Direct stenting in angiographically apparent thrombus-containing lesions.

The data regarding the potential benefits of direct stenting in the setting of angiographically apparent thrombus-containing lesions are scarce. The aim of this study was to evaluate the impact of direct stenting on the angiographic results in the setting of thrombus. We reviewed our institutional interventional database and identified 30 patients who had undergone stenting in the setting of angiographically apparent thrombus-containing lesions (33% unstable angina pectoris, 67% acute myocardial infarction). The majority of patients had a baseline TIMI 2 and 3 flow (80%). Of the 6 patients (20%) who had TIMI 0-1 flow at baseline, four of them achieved a TIMI 2 flow immediately after crossing the lesion with a 0.014 guidewire. Although the remaining 2 patients had TIMI 1 flow, as distal opacification beyond the stenosis was obtained we successfully implanted the stents directly. All stents were successfully implanted without any crossing failure or stent loss. There was no "no re-flow", with a final TIMI 3 flow rate in 93%. In 1 patient with TIMI 2 flow after stenting, TIMI 3 flow was obtained after intracoronary verapamil. In 2 patients (7%, TIMI 2 flow), a final TIMI 3 flow could not be achieved despite intracoronary nitroglycerin and verapamil. There was no stent loss and imprecise stent placement. There were no in-hospital deaths, repeat interventions or coronary artery bypass graft surgeries. However, two patients had undergone mitral valve replacement due to severe mitral regurgitation. Eight patients with recurrent ischemia had control angiography; stents were found to be patent in all 8 patients. Two patients experienced recurrent myocardial infarction (6.6%). Direct stenting strategy in thrombus-containing lesions seems to be a safe and feasible approach in avoiding no re-flow. We believe that benefits observed with direct stenting in this study should be compared to conventional stenting in the same setting with a randomized study.

Stenting of the septal perforator coronary artery.

This report describes the first application of intracoronary stenting to the septal perforator coronary artery in a patient with a totally occluded left anterior descending coronary artery (LAD) and a patent venous graft to the distal LAD. The procedure was successful and resulted in almost complete relief of class III angina. Therefore, diseased large septal perforators may cause angina and be treated effectively by intracoronary stenting in selected cases.

Adjunctive therapies in the cath lab. Subacute stent thrombosis developing twelve days after discontinuation of ticlopidine treatment.

The two structurally related thienopyridines, ticlopidine and clopidogrel in addition to aspirin, have become the standard regimen for prevention of subacute thrombosis (SAT) after coronary stent implantation. Although both regimens are highly effective, ticlopidine suffers from severe hematologic side effects. Recent trials encourage shorter duration of therapy with these agents. However, the optimal duration of antiplatelet therapy after stenting is still not clear. We report a case of SAT developing 12 days after discontinuation of 2 weeks of aspirin plus ticlopidine therapy. We believe that the present data are still not clear regarding the optimum duration of antiplatelet therapy after stenting.

Adjunctive therapies in the cath lab. Intracoronary tirofiban infusion in a case with massive intracoronary thrombus.

By inhibiting platelet aggregation, glycoprotein IIb/IIIa inhibitors prevent arterial occlusion and reduce ischemic complications in the setting of acute ischemic coronary syndromes associated with intracoronary thrombus. There are also accumulating data in the literature regarding the local use of these agents for thrombus dissolution. We report a case with massive right coronary artery thrombus in which the thrombus was successfully dissolved with intracoronary tirofiban infusion. To the best of our knowledge, this is the first case of this kind.

Coronary artery to left ventricular fistula: case report and review of the literature.

In this report, an unusual case with a multiple plexiform type of coronary artery-to-left ventricular fistula and coexisting atherosclerotic involvement of the contralateral coronary artery is described and the pertinent literature is reviewed briefly.

Primary angioplasty and stenting in a patient with primary antiphospholipid syndrome and thrombocytopenia.

Antiphospholipid syndrome is characterized by venous and arterial thrombosis, thrombocytopenia, stroke and, rarely, acute coronary syndromes. However, there are no data available regarding the management of acute myocardial infarction in primary antiphospholipid syndrome with accompanying severe thrombocytopenia and cardiogenic shock. We describe such a case, which was managed by successful primary percutaneous transluminal coronary angioplasty and stent implantation with accompanying immunosuppression therapy.

Alterations in cardiac flow parameters in patients with polycystic ovarian syndrome.

The aim of this study was to examine the echocardiographic profiles of patients with polycystic ovarian syndrome (PCOS). Serum concentrations of follicle stimulating hormone, luteinizing hormone, androstenedione, free testosterone, prolactin, DHEA-SO(4) and 17-OH-progesterone, lipid profile (high and low density lipoproteins, triglyceride and total cholesterol) and basal and total insulin after a glucose tolerance test were measured in 35 patients with PCOS and 35 healthy controls matched for body mass index. Doppler, two dimensional M mode echocardiography was performed for the following indices: isovolumetric relaxation time (IVRT), E wave duration time (EVT), A wave duration time (AVT), E wave deceleration time (DT), peak early diastolic flow velocity (PEV), peak late diastolic flow velocity (PAV), E wave velocity time integral (FVI-E), A wave velocity time integral (FVI-A), atrial filling fraction (AFF), ejection fraction (EF), pre-ejection time (PEP), ejection time (ET) and aortic flow velocity time integral (FVI). Androstenedione, free testosterone, low density lipoproteins and cholesterol concentrations were significantly higher in patients with PCOS. There was no difference in basal and total insulin concentrations. IVRT, AVT, FVI-A, AFF, and PEP were higher in patients with PCOS, while PEV, FVI-E, EF, ET, EVT and EVT/AVT were higher in the control group. There was a positive correlation between basal insulin values and IVRT, and between total insulin values and EF. These changes are consistent with a non-restrictive type of diastolic dysfunction and left ventricular stiffness. PCOS may lead to diastolic dysfunction via hyperinsulinaemia and male type dyslipidaemia.

Left atrial free floating thrombus. Diagnosis by two dimensional and M-mode echocardiography.

Left atrial thrombus, which is a frequent finding in patients with mitral valve disease, is generally attached to the atrial wall. Left atrial free-floating thrombus has rarely been reported. Since the risk of peripheral emboli is fairly high, patients with such a thrombus are candidates for emergency surgery. Our first case was a 45-year-old female with mitral stenosis and regurgitation. The typically appearing free floating thrombus with a diameter of 3.4 cm was detected by two-dimensional and M-mode echocardiography, and an appropriate surgical procedure was performed. The surgical findings were consistent with the echocardiographic findings. Our second case was a 59-year-old female. A free floating thrombus with a diameter of 2 cm was detected by echocardiography when this patient with mitral stenosis was hospitalized because of right hemiplegia and aphasia. The thrombus was extracted by an immediate surgical procedure. Transthoracic echocardiographic (TTE) study was definitely specific in both cases; no other study was thus required.

A case of pericardial lipoma diagnosed by noninvasive techniques.

Intracardiac lipomas that consist of mature fat cells with fibrous and myxoid tissues are regarded as rather rare lesions. The diagnosis may frequently be established during surgical intervention or at autopsy. The patient presented is a 23-year-old male who had had no complaints. The lesion had been incidentally detected on x ray examination which had revealed an enlarged heart shadow. His physical examination revealed no abnormality except displacement of the heart to the right and sinus tachycardia. A solid mass derived from the pericardium was observed on CT scans and echocardiography. On CT scans the mass exhibited a density consistent with a lipoma. The patient was operated on and the mass, which was encapsulated and 19 x 17 x 10 cm in size, was removed. Histopathological examination revealed a lipoma.

Subacute rupture of the free left ventricular wall following acute myocardial infarction. Successful surgery in a case.

Free left ventricular wall rupture following acute myocardial infarction usually results in cardiac tamponade and sudden death. Occasionally, the bleeding into the pericardial sac is arrested by the surrounding pericardial tissue causing formation of a pseudoaneurysm. The case herein reported presented with a refractory pericardial effusion 1 month after an anterior myocardial infarction. While echocardiography failed to reveal a pseudoaneurysm or to localize a rupture, cineventriculography disclosed the diagnosis of a minimal rupture of the left ventricular free wall. The patient was successfully treated by surgery.

Prevention by a carbacyclin analogue (ZK 36 374) of digoxin-induced ventricular extrasystoles in guinea-pig myocardium.

Intravenous infusion of ZK 36 374 to the anesthetized guinea-pig or addition of the compound to the perfusion medium of the isolated perfused guinea-pig heart prevented digoxin-induced ventricular premature beats without altering the prolongation of the P-R interval by the glycoside. The prevention by ZK 36 374 of the ventricular extrasystoles induced by digoxin was obtained at lower concentrations while higher doses of the compound produced a dysrhythmic effect which terminated within a few min after the cessation of drug application.