RESUMEN
We report about a 67-year old man, who was submitted to our clinic with acute coronary syndrome. The cardiac catheterization showed a proximal thrombus in the left anterior descending (LAD). The other coronary arteries did not have significant lesions. After percutaneous transluminal coronary angioplasty with stent-implantation into the proximal LAD the patient remained clinically stable. Cardiac enzymes confirmed no myocardial necrosis. Three days after the acute coronary syndrome the patient developed a podagra, which was treated with colchicinum, diclofenac and local cooling. Five hours after initial therapy the patient developed severe symptoms of angina pectoris and electrocardiographical signs of an acute posterior and anterior myocardial infarction. Immediate coronary angiography demonstrated extended vasospasm of the right coronary artery. Intracoronary application of verapamil and nitroglycerin resolved the coronary spasm. The patient reported about a self-indicated application of diclofenac six hours before hospital admission. This case demonstrates that oral application of diclofenac can provoke coronary vasospasm.
Asunto(s)
Angina Inestable/inducido químicamente , Angina Inestable/diagnóstico , Enfermedad Coronaria/inducido químicamente , Enfermedad Coronaria/diagnóstico , Diclofenaco/efectos adversos , Infarto del Miocardio/inducido químicamente , Infarto del Miocardio/diagnóstico , Enfermedad Aguda , Anciano , Angina Inestable/tratamiento farmacológico , Antiinflamatorios no Esteroideos/efectos adversos , Antiinflamatorios no Esteroideos/uso terapéutico , Enfermedad Coronaria/tratamiento farmacológico , Diclofenaco/uso terapéutico , Gota/tratamiento farmacológico , Humanos , Masculino , Infarto del Miocardio/tratamiento farmacológico , Síndrome , Resultado del TratamientoRESUMEN
We report about a 47-year-old woman, who presented with a history of cardiac failure. Echocardiography showed an impaired left ventricular function, clinically significant mitral regurgitation and pulmonary hypertension. Diagnosis of a Bland- White-Garland syndrome was made by coronary angiography. Subsequent therapy consisted of ligation of the anomalus origin of the left coronary artery, implantation of a Mammaria interna graft to the left coronary artery and replacement of the mitral valve by a mechanical prosthesis. One year after operation, left ventricular function was still impaired. At a 3-year follow-up, left ventricular function improved continuously.
Asunto(s)
Anomalías de los Vasos Coronarios/diagnóstico , Insuficiencia Cardíaca/etiología , Hipertensión Pulmonar/etiología , Insuficiencia de la Válvula Mitral/etiología , Arteria Pulmonar/anomalías , Disfunción Ventricular Izquierda/etiología , Angiografía Coronaria , Anomalías de los Vasos Coronarios/cirugía , Ecocardiografía , Femenino , Estudios de Seguimiento , Insuficiencia Cardíaca/diagnóstico , Insuficiencia Cardíaca/cirugía , Implantación de Prótesis de Válvulas Cardíacas , Humanos , Hipertensión Pulmonar/diagnóstico , Hipertensión Pulmonar/cirugía , Persona de Mediana Edad , Insuficiencia de la Válvula Mitral/diagnóstico , Insuficiencia de la Válvula Mitral/cirugía , Revascularización Miocárdica , Complicaciones Posoperatorias/diagnóstico , Arteria Pulmonar/cirugía , Disfunción Ventricular Izquierda/diagnóstico , Disfunción Ventricular Izquierda/cirugíaRESUMEN
The discrimination of supraventricular versus ventricular tachycardias by an implantable cardioverter-defibrillator (ICD) is still a remaining clinical problem. The false positive detection of supraventricular as ventricular tachycardias causes inadequate electrical therapies of the ICD. To improve the increase of specificity criterias like "Onset" or "Stability" are offered. If these criterias during tachycardia are not fulfilled, the "sustained rate duration" (SRD) is offered as a security criterion. The SRD reasons the delivery of the therapy during tachycardia after a programmable time. Aim of the study was to evaluate, if SRD in patients with known arrhythmia absoluta (AA) in atrial fibrillation and programmed "Onset"/"Stability" increases the sensitivity without loss of specificity in the treatment of hemodynamically tolerated ventricular tachycardias and which programming should be chosen. Our patient collective included 274 patients (pts) with new implanted ICD of the third generation. In 39 (14%) pts AA was known in the medical history. From these 39 (100%) pts, 18 (46%) pts had known tachyarrhythmic episodes (group I) in the area of the ventricular tachycardia-zone > or = 160 beats per minute, whereas in 21 (54%) pts a tachyarrhythmia absoluta (TAA) was unknown (group II). During follow-up of 12 +/- 8 (2-26) months, 151 tachycardias occurred and could be classified as supraventricular tachycardias by stored electrograms. In 9/18 pts of group I, a TAA occurred during follow-up. The initial programmed SRD during first TAA was 62 +/- 39 (35-90) s and was prolonged to 135 +/- 64 (90-180) s. After this prolongation, no inadequate therapy was delivered. In group II, 19/21 (90%) were inadequately treated during TAA. The initial SRD-programming was 45 +/- 28 (0-90) s and was prolonged to 201 +/- 150 (60-480) s during follow-up. After prolongation of the SRD, no more inadequate therapies due to AA were delivered. In pts with new implanted ICD and known TAA, which is hemodynamically tolerated, the SRD should be programmed beside all other available detection parameters for improving the increase of specificity at least 135 s to avoid inadequate therapies of the ICD. In pts with unknown TAA, SRD should be prolonged to 135 s at least the second tachyarrhythmic episode, which is hemodynamically well tolerated.
Asunto(s)
Fibrilación Atrial/terapia , Desfibriladores Implantables , Electrocardiografía/instrumentación , Frecuencia Cardíaca/fisiología , Programas Informáticos , Adolescente , Adulto , Anciano , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/etiología , Niño , Femenino , Humanos , Masculino , Persona de Mediana Edad , Sensibilidad y Especificidad , Procesamiento de Señales Asistido por Computador/instrumentaciónRESUMEN
HISTORY AND CLINICAL FINDINGS: 24-hour ECG monitoring in a 64-year-old man revealed self-limited (< 30 s) ventricular tachycardias (VT) of > 200/min. He had triple-vessel coronary artery disease with both anterior and posterior wall infarctions treated by three aortocoronary venous grafts. Physical examination was unremarkable except for a well healed thoracotomy scar. INVESTIGATIONS: Programmed ventricular stimulation induced prolonged monomorphic VT of 320 beats/min, despite aminodarone treatment. Left-heart catheterization demonstrated the three patent aortocoronary grafts and a left-ventricular ejection fraction of only 20%. TREATMENT AND COURSE: Because of the inducible and prolonged VT, despite antiarrhythmic treatment with amiodarone, a cardioverter-defibrillator was implanted (ICD). During threshold measurements of the pacemaker integrated into the ICD the pacemaker impulse was noted to produce a right bundle branch block pattern, the ICD lead having erroneously been placed in the left ventricle via a patent foramen ovale. The lead was left in place, because the ICD was functioning well and lead removal with the possible need of a thoracotomy carried a high risk. CONCLUSION: Extreme caution is needed to avoid malpositioning an implantable cardioverter-defibrillator. If the lead tip is unwittingly fixed in the left ventricle but functions well it should be left in place under prophylactic anticoagulation, because of the potentially high risk of its operative removal.
Asunto(s)
Desfibriladores Implantables/efectos adversos , Defectos del Tabique Interatrial/complicaciones , Taquicardia Ventricular/terapia , Amiodarona/uso terapéutico , Cateterismo Cardíaco , Puente de Arteria Coronaria , Ecocardiografía , Electrocardiografía , Frecuencia Cardíaca , Defectos del Tabique Interatrial/diagnóstico por imagen , Humanos , Masculino , Persona de Mediana Edad , Radiografía , Taquicardia Ventricular/diagnóstico por imagenRESUMEN
The necessity of routine invasive implantable cardioverter-defibrillator (ICD) testing before hospital discharge was analyzed in 268 patients. In 98% of the patients, invasive ICD testing was not necessary if a preimplant electrophysiologic test was performed; most of the observed problems can be solved by noninvasive control.
Asunto(s)
Desfibriladores Implantables , Taquicardia Ventricular/prevención & control , Fibrilación Ventricular/prevención & control , Cateterismo Cardíaco/estadística & datos numéricos , Estimulación Cardíaca Artificial/estadística & datos numéricos , Electrofisiología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios RetrospectivosRESUMEN
Direct comparison of the utility of dipyridamole stress echocardiography and dobutamine stress echocardiography was performed to identify patients at risk of future cardiac events in 134 patients with suspected or known coronary artery disease. The predictive values of dobutamine and dipyridamole were remarkably similar.