Difficult management of coronary artery disease in a patient with thrombotic thrombocytopenic purpura

Thrombotic thrombocytopenic purpura [TTP] is a rare syndrome affecting multiple organs. There is no sufficient evidence regarding the clinical cardiac manifestations of TTP. Nonetheless, pathologic cardiac involvement is quite frequent in acute TTP, which is predominantly manifested as myocardial necrosis due to coronary arteriolar microthrombosis. The present case report describes a 43-year-old man with long-standing remitted TTP, who suffered from a sequence of refractory thrombotic epicardial coronary events. Aggressive medical and interventional therapies, including long-term dual antiplatelets and coronary angioplasty, were finally successful in remitting the thrombotic events. During his two-year follow up, he has been asymptomatic

Intracoronary adenosine to prevent myonecrosis in patients with stable angina undergoing percutaneous interventions: a double-blinded randomized controlled trial

Significant elevation of cardiac biomarkers after percutaneous coronary intervention [PCI] is associated with increased mortality. However, clinical importance of lesser degrees of cardiac enzyme elevation has not been well understood. Multiple factors might have an etiologic role, and the incidence of myonecrosis has not changed dramatically despite pharmacological and technological advances in PCI. The aim of this study was to evaluate the role of intracoronary [1C] Adenosine in preventing the elevation of cardiac enzymes as a marker of myonecrosis after PCI in patients with chronic stable angina. Two hundred sixty patients with chronic stable angina who were candidates for PCI were randomly assigned to double-blinded pretreatment with 1C Adenosine or placebo before crossing of the guide wire. The patients were observed during the hospital course, and blood samples were obtained in standard intervals after the intervention for cardiac biomarkers. The primary end point of this study was post-PCI myonecrosis, and secondary end point was safety of 1C Adenosine administration in the setting of PCI in patients with chronic stable angina. Of the 260 patients, who were initially randomized, finally 83 patients were analyzed in the placebo and 96 in the Adenosine arms. The study patients were comparable in clinical and angio graphic characteristics. The mean of the patients age was 57.3 years [range = 35 to 79 years], and 77.5% were male. There were no differences in the mean serum cardiac biomarkers between the study groups [mean creatine kinase-MB [CK.MB] level of 29.5 +/- 14.5 IU/L in the placebo group and 31.5 +/- 18.5 IU/L in the control group; p value = 0.41; mean cardiac troponin I [cTnI] level of 0. 097 _0.178 microg/L in the placebo group and 0.167 +/- 0.5 microg/L in the control group; p value = 0.24]. Despite promising results in primary PCI, our study showed that a strategy of 1C Adenosine pretreatment is not beneficial in reducing post-PCI myonecrosis in patients with chronic stable angina and should not be routinely used

Risk factors of reperfusion failure following primary angioplasty for ST-segment elevation myocardial infarction [STEMI]

Although percutaneous coronary intervention [PCI] improves outcomes compared to thrombolysis, a substantial number of ST-elevation myocardial infarction [STEMI] patients do not achieve optimal myocardial reperfusion. This study was designed to evaluate factors related to suboptimal myocardial reperfusion after primary PCI in patients with STEMI. Totally, 155 patients [124 men; mean age = 56.6 +/- 11.03 years, range = 31- 85 years] with STEMI undergoing primary PCI were retrospectively studied. Additionally, the relationships between the occurrence of reperfusion failure and variables such as age, sex, cardiac risk factors, family history, Body Mass Index, time of symptom onset, ejection fraction, previous PCI, coronary artery bypass graft surgery or previous myocardial infarction, and angiographic data were analyzed. Procedural success was 97.1% and complete ST resolution occurred in 43.2%. Age; cardiac risk factors; family history; body mass index; previous MI, coronary artery bypass graft surgery, or PCI; and use of thrombectomy device and GP2b/3a inhibitor were not the determining factors [p value > 0.05]. According to our multivariate analysis, time of symptom onset [OR [95% CI]: 045 [0.2 to 0.98]; p value = 0.044] and ejection fraction [OR [95% CI]:0.37 [0.26 to .091]; p value = 0.050] had reverse and male gender had direct significant associations with failed reperfusion [OR [95% CI]: 0.34 [0.11 to 1.08]; p value = 0.068]. More degrees of ST resolution occurred when the right coronary artery was the culprit vessel [p value = 0.001]. The presence of more than three cardiac risk factors was associated with failed reperfusion [p value = 0.050]. Considering the initial risk profile of patients with acute STEMI, including time of symptom onset and ejection fraction, as well as the accumulation of cardiac risk factors in a given patient, we could predict failed myocardial reperfusion to design a more aggressive therapeutic strategy

Percutaneous device closure for secundum-type atrial septal defect: short and intermediate-term results

Device closure of an isolated secundum type atrial septal defect [ASD] has been used as an alternative method for open surgical closure with comparable success and lower morbidity. In this study we evaluated the procedural success and mid-term follow-up results of percutaneous closure of secundum ASD with an Amplatzer TM Septal Occluder [ASO] device or a Figula ASD occluder device. From June 2001 to January 2009, 74 consecutive patients were scheduled for percutaneous device closure in two centers in Tehran, Iran. All patients had a stretched defect diameter of 30mm or less. After using a sizing balloon to measure the stop-flow diameter, device implantation was performed under the guidance of a trans-esophageal echocardiography [TEE].The size was generally 1 - 2 mm larger than the stretched diameter. Patients were followed for an average of 11 +/- 4 months. The median stretched diameter of the defect was 20.7 +/- 4.8 mm [range: 8 - 30 mm].A total of 73 devices were used in this study. Device closure was successful in 72 [97.2%] out of 74 patients. Repositioning of the device was required in one patient. Major complications [including significant residual shunt and device embolization] occurred in 3 [4%] patients. There was no procedure-related mortality in our patients. Mild-to-moderate residual shunt was detectable in 10 [13.7%] patients immediately following the procedure and in 5 [6.7%] patients 24 hours after the procedure. None had residual flow across the device at the end of the follow-up period. Device closure of ASD has a safety profile comparable to open surgical repair and can effectively close the defect with excellent procedural and mid-term results

Recognition of special form of amphetamine acquaintance in iran and presentation of 4 cases with neurovascular complication

Ecstasy and crystal are recently new most widely abused illegal drugs in Iran. Ecstasy/MDMA abuse may cause acute complications that have fatal consequences. Pt 1: A 26 year old who referred to emergency room due to acute paraplegia and finally died with cardiac arrest. Pt 2: A 45 year old woman who came with seizure disorder and unconsciousness. Finally she died due to cardiac arrest. Pt 3: A 32 year old man was admitted due to acute flaccid paraplegia. He had diffused skin rash due to vasculitis. The patient died despite of supportive cares. Pt 4: A 23 year old man who referred to neurological ward because of generalized tonic-clonic seizures following Crystal and Ecstasy abuse. The patient was discharged after 4 days with good general conditions. Unfortunately recently, the rate of Ecstasy and Crystal drugs abusers in Iran have increased. This paper notify about the neurological side effects of these drugs

Approach to the patient with combined coarctation of aorta and Wolf-Parkinson-White syndrome

At the present time the treatment of choice for postductal coarctation of aorta is percutaneous angioplasty and stenting. One crucial step for successful stenting of coarctation is accurate positioning of the stent across the lesion, which is difficult due to high pressure blood flow at the site of the coarct. To solve this problem, rapid pacing has been used to decrease cardiac output and blood pressure for a few seconds and prevent excessive motion of the stent during deployment. However, if coarctation is combined with pre-excitation syndrome, rapid atrial/ventricular pacing could cause life-threatening tachyarrhythmias. In this paper, we report a 28-year-old women with combined coarctation of aorta and Wolf-Parkinson-White syndrome who underwent radio frequency catheter ablation of the accessory pathway and then stenting angioplasty of the coarctation was performed without any complication