Tamponade following breast augmentation.

Breast augmentation is one of most commonly performed cosmetic surgical procedures. Pneumothorax has been reported as a rare complication of breast augmentation but the incidence is not known. Our patient presented with dyspnea on exertion about 6 days following breast augmentation. She was found to have cardiac tamponade and pneumothorax. We present a case of cardiac tamponade following breast augmentation, a previously unreported complication.

Culotte bifurcation stenting with paclitaxel drug-eluting stent.

The results of using the culotte bifurcation technique have not been promising with regard to bare metal stents; however, some possible advantages with regard to drug-eluting stents (DES) must be taken into account, such as the possibility to stent provisionally, to use lower French sizes, and to completely cover the coronary wall and the new carina with a single or double stent layer. The crush technique, which aims to reach a complete coverage of the coronary wall to allow antiproliferative drugs to homogeneously distribute into the coronary walls, has been introduced. The culotte technique seems to act more physiologically, allowing the creation of a new, homogeneously covered carina, without any crushed metal inside the coronary wall. We present the case of a coronary bifurcation treated with the use of the culotte technique and paclitaxel-eluting stent deployment, with good angiographic results after 10 months of follow-up. Further data are needed to evaluate the potential utility of the culotte technique in treating bifurcation coronary lesions in the area of DES.

Aortic pseudoaneurysm as a rare cause of superior vena cava syndrome--a case report.

This case is about an aortic pseudoaneurysm after Dacron graft replacement that presented as a rapidly evolving superior vena cava syndrome.

Simultaneous double-culprit in-stent thrombosis. Who is the guilty prisoner behind bars: drug-eluting stent, bare-metal stent, or indication for treatment?

BACKGROUND: The intrinsic thrombogeneity of stents was the historic limitation to their usage during the early phases of stenting. The risk of stent thrombosis has been minimized by the widespread use of platelet antiaggregation. Nowadays, the risk of subacute stent thrombosis is around 1%. Thrombotic risk depends on several factors, such as type of stent, complexity of lesion, and clinical picture. CASE REPORT: We present a case of recurrent acute in-stent thrombosis in a patient with mild antithrombin III (AT) deficiency despite the combined administration of clopidogrel and aspirin. CONCLUSION: In our patient, several factors, such as diabetes, AT deficiency, and the use of a paclitaxel-eluting stent, have contributed to the development of recurrent acute stent thrombosis. Although we were not able to identify the culprit factor, we should keep in mind that the deployment of a drug-eluting stent could be unsafe if it is not supported by a clear clinically oriented pathway that considers the overall condition of the patient since, in some cases, neither coronary lesions nor coronary stents are responsible for the negative outcome of patient therapy, which may be caused instead by incomplete or inadequate patient assessment.

The new patent foramen ovale occluder FIGULLA in complex septal anatomy: a case series.

BACKGROUND: The appropriate treatment strategy for secondary stroke prevention in patients with cryptogenic stroke and patent foramen ovale (PFO) remains challenging. The aim of this study was to describe a case series of patients with PFO and complex septal anatomy who underwent percutaneous correction using a FIGULLA (Occlutech) septal occluder (FSO). PATIENTS: Ten consecutive patients (6 females, 4 males, mean age 41.6 ± 16.0 years, range 17-52 years; group 1) with cryptogenetic stroke and/or transient cerebral ischemia and complex septal anatomy, as defined by intraprocedural transesophageal echocardiogram (TEE) were compared with a group of 25 patients (10 females, 15 males, mean age 43.7 ± 12.3 years; group 2) with usual tunnel-like PFO anatomy in whom PFO was closed by an Amplatzer septal occluder (ASO; AGA). RESULTS: No significant differences were noted between group 1 and group 2 for immediate success rate, residual intraprosthetic shunt at the end of the procedure, discharge, 1, 6 and 12 months follow up, number of attempts, procedure time, fluoroscopy time, or cardiac complication (atrial arrhythmias, device embolism). The only significant difference was shown for delivery sheath size (11 ± 2 versus 9 ± 1 F) and incidence of local hematoma (30% versus 12%) between group 1 and group 2, without any clinical consequence (need of transfusion) or increase in length of stay. CONCLUSION: FSO shows high performance in patients with PFO and complex septal anatomy when compared with patients with PFO and uncomplicated atrial anatomy treated by ASO. Its favorable behavior is probably related to fabric features such as the total amount of metal and the presence of titanium.

In-stent thrombosis after 68 months of implantation inspite of continuous dual antiplatelet therapy: a case report.

Lately, there has been an increased incidence of late stent thrombosis; especially following Drug eluting stent (DES) implantation. Several factors are associated with an increased risk of stent thrombosis, including the procedure itself, patient and lesion characteristics, stent design, and premature cessation of anti-platelet drugs. We present a case of late stent thrombosis (LST) following DES implantation after a period of 68 months, making it the longest reported case of LST reported in the literature, despite the use of dual anti-platelet therapy.

Usefulness of neutrophil to lymphocyte ratio in predicting short- and long-term mortality after non-ST-elevation myocardial infarction.

Neutrophil/lymphocyte ratio (NLR) is the strongest white blood cell predictor of adverse outcomes in stable and unstable coronary artery syndromes. The aim of our study was to explore the utility of NLR in predicting long-term mortality in patients with non-ST-segment elevation myocardial infarction (NSTEMI). Consecutive patients with NSTEMI at Staten Island University Hospital were evaluated for study inclusion. Of the 1,345 patients with NSTEMI admitted from September 2004 to September 2006, 619 qualified for study inclusion. Survival analysis, stratified by NLR tertiles, was used to evaluate the predictive value of average inpatient NLR levels. Four-year vital status was accessed with electronic medical records and Social Security Death Index. Patients in the highest NLR tertile (NLR >4.7) had a higher 4-year mortality rate (29.8% vs 8.4%) compared to those in the lowest tertile (NLR <3, Wilcoxon chi-square 34.64, p <0.0001). After controlling for Global Registry of Acute Coronary Events risk profile scores, average NLR level remained a significant predictor of inpatient and 4-year mortality. Hazard ratios per unit increase of average NLR (log) increased by 1.06 (p = 0.0133) and 1.09 (p = 0.0006), respectively. In conclusion, NLR is an independent predictor of short-term and long-term mortalities in patients with NSTEMI with an average NLR >4.7. We strongly suggest the use of NLR rather than other leukocyte parameters (e.g., total white blood cell count) in risk stratification of the NSTEMI population.

A planned hybrid culotte stenting procedure in the setting of an acute STEMI.

INTRODUCTION: Bifurcation lesions have traditionally presented a unique problem for interventional cardiologists because of their inherent anatomy and risk of closure of the side branch, after a percutaneous intervention for the primary lesion of the main branch. CASE PRESENTATION: We report the case of a 57-year-old man who presented with acute ST-segment elevation myocardial infarction secondary to a 100% occlusion at the ostium of first diagonal (D1) branch. Patient also had a 70% stenosis of the mid-segment of the left anterior descending (LAD) coronary artery at the D1 branching point (1,1,1 Medina classification). A bare metal stent (BMS) was deployed at the site of the culprit lesion in the D1, while a drug eluting stent (DES) was placed in the LAD. We believe that the BMS at the culprit thrombotic, inflamed site in D1 is more likely to re endothelialize than a DES and the DES in the LAD, is less likely to re-stenose than a BMS. CONCLUSION: This is the only reported case, where in the setting of an acute ST elevation myocardial infarction, a hybrid Culotte technique was successfully performed with excellent long-term results, thus achieving an acceptable balance of risks between restenosis (in the case of a BMS) and stent thrombosis (in the case of a DES).

A STEMI code protocol improves door-to-balloon time on weekdays and weekends.

Primary percutaneous coronary intervention (PCI) has emerged as the standard of care for the management of ST-elevation myocardial infarctions (STEMI). Only 32% of patients with STEMI receive this procedure within the recommended 90 min for door-to-balloon time (DTB). We reviewed all STEMI cases that presented to our institution before and after the implementation of a STEMI Code protocol. Before the STEMI Code protocol, 27.1% of weekday cases and 6.3% of weekend cases were performed within 90 min. After the STEMI Code protocol, there was a threefold increase in the number of patients who received PCI within 90 min (p<.0001). A STEMI Code protocol dramatically improves DTB and equalizes disparities between weekday and weekend care.

Location and clinical implications of high-degree atrioventricular block during dipyridamole infusion: a case report.

We describe a patient with bifascicular block, who developed transient high-degree atrioventricular block during dipyridamole infusion. This patient was subsequently found to have significant His-Purkinje disease at electrophysiology study, and underwent permanent pacemaker implantation. Spontaneous atrioventricular block was documented during follow-up. This case report raises the issue of dipyridamole safety in patients with intraventricular conduction defects, and contributes an additional mechanism to the possible explanation of dipyridamole-induced atrioventricular block.