Coronary artery-bronchial artery fistulas: report of two Dutch cases with a review of the literature.

BACKGROUND: Coronary bronchial artery fistulas (CBFs) are rare anomalies, which may be isolated or associated with other disorders. MATERIALS AND METHODS: Two adult patients with CBFs are described and a PubMed search was performed using the keywords "coronary bronchial artery fistulas" in the period from 2008 to 2013. RESULTS: Twenty-seven reviewed subjects resulting in a total of 31 fistulas were collected. Asymptomatic presentation was reported in 5 subjects (19 %), chest pain (n = 17) was frequently present followed by haemoptysis (n = 7) and dyspnoea (n = 5). Concomitant disorders were bronchiectasis (44 %), diabetes (33 %) and hypertension (28 %). Multimodality and single-modality diagnostic strategies were applied in 56 % and 44 %, respectively. The origin of the CBFs was the left circumflex artery in 61 %, the right coronary artery in 36 % and the left anterior descending artery in 3 %. Management was conservative (22 %), surgical ligation (11 %), percutaneous transcatheter embolisation (30 %), awaiting lung transplantation (7 %) or not reported (30 %). CONCLUSIONS: CBFs may remain clinically silent, or present with chest pain or haemoptysis. CBFs are commonly associated with bronchiectasis and usually require a multimodality approach to be diagnosed. Several treatment strategies are available. This report presents two adult cases with CBFs and a review of the literature.

Towards a better risk stratification for sudden cardiac death in patients with structural heart disease.

With the introduction of the implantable cardioverter defibrillator (ICD), patients can be protected against sudden cardiac death (SCD) due to ventricular arrhythmia (VA). Guidelines have been drawn up for selecting patients for primary and secondary prophylaxis. However, most ICD recipients today who receive an ICD for primary prevention will not experience a life-threatening VA requiring antitachypacing or shock therapy. Better risk stratification is desirable with efficacy, costs and complication rate in mind. An overview is presented of widely accepted and potentially valuable risk markers and the role they may play in better identifying candidates for ICD therapy. (Neth Heart J 2009;17:101-6.).

Acute stress-related gastrointestinal ischemia.

We report a case of acute gastrointestinal ischemia during a very stressful event in whom the diagnosis was made by 24-hour tonometry. This case report unequivocally links a stressful event with increased catecholamine release and subsequent severe symptomatic gastrointestinal ischemia. The role of ischemia as potential pathophysiological mechanism has never been studied in detail. The clinical significance of finding such an association is underscored by this case report, where a vasoactive drug normally used for hypertension treatment resulted in greatly improved abdominal symptoms.

Transesophageal echocardiography for early cardioversion of atrial fibrillation.

Exclusion of thrombi in the setting of atrial fibrillation (AF) has important implications for early cardioversion. Cardioversion guided by transesophageal echocardiography (TEE) is a safe and relatively cost-effective technique with a high accuracy for detecting left-atrial thrombi. Nowadays, TEE-guided cardioversion may help to select patients suitable for early cardioversion. However, the long-term effect of early TEE-guided cardioversion on the maintenance of sinus rhythm needs to be determined.

Left atrial appendage flow velocity assessment using transesophageal echocardiography in nonrheumatic atrial fibrillation and systemic embolism.

Fifty-four patients with nonrheumatic atrial fibrillation (AF) were studied: 16 patients with (group I) and 38 patients without (group II) documented systemic embolism. Transesophageal echocardiography (TEE) was performed to evaluate the presence of left atrial (LA) appendage thrombus and LA spontaneous contrast, LA size, systolic and diastolic peak velocity of the left pulmonary vein, and forward and backward peak velocity of the LA appendage. No difference was observed in the presence of LA thrombus between the 2 groups. The occurrence of LA spontaneous contrast was significantly (p = 0.01) higher in the group with embolism. LA size, measured by atrial length (4.96 +/- 0.84 vs 4.79 +/- 1.38 cm; p = NS) and atrial width (4.50 +/- 0.96 vs 4.31 +/- 1.24 cm; p = NS), was the same for both groups and thus not associated with embolism. There was no difference in systolic peak velocity (0.39 +/- 0.22 vs 0.44 +/- 0.22 m/s; p = NS), and a trend toward a higher diastolic peak velocity (0.50 +/- 0.17 vs 0.42 +/- 0.15 m/s; p = 0.08) was seen in the left pulmonary vein in the group with embolism. Forward (0.25 +/- 0.19 vs 0.39 +/- 0.23 m/s; p < 0.05) and backward (0.23 +/- 0.15 vs 0.33 +/- 0.16 m/s; p < 0.05) peak velocities of the LA appendage were significantly lower in the embolism group. Assessment of LA appendage flow velocity may potentially identify patients with nonrheumatic AF at high risk for systemic embolism.

Transesophageal echocardiographic predictors for maintenance of sinus rhythm after electrical cardioversion of atrial fibrillation.

The aim of this study was to assess the value of transesophageal echocardiography (TEE) in patients with atrial fibrillation in predicting restoration and maintenance of sinus rhythm after electrical cardioversion. TEE was performed in 62 patients with atrial fibrillation before their first elective cardioversion. Clinical variables evaluated were: age, gender, duration, and etiology of atrial fibrillation. TEE variables included: left atrial (LA) length, width, and size, LA annulus size, as well as presence of LA spontaneous contrast, thrombus and mitral regurgitation, LA appendage size and flow, and left ventricular function. Based on initial outcome of cardioversion, patients were grouped into patients who remained in atrial fibrillation and in whom sinus rhythm was restored. The latter group of patients was followed for 1 year, and grouped into patients who reverted to atrial fibrillation and in whom sinus rhythm was maintained. Successful cardioversion was achieved in 50 of 62 patients (81%). None of the clinical or TEE variables were related to initial outcome. At 1-year follow-up, 29 of 50 patients (58%) who underwent successful cardioversion continued to have sinus rhythm. The following variables were related to maintenance of sinus rhythm: duration of atrial fibrillation (6.7 +/- 7.3 vs 2.0 +/- 2.4 months; p < 0.005); LA length (6.2 +/- 0.7 vs. 5.5 +/- 1.0 cm; p < 0.008); width (5.1 +/- 0.5 vs. 4.5 +/- 0.7 cm; p < 0.002); size (26.4 +/- 5.0 vs 19.8 +/- 6.5 cm2; p < 0.0005); annulus size (4.0 +/- 0.2 vs 3.7 +/- 0.3 cm; p < 0.0005); presence of LA spontaneous contrast (13 [62%] vs 4 [14%]; p < 0.002), and LA appendage flow (19 +/- 8 vs 36 +/- 15 cm/s; p < 0.0005). In multivariate logistic regression analysis, LA annulus size, but especially LA appendage flow, were significantly associated with maintenance of sinus rhythm. Thus, in TEE-guided electrical cardioversion of atrial fibrillation, variables often used to assess thromboembolic risk may also be used to predict 1-year outcome of cardioversion.

In-hospital and long-term prognostic value of viable myocardium detected by dobutamine echocardiography early after acute myocardial infarction and its relation to indicators of left ventricular systolic dysfunction.

The prognostic value of myocardial viability early after acute myocardial infarction (AMI) is still controversial, depending on the patient under study and the outcome end point considered. Furthermore, the relative prognostic importance of viability compared with indicators of systolic left ventricular (LV) dysfunction is not known. One hundred thirty-eight patients were studied with low-dose dobutamine echocardiography 3 +/- 1 days after AMI. Patients were divided in 2 groups based on presence (n = 55) or absence (n = 83) of myocardial viability and followed up for in-hospital and late cardiac events. During hospitalization, myocardial viability was the only independent predictor for recurrent ischemic events (chi-square 5.0, p = 0.025). End-systolic volume index and ejection fraction were both independent predictors of the occurrence of heart failure, whereas gender and end-systolic volume index emerged as independent predictors of hard cardiac events (death and sustained ventricular tachycardia). After hospital discharge, patients were followed for 19 +/- 7 months. Again, myocardial viability emerged as the only independent predictor of unstable angina (chi-square 7.7, p = 0.005). Age, hypertension, and ejection fraction were the most important independent predictors of hospitalization for heart failure, whereas ejection fraction was the only independent predictor of hard cardiac events. Presence of myocardial viability early after AMI is the single best predictor of recurrent in-hospital ischemic events and unstable angina after discharge. With respect to hard cardiac events and occurrence of heart failure, indicators of LV systolic dysfunction have a higher prognostic value than presence of myocardial viability.

Tissue plasminogen activator activity and inhibition in acute myocardial infarction and angiographically normal coronary arteries.

Parameters of blood coagulation, blood platelet reactivity and fibrinolysis were analyzed in 18 patients with acute myocardial infarction (AMI) and angiographically normal coronary arteries. This study group was compared with a patient control group of 18 AMI patients with 1-vessel obstructive coronary artery disease. Patients were matched for sex, age and AMI date. A healthy control group consisted of 18 sex- and age-matched volunteers. Blood coagulation measurements and platelet reactivity were similar in the 3 groups, except for fibrinogen, which was significantly higher in the patient control group. Plasma activity of tissue plasminogen activator (tPA) was detectable in only 2 patients in the study group, 9 in the patient control group (p less than 0.02) and 12 in the healthy control group (p less than 0.0001). Median plasma tPA inhibitory activity was higher in the study group (10.3 IU/ml) and the patient control group (8.1 IU/ml) than in the healthy control group (2.7 IU/ml, p less than 0.0001 and p less than 0.03). Thus, reduced activity and enhanced inhibition of plasma tPA may be important factors in the origin of coronary thrombosis, especially in the absence of coronary artery disease.

Exercise-induced syncope as late consequence of radiotherapy.

This report describes a 34-year-old female with an exercise-induced atrioventricular block resulting from transient ischemia caused by a radiation-induced ostial stenosis of the right coronary artery. Patient first underwent coronary artery surgery with a right internal mammary artery to the right coronary artery. After 18 months she was readmitted with exercise-induced syncope due to graft occlusion. This time a successful rotablator procedure was performed on the ostial stenosis.

[Trans-esophageal contrast echocardiography in suspicion of paradoxal embolism]. / Transoesofageale contrast-echocardiografie bij vermoeden van paradoxe embolie.

In two patients, women of 35 and 74 years old, paradoxical embolism was diagnosed. Patient A presented with multiple pulmonary embolism. Transoesophageal echocardiography demonstrated a thrombus mass which protruded from the right atrium through a patent foramen ovale into the left atrium: explicit proof of the possibility of paradoxical embolism. Patient B presented with systemic arterial embolism. During hospitalisation multiple pulmonary embolism occurred. With the use of transoesophageal contrast echocardiography a patent foramen ovale was observed, the probable cause of paradoxical embolism. Both patients were treated with intravenous heparin and oral anticoagulants.

Coexistence of a bradycardia- and tachycardia-dependent bundle branch block.

Aberrant ventricular conduction is a rare phenomenon as compared with the more frequently occurring antrioventricular conduction disturbances. It leads to widening of the QRS complex, which is either due to a complete or functional block in one of the bundle branches or a block within the intramyocardial conduction system itself. Mechanisms that are potentially involved in the genesis of aberrant ventricular conduction are sudden shortening of cycle length (tachycardia-dependent phase III), antegrade block with retrograde concealed conduction, or bradycardia-dependent block (enhanced phase IV). In this paper, we present a patient with aberrant ventricular conduction with the occurrence of a tachycardia-dependent, as well as a bradycardia-dependent bundle branch block, which is an even rarer phenomenon.

Arrhythmogenic right ventricular dysplasia as a possible cause of sudden cardiac death: a case report and clinical review.

Sudden cardiac death can be described as an unexplained natural death due to a cardiac cause. It occurs within a short period, one hour or less, after onset of symptoms in a person without any prior medical history. Among the many causes of unexplained sudden cardiac death, we would like to specifically discuss arrhythmogenic right ventricular dysplasia as a rare cause in otherwise healthy and usually young individuals.

TWENTE Study: The Real-World Endeavor Resolute Versus Xience V Drug-Eluting Stent Study in Twente: study design, rationale and objectives.

Background. New-generation drug-eluting stents (DES) may solve several problems encountered with first-generation DES, but there is a lack of prospective head-to-head comparisons between new-generation DES. In addition, the outcome of regulatory trials may not perfectly reflect the outcome in 'real world' patients.Objectives. To compare the efficacy and safety of two new-generation DES in a 'real world' patient population.Methods. A prospective, randomised, single-blinded clinical trial to evaluate clinical outcome after Endeavor Resolute vs. Xience V stent implantation. The primary endpoint is target vessel failure at one-year follow-up. In addition, the study comprises a two-year and an open-label five-year follow-up. (Neth Heart J 2010;18:360-4.).