Predictors of inhospital outcome after acute inferior wall myocardial infarction.

INTRODUCTION: Compared with anterior wall myocardial infarction, inferior wall myocardial infarction is generally regarded as being low risk. The aim of this study was to elucidate the clinical factors affecting its inhospital outcome. METHODS: From January 1997 to March 2006, 546 consecutive patients who suffered from their first inferior wall myocardial infarction were recruited for the study. The demographic, clinical, electrocardiographical and angiographical characteristics, treatment and medications, complications and inhospital deaths were subjected to univariate analysis. The factors that had a p-value of less than 0.1 were included for multivariate logistic regression analysis. A p-value of less than 0.05 was considered significant. The impact of thrombolysis on clinical outcome in various high-risk patient subsets was also examined. RESULTS: An advanced age of more than 74 years, female gender, lateral wall extension, complete atrioventricular block, bundle branch block, and cardiac free-wall rupture were found to be independent predictors of inhospital mortality, whereas the use of thrombolysis was associated with a favourable outcome. On the other hand, right ventricular infarction and precordial ST-segment depression are not predictive of poor outcome. In addition, thrombolysis reduced inhospital mortality in patients with an age above 64 years, male gender, lateral wall extension, haemodynamically-significant right ventricular infarction and complete atrioventricular block. CONCLUSION: In inferior wall myocardial infarction, independent predictors of poor inhospital outcome are advanced age, female gender, lateral wall extension, complete atrioventricular block, bundle branch block and cardiac free-wall rupture. The use of thrombolysis is generally beneficial, especially in those of the high-risk subsets.

Isolated left ventricular non-compaction: an unusual indication for heart transplantation.

We report a patient with isolated left ventricular non-compaction diagnosed by echocardiography and cardiac magnetic resonance imaging. She developed refractory congestive heart failure and subsequently underwent successful heart transplantation. This type of cardiomyopathy is thought to be caused by the arrest of normal embryogenesis of the endocardium and myocardium. The spectrum of clinical, radiological, and pathological abnormalities is discussed.

Iatrogenic Tako-Tsubo cardiomyopathy.

We report a rare case of Tako-Tsubo cardiomyopathy developed after excision of left atrial myxoma and adrenaline infusion given for blood pressure augmentation in a 56-year-old lady. Although the risk for developing Tako-Tsubo cardiomyopathy associated with adrenaline use has not been established, caution is still warranted.

Coexistence between colorectal cancer/adenoma and coronary artery disease: results from 1382 patients.

BACKGROUND: Common risk factors exist in colorectal neoplasia (cancer or adenoma) and coronary artery disease. AIM: To investigate in a retrospective study if there is coexistence of the two events in patients > OR =50 years. METHODS: Computer data on colonoscopies performed on symptomatic patients, the corresponding medical record and colonic histology in 1997-2000 were retrieved. History of coronary artery disease was recorded. To adjust for the factors of age and sex, bivariate logistic regression analysis was used to test for coexistence. RESULTS: 1382 patients were recruited. Colorectal neoplasia and history of coronary artery disease were present in 27% (373) and 12% (167) of patients, respectively. The mean age of patients was older in colorectal neoplasia+ (75 +/- 11 vs. 69 +/- 13 years, P < 0.0001) and in coronary artery disease+ (79 +/- 9 vs. 69 +/- 12 years, P < 0.0001) patients. Male was the predominant sex in colorectal neoplasia+: 33% vs. 22% (P < 0.0001), but not in coronary artery disease+ (P = 0.29). Colorectal neoplasia+ patients were more likely to have coronary artery disease+ [21.2% (79/373) vs. 8.8% (89/1098) (P < 0.0001)]. Bivariate logistic regression analysis showed strong association between the two events (OR: 2.12, 95% CI: 1.5, 3.0). CONCLUSION: There is strong coexistence of colorectal neoplasia and coronary artery disease, probably due to exposure to common risk factors.

Recurrent acute heart failure caused by sliding hiatus hernia.

The case is reported of a 75 year old woman who presented with recurrent nocturnal episodes of acute pulmonary oedema. The cause was uncertain as she had normal cardiothoracic ratio on chest radiography and normal left ventricular systolic and diastolic function by transthoracic echocardiogram. Another transthoracic echocardiogram was repeated when she was recumbent for an hour and had a full stomach. It showed a striking finding of severe left atrial compression by an external structure. Computed tomography of the thorax showed an intrathoracic mass behind the left atrium causing external compression of the left atrium suggestive of a sliding hiatus hernia. Cardiac catheterisation confirmed the diagnosis by showing a pronounced rise of pulmonary capillary wedge pressure in the recumbent position compared with the sitting up position.

Multiple brain abscesses in a patient with bilateral pulmonary arteriovenous malformations and immunoglobulin deficiency.

A 34 year old Chinese man presented with grand mal seizures complicating multiple brain abscesses caused by mixed oral flora. Because of persistent hypoxaemia contrast spiral thoracic computed tomography was done, which revealed bilateral pulmonary arteriovenous malformations (PAVMs). Concomitant IgA and IgG subclass deficiency was also found. The combination of these two conditions appears to have predisposed this patient to presumably paradoxical septic embolism. The patient's cerebral condition responded to postoperative antibiotic treatment and he eventually received selective coil embolisation of right lower lobe PAVMs, which relieved his hypoxaemia and dyspnoea.

Triple wire technique for a bifurcation lesion and a subtotal occlusive lesion.

In a critical distal right coronary artery bifurcation lesion, the proximal course of the posterior descending artery was also subtotally occluded. The posterior descending artery gave rise to a small sidebranch just before the occlusion. In the subsequent revascularization procedure, the bifurcation lesion was double-wired. One wire was placed in the postero-lateral branch, and another wire was intended for placement in the posterior descending artery, but it repeatedly selected the sidebranch despite multiple shapings of the wire tip. While the second wire was deliberately kept in the sidebranch, a third wire was used and crossed the occlusive lesion without much difficulty. The second wire was then withdrawn and the revascularization procedure proceeded in the usual manner. The positioning of the second wire in the sidebranch significantly shortened the procedure.

Subvalvular pulmonary stenosis, demyelination and myelodysplasia with monosomy 7.

We report a 23-year-old male with subvalvular pulmonary stenosis (PS) presenting with concurrent acute demyelinating neuropathy and myelodysplasia with monosomy 7. There was no stigmata of Noonan syndrome or neurofibromatosis, nor any family history of cardiac or hematologic disorders. There are 40 reported pediatric cases of Noonan syndrome with subvalvular PS that developed leukemia, over two-thirds with monosomy 7. There is also a genetic overlap between Noonan syndrome and neurofibromatosis, which is also closely associated with demyelination and leukemia. The importance of recognition of rare clinical syndromes that may predispose to leukemia is discussed.

Acute occlusion of left internal mammary artery graft during dual-chamber pacemaker implantation.

A patient who had undergone bypass surgery 5 yr earlier, including left internal mammary artery (LIMA) grafting to the left anterior descending artery, underwent transvenous dual-chamber permanent pacemaker implantation for persistent advanced atrioventricular block. Intraoperative LIMA graft obstruction occurred, resulting in anterior myocardial infarction that was treated successfully by primary percutaneous transluminal coronary angioplasty and stenting. This is the first report of the occurrence of this complication during pacemaker implantation.

Treatment of in-stent coronary restenosis with excimer laser angioplasty.

OBJECTIVE: To evaluate the efficacy and safety of excimer laser coronary angioplasty (ELCA) with adjunctive balloon angioplasty in patient with in-stent restenosis. METHODS: ELCA was performed in 20 patients of instent restenosis. All patients were symptomatic and had class III-IV angina. ELCA was performed with the Spectranetics CVX-300 System. The laser catheter of Vittesse C (concentric) and E (eccentric) with diameter of 1.4-2.0 mm was used. RESULTS: Laser catheter crossed all stenotic stents without difficulty. The lesion length was 4.6-51.2 mm, mean 20.7 +/- 13.7 mm, including 14 lesions > 10 mm. Laser treatment alone increased minimal lumen diameter (MLD) from 0.3 +/- 0.3 mm to 1.4 +/- 0.3 mm (P < 0.0001) and improved the diameter stenosis from 88.8% +/- 10.0% to 46.0% +/- 8.0% (P < 0.0001). Adjunctive balloon angioplasty further increased minimal lumen diameter to 2.3 +/- 0.7 mm and reduced diameter stenosis to 14.2% +/- 8.2% (P < 0.0001). At follow-up (1-17 months, mean 8.9 +/- 5.7 months), 17 (85%) patients had remained asymptomatic, 3 (15%) patients had mild to moderate exertional angina, 1 (5%) patient received CABG. CONCLUSION: ELCA with adjunctive percutaneous transluminal coronary angioplasty (PTCA) is an efficient and safe technique to debulk tissue in the patient with in-stent restenosis. The incidence of procedural related complication was low and ELCA may be used as a good method for in-stent restenosis treatment.

Stent thrombosis with different types of intracoronary stents: is it still a problem?

OBJECTIVE: The reported results of intracoronary stenting with Palmaz-Schatz stents using the low dose anticoagulation protocol have been encouraging and no stent thrombosis was observed. The effectiveness of such method extending to the use of other types of stents was therefore evaluated in this study. METHODS: All patients followed the anticoagulation protocol (heparin and warfarin) using non-heparin-coated stents. From September 1995, 92 patients received intracoronary stenting (69 men, 23 women, mean age 60.9 years). Altogether 117 stents were implanted in 99 target arteries and 106 lesions. RESULTS: A total of 50.4% of the stents were bare stents (stents without protective sheaths). Both coil stents and slotted tubular stents were used. Stenting was performed without the guidance of intravascular ultrasonography and high-pressure poststenting inflation was used in only 24.0% of patients with less than optimal angiographic results. The mean (+/- SD) coronary minimum luminal diameter changed from 0.63 +/- 0.39 mm to 3.12 +/- 0.48 mm immediately after stenting. Both stent thrombosis rate and femoral bleeding complication rate remained at 0%. Four bare stents could not be deployed in the first instance but without sequels. No morbidity nor mortality was recorded. The mean hospital stay remained at a mean of 4.5 days. All patients (100%) were followed up regularly. The mean (+/- SD) clinical follow-up period was 229 +/- 173 days. Clinical symptoms improved in all patients. CONCLUSIONS: These findings further support that the method is safe and stent thrombosis was not observed. Post-stenting recoil was more with coil stents. Dislodgment and potential risk of embolization could not be underestimated with bare stents. The restenosis rate between different types of stents remains to be determined.