Cryptogenic ischemic stroke and paradoxical embolism: should a patent foramen ovale be closed? Case report and literature review.

Paradoxical embolism is a well-recognized cause of stroke. While the diagnosis in the majority of the cases with a patent foramen ovale is presumptive, numerous treatment strategies have been described. However, there is no single approach that has been overwhelmingly recommended for these patients. A patient is described who presented with ischemic stroke. Transesophageal echocardiography revealed a thrombus that straddled a patent foramen ovale. Anticoagulation with intravenous heparin resulted in resolution of thrombus and neurologic deficit. The literature regarding diagnosis and treatment of paradoxical embolism in the presence of patent foramen ovale is reviewed.

Dipyridamole-induced ST-segment elevation indicative of transmural myocardial ischemia--a case report.

Dipyridamole nuclear myocardial perfusion test is a safe and effective alternative to exercise nuclear perfusion testing for detecting myocardial ischemia. It is the procedure of choice in selected patients who are unable to exercise adequately. Intravenous dipyridamole causes coronary vasodilation with resultant maldistribution and heterogeneity of coronary flow in the presence of significant coronary artery disease. True ischemia, causing symptoms or ST-segment depression, is uncommon, in part because there is no increase in myocardial oxygen demand. A patient in whom myocardial ischemia developed, manifested by ST-segment elevation, during dipyridamole stress testing is described. Scintigraphic images illustrated a myocardial perfusion defect, which was consistent with coronary angiographic findings. This case report addresses the importance of dipyridamole-induced ST-segment elevation, its correlation with angiographic findings, and the need for continued hemodynamic and electrocardiographic monitoring in patients following dipyridamole infusion.

Cardiovascular risks of sexual activity.

The risks associated with sexual activity relate in part to the pathophysiology of the cardiovascular response to sexual activity. This review addresses this subject and reviews studies that directly address the cardiovascular risk associated with sexual activity.

Anomalous origin of the left main coronary artery from the right sinus of Valsalva: disabling angina and syncope with noninterarterial courses case report of two patients.

Anomalous origin of the left main coronary artery from the right sinus of Valsalva or the right coronary artery is a rare coronary anomaly. This anomaly has been associated with sudden cardiac death in younger patients, depending on its course relative to the pulmonary artery. The authors report this rare anomaly in two patients. It presented as unstable angina in the first patient with a septal course. In the second patient, it presented as syncope with an anterior free wall course and absent left circumflex artery. A septal course causing unstable angina has not been reported previously.

Use of intracoronary electrocardiography for detecting ST-T, QTc, and U wave changes during coronary balloon angioplasty.

Intracoronary electrocardiography (IC-ECG) is a more sensitive method than surface ECG to detect electrical changes during percutaneous transluminal coronary angioplasty (PTCA). It also provides direct monitoring of ST-T segment, QTc intervals, and U-wave genesis during balloon inflation. These changes are reflective of myocardial ischemia. The authors studied the effect of transient myocardial ischemia on ST-T segment, QTc intervals, and U-wave appearance by comparing standard and perfusion balloon angioplasty. PTCA of left anterior descending artery was performed in 14 patients using the standard balloons and in 11 patients using the perfusion balloons. Patients with perfusion balloon angioplasty had less ST-T elevation (0.15 +/- 0.05 mV versus 1.04 +/- 0.19 mV, P < 0.001), less QTc-shortening intervals (0.01 +/- 0.02 seconds versus -0.05 +/- 0.04 seconds, P < 0.001), and less positive U waves (two versus nine). The authors concluded that balloon angioplasty with perfusion balloons is associated with less ischemia as reflected by ST-T, QTc-shortening intervals, and U-wave changes. There was more positive U-wave appearance with the standard balloon angioplasty, which implies more ischemia. In addition, QTc-shortening intervals are associated with the development of U waves during standard balloon angioplasty. These findings suggest that IC-ECG is a sensitive tool in detecting myocardial ischemia. IC-ECG may also help to clarify the nature of chest pain during PTCA in some patients. Like QT dispersion (QTd), QTc-shortening intervals and new U waves can have prognostic implications and additional studies are needed to define this role.

Anterior mitral valve aneurysm: a subaortic complication of aortic valve endocarditis: a case report and review of literature.

Mitral valve aneurysm is a rare cause of mitral regurgitation, and is usually associated with aortic valve endocarditis. Prompt diagnosis and early surgical treatment can prevent complications such as embolization and rupture of the aneurysm. The authors report a case of aortic valve endocarditis and mitral valve aneurysm in a patient who initially presented with urinary tract infection.

Exercise update 2001.

Recent studies addressing the role of exercise in the detection, prevention, and treatment of coronary heart disease have significantly expanded our knowledge base in this area. This therapeutic review is focused on physiologic parameters in exercise, electrocardiogram testing, and the preventive impact of low-intensity regular exercise and the role of exercise training in selected patient populations.

Multi-morphology wide QRS tachycardias in a patient without structural heart disease: an unusual presentation of ventricular tachycardia.

Ventricular tachycardia occurs infrequently in patients without structural heart disease. These tachycardias commonly originate from the right ventricular outflow tract. However, the presence of more than one arrhythmogenic substrate in a patient without structural heart disease is rare. We report such a 48-year old patient with no structural heart disease who presented with three morphology wide QRS tachycardia. A brief review of the pathophysiology and management is discussed.

Paravalvular regurgitation: a rare complication following valve replacement surgery.

Paravalvular regurgitation is an uncommon but important complication, usually following valve replacement surgery. Early recognition and management are important for reoperations are associated with high morbidity and mortality rates. Presently, little data are available on this topic. The authors review the subject.

Percutaneous coronary intervention as a bridge to renal transplantation in a patient with end-stage renal disease--a case report.

Renal transplantation is one of the preferred modes of replacement therapy in patients with end-stage renal disease. Cardiovascular disease remains the leading cause of morbidity and mortality in patients with end-stage renal disease and renal transplant recipients. The authors describe a patient with end-stage renal disease who developed unstable angina before renal transplantation. Emergent cardiac catheterization and percutaneous coronary intervention served as a bridge to his successful renal transplantation without complications.

Fatal left main coronary artery embolism from aortic valve endocarditis following cardiac catheterization.

Coronary artery embolization has been associated with sudden cardiac death. It is more commonly seen with aortic valve endocarditis. It manifests as acute myocardial ischemia or infarction, causing instability of the cardiac rhythm, which may be fatal. We report a patient with aortic valve endocarditis who had sudden cardiac death following coronary angiography. Autopsy revealed embolic occlusion of the left main coronary artery.

"No-reflow" phenomenon following percutaneous coronary intervention: an uncommon complication.

The no-reflow phenomenon has been recognized as an uncommon complication after reperfusion therapy (thrombolytic or mechanical) for acute myocardial infarction and after percutaneous coronary intervention. As management and outcomes differ, early diagnosis and angiographic exclusion of other causes of impaired blood flow are important. The authors describe a case report of a patient with no-reflow following emergent stenting of the left circumflex artery (LCX). Pathophysiology and management of the no-reflow phenomenon are described along with the case report.

Successful percutaneous balloon mitral valvuloplasty using left ventricular pressure as a guide to cross the mitral valve--a case report.

Percutaneous balloon mitral valvuloplasty (PBMV) provides an effective alternative to surgery in a selective group of patients with symptomatic mitral stenosis. The Inoue balloon technique involves transseptal catheterization followed by catheter manipulation to cross the mitral valve. The authors describe a case of successful percutaneous balloon mitral valvuloplasty in a patient with severe mitral stenosis and pulmonary hypertension. Left ventricular systolic pressure was used as a guide to locate and to advance the balloon catheter across the mitral valve. This technique to cross the mitral valve has not been reported in the literature.

Successful percutaneous stenting of a right gastroepiploic coronary bypass graft using monorail delivery system: a case report.

The right gastroepiploic artery (RGEA) is being successfully used as an arterial conduit in a selected group of patients undergoing coronary artery bypass graft surgery. However, myocardial ischemia may result due to spasm, occlusion, and stenosis of this graft. The anastamosis site at distal right coronary artery (RCA) or posterior descending artery (PDA) is the most common location for stenosis of an in situ gastroepiploic coronary bypass graft. Balloon angioplasty of such stenoses has been reported with optimal short-term results. Stent deployment would decrease the restenosis rate, so that repeat procedures could be minimized for these technically challenging lesions. We describe a case of successful deployment of a stent with monorail delivery system at the anastamotic site stenosis of an in situ gastroepiploic right coronary artery bypass graft. This percutaneous coronary intervention could prevent redo coronary artery bypass graft surgery. Cathet. Cardiovasc. Intervent. 49:197-199, 2000.

Ventricular septal defect and left ventricular aneurysm: late occurrence as complications of an acute myocardial infarction.

Mechanical complications of acute myocardial infarction (AMI) such as a ventricular septal defect (VSD) usually occur within the first week. In the thrombolytic era, the incidence of a VSD has not increased, but has been reported to occur earlier than previously described. We report an unusual case of an elderly Caucasian female with an acute anterior wall myocardial infarction treated with thrombolytic therapy. Her AMI was complicated by pulmonary edema secondary to a VSD and a left ventricular aneurysm five weeks later. Prompt diagnosis, immediate surgical closure of the VSD, and aneurysmectomy resulted in her complete recovery.

Recurrent right atrial thrombus after repair of ruptured sinus of valsalva aneurysm.

Ruptured sinus of Valsalva aneurysm is a rare cardiac abnormality. Early surgical repair is indicated to prevent complications such as heart failure, infective endocarditis, arrhythmias, and thromboembolic events. The authors report an unusual case of recurrent right atrial thrombus after the surgical repair and closure of ruptured sinus of Valsalva aneurysm.

Coronary artery aneurysms, aortic dissection, and hypertension secondary to primary aldosteronism: a rare triad. A case report.

Primary aldosteronism is a relatively uncommon etiology of hypertension. Plasma renin activity is suppressed in the majority of the cases but not always. Plasma renin activity has been associated with increased vascular injury. The occurrence of vascular complications has rarely been reported with low plasma renin activity. The authors report a case of long-standing secondary hypertension due to primary aldosteronism with coronary artery aneurysms and aortic dissection. Diagnosing is important, for therapeutic intervention can be curative.

Successful transcatheter closure of a patent ductus arteriosus: using two Gianturco coils in a 41-year-old woman. A case report.

Patent ductus arteriosus (PDA) is a form of congenital heart disease uncommonly diagnosed in adult patients. Transcatheter closure of PDA has been widely used in children. However, the experience is limited in adults especially with use of Gianturco coils. The authors describe a case of successful transcatheter closure of a PDA, incidentally diagnosed in a 41-year-old woman, by successively deploying two coils by a transarterial approach. No residual shunting was seen angiographically after the procedure. A literature review of similar procedures in adult patients is discussed.

Takayasu's arteritis: an unusual manifestation--a case report.

Takayasu's arteritis is a rare entity. The authors describe a case of a middle-aged woman with an atypical form of Takayasu's arteritis. This manifestation has not been described previously.