Recurrent In-stent Restenosis in the Area of Previous Stent Fracture: A Management Dilemma.

Drug eluting stents (DES) have been increasingly being used for treatment of coronary artery disease (CAD) and have been shown to be very effective in prevention of primary in-stent restenosis (ISR). However DES have been increasingly associated with acute to subacute risk of stent fractures (SF). There is also a paucity of data about different management strategies for SF, especially in the long term. We present a case of recurrent ISR in an area of previous acute SF at the touchdown of saphenous venous graft (SVG) to first diagonal artery (D1). In our knowledge this is the first case reported of recurrent ISR due to prior acute stent fracture in a saphenous venous graft. It presents an interesting management dilemma with multiple layers of stent in the area of recurrent ISR which was managed with balloon angioplasty with good results.

Successful Resolution of a Large Left Ventricular Thrombus with Rivaroxaban Therapy after Acute Myocardial Infarction.

Left ventricular (LV) thrombus is a major complication of acute systolic cardiomyopathy especially after a large anterior myocardial infarction (AMI), and it poses a significant embolic risk, up to five times higher than the general population. Current guidelines for LV thrombi recommend vitamin K antagonist for anticoagulation in contrast to novel oral anticoagulants (NOACs) which have not been studied well in cases of LV thrombus. We present a case of patient with AMI, who was noted to have severe systolic dysfunction and a large LV thrombus which was successfully treated with rivaroxaban therapy with complete resolution of LV thrombus on two months follow-up.

Paclitaxel Induced MDS and AML: A Case Report and Literature Review.

Therapy related acute myelogenous leukemia (AML) and myelodysplastic syndromes (MDS) have been classically linked to alkylating agents and topoisomerase inhibitors. They constitute about 1% of all AMLs. There is less evidence on association of taxanes (paclitaxel and docetaxel) with these myeloid neoplasms. We present a case of paclitaxel therapy related acute myelogenous leukemia after treatment of endometrial cancer with a regimen containing paclitaxel and carboplatin. A 63-year-old female underwent surgery followed by a total of 6 cycles of chemotherapy with carboplatin and paclitaxel. Six months after last cycle of chemotherapy, she was diagnosed with myelodysplastic syndrome with refractory anemia and excess blasts. Six weeks later, she had worsening anemia and thrombocytopenia which prompted a bone marrow biopsy which revealed acute myelomonocytic leukemia. A thorough literature review revealed 12 other case reports where taxanes have been implicated in the development of therapy related myeloid neoplasm. Based on the timeline of events in our patient, paclitaxel is the likely culprit in the pathogenesis of this myeloid neoplasm. This rare but significantly grave adverse effect should be kept in consideration when deciding on treatment options for gynecological malignancies.

Refractory ventricular fibrillation managed by coronary revascularisation performed during ongoing manual cardiac resuscitation lasting 1½ h.

Myocardial infarction is the most common cause of ventricular arrhythmias. Although there have been several improvements and refinements in coronary catheterisation with percutaneous intervention over the years, this intervention is still rarely considered during active ongoing resuscitation of patients, especially in cases of persistent ventricular arrhythmias. We present a case of refractory ventricular fibrillations due to in-stent thrombosis that was managed by emergent coronary angiogram and stent placement during ongoing cardiopulmonary resuscitation in a code that lasted about 1½ h. The patient subsequently made an excellent recovery and was discharged home 13 days later.