Triple-Access Retrograde Chronic Total Occlusion Intervention Through Vein Graft and Epicardial Collaterals.

Based on the patient's symptoms and examination, a decision was made to recanalize his totally occluded RCA via retrograde approach through the SVG to the OM. Due to inadequate visualization of the epicardial collaterals and distal RCA via SVG, triple-access was used and injection via left main. In selected CTO cases, triple access may facilitate the retrograde approach, allowing optimal collateral visualization.

Dissection Re-entry Technique: How is it Really Looking?

Dissection re-entry is a widely used technique in many chronic total occlusion centers. This account of a failed re-entry attempt provides in vivo photographic evidence of how the vessel looked after such an attempt. Operators are advised to keep dissection of subintimal space and hematoma limited and use dedicated materials and techniques for controlled re-entry.

The Reverse T-Stenting and Small Protrusion Technique: A Novel Technique for Coronary Bifurcation Lesions.

Bifurcation lesions may be encountered in approximately 15%-20% of percutaneous coronary interventions. A 2-stent approach is required in up to 30% of these procedures. We describe a novel technique based on a modification of TAP stenting, suitable for procedures where a 2-stent strategy is predetermined.

Reversible dilated cardiomyopathy due to subclinical hyperthyroidism.

We present a patient without primary heart disease in whom subclinical hyperthyroidism was accompanied by manifestations of dilated cardiomyopathy, as evaluated by echocardiography, coronary angiography, and radionuclide ventriculography. His condition was reversed 6 months after conventional treatment (furosemide, carvedilol, angiotensin-converting-enzyme inhibitor and thiamazole administration). This patient represents an exceptional case, as overt congestive heart failure with left ventricular dilatation and depressed ventricular ejection fraction is not a common finding in patients with hyperthyroidism, let alone patients with subclinical hyperthyroidism and no underlying heart disease.

Free floating thrombus in the right atrium causing massive pulmonary embolism.

The movement of thrombi migrating from the veins of the lower limbs can give rise to pulmonary emboli within 24 hours. This is manifested as massive pulmonary embolism in 30% of cases, with a mortality rate of around 50%. Free-floating thrombi within the right cardiac cavities are rare, and the diagnosis is made mainly by transthoracic and transoesophageal echocardiography. Treatment includes surgery, invasive percutaneous embolectomy, thrombolysis and heparin administration. Here we report the case of an 80-years-old patient with massive pulmonary embolism caused by a free floating thrombus within the right atrium. Tenecteplase was administered with excellent results.

Consecutive administration of atropine and isoproterenol for the evaluation of asymptomatic sinus bradycardia.

AIMS: Sinus node function is commonly evaluated by the atropine test. The isoproterenol test is less used. The aim of this study was to evaluate chronotropic reserve in patients with asymptomatic sinus bradycardia using the combined administration of atropine and isoproterenol. METHODS AND RESULTS: A total of 100 patients were studied, 18-70 years old, with permanent, asymptomatic, sinus bradycardia and no detectable cardiac disease. The standard administration protocols for atropine and isoproterenol were used and successive heart rate recorded. Patients were stratified into three groups: Group A (control), showing normal response to atropine and isoproterenol; Group B, demonstrating abnormal response to atropine; Group C, with abnormal response to atropine and isoproterenol. No statistically significant difference was observed between Groups A and B (P = 0.11), whereas Group C differed statistically from both Groups A (P < 0.000001) and B (P = 0.000003) to a significant extent. By the end of the 3-year follow-up period, 47% of the Group C patients had undergone permanent pacemaker implantation (DDDR)--Kaplan-Maier survival curves predict only 35% survival without pacing--whereas none did so in Groups A and B. CONCLUSIONS: In patients with deficient chronotropic response to atropine administration, isoproterenol tests could differentiate those with inadequate chronotropic reserves, possibly requiring preventive pacemaker implantations.