Same-day dual radial artery puncture examination in patients requiring percutaneous coronary intervention and the incidence of radial artery occlusion.

BACKGROUND: We sought to investigate the rate of radial artery occlusion (RAO) after same-day dual radial artery puncture. The trans-radial arterial approach (TRA) for diagnostic and interventional procedures has risen significantly in the United States. Although becoming more commonly performed, TRA is not without risk, and a potential complication is RAO. The rate of RAO after same-day dual artery puncture is unknown. METHODS: A retrospective analysis of 27 patients who underwent same-day dual radial artery puncture for percutaneous coronary intervention (PCI) at our institution (Providence Heart Institute in Southfield, MI, USA) from November 2011 to December 2013 were included after initially presenting for cardiac catheterization at a non-PCI-capable facility. The study patients were asked to follow up for evaluation of the radial artery, including obtaining a duplex ultrasound evaluation. RESULTS: The mean age of the patients was 65 years old with 66% of the patients being male. Of the 27 study participants, there were no symptoms reported that were related to RAO. Overall, one (3.7%) patient had an absent radial pulse. The modified Allen's test was normal in all of the patients with a mean return of palmar flush time of 4 seconds. Duplex ultrasound revealed subtotal RAO in four (14.8%) patients and no patients experienced total occlusion following the intervention. CONCLUSION: Dual radial artery puncture appears to be a well-tolerated and viable strategy in patients that are transferred to a PCI-capable hospital for coronary interventions.

Unloading of right ventricle and clinical improvement after ultrasound-accelerated thrombolysis in patients with submassive pulmonary embolism.

Acute pulmonary embolism (PE) can be devastating. It is classified into three categories based on clinical scenario, elevated biomarkers, radiographic or echocardiographic features of right ventricular strain, and hemodynamic instability. Submassive PE is diagnosed when a patient has elevated biomarkers, CT-scan, or echocardiogram showing right ventricular strain and no signs of hemodynamic compromise. Thromboemboli in the acute setting increase pulmonary vascular resistance by obstruction and vasoconstriction, resulting in pulmonary hypertension. This, further, deteriorates symptoms and hemodynamic status. Studies have shown that elevated biomarkers and right ventricular (RV) dysfunction have been associated with increased risk of mortality. Therefore, aggressive treatment is necessary to "unload" right ventricle. The treatment of submassive PE with thrombolysis is controversial, though recent data have favored thrombolysis over conventional anticoagulants in acute setting. The most feared complication of systemic thrombolysis is intracranial or major bleeding. To circumvent this problem, a newer and safer approach is sought. Ultrasound-accelerated thrombolysis is a relatively newer and safer approach that requires local administration of thrombolytic agents. Herein, we report a case series of five patients who underwent ultrasound-accelerated thrombolysis with notable improvement in symptoms and right ventricular function.

A forgotten devil; Rupture of mitral valve papillary muscle.

BACKGROUND: Papillary muscle rupture is one of the catastrophic mechanical complications following myocardial infarction. Rupture leads to acute mitral valve regurgitation, pulmonary edema, and cardiogenic shock. Survival is dependent on prompt recognition and surgical intervention. CASES REPORT: We present two cases where acute myocardial infarction was complicated by papillary muscle rupture resulting in severe mitral regurgitation and cardiogenic shock. In both cases rupture occurred within one week of infarction. Both patients did not receive coronary revascularization; one patient presented late after the onset of chest pain, the other patient percutaneous revascularization attempted and was not successful. Both patients suffered an inferior wall infarction. Echocardiogram demonstrated severe mitral regurgitation with a jet directed posteriorly. In both cases rupture of the posteromedial papillary muscle resulted in flail of the anterior mitral valve leaflet, thus serving as a reminder that both the anterior and the posterior leaflets attach to both papillary muscles. CONCLUSIONS: While one case had a good outcome, the other reinforces the fact that this is a very serious complication requiring prompt recognition and treatment.

A forgotten vascular disease with important clinical implications. Subclavian steal syndrome.

BACKGROUND: Subclavian Steal Syndrome (SSS) is a fascinating vascular phenomenon in which a steno-occlusive lesion of the proximal subclavian artery causes retrograde flow in the vertebral artery away from the brain stem subsequently causing vertebrobasilar insufficiency. SSS can present with a myriad of neurological and vascular signs and symptoms, but most commonly this phenomenon presents as an incidental finding in an asymptomatic patient. CASE REPORT: Our patient is a 73-year-old female sent to the cardiology clinic for surgical clearance in preparation for an elective cholecystectomy. Shortness of breath was her only complaint. Review of systems was remarkable for left arm pain and blurry vision with repetitive movement. Physical examination noticeable for absence of left radial pulse. Percutaneous angiography demonstrated a totally occulted left subclavian artery with collateral circulation form the vertebrobasilar apparatus. CONCLUSIONS: Atypical presentation of this unique entity represents a challenge for physicians who require a high index of suspicion to make the diagnosis. We present an atypical case with radiographical evidence of the steal syndrome, followed by an extensive literature review of the most current diagnostic methods as well as latest recommendations for treatment options and secondary prevention.

Echocardiographic parameters to predict inadequate defibrillation safety margin in patients receiving implantable cardioverter defibrillators for primary prevention.

BACKGROUND: Implantable cardioverter defibrillators (ICDs) have become an important part of the management of patients with congestive heart failure. At the time of ICD implantation, ventricular fibrillation (VF) is induced to assess adequate energy required for defibrillation. There are multiple parameters which influence the defibrillation safety margin (DSM); however, these factors are not well-established when ICDs are implanted for the primary prevention of sudden cardiac death (SCD) in patients with severe systolic dysfunction. We evaluated multiple clinical and echocardiographic parameters as predictors of adequate DSM in patients referred for ICD implantation for the primary prevention of SCD. METHODS: We prospectively enrolled 41 patients for ICD implantation with clinical indications for the primary prevention of SCD. Two blinded independent readers evaluated the prespecified echocardiographic parameters. These included left ventricular (LV) mass, indices of right ventricular and LV systolic and diastolic functions, and LV geometric dimensions. Basic clinical demographics, including age, gender, comorbidities, and etiology of cardiomyopathy, were also evaluated. DSM was established using our standard protocol for defibrillation testing which includes VF with successful first shock terminating VF at a value at least 10 J below the maximum output of the implanted device. High defibrillation thresholds (DFT) were defined as >21 J. RESULTS: The mean age is 61.8 ± 14.7 years, with men comprising the majority of the patients (73 %). The only clinical variables which predicted the high DFT were age (in years) (54.5 ± 17.5 vs. 65.7 ± 11.3, p = 0.044), QRS duration (in milliseconds) (116.0 ± 29.5 vs. 110.5 ± 21.8, p = 0.03), LV mass (in grams) (241.0 ± 77.9 vs. 181.9 ± 52.3, p = 0.006), and LV mass index (in grams per square meter) (111.1 ± 38.2 vs. 86.4 ± 21.1, p = 0.02). On multivariate logistic regression analysis, LV mass was the only independent predictor of low DFT (≤22 J) in patients with ICD implanted for the primary prevention of SCD. CONCLUSION: LV mass may help predict an adequate DSM in patients who are referred for ICD implantation for the primary prevention of SCD. These results may help distinguish the patients who may require high-energy devices prior to the implantation procedure. These results may help distinguish patients requiring high-energy devices, coils, or advanced programming prior to implantation and appropriate referral to electrophysiologists.