Survival with good neurological outcome in a patient with prolonged ischemic cardiac arrest--utility of automated chest compression systems in the cardiac catheterization laboratory.

The management of refractory cardiac arrest during invasive coronary procedures has substantial logistical challenges and is typically associated with disappointing outcomes. We describe the case of a young woman with recalcitrant ventricular fibrillation due to acute anterior ST-elevation myocardial infarction caused by occlusion of her proximal left anterior descending artery. Survival without neurological deficit or organ failure was achieved following primary percutaneous reperfusion and a total of 52 min of intra-procedural chest compression support, made possible by the use of an automated chest compression device.

Guideline recommended door-to-balloon time can be achieved in transradial primary PCI--the usefulness of a dedicated radial guide catheter.

BACKGROUND: Radial access for primary percutaneous coronary intervention (PPCI) is well established in terms of safety and efficacy. However, there are limited data on the impact of the use of a single dedicated radial guide catheter in primary PCI using radial access. AIMS: To determine the overall cardiac catheterisation laboratory to balloon time (CCL2BT) and door to balloon (D2BT) time in transradial PPCI. To determine the impact of a single dedicated radial guide catheter on CCLD2BT and D2BT in transradial PPCI compared to conventional transfemoral PPCI. METHODS: The procedural and clinical outcomes of consecutive patients who had transradial primary PCI between 2005 and 2009 were included in this study and compared with a matched cohort who underwent transfemoral primary PCI. RESULTS: Overall D2BT and inpatient MACE were similar between the radial (n=53) and femoral (n=53) groups (85 and 82 min, P=0.889; 0% and 1.8% P=0.317 respectively). An increase in the CCL2BT and procedural times was noted in the radial compared to the femoral group (34 min versus 29 min P=0.028; 15.8 min versus 11.6 min P=0.001). When a single radial guide catheter was used for the entire procedure, there was no difference in CCL2BT, D2BT and procedural times between the radial and femoral groups (31 min versus 29 min P=0.599; 74 min versus 82 min P=0.418; 50 min versus 47 min P=0.086). CONCLUSION: The radial approach is safe and results in guideline recommended D2BT in STEMI. The use of a dedicated radial guide catheter reduces treatment time, demonstrating equivalent times to a femoral approach.

Drug-eluting stents for the treatment of acute myocardial infarction: the view to the HORIZONS.

Drug-eluting stents (DES) offer an attractive option for the treatment of acute thrombotic lesions during acute ST-elevation myocardial infarction (STEMI) due to their ability to inhibit restenosis. Several randomised trials have demonstrated the efficacy of DES in reducing target vessel revascularisation (TVR) in this setting. However, several registries of real-world patients receiving DES for STEMI have raised long-term safety concerns about DES use in this patient subset. Given the inherent limitations of registry data, this issue is likely to remain unresolved until further data is made available from large-scale ongoing trials with long-term follow-up such as the HORIZONS-AMI trial.

Simultaneous late stent thrombosis in two coronary arteries following drug-eluting stent implantation.

Late stent thrombosis has emerged as an infrequent but serious complication of drug-eluting stent (DES) implantation. Premature cessation of dual antiplatelet therapy is the most common risk factor for its occurrence. In the era of multivessel stenting with DES, there is a potential for multivessel late stent thrombosis following cessation of dual antiplatelet therapy. We present a rare case of a patient who sustained simultaneous late stent thromboses in DESs implanted in two coronary arteries as a result of premature cessation of dual antiplatelet therapy.

Transradial left main stem rotational artherectomy and stenting: case report and literature review.

Percutaneous coronary interventions (PCI) on complex unprotected left main stem (LMS) lesions involving rotational artherectomy are technically challenging and high risk cases. There is limited experience in performing these cases via a radial approach. We report a case of an unstable patient with severe distal LMS disease in whom cardiac surgery, intra-aortic balloon pumping and femoral approach were all contraindicated, who was successfully treated via a radial approach. We also review the technical challenges of LMS PCI through a radial approach.

Primary percutaneous coronary intervention for acute myocardial infarction caused by unprotected left main stem thrombosis.

BACKGROUND: There is a paucity of data on outcomes in patients undergoing percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI) caused by left main stem (LMS) thrombosis. OBJECTIVES: We sought to determine (i) the clinical features, (ii) correlates of early mortality, and (iii) long-term outcomes in contemporary patients undergoing primary PCI for unprotected LMS thrombosis. METHODS: From 1,115 consecutive primary PCI cases at two tertiary referral centers between January 2004 and September 2007, 28 cases (2.5%) with unprotected LMS culprit lesions were identified. Data were obtained from review of institutional databases, folder audit, telephone survey of patients, and independent review of angiograms. RESULTS: The mean age of patients was 68 +/- 14 years. Males comprised 76%, and 21% had diabetes. Significant morbidity was noted at presentation: shock in 18 (62%), pulmonary oedema in 15 (52%), and cardiac arrest in 10 (35%) patients, respectively. Lesion location was ostial in 7 (25%), body in 8 (29%), and distal in 13 (46%) patients, respectively. Angiographic success was achieved in 24 patients (83%). Stents were deployed in 27 patients (96%); drug-eluting stents in 11 patients (39%). No patient required in-hospital CABG. Cumulative in-hospital mortality was 36%. Univariate predictors of in-hospital mortality included shock, preceding cardiac arrest, and angiographic failure (all P < 0.05). At a mean follow-up of 26 +/- 12 months in hospital survivors, there were two TVR (elective CABGs), one death, and no reinfarctions. CONCLUSION: We report a lower than previously reported in-hospital mortality of 36% in contemporary patients undergoing primary PCI for unprotected LMS thrombosis. Long-term outcomes in hospital survivors appear favorable.

Transradial retrieval of a dislodged stent from the left main coronary artery.

We report a case of successful transradial retrieval of a dislodged and mechanically distorted coronary artery stent from the left main stem in an elderly male. Transradial percutaneous coronary intervention was undertaken to reconstruct a lesion in the left circumflex artery complicated by stent dislodgement. A microsnare was used to successfully retrieve the stent.

Fabry's disease presenting as ventricular tachycardia and left ventricular 'hypertrophy'.

Fabry's disease (FD) is a genetic disorder leading to deficiency of alpha-galactosidase A. Enzymatic replacement therapy has recently become available. Patients with classical FD develop multi-system involvement; however, there is an increasingly recognized cardiac variant that presents as unexplained left ventricular hypertrophy. We describe a patient with Fabry's disease who presented with ventricular tachycardia.

Campylobacter fetus infection of an internal cardioverter defibrillator.

Infection is a serious complication post implantation of an implantable cardiac defibrillator (ICD). We report a case of a 77-year-old man who had an ICD generator change complicated by a hematoma. The generator became infected at the time of Campylobacter fetus bacteremia. The ICD was removed and a new device was implanted without complication.

Acute ST elevation myocardial infarction with angiographically normal coronary arteries: causes and outcomes.

A minority of patients presenting with ST elevation myocardial infarction (STEMI) have angiographically normal coronary arteries. We aimed to assess its incidence, identify possible aetiologies and determine long-term prognosis. We retrospectively analysed 714 consecutive patients presenting with STEMI over a 10-year period (1995 to 2005), and identified 41 patients with angiographically normal coronary arteries. Mean age was 44+/-15 years; the majority were male. Specific diagnoses were made in 13/41 (32%) patients, including peri-myocarditis (11/41) and Takotsubo cardiomyopathy (2/41). No specific diagnosis was made in the remainder and these were considered cryptogenic AMI's. At a mean follow-up of 44+/-30 months, 1 patient with cryptogenic AMI had a non-cardiovascular death and 1 patient required pacing. In conclusion, there is a small but definite incidence of angiographically normal coronary arteries in patients presenting with STEMI. While the eventual aetiology remains uncertain in most patients, long-term outcomes appear favourable.

Sternal fracture and osteomyelitis: an unusual complication of a precordial thump.

Out of hospital cardiac arrest is generally managed by cardiopulmonary resuscitation (CPR) and defibrillation. The precordial thump can also be used in the initial management of witnessed cardiac arrest whilst awaiting direct current cardioversion. However, complications are associated with a precordial thump. We report a case of an out-of-hospital cardiac arrest due to ventricular fibrillation that was treated initially with a precordial thump, which resulted in a sternal fracture and the development of sternal osteomyelitis.

Closure of patent Potts shunt with aortic endoluminal stent graft.

Pulmonary hypertension secondary to residual Potts shunt is not an uncommon phenomenon. A 59-year-old male with a history of tetralogy of Fallot was noted, on a full heart study, to have persistent pulmonary hypertension, normal left ventricular function, severe aortic regurgitation, and a residual Potts shunt. A previous surgical attempt at closure of the shunt during definitive repair was unsuccessful. An aortic endoluminal stent graft was deployed to definitively close the shunt. There was a subsequent normalization of pulmonary pressures following Potts shunt closure. The patient will now proceed with surgical aortic root repair and aortic valve replacement.

Anomalous right coronary artery angioplasty complicated by intramural hematoma in the ascending aorta.

An iatrogenic intramural hematoma (IMH) localized in the ascending aorta is a rare and potentially life-threatening complication following percutaneous coronary intervention (PCI). We describe the case of an ascending aortic IMH after the PCI of an anomalous right coronary artery. Early extension of the hematoma was observed during transesophageal echocardiography; the patient underwent successful surgical repair.