Lower plasma protein C activity is associated with early myocardial necrosis and no-reflow phenomenon in patients with ST elevation myocardial infarction.

Background: Activity of protein C has important role in the development of early necrosis and no-reflow phenomenon in patients with ST-segment elevation myocardial infarction (STEMI) after successful primary percutaneous coronary intervention (pPCI). Methods: We examined association between plasma activity of protein C, antithrombin, coagulation factors II, VII, VIII and fibrinogen to early formation of new Q-waves (myocardial necrosis) before pPCI and early ST-segment resolution (microcirculatory reperfusion) after pPCI in patients with acute STEMI. According to ischaemic time, patients were considered as early or late presenters. 12-lead ECG was analysed for the presence of new Q-wave at admission and for significant ST-segment resolution 60 minutes after primary PCI. Results: In early presenters' group, protein C activity was significantly lower in patients who did not achieve significant ST-segment resolution after pPCI compared to patients who did (1.11 IU/L vs. 0.99 IU/L, p = .006) and in patients who had new Q-waves compared to group who had not (1.04 UI/l vs. 1.11 IU/L, p = .038). There was significant negative correlation between protein C activity and maximal CK-MB levels (R2 = 0.06, p = .009) and BNP levels (R2 = 0.109, p = .003) and significant positive correlation between protein C activity with LVEF (R2 = 0.065, constant = 33.940, b = 11.968, p = .007) in early STEMI presenters. There were no differences between the activity of other examined haemostasis factors. Conclusion: Therefore we concluded that STEMI patients with early myocardial necrosis and no-reflow phenomenon after pPCI have lower activity of plasma protein C levels.

Diagnostic significance of three-dimensional echocardiography in asymptomatic unicuspid aortic valve.

Unicuspid aortic valve (UAV) is a rare congenital anomaly of aorta associated with a faster progress of valvular dysfunction, aortic dilatation and with necessity for more frequent controls and precise evaluation Asymptomatic 35 year old man had abnormal systolic diastolic murmur on aortic valve during routine examination. Initial diagnostic with transthoracic echocardiography (TTE) supposed bicuspid aortic valve, while three-dimensional transesophageal echocardiography (3D TEE) and multidetector computed tomography defined unicuspid, unicomissural aortic valve with moderate aortic stenosis and regurgitation. This case report confirmed that 3D TEE gives us opportunity for early, improved and precise diagnosis of UAV.

Retroperitoneal fibrosis and constrictive pericarditis-IgG4 related diseases: A case report.

Retroperitoneal fibrosis (RPF) is a rare disease characterized by infiltration of inflammatory cells and deposition of thickened fibrous tissues. The present study presents the case of a 53-year-old patient treated for generalized weakness and fatigue for 1 year prior to hospitalization. A cardiac ultrasound revealed pericardial effusion that required pericardiocentesis, during which 1,400 ml serous fluid with the characteristics of an exudate was aspirated. A pericardiectomy was performed due to persistent effusion and histological examination indicated pericardial fibrosis. A thoracic-abdominal computed tomography scan revealed the presence of retroperitoneal fibrosis. The patient was treated with corticosteroids and azathioprine. Follow-up examinations showed a significant reduction in the amount of abdominal fibrous tissue and no increase in pericardial effusion 1 year following the end of treatment. The patient continues to have regular follow-up control examinations with a cardiologist and nephrologist.

Iatrogenic dissection of the left main coronary artery during elective diagnostic procedures--A report on three cases.

UNLABELLED: INTRODUCTION. Left main coronary artery dissection is a rare and potentially life-threatening complication of coronary angiography and angioplasty which requests urgent revascularization. CASE REPORT: During the period between 2010 and November 2014 at single healthcare center we did totally 8,884 coronary procedures, out of which 2333 were percutaneous coronary interventions (PCI). In this period we had a total of 3 (0.03%) left main coronary artery dissections, and all of them were successfully treated by PCI. We presented three cases with iatrogenic dissection of the left main coronary artery, occurred during elective diagnostic procedures, successfully treated with PCI with different techniques. CONCLUSION: PCI could be fast and life-saving approach in iatrogenic dissections of the left main coronary artery.

Successful primary percutaneous coronary interventions in a patient with two consecutive ST-segment elevation myocardial infarctions and dual left anterior descending artery (type IV).

INTRODUCTION: Dual left anterior descending (LAD) artery is a very rare inherited anomaly. It can be incidentally revealed during primary percutaneous coronary intervention (pPCI) and may produce difficulties in detecting and treating the culprit lesion. CASE REPORT: We presented a 52-year-old male patient with ST-segment elevation myocardial infarction (STEM1) of inferior wall, in whom dual LAD anomaly was revealed during pPCI: a short LAD artery originated from the left main coronary artery and a long LAD artery originated from the proximal part of the right coronary artery (RCA). A bare metal stent was successfully implanted in the place of the culprit lesion in RCA and ST-segment resolution was achieved in ECG. After two hours, the patient was referred again to the catheter lab due to new STEMI of anteroseptal wall. Another bare metal stent was implanted in new infarction related artery, this time it was proximal part of the short LAD. CONCLUSION: Careful and correct interpretation of ECG is very helpful in detection and treatment of the culprit lesion in cases with dual LAD.

Very late stent thrombosis of bare-metal coronary stent nine years after primary percutaneous coronary intervention.

Introduction: Stent thrombosis (ST) in clinical practice can be classified according to time of onset as early (0­30 days after stent implantation), which is further divided into acute (< 24 hours) and subacute (1­30 days), late (> 30 days) and very late (> 12 months). Myocardial reinfaction due to very late ST in a patient receiving antithrombotic therapy is very rare, and potentially fatal. The procedure alone and related mechanical factors seem to be associated with acute/subacute ST. On the other hand, in-stent neoathero-sclerosis, inflammation, premature cessation of antiplatelet therapy, as well as stent fracture, stent malapposition, un-covered stent struts may play role in late/very late ST. Some findings implicate that the etiology of very late ST of bare-metal stent (BMS) is quite different from those following drug-eluting stent (DES) implantation. Case report: We presented a 56-year old male with acute inferoposterior ST segment elevation myocardial infarction (STEMI) related to very late stent thrombosis, 9 years after BMS implantation, despite antithrombotic therapy. Thrombus aspiration was successfully performed followed by percutaneous coronary intervention (PCI) with implantation of DES into the pre-viously implanted two stents to solve the in-stent restenosis. Conclusion: Very late stent thrombosis, although fortu-nately very rare, not completely understood, might cause myocardial reinfaction, but could be successfully treated with thrombus aspiration followed by primary PCI. Very late ST in the presented patient might be connected with neointimal plaque rupture, followed by thrombotic events.

Does thrombolytic therapy harm or help in ST elevation myocardial infarction (STEMI) caused by the spontaneous coronary dissection?

INTRODUCTION: Spontaneous coronary artery dissection (SCAD) is a very rare disease with poor prognosis. It mainly affects young women free of risk factors for coronary artery disease (CAD) and women during the peripartum period. The prognosis for myocardial infarction caused by SCAD is poor, management is often difficult and guidelines still missing. CASE REPORT: We presented a woman with acute myocardial infarction of anterior wall of the left ventricle, caused by spontaneous dissection of medial segment of the left anterior descending coronary artery. We treated the patient with thrombolytic therapy and performed coronary angiography after that. Finally we decided to do nothing more. Two years later we performed coronary angiography again and founded the coronary artery normal. We also analyzed 19 cases publiched from 1996 to 2012 when coronary artery dissection had been treated with thrombolytic agent Analysis revealed only one case of 19, with complication after treating SCAD with thrombolysis. CONCLUSION: Sometimes, regarding myocardial infarction in young women with no risk factors for CAD, especially in young women in peripartum, we should think about SCAD. The presented case, like eight others, demonstrates that good clinical outcomes can be achieved with thrombolysis. In spite of all this, we still need more data to verify that thrombolysis does not have to harm the therapy for SCAD. For the time being thrombolytic therapy could be an option.

Correlation between the Finnish Diabetes risk Score and the severity of coronary artery disease.

BACKGROUND/AIM: The FINish Diabetes RIsk SCore (FINDRISC) which includes age, body mass index (BMI), waist circumference, physical (in) activity, diet, arterial hypertension, history of high glucose levels, and family history of diabetes, is of a great significance in identifying patients with impaired glucose tolerance and a 10-year risk assessment of developing type 2 diabetes in adults. Due to the fact that the FINDRISC score includes parameters which are risk factors for coronary artery disease (CAD), our aim was to determine a correlation between this score, and some of its parameters respectively, with the severity of angiographically verified CAD in patients with stable angina in two ways: according to the Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery (SYNTAX) score and the number of diseased coronary arteries. METHODS: The study included 70 patients with stable angina consecutively admitted to the Clinic of Cardiology, Military Medical Academy, Belgrade. The FINDRISC score was calculated in all the patients immediately prior to angiography. Venous blood samples were collected and inflammatory markers [erythrocyte sedimentation rate (ESR), leucocytes, C-reactive protein (CRP), total cholesterol, HDL cholesterol, triglycerides and fasting glucose] determined. Coronary angiography was performed in order to determine the severity of coronary artery disease according to the SYNTAX score and the number of affected coronary vessels: 1-vessel, 2-vessel or 3-vessel disease (hemodynamically significant stenoses: more than 70% of the blood vessel lumen). The patients were divided into three groups regarding the FINDRISC score: group I: 5-11 points; group II: 12-16 points; group III: 17-22 points. RESULTS: Out of 70 patients (52 men and 18 women) enrolled in this study, 14 had normal coronary angiogram. There was a statistically significant positive correlation between the FINDRISC score and its parameters respectively (age, body mass index-BMI, waist circumference) and the severity of CAD according to the SYNTAX score (p < 0.001) and the number of diseased coronary arteries (p < 0.001). The patients with higher FINDRISC score (groups II and III) had more severe and extensive-CAD according to the SYNTAX score than the group I. The odds ratio with 95% confidence intervals (CI) between the group III and the group I was 5.143 (95% CI 1.299-20.360, p = 0.002) and between the group II and the group I 5.867 (95% CI 1.590- 21.525, p = 0.007). There were no differences in odds ratio for multivessel disease according to FINDRISC score between the group II and the group III [1.141; (95% CI 0.348-3.734). In the group I mean SYNTAX score was 5.18, and more than 70% of patients had normal coronary angiogram. In the group II mean SYNTAX score was 17.06, and more than 70% of patients had 2-vessel disease and 3-vessel disease, and in the group III mean SYNTAX score was 18.89, and 2-vessel and 3-vessel disease had 36.36% and 31.82% patients, respectively. In multiple regression analysis, where SYNTAX score was dependent variable, and age, BMI, waist circumference, FINDRISC score were independent variables, we found that only FINDRISC score was independent predictor of SYNTAX score. CONCLUSION: The obtained results suggest a statistically significant correlation between the FINDRISC score and its parameters (age, BMI, waist circumference) and the severity of CAD according to the SYNTAX score and the number of diseased coronary arteries. The FINDRISC score may be useful in identifying patients at the high risk for coronary artery disease.