Complications of chronic total occlusion percutaneous coronary intervention.

Chronic total occlusion percutaneous coronary interventions can be highly complex and are associated with an increased risk of complications, such as perforation, acute vessel closure (which can lead to rapid haemodynamic compromise if it involves the donor vessel), and equipment loss or entrapment. Awareness of the potential complications and meticulous attention to equipment position and patient monitoring can help minimise the risk of complications and allow prompt treatment should they occur.

Prediction of myocardial tissue loss by quantitative densitometric myocardial blush parameters following ST-elevation myocardial infarction.

UNLABELLED: Tissue level myocardial perfusion is one of the most important prognostic factors after successful recanalisation of the occluded coronary artery in patients suffering acute ST elevation myocardial infarction (STEMI). The primary objective of the present study was to examine the relationship between videodensitometric myocardial perfusion parameters as assessed on coronary angiograms directly following successful recanalization therapy and magnetic resonance imaging (MRI)-derived myocardial tissue loss late after STEMI. The study comprised 29 STEMI patients. Videodensitometric parameter G(max)/T(max) was calculated to characterize myocardial perfusion, derived from the plateau of grey-level intensity (G(max)), divided by the time-to-peak intensity (Tmax). Myocardial loss index (MLI) was assessed by cardiac MRI following 376 ± 254 days after PCI. RESULTS: Significant correlations could be demonstrated between MLI and G(max) (r = 0.36, p = 0.05) and G(max)/T(max) (r = 0.40, p = 0.03) using vessel masking. Using receiver operating characteristic curve analysis, G(max)/T(max) < 2.17 predicted best MLI = 0.3, 0.4, 0.5 and 0.6 with good sensitivity and specificity data, while G(max)/T(max) < 3.25 proved to have a prognostic role in the prediction of MLI = 0.7. CONCLUSIONS: Selective myocardial tissue level perfusion quantitative measurement method is feasible and can serve as a good predictor of myocardial tissue loss following STEMI and revascularization therapy.

Videodensitometric time-density curve change after alcohol septal ablation of obstructive hypertrophic cardiomyopathy.

A recently developed computerized method for estimation of myocardial perfusion, based on the analysis of the time-density curves, is demonstrated to assess myocardial blush over a selected myocardial region of interest in a patient with obstructive hypertrophic cardiomyopathy before and after alcohol septal ablation.

Non-invasive prediction of angiographic progression of coronary artery disease by dipyridamole-stress echocardiography.

BACKGROUND: Coronary angiography is the currently accepted standard means for assessing progression of coronary artery disease. A dipyridamole-echocardiography test (DET) might provide an alternative non-invasive functional imaging method for this purpose. OBJECTIVE: To assess whether variations in results of serial DET match variations in angiographic assessments of coronary artery disease. METHODS: From the Pisa Institute of Clinical Physiology stress-echocardiography data bank (1983-1998), we selected 60 patients satisfying the inclusion criteria of coronary angiography and DET having each been performed and interpreted twice independently and within 1 week. The second angiographic and stress-echocardiographic assessment was performed 45+/-31 months after the initial one. Angiographic progressors were defined a priori as patients with any progression of stenosis to occlusion and those with any stenosis > 30% with > 20% progression of stenosis measured by visual and quantitative coronary angiography. Stress-echocardiography progressors were defined as those patients who had previously had a negative test of a test having a positive result and those patients who had positive results of tests both in initial testing and in a second session of testing with the latter having a peak wall-motion-score index > 0.12 (on a scale of 1, normal to 4, dyskinetic in a 16-segment model) larger than the former. RESULTS: Of the 60 patients, 44 were angiographic 'progressors' and 16 were 'non progressors'. Stress-echocardiographic responses were concordant with angiographic identification for 39 of 44 progressors and 15 of 16 non-progressors, with an overall concordance of 90%. CONCLUSIONS: Measurement of dipyridamole-stress-echocardiographic response allows one to separate angiographic progressors and non-progressors efficiently, simply by taking into account the presence, extent and severity of stress-induced abnormalities of wall motion.

[The clinical value of coronary flow reserve in ischemic heart disease as measured by dipyridamole stress transesophageal echocardiography]. / A dipyridamol-terheléses transoesophagealis echokardiográfia segítségével számított coronaria-áramlási rezerv klinikai értéke ischaemiás szívbetegségben.

The relationship between coronary flow reserve and the result of coronarography was examined. 152 patients were investigated by stress transoesophageal echocardiography and coronary angiography. The value of coronary flow reserve was significantly lower in cases of significant coronary stenosis than in those patients who had a normal coronarography (in patients with left anterior descending coronary artery stenosis: 1.77 +/- 0.47 vs in cases with normal coronary angiogram: 3.19 +/- 1.15). There was no difference in the value of CFR in those cases where not only LAD stenosis but CX or RC stenosis was also found. The value of coronary flow reserve was significantly higher in RC or CX patients than that of LAD patients. In patients with positive stress and negative coronarography (X syndrome) the coronary flow reserve was 1.23 +/- 0.2, which value was significantly lower as compared to patients with significant coronary stenosis.

[Risk assessment and measuring the need for revascularization on the basis of residual ischemia by means of dobutamine stress echocardiography in the early phase of the first myocardial infarction]. / A kockázat meghatározása és a várható revascularisatiós igény felmérése residualis ischaemia kimutatása alapján az elsö acut myocardialis infarctus korai fázisában dobutamin stressz echocardiographia segítségével.

The aim of this study is to present a modern method which can be used in the early phase of myocardial infarction. Its results show that with the detection of residual ischaemia, valuable information can be gained concerning the progression of the disease and the claim to revascularisation. During the first week (2-7 days), the authors performed risk assessing dobutamine stress echocardiography in 52 nonselected acute patients with first myocardial infarction. Patients with negative results were regarded as low risk cases 35/52 (67.3%), while those with positive results were regarded as high risk cases 17/52 (32.7%). The number of the serious postinfarction hard events was 22/52 (42.3%) during the one-year following period. In the case of the positive group, during mainly the first three months the occurrence of such events was found to be extremely high: 16/17 (94.1%), while in the case of the negative group it was only 6/35 (17.1%). On the basis of the test results it can be stated that coronarography was performed in 14/17 (82.4%) vs. 3/35 (8.6%) of the cases, and revascularisation in 10/17 (58.8%) vs. 1/35 (2.9%) of the cases. In 2/17 (11.8%) vs. 3/35 (8.6%) of the cases, the patients suffered from acute coronary syndrome and the mortality rate was 2/17 (11.8%) vs. 1/35 (2.9%). The sensitivity value was 79.1%, the specificity value 90.6%, and the positive and negative predictive values 86.3% and 85.3%. There was no such significant complication detected which could be attributable to the examination. On the basis of the results and corresponding to the data in special literature, the authors found the dobutamine stress test a good and safe prognostical method even some days after the infarction. With the help of this method the high and low risk groups of patients can be separated early, and at the same time the claim to revascularisation in the first three months can be measured too.

[Unstable angina pectoris associated with surgically treated coronary artery atresia]. / Instabil angina pectorissal járó egyszájadékú koszorúér-hálózat operált esete.

A case report of a rare, presumably congenital form of "single coronary artery", is presented. The authors review the classification and clinical significance of the entity with special emphasis with regard to anginal symptoms and the so called sudden unexpected death syndrome. Details and result of surgical intervention (conventional aorto-coronary saphenous bypass) are discussed.

Amanita poisoning during the second trimester of pregnancy. A case report and a review of the literature.

Amanita phalloides-type mushroom poisoning is well recognized as causing acute liver injury and often death. Less is known, however, of whether maternal Amanita poisoning is associated with fetal damage or not. In August 1991 four members of a family were hospitalized with food intoxication caused by Amanita phalloides and Amanita verna. One of them died from hepatic and renal failure. The survivors included a 26-year-old woman in the 23rd week of pregnancy. Her clinical symptoms and blood chemistry data (lowest prothrombin activity 23%) indicated intoxication of medium severity. The management consisted of i.v. hydration, forced diuresis, and administration of silibinin, high-dose penicillin, thioctic acid, hydrocortisone, vitamin K, and fresh frozen plasma. Sonographic and obstetric controls failed to show any fetal abnormalities in the acute phase of poisoning. In the 38th week of pregnancy she gave birth to a healthy baby, who has subsequently undergone an undisturbed development. This observation indicated that severe fetal damage did not occur in maternal Amanita poisoning in the second trimester of pregnancy. Thus, at least from the second trimester on, maternal Amanita poisoning is not necessarily an indication for induced abortion.

[Primary malignant pericardial mesothelioma]. / Primer malignus pericardialis mesothelioma.

The case-history of a 41-year-old man is reported. He was admitted because of the sudden development of left hemiparesis, loss of consciousness and increasingly deeper coma. The ECG demonstrated second-degree AV block with Wenkebach conduction or episodes with complete AV block. The colour Doppler ultrasound and cranial CT examination revealed occlusion of the right internal carotid artery and a cerebral infarct of the right hemisphere. Within 24 hours patient died from herniation of the brainstem. Postmortem examination revealed a pericardial neoplasm infiltrating both left and right atrium, AV junctional area, interventricular septum and right ventricle. The tumor tissue grew transmurally and protruded into the cavities of the heart. The right internal carotid artery was occluded by a tumor embolism. The histochemical and immunohistochemical results proved that the tumor was a primary malignant pericardial mesothelioma. This kind of cardiac tumor involving the AV node and mimicking stroke is very rare.

[Amidaron-induced dermatopathy resulting from unnecessary Cordarone therapy of ventricular parasystole]. / Kamrai parasystolia felesleges Cordarone-kezelése kapacsán jelentkezö amiodaron-dermatopathia.

The case history of a patient is reported who was treated with a variety of antiarrhythmics over a period of years because of refractory ventricular "bigeminy". As the arrhythmia did not respond to any kind of therapy, amiodarone treatment was started, which the patient received in a maintenance dose of 600-400 mg/day for 4 years. More recently, a bluish-grey hyperpigmentation of the face and other areas of the skin exposed to sunlight developed. A cutaneous biopsy of the hand revealed pigment deposits and lamellated lysosomal inclusions characteristic for amiodarone dermatopathy. The interactive, computer-assisted analysis of the ventricular ectopic activity has clearly demonstrated its innocent, parasystolic nature. The differentiation between ventricular extrasystolic and parasystolic activity is essential, because the latter arrhythmia does not require specific antiarrhythmic pharmacotherapy.

Inactivation of cholecystokinin octapeptide by normal and cirrhotic liver in rats.

In anesthetized rats, a marked decrease in CCK-OP activity and, to a far lesser extent, in the pancreatic secretory effect of CCK-33 were found after portal administration, compared to the femoral route. Changes in the biological activity of CCK-OP were further investigated after 30 min incubation with different subcellular liver fractions (1000 X g, 12,000 X g, microsomal fraction with or without NADPH). All the subcellular liver fractions caused an approximately 70% decrease in the CCK-effect, as calculated from dose-response relationships. The inactivation of CCK-OP after incubation with microsomal fractions of thioacetamide (TAA)-induced cirrhotic liver did not differ from that of control rats. The CCK-OP dose-response curves were similar in cirrhotic and control rats, but the pancreatic secretion was sustained to a greater extent and the inhibitory effect of supramaximal stimulation was delayed in cirrhotic rats. It was concluded that CCK-OP can be inactivated by liver proteins present in microsomal fractions, by a NADPH-independent mechanism. This inactivation did not diminish in liver cirrhosis. There were no changes in CCK-OP elimination in cirrhotic rats in vivo, thus pancreatic hypertrophy in experimental cirrhosis must be explained by other mechanisms.