Hospital Chronicles (E-Journal)
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Dilated Right Ventricle with Impaired Systolic Function
Get PDFWe describe a 50-year old female admitted to our cardiac department with an episode of palpitations and associated dyspnea. She had never had any previous medical history. Physical examination revealed an irregular heart rate of 130 beats per minute, blood pressure of 122/70 mmHg and no pyrexia. Twelve–lead ECG demonstrated atrial fibrillation. Transthoracic echocardiogram showed a dilated right ventricle... (excerpt
Atrial Fibrillation: Obviating the Need for Anticoagulants With Percutaneous Closure of Left Atrial Appendage/ PLAATO & PROTECT-AF Trials
Get PDFLeft atrial appendage (LAA) occlusion is a potential alternative to warfarin in patients with atrial fibrillation who have contraindications to anticoagulation. Currently, there are two devices specifically designed for percutaneous LAA occlusion: the Percutaneous LAA Transcatheter Occlusion (PLAATO System, ev3 Inc., Plymouth, Minnesota) and the WATCHMAN LAA system (Atritech Inc., Plymouth, Minnesota). Despite early interesting and promising data from the PLAATO device, this device was withdrawn by the manufacturer in 2006. Early data on the WATCHMAN system were reported in 2007, and this device is the focus of the recently published PROTECT-AF (WATCHMAN Left Atrial Appendage System for Embolic Protection in Patients with Atrial Fibrillation) study. According to the results of the study, the efficacy of percutaneous closure of the LAA with this device was non-inferior to that of warfarin therapy, suggesting that closure of the LAA might provide an alternative strategy to chronic warfarin therapy for stroke prophylaxis in patients with non-valvular atrial fibrillation
Acute myocardial infarction presumambly embolic, in a patient with a mechanical aortic valve: a rare cause of non atherosclerotic coronary arterial occlusion
Get PDFAbstractWe present a case of an acute myocardial infarction with ST segment elevation in a patient with a mechanical aortic valve prosthesis who had discontinued anticoagulant therapy. We performed a primary coronary intervention procedure, including thrombus aspiration as well as plain balloon angioplasty (low atmospheres), in order to restore coronary flow in left anterior descending artery as soon as possible. Review of the literature suggests that in such cases the diagnosis of the embolic origin of the acute coronary syndrome is assumed and can never been proved definitely. Thrombus aspiration must be included in the therapeutic strategy of these patients.  
Advances in Post-Resuscitation Care: the Role of Therapeutic Hypothermia
Get PDFMild therapeutic hypothermia (32°C-34°C) is the only therapy that improved neurological outcome after cardiac arrest in randomized, controlled trials. It protects the brain after ischemia by reduction of brain metabolism, attenuation of reactive oxygen species formation, inhibition of excitatory amino acid release, attenuation of the immune response during reperfusion and inhibition of apoptosis. Its use is recommended by the American Heart Association and the International Liaison Committee on Resuscitation for unconscious adult patients with spontaneous circulation after out-of-hospital ventricular fibrillation cardiac arrest , 12 to 24 hours following resuscitation. The role of therapeutic hypothermia is uncertain when the initial cardiac rhythm is asystole or pulseless electrical activity, or when the cardiac arrest is primarily due to a noncardiac cause, such as asphyxia or drug overdose. Therefore, in patients with anoxic brain injury after nonventricular fibrillation cardiac arrest, clinicians will need to balance the possible benefit of therapeutic hypothermia with the possible side effects of this therapy. Mild hypothermia is a safe and effective therapy after cardiac arrest, even in hemodynamically compromised patients and in patients undergoing percutaneous coronary intervention. Because the induction of therapeutic hypothermia has become more feasible with the development of simple intravenous cooling techniques and specialized equipment for improved temperature control in the critical care unit, it is expected that therapeutic hypothermia will become more widely used in the management of anoxic neurological injury whatever the presenting cardiac rhythm. Potential side effects have to be kept in mind and treated accordingly
Subacute Stent Thrombosis in a Clopidogrel Resistant Octogenarian
Get PDFTel: 2610 999281, e-mail: [email protected]: An octogenarian on double clopidogrel maintenance dose (150 mg qd), due to clopidogrel resistance determined with a point-of-care assay, was subjected to percutaneous intervention (PCI) of the left anterior descending artery with two drug eluting stents. Twenty-four hours latter the patient sustained sub acute stent thrombosis manifesting as an anterior ST-elevation myocardial infarction with cardiogenic shock. Optical coherence tomography disclosed thrombus inside the stent without malapposition. Thrombus aspiration and balloon inflation of the thrombosed stent restored vessel patency. The issue of clopidogrel resistance and methods to overcome it are discussed
Routine Early Coronary Angioplasty After Thrombolysis
Get PDF Over the recent years it has become abundantly clear that reperfusion by primary angioplasty in patients with ST-elevation myocardial infarction (STEMI) is the treatment of choice. For hospitals that lack facilities for percutaneous coronary intervention (PCI), on site thrombolysis remains their first option, or alternatively patients can be transferred to other institutions for PCI, if this can be accomplished within a tight time frame. For the latter strategy, an organized network of centers is needed to rapidly and safely transfer STEMI patients for primary PCI. Thus, although transferring STEMI patients for primary PCI appears to be a superior reperfusion strategy compared with on-site fibrinolysis at a no-PCI capable hospital, time delays associated with transferring patients for PCI in routine clinical practice remains a major drawback of the whole concept. The tight time interval of 90-120 min needed to take full advantage of primary PCI, probably can be extended several hours, if an initial reperfusion treatment with thrombolysis is chosen, followed by routine angioplasty in the subsequent hours. At least these are the convincing results from recent trials published over the last three years, such as TRANSFER-AMI, FAST-MI, GRACIA-1 and GRACIA-2, WEST-MI, and CARESS-AMI. When used early after the onset of symptoms, a pharmacoinvasive strategy that combines thrombolysis with a liberal use of PCI yields early and 1-year survival rates that are comparable to those of primary PCI. Finally, when analyzed according to the timing of PCI after thrombolysis, mortality tended to be lower with increasing time from thrombolysis when PCI was performed on a systematic basis, whereas it tended to increase with increasing time from thrombolysis when PCI was performed as a rescue procedure. Sufficient time course (probably >2-3 hours to 6-12 hours), which neutralizes the pre-hemorrhagic effect of thrombolysis and allows the antiplatelet agents to act, is the key point for a better outcome when thrombolysis is combined with early angioplasty, and this appears to be a more effective and practical way to treat STEMI patients, at least for those hospitals, whereby immediate PCI is not available. Key Words: myocardial infarction; thrombolysis; reperfusion; coronary angioplast
Ticagrelor: a Novel P2Y12 Platelet Receptor Antagonist
Get PDFBlockade of platelet adenosine-diphosphate (ADP) receptors has been established as a key therapeutic strategy in cardiovascular disease. Among the thienopyridines, clopidogrel decreases ischemic outcome in patients who present with acute coronary syndromes and the more potent prasugrel has been demonstrated to be superior to clopidogrel in patients who are scheduled to undergo percutaneous coronary intervention. However, the antiplatelet potency is also associated with an increased risk of bleeding complications, and the irreversible ADP receptor antagonism has potential implications especially in the setting of coronary by-pass operation. Ticagrelor is a new reversible antagonist of the P2Y12 receptor, which seems to be more effective and at the same time equally safe to the so far established antiplatelet regimens. This article reviews the current data on this novel compound focusing on its advantageous pharmacology and the clinical results provided by the first phase IIb and III trials
Inordinately Sluggish Coronary Artery Flow in an Angiographically Normal Coronary Artery
Get PDFA 53-year-old male smoker, without any significant medical history was admitted via the emergency room to the cardiac care unit due to a single episode of unstable angina lasting for approximately 10 minutes. Over the last one year he admits to symptoms indicative of CCS class II effort angina. He had a positive exercise stress test a year earlier. On admission no ischemic ECG changes were noted. Cardiac enzymes were normal. Coronary angiography, performed the next day, revealed no significant atherosclerotic lesions, however an impressively sluggish flow was observed in the left anterior descending (LAD) coronary artery. The patient was discharged home the following day on full antianginal regimen, including aspirin, clopidogrel, nitrates, β-blocker and statin. At three months later the patient has remained free of symptoms
Pre-procedural Transesophageal Echocardiography Underestimates Atrial Septal Defect Size Compared to the Balloon Sizing Technique
Get PDFBackground: Secundum-type atrial septal defects (ASD) are increasingly being treated with percutaneous placement of occluding devices. Accurate sizing of the ASD is mandatory for subsequent optimal selection of the device. We sought to compare the two most commonly used methods, 2 – dimensional transesophageal echocardiography (2D-TEE) and stretched- balloon sizing . Methods: Sixteen patients (8 men and 8 women) aged 53.8±9.8 years with ASD were scheduled for implantation of an Amplatzer septal occluder device. The procedure was performed with the use of local only anesthesia via the right femoral vein with fluoroscopic guidance alone and without the intra-procedural use of 2D-TEE. The size of the defect was measured with 2D-TEE prior to the procedure. In the catheterization laboratory the ASD size was measured again with the insertion of a sizing ballon inflated with diluted contrast agent until a waist appeared. Waist dimensions were measured using cineangiographic quantitation (QCA) software. Results: All ASDs were successfully closed with Amplatzer occluders. A significant correlation was found between echocardiographic and fluoroscopic measurements of the ASD size (r=0.863, p=0.000). However, most of the echocardiographic measurements underestimated ASD diameters compared with conventional QCA balloon sizing by a mean of 3 mm (16.46±5.93 mm vs 19.83 ±6.3 mm, t= 4.18, p= 0.001). Conclusions: Atrial septal defects can be treated safely and effectively with the percutaneous placement of an Amplatzer septal occluder device via a simple percutaneous technique with use of local anesthesia and fluoroscopy alone without a need for intra-procedural 2D-TEE. Although the use of pre-procedural 2D-TEE has been a common practice for establishing the diagnosis and offering an initial assessment of the size of the defect, it largely underestimates the latter. The single-plane fluoroscopic balloon sizing performed during the procedure seems indispensable for choosing an occluding device of appropriate size.  
Successful Treatment of Lichen Striatus With Occlusive Imiquimod 5% Cream
Get PDFLichen striatus is an uncommon acquired linear inflammatory skin disorder, that preferentially occurs in children. We report a 15-year-old girl with a 16-month history of lichen striatus. Topical application of imiquimod 5% cream twice-daily under occlusion led to resolution of the intense pruritus within 6 days of treatment and to complete remission of the cutaneous lesions after 5 weeks of treatment. The patient experienced no local or systemic side effects. She has been followed-up for 13 months and revealed no evidence of recurrence. Topical imiquimod may be an effective and safe alternative treatment for recalcitrant lichen striatus