Routine Functional Testing or Standard Care in High-Risk Patients after Percutaneous Coronary Intervention.

PURPOSE OF REVIEW: This review aimed to collate the available evidence on outcomes following routine functional stress testing vs standard of care (i.e. symptom-guided stress testing) in high-risk patients following percutaneous coronary intervention (PCI). RECENT FINDINGS: The most recent pragmatic POST-PCI trial provided randomized evidence showing that routine functional stress testing post-PCI did not lead to a reduction in 2-year ischemic cardiovascular events or all-cause mortality, as compared to a symptom-guided standard-of-care approach. This was also true for sub-analyses including multivessel or left main disease, diabetics, as well as following imaging or physiology guided PCI. In the absence of a change in their clinical or functional status suggestive of stent failure, post-PCI routine periodic stress testing in stable patients on guideline-directed medical therapy is currently not recommended by American clinical practice guidelines. While evidence on the cost-effectiveness of routine stress testing strategy is scarce, physician, payer, and policy-level interventions to reduce inappropriate use of routine functional testing need to be addressed.

Spontaneous coronary artery dissection: an overview.

The prevalence of spontaneous coronary artery dissection (SCAD) has increased over the last decades in young adults presenting with acute coronary syndrome. Although the diagnostic tools, including intracoronary imaging, have permitted a more accurate diagnosis of SCAD, the prognosis and overall outcomes remain dismal. Furthermore, the disproportionate sex distribution affecting more women and the underdiagnosis in many parts of the world render this pathology a persistent clinical challenge, particularly since the management remains largely supportive with a limited and controversial role for percutaneous or surgical interventions. The purpose of this review is to summarize the available literature on SCAD and to provide insights into the gaps in knowledge and areas requiring further investigation.

Type IV dual left anterior descending coronary artery: a case report.

BACKGROUND: Dual left anterior descending (LAD) artery or duplication of LAD is a rarely reported coronary anomaly, consisting of two branches supplying the usual distribution of the LAD. Type IV dual LAD, in which a short LAD arises from the left main coronary artery and a long LAD arises from the right coronary artery is remarkably rare, and has not been reported in a Bangladeshi subject. CASE PRESENTATION: We describe the case of a 70-year old Bangladeshi male who presented with breathlessness in the background of a prior inferior myocardial infarction. Coronary angiography revealed an anomalous dual LAD. The short LAD which arose from the left main coronary artery gave off the first septal branch and terminated after giving off a large diagonal branch which continued further down towards the apex. The long LAD arose from the proximal right coronary artery and after traversing a distance, arrived at the interventricular septum, terminating at the apex after giving off diagonal branches. The right coronary artery was totally occluded from its early mid part and well-collateralized with retrograde flow from the left system. CONCLUSION: We describe a case with unique variation of dual LAD type IV, which has previously not been described in a Bangladeshi subject thus far. Coronary angiography is vital to determine this coronary anomaly, which is usually detected incidentally on routine angiography for chest pain, sometimes with involvement of significant lesion of other coronary arteries, as in this case.

Right coronary artery perforation extending to the coronary sinus of Valsalva during percutaneous intervention successfully sealed with polytetrafluoroethylene-covered stent: a case report.

BACKGROUND: Right coronary artery perforation extending to the sinus of Valsalva is a rare and potentially fatal complication of percutaneous coronary intervention. There are no definite guidelines on the management strategies for such complications. Treatment modality depends on the patient's haemodynamic stability and the extent of aortic involvement. Polytetrafluoroethylene-covered stents have emerged as a revolutionary strategy, enabling efficient endovascular repair of the entry port of such dissections, particularly the coronary ostia, and obviating the need for high-risk emergent surgical intervention. CASE PRESENTATION: A 60 year old Bangladeshi gentleman underwent a coronary angiogram following a prior inferior ST elevation myocardial infarction (MI), 1 month previously. Coronary angiography done via right radial approach using 5 FR TIG catheter showed diffuse mid RCA disease with maximum 90% stenosis. Angioplasty of the RCA was planned. The RCA was cannulated with a 6-French JR 3.5 guiding catheter (USA). The lesion was crossed by a 0.014 inch guide wire and stented with a 2.75 × 38 mm novolimus-eluting DESyne stent, after predilatation. Immediately after stenting, a Type II perforation was observed in the ostial RCA, which progressed into the right coronary sinus of Valsalva. As the patient was haemodynamically stable with no ischaemia on ECG, we attempted to seal the ostial RCA with bare metal stents. Two successive bare metal stents failed to seal the aorto-coronary dissection. Ultimately, a 3.0 × 19 mm polytetrafluoroethylene-covered stent was deployed to seal the entry port in the ostial RCA, yielding a satisfactory angiographic result with only minimal contrast staining limited to the right sinus of Valsalva. The patient was closely monitored and discharged on dual antiplatelet therapy comprising of aspirin and prasugrel. He remained asymptomatic and with follow up echocardiograms showing no pericardial effusion nor extension of the dissection. CONCLUSIONS: The polytetrafluoroethylene-covered stent provides a safe and effective means of sealing iatrogenic aorto-coronary dissections complicated by Ellis type II or II perforations, thus avoiding emergency surgery. However, as they are associated with increased incidence of stent thrombosis, an efficient and prolonged post-PCI antiplatelet regimen is recommended.

Pericardial tamponade due to haemorrhagic pericardial effusion as a complication of prasugrel: a case report.

BACKGROUND: Striking an adequate balance between bleeding risks and prevention of stent thrombosis can be challenging in the setting of percutaneous coronary intervention (PCI) with drug eluting stents (DES) in acute myocardial infarction (MI). This is more pronounced in patients treated with both low molecular weight heparin (LMWH) and dual antiplatelet therapy (DAPT). Prasugrel, a second generation thienopyridine with more potent platelet inhibition capability, is associated with significant bleeding risks. This risk of bleeding is often underestimated when prescribing pharmacological agents such as DAPT and LMWH, designed to reduce ischaemic events following PCI in acute MI. Life-threatening haemorrhagic pericardial and pleural effusions not associated with access site bleeding are a rare example of such bleeding complications. CASE PRESENTATION: We report a case of a Bangladeshi male who developed cardiac tamponade resulting from haemorrhagic pericardial effusion as well as bilateral pleural effusions, 9 days after PCI with a DES, while on prasugrel and aspirin. He had presented late with inferior ST elevation myocardial infarction (STEMI), and was therefore also given enoxaparin initially. Haemorrhagic pericardial and pleural fluid were drained, and the patient was discharged on DAPT comprising of aspirin and clopidogrel. Following PCI to obtuse marginal, which was done as a staged procedure 6 months later, he was commenced on ticagrelor instead of clopidogrel. He developed no further bleeding complications over 1 year of follow up. CONCLUSION: Non-access site bleeding such as this, leading to haemorrhagic pericardial and pleural effusions can be rare and life-threatening. Furthermore, patients with acute coronary syndromes (ACS) have marked variation in their risk of major bleeding. Since haemorrhagic complications are associated with mortality, maintaining a balance between the risk of recurrent ischemia and that of bleeding is of paramount importance. The use of validated bleeding risk scores, careful monitoring of patients on DAPT with LMWH, or a switch over to agents with lesser risk of bleeding may reduce such complications.

Pulmonary embolism with floating right atrial thrombus successfully treated with streptokinase: a case report.

BACKGROUND: Massive pulmonary embolism (PE) is associated with significant mortality, especially if compounded by haemodynamic instability, right ventricular (RV) dysfunction and right atrial (RA) thrombus. Thrombolysis can be lifesaving in patients with major embolism and cardiogenic shock, and accelerates the resolution of thrombus. Only three fibrinolytic agents-namely streptokinase, urokinase, and recombinant tissue plasminogen activator (alteplase) have been approved in the treatment of PE, with studies demonstrating similar safety profiles. CASE PRESENTATION: We report the case of a 33-year-old Bangladeshi Bengali female with a history of recent ankle fracture and immobilization, who presented with massive PE, leading to cardiac arrest. Upon rapid resuscitation, urgent echocardiogram revealed RV dysfunction with floating RA thrombus, and she was successfully treated with 1.5 million IU of streptokinase over 2 h as per accelerated regimen recommended by the European Society of Cardiology guidelines, resulting in successful resolution of the right heart thrombus, and significant clinical improvement. Subsequent CT pulmonary angiogram confirmed the diagnosis of PE, and she was anticoagulated to a PT/INR of 2.0-3.0 for 3 months. CONCLUSIONS: Echocardiography is a suitable alternative for rapid diagnosis of acute massive PE associated with RA thrombus and cardiovascular collapse, especially when a delay to CT pulmonary angiogram may be anticipated, and in the setting of immediate cardio-pulmonary resuscitation. Thrombolysis is a rapid and life-saving therapeutic measure in such cases.

Pulmonary embolism as a complication of an electrophysiological study: a case report.

BACKGROUND: Electrophysiological studies have become an established practice in the evaluation and treatment of arrhythmias. Symptomatic pulmonary embolism as a result of deep vein thrombosis arising from multiple venous sheath femoral vein catheterization is an uncommon complication associated with it. We report the case of a 33-year-old woman who developed pulmonary embolism after an electrophysiological study, which was successfully treated at a cardiac hospital in Bangladesh. CASE PRESENTATION: A 33-year-old Bangladeshi woman with hypertension and diabetes had initially presented with recurrent episodes of paroxysmal atrial fibrillation that manifested as palpitations for 2 years. Her atrial fibrillation was drug-refractory and could not be attributed to a treatable etiology. She had undergone an electrophysiological study at a different hospital, where right femoral venous catheterization was performed followed by the insertion of three venous sheaths. However, tachyarrhythmia could not be induced and a procedure to isolate the pulmonary vein was postponed because all the veins could not be isolated. Forty-eight hours later, she presented to our hospital with shortness of breath, chest heaviness, palpitations, and recurrent episodes of syncope. She had normal coronary arteries and no other risk factors for venous thromboembolism. She was hemodynamically stable on examination. There was echocardiographic evidence of pulmonary hypertension and right ventricular dilatation and dysfunction. A computed tomography pulmonary angiogram confirmed pulmonary embolus in the descending branch of her left pulmonary artery, extending up to the segmental arteries. Subsequently, a duplex ultrasound confirmed acute deep vein thrombosis affecting her right ilio-femoral segment. She was successfully managed with subcutaneous enoxaparin and oral warfarin (target international normalized ratio 2.5-3). CONCLUSIONS: Pulmonary embolism is a rare but serious complication that may occur in patients who undergo electrophysiological studies. Multiple venous sheaths inserted into the femoral vein and catheter-induced endothelial injury, further compounded by prolonged procedural time, may be responsible for the increased thrombogenicity leading to deep vein thrombosis and subsequent pulmonary embolism. An adequate observation time after the procedure and clinical alertness are necessary for rapid diagnosis and treatment.

The pacemaker-twiddler's syndrome: an infrequent cause of pacemaker failure.

BACKGROUND: The pacemaker-twiddler's syndrome is an uncommon cause of pacemaker malfunction. It occurs due to unintentional or deliberate manipulation of the pacemaker pulse generator within its skin pocket by the patient. This causes coiling of the lead and its dislodgement, resulting in failure of ventricular pacing. More commonly reported among elderly females with impaired cognition, the phenomenon usually occurs in the first year following pacemaker implantation. Treatment involves repositioning of the dislodged leads and suture fixation of the lead and pulse generator within its pocket. CASE PRESENTATION: An 87 year old Bangladeshi lady who underwent a single chamber ventricular pacemaker (VVI mode: i.e. ventricle paced, ventricle sensed, inhibitory mode) implantation with the indication of complete heart block, and presented to us again 7 weeks later, with syncopal attacks. She admitted to repeatedly manipulating the pacemaker generator in her left pectoral region. Physical examination revealed a heart rate of 42 beats/minute, blood pressure 140/80 mmHg and bilateral crackles on lung auscultation. She had no cognitive deficit. An immediate electrocardiogram showed complete heart block with pacemaker spikes and failure to capture. Chest X-ray showed coiled and retracted right ventricular lead and rotated pulse generator. An emergent temporary pace maker was set at a rate of 60 beats per minute. Subsequently, she underwent successful lead repositioning with strong counselling to avoid further twiddling. CONCLUSION: Twiddler's syndrome should be considered as a cause of pacemaker failure in elderly patients presenting with bradyarrythmias following pacemaker implantation. Chest X-ray and electrocardiograms are simple and easily-available first line investigations for its diagnosis. Lead repositioning is required, however proper patient education and counselling against further manipulation is paramount to long-term management.

Graves' disease presenting as bi-ventricular heart failure with severe pulmonary hypertension and pre-eclampsia in pregnancy--a case report and review of the literature.

BACKGROUND: Graves' disease, a well-known cause of hyperthyroidism, is an autoimmune disease with multi-system involvement. More prevalent among young women, it appears as an uncommon cardiovascular complication during pregnancy, posing a diagnostic challenge, largely owing to difficulty in detecting the complication, as a result of a low index of suspicion of Graves' disease presenting during pregnancy. Globally, cardiovascular disease is an important factor for pregnancy-related morbidity and mortality. Here, we report a case of Graves' disease detected for the first time in pregnancy, in a patient presenting with bi- ventricular heart failure, severe pulmonary hypertension and pre- eclampsia. Emphasis is placed on the spectrum of clinical presentations of Graves' disease, and the importance of considering this thyroid disorder as a possible aetiological factor for such a presentation in pregnancy. CASE PRESENTATION: A 30-year-old Bangladeshi-Bengali woman, in her 28th week of pregnancy presented with severe systemic hypertension, bi-ventricular heart failure and severe pulmonary hypertension with a moderately enlarged thyroid gland. She improved following the administration of high dose intravenous diuretics, and delivered a premature female baby of low birth weight per vaginally, twenty four hours later. Pre-eclampsia was diagnosed on the basis of hypertension first detected in the third trimester, 3+ oedema and mild proteinuria. Electrocardiography revealed sinus tachycardia with incomplete right bundle branch block and echocardiography showed severe pulmonary hypertension with an estimated pulmonary arterial systolic pressure of 73 mm Hg, septal and anterior wall hypokinesia with an ejection fraction of 51%, grade I mitral and tricuspid regurgitation. Thyroid function tests revealed a biochemically hyperthyroid state and positive anti- thyroid peroxidase antibodies was found. (99m)Technetium pertechnetate thyroid scans demonstrated diffuse toxic goiter as evidenced by an enlarged thyroid gland with intense radiotracer concentration all over the gland. The clinical and biochemical findings confirmed the diagnosis of Graves' disease. CONCLUSIONS: Graves' disease is an uncommon cause of bi-ventricular heart failure and severe pulmonary hypertension in pregnancy, and a high index of clinical suspicion is paramount to its effective diagnosis and treatment.