Use of intracoronary electrocardiography for detecting ST-T, QTc, and U wave changes during coronary balloon angioplasty.

Intracoronary electrocardiography (IC-ECG) is a more sensitive method than surface ECG to detect electrical changes during percutaneous transluminal coronary angioplasty (PTCA). It also provides direct monitoring of ST-T segment, QTc intervals, and U-wave genesis during balloon inflation. These changes are reflective of myocardial ischemia. The authors studied the effect of transient myocardial ischemia on ST-T segment, QTc intervals, and U-wave appearance by comparing standard and perfusion balloon angioplasty. PTCA of left anterior descending artery was performed in 14 patients using the standard balloons and in 11 patients using the perfusion balloons. Patients with perfusion balloon angioplasty had less ST-T elevation (0.15 +/- 0.05 mV versus 1.04 +/- 0.19 mV, P < 0.001), less QTc-shortening intervals (0.01 +/- 0.02 seconds versus -0.05 +/- 0.04 seconds, P < 0.001), and less positive U waves (two versus nine). The authors concluded that balloon angioplasty with perfusion balloons is associated with less ischemia as reflected by ST-T, QTc-shortening intervals, and U-wave changes. There was more positive U-wave appearance with the standard balloon angioplasty, which implies more ischemia. In addition, QTc-shortening intervals are associated with the development of U waves during standard balloon angioplasty. These findings suggest that IC-ECG is a sensitive tool in detecting myocardial ischemia. IC-ECG may also help to clarify the nature of chest pain during PTCA in some patients. Like QT dispersion (QTd), QTc-shortening intervals and new U waves can have prognostic implications and additional studies are needed to define this role.

Relationship between cytokine levels and coronary artery disease in women.

Inflammation is thought to have a role in the pathogenesis of atherosclerotic coronary artery disease (CAD), and the measurement of markers of inflammation has been suggested to improve the identification of individuals at risk for this disease. The incidence of CAD in women is not accounted for by conventional risk factors, and the association of CAD and the antiinflammatory cytokine transforming growth factor beta1 (TGF-beta1) in this population is unknown. Associations among TGF-beta1, the inflammatory cytokine tumor necrosis factor alpha (TNF-alpha), and CAD severity in inner city women were examined. Fifty-three women requiring angiography (mean age, 60.7 years) were stratified as having on of the following conditions: 0 vessel disease (VD) (n = 20), 1 (VD) (n = 10), 2 VD (n = 9), or 3 VD (n = 14). Fasting serum cytokine levels were determined by enzyme-linked immunosorbent assay. Serum TGF-beta1 was lower in patients with extensive disease (2 and 3 VD versus 0 and 1 VD). The lowest TGF-beta1 levels (<30 ng/mL) were in the 2 and 3 VD groups. In contrast, in the 0 and 1 VD groups, TGF-beta1 was above 41 ng/mL. Serum TGF-beta1 correctly classified the severity of CAD in 62.3% of patients, with a predictive threshold of 58 ng/mL by discriminant function analysis. TGF-beta1 may be a determinant of clinical events and outcome in CAD in women.

Fatal left main coronary artery embolism from aortic valve endocarditis following cardiac catheterization.

Coronary artery embolization has been associated with sudden cardiac death. It is more commonly seen with aortic valve endocarditis. It manifests as acute myocardial ischemia or infarction, causing instability of the cardiac rhythm, which may be fatal. We report a patient with aortic valve endocarditis who had sudden cardiac death following coronary angiography. Autopsy revealed embolic occlusion of the left main coronary artery.

Successful percutaneous stenting of a right gastroepiploic coronary bypass graft using monorail delivery system: a case report.

The right gastroepiploic artery (RGEA) is being successfully used as an arterial conduit in a selected group of patients undergoing coronary artery bypass graft surgery. However, myocardial ischemia may result due to spasm, occlusion, and stenosis of this graft. The anastamosis site at distal right coronary artery (RCA) or posterior descending artery (PDA) is the most common location for stenosis of an in situ gastroepiploic coronary bypass graft. Balloon angioplasty of such stenoses has been reported with optimal short-term results. Stent deployment would decrease the restenosis rate, so that repeat procedures could be minimized for these technically challenging lesions. We describe a case of successful deployment of a stent with monorail delivery system at the anastamotic site stenosis of an in situ gastroepiploic right coronary artery bypass graft. This percutaneous coronary intervention could prevent redo coronary artery bypass graft surgery. Cathet. Cardiovasc. Intervent. 49:197-199, 2000.

Recurrent right atrial thrombus after repair of ruptured sinus of valsalva aneurysm.

Ruptured sinus of Valsalva aneurysm is a rare cardiac abnormality. Early surgical repair is indicated to prevent complications such as heart failure, infective endocarditis, arrhythmias, and thromboembolic events. The authors report an unusual case of recurrent right atrial thrombus after the surgical repair and closure of ruptured sinus of Valsalva aneurysm.

Takayasu's arteritis: an unusual manifestation--a case report.

Takayasu's arteritis is a rare entity. The authors describe a case of a middle-aged woman with an atypical form of Takayasu's arteritis. This manifestation has not been described previously.

Rescue PTCA complicated by pulmonary artery rupture after tPA and abciximab.

Since the introduction of pulmonary artery catheterization for hemodynamic monitoring, several complications associated with its use have been described. Pulmonary artery rupture is an infrequent complication of flow-directed pulmonary artery catheters. We report a case of pulmonary artery rupture complicating rescue PTCA in the presence of systemic platelet inhibition with abciximab (Reopro), anticoagulation, and thrombolytic therapy. With the increasing use of these medications in patients undergoing acute coronary interventions, particularly those patients requiring hemodynamic monitoring, this uncommon but potentially fatal complication may be seen more frequently.

ST-T alternans and myocardial ischemia.

Previous studies using intracoronary electrocardiography have demonstrated that ST-T alternans can develop during standard balloon coronary angioplasty. Total occlusion with a large amount of myocardium in jeopardy is the postulated prerequisite. In this study, the authors used perfusion balloons instead of standard balloons, so coronary perfusion was maintained and ischemia was minimized. Fourteen patients with standard balloon technique and 11 patients with perfusion balloon technique were studied. The ST segment was less elevated during perfusion angioplasty (0.15 +/- 0.05 mV vs 1.04 +/- 0.19 mV, p<0.001). There were six (43%) patients with ST-T alternans with standard balloon technique compared with none in the perfusion balloon group (p<0.001). In this study, the authors found that there was less ischemia, less ST segment elevation, and lack of ST-T alternans on the intracoronary electrocardiogram during perfusion balloon angioplasty. These findings support the postulate that a large amount of ischemic myocardium is a prerequisite for ST-T alternans.

Successful percutaneous balloon mitral valvuloplasty in a patient with left atrial thrombus--a case report.

Percutaneous balloon mitral valvuloplasty (PBMV) described by Inoue et al, is a safe FDA (Food and Drug Administration) approved procedure in patients with severe mitral stenosis. One of the contraindications of the procedure is presence of a left atrial thrombus; however, it has been reported that intense warfarin therapy may led to dissolution of the thrombus. The authors report a patient who was referred for PBMV and was found to have a left atrial thrombus. After intense warfarin therapy, successful PBMV was undertaken without complications.

New hemoglobin substitutes.

Blood transfusion is an essential and ubiquitous component of medical therapy. Despite careful screening and processing, allogeneic blood still carries a small but definable risk of the transmission of severe viral disease and the induction of immunological reactions. The logistics of its storage and transport continue to present a challenge, and its dependence on human donors will always keep it a scarce resource. It is not surprising that in the latter half of the 20th century efforts to develop blood substitutes have gained increasing momentum.

Pulsus alternans in diastolic left ventricular dysfunction--a case report.

Pulsus alternans is usually found in patients with reduced systolic ventricular function. We describe a patient with recurrent pulmonary edema, hypertension, bilateral renal artery stenosis, but with normal systolic function. Pulsus alternans was demonstrated in both pulmonary artery, right ventricle, and left ventricle pressures. After successful renal artery revascularization, the pulsus alternans disappeared. This case illustrates that pulsus alternans can be present with diastolic dysfunction of the left ventricle in the absence of systolic dysfunction.

Cardiac catheterization and selective coronary angiography with tortuous aorta and anomalous coronary artery.

The authors report a case of selective coronary angiography by use of a modified technique in a patient with tortuous iliac artery, distorted thoracic descending aorta, and anomalous left coronary artery. This approach to such anatomy can decrease the fluoroscopy time and reduce the likelihood of complications.

Combined dissection of the right coronary artery and right coronary cusp during coronary angiography.

Dissection of coronary arteries during diagnostic coronary angiography is infrequent; dissection of the coronary cusp is extremely rare. The combination of coronary artery and coronary cusp dissection has not been reported previously. A case of right coronary artery dissection and right coronary cusp dissection during diagnostic coronary angiography is described.

Pseudo-alternans of left ventricular end diastolic pressure. A case report.

The authors report a case of left ventricular end diastolic pressure alternans without systolic alternans in a patient with bradycardia and tachypnea. This is an artifact due to the heart rate falling in a 2:1 ratio to the respiratory cycle. Alternation of left ventricular end diastolic pressure should be interpreted carefully in patients with bradycardia.

Intracoronary ST-T alternans during coronary balloon angioplasty.

To evaluate the presence and clinical significance of electrical alternans during PTCA, intracoronary electrocardiography (ic-ECG) was performed in 65 consecutive lesions. ST-T alternans, defined as a beat-to-beat difference in the ST elevation > or = 1 mm, was present in five lesions (7.7%), all in the proximal left anterior descending (LAD) coronary artery. The phenomenon was seen only after 130 sec (mean 174 +/- 57) of balloon inflation. Only two of the five showed ST-T alternans simultaneously on both surface and ic-ECG. One of five patients had premature ventricular contractions following ST-T alternans. Three of these five lesions required a second balloon inflation with duration of > or = 300 sec; there was no ST-T alternans on the second inflation in any of these lesions. We conclude: (1) the detection of ST-T alternans during PTCA is enhanced by use of ic-ECG, (2) electrical alternans during PTCA was seen only in proximal LAD lesions, implicating a large amount of ischemic myocardium as a requisite for the phenomenon, (3) electrical alternans is not immediate, requiring a certain duration of balloon occlusion and hence ischemia to occur, and (4) the absence of ST-T alternans during second balloon inflations suggests ischemic preconditioning may abolish this phenomenon.

Coronary artery fistula coexisting with a ventricular septal defect due to a penetrating gunshot wound.

We describe a patient who survived a penetrating gunshot wound to the chest. Cardiac evaluation including echocardiography and cardiac catheterization revealed a coronary artery fistula and a ventricular septal defect. This combination has been rarely reported in patients with penetrating cardiac injury. Follow-up echocardiography performed 15 mo later showed persistent left-to-right shunt. This is the first case in the literature demonstrating the natural history of combined coronary artery fistula and ventricular septal defect without surgical correction.

Cardiac disease and nonorganic chest pain: factors leading to disability.

Research has shown that many chest pain patients, without coronary artery disease, may suffer from panic disorder, hypochondriasis, depression, and/or multiple phobias. Some patients with coronary artery disease may also suffer from these disorders and are often unable to return to previous activity. In spite of good prognosis for longevity and acceptable exercise test results, a large proportion of these patients continue to be disabled by chest pain and/or chronic cardiac fears and demand constant medical attention. This study examined the psychiatric and behavioral symptomatology that differentiated four groups of patients experiencing chest pain: the able (active/working patient) with and without coronary artery disease, as determined by exercise thallium-201 studies, and the disabled (inactive/nonworking patient) with and without coronary artery disease. The results of the study indicated that the inactive patients, both with and without heart disease, suffered from a host of debilitating psychiatric conditions.

Anomalous origin of the right coronary artery above the left posterior sinus of Valsalva associated with a normal aortic valve. A case history.

This case report describes a right coronary artery arising from the ascending aorta, above the left posterior sinus. Unlike previously reported cases, this was associated with a normal aortic valve. The clinical significance and approach during angiography are discussed.