TAKOTSUBO SYNDROME AND CORONARY ARTERY FISTULA: CASE REPORT AND LITERATURE REVIEW.

Takotsubo syndrome (TTS) has been reported in various clinical conditions. Coronary artery fistula (CAF) is diagnosed in 0.2- 0.4% of patients undergoing coronary angiography. Pathologic communication between coronary artery (e.g., left anterior de¬scending coronary artery - LAD) and cardiac chambers (e.g., left ventricle - LV) is cameral type of CAF which particularly predis¬pose to myocardial ischemia due to a steal syndrome. Eight cases of coexistent TTS and CAF have been reported so far; in 6 of them LAD cameral fistulas drained LV, in 2 others communications between coronary arteries and pulmonary artery were found. The authors describe a case of a 75-year-old female, admitted due to chest pain and dyspnea. Her clinical picture with ST-segment elevation in ECG, moderately increased troponin I and apical ballooning in echocardiography, was more typical for TTS than for myocardial infarction; besides that, color doppler imaging was suggestive of multiple CAF to LV. Coronary angiography showed communication between all (normal) coronary arteries and LV. Throughout the conservative therapy, first, an improve¬ment and then normalization of LV function were observed after 2 and 6 days, respectively. Chest x-ray and computed tomogra¬phy revealed mediastinal tumor (eventually diagnosed as lung cancer). Cardiac magnetic resonance performed after one month did not show late gadolinium enhancement. During the course of 24 months follow-up, she was taking bisoprolol and ramipril and her cardiologic state remained stable, even during chemotherapy and radiotherapy. The authors collected the clinical data of all 9 cases with concomitant TTS and CAF. Specific TTS triggering factors/predisposing conditions were present in all patients, which has indicated that coexistence of TTS and CAF is rather coincidental.

[Progressive cardiac tamponade and right ventricular free wall perforation as complications after dual-chamber pacemaker implantation - a case report]. / Perforacja wolnej sciany prawej komory i postepujaca tamponada serca jako powiklanie po implantacji dwujamowego ukladu stymulujacego - opis przypadku.

In recent years the number of complications related to implantation of cardiac stimulating systems is increasing. Life-threatening myocardial perforation leading to cardiac tamponade is one of the rarest complications. In that case it is necessary to take the immediate lifesaving procedures. A CASE REPORT: 61-year-old woman ended up in the cardiac surgery department with progressive cardiac tamponade and cardiogenic shock symptoms. Three weeks earlier due to the tachycardia-bradycardia syndrome with second-degree atrioventricular block diagnosis, the cardiac stimulating system was implanted into the heart at the cardiology department. Two days after the discharge from hospital the patient appeared in the emergency department with non-specific chest symptoms, which disappeared after analgesic drugs. After another two weeks the patient returned to the emergency department in general poor condition. Echocardiographic examination showed fluid in both pleural cavities, a dense layer around heart and fluid out wards from the layer in the pericardial space. Furthermore, CT scan showed unobvious shape crossing the heart muscle. Firstly, the patient was admitted to the cardiology department and next transferred to the cardio surgery where on account of deteriorating condition was made a decision urgent sternotomy and revision pericardial sac. Intraoperatively were found perforation of right ventricular free wall caused by stimulation electrode and hole communicating pericardial space with left pleural cavity. The operation went well, without any complications. The patient was discharged from hospital 12 days after surgery. CONCLUSIONS: In the case of suspected complications related to the implantation of electrostimulation equipment, it is necessary to perform appropriate diagnostics and implement urgent procedures, including surgery.

Lack of Serum Creatinine Decrease After Coronary Angiography Despite Prophylactic Hydration After Routine Coronary Angiography/Angioplasty in Stable Angina Patients--Pilot Study.

BACKGROUND/AIMS: To prevent contrast induced renal dysfunction a periprocedural prophylactic hydration is applied. Due to dilution it should cause a drop in serum creatinine concentration (SCR). Surprisingly, no reduction in SCR after contrast admission is found in up to 25% of patients as early as 12-18 hours after coronary angiography/angioplasty. This study aims to find a clinical explanation as well as predict circumstances for this phenomenon. METHODS: Retrospective clinical and laboratory data was used from 341 patients who underwent elective coronary angiography/angioplasty, received a prophylactic hydration, and had serum creatinine concentration measured prior to, and 12-18 hours after invasive procedure with iodine contrast administration. To exclude an improper hydration due to no creatinine decrease, the number of red blood cells was analysed as well as hemoglobin and hematocrit in blood donations collected during the study time points. RESULTS: The resulting lack of serum creatinine reduction could be explained by dehydration (measured by increase in number of RBC, HGB and HCT) only in 13.5% , 10.8%, and 20% of cases, respectively. Any form of abnormal glucose metabolism combined with either baseline serum creatinine concentration <0.87 mg/dL or creatinine clearance >86.77 mL/min, or GFR by CKD EPI >80.08 mL/min/1.73 m2, or GFR by MDRD >74.48 mL/min/1.73 m2 were the predictors for no creatinine decrease at outcome. Additionally, it was demonstrated that the lack of creatinine decrease was more often observed among those patients whose initial renal function was better than in the subjects with reduction of SCR. CONCLUSIONS: This observation requires further prospective investigation on extended group of patients.

[Multiple right ventricular thrombi in arrhythmogenic right ventricular cardiomyopathy - a case report]. / Mnogie skrzepliny w prawej komorze w przebiegu arytmogennej kardiomiopatii prawej komory - opis przypadku.

Typical complications of arrhythmogenic right ventricular cardiomyopathy (ARVC) are heart failure and ventricular arrhythmias which may lead to sudden cardiac death. Intracardiac thrombosis is diagnosed only in 2-4% of patients. The authors present a case of a 50-year-old male admitted to hospital due to symptomatic ventricular tachycardia. Echocardiography and cardiac magnetic resonance showed advanced ARVC with multiple right ventricular thrombi. The biggest one was localized in the inflow tract below the tricuspid valve, whereas the smallest one beneath it, on the inferior wall; the remaining two - in the apex. Chest computed tomography did not confirm pulmonary embolism. Disappearance of thrombi was observed after 4 weeks of anticoagulation. Detection and appropriate treatment of intracardiac thrombi in ARVC may have relevance in prevention of sudden death, not related to arrhythmia, and is of special importance before cardioverterdefibrillator implantation.

[Debranching of aortic arch as part of a complex cardiac surgery]. / Debranching luku aorty jako element zlozonego zabiegu kardiochirurgicznego.

We present 54 year-old man diagnosed with an aneurysm of the ascending aorta and arch with aortic regurgitation and coronary artery disease. Surgery consisted of removing an aneurysm of the ascending aorta and arch of subtraction (debranching)cephalic brachiocephalic trunk and the common carotid artery and anastomosis of the descending aorta with vascular prosthesis and coronary artery bypass grafting. Postoperative course was uneventful. In 14 days after surgery the patient was discharged from the unit. Debranching method allowed avoiding hypothermia during surgery and shortening the time of cardio pulmonary bypass.

[Reversible dilated cardiomyopathy as an atypical form of takotsubo cardiomyopathy]. / Odwracalna kardiomiopatia rozstrzeniowa jako nietypowa postac kardiomiopatii takotsubo.

Stress-induced cardiomyopathy is characterized by transient regional left ventricular (LV) dysfunction that may involve, in different forms, midventricular, apical or basal segments. The authors describe a case of a 41-year-old woman with reversible, but global LV systolic dysfunction, complicated with apical thrombi. Clinical symptoms of dilated cardiomyopathy were preceded by persistent stressful workplace conditions. Ischemic, inflammatory, metabolic and endocrine causes of the disease were excluded. After 6 weeks, complete recovery of LV function in echocardiography and normal cardiac magnetic resonance imaging were observed, despite only modest doses of ramipril, carvedilol and diuretics. Six months later, as a result of another episode of emotional stress, she was hospitalized for typical takotsubo cardiomyopathy. Reversible global LV hypokinesis may be an atypical variant of stress-induced cardiomyopathy.

[Acute myocardial infarction mimicking takotsubo cardiomyopathy in a patient with myocardial bridging]. / Ostry zawal miesnia sercowego nasladujacy kardiomiopatie takotsubo u chorej z mostkiem miesniowym.

The authors present a case of a 70-year-old woman in whom clinical picture of an acute coronary syndrome with ST segment elevation was suggestive of takotsubo cardiomyopathy (TC). Chest pain, extensive ECG changes and typical TC left ventricular contraction pattern were preceded by emotional and physical stress, while in coronary angiography no atherosclerotic lesions were found. There was however left anterior descending coronary artery myocardial bridging with total systolic compression. Following treatment with beta-blocker and diltiazem, spectacular left ventricle function improvement, with near total recovery after 6 months was observed. Magnetic resonance imaging detected the presence of subendocardial late gadolinium enhancement indicative of postmyocardial scar.

[Massive infective endocarditis treated with triple bioprostheses implantation]. / Masywne infekcyjne zapalenie wsierdzia leczone metoda implantacji trzech biologicznych protez zastawkowych.

A case of a 50-year-old man admitted to the cardiology department due to massive infective endocarditis is presented. Diagnosis was confirmed by further investigations and patient was referred to cardiosurgery department. The surgery revealed destruction of mitral, tricuspid and aortic valve, thus three bioprostheses were implanted. The treatment was successful and six months after surgery patient was in good overall condition.

[Multiple left descending artery fistulas drained into left ventricle--a case report]. / Mezczyzna z wrodzonymi licznymi przetokami lewej tetnicy wiencowej do lewej komory serca.

We present a case of a 65-year-old male with multiple coronary artery fistulas draining into left ventricle.

[Giant left ventricular postinfarction pseudoaneurysm - an echocardiographic case report]. / Olbrzymi pozawalowy tetniak rzekomy lewej komory - opis przypadku.

We present a rare case of a 71-year-old man who had myocardial infarction 9 years ago. Transthoracic and transesophageal echocardiography revealed presence of a large pseudoaneurysm of the left ventricular (LV) apex and anterior wall with thrombus. The diagnosis of LV pseudoaneurysm was confirmed by electrocardiography - gated multidetector computed tomography. The patient did not consent for surgery and remained on pharmacological treatment.

Expression of activation antigens on lymphocyte surface and circulating platelet-leukocyte aggregates in ischaemic heart disease.

BACKGROUND: Data from literature documented the role of the activation of circulating T lymphocytes and increased leukocyte adhesion to blood platelets in the destabilisation of an atheromatous plaque and progression of ischaemic heart disease to acute coronary syndrome. AIM: To assess whether there is an increased proportion of activated T lymphocytes and platelet-leukocyte aggregates (PLA) in the circulating blood in patients with myocardial infarction or with stable angina, and to examine whether these changes are related to the progression of clinical symptoms or coronary angiography results. METHODS: The study group consisted of 36 patients with ST-segment elevation acute myocardial infarction (STEMI), confirmed by elevated troponin T level (36 patients, 26 males, 10 females, mean age 61.8 years, range 42-78 years), 30 patients with stable angina and single-vessel disease (24 males, 6 females, mean age 58.8 years, range 43-69 years), and 20 control healthy age and gender-matched subjects. Lymphocyte activation was evaluated by the assessment of T lymphocytes CD3+ /CD69+, CD3+/HLA-DR+ and CD4+/CD154+. The PLA assessment, including platelet-granulocyte aggregates (PGA), platelet-monocyte aggregates (PMA) and platelet-lymphocyte aggregates (PlymphA) was based on the measurement of the proportion of CD45+/CD41a+ cells with the use of flow cytometry. RESULTS: The proportion of T lymphocytes CD3+/HLA-DR+, CD3+/CD69+ and CD4+/CD154 was significantly higher in patients with STEMI than in controls, and T lymphocytes CD3+/CD69+ - significantly higher in STEMI group than in both patients with angina or controls. There was no significant relationship between the proportion of activated lymphocytes and duration of anginal pain, troponin T concentration or the number of coronary vessels with critical stenosis. The proportion of PGA, PMA and PlymphA was significantly greater in STEMI patients than in patients with angina or controls. There was a significant positive correlation between the proportion of PLA and PMA, and the duration of anginal pain. Patients with stable angina had a significantly higher proportion of T lymphocytes CD3+/HLA-DR+ compared with controls. CONCLUSIONS: Circulating T lymphocyte activation is present in ischaemic heart disease. This phenomenon is more pronounced in patients with acute MI than in those with stable angina, and is not related to the degree of cardiac injury. An increased formation of platelet-leukocyte aggregates is also present in patients with acute MI.