Conservative Management of Spontaneous Left Main Coronary Artery Dissection (SCAD) Triggered by Emotional Stress in the Late Postpartum Period: Case Report and Pathophysiology.

A spontaneous coronary artery dissection (SCAD) during the postpartum period is a serious medical emergency and the most important non-atherosclerotic cause of coronary artery disease (CAD) in this population. While conservative management is recommended in most SCAD scenarios, cases complicated by hemodynamic instability or cardiogenic shock are particularly challenging and might be amenable only with invasive percutaneous or cardiothoracic surgical management. Herein, we present a case of a 35-year-old otherwise healthy woman that suffered an intense emotional stress event and was subsequently admitted with crushing chest pain to the emergency department. The initial electrocardiogram showed dynamic changes suggesting anterolateral ST-elevation myocardial infarction. She gave birth to a healthy child 3 months before the current presentation. Diagnostic angiography found no occlusive CAD but instead an extensive intramural hematoma originating from the left main artery dissection and extending to the whole left coronary circulation was observed. Hemodynamic instability and hypotension soon followed, and the patient went into cardiogenic shock. The heart team opted for conservative and supportive intensive care management without surgical or percutaneous intervention. This decision ultimately led to the successful extubation of the patient and the achievement of hemodynamic stability. The patient was eventually safely discharged home without any permanent disability.

LEFT LATERAL VIEW FOR PCI TREATMENT OF INFERIOR STEMI IN A PATIENT WITH DEXTROCARDIA.

Rapid recognition of ST-segment elevation myocardial infarction and electrocardiogram interpretation in patients with dextrocardia could be a challenging situation. This case report discusses presentation in a patient with dextrocardia and situs inversus who was found to have acute inferior myocardial infarction. Percutaneous coronary intervention in cases of dextrocardia can be technically challenging considering coronary origin and orientation, and difficulty in appropriate catheter selection.

Feasibility and safety of catheter-directed thrombolysis via superficial cubital vein for the treatment of acute massive and submassive pulmonary embolism.

INTRODUCTION: Proximal venous approaches (femoral or jugular) for catheter-directed thrombolysis (CDT) of acute pulmonary embolism (PE) dominate in clinical practice. AIM: We investigated the feasibility and safety of CDT in acute PE by using the superficial cubital venous approach. MATERIAL AND METHODS: All patients with acute PE received intravenous unfractionated heparin plus CDT. CDT included mechanical thrombus fragmentation and the local application of adjuvant thrombolytic therapy through the pigtail catheter - alteplase administered as 2.5 mg bolus in each main branch of the pulmonary artery plus adjuvant 25 mg for 12 h in the more severely affected branch of the pulmonary artery. RESULTS: Twenty-seven consecutive patients presenting with acute massive (high risk) PE (n = 10) or submassive (intermediate risk) PE (n = 17) were enrolled in the study. The mean age of the enrolled cohort was 60.6 (14.1) years and most patients were female (n = 14, 52%). The procedural success of CDT application through the cubital vein was achieved in all patients. After the procedure, the systolic pulmonary artery pressure decreased from 61.4 (18.3) to 35.8 (12.3) mm Hg (p < 0.001) while the mean pulmonary artery pressure decreased from 35.7 (10.8) to 21.1 (6.5) mm Hg (p < 0.001). Similarly, the mean arterial pressure increased from 81.9 (12.8) to 89.0 (10.3) mm Hg (p = 0.031). Miller angiographic obstruction score and Miller index decreased significantly after the CDT intervention (p < 0.001). There were no deaths, major bleeding events, or hemorrhagic strokes. CONCLUSIONS: CDT by using the cubital approach is a simple, safe, and feasible treatment option for PE. This approach was associated with significant improvement in hemodynamic parameters without fatal outcomes or major periprocedural complications.

Anesthesia and perioperative pain management during cardiac electronic device implantation.

BACKGROUND: The degree of pain caused by the implantation of cardiac electronic devices (CEDs) and the type of anesthesia or perioperative pain management used with the procedure have been insufficiently studied. The aim of this study was to analyze perioperative pain management, as well as intensity and location of pain among patients undergoing implantation of CED, and to compare the practice with published guidelines. PATIENTS AND METHODS: This was a combined retrospective and prospective study conducted at the tertiary hospital, University Hospital Split, Croatia. The sample included 372 patients who underwent CED implantation. Perioperative pain management was analyzed retrospectively in 321 patients who underwent CED implantation during 2014. In a prospective study, intensity and location of pain before, during, and after the procedure were measured by using a numerical rating scale (NRS) ranging from 0 to 10 in 51 patients at the same institution from November 2014 to August 2015. RESULTS: A quarter of patients received analgesia or sedation before surgery. All the patients received local lidocaine anesthesia. After surgery, 31% of patients received pain medication or sedation. The highest pain intensity was observed during CED implantation with the highest NRS pain score being 8. Some patients reported severe pain (NRS >5) also at 1, 3, 6, 8, and 24 hours after surgery. The most common pain locations were surgical site, shoulder, and chest. Adherence to guidelines for acute perioperative pain management was insufficient. CONCLUSION: Patients may experience severe pain during and after CED implantation. Perioperative pain management was suboptimal, and higher doses of sedation and intensive analgesia are required. Guidelines for acute perioperative pain management and anesthesia during CED implantation should be developed.

Cardiac Tamponade after Right Ventricular Perforation Caused by Screw-in Lead.

A 69-year-old man was admitted after syncope followed with chest pain and signs of cardiac tamponade. He had undergone permanent dual-chamber pacemaker implantation 3 weeks earlier. Transthoracic echocardiography (TTE) confirmed a pericardial effusion, and urgent pericardial drainage was performed. Right ventricular perforation caused by active-fixation (screw-in) lead was verified by multislice computed tomography. The lead was extracted under fluoroscopy and bedside TTE monitoring in the operating room with cardiothoracic surgery backup. In the same act, the new ventricular passive-fixation lead was implanted.

SEVEN-YEAR TRENDS IN THE CROATIAN PRIMARY PERCUTANEOUS CORONARY INTERVENTION NETWORK.

The authors investigated trends in the Croatian primary Percutaneous Coronary Intervention (pPCI) Network results among three consecutive time intervals (2005-2007, first phase; 2008-2009, second phase; and 2010-2011, third phase). Data on 5650 patients with acute myocardial infarction with ST-elevation (STEMI) transferred or directly admitted and treated with pPCI in 11 Croatian PCI centers during the study period were collected and analyzed. The number of patients with acute STEMI treated with pPCI per year rose continuously during the study period (581 vs. 1272 vs. 1949 patients/year). The patient risk profile worsened during the study period: age (60 vs. 61 vs. 63 years; p<0.01), anterior myocardial wall involvement (43% vs. 44% vs. 51%; p<0.01), shock rate (7% vs. 9% vs. 11%; p<0.05), and percentage of transferred patients (42% vs. 36% vs. 46%; p<0.01). While the door-to-balloon time shortened (108 vs. 98 vs. 75 min; p<0.01), the symptom onset-to-door time increased (130 vs. 175 vs. 195 min; p<0.01), but without statistically significant influence on the total ischemic time. Multivariate log-linear analysis eliminated influence of a higher risk profile on the results of treatment and yielded no statistically significant changes in final TIMI 3 flow (Thrombolysis In Myocardial Infarction 3), in-hospital mortality, and six-month mortality rate, but revealed a significant increase in the rate of angina pectoris (12 vs. 22 vs. 36%; p<0.01) and other major adverse cardiovascular events (MACE; 6 vs. 23 vs. 14%; p<0.01) during follow up. In conclusion, the Croatian pPCI Network continuously ensures very good results of STEMI treatment in this economically less developed European country despite worsening of the risk profile in treated patients and opening of new, less experienced PCI centers. The higher percentage of MACE over time could be explained by changes in the pPCI strategy introduced over time (the culprit lesion only) and higher availability of PCI centers for additional PCI after acute STEMI. However, there is room for improvement, especially in reducing prehospital delay.

[Primary percutaneous coronary intervention (pPCI) in hospital without regional cardiac surgery support, data from Split region]. / Primarna perkutana koronarna intervencija (pPCI) bez kardiokirurske potpore u regiji; iskustvo iz Splita.

OBJECTIVES: The aim of our study was to investigate the feasibility of pPCI in hospital without cardiac surgery, and to compare our "real-world" results to current guidelines and historical controls. METHODS: Data of all STEMI patients treated by PCI were prospectively recorded. RESULTS: From January 2005 through October 2007, 366 consecutive patients with STEMI were enrolled. In-hospital mortality was 6.3%, as compared to 15% (87/543) in historical records of a three year period before pPCI program was developed. Pain to balloon time was 315 minutes, pain to first medical contact was 102 minutes, first medical contact to door was 94 minutes, door to cathlab time was 84 minutes, cathlab to balloon time was 45 minutes, and door to balloon time was 129 minutes. CONCLUSIONS: Our preliminary experience indicates that implementation of pPCI in a hospital without regional cardiac surgical back-up is feasible and offers significant mortality reduction in STEMI patients. Intrahospital time delays should be managed aggressively.

Evaluation of importance of door-to-balloon time and total ischemic time in acute myocardial infarction with ST-elevation treated with primary percutaneous coronary intervention.

The aim of the study was to evaluate the influence of door-to-balloon time and symptom onset-to-balloon time on the prognosis of patients with acute ST-elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI) in the Croatian Primary PCI Network. A total of 1190 acute STEMI patients treated with primary PCI were prospectively investigated in eight centers across Croatia (677 non-transferred, 513 transferred). All patients were divided according to door-to-balloon time in three subgroups (< 90, 90-180, and > 180 minutes) and according to symptom onset-to-balloon time in three subgroups (<180, 180-360, and > 360 minutes). The postprocedural Thrombolysis in Myocardial Infarction flow, in-hospital mortality, and major adverse cardiovascular events (mortality, pectoral angina, restenosis, reinfarction, coronary artery by-pass graft and cerebrovascular accident rate) in six-month follow-up were compared between the subgroups. The Croatian Primary PCI Network ensures results of treatment of acute STEMI comparable with randomized studies and registries abroad. None of the result differences among the door-to-balloon time subgroups was statistically significant. Considering the symptom onset-to-balloon time subgroups, a statistically significant difference at multivariate level was highest for in-hospital mortality in the subgroup of patients with longest onset-to-balloon time (4.5 vs. 2.6 vs. 5.7%; p = 0.04). Door-to-balloon time is one of the metrics of organization quality of primary PCI network and targets for quality improvement, but without an impact on early and six-month follow-up results of treatment for acute STEMI. Symptom onset-to-balloon time is more accurate for this purpose; unfortunately, reduction of the symptom onset-to-balloon time is more complex than reduction of the former.

Results of the Croatian Primary Percutaneous Coronary Intervention Network for patients with ST-segment elevation acute myocardial infarction.

The Republic of Croatia, with a gross domestic product per capita of US$11,554 in 2008, is an economically less-developed Western country. The goal of the present investigation was to prove that a well-organized primary percutaneous coronary intervention network in an economically less-developed country equalizes the prospects of all patients with acute ST-segment elevation myocardial infarction at a level comparable to that of more economically developed countries. We prospectively investigated 1,190 patients with acute ST-segment elevation myocardial infarction treated with primary PCI in 8 centers across Croatia (677 nontransferred and 513 transferred). The postprocedural Thrombolysis In Myocardial Infarction flow, in-hospital mortality, and incidence of major adverse cardiovascular events (ie, mortality, pectoral angina, restenosis, reinfarction, coronary artery bypass graft, and cerebrovascular accident rate) during 6 months of follow-up were compared between the nontransferred and transferred subgroups and in the subgroups of older patients, women, and those with cardiogenic shock. In all investigated patients, the average door-to-balloon time was 108 minutes, and the total ischemic time was 265 minutes. Postprocedural Thrombolysis In Myocardial Infarction 3 flow was established in 87.1% of the patients, and the in-hospital mortality rate was 4.4%. No statistically significant difference was found in the results of treatment between the transferred and nontransferred patients overall or in the subgroups of patients >75 years, women, and those with cardiogenic shock. In conclusion, the Croatian Primary Percutaneous Coronary Intervention Network has ensured treatment results of acute ST-segment elevation myocardial infarction comparable to those of randomized studies and registries of more economically developed countries.

Gender differences in in-hospital mortality and angiographic findings of patients with acute ST-segment elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI).

There are conflicting reports in the literature regarding the role of sex on the in-hospital mortality of patients with acute myocardial infarction. The objective of this study is to determine whether there are gender differences in in-hospital mortality and angiographic findings of patients with acute ST-segment elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI). We conducted a prospective study of all patients admitted to University Hospital Center Split, Croatia with STEMI from 2004 to 2008 who underwent PCI. From March 2004 throughout September 2008, 488 patients with STEMI underwent PCI (364 men, 74.6%; 124 women, 25.4%). Compared with men, women were significantly older (mean age, 67.3 vs. 60.3 years; p < 0.001). Men had a significantly higher proportion of circumflex artery occlusion (19.5% vs. 10.5%, p = 0.022). A higher proportion of men had a multivessel disease than women (56.8% vs. 41.9%; p = 0.004). In-hospital mortality was significantly higher among women (11.3% vs. 4.6%; p = 0.002) but after adjustment for the baseline difference in age, the female sex was not an independent predictor of in-hospital mortality (adjusted OR 1.15; 95% CI 0.82-1.84). In men, occlusions of left anterior descending artery showed higher mortality rate than occlusions of other coronary arteries (LM 0%, LAD 7.3%, Cx 2.8%, RCA 0.7%, p = 0.03). According to our results female gender is not an independent predictor of in-hospital mortality after percutaneous coronary intervention. In men, occlusions of left anterior descending arteries are associated with higher mortality rate comparing to occlusions of other coronary arteries.

Right atrial pacemaker lead thrombosis incidentally detected by transesophageal echocardiography.

In a 62-year-old man with permanent atrial fibrillation and recurrent stroke, a large right atrial thrombus attached to a permanent pacemaker lead was incidentally identified by transesophageal echocardiography. Surgical treatment, recommended because of the large dimensions of the mass, was refused by the patient, and thrombus was successfully dissolved by anticoagulant treatment. Pathogenesis of pacemaker lead thrombosis, clinical implications, diagnostic and therapeutic options are discussed.

Predictors of type and site of first acute myocardial infarction in men and women.

BACKGROUND: The importance of pathophysiological mechanisms involved in onset of acute myocardial infarction (AMI) differs with age, gender, and risk profiles. Diversity in the triggering of cardiovascular events has been observed, particularly between men and women. Therefore, we investigated the relationship between age, gender, and risk factors and location of AMI and the presence of Q waves in ECG. PATIENTS AND METHODS: Data was obtained from a chart review of 2958 patients with first AMI: 770 (26%) patients with non-Q-wave AMI and 2188 (74%) patients with Q-wave AMI. Four clinical groups were formed by predetermined criteria (anterior Q-wave, anterior non-Q-wave, inferior Q-wave, inferior non-Q-wave). A logistic regression was performed to assess independent predictors of AMI type and site. RESULTS: Key findings were: 1) inferior non-Q-wave AMI was more frequent in young women (P<0.001); 2) inferior Q-wave AMI was more common in young men (P<0.001); 3) anterior non-Q-wave AMI was more common in older men (P<0.001). Multivariate analysis revealed that independent predictors of anterior non-Q-wave AMI were age over 65 (P=0.002), male gender (P=0.04) and hypercholesterolemia (P=0.0003), and that predictors of inferior Q-wave AMI were male gender (P<0.0001), smoking (P=0.04) and diabetes (P=0.049). In the gender-subgroup analyses, age <45 years (P=0.04), hypecholesterolemia (P=0.02) and smoking (P=0.01) were independent predictors of inferior Q-wave AMI whereas age >65 years (P<0.0001) and smoking (P=0.0003) were predictors of anterior non-Q-wave AMI in men. In women, age <45 years (P<0.0001) and smoking (P=0.02) were independent predictors of non-Q-wave AMI and hypercholesterolemia (P=0.02) was a predictor of inferior Q-wave AMI. CONCLUSION: The link between particular types and the site of AMI and age, gender and risk factors suggest that the importance of pathophysiological mechanisms for onset of AMI differs according to sex and age subgroup.

Triggering of ventricular tachycardia by meteorologic and emotional stress: protective effect of beta-blockers and anxiolytics in men and elderly.

A circadian pattern with a morning peak and the triggering role of emotional stress have been suggested for ventricular arrhythmias. After controlling for participant baseline characteristics and medication used, the authors studied the association of emotional upset, physical activity, and meteorologic parameters with occurrence of ventricular tachycardia (VT) in 457 Croatian participants aged 11-88 years consecutively assigned to undergo continuous 24-hour Holter monitoring. In 2001, multivariate analysis of possible VT precipitators was performed separately for men, women, those aged <65 years, and those aged >64 years. A U-shaped pattern of wind speed (either very weak or very strong), rising relative air moisture, falling atmospheric pressure, and emotional upset were independent predictors of VT episodes in all participant subgroups. Positive association of VT with higher atmospheric temperature or pressure was observed in women and elderly. After adjustment for external triggers, a circadian variation in VT episodes persisted in women (p = 0.01) and those aged <65 years (p < 0.0001) only. A protective effect of beta-blockers and anxiolytics was especially apparent for men and elderly, as well as an adverse effect of digitalis in women. Results suggest that meteorologic and emotional stress could be considered external triggers of VT, with age- and sex-dependent susceptibility.

Mine clearance injuries in South Croatia.

OBJECTIVE: The purpose of this retrospective study was to describe and analyze casualties in mine-clearance operations in South Croatia from 1991 to 1995. During the war in Croatia, the laying of mines by both sides was largely unplanned, without mapping or documentation, making demining, an already expensive, complicated task, even more dangerous. METHODS: The study comprised all those injured in mine-clearance operations treated at Clinical Hospital Split. The type of mines used, the mechanism of the incident, and the location and severity of injury according to the Abbreviated Injury Scale and the Injury Severity Score were analyzed. RESULTS: In a 5-year period, 160 pyrotechnicians of the Croatian Army performed demining in Southern Croatia. In 29 incidents, 53 deminers were injured. The degree of injury according to the Abbreviated Injury Scale was 2.85 +/- 0.6 and Injury Severity Score grade was 19.68 +/- 8.57. Two of the injured died. CONCLUSION: To find and remove approximately 2 million mines laid in Croatia will take at least 10 years and 2,000 to 3,000 specialized personnel. Unfortunately, the results of the study demonstrate that a significant number of deminers will suffer grave injuries or die in the process.

Antipersonnel mine injuries in Southern Croatia.

OBJECTIVES: In this retrospective study, antipersonnel mine casualties in Southern Croatia from 1991 to 1995 are analyzed and treatment options are discussed. METHODS: Mechanism, degree of injury according to Abbreviated Injury Scale (AIS) and Injury Severity Score (ISS), as well as surgical treatment were analyzed. RESULTS: Of a 2,693 war trauma population, 422 (15.67%) patients sustained antipersonnel mine injuries, 241 (57.11%) from pressure mines and 181 (42.89%) from fragmentation mines. Military personnel were injured in 329 cases, civilians in 60 cases, and children in 33 cases. AIS was 3.01 +/- 0.56 and ISS was 17.92 +/- 6.59. Of 39 fatalities (9.24%) with a mean age of 27.98 +/- 1.70 years, 34 were soldiers, 4 were civilians, and 1 was a child. AIS was 5.35 +/- 0.39 and ISS was 54.94 +/- 2.36. CONCLUSION: Fatalities and morbidity arising from antipersonnel mines can be reduced by the provision of appropriate surgical and evacuation facilities at the actual battlefield.

Injuries from Antitank mines in Southern Croatia.

OBJECTIVE: Antitank mines inflict devastating injuries that are usually fatal. The objective of this retrospective study was to analyze antitank mine casualties in South Croatia during the period from 1991 to 1995. METHODS: Mechanism, degree of injury according to Abbreviated Injury Scale and Injury Severity Score, as well as surgical treatment were analyzed. FINDINGS: Of 464 mine victims, 42 (9.0%) patients sustained antitank mine injuries, and 12 of these were fatal (29%). Abbreviated Injury Scale of the antitank mine injuries was 5.3 +/- 10.6. Military personnel were injured in 29 cases, and civilians were injured in 13 cases. CONCLUSION: Although injuries from antitank mines were ravaging, and frequently fatal, a significant number of patients survived.

[Epidemiologic characteristics of patients with myocardial infarct in the region of Split during the period of war in the homeland]. / Epidemioloske osobitosti bolesnika s infarktom miokarda na splitskome podrucju tijekom domovinskog rata.

The aim of this study was to determine the pattern of myocardial infarction (MI) incidence regarding the age, gender, infarction site and the most important risk factors. Between 1989 and 1997 there were 3454 patients hospitalized in coronary care units of Clinical Hospital Split. In the three-year period preceding the war, from 1989-1991, 1024 patients were hospitalized because of MI. During the three years of full was activities, from 1992-1994, there were 1257 patients (significantly more, p < 0.05), and in the three-year period after the was, from 1995-1997, there were 1173 patients. In the war period there were 12% (151) patients under the 45 years of age (p < 0.05); of that number, 95% (143) were men (significantly more than in other two periods, p < 0.05), and 5% (8) were women. In the period preceding the was there were 6.5% (66) patients under the 45 years; 91% (60) men and 9% (6) women, whereas in the period after the war there were 7.5% (88), 92% (81) and 8% (7), respectively. The patients under 45 (305) more often had MI of inferior than anterior site (49 vs. 28%, p < 0.001), whereas there was no difference in patients over 45 (36 vs. 37%, p > 0.05). The patients over 45 had significantly higher hospital mortality (21 vs. 4%, p < 0.001), and were more likely to have hypertension (51 vs. 15%, p < 0.001) as well as hypercholesterolemia (54 vs. 14%, p < 0.001). Smokers were more prevalent among those under the 45 (75 vs. 51%, p < 0.001). The number of hospitalized patients with MI was the greatest during the war period. It included significant increase in incidence in men under 45 (12 vs. 7%, p < 0.05), with smoking as the most important risk factor, especially for infarctions of inferior site.