Non-invasive diagnosis of coronary-subclavian steal: role of the Doppler ultrasound.

Coronary subclavian steal syndrome (CSSS) is a well documented cause of graft function failure in patients after left internal mammary artery (LIMA)--left anterior descending (LAD) coronary artery grafting. We present a case of the CSSS in a patient with cardiac arrest due to ventricular fibrillation. To our knowledge such a case has not yet been described. Patient with a history of LIMA-LAD grafting, complaining only of a mild chronic exertional dyspnoea developed ventricular fibrillation while walking outdoor. After successful resuscitation, blood pressure difference between both arms and abnormal LIMA flow with systolic reversal flow on the Doppler ultrasonography were suggestive of CSSS. Angiography proved the left subclavian artery (LSA) occlusion and coronary angiography confirmed reversal flow in the LIMA graft. Successful percutaneous transluminal angioplasty of the LSA re-established normal LIMA flow and improved the left ventricular hypokinesis and systolic function.

[Late coronary stent thrombosis and clopidogrel]. / Pozdní trombóza koronárního stentu a kiopidogrel.

The existence of late coronary stent thrombosis is a topical issue in cardiology today. The synoptic article discusses current definition of the above phenomenon, its delimitation in time and actual incidence. Based on data from available observation and randomised studies, long-term safety of conventional bare metal and drug-eluting stents is evaluated, as well as the safety profile following implantation. The length of thienopyridin treatment after percutaneous coronary intervention (PCI) varies according to the type of stent used. While a conventional bare metal stent (BMS) implant provides long-term safety with one month treatment, the implantation of a drug-eluting stent (DES) should be complemented with a 12-month period of clopidogrel administration. This approach may be in the future influenced by further progress in drug-eluting stents development and by prospectively acquired information on long-term administration of clopidogrel to such patients.

[Double serious complication of the surgical treatment of a female patient with scoliosis (case report).]. / Dvojitá závazná komplikace pri operacním osetrení nemocné se skoliózou.

The authors present the case-history of a female patient who developed during operation of a thoracolumbal scoliotic curve haemorrhagic shock with circulatory arrest due to massive haemorrhage from the spongiosa. After more than six weeks after admission to hospital she developed tense hameothorax from the injured diaphragm caused by the edge of the osteomotized rib of the concavity. The condition was treated by leftesided posterolateral thoracotomy. The authors draw attention to some special features associated with treatment of deformities of the spine. Key words: cardiac arrest, late haemothorax.

[Selection of a compatible donor using the blood platelet aggregation technic]. / Výber kompatibilního dárce technikou agregace krevních desticek.

The authors assessed the test of platelet aggregation for the selection of a compatible donor. The test was compared with the hitherto used microlymphocytotoxic test. Consistent with data published abroad, the authors confirmed that the aggregation test improves the accuracy of selection of a suitable donor. The test can be performed in a shorter time than the microlymphocytotoxic test, this being important in particular in case of acute haemorrhage.

[Increase in troponin levels after coronary angioplasty (PTCA) in stable angina pectoris]. / Vzestup troponinu po koronární angioplastice (PTCA) pro stabilní anginu pectoris.

GOAL: To determine frequency of elevated troponin levels following PTCA in patients with stable angina pectoris. To identify risk factors related to troponin elevation. METHOD: Multicentric prospective study. Troponin I level (cTnI) was determined in a group of 261 patients treated for stable angina pectoris with coronary angioplasty (PTCA) 12 hours after the intervention. A group of patients with cTnI levels above the upper level of a normal range was compared to patients without troponin elevation. Clinical, angiography, and peri-procedural indicators were assessed and frequency of their incidence in both groups of patients was compared. RESULTS: Elevation of cTnI levels above the upper levels of the normal range was identified in 32 patients (12.3%). There were no differences in age, risk factors for ischemic heart disease (IHD), nor number of impaired coronary arteries between this group of patients and the rest of them. Associated antithrombotic treatment (acetylsalicylic acid + ticlopidine 87.5% vs. 86.9%, p = NS; low-molecular heparin for PTCA 46.9% vs. 57.2%, p = NS) was comparable in both groups. On angiography, according to ACC/AHA, lesions were worse in patients with elevated cTnI (2.73 vs. 2.33, p = 0.02). Troponin elevation was significantly more often connected with calcification of coronary arteries (37.5% vs. 17%, p = 0.03), with intracoronary thrombus on angiography (15.6% vs. 2.2%, p = 0.05), and with increased number of implanted stents (1.13 vs. 0.90, p = 0.03). Incidence of peri-procedural complications (temporarily occluded artery, arterial dissection type C and worse, forced administration of inhibitors GP IIb/IIIa) was comparable. Chest pain after PTCA was accompanied with consecutive elevation of cTnI in 40%, while in absence of chest pain cTnI was elevated only in 8% of patients. CONCLUSION: Elevation of troponin after PTCA in stable angina pectoris is significantly related to angiography findings in treated lesion. Elevation of cTnI is comparable both in use of unfractionated heparin during PTCA and in use of low-molecular heparin during PTCA. A combined antiaggregation treatment with acetyl salicylic acid (ASA) and ticlopidine did not lead to a lower incidence of cTnI elevation compared to treatment only with ASA. Heaviness in chest after PTCA has low positive and high negative predictive value for cTnI elevation.

[Percutaneous rescue transluminal coronary angioplasty]. / Záchranná (rescue) perkutánní transluminální koronární angioplastika.

Rescue angioplasty is an operation performed in the acute stage of myocardial infarction where systemic thrombolysis did not lead to opening of the artery. Investigations made in recent years indicate the benefit of rescue angioplasty only in those patients where the infarcted artery is patent several hours after evidence that thrombolysis failed. At the same time they provide evidence of the increasing safety and technical success of the operation. The authors present a brief review of the literature pertaining to the development of views, and emphasize the need of early and correct indication.

[Preparation of thrombocyte concentrates in the Travenol CS-3000 separator (factors affecting the thrombocyte yield and presence of leukocytes)]. / Príprava trombocytárních koncentrátu separátorem Travenol CS-3000 (faktory mající vliv na výtezek trombocytu a prímes leukocytu).

The authors made 184 thrombocytaphereses for the preparation of thrombocyte concentrates on a Travenol CS-3000 separator. They evaluate indicators on which the thrombocyte yield depends: it was found that the yield is higher in donors with a higher number of platelets and that it increases with the period of separation. The mean thrombocyte yield was 2.91 +/- 0.84 x 10(11). It corresponded to the average lower platelet number of donors--182 x 10(9)/L. In those donors where the number of platelets was higher than 180 x 10(9)/L, the yield was 3.21 x 10(9)/L. The undesirable presence of leucocytes (in 98% lymphocytes) increases in relation to the number of leucocytes in the donor and their decline after separation. It was lower in longer separations. The authors discuss the possibility to increase the thrombocyte yield without contamination with leucocytes.

[Primary PTCA in the treatment of acute myocardial infarct. Experience at the Faculty Hospital in Hradec Kralove]. / Primární PTCA v lécbe akutního infarktu myokardu. Zkusenosti ve FN Hradec Králové.

INTRODUCTION: Primary coronary angioplasty is at present a fully accepted and worldwide method of treatment of acute myocardial infarction. As proved by a number of randomized studies, this treatment is associated with a higher rate of coronary patency, a smaller infarction focus an better clinical results as compared with thrombolytic treatment. METHOD: The authors analyzed a register of 233 consecutively treated patients with primary coronary angioplasty in the Faculty Hospital in Hradec Králové with elevation of the ST sections on electrocardiographic examination during the period from September 1997-January 2001. RESULTS: Acute success defined as a residual stenosis < 30%, normal flow through the vessel (TIMI III) and survival for the first 24 hours was 91.0% and without patients with cardiogenic shock even 96.0%. The total mortality on hospitalization was 9.1%. The mortality of patients without cardiogenic shock was only 1.9%. A high mortality was recorded in patients in cardiogenic shock (74.0%). A stent was implanted in 65.0% patients, subacute thrombosis of the stent occurred in 1.9%. During a 6-month follow up the total mortality was 10.3%. The percentage of patients without any cardiovascular even (event free survival, EFS) after discharge from hospital was 81.0%. CONCLUSIONS: The authors provided evidence that primary coronary angiolpasty is a safe and highly effective method in the treatment of acute myocardial infarction. It is associated with a total hospitalization mortality of ca 10% and a mortality of less than 2% in patients without cardiogenic shock. Cardiogenic shock, on the other hand, remains a problem despite intensive treatment such as inotropic support, mechanical reperfusion and intraortal balloon counterpulsation. In the presented work the mortality of patients with cardiogenic shock was 74.1%. Implantation of a stent does not involve a major risk for the patient, the incidence of subacute thrombosis of the stent is low and does not differ from elective procedures. The fate of patients during the follow up after primary angioplasty is favourable. In the presented work the total 6-month mortality was 10.3% and EFS was 81.0%.

Axillary-coronary artery bypass reconstruction as an alternative in coronary artery reoperations.

BACKGROUND AND AIMS: The increasing incidence of reoperations in coronary surgery associated with higher perioperative risks is a challenge for refinement of the surgical methods. The aim of the work is to prove the feasibility and satisfactory intermediate results of minimally invasive axillary-coronary artery bypass reconstruction in redo coronary surgery in case the left internal mammary artery had already been harvested. MATERIAL AND METHODS: Three patients (six months, two and six years after primary coronary artery bypass grafting) admitted for redo coronary surgery because of a recurrence of angina and proven malfunction of the left internal mammary artery-left anterior descending coronary artery anastomosis. An axillary-coronary venous graft was performed via left anterior small thoracotomy (LAST) on a beating heart in all three cases. RESULTS: Excellent patency of the graft was noted on control angiography within 9 days after the procedure together with good clinical improvement in midterm follow-up. CONCLUSION: Minimally invasive axillary-coronary artery bypass via LAST access in redo coronary surgery is a good alternative in cases where the left internal mammary artery cannot be used.

Paraplegia as an unusual manifestation of aortic coarctation.

In this report, we present an unusual case of a 20-year-old man whose first symptom of aortic coarctation was sudden paraplegia due to spinal epidural hemorrhage caused by rupture of an aneurysmal collateral vessel. Now, one year after surgical correction of coarctation, the patient has had no cardiac or neurological problems. To our knowledge, this is the only clearly documented case of such an aortic coarctation complication.