Case 270: Spontaneous Coronary Artery Dissection Associated with Fibromuscular Dysplasia.

HistoryA 54-year-old woman presented with typical chest pain during physical training at the gym. She had a history of hypertension controlled with hydrochlorothiazide, without any other cardiovascular risk factor and with neither personal nor family history of ischemic heart disease. She was postmenopausal and had a long-standing history of migraine headaches without hormonal or drug therapy. The patient had no history of clinically important thoracic trauma or invasive chest interventions. Initial electrocardiography (ECG) showed signs of ongoing anterior ST segment elevation myocardial infarction, and emergent coronary angiography with angioplasty and intravascular US were performed. Maximal level of high-sensitive T troponins was 820 ng/L (normal, <13 ng/L), while echocardiography showed a normal left ventricular ejection fraction, with no apparent regional wall motion abnormalities. General physical examination findings were unremarkable, excluding ligamentous hyperlaxity and joint instability. C-reactive protein, rheumatoid factor, antinuclear antibody, cytoplasmic antineutrophil cytoplasmic antibody, and angiotensin-converting enzyme blood test results were negative. For further evaluation, arterial phase ECG-synchronized CT angiography from the skull base to the pubis symphysis was performed.

Case 270.

History A 54-year-old woman presented with typical chest pain during physical training at the gym. She had a history of hypertension controlled with hydrochlorothiazide, without any other cardiovascular risk factor and with neither personal nor family history of ischemic heart disease. She was postmenopausal and had a long-standing history of migraine headaches without hormonal or drug therapy. The patient had no history of clinically important thoracic trauma or invasive chest interventions. Initial electrocardiography (ECG) showed signs of ongoing anterior ST segment elevation myocardial infarction, and emergent coronary angiography with angioplasty and intravascular US were performed ( Fig 1 ). Maximal level of high-sensitive T troponins was 820 ng/L (normal, <13 ng/L), while echocardiography showed a normal left ventricular ejection fraction, with no apparent regional wall motion abnormalities. General physical examination findings were unremarkable, excluding ligamentous hyperlaxity and joint instability. C-reactive protein, rheumatoid factor, antinuclear antibody, cytoplasmic antineutrophil cytoplasmic antibody, and angiotensin-converting enzyme blood test results were negative. For further evaluation, arterial phase ECG-synchronized CT angiography from the skull base to the pubis symphysis was performed ( Fig 2 ). Figure 1a: Coronary angiography of the left anterior descending (LAD) and left circumflex (LCX) arteries (30° right anterior oblique and 20° caudally angulated projection) and intravascular US of the LCX artery were performed. (a) Initial coronary angiography projection. (b) Coronary angiography projection after LAD stent placement. (c, d) Intravenous US images of the distal (c) and proximal (d) LCX artery obtained after b. Figure 1b: Coronary angiography of the left anterior descending (LAD) and left circumflex (LCX) arteries (30° right anterior oblique and 20° caudally angulated projection) and intravascular US of the LCX artery were performed. (a) Initial coronary angiography projection. (b) Coronary angiography projection after LAD stent placement. (c, d) Intravenous US images of the distal (c) and proximal (d) LCX artery obtained after b. Figure 1c: Coronary angiography of the left anterior descending (LAD) and left circumflex (LCX) arteries (30° right anterior oblique and 20° caudally angulated projection) and intravascular US of the LCX artery were performed. (a) Initial coronary angiography projection. (b) Coronary angiography projection after LAD stent placement. (c, d) Intravenous US images of the distal (c) and proximal (d) LCX artery obtained after b. Figure 1d: Coronary angiography of the left anterior descending (LAD) and left circumflex (LCX) arteries (30° right anterior oblique and 20° caudally angulated projection) and intravascular US of the LCX artery were performed. (a) Initial coronary angiography projection. (b) Coronary angiography projection after LAD stent placement. (c, d) Intravenous US images of the distal (c) and proximal (d) LCX artery obtained after b. Figure 2a: Arterial phase electrocardiography-synchronized CT angiography from the skull base to the pubis symphysis was performed after coronary angiography, subsequent interventional procedures, and intravenous US. (a, b) Axial oblique slab maximum intensity projection image at the level of the left (a) and right (b) renal arteries. (c) Coronal volume-rendering image shows an anterior view of the renal arteries. Figure 2b: Arterial phase electrocardiography-synchronized CT angiography from the skull base to the pubis symphysis was performed after coronary angiography, subsequent interventional procedures, and intravenous US. (a, b) Axial oblique slab maximum intensity projection image at the level of the left (a) and right (b) renal arteries. (c) Coronal volume-rendering image shows an anterior view of the renal arteries. Figure 2c: Arterial phase electrocardiography-synchronized CT angiography from the skull base to the pubis symphysis was performed after coronary angiography, subsequent interventional procedures, and intravenous US. (a, b) Axial oblique slab maximum intensity projection image at the level of the left (a) and right (b) renal arteries. (c) Coronal volume-rendering image shows an anterior view of the renal arteries.

Prognostic impact of shock in patients with type A acute aortic syndrome. Results of a nationwide multicenter study.

OBJECTIVE: To evaluate the clinical characteristics, imaging findings, treatment, and prognosis of patients with type A acute aortic syndrome (AAS-A) presenting with shock. To assess the impact of surgery on this patient population. METHODS: The study included 521 patients with A-AAS enrolled in the Spanish Registry of Acute Aortic Syndrome (RESA-III) from January 2018 to December 2019. The RESA-III is a prospective, multicenter registry that contains AAS data from 30 tertiary-care hospitals. Patients were classified into two groups according to their clinical presentation, with or without shock. Shock was defined as persistent systolic blood pressure <80 mmHg despite adequate volume resuscitation. RESULTS: 97 (18.6%) patients with A-AAS presented with shock. Clinical presentation with syncope was much more common in the Shock group (45.4% vs 10.1%, p = 0.001). Patients in the Shock group had more complications at diagnosis and before surgery: cardiac tamponade (36.2% vs 9%, p < 0.001), acute renal failure (28.9% vs 18.2%, p = 0.018), and need for orotracheal intubation (40% vs 9.1%, p < 0.001). There were no significant differences in aortic regurgitation (51.6% vs 46.7%, p = 0.396) between groups. In-hospital mortality was higher among patients with shock (48.5% vs 27.4%, p < 0.001). Surgery was associated with a significant mortality reduction both in patients with and without shock. Surgery had an independent protective effect on mortality (OR 0.03, 95% CI (0.00-0.32)). CONCLUSION: Patients with AAS-A admitted with shock have a heavily increased risk of mortality. Syncope and pericardial effusion at diagnosis are strongly associated with shock. Surgery was independently associated with a mortality reduction in patients with AAS-A and shock.

Case Report: Kommerell's diverticulum and left aberrant subclavian artery stenosis hybrid treatment with branched aortic stent-graft.

Kommerell's diverticulum in association with left or right aberrant subclavian arteries is a rare finding and is challenging to treat. Contemporary surgical and endovascular techniques provide a broad arsenal of possible treatments. Imaging techniques and modeling technology allow a more personalized strategy for each patient. In this case, we present a symptomatic patient with a Kommerell's diverticulum and a left aberrant subclavian artery complicated by proximal stenosis and poststenotic aneurysm. A hybrid technique using a single-branched thoracic stent-graft (Castor, MicroPort Medical, Shanghai, China) in combination with a surgical left subclavian-carotid bypass and endovascular occlusion of the poststenotic aneurysm using a vascular plug device (Amplatzer Vascular Plug, Abbott, Chicago, United States) was performed. This approach was planned and facilitated by the use of a 3D model. Alternative treatment options and the strengths of this approach are briefly reviewed and discussed.

Oxidative Stress and Inflammatory Markers in Abdominal Aortic Aneurysm.

Abdominal aortic aneurysm (AAA) is increasing due to aging of the population and is a major cause of death among the elderly. Ultrasound screening programs are useful in early diagnosis, but aneurysm size is not always a good predictor of rupture. Our aim was to analyze the value of circulating molecules related to oxidative stress and inflammation as new biomarkers to assist the management of AAA. The markers were quantified by ELISA, and their expression in the aneurysmal wall was studied by real-time PCR and by immunostaining. Correlation analysis of the studied markers with aneurysm diameter and peak wall stress (PWS), obtained by finite element analysis, and multivariate regression analysis to assess potential confounding factors were performed. Our study shows an extensive inflammatory infiltration in the aneurysmal wall, mainly composed by T-cells, macrophages and B-cells and altered levels of reactive oxygen species (ROS), IgM, IgG, CD38, GDF15, S100A4 and CD36 in plasma and in the aneurysmal tissue of AAA patients compared with controls. Circulating levels of IgG, CD38 and GDF15 positively correlated with abdominal aortic diameter, and CD38 was correlated with PWS. Our data show that altered levels of IgG, CD38 and GDF15 have potential diagnostic value in the assessment of AAA.

A propósito de un soplo / Speaking of murmurs

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