Simple and new technique to assess left internal mammary artery function by left ventriculography : LIMA imaging with ventriculography.

The aim of this study was to demonstrate an assessment of left internal mammary artery (LIMA) patency and anatomy by standard left ventriculography, and to define a proposal for predicting LIMA function according to left ventriculography outcome. A total of 335 patients with an indication of coronary angiography were included. Standard coronary angiography and left ventriculography were performed initially. Visualization of LIMA occurred in the late phase of ventriculography and the LIMA visualization frame rate was counted for each patient. Then selective LIMA angiography was performed and LIMA diameter, LIMA course and anatomy, and subclavian artery anatomy were noted. Finally, the results of left ventriculography and LIMA angiography were compared by statistical analysis. During left ventriculography, LIMA was visualized in 96.4% of the patients. The mean LIMA visualization frame rate was 53.8 ± 17.7 and the mean LIMA diameter was 2.60 ± 0.36 mm. There was a strong correlation between LIMA visualization frame rate and LIMA diameter, LIMA course, and also asymptomatic subclavian artery disease (P < 0.001). Regression analysis showed that LIMA visualization frame rate is the major independent determinant for LIMA diameter prediction (P < 0.001); LIMA diameter, LIMA course, proximal LIMA side branch, and subclavian artery disease are the major predictors of LIMA visualization on left ventriculography (P < 0.001). LIMA patency and anatomy can be evaluated accurately with a simple method using left ventriculography. Besides direct visualization of LIMA, the visualization frame rate may constitute a reliable parameter for assessing LIMA function. A LIMA visualization frame rate of less than 50 is associated with a healthy and well-sized LIMA.

Association between preinfarction angina and coronary artery ectasia in the acute myocardial infarction.

OBJECTIVE: The objective of this study was to investigate the predictors of preinfarction angina (PA) and to show the association between PA and coronary ectasia (CE). METHODS: A total of 222 patients with acute myocardial infarction were included. All patients were treated with primary coronary intervention and interviewed by the staff physicians within 24 h of presentation after reperfusion had succeeded. The patients were classified according to the presence of PA and CE. All groups were compared statistically according to their clinicodemographic characteristics and angiographic results. Regression analysis was performed to show the predictors of PA. RESULTS: Half of the patients were defined as preinfarction angina (48.2%) and the success rate of primary coronary intervention did not differ statistically in the PA present group. More than half of the patients had multivessel disease and coronary ectasia was found in the 11.7%. The right coronary artery (RCA) was the most common localization for ectasia and 61.5% of the ectatic vessels were also infarct-related. Diabetes mellitus, hypertension and previous coronary heart disease were slightly more common in the PA present group. In the regression analysis, coronary ectasia, multivessel disease and previously diagnosed coronary artery disease were independent predictors of PA (P = 0.001, P = 0.01 and P = 0.03, respectively) CONCLUSIONS: CE is more common in patients with PA and more than half of the patients showed CE in the infarct-related vessel. CE and multivessel disease are independent predictors of PA. The success rate of primary coronary intervention in ectatic infarct-related vessels did not differ in the PA group.

[Myocardial noncompaction recognized following a transient ischemic attack]. / Geçici iskemik atak sonrasi saptanan süngerimsi miyokart (noncompaction).

Myocardial noncompaction is a rare type of congenital cardiomyopathy characterized by excessively prominent trabeculations in one or more segments of the ventricles and deep intertrabecular recesses in ventricular walls. A 25-year-old male patient presented to the neurology department with complaints of weakness in the left extremities. A mild loss of muscle strength was detected on neurological examination. With a preliminary diagnosis of acute cerebrovascular event, treatment with aspirin and enoxaparin was instituted, which improved his complaints within two hours. Electrocardiography showed sinus rhythm, left ventricular hypertrophy, and loss of R-wave progression in the precordial leads. Transthoracic echocardiography showed apical hypokinesia, marked left ventricular hypertrophy, and normal left ventricular diameters. There were numerous trabeculations in the apex, apical, lateral, and inferior walls, and deep intertrabecular recesses. Color Doppler showed blood flow into the intertrabecular recesses. He also had mild mitral regurgitation and diastolic dysfunction of restrictive type. He was scheduled for outpatient follow-up on aspirin and warfarin treatment.

Simvastatin may improve myocardial perfusion abnormality in slow coronary flow.

BACKGROUND: The slow coronary flow (SCF) phenomenon is a coronary microvascular disorder characterized by the delayed passage of contrast in the absence of obstructive epicardial coronary disease. Recent studies showed the possible role of endothelial dysfunction, diffuse atherosclerosis and inflammation in the pathogenesis of this phenomenon. We aimed to investigate the effect of statin on myocardial perfusion in patients with SCF. METHODS AND RESULTS: The study population consisted of 97 patients with SCF. Coronary flow patterns of the cases are determined by thrombolysis in myocardial infarction (TIMI) frame count method. Single-photon emission computed tomographic myocardial perfusion imaging studies and lipid parameters of the patients were obtained before and after 6 months of simvastatin treatment period. During the study, daily single dose of 40 mg simvastatin has been given to each subject. We found a significant positive correlation between mean TIMI frame count and basal reversibility score (r = 0.84, p = 0.0001). In addition, analysis of the reversibility scores demonstrates that simvastatin treatment has significantly improved the myocardial perfusion abnormality at the end of the follow-up period. CONCLUSION: Present findings allow us to conclude that simvastatin improved myocardial perfusion in patients with SCF.

Effects of radiofrequency catheter ablation on myocardial performance index and plasma NT-Pro-BNP levels in patients with Wolff-Parkinson-White syndrome.

BACKGROUND: The myocardial performance index (Tei index) is an echocardiographic index of combined systolic and diastolic functions. Brain natriuretic peptide (BNP) and its biologically inactive fragment N-terminal pro-BNP (NT-pro-BNP) are secreted by the heart in response to myocardial stretch. In this study, we investigated Tei index and NT-pro-BNP levels in patients with Wolff-Parkinson-White (WPW) syndrome before and after radiofrequency catheter ablation therapy (RFCA). METHODS: Thirty patients (19 males, 11 females, aged 35.5 +/- 14.4 years) with WPW syndrome were enrolled in this study. Echocardiographic examination was performed before and 24 hours after RFCA. Tei index was calculated using Doppler echocardiography. Blood samples were taken before and 24 hours after RFCA to detect levels of NT-pro-BNP. RESULTS: Although isovolumic contraction time (IVCT) and isovolumic relaxation time (IVRT) did not change, aortic ejection time (ET) was decreased after RFCA (276 +/- 22 ms vs 254 +/- 30 ms, P < 0.01). So Tei index was significantly higher in postablation period (0.36 +/- 0.11 vs 0.42 +/- 0.21, P < 0.05). NT-pro-BNP levels did not change significantly after RFCA. CONCLUSIONS: We demonstrated that restoration of normal atrioventricular conduction by RFCA, leads to increase in Tei index but does not effect plasma NT-pro-BNP levels.

Does the level of soluble intercellular adhesion molecule 1 predict myocardial injury before cardiac markers increase?

BACKGROUND: The measurement of cardiac markers is still the gold standard for diagnosing myocardial infarction (MI), but there is always a transition period between the time of infarction and when a marker can be measured in the blood. Therefore, clinicians are shifting their focus to the identification of potential new analytes capable of predicting MIs before the standard cardiac markers increase. In this study, we tested whether measurement of the concentration of soluble intercellular adhesion molecule 1 (sICAM-1) in plasma can be used for this purpose. MATERIALS AND METHODS: In this prospective study, we included 60 male patients who had a left main coronary artery lesion or a left main equivalent and who underwent elective (group I, n = 20), urgent (group II, n = 20), or emergent (group III, n = 20) coronary artery bypass grafting (CABG). We excluded patients who had increased cardiac markers at admission, and drew blood samples for sICAM-1 measurements from other patients immediately after coronary angiography evaluations. We divided the patients into 3 groups according to their clinical characteristics and cardiac marker levels. Only patients with increased cardiac markers underwent emergent CABG (group III). We measured sICAM-1 concentrations immediately after coronary angiography and measured creatine kinase MB (CK-MB) and cardiac troponin I (cTnI) just before CABG. We then evaluated the results for correlations. RESULTS: CK-MB, cTnI, and sICAM-1 levels were significantly higher in group III than in groups I and II (P < .05 for all). Our analysis for correlations between the sICAM-1 level and cardiac marker levels revealed no significant correlations in group I (CK-MB, r = 0.241 [P = .15]; cTnI, r = -0.107 [P = .32]) and group II (CK-MB, r = -0.202 [P = .19]; cTnI, r = 0.606 [P = .002]), but our analysis did reveal highly significant correlations in group III (CK-MB, r = 0.584 [P = .003]; cTnI, r = 0.605 [P = .002]). CONCLUSION: Measuring the plasma concentration of sICAM-1 before the concentrations of cardiac markers increase in patients with MI may provide clinicians with faster and reliable data for deciding on and administering the most appropriate procedures and/or therapies.

Paradoxical mesentery embolism and silent myocardial infarction in primary antiphospholipid syndrome: a case report.

In this case, we describe a 33-year-old man presenting with acute mesenteric ischemia. When we searched for a source of embolism, a giant right atrial mass and patent foramen ovale was discovered. Standard electrocardiography showed signs of an old, silent anteroseptal wall myocardial infarction, confirmed by echocardiography and left ventriculography. Coronary angiography revealed complete occlusion of the left anterior descending artery. The diagnosis of primary antiphospholipid syndrome was confirmed by anticardiolipin antibodies test. Surgical myocardial revascularization along with the resection of the mass and the closure of the patent foramen ovale were performed. Histological examination of the operative specimen showed a thrombus. This is the first reported case presenting with acute paradoxical mesentery embolism accompanying an old myocardial infarction in a young patient with primary antiphospholipid syndrome.

Treatment strategies in the left main coronary artery disease associated with acute coronary syndromes.

Significant left main coronary artery (LMCA) stenosis is not rare and reported 3 to 10% of patients undergoing coronary angiography. Unprotected LMCA intervention is a still clinical challenge and surgery is still going to be a traditional management method in many cardiac centers. With a presentation of drug eluting stent (DES), extensive use of IVUS and skilled operators, number of such interventions increased rapidly which lead to change in recommendation in the guidelines regarding LMCA procedures in the stable angina (Class 2a recommendation for ostial and shaft lesion and class 2b recommendation for distal bifurcation lesion). However, there was not clear consensus about the management of unprotected LMCA lesion associated with acute myocardial infarction (MI) with a LMCA culprit lesion itself or distinct culprit lesion of other major coronary arteries. Surgery could be preferred as an obligatory management strategy even in the high risk patients. With this review, we aimed to demonstrate treatment strategies of LMCA disease associated with acute coronary syndrome, particularly acute myocardial infarction (MI). In addition, we presented a short case series with LMCA lesion and ST elevated acute MI in which culprit lesion placed either in the left anterior descending artery or circumflex artery. We reviewed the current medical literature and propose simple algorithm for management.

Congestive heart failure due to traumatic arteriovenous fistula--two case reports.

Arteriovenous fistulas are abnormal connections between the high-pressure and high-resistance arterial system and the venous system with opposite features. Due to its lower resistance, the blood preferentially flows via the fistula rather than through the capillary bed. The amount of shunt flow depends on its size and proximity to the heart. Due to the increase in circulating volume, progressive dilation develops in the whole vascular system proximal to the shunt. Cardiomegaly and venous distention may return to normal after surgical repair of this vascular abnormality. Two cases are presented of heart failure due to traumatic arteriovenous fistula, one of which was between the right renal artery and inferior vena cava and the other between the left renal artery and renal vein.

Candida albicans endocarditis and a review of fungal endocarditis: case report.

Endocarditis due to fungal etiology is rare, but it is the most severe form of infective endocarditis. Fungal endocarditis is commonly complicated by systemic embolizations, and the difficulty in isolating the fungi with routine blood cultures complicates the diagnostic process. In these culture-negative cases of endocarditis, etiologic diagnosis is made with histopathologic examination of the cardiac valve, embolic materials, and systemic ulcers. In this case report, the presented patient with fungal endocarditis and its neurologic complications was treated with a surgical and medical approach.

Coronary-carotid artery collateral formation in Takayasu's arteritis: First reported case in the literature.

We present the first case report of coronary-carotid artery collateral formation in Takayasu's arteritis. There was a vasculitic involvement of both subclavian and carotid arteries with critical stenosis; cerebral perfusion was supported with collaterals arising from the mesenteric arteries and coronary artery. .

Impact of serum alkaline phosphatase level on the pathophysiologic mechanism of contrast-induced nephropathy.

BACKGROUND: Contrast-induced nephropathy (CIN) accounts for 10% of all causes of hospital-acquired renal failure. It leadsto a prolonged in-hospital stay, and represents a powerful predictor of poor early and late outcomes. More than half of casesare observed after cardiovascular procedures. AIM: To determine the predictive value of the serum alkaline phosphatase (ALP) level in the development of CIN, something which has not been assessed before. METHODS: We prospectively evaluated a total of 430 patients with acute coronary syndrome. Patients were classified according to the development of CIN and both groups were compared statistically according to clinical, laboratory and demographic features, including the serum ALP level. RESULTS: CIN was observed in 20.5% of patients. Advanced age, male gender, elevated creatinine, uric acid and phosphate levels, and low glomerular filtration rate were correlated with the development of CIN. Correlation analysis also showed a significant association between the ALP level and the development of CIN (126.1 ± 144.9 vs. 97.2 ± 46.9, p = 0.004). Univariate regression analysis also showed the impact of ALP on the development of CIN (OR 1.004, 95% CI 1.001­1.007, p = 0.02). Conclusions: Our outcomes indicate a possible active role of ALP in the mechanism of CIN. An elevated ALP level may predict the development of CIN.

Is it feasible to perform coronary chronic total occlusion intervention with conventional angioplasty equipment.

OBJECTIVE: To demonstrate feasibility of coronary chronic total occlusion (CTO) procedures with conventional interventional equipment. METHODS: Ninety-five subsequent CTO patients were analyzed retrospectively. Patients who met the inclusion criteria were intervented with standard angioplasty catheters, guidewires, and balloon catheters. The procedural success rate of the interventions was discussed according to clinical and demographic characteristics of patients and equipment used for intervention. This study was carried out in Istanbul Medicine Hospital, Istanbul, Turkey between January 2007 and June 2011. RESULTS: Successful revascularization was achieved in 80% of patients, and all patients were discharged on the day after the procedure without complication. The success rate decreased to 60% in the CTOs of more than one year and approximately 90% in the shorter duration. Stent implantation was carried out in 82.9% of patients with a mean stent length of 42.7+/-21.4 mm. Occlusion duration was the major predictor of successful procedure on regression analysis (p=0.01). CONCLUSION: Coronary intervention for CTO with conventional equipment is still reasonable in the CTOs of short duration. Duration of coronary CTO over a year should be referred to a reference center where skilled operators and specialized equipment for CTOs are widely available.

Impact of emergency services and ambulance type on pain-to-balloon time in the acute myocardial infarction: an observational study.

OBJECTIVE: The objective of this study was to evaluate the role of first contact emergency departments and ambulances on transport duration, pain-to-balloon time, door-to-balloon time and first contact-to-balloon time in acute myocardial infarction (AMI) patients. METHODS: The study was a prospective and observational investigation. A total of 374 AMI patients initially admitted to primary coronary intervention (PCI) incapable centers were included in this study. Patients were classified according to initial presentation site (daily clinic, public hospital or private hospital) and transport manner (public or private ambulance). All groups were compared by the Kruskal-Wallis and Mann-Whitney U tests statistically according to their characteristics, transport duration and pain-to-balloon time. RESULTS: A majority of the patients were initially admitted to public (40.1%) or private hospitals (47.1%). The average door-to-balloon time was 45.0 ± 18.5 min and the mean pain-to-balloon time was 310.6 ± 160.8 min. Nearly half of the patients initially admitted to daily clinics were first transported to PCI-incapable centers, leading to delayed admission to PCI-capable centers and increased pain-to-balloon and first contact-to-balloon times (361.7 ± 194.5 min, p=0.01 and 279.7±158.2 min, p<0.001). Patients admitted to private hospitals experienced shorter average pain-to-balloon and first contact-to-balloon times (277.5 ± 148.6 min, p=0.01 and 157.4 ± 83.1 min, p<0.001). Patients transported by private ambulances also experienced shorter waiting times and shorter pain-to-balloon times (107.4 ± 70.4 and 270.1 ± 150.4 min, p<0.001). CONCLUSION: Physicians and healthcare professionals in first contact emergency departments and ambulance type appear to be factors in the increased pain-to-balloon time. AMI patients are often initially admitted to PCI-incapable centers, leading to delayed admission to PCI-capable centers and increased pain-to-balloon time.

Elevated red cell distribution width level predicts worse postinterventional thrombolysis in myocardial infarction flow reflecting abnormal reperfusion in acute myocardial infarction treated with a primary coronary intervention.

OBJECTIVES: Red cell distribution width (RDW), a measure of circulating erythrocyte size heterogeneity, is an established predictor of long-term prognosis and also all-cause mortality in a variety of cardiovascular settings. The correlation of RDW and reperfusion in acute myocardial infarction (AMI) has not been reported. Herein, we aimed to demonstrate the impact of an elevated RDW level on the postinterventional thrombolysis in myocardial infarction (TIMI) flow in AMI patients. METHODS: A total of 556 patients with an ST elevation AMI were evaluated retrospectively. Upon admission, the RDW level was measured with an automated complete blood count. Postinterventional TIMI flow was documented for all patients. Then, the patients were classified according to the RDW level and the TIMI flow. TIMI 0-1-2 flow was defined as abnormal reperfusion and RDW more than 14.8% was defined as elevated level. All groups were statistically compared according to the preinterventional clinical and demographic features. RESULTS: Abnormal reperfusion was observed in 26% of the patients. Advanced age, female sex, diabetes mellitus, and hypertension were correlated with TIMI flow less than 3. Elevated RDW (>14.8%) was observed in 21.9% of the patients and it was more common in patients who were older, women, and hypertensive patients. Elevated RDW was also strongly correlated with TIMI flow less than 3 (P<0.001). In addition, elevated RDW was found to be an independent predictor of abnormal reperfusion in multivariate regression analysis (odds ratio: 2.20, with a 95% confidence interval 1.012-4.569; P=0.05). CONCLUSION: An elevated RDW level on admission is associated with worse reperfusion in AMI treated with a primary coronary intervention, which could be one of the factors that may contribute toward the association between elevated RDW and long-term adverse cardiovascular outcomes and mortality.

What is the optimal length of stay in hospital for ST elevation myocardial infarction treated with primary percutaneous coronary intervention?

BACKGROUND: The aim of this study was to evaluate the safety and practicality of very early (within 48 h) discharge with long-term follow-up results, and to define an optimal length of stay in hospital for patients with ST elevation myocardial infarction (STEMI) according to their demographic characteristics and risk assessment. METHODS: A total of 267 patients with STEMI successfully treated with primary coronary intervention were retrospectively analyzed. Patients was divided into four groups according to length of hospitalization: 24 hours, 48 hours, 72 hours, and more than 72 hours. The groups were compared in terms of the patients' demographic and clinical characteristics, short- and long-term follow-up results, mortality, revascularization and major adverse cardiac events (MACE). RESULTS: More than two thirds of the patients were discharged within 48 hours (68.9%). No difference was observed between groups in terms of one month and one year MACE and one year restenosis. However, one month restenosis was slightly higher in the fourth group. At the end of the first year, there had been only four deaths, and these were in the third and fourth groups. There were no deaths among patients discharged within 48 hours. Killip class, left ventricular ejection fraction, multi-vessel disease and diabetes were the major determinants of length of stay in hospital. CONCLUSIONS: Very early discharge is safe and feasible and does not increase the mortality rate. Uncomplicated STEMI patients with single vessel disease could be discharged after 24 hours. Patients with multi-vessel disease classified in the low risk group could be discharged after 48 hours.

Pericardial tamponade due to synergistic effects of tuberculosis and myxedema.

Tuberculosis is a leading cause of massive pericardial effusion and tamponade especially in underdeveloped and developing countries. Hypothyroidism is also associated with pericardial effusion with rare progression to tamponade. We present a case of pericardial tamponade who diagnosed as both tuberculosis and myxedema at admission. Urgent pericardiocentesis performed as an initial therapy and four-agents antituberculous and thyroxine replacement therapy started immediately as long-term management. Coexistance of tuberculosis and myxedema is a rare condition and they can cause tamponade formation with synergistic effect. Such a additive etiologies of pericardial tamponade have not been reported.

ST segment elevation myocardial infarction due to slow coronary flow occurring after cannabis consumption.

Slow coronary flow (SCF) is an angiographic finding defined as the slow movement of contrast throughout the coronary lumen in the absence of epicardial coronary stenosis. It has been reported that SCF can on rare occasions cause ST elevated myocardial infarction (MI). Recent studies have shown that cannabis consumption can increase the risk of coronary heart disease and can trigger acute coronary syndromes, especially in young individuals without common risk factors. Here, we present a case of inferior MI in a patient who had consumed cannabis regularly over a long period and whose coronary angiography revealed SCF.

Entrapment of hydrophilic coated coronary guidewire tips: which form of management is best?

Fracture, detachment and entrapment of coronary guidewires is seen infrequently. Different treatment strategies have been performed for such cases in medical literature. Here, we present three different cases of hydrophilic coated coronary guidewire non-metallic tip entrapment. Conservative management was preferred as the main strategy, with a practical approach to fix the guidewire remnant to the coronary bed during intervention. All three patients were asymptomatic following the interventions. Besides case presentation and our treatment, we also briefly review the history and management strategies reported and discussed in the medical literature.