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Background: Caseous mitral annular calcification (CMAC) is a rare variant of mitral annular calcification. Symptoms can be related to mitral valvular dysfunction, arterial embolization, and transient aortic outflow tract obstruction. CMAC usually affects the posterior fibrous mitral annulus and is commonly diagnosed in elderly patients with a history of hypertension, dyslipidaemia, and renal failure. Case summary: A 68-year-old patient was transferred to our department for late presenting acute myocardial infarction and acute heart failure. Coronary angiography revealed a significant extrinsic compression of the circumflex artery. Transthoracic echocardiography revealed an ovoid calcified mass of 3.6â cm × 2â cm originating from the posterior mitral annulus causing moderate mitral stenosis as well as akinesia of the inferolateral wall, reduced left ventricle ejection fraction (35%), and a low-flow low-gradient severe aortic stenosis. Cardiac computed tomography scan confirmed the presence of a large calcified mass, inserted to the posterior mitral annulus evocating caseous necrosis. The patient underwent a double valve replacement with implantation of both aortic and mitral bioprostheses. Histopathology of the excised mass revealed a chronic mitral valve fibrocalcification with aseptic necrosis, consistent with a caseous calcification of the posterior mitral annulus. Discussion: Extrinsic coronary artery compression is a rare disease entity. We report a rather peculiar cause of extrinsic artery compression: CMAC inducing significant mitral stenosis and compressing the circumflex artery leading to myocardial infarction. To the best of our knowledge, this is the first case of extrinsic artery compression caused by CMAC.
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OBJECTIVES: To compare three FFR technologies: the electric-sensor Pressurewire® (P), the optic-sensor Comet® (C) guidewire, and the optic-sensor Navvus® (N) microcatheter. BACKGROUND: Different technologies are used to measure fractional flow reserve (FFR) for the functional assessment of coronary lesions with potential discrepancies. METHODS: Sixty-six FFR measurements performed on 32 lesions using each technology were used for a paired comparison of FFR on simultaneous measurements and in clinically relevant conditions (guidewires alone, N on a guidewire). RESULTS: Simultaneous measurements of FFR were significantly (p < .0001) correlated between systems (ρ = 0.88, 0.81 and 0.86 for P and N, P and C and, C and N, respectively). The presence of the N microcatheter, led to reduced values of FFR measured by P or C guidewires (p < .0001). The concomitant presence of P and C guidewires led to significantly lower FFR values (p < .0001) measured by P but not by C. In clinically relevant conditions, values of FFR measured by the optic-sensor C guidewire and N catheter were similar and lower than those measured by the P guidewire (p < .0001). The agreement between the three technologies (FFR ≤ 0.80) was 94%. CONCLUSIONS: FFR values simultaneously measured by three different technologies, are strongly correlated, and provide strongly concordant results. However, significant differences are found between values of FFR. The presence of N, but also C lead to a decrease of FFR measured by P. In clinically relevant conditions, the two optic-sensor technologies provide similar FFR measurements, lower than those measured by the piezo-electric technology suggesting a sensor-technology-related measurement variability. CLINICAL TRIAL REGISTRATION: NCT#03052803.
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Cateterismo Cardíaco/instrumentación , Catéteres Cardíacos , Enfermedad de la Arteria Coronaria/diagnóstico , Vasos Coronarios/fisiopatología , Reserva del Flujo Fraccional Miocárdico , Hemodinámica , Dispositivos Ópticos , Transductores de Presión , Anciano , Enfermedad de la Arteria Coronaria/fisiopatología , Diseño de Equipo , Femenino , Humanos , Masculino , Persona de Mediana Edad , Miniaturización , Valor Predictivo de las Pruebas , Estudios Prospectivos , Reproducibilidad de los ResultadosRESUMEN
RATIONALE: Necrotic core formation during the development of atherosclerosis is associated with a chronic inflammatory response and promotes accelerated plaque development and instability. However, the molecular links between necrosis and the development of atherosclerosis are not completely understood. Clec9a (C-type lectin receptor) or DNGR-1 (dendritic cell NK lectin group receptor-1) is preferentially expressed by the CD8α+ subset of dendritic cells (CD8α+ DCs) and is involved in sensing necrotic cells. We hypothesized that sensing of necrotic cells by DNGR-1 plays a determinant role in the inflammatory response of atherosclerosis. OBJECTIVE: We sought to address the impact of total, bone marrow-restricted, or CD8α+ DC-restricted deletion of DNGR-1 on atherosclerosis development. METHODS AND RESULTS: We show that total absence of DNGR-1 in Apoe (apolipoprotein e)-deficient mice (Apoe-/-) and bone marrow-restricted deletion of DNGR-1 in Ldlr (low-density lipoprotein receptor)-deficient mice (Ldlr-/-) significantly reduce inflammatory cell content within arterial plaques and limit atherosclerosis development in a context of moderate hypercholesterolemia. This is associated with a significant increase of the expression of interleukin-10 (IL-10). The atheroprotective effect of DNGR-1 deletion is completely abrogated in the absence of bone marrow-derived IL-10. Furthermore, a specific deletion of DNGR-1 in CD8α+ DCs significantly increases IL-10 expression, reduces macrophage and T-cell contents within the lesions, and limits the development of atherosclerosis. CONCLUSIONS: Our results unravel a new role of DNGR-1 in regulating vascular inflammation and atherosclerosis and potentially identify a new target for disease modulation.
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Aterosclerosis/metabolismo , Aterosclerosis/patología , Células Dendríticas/metabolismo , Células Dendríticas/patología , Interleucina-10/biosíntesis , Lectinas Tipo C/deficiencia , Receptores Inmunológicos/deficiencia , Animales , Masculino , Ratones , Ratones Endogámicos C57BL , Ratones NoqueadosAsunto(s)
Seno Coronario/anomalías , Trombosis Coronaria , Anomalías de los Vasos Coronarios , Infarto del Miocardio con Elevación del ST , Adulto , Angiografía por Tomografía Computarizada , Angiografía Coronaria/métodos , Puente de Arteria Coronaria , Seno Coronario/diagnóstico por imagen , Trombosis Coronaria/diagnóstico por imagen , Trombosis Coronaria/terapia , Anomalías de los Vasos Coronarios/diagnóstico por imagen , Anomalías de los Vasos Coronarios/cirugía , Humanos , Ligadura , Masculino , Tomografía Computarizada Multidetector , Infarto del Miocardio con Elevación del ST/diagnóstico por imagen , Infarto del Miocardio con Elevación del ST/terapia , Terapia Trombolítica , Tomografía de Coherencia ÓpticaRESUMEN
BACKGROUND: Primary percutaneous coronary intervention (PPCI) is the preferred reperfusion strategy in patients with ST-elevation myocardial infarction (STEMI), but its benefit over prehospital fibrinolysis (FL) is not clear. METHODS: We performed a systematic review and meta-analysis of randomized controlled trials in which outcomes of patients with STEMI managed with FL early in the prehospital setting versus PPCI were compared. RESULTS: Compared with PPCI, FL was consistently associated with similar rates of short-term (30-90 days) death (relative risk [RR] 0.94, 95 % CI 0.67-1.31) and cardiovascular death (RR 0.95, 95 % CI 0.64-1.4), a decreased risk of cardiogenic shock (RR 0.67, 95 % CI 0.48-0.95), and an increased risk of any stroke (RR 3.57, 95 % CI 1.39-9.17) and hemorrhagic stroke (RR 4.37, 95 % CI 1.25-15.26). FL was also associated with similar rates of 1-year mortality (RR 1.01, 95 % CI 0.75-1.34) and major bleeding (RR 1.31, 95 % CI 0.96-1.78) in comparison with PPCI, but with a notable level (I 2 index 30.5 % and 59.8 %) of heterogeneity among studies. CONCLUSIONS: Our study suggests that, compared with PPCI, FL performed in the early prehospital setting is associated with similar mortality rates, lower rates of cardiogenic shock, and higher rates of stroke in patients with STEMI. Although the number of studies comparing the two strategies is relatively low, our results support prehospital FL and transfer to hub percutaneous coronary intervention (PCI) centers as a valid alternative to PPCI, allowing potential limitation of resources allocated to developing proximity 24/7 PCI facilities.
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Servicios Médicos de Urgencia/métodos , Fibrinolíticos/administración & dosificación , Intervención Coronaria Percutánea/métodos , Ensayos Clínicos Controlados Aleatorios como Asunto/métodos , Infarto del Miocardio con Elevación del ST/terapia , Servicios Médicos de Urgencia/tendencias , Fibrinólisis/efectos de los fármacos , Fibrinólisis/fisiología , Humanos , Mortalidad/tendencias , Intervención Coronaria Percutánea/mortalidad , Intervención Coronaria Percutánea/tendencias , Infarto del Miocardio con Elevación del ST/diagnóstico , Infarto del Miocardio con Elevación del ST/mortalidad , Resultado del TratamientoRESUMEN
Although rare, iatrogenic aortocoronary dissection is one of the complications most dreaded by the interventional cardiologist. If not managed promptly, it can have redoubted and serious consequences. Herein, we present the case of a 70 year-old woman who was treated by stenting of the second segment of the right coronary artery (RCA) for recurrent angina but, unfortunately, the procedure was complicated by anterograde dissection of the RCA with a simultaneous retrograde propagation to the proximal part of the ascending aorta. Successful stenting of the entry point was able to recuperate the RCA and to limit the retrograde propagation to the ascending aorta, but there was an extension of the dissection to the aortic valve leaflets resulting in a massive aortic insufficiency. Therefore, surgical aortic valve replacement with prosthetic tube graft was performed [corrected].
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OBJECTIVES: The purpose of this study was to assess the feasibility and safety of thrombus-aspiration through a 5 Fr guiding catheter with transradial approach in acute coronary syndromes. BACKGROUND: The use of thrombus-aspirating devices improves myocardial reperfusion but requires at least a 6 Fr guiding catheter. Transradial coronary interventions using a 5 Fr guiding catheter are attractive to reduce bleeding complications. METHODS: We retrospectively selected patients presenting acute coronary syndromes with angiographically visible thrombus who underwent thrombus-aspiration through radial access using a 4 Fr multipurpose catheter in a 5 Fr guiding catheter. We described clinical and angiographic characteristics of the cohort, and the procedure's technique, success and complications. RESULTS: Among the 34 included patients, 29 presented ST-segment elevation myocardial infarction. Complete resolution of the ST-segment elevation was effective in 93% of these patients. TIMI flow grade after thrombus-aspiration was significantly improved compared to baseline TIMI flow grade or after passage of the guidewire (P < 0.001 for both). There was no dissection or perforation but we noted distal embolization in 5 cases probably explained by the high grade of intracoronary thrombus in our cohort. CONCLUSION: Thrombus-aspiration through a 5 Fr guiding catheter with transradial approach seems to be safe and effective in selected patients with acute coronary syndrome. This mini-invasive approach brought the advantages of the transradial access in 5 Fr but also its limitations.
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Síndrome Coronario Agudo/complicaciones , Cateterismo Cardíaco/instrumentación , Trombosis Coronaria/terapia , Succión/métodos , Anciano , Estudios de Cohortes , Angiografía Coronaria , Trombosis Coronaria/etiología , Estudios de Factibilidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Infarto del Miocardio/etiología , Estudios Retrospectivos , Succión/efectos adversosRESUMEN
Spontaneous coronary artery dissection is an unusual and a rare cause of acute coronary syndrome and sudden death with multiple predisposing factors. Prompt recognition is crucial for appropriate patient management, but specific guidelines for optimal treatment are lacking. We report four cases of women with spontaneous coronary artery dissection revealed by ST-segment elevation, three in women during postpartum and one case associated with a Marfan syndrome. Our cases span the different therapeutic options from medical treatment, stenting, to coronary artery bypass graft surgery.
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Síndrome Coronario Agudo/terapia , Disección Aórtica/terapia , Aneurisma Coronario/terapia , Síndrome Coronario Agudo/diagnóstico por imagen , Síndrome Coronario Agudo/etiología , Adulto , Disección Aórtica/diagnóstico por imagen , Disección Aórtica/etiología , Angioplastia Coronaria con Balón , Fármacos Cardiovasculares/uso terapéutico , Aneurisma Coronario/diagnóstico por imagen , Aneurisma Coronario/etiología , Angiografía Coronaria , Puente de Arteria Coronaria , Femenino , Humanos , Contrapulsador Intraaórtico , Síndrome de Marfan/complicaciones , Periodo Posparto , Embarazo , Factores de Riesgo , Resultado del TratamientoRESUMEN
The case of a woman with anomalous origin of the circumflex coronary artery that communicates with the left ventricle via a fistula, revealed by typical angina, is described and the several pathomechanisms involved are discussed.
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Fístula Arterio-Arterial/diagnóstico por imagen , Anomalías de los Vasos Coronarios/diagnóstico por imagen , Ventrículos Cardíacos/anomalías , Anciano , Angina de Pecho/etiología , Angiografía Coronaria , Femenino , Ventrículos Cardíacos/diagnóstico por imagen , HumanosRESUMEN
We report the case of a patient with a huge nonocclusive left main thrombus without underlying angiographic coronary lesion associated with bilateral coronary embolization, which was successfully and exclusively medically treated.
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Fármacos Cardiovasculares/uso terapéutico , Trombosis Coronaria/tratamiento farmacológico , Embolia/tratamiento farmacológico , Angiografía Coronaria , Trombosis Coronaria/complicaciones , Trombosis Coronaria/diagnóstico , Electrocardiografía , Embolia/diagnóstico , Embolia/etiología , Humanos , Masculino , Persona de Mediana Edad , Resultado del TratamientoRESUMEN
Tako-Tsubo cardiomyopathy (TTC), also known as transient left ventricular apical ballooning syndrome or stress-induced cardiomyopathy, is a novel reversible cardiomyopathy mimicking acute myocardial infarction without epicardial coronary artery disease. The exact physiopathology of TTC remains unclear. It is usually precipitated by acute physical or emotional stress and it most commonly affects postmenopausal women. The growing number of clinical cases of TTC have demonstrated a wide field of possible etiologies beyond the emotional stress. We report a case of a 67-year-old postmenopausal woman who was being supplemented by enteral feeding via a nasogastric tube and who developed TTC due to misdirection, probably favored by the mechanical blockade by the nasogastric tube, while swallowing the drug pills.