Myocardial infarction with angiographically normal coronary arteries.

To determine the prevalence rate and clinical and hemodynamic profile of patients with myocardial infarction (MI) with angiographically normal coronary arteries, we analyzed 3,403 consecutive angiograms performed within a 4.5-year period. Of these studies, 1,124 were performed following an acute MI. Through a computerized search, 12 patients were identified who had documented MI with normal or insignificant (< 30% stenosis in one epicardial vessel only) coronary disease. Q-wave MI developed in five patients (group A) and non-Q-wave MI developed in seven patients (group B). Group A patients were all men whereas group B patients were all women. Overall, group A patients were younger (p = 0.003), had a longer smoking history (p = 0.008), and a higher cardiac index (p = 0.005). In ten patients, areas of localized dyskinesia or hypokinesia were shown on left ventricular cineangiography. Mitral valve prolapse was present in four of the patients and varying degrees of mitral regurgitation were identified in another six. The prevalence rate of MI with angiographically normal coronary arteries was 1% in this study. This entity had a bimodal age and sex distribution: a younger age group, all men, with a stronger cigarette smoking history who had Q-wave MI vs an older age group, all women, and no significant association with cigarette smoking who developed non-Q-wave MI. A mean follow-up of 4 years demonstrated a favorable prognosis in both groups.

Primary cutaneous aspergillosis in a heart transplant recipient treated with surgical excision and oral itraconazole.

A 24-year-old man underwent orthotopic heart transplantation for treatment of end-stage complex congenital heart disease. Six weeks postoperatively, five erythematous skin lesions developed on the patient's right forearm. Punch biopsy revealed Aspergillus. Despite extensive testing, no other potential primary site was located. Because of concern of dissemination, the patient was treated with a combination of local debridement and systemic antifungal therapy with itraconazole. He is presently without signs or symptoms of recurrent disease.

Right lower lobectomy for pulmonary infarction before orthotopic heart transplantation.

A 39-year-old potential heart transplant recipient had a right lower lobe infiltrate and on pulmonary angiography was found to have an embolous to the common basilar artery. This was successfully managed by a right lower lobectomy, after aggressive medical management failed. The patient was treated postoperatively with antibiotics and subsequently underwent orthotopic heart transplantation. At 1 year after transplant the patient has no evidence of cardiac or pulmonary insufficiency.

Systemic and local saphenous vein graft thrombolysis using a tissue plasminogen activator.

Many studies are currently evaluating the potential role of thrombolytic therapy in patients with ischemic syndromes who have undergone previous coronary artery bypass grafting. Limited experience has been published regarding the use of local urokinase and streptokinase infusions and the use of systemic recombinant tissue-type plasminogen activator as thrombolytic agents in patients with previous coronary artery bypass surgery. To date, however, there has been no published experience regarding the use of recombinant tissue-type plasminogen activator (rt-PA) either systemically or locally in the post-bypass patient where angiographic demonstration of aortocoronary saphenous vein graft obstruction was available pre- and post-therapy. Similarly there has been no previous report of the use of rt-PA infused locally to recanalize an occluded aortocoronary saphenous vein graft. This report describes successful thrombolysis and subsequent balloon angioplasty of saphenous vein grafts with angiographically documented thrombus using systemic and local rt-PA infusion.