and with equal safety and no increase in complications. The higher rates of all-cause death and MACE were attributed to an older age and other traditional risk factors.

Rotablation in Patients with Advanced Renal Insufficiency through End-Stage Renal Disease: Short- and Intermediate-Term Results.

Objective: Patients with advanced renal insufficiency are at high risk of coronary artery disease (CAD) and complex lesions. Treating complex calcified lesion with rotational atherectomy (RA) in these patients might be associated with higher risks and poorer outcomes. This study was set to evaluate features and outcomes of RA in these patients. Method: Consecutive patients who received coronary RA from April 2010 to April 2018 were queried from the Cath Lab database. The procedural details, angiography, and clinical information were reviewed in detail. Results: A total of 411 patients were enrolled and divided into Group A (baseline serum creatinine <5 mg/dl, n = 338) and Group B (baseline serum creatinine ≥ 5 mg/dl through ESRD, n = 73). Most patients had high-risk features (65.7% of acute coronary syndrome (ACS), 14.1% of ischemic cardiomyopathy, and 5.1% of cardiogenic shock). Group B patients were significantly younger (66.8 ± 11.4 vs. 75.2 ± 10.7 years, p < 0.001) and had more RCA and LCX but less LAD treated with RA. No difference was found in lesion location, vessel tortuosity, bifurcation lesions, chronic total occlusion, total lesion length, or total lesion numbers between the two groups. Less patients in Group B obtained completion of RA (95.9% vs 99.1%, p=0.037). There was no difference in the incidence of procedural complication or acute contrast-induced nephropathy. Group B patients had more deaths and MACE while in the hospital. The MACE and CV MACE were also higher in Group B patients at 180 days and one year, mostly due to TLR and TVR. Multivariate regression analysis showed that ACS, age, peripheral artery disease (PAD), advanced renal insufficiency, ischemic cardiomyopathy/shock, and high residual SYNTAX score were independent risk factors for in-hospital MACE, whereas ACS, advanced renal insufficiency, ischemic cardiomyopathy/shock, triple-vessel disease, and PAD independently predicted MACE at 6 months. Conclusions: Rotablation is feasible, safe, and could be carried out with very high success rate in very-high-risk patients with advanced renal dysfunction through ESRD without an increase in procedural complication.

A HANC Risk Stratification Score for Antiplatelet Therapy Optimization with Low-Dose Prasugrel in Taiwanese Acute Coronary Syndrome Patients from the Switch Study.

Background: A significant proportion of acute coronary syndrome (ACS) patients experience high on-treatment platelet reactivity (HPR) on clopidogrel-based dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI). Objectives: This study assessed key independent risk factors associated with significant HPR risk on clopidogrel, but not prasugrel, in the Switch Study cohort of 200 Taiwanese ACS patients who switched from clopidogrel to low-dose prasugrel for maintenance DAPT after PCI. Methods: Univariate analysis and stepwise multivariate logistic regression analysis were conducted to identify key independent risk factors for HPR on clopidogrel, but not prasugrel. Results: A HANC [H: low hemoglobin (< 13 g/dL for men and < 12 g/dL for women); A: age ≥ 65 years; N: non-ST elevation myocardial infarction; C: chronic kidney disease as defined by estimated glomerular filtration rate < 60 mL/min] risk stratification score was developed, and demonstrated optimal sensitivity and specificity at a cutoff score of ≥ 2. The HANC score compared favorably against the recently validated ABCD score in the full Switch Study cohort (n = 200), and the ABCD-GENE score in a genotyped cohort (n = 102). Conclusions: The HANC score may serve to alert clinicians to patients at potentially higher HPR risk on clopidogrel, but not prasugrel. Further research to validate this score and assess its correlation with clinical outcomes is warranted.

Incidence and Mechanisms of Coronary Perforations during Rotational Atherectomy in Modern Practice.

OBJECTIVE: Heavy calcifications remain formidable challenges to PCI, even for well-experienced operators. However, rotational atherectomy (RA)-induced coronary perforations (CPs) still could not be obviated. This study was to explore incidence and mechanisms of RA-induced CP in real-world practice. Knowing why CPs occur in RA should help operators avert such mishaps. METHOD: Patients who received coronary RA from April 2010 to December 2019 with keywords related to perforations were retrieved from database. The procedure details, angiography, and clinical information were reviewed in detail. RESULTS: A total of 479 RAs were performed with 11 perforations in 10 procedures among 9 patients documented. The incidence of RA-induced CP was 2.1%. The RA vessels were distributed in different territories, including first diagonal branch. Most CPs could be treated conservatively, but prolonged profound shock predisposed to poor outcome. CPs caused by rotawire tip occurred in 18.2% of cases, inappropriately sized burrs in 18.2% of cases, and rotawire damage with subsequent transection and perforation in another 18.2% of cases. A total of 5 (45.5%) perforations were caused by unintended and unnoticed bias cutting into noncalcified plaques (4, 36.4%) or through calcified vessel wall (1, 9.1%). The mechanisms for certain CPs were unique and illustrated in diagrams. CONCLUSION: CPs due to RA occur in certain percentage of patients. The mechanisms for CPs are diverse. Wire damage with subsequent transection could occur due to inappropriately repetitive burr stress on the wire body. A significant portion was due to unintended and unnoticed bias cutting into noncalcified plaque or through calcified vessel wall.

The Characteristics and Clinical Outcomes of Rotational Atherectomy under Intra-Aortic Balloon Counterpulsation Assistance for Complex and Very High-Risk Coronary Interventions in Contemporary Practice: An Eight-Year Experience from a Tertiary Center.

BACKGROUND: The use of Complex and High-risk Coronary Interventions (CHIPs) has increased in recent years. Both rotational atherectomy (RA) and hemodynamic support are important parts of CHIPs. OBJECTIVES: This study aimed to retrospectively investigate the procedure results and clinical outcomes of intra-aortic balloon pump (IABP)-assisted RA in the contemporary drug-eluting stent era. METHODS: All consecutive patients who received RA under in-procedure IABP assistance from April 2010 to March 2018 were analyzed retrospectively. RESULTS: A total of 63 patients (77.7 ± 10.1 years, 69.8% male) were recruited, of whom 51 underwent RA with primary IABP assistance and 12 underwent bailout IABP. RA could be completed in 61 (96.8%) of the patients. Overall, vessel perforation, profound in-procedure shock, and ventricular arrhythmia occurred in 1.6%, 4.8% and 3.2% of the patients, respectively. The in-hospital, 30-day and 90-day major adverse cardiac event (MACE) rates were 22.2%, 27.4% and 36.1%, respectively, mostly driven by mortality. The MACE rates were significantly higher in the bail-out group in the hospital (50.0% vs. 15.7%, p = 0.018) at 30 days (58.3% vs. 20.0%, p = 0.013) and 90 days (66.7% vs. 28.6%, p = 0.020). CONCLUSIONS: Bail-out IABP was associated with increased MACEs, implying that the use of IABP should be implemented at the beginning of RA if a complex procedure is anticipated.

Acute Angiographic and Intermediate-Term Clinical Results of Patients with Non-Left Main Coronary Bifurcation Lesions Treated with BVS by Jailed Semi-Inflated Balloon Technique and Provisional Side-Branch Stenting Strategy.

BACKGROUND: To evaluate the acute angiographic and intermediate-term clinical results of patients with non-left main (LM) coronary artery bifurcation disease (CABD) treated with BVS, as compared with those treated with DES, using the jailed semi-inflated balloon technique (JSIBT) for side branch (SB) protection and provisional stenting. METHODS AND RESULTS: Sixty-eight patients with non-LM CABD who had undergone provisional one-stent implantation with SB protection by JSIBT between January 2015 and December 2017 were retrospectively enrolled. Among them, 20 patients received Absorb BVS implantation and 48 patients received DES implantation. Patients in the BVS group were younger and had higher BMI, total cholesterol, low-density lipoprotein cholesterol, and hemoglobin but had lower serum creatinine and lower prevalence of prior PCI and MI. No SB balloon rupture/entrapment occurred in either group. The incidence of SB dissection/occlusion and SB in need of rewiring or stenting was rare in both groups and showed no significant difference between them. Postinterventional TIMI flow significantly increased in both groups. The intermediate-term clinical outcomes were good in terms of incidence of target lesion failure, target lesion revascularization, target vessel revascularization, myocardial infarction, and all-cause death in both groups. CONCLUSION: The use of JSIBT for treating CABD with modern BVS can provide SB protection as similar as those with DES, even with higher incidence of acute SB dissection/occlusion. The immediate angiographic results and acute and intermediate-term clinical outcomes were also similar in both groups. Our study results demonstrate that JSIBT might be a safe and alternative SB protection tool for BVS in patients with complex CABD.

Clinical outcomes of coronary artery bifurcation disease patients underwent Culotte two-stent technique: a single center experience.

BACKGROUND: Percutaneous coronary intervention for coronary artery bifurcation disease (CABD) remains challenging. In patients of CABD with situations that two-stent strategy is needed, the culotte technique is a widely used method and also as the majority at out institution. We sought to take a look of the clinical outcomes of our culotte stenting patients. METHODS: This retrospective study analyzed 238 consecutive CABD patients who underwent culotte two-stent technique at a tertiary medical center between July 2008 and November 2015. RESULTS: Culotte technique was used in 238 lesions in 238 patients. Of these patients, all DES were implanted for culotte two-stent technique. Most of these patients were elderly, male gender, ACS on admission and multiple vessel disease. The bifurcation lesions were mostly located at left coronary artery (51.3%), categorized as true bifurcation lesion (92%) and calculated less than 70 degree of bifurcation angle (74.4%). During a medium 3.27-year follow up, the angle of bifurcation lesion ≥70° and body mass index were positively independent predictors for target lesion failure (TLF), diabetes mellitus was an independent predictor of target vessel revascularization, and statin therapy for hyperlipidemia, hemoglobin and EF were negatively independent factors associated to total mortality. The rates of in-hospital and total mortalities were 4.2 and 17.6%. CONCLUSION: In this cohort of CABD patients with most left main and left anterior descending artery lesions treated by culotte stenting, the procedural success rate was high and the intermediate clinical outcomes were acceptable. (Reviewer #1, Comment #1) Bifurcation angle (≥ 70°) is an inherently independent predictor of TLF and other two-stent strategy replaced needed to be considered in this situation.

Feasibility and clinical outcomes of rotational atherectomy for heavily-calcified side branches of complex coronary bifurcation lesions in the real-world practice of the drug-eluting stent era.

OBJECTIVES: To evaluate the outcomes of rotational atherectomy for heavily-calcified side branches of coronary bifurcation lesions. BACKGROUND: Side-branch (SB) preservation is clinically important but technically challenging in heavily-calcified non-left main true bifurcation lesions. SB rotational atherectomy (SB RA) is sometimes mandatory but the clinical outcomes are not well studied. METHODS: We retrospectively studied the outcomes of patients who underwent RA at our institute for heavily calcified, balloon-uncrossable or-undilatable SB lesions over an approximately 5-year period (January 2011 to September 2016). RESULTS: Two hundred and forty-four patients underwent main vessel only RA (SB-MV + RA group) and another 48 patients underwent SB RA (SB + MV ± RA group) for 49 side branches. The demographic variables were comparable between the two groups. However, patients underwent SB RA experienced more SB perforations and greater acute contrast-induced nephropathy (CIN). Among the SB RA patients, 30 (62.5%) underwent RA for both SB and MV (SB + MV + RA subgroup), whereas the other 18 underwent SB only RA (SB + MV-RA subgroup). Patients in these two subgroups could be completed with similar procedural, fluoroscopic durations, and contrast doses. The long-term MACE rate of SB RA was 27.1% over a mean follow-up period of 25.1 months with no differences between the two subgroups. CONCLUSIONS: RA for SB preservation in complex and heavily-calcified bifurcation lesions was feasible with high success rate and quite favorable long-term outcomes in the drug-eluting stent (DES) era. Given the higher rates in SB perforation and acute CIN, we recommend that SB RA should be conducted by experienced operators.

Percutaneous intervention to correct central venous port catheter malposition.

The use of central venous port access is increasing due to the requirements of multimodal intravenous therapy.1 However, catheter malposition in smaller veins can lead to vein thrombosis, phlebitis and pain. Herein, we report our experience with the use of percutaneous interventions to correct migrated port catheter malposition. Minimally invasive percutaneous interventional correction of malposition could be an alternative to extraction and re-implantation of malpositioned port catheters.

Prediction of Both Electrical and Mechanical Reverse Remodeling on Acute Electrocardiogram Changes After Cardiac Resynchronization Therapy.

BACKGROUND: The development of both electrical reverse remodeling and mechanical reverse remodeling (ERR+MRR) after cardiac resynchronization therapy (CRT) implantation could reduce the incidence of lethal arrhythmia, hence the prediction of ERR+MRR is clinically important.Methods and Results:Eighty-three patients (54 male; 67±12 years old) with CRT >6 months were enrolled. ERR was defined as baseline intrinsic QRS duration (iQRSd) shortening ≥10 ms in lead II on ECG after CRT, and MRR as improvement in LVEF ≥25% on echocardiography after CRT. Acute ECG changes were measured by comparing the pre-implant and immediate post-implant ECG. Ventricular arrhythmia episodes, including ventricular tachycardia and ventricular fibrillation, detected by the implanted device were recorded. Patients were classified as ERR only (n=12), MRR only (n=23), ERR+MRR (n=26), or non-responder (ERR- & MRR-, n=22). On multivariate regression analysis, difference between baseline intrinsic QRS and paced QRS duration (∆QRSd) >35 ms was a significant predictor of ERR+MRR (sensitivity, 68%; specificity, 64%; AUC, 0.7; P=0.003), and paced QTc >443 ms was a negative predictor of ERR+MRR (sensitivity, 78%; specificity, 60%; AUC, 0.7; P=0.002). On Cox proportional hazard modeling, ERR+MRR may reduce risk of ventricular arrhythma around 70% compared with non-responder (HR, 0.29; 95% CI: 0.13-0.65). CONCLUSIONS: Acute ECG changes after CRT were useful predictors of ERR+MRR. ERR+MRR was also a protective factor for ventricular arrhythmia.

Dramatic and early response to low-dose steroid in the treatment of acute eosinophilic myocarditis: a case report.

BACKGROUND: Eosinophilic myocarditis encompasses a variety of etiologies and the prognosis varies. For patients with a hypersensitive response to medications, high-dose corticosteroids and discontinuation of culprit medications are the main treatments. CASE PRESENTATION: We reported a young man with biopsy-proven eosinophilic myocarditis which was possibly induced by Chinese herbal medicine. His heart failure and left ventricular hypertrophy improved soon after low-dose corticosteroid. CONCLUSION: Low-dose corticosteroid may be effective in selected patients with eosinophilic myocarditis. Early echocardiographic follow-up is mandatory for evaluation of the clinical response.

Modified drug-eluting balloon angioplasty to treat high-risk carotid in-stent restenosis.

Carotid artery stenting is commonly used to treat carotid artery stenosis. However, carotid in-stent restenosis remains a challenging problem. Herein, we report a difficult case of recurrent severe carotid in-stent restenosis with total contralateral internal carotid artery occlusion treated with repeat drug-eluting balloon inflations. The outcome after one year of follow-up showed a good result.

Endovascular Treatment of Concomitant Obstructions of a Denver Drainage Catheter and Superior Vena Cava in a Patient With Liver Cirrhosis.

With the increased use of intravascular catheters and devices, they have become the major non-malignant cause of superior vein cava (SVC) syndrome. We report a patient with liver cirrhosis who had received a peritoneovenous drainage catheter for refractory ascites, and then developed SVC syndrome because of concomitant occlusions of both the SVC and the drainage catheter. The patient regained patency of both the occluded vessel and the drainage catheter through percutaneous transluminal venoplasty, and there was dramatic improvement of clinical symptoms and good performance of the drainage catheter. Percutaneous intervention may be a feasible and effective therapy for SVC syndrome and intra-catheter thrombosis-related dysfunction.

Efficacious and safe orotracheal intubation for laboratory mice using slim torqueable guidewire-based technique: comparisons between a modified and a conventional method.

BACKGROUND: Tracheal intubation of laboratory mice remains essential yet challenging for most researchers. The aim of this study was to investigate whether this procedure can be more efficiently and safely accomplished by a novel method using slim and torqueable guidewires to guide access to the trachea. METHODS: This study was carried out in an animal laboratory affiliated to a tertiary medical center. Mice weighing 22 to 28 g were subjected to various open-chest experiments after being anesthetized with intraperitoneal ketamine (100 mg/kg) and lidocaine hydrochloride (10 mg/kg). The oropharyngeal cavity was opened with angled tissue forceps, and the trachea was transilluminated using an external light. The vocal cords were then crossed using either the Conventional method with a 38-mm-long, end-blunted stiff needle as a guide for insertion of a 22-gauge, 25-mm-long intravenous catheter into the trachea, or the Modified method utilizing using a 0.014-inch-thin torqueable wire as the guide to introduce an identical tube over it into the trachea. The epithelial integrity of the trachea was later examined histologically when the animals were sacrificed either immediately after the surgery or at 28 days post-surgery, depending on the corresponding research protocols. RESULTS: Orotracheal intubation was successfully completed in all mice using either the Conventional (N = 42) or the Modified method (N = 50). With the Modified method, intubation took less time (1.73 vs. 2.17 min, Modified vs. Conventional, p < 0.001) and fewer attempts (1.0 vs. 1.33, p < 0.001), and there were fewer procedural difficulties (0% vs. 16.7%, p = 0.009) and complications (0% vs. 11.9%, p = 0.041) compared with the Conventional method. Histological analysis revealed a significantly lower incidence of immediate (0% vs. 39%, p < 0.001) and late (0% vs. 58%, p < 0.001) injuries to the tracheal epithelial lining with the Modified method compared to the Conventional method. CONCLUSIONS: Tracheal intubation for laboratory mice can be completed efficiently, safely and atraumatically using the proposed Modified method employing readily available inexpensive instruments.

"DK Crush" Technique for a Tightly Stenosed Conjoined SVG Lesion in a Patient with Acute Coronary Syndrome and Cardiogenic Shock.

UNLABELLED: Coronary artery bifurcation disease of saphenous venous graft (SVG) is extremely rare. SVG disease remains a challenging lesion to treat because of increased morbidity and mortality with repeated coronary artery bypass graft surgery (CABG), high rates of periprocedural complications, and in-stent restenosis or occlusion requiring repeat revascularization with percutaneous coronary intervention. Herein, we present the first reported case of using the "DK crush" technique to treat an inverted Y-shaped SVG bifurcation disease in a patient with a prior CABG and new-onset acute coronary syndrome. Arising from our treatment, favorable immediate and mid-term angiographic and clinical outcomes were obtained. KEY WORDS: Coronary artery bypass surgery (CABG); "DK crush" technique; Saphenous venous graft (SVG).

Lack of Association between High-Density Lipoprotein Cholesterol and Angiographic Coronary Lesion Severity in Chinese Patients with Low Background Low-Density Lipoprotein Cholesterol.

BACKGROUND: The atheroprotective role of high-density lipoprotein (HDL-C) particles as measured by HDL-C level in coronary arterial disease (CAD) remains unsettled. The aim of our study was to ascertain whether HDL-C was associated with the development and severity of coronary artery disease in Chinese patients who underwent coronary angiogram with low background Low-density lipoprotein (LDL-C) levels, which has not been previously investigated. METHODS: Between March 1995 and May 2000, 566 consecutive patients (408 males, 66.7 ± 11.3 years of age) with background LDL-C less than 100 mg/dl who underwent coronary artery angiography at our cath lab for suspected CAD were retrospectively recruited into the study. The severity of coronary lesions was measured by conventional coronary angiography and modified Gensini scores. RESULTS: In those subjects with significant coronary lesions, there were more males and conventional CAD risk factors of diabetes mellitus, smoking, and chronic renal disease. They were also older compared to those in the control group. However, total cholesterol, LDL-C, HDL-C, triglyceride levels and use of statins were similar in both groups. In those subjects with significant coronary lesions, there was no difference in conventional coronary lesion severity or modified Gensini score between the quartered HDL-C subgroups. Furthermore, there was no significant correlation between serum HDL-C level and modified Gensini scores. In linear regression analysis, HDL-C was not an independent predictor for modified Gensini scores. Furthermore, HDL-C was also not an independent risk factor for the presence of significant coronary lesions in low LDL-C patients in logistic regression analysis. CONCLUSIONS: In Chinese patients with low background LDL-C, serum HDL-C was not associated with development of CAD or lesion severity in patients with suspected CAD. Therefore, HDL-C did not appear to be atheroprotective in these patients. KEY WORDS: Coronary artery disease; Gensini score; High-density lipoprotein cholesterol.

Lower serum triglyceride level is a risk factor for in-hospital and late major adverse events in patients with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention- a cohort study.

BACKGROUND: Whether serum triglyceride level correlates with clinical outcomes of patients with ST segment elevation myocardial infarction (STEMI) treated by primary percutaneous coronary intervention (pPCI) remains unclear. METHODS: From June 2008 to February 2012, all patients with STEMI who were treated with pPCI in this tertiary referral hospital and then had fasting lipid profiles measured within 24 hours were included and dichotomized into lower- (≦ 150 mg/dl) and higher-triglyceridemic (>150 mg/dl) groups. Baseline characteristics, in-hospital outcomes, and late major adverse cardiovascular events (MACE) were compared in-between. Independent predictors for in-hospital death and late adverse events were identified by multivariate logistic and Cox regression analyses. RESULTS: A total of 247 patients were enrolled, including 163 lower-triglyceridemic and 84 higher-triglyceridemic subjects. The angiographic characteristics, pPCI results and in-hospital outcomes were similar between the two groups. However, multivariate logistic analysis identified triglyceride level as a negative predictor for in-hospital death (OR 0.963, 95% CI 0.931-0.995, p = 0.023). At follow-up for a mean period of 1.23 to 1.40 years, compared with the high-triglyceridemic group, low-triglyceridemic patients had fewer cumulative incidences of target vessel revascularization (TVR) (21.7% vs. 9.5%, p = 0.011) and overall MACE (26.1% vs. 11.9%, p = 0.0137). Cox regression analysis confirmed serum triglyceride as a negative predictor for TVR and overall MACE. CONCLUSIONS: Serum triglyceride level inversely correlates with in-hospital death and late outcomes in patients with STEMI treated with pPCI. Thus, when managing such patients, a high serum triglyceride level can be regarded as a benign factor but not a target for aggressive therapy.

Endovascular Angioplasty of Celiac Axis Obstruction Prior to Pancreaticoduodenectomy in a Patient with Pancreatic Neuroendocrine Carcinoma.

UNLABELLED: In patients with celiac axis stenosis or occlusion, a pancreaticoduodenectomy procedure can increase the risk of hepato-pancreato-biliary and other organ ischemia or failure unless a complete revascularization of the celiac axis is performed prior to or simultaneous with such surgery. Celiac axis occlusion does not appear to be an uncommon finding in cases of pancreaticoduodenectomy. Preoperative abdominal angiography can play an important role in diagnosing this high risk comorbid disease, and adequate intervention can lead to a successful operation and good postoperative outcome. Herein, we reported a patient with periampullary malignancy and metastatic liver cancer, whose preoperative diagnosis of severe celiac axis stenosis was proved by preoperative abdominal angiography. Preoperative angioplasty was subsequently performed. After angioplasty, pancreaticoduodenectomy with resection of segments 4, 6 and 7 of liver was done and the postoperative course was uneventful. KEY WORDS: Celiac axis occlusion; Endovascular angioplasty; Pancreaticoduodenectomy.

Hypercalcemia-Induced New Onset Left Bundle Branch Block Mimicking Acute Myocardial Infarction in a Patient with Primary Hyperparathyroidism.

UNLABELLED: A 78-year-old women with a recent diagnosis of primary hyperparathyroidism presented with vague chest pain, and new onset left bundle block (LBBB) on the electrocardiogram (ECG) mimicking acute myocardial infarction (AMI). LBBB resolved without abnormal Q waves only after correction of hypercalcemia. The cardiac enzymes, including creatine kinase, creatine kinase-MB, and troponin-I were all within normal range. Hypercalcemia provoking ECG changes that mimic acute myocardial infarction is infrequently reported. To our knowledge, this is the first report of hypercalcemia-induced new onset LBBB mimicking AMI. Emergency physicians should include hypercalcemia-induced new onset LBBB on the ECG in the differential diagnosis of AMI. KEY WORDS: Acute myocardial infarction; Hypercalcemia; Hyperparathyroidism; left bundle branch block.