Cardiovascular Diseases & Diagnosis

We report a case of rescue thrombolysis followed by salvage percutaneous coronary intervention (PCI) for the treatment of inferior ST elevation myocardial infarction (STEMI) combined with cardiogenic shock in a patient with an anomalous right coronary artery (RCA) origin. When it is not feasible to perform primary PCI due to the anomalous origin of theRCA, rescue thrombolysis can be an optional treatment strategy that may allow sufficient time to perform facilitated PCI in a STEMI patient with hemodynamic instability.

Despite more than 30 years of experience with coronary artery bypass grafting (CABG), controversy still exists on the optimal timing of surgical revascularization after acute myocardial infarction (AMI). Systemic fibrinolytic treatment and primary percutaneous coronary intervention (PCI) are both effective and represent the first-choice treatment for acute ST-segment elevation myocardial infarction (STEMI), although several randomized studies have shown that primary PCI is superior to thrombolytic therapy achieving early reperfusion and reducing mortality. In the last 2 decades, CABG during AMI was performed only in patients with mechanical complications or refractory cardiogenic shock (high mortality and morbidity rates). Emergency CABG in patients with STEMI is still associated with high mortality and morbidity, and the early outcome is poor compared with the outcome in patients with stable angina. Furthermore, it may be advisable to delay surgery whenever possible. However, in patients with STEMI, early surgery (within the first hours) is indicated. Current indications for emergency CABG in patients with STEMI are limited to those presenting with evolving myocardial ischemia refractory to optimal medical therapy, presence of left main stenosis or 3-vessel disease, ongoing ischemia despite successful or failed PCI, complicated PCI, or cardiogenic shock accompanied by complex coronary anatomy.

Operative mortality for these patients using conventional OPCABG (On-pump coronary artery bypass grafting) is from 1.6% to 32% and strongly depends on the preoperative hemodynamic condition. The use of off-pump strategies for CABG is being still debated at present. Several retrospective studies have suggested the benefits of off-pump surgery in terms of in-hospital mortality and postoperative outcomes. This chapter focuses on the impact of off-pump surgery in patients with STEMI who undergo urgent CABG.

Introduction: The subclavian venous approach is a widely used method for venous access in device implantation and is associated with pneumothorax as a short term complication and lead fracture as a long term complication. The axillary vein approach is an alternate method for venous access, and this study evaluates the successfulness and immediate complications of fluoroscopy-guided axillary vein puncture compared to other venous approach methods.

Methods: This is a retrospective observational study on all patients who underwent pacemaker, defibrillator implant or lead change over 23 months. The fluoroscopy-guided modified Seldinger technique was used for axillary vein puncture and if failed, venography was performed.

Results: Out of 261 device implants or lead changes, 210 patients underwent fluoroscopy-guided axillary vein puncture. The mean age of the patients was 65.43 ± 15.7 years; 96.1% were African American; 57.6% were males. In 194 (92.3%) patients left or right axillary vein approaches were successful by either fluoroscopy or venography guidance. When anatomical abnormalities were excluded the success rate for axillary vein puncture was 97% and for fluoroscopy-guided axillary vein puncture was 94.5 %. Multiple leads were placed without any resistance and none of the patients had pneumothorax, hemothorax or hematoma as immediate complications.

Conclusion: Based on this first study conducted in a relatively large consecutive United Sates patient population, we report that fluoroscopy-guided axillary vein puncture using the first rib as a landmark, is a safe and effective method for device implantation with single or multiple leads, without patients getting exposed to intravenous contrasts.

Introduction: Cardiac Resynchronization Therapy (CRT) improves hemodynamics, symptoms, and overall mortality in patients with advanced heart failure (HF) and ventricular electrical dyssynchrony (QRS duration >120 msec). Previous studies have shown that mechanical dyssynchrony (MD) may be present in up to 45% of patients with advanced HF and QRS duration <120 ms at rest. We determined whether activity induces MD in patients with QRS duration <120 msec.

Methods: A total of 47 consecutive patients with left ventricular ejection fraction (LVEF) ≤ 30%, New York Heart Association (NYHA) class II-IV HF, and a QRS complex <120 ms were evaluated for MD at rest and exercise utilizing a modified Bruce protocol and three dimensional echocardiography. Time to peak systolic velocity was measured via Tissue Doppler and MD was defined as a time delay of >65 msec from peak systolic activation of the septal wall to the lateral wall of the left ventricle. Minnesota living with heart failure questionnaire (MLWHFq), EF and NYHA class were assessed to determine risk factors for exercise induced MD.

Results: Of the 47 patients, MD occurred in 11 patients (23%) at rest and 5 patients (13%) at exercise. The mean time to peak systolic velocity in the rest and exercise dyssynchrony groups was 105 ± 32 msec and 124 ± 29 msec respectively, compared with 45 +/- 15 msec in patients not experiencing dyssynchrony. No patients experienced electrical dyssynchrony with activity. EF, NYHA class or MLWHF questionnaire were not predictive.

Conclusion: MD with activity is not uncommon in patients with HF and a narrow QRS. MD should consider including patients with exercise induced MD as this population otherwise may go ignored. Additionally, patients with pre-existing electrical dyssynchrony who develop MD with exercise may benefit from optimization of their device settings to meet the potential hemodynamic challenge rendered by increased physical activity and heart rate.

We report a case of a ruptured proximal aortic dissection with cardiac tamponade, which masqueraded as myocardial rupture or cardiorrhexis. An 84-year-old female had sudden onset of chest pain with loss of consciousness and a mechanical fall. Echocardiography demonstrated pericardial effusion with hematoma overlying the apical-lateral wall and an echo free space suggestive of contained, ventricular free-wall rupture. However, intravenous injection of ultrasound contrast agent revealed no flow into the pericardial space excluding cardiorrhexis. Refractory hemodynamic compromise required an emergency pericardial window, but the patient remained unstable. Surgical exploration revealed a Debakey Type-A aortic dissection with communication into the pericardial space. To our knowledge, this is the first description of the use of ultrasound contrast microbubbles as a diagnostic strategy to exclude cardiorrhexis. The impact of tamponade treatment as the result of aortic dissections and the diagnostic challenge in differentiating it from other catastrophic causes of tamponade are reviewed.

Background/Aims: Cytostatics and human antibodies are successfully being used to treat oncological diseases. Despite the beneficial effects of these potent drugs, cardiotoxicity represents one of the most relevant side effects and limits their usage. It is very important to detect cardiotoxicity at an early stage particular in patients under curative chemotherapy to avoid long-term side effects and impairment of quality of life. The aim of this prospective study was to investigate the value of natriuretic peptides and troponin for early detection of cardiotoxicity.

Patients and Methods: In this single-center study, 99 cancer patients under treatment with anthracyclines, taxanes, and/or trastuzumab were prospectively included. Clinical examination, echocardiography, and blood sampling (brain natriuretic peptide (BNP), N-terminal-proBNP, and troponin I) were performed at baseline and at 3 and 12 months, respectively. Cardiotoxicity was defined as clinical or echocardiographic signs of heart failure as defined by an increment in New York Heart Association (NYHA) class by more than one and a decline in left ventricular ejection fraction (LVEF) depending on baseline situation. 

Results: During the 12-month follow-up, 27 patients presented with at least one predefined endpoint. Neither BNP, nor NT-proBNP, nor troponin I was related to the incidence of cardiotoxicity as defined by the combined endpoint. In post-hoc analysis a significant association between an increasing NYHA stage and a decrease in LVEF was found (negative predictive value of 91%). 

Conclusion: The occurrence of cardiotoxicity could not be detected either by natriuretic peptides or troponin. However, we hypothesize that an increase of more than one NYHA stage as a marker for dyspnea may be an indicator of cardiotoxicity.

Background: The relationship between periodontopathic bacteria and cardiovascular disease has been shown in many studies. Additionally, it has been reported that the plasma antibody titer for periodontopathic bacteria is associated with the occurrence of coronary disease. In this study, we randomly evaluated the relation between the plasma antibody titer for periodontopathic bacteria and the existence of vascular diseases such as hypertension, stroke, and ischemic heart disease (IHD) in patients of the emergency room. 

Methods: Sixty patients who had medical examination in the emergency department of our hospital from January to December 2009 were randomly and inconsecutively included. We measured the levels of immunoglobulin (Ig) G antibodies against Porphyromonas gingivalis (P. g.), Aggregatibacter actinomycetemcomitans (A. a.), Prevotella intermedia (P. i.), and Eikenella corrodens (E. c.) in patients’ blood. Patients were divided into two groups; the positive group (even if one IgG antibody was significantly positive among four antibodies) and the negative group (negative for IgG antibody). The percentage of patients with vascular diseases (hypertension, stroke and IHD) was compared between the two groups.

Results: Vascular diseases found were as follows; hypertension (n=11), stroke (n=8), and ischemic heart disease (n=5). There were 26 patients in the positive group and 34 patients in the negative group. The mean of age and the serum total protein in the positive group was significantly (p>0.05) higher than in the negative group. The presence of vascular diseases excluding stroke was higher in the positive group, and hypertension and IHD separately, and all vascular diseases together were independently associated with the presence of antibodies against periodontopathic bacteria.

Conclusions: The presence of IgG antibodies against periodontopathic bacteria is significantly associated with the presence of vascular diseases. These results suggest that the evaluation of IgG antibodies for periodontopathic bacteria is useful for prediction of the presence of vascular disease.