Rationale for Percutaneous Intervention of CTO.

Chronic total occlusion accounts for 15% of cases during diagnostic angiography with higher referral rate to surgical revascularization. With contemporary strategies and techniques, the success rate with experienced operators can exceed 90%. Currently available observational studies in carefully selected patient populations show evidence of a trend toward symptom relief; improvement in quality of life, left ventricular function, and mortality; and improved tolerance toward future ischemic events. Lack of randomized controlled trials comparing current optimal medical management with percutaneous coronary intervention for chronic total occlusion is a major barrier to widespread adaptation of this advanced complex interventional technique.

Barriers to surgery in severe aortic stenosis patients with Class I indications for aortic valve replacement.

BACKGROUND AND AIM OF THE STUDY: Despite a dismal natural history of severe aortic stenosis (AS) in patients with symptoms, there is a high non-surgical rate. The study aim was to analyze in detail the decision-making process for aortic valve replacement (AVR) that follows the diagnosis of severe AS with Class I indications, in order to identify the barriers to surgery. METHODS: A total of 187 consecutive patients (105 men, 82 women; mean age 74 +/- 14 years) with severe AS, defined as aortic valve area (AVA) <1.0 cm2, was evaluated. Detailed reviews were performed for patient symptoms, and actions by physicians. The sources and reasons for non-surgical management were analyzed. RESULTS: The mean AVA was 0.72 +/- 0.19 cm2 and the left ventricular ejection fraction 54 +/- 21%. A Class I indication for AVR was present in 174 patients (93%), of whom 125 (72%) were referred for AVR, which was performed in 93 cases (53%). The reasons for no AVR (n = 81) were patient refusal in 29 cases (36%), comorbidities in 28 (35%), while in 19 patients (23%) the AS was considered as 'not severe', despite being categorized as severe by ACC/AHA guidelines. The predominant factors in making the non-surgical decision were the patient or family (36%), the cardiologist (33%), and the surgeon (21%). CONCLUSION: Class I indications for AVR are present in most patients with severe AS referred for echocardiography to a tertiary care center. Despite a Class I indication, the non-surgical rate remains high and attributable to patient reluctance, comorbidities and physician reluctance to offer AVR. It is speculated that patient discussions of the dismal natural history of severe AS and the major benefit of AVR, preferably conducted within a specialized valve clinic set-up, may help to improve the surgical rates.

A rare case of amiodarone-induced hypothyroidism presenting with cardiac tamponade.

Subclinical pericardial effusions are common in patients with untreated hypothyroidism and usually resolve with thyroid replacement therapy, but cardiac tamponade is a rare presentation of prolonged untreated hypothyroidism. We report the first case of cardiac tamponade due to hypothyroidism produced by administration of amiodarone.