Urgent Cardiac Catheterization Research Articles

A novel concept in endovascular stenting for the treatment of old severely degenerated saphenous vein graft in the urgent setting

We report a critically ill-patient admitted for NSTEMI with acute pulmonary congestion, showing at urgent cardiac catheterization a severely diseased saphenous vein graft as the culprit vessel, with huge atherothrombotic burden. The graft was successfully revascularized by the implantation of 4 M-Guard stent (for proximal to distal) creating a full metal jacket. The M-Guard technology consists on a stainless steel platform wrapped by a micron-level polymer net, that seamlessly expands when the stent is deployed, providing protection from embolic showers.

An unusual case of spontaneous multi vessel coronary artery dissection in an elderly patient: a case report.

Spontaneous coronary artery dissection is an uncommon cause of acute coronary syndrome and sudden cardiac death. We report an unusual case of multi vessel spontaneous coronary artery dissection in an elderly woman with successful medical management. A 65 year-old woman with hypertension and Parkinson's disease presented with sudden onset severe chest pain. Electrocardiogram showed ischemic ST-segment elevation in inferior and lateral leads. Urgent cardiac catheterization revealed focal dissections in four small caliber coronary arteries in right and left coronary systems including right posterior decending, posterolateral, obtuse marginal and septal arteries. Angiography demonstrated no significant atherosclerotic coronary artery disease. The patient was medically managed with Eptifibatide, Aspirin, Clopidogrel and beta blocker since dissected vessels were not technically suitable for percutaneous coronary intervention. Antiparkinson medications were held as a potential cause of dissection. She responded well to medical management. Coronary dissection should be considered in all patients with an acute coronary syndrome. Medical management is an effective therapeutic option for the patient with small vessel dissections.

ST Elevation Myocardial Infarction With No Structural Lesions After a Wasp Sting

Background: Acute coronary syndromes after hymenoptera stings and other environmental exposures are referred to as the Kounis syndrome or allergic myocardial ischemia and infarction. Case Report: We report the case of a 58-year-old man with transient inferior ST-segment elevation consistent with myocardial ischemia after a single wasp sting. Urgent cardiac catheterization revealed normal coronary arteries with a normal left ventriculogram. The evaluation and treatment of cardiac ischemia associated with an allergic reaction is discussed. Conclusion: ST elevation myocardial infarction after wasp envenomation is an exceptional and interesting pathology with a partially elucidated pathogenesis. The management of cardiac ischemia in this setting is uncertain.

Preoperative management of hypoplastic left heart syndrome

Pediatricians are frequently involved in the care of cyanotic newborns in the labor and delivery room, as well as in the well baby nursery. Causes of hypoxia and cyanosis in the term newborn can be found within all physiological systems. Congenital heart structural diseases account for the largest diagnostic category. There have been significant advances during the past years in the diagnosis and treatment of neonates with critical congenital heart disease, especially in the field of pre- and post-operative intensive care. The term hypoplastic left heart syndrome (HLHS) describes a spectrum of cardiac structural abnormalities characterized by marked hypoplasia of the left ventricle and ascending aorta. Prenatal diagnosis, initial resuscitation and optimal preoperative management are key elements that allow the best opportunity for low mortality and normal neurodevelopment in affected newborns. Preoperatively, the goal is to achieve adequate systemic oxygen delivery. Patency of the ductus arteriosus (DA) is critical for survival until surgery. Blood flow to the pulmonary and systemic circulations should be nearly balanced (goal Q p /Q s ratio of 1). The immediate therapy for all infants with HLHS is an intravenous infusion of prostaglandin E 1 (PGE 1 ) in order to manipulate the DA and maintain ductal patency. Oxygen saturations of 75% to 85% by pulse oximetry suggest an adequate balance between systemic and pulmonary blood flow. Judicious use of inotropic support is initiated if evidence of low cardiac output is detected. Diuretics may be necessary to help alleviate the increased volume load on the right ventricle. The goal of respiratory management is to increase pulmonary vascular resistance and decrease systemic vascular resistance. Infants with HLHS who are born with a severely restricted or no inter-atrial communication, a rare occurrence, have profound hypoxemia. The severe restriction of blood flow across the atrial septum results in a life-threatening situation and these patients, which present with severe cyanosis and hemodynamic instability, require urgent postnatal cardiac catheterization to relieve the septal obstruction and improve oxygenation. Special attention should be paid to the prevention of brain injury and poor neurodevelopmental outcome. Care for infants with HLHS is complex, and often multiple specialists are involved. Despite an increase in the number of newborns with complex congenital heart disease and a growing percentage of patients with single-ventricle physiology, it is possible to care for this particular group of patients and achieve acceptable mortality risks, even in centres with no pediatric cardiac surgery facilities, if good preoperative management protocols are followed.

Dobutamine stress test and beta-agonist - a potential concern for nuclear cardiology testing: a case report

IntroductionChest pain with ST-segment elevation is a rare clinical problem during dobutamine stress testing. Although beta-agonists treatment prior to dobutamine stress testing has been shown to reduce the duration and amount of dobutamine infusion and atropine requirement, there is insufficient information about potential complications of this pharmacologic combination.Case presentationWe present a 67-year-old patient with dobutamine stress testing -induced chest pain and ST elevation who received albuterol for clinical treatment of bronchospastic disease prior to the test. She developed persistent chest pain and ST elevation despite medical management. Urgent cardiac catheterization showed no significant obstructive coronary artery disease. Thus coronary artery spasm was likely responsible for the chest pain and electrocardiogram abnormality in our patient as a result of β-agonist and dobutamine combination.ConclusionsBeta-agonists pre-treatment with dobutamine stress testing may induce coronary spasm in association with chest pain and ST elevation. Clinicians and nuclear cardiologist should be aware of this potential side effect of β-agonists treatment with dobutamine stress testing, particularly since dobutamine stress testing in nuclear cardiology is done in patient with chronic obstructive lung disease.

An unusual case of spontaneous multi vessel coronary artery dissection in an elderly patient: a case report

IntroductionSpontaneous coronary artery dissection is an uncommon cause of acute coronary syndrome and sudden cardiac death. We report an unusual case of multi vessel spontaneous coronary artery dissection in an elderly woman with successful medical management.Case presentationA 65 year-old woman with hypertension and Parkinson's disease presented with sudden onset severe chest pain. Electrocardiogram showed ischemic ST-segment elevation in inferior and lateral leads. Urgent cardiac catheterization revealed focal dissections in four small caliber coronary arteries in right and left coronary systems including right posterior decending, posterolateral, obtuse marginal and septal arteries. Angiography demonstrated no significant atherosclerotic coronary artery disease. The patient was medically managed with Eptifibatide, Aspirin, Clopidogrel and β blocker since dissected vessels were not technically suitable for percutaneous coronary intervention. Antiparkinson medications were held as a potential cause of dissection. She responded well to medical management.ConclusionCoronary dissection should be considered in all patients with an acute coronary syndrome. Medical management is an effective therapeutic option for the patient with small vessel dissections.

Unicuspid aortic valve: an interesting presentation

A 52-year-old male presented with acute onset chest pain and ST-segment elevation myocardial infarction (Panel A). An urgent cardiac catheterization was performed which showed a filling defect in the left anterior descending (LAD) artery (Panel B). After failure at attempts to reperfuse the LAD, the patient underwent emergent cardiopulmonary bypass surgery with a left internal mammary graft to LAD. He was found …

Pseudo-Wellens’ syndrome after crack cocaine use

A 41-year-old man without a history of coronary artery disease presented with cardiac chest pain 3 h in duration. The initial electrocardiogram (Figure 1) revealed T wave inversions in leads V1 to V4 without loss of R wave or ST segment changes. He admitted to crack cocaine use all day. The physical examination was within normal limits. His urine drug screen was positive for cocaine. Urgent cardiac catheterization revealed normal coronary arteries and an ejection fraction of 60%. Cardiac enzymes were negative. Twenty-four hours later, a repeat electrocardiogram (Figure 2) showed reversal of T wave inversions. It is important for cardiologists to keep in mind that Wellens’ syndrome can be mimicked by cocaine-induced vasospasm of the proximal left anterior descending artery, because administration of beta-blockers in such circumstances can prove to be disastrous. Figure 1) Initial electrocardiogram on presentation revealing T wave inversion in leads V1 to V4, called Wellens’ T waves, which signified cocaine-induced vasospasm of the left anterior descending artery Figure 2) Repeat electrocardiogram showing resolution of Wellens’ T waves, which signfied resolution of vasospasm

Cholesterol Emboli after Coronary Angioplasty

A 72-year-old man presented with unstable angina. An urgent cardiac catheterization showed clinically significant disease in the right coronary artery, which was stented. Twelve hours after the procedure, livedo reticularis developed on his legs and there was a bluish discoloration of his toes (Panels A and B). The evaluation was notable for an increase in his serum creatinine level from 1.5 mg per deciliter (135 μmol per liter) to 3.1 mg per deciliter (276 μmol per liter), eosinophilia of 7.4 percent, and a normal result on renal ultrasonography. A diagnosis of cholesterol emboli was made. The patient recovered uneventfully.

Management of Massive Pulmonary Embolism

A 63-year-old woman was transferred to Brigham and Women’s Hospital with massive saddle pulmonary embolism (PE) diagnosed by chest CT scan. She was being treated at a suburban hospital for ulcerative colitis manifested by 10 episodes of bloody diarrhea daily. The diagnosis of PE was suspected when she suffered sudden onset of syncope and hypotension, followed by arterial oxygen desaturation and tachycardia. Echocardiography showed an extremely dilated right ventricle with septal flattening. At Brigham and Women’s Hospital, she underwent urgent cardiac catheterization. The mixed venous oxygen saturation percentage was in the 50s. Manual injection of contrast agent into the main pulmonary artery confirmed massive bilateral PE. A Gunther Tulip (Cook, Inc) vena caval filter was placed just below the renal veins, and she was taken to the operating room, where she underwent successful emergency pulmonary embolectomy (Figure 1). Figure 1. This pulmonary embolectomy specimen measures 11×6×1.5 cm in aggregate. Massive PE is life-threatening. Some patients may present with abrupt onset of critical illness, and others may suffer stuttering but progressive clinical deterioration despite therapeutic levels of anticoagulation. In the International Cooperative Pulmonary Embolism Registry (ICOPER) of 2454 consecutive patients from 7 countries,1 4.2% had massive PE. In the United States, ≈150 000 patients per year are diagnosed with acute PE,2 resulting in thousands of recognized deaths annually from massive PE. Many additional deaths occur each year in the United States as a result of undiagnosed massive PE that is mistaken for acute myocardial infarction or ventricular arrhythmia. The principal criteria for categorizing PE as massive are arterial hypotension and cardiogenic shock. Arterial hypotension is defined as a systolic arterial pressure <90 mm Hg or a drop in systolic arterial pressure of at least 40 mm Hg for at least 15 minutes.3 Shock is manifested by tissue hypoperfusion …

“Tako‐Tsubo‐Like Left Ventricular Dysfuntion”: A clinical Entity Mimicking Acute Myocardial Infarction With a Favorable Prognosis

An emotionally-distressed, elderly Caucasian woman presented with chest pain and hypertension. Electrocardiogram showed inferior ST-segment elevation, and an urgent cardiac catheterization was performed. Coronary angiography revealed normal appearing coronary arteries; however, left ventriculography showed extensive left ventricular apical akinesis. The patient had a mild rise in cardiac enzyme levels indicative of myocardial injury. She was discharged after an uncomplicated in-hospital course. One month later, the left ventricular wall motion abnormality had improved. In this report, the authors discuss this compilation of findings known as tako-tsubo-like left ventricular dysfunction.

Thrombosis of a Coronary Artery Aneurysm in a Young Man Presenting With Acute Myocardial Infarction

A 27-year-old avid amateur basketball player was brought to the emergency room after suddenly collapsing at work. ECG showed ST-segment elevation in leads of the inferior-posterior wall. A transthoracic echocardiogram revealed severely diminished contraction of the left ventricle (25% ejection fraction) and a space-occupying lesion in the anterior atrioventricular groove. Urgent cardiac catheterization demonstrated an ectatic left anterior descending coronary …

MYOCARDIAL INFARCTION PRECIPITATED BY INFLIXIMAB INFUSION

Infliximab, a chimeric tumor necrosis factor antibody, is an established method of therapy for the treatment of patients with Crohn's disease. The widespread use of this medication has confirmed the safety profile reported in earlier trials. Myocardial ischemia has not been reported to be associated with the use of this medication. We report a case of a patient who developed myocardial ischemia and subsequent infarction while receiving an infusion of infliximab. A 63 year old woman diagnosed with Crohn's disease in early 2001 presented with a recurrence of disease. She had been treated with mesalamine in the past and had done well. Despite the use of high dose mesalamine, recurrent diarrhea developed requiring the use of Prednisone. A small bowel series showed significant inflammation of the distal ileum. In order to facilitate weaning from the Prednisone, an in-flixmab infusion was performed. Past medical history was remarkable for non-insulin dependent diabetes, goiter, osteoarthritis. The patients physical examination immediately prior to the infusion was unremarkable. She was premedicated with diphenhydramine. After receiving 50 ug of the infliximab infusion over 30 minutes, severe crushing substernal chest pain was described. There was associated shortness of breath and diaphoresis. Although a recent cardiac stress test had been performed which was normal, an ECG was performed. The ECG revealed ST segment elevations in left lateral leads. Aspirin was given. The patient was transferred to a tertiery care facility. Serum tropinin levels were elevated consistent with myocardial infarction. An urgent cardiac catheterization was performed. Cardiac catheterization revealed no obstructive lesions. There was a mid LAD lesion with a maximal occlusion of 50% of the lumen. Within 24 hours, repeat ECG demonstrated q waves in the left lateral leads confirming the diagnosis of myocardial infarction. Although this patient had risk factors for coronary artery disease, a recent stress test had been normal. The ischemic events leading to myocardial infarction developed at rest, during an infliximab infusion. This case represents the first case of infliximab precipitating a myocardial infarction.

Cunninghamella bertholletiae Endocarditis

Cunninghamella bertholletiae Endocarditis

Cardiogenic Shock: Single Center Experience with and without On-Site Catheterization Facilities

Background: The beneficial effect of on-site catheterization facilities on the survival of all patients with myocardial infarction complicated by cardiogenic shock has been questioned. Our objective was to evaluate the impact of the availability of on-site catheterization facilities on the outcome of unselected patients with cardiogenic shock. Methods and Results: We studied the hospital records of 70 consecutive patients with cardiogenic shock admitted to our intensive coronary care unit during 1990–1996, and compared two groups of patients: those admitted before (n = 34) and after (n = 36) the opening of our catheterization laboratory. Patients admitted when the catheterization laboratory was available were of similar age, but included fewer males and fewer patients with prior myocardial infarction. Following the activation of the catheterization laboratory, utilization rates of coronary angiography, percutaneous transluminal coronary angioplasty and intra-aortic balloon pump increased, compared with the previous period. However, there was no improvement in in-hospital (88 vs. 83%; p = 0.7) and 30-day mortality (91 vs. 86%; p = 0.7) before versus after the activation of our catheterization laboratory. Twelve patients selected to cardiac catheterization (9 underwent percutaneous transluminal coronary angioplasty) experienced lower in-hospital and 30-day mortality compared with patients who were not selected (58 vs. 96, and 67 vs. 96%, respectively; p < 0.02). Conclusions: Following the activation of the catheterization laboratory, the mortality of the entire population of cardiogenic shock patients remained relatively unchanged. Still, a small subgroup of these patients selected for urgent cardiac catheterization had a lower mortality compared with patients who were not selected.

Spinal Cord Stimulation for Intractable Angina Pectoris

Spinal Cord Stimulation for Intractable Angina Pectoris

Answer

The most likely answer in this case is D, but the correct answer is B. Because of diagnostic uncertainty, this man underwent urgent cardiac catheterization. Angiography revealed 80% occlusion of the left main coronary artery resulting from the false lumen created by an ascending aortic dissection. An immediate transesophageal echocardiogram showed mild aortic insufficiency, a left ventricular ejection fraction of 40%, and diffuse anterior hypokinesis. The patient underwent emergency surgery to repair both aortic dissection and the aortic valve, and to perform bypass grafting to the left main coronary artery.

Determinants of the need for early acute intervention in patients treated conservatively after thrombolytic therapy for acute myocardial infarction

This study sought to determine whether clinical variables can be used to identify patients at high risk of recurrent spontaneous myocardial ischemia or hemodynamic compromise during the 1st 4 days after intravenous thrombolysis for acute myocardial infarction. Of 288 patients randomly assigned to a conservative postthrombolysis strategy, 54 (19%) required urgent cardiac catheterization within 24 h; 75 (26%) underwent urgent cardiac catheterization within 4 days of admission. Of the clinical variables examined by multiple logistic regression analysis, only patient age and anterior wall myocardial infarction correlated with the need for urgent cardiac catheterization (p = 0.0016 and p = 0.017, respectively). Compared with recombinant tissue-type plasminogen activator or urokinase monotherapy, combination therapy with these agents was associated with a lower need for acute intervention during the 1st 24 h after admission, but the difference did not reach statistical significance (14% for combination therapy vs. 21 % for each agent alone, p = 0.30).Of the 75 patients undergoing urgent coronary angiography, only 39% had an occluded infarct-related artery. Emergency coronary angioplasty was performed in 49% of the patients and coronary artery bypass graft surgery was performed urgently in 3%. Despite these interventions, the need for urgent cardiac catheterization was associated with an in-hospital mortality rate of 7% (vs. 3% in the group not requiring urgent angiography, p = 0.36); mean left ventricular ejection fraction was 50.5 ± 11% (vs. 54.3 ± 10.8%, p = 0.12) and regional infarct zone wall motion was −2.68 ± 1.07 SD/chord (vs. −2.46 ± 1.19 SD/chord; p = 0.44).These data suggest that a relatively large proportion of patients treated conservatively after thrombolytic therapy require early triage to urgent coronary angiography; 2) baseline clinical characteristics are poorly predictive of the need for urgent intervention; and 3) despite ready access to facilities for aggressive intervention, the in-hospital clinical outcome of this group of patients appears to be poorer than that of patients without recurrent ischemia or hemodynamic instability.

Acute myocardial infarction associated with intravenous dipyridamole for rubidium‐82 pet imaging

This report describes the occurrence of chest pain and electrocardiographic features of acute myocardial infarction following intravenous dipyridamole-handgrip stress. Myocardial perfusion imaging (Rb-82 PET) demonstrated a stress-induced perfusion defect. Following failure to respond to medical therapy, urgent cardiac catheterization demonstrated total occlusion of the left anterior descending coronary artery. The vessel was revascularized, with limitation of myocardial damage evidenced by failure to develop anterior Q waves and only modest elevation of cardiac enzyme levels. Complications of intravenous dipyridamole stress are rare, this case constituting the first major problem in over 500 such procedures at this institution. However, this experience demonstrates the importance of vigilant observation during the performance of this technique.

Intermittent mitral regurgitation: an indicator of severe Beall valve dysfunction.

The Teflon disc of Beall valves is subject to extraordinary wear and tear. Clinical evidence of valvular dysfunction is critical in following patients who have implanted Beall valves. We describe 4 patients with the interesting auscultatory finding of intermittent mitral regurgitation. Each of these patients demonstrated severe wear of the Teflon disc with abnormal intermittent disc tilting noted at cardiac catheterization. Intermittent mitral regurgitation in patients with Beall valves in the mitral position heralds severe valvular dysfunction and should prompt urgent cardiac catheterization and valve replacement.