ECMO as a bridge to high-risk rotablation of heavily calcified coronary arteries.

Mechanical circulatory support (MCS) with short-term ventricular assist devices has been used as a bridge to high-risk percutaneous coronary interventions (PCI), as well as during interventions and in the post-procedural recovery period. Percutaneous extracorporeal membrane oxygenation (ECMO) is used when full cardiopulmonary support is necessary due to severe biventricular and pulmonary dysfunction. Prompted by two cases of high-risk rotablation of heavily calcified coronary arteries where ECMO was used as a bridge to intervention and post-intervention recovery, we reviewed the bibliography and the new guidelines on cardiac revascularization with regard to the utility of MCS devices in high-risk PCI cases.

Echocardiographic evidence of atrial myopathy in amyloidosis: a case report.

Cardiac involvement occurs in up to 50% of patients with primary amyloidosis. Diffuse amyloid deposits lead to impairment of myocardial systolic and diastolic function. Due to the severe left ventricular diastolic abnormality, left atrial contribution to left ventricular stroke volume remains critical. We report a case of primary amyloidosis where we assessed non-invasively left atrial systolic function.

Noninvasive indexes of left atrial diastolic function in hypertrophic cardiomyopathy.

OBJECTIVES: Our goal was to noninvasively assess left atrial diastolic function and its relation to the impaired left ventricular filling in patients with hypertrophic cardiomyopathy. METHODS AND RESULTS: We studied 34 patients with hypertrophic cardiomyopathy, 26 patients with secondary forms of left ventricular hypertrophy (aortic stenosis, fixed subaortic stenosis, hypertension), and 21 control subjects. Left atrial diastolic function was assessed by measuring acceleration time (SAT), deceleration time (SDT), and the EF (mean deceleration rate) slope of the pulmonary venous flow systolic wave (SW). Left ventricular diastolic function assessed by transmitral Doppler included peak early left ventricular and peak atrial filling velocities, the ratio of early-to-late peak velocities, isovolumic relaxation time, deceleration time, and EF slope. In patients with hypertrophic cardiomyopathy, acceleration time was significantly reduced (P<.05), deceleration time was significantly prolonged (P<.0001), and EF slope was significantly reduced (P<.01). These indexes were similar among the other two groups. No statistically significant difference existed between the subgroups of hypertrophic cardiomyopathy in the above indexes. Patients with hypertrophic cardiomyopathy and secondary forms of left ventricular hypertrophy had evidence of left ventricular diastolic dysfunction. In patients with hypertrophic cardiomyopathy, no correlation existed between left atrial and left ventricular diastolic function indexes (r = -0.26 to 0.33). CONCLUSIONS: Echocardiographic indexes of left atrial relaxation and filling are abnormal in patients with hypertrophic cardiomyopathy but not in secondary forms of left ventricular hypertrophy. These indexes are abnormal in all forms of hypertrophic cardiomyopathy irrespective of left ventricular outflow tract obstruction and distribution of hypertrophy; they are not solely attributable to left ventricular diastolic dysfunction. The above may imply that hypertrophic cardiomyopathy is a cardiac myopathic disease that involves the heart muscle as a whole, irrespective of distribution of hypertrophy and obstruction.

Incomplete ventricular septal rupture following blunt chest trauma.

Nonpenetrating cardiac trauma should be considered in the diagnosis of electrocardiographic changes after road traffic accidents. Transesophageal echocardiography is the most useful noninvasive technique for the diagnosis of cardiac trauma. This paper reports the case of a patient with traumatic contusion of the ventricular septum following a fall from a 20 m height onto the roof of a car.

Stenting of an anomalous left circumflex coronary artery arising from the right coronary artery.

Coronary angioplasty can provide excellent means of revascularization of anomalous coronary arteries. Successful application of angioplasty to these vessels requires angiographic knowledge of their course, structure and appropriate equipment selection. Advancement of stent delivery systems in such cases requires good support with the possibility of selective cannulation and deep engagement of the guiding catheter. We report a case of stent placement in an anomalous circumflex artery arising from the right coronary artery.

Constrictive pericarditis after coronary artery bypass surgery as a cause of unexplained dyspnea: a report of five cases.

Constrictive pericarditis after coronary artery bypass grafting (CABG) is rare and can present as unexplained dyspnea. We report five consecutive cases of post-CABG constrictive pericarditis seen within a period of 17 months at our institution. All patients presented with heart failure of unknown etiology within a period of 8-84 months after surgery. During the initial post-CABG period, two patients had developed postcardiotomy syndrome that was successfully treated with steroids. They were all assessed noninvasively and invasively. In all patients, the diagnosis of constriction was initially suspected clinically (symptoms, high jugular venous pressure with deep "X" and "Y" descents, pericardial knock). Echocardiography showed transmitral flow typical of constriction in all patients and hepatic venous flow in two. Two patients showed rapid left ventricular relaxation. In all patients, hemodynamic assessment showed diastolic equalization of pressures in all chambers, "W" shape waveform in right atrial pressure, and "dip and plateau" configuration in right and left ventricular pressure waveforms. Diagnosis was confirmed surgically in four patients who were subjected to pericardiectomy-pericardial stripping (three survived, one died). One patient refused surgery. We conclude that constrictive pericarditis, although rare, should be suspected in every case of unexplained dyspnea post CABG. It can appear early or late after surgery, and clinical examination plays an important role in its early recognition. It requires a full noninvasive and invasive assessment in case of clinical suspicion.

Complete left atrial obliteration due to localized tamponade after coronary artery perforation during PTCA.

Coronary artery perforation is a rare but important complication of percutaneous revascularization (PTCA). Clinical events following coronary perforation may include cardiac tamponade. After bypass graft operation (CABG), however, cardiac tamponade with subsequent hemodynamic instability is unusual due to the development of pericardial adhesions. We report an unusual case of localized tamponade after coronary artery perforation during PTCA in a patient with previous CABG.

Variable and circadian response to a fixed high-dose (12 500 IU twice daily) subcutaneous heparin regimen after thrombolytic therapy for acute myocardial infarction.

AIM: To determine the effect of a fixed high-dose (12 500 IU twice daily) subcutaneous heparin regimen on coagulation parameters after thrombolysis with streptokinase. BACKGROUND AND METHODS: A number of large thrombolytic trials have allocated patients to fixed high-dose (12 500 IU twice daily) subcutaneous heparin with no monitoring of coagulation parameters. We hypothesized that heparin's apparent lack of benefit and increased haemorrhagic complications in these trials may be the result of inappropriate anticoagulation. We therefore studied 11 patients who received intravenous streptokinase and oral aspirin for acute myocardial infarction and were subsequently started on the above heparin regimen. Blood samples were taken for activated partial thromboplastin time (APTT) and thrombin time before streptokinase and then immediately before and 6 h after each heparin injection on days 1,4, and 6, and 3 and 6 h after streptokinase on day 5. Plasma heparin levels were also measured on all post-streptokinase samples. Plasma fibrinogen was measured before the administration of streptokinase and once daily on the other sampling days. RESULTS: Both the median APTT and thrombin time were prolonged above the normal range throughout day 1, when fibrinogen levels were depressed, with a non-significant variation between the sampling points. By day 4, however, when fibrinogen levels had returned to pre-streptokinase levels, the median (range) APTTs at 8 a.m. and 8 p.m. (pre-heparin) were similar, and below the therapeutic range, at 52 (38-76) and 48 (39-79) s (NS). Six hours after each heparin injection the APTTs were elevated, but the median (range) 2 p.m. peak of 63 (46-138) s was lower than that at 2 a.m., 125 (58-178) s (P = 0.003). A similar peak and trough, and apparent circadian, APTT response pattern was seen on days 5 and 6. The thrombin time showed the same variation, which was also mirrored in the plasma heparin levels, although the circadian effect was not as marked. CONCLUSION: There is a marked individual variation in response to fixed-dose (12 500 IU twice daily) subcutaneous heparin, with many patients inadequately anticoagulated and an obvious circadian pattern of response. These findings have important implications when considering the benefits and haemorrhagic complications of subcutaneous heparin therapy in general and following thrombolysis in particular.

Tracker tricks: applications of a novel infusion catheter in coronary intervention.

The "Tracker" is a highly trackable and readily exchangeable catheter which can be used to facilitate coronary angioplasty in situations where the guide wire is unable to cross the lesion and is buckling under pressure. In addition it is also useful in assessing the severity of borderline coronary artery stenoses and for local infusion therapy.