The drop that spilled the cup: acute myocardial infarction in a young woman with underlying thrombophilic polymorphisms and oral contraceptive use.

We present the case of a 28-year-old woman who was admitted to our cardiology unit for acute coronary syndrome. Her history was notable for cardiovascular disease familiarity, active smoking, and oral contraceptive use. On further analysis, she was noted to have thrombophilic polymorphisms involving the plasminogen activator inhibitor (PAI), angiotensin-converting enzyme (ACE), and methylenetetrahydrofolate reductase (MTHFR) genes. We discuss the implications that these cofactors may have had in the genesis of the disease.

Minimally invasive implantation of the myopore sutureless myocardial pacing lead.

Cardiac resynchronization therapy improves symptoms and survival of patients with congestive heart failure. Usually, the transvenous placement of the left ventricular lead is feasible, but in case of anatomic abnormalities of the coronary sinus, an unintended left phrenic nerve stimulation, a dislodgement of the percutaneous electrode, or a loss of capture of the electrode, surgical treatment should be considered. From January 2010 to September 2011, 15 patients underwent surgical implantation of the left ventricular lead after failure of transvenous placement. The MyoPore sutureless myocardial pacing lead (MSMPL) was implanted through a left minithoracotomy (~5 cm) under selective right lung ventilation. Time of surgery was 38.5 ± 3.0 minutes, and no surgical complications or early deaths are reported so far. After 10.7 ± 8.3 months of follow-up, no cases of late mortality, dislodgement, or loss of capture of the electrode are described. The use of the MSMPL is not novel, although the association with a minimally invasive approach may represent an alternative for a high-risk population. The screw-in of the lead ensures low impedance and threshold of stimulation (1.1 ± 0.6 V at 0.5 milliseconds) both in early and medium terms. In conclusion, in case of failure of the transvenous approach, the MSMPL may be easily implanted through a left minithoracotomy, and the results are noteworthy.

Successful removal of a jugular implantable defibrillator lead with mechanical single-sheath technique.

We describe the case of a man with an implantable defibrillator and a dual-coil lead introduced via the right internal jugular vein. Due to pocket infection and lead erosion at the jugular vein, transvenous lead extraction was attempted with a mechanical single-sheath technique. The lead was completely removed without complications with culture and sensitivity results guiding an effective antibiotic therapy.

[Treatment of chronic total coronary occlusions by the subintimal tracking and reentry modified technique. The contrast-guided STAR technique]. / Trattamento delle occlusioni croniche totali delle coronarie mediante la tecnica subintimal tracking and reentry (STAR) modificata. La tecnica STAR guidata dal contrasto.

BACKGROUND: Previous data showed that recanalization of chronic total occlusions (CTO) with the subintimal tracking and reentry (STAR) technique is feasible. However, this technique is challenging and requires skilled operators to be performed. The aim of this study was to evaluate procedural and clinical outcomes of patients undergoing a contrast-guided STAR procedure. METHODS: All consecutive patients (n=121) with coronary CTO treated with the contrast-guided STAR technique in three Italian centers were included in this study, after failure of conventional CTO approaches. RESULTS: The right coronary artery was involved in 76.8%, with blunt morphology in 62.8%. Angiographic and procedural success rates were 82.6% and 64.4%, respectively, with a 69.4% rate of complete recanalization. Stent implantation was performed in 81.8% of cases, using drug-eluting stents in 94.4%. Procedural complications occurred in 7.4% of cases. During follow-up no episodes of myocardial infarction were observed, but one cardiac death (0.8%). No definite or probable stent thrombosis was reported. The overall rate of target lesion revascularization was 21.4%. CONCLUSIONS: This study demonstrated that the contrast-guided STAR technique appears to be a feasible and relatively safe procedure when performed as rescue technique after failure of conventional CTO approaches. However, this procedure is limited by a high rate of target lesion revascularization and a second procedure may be necessary to obtain a definitive result.

Single-operator experience with a mechanical approach for removal of pacing and implantable defibrillator leads.

AIMS: Recently, a mechanical single-sheath technique with a multiple venous entry-site approach for the removal of pacemaker and implantable defibrillator leads was reported to have a high success rate and few complications. In our institution, this technique of lead removal has been used since 2002. In this paper, we report our experience, with the aim of evaluating the effectiveness and safety of the proposed procedure. METHODS AND RESULTS: This study is a retrospective analysis of the case records of all patients referred to our institution for transvenous lead extraction, according to class I or II Heart Rhythm Society indications. Over 7 years, 300 consecutive patients underwent procedures for transvenous removal of 518 leads. The most frequent indication for extraction was infection (74%). Complete removal of 502 (96.9%) leads and partial removal of 10 leads (1.9%) were achieved. Six leads (1.2%) could not be removed. All defibrillation coils and coronary sinus leads were successfully removed. There were no procedure-related deaths but only one major complication (0.3%). CONCLUSION: Our experience shows that the proposed mechanical technique is very effective and associated with few serious complications, thus confirming previous findings. This approach may be reproduced in other settings with very satisfactory results.

Acute myocardial infarction in a young patient with myocardial bridge and elevated levels of free triiodothyronine.

Revelation of a myocardial bridge has been described at coronary angiography. The pathophysiology of myocardial bridging is incompletely understood. It is sometimes associated with overt pathology, as well as it can just be an incidental finding without any significance. It has been also reported an acute myocardial infarction with normal coronary arteries associated with iatrogenic hyperthyroidism. We present a case of acute myocardial infarction in a 28-year-old Italian man with normal coronary arteries, iatrogenic elevated levels of free triiodothyronine and myocardial bridge.