Left Main Coronary Artery Aneurysm With Rare Quadfurcation Anatomy.

Coronary artery aneurysms (CAAs) are found in a small percentage of coronary angiograms, with left main coronary artery (LMCA) aneurysms being the least common. We present a 63-year-old male patient with a history of chest pain and an abnormal nuclear stress test. Cardiac catheterization showed a large LMCA aneurysm with unusual quadfurcation left main (LM) anatomy, but otherwise showed no evidence of obstructive coronary artery disease. The patient remained clinically stable, and a repeat cardiac catheterization 2 years later showed unchanged coronary anatomy. Further medical management with close observation was elected. This case illustrates that in select cases, large LMCA aneurysms can be successfully managed medically without surgical or percutaneous interventions. To our knowledge, this is the first report of LMCA aneurysm with quadfurcation anatomy. In addition to the case description, a review of the literature is provided.

The SYNTAX II Score Predicts Mortality at 4 Years in Patients Undergoing Percutaneous Coronary Intervention.

BACKGROUND: Short-term outcome after percutaneous coronary intervention (PCI) has improved dramatically, but the association between clinical or angiographic characteristics and long-term outcome remains less well described. The SYNTAX (Synergy Between PCI With TAXUS and Cardiac Surgery) II score has been designed to overcome the limitations of the purely angiographic SYNTAX I score by including clinical parameters and comorbidities. It has not been tested extensively in "real-world" PCI patients, outside of randomized clinical studies. METHODS AND RESULTS: We identified unique patients undergoing PCI between January 1, 2011 and January 24, 2013 and followed for at least 60 days. We calculated the SYNTAX I and II scores for each patient and collected data at longest follow-up available for vital status, recurrent PCI, systolic heart failure, stroke, or Q-wave myocardial infarction. Cox proportional hazards regression was used to assess independent predictors of mortality. There were 831 patients followed for a mean of 4 years. The average age was 66 ± 10 years. Nearly 40% were women and 50% had diabetes mellitus. The mean follow-up interval was 4 years, during which 42 patients died (Kaplan-Meier rate, 4.3% [IQR, 3.0-6.2%]). The PCI-SYNTAX II score was significantly higher in patients who died than in survivors (43 ± 12 vs 32 ± 12, respectively; P<.001). The SYNTAX II score was the only variable associated with death at a mean follow-up of 4 years (hazard ratio per 1 point, 1.05 [95% confidence interval, 1.03-1.08]; P<.001). CONCLUSION: The SYNTAX II score, incorporating angiographic and clinical parameters, is a useful tool for risk stratification and prediction of 4-year mortality in "real-world" patients.

Safety and predictors of next-day discharge after elective transfemoral transcatheter aortic valve replacement.

OBJECTIVES: We sought to determine the predictors of next-day discharge (NDD) for selected patients undergoing elective transfemoral transcatheter aortic valve replacement (TF-TAVR). BACKGROUND: Techniques have rapidly evolved over the last several years to simplify TF-TAVR allowing for a subset of patients to be discharged the next day. METHODS: Baseline and procedural characteristics, in-hospital and 30-day follow-up outcomes, complications and readmission rates of 100 TF-TAVR cases were assessed. Patients selected for NDD all met the following criteria: no procedural complications, same day ambulation, strong family support with home supervision, and access to our valve coordinator post discharge. RESULTS: There were 22 patients in NDD and 78 in later-day discharge (LDD) groups respectively. The mean length of stay was 3.4days for LDD. There were no significant differences in baseline, pre-procedural characteristics, or frailty indices of the two groups. However, there were more baseline oxygen dependent patients in LDD (p=0.004). Procedural characteristics included more balloon expandable valves (p=0.005), less fluoroscopy time (p=0.008), and higher use of moderate sedation (p=0.0001) in NDD group. There were more minor vascular complications (p=0.04) and new permanent pacemaker implantations (p=0.016) in the LDD group. There were no vascular complications, stroke or blood transfusions in the NDD group. The 30-day re-admission and mortality rates were similar in both groups. In logistic analyses only moderate sedation was a strong predictor of next day discharge after TF-TAVR (p=0.003). CONCLUSION: Carefully selected patients without complications following TF-TAVR can be discharged safely the next day.

Purulent pericarditis caused by Haemophilus parainfluenzae.

Bacterial pericarditis is a rare disease in the era of antibiotics. Purulent pericarditis is most often caused by Staphylococcus aureus, Streptococcus pneumoniae, or Haemophilus influenzae. The number of H. parainfluenzae infections has been increasing; in rare cases, it has caused endocarditis. We report a case of purulent pericarditis caused by H. parainfluenzae in a 62-year-old woman who reported a recent upper respiratory tract infection. The patient presented with signs and symptoms of pericardial tamponade. Urgent pericardiocentesis restored her hemodynamic stability. However, within 24 hours, fluid reaccumulation led to recurrent pericardial tamponade and necessitated the creation of a pericardial window. Cultures of the first pericardial fluid grew H. parainfluenzae. Levofloxacin therapy was started, and the patient recovered. Haemophilus parainfluenzae should be considered in a patient who has signs and symptoms of purulent pericarditis. Prompt diagnosis, treatment, and antibiotic therapy are necessary for the patient's survival. To our knowledge, this is the first report of purulent pericarditis caused by H. parainfluenzae.