Coarctation of Aorta and Post-Stenotic Dissecting Aortic Aneurysm Successfully Treated with Endovascular Stent.

Coarctation associated with a dissected aneurysm is uncommon and has an incidence of less than 1%. There are few reports describing treatment of this condition with stent graft. Challenging as it may be, endovascular treatment of complex cases has become the preferred modality especially when the anatomy is amenable. We describe the case of a 36-year old male, who suffered a car accident and was diagnosed with acute type B aortic dissection (ATBAD). CT-scan revealed a coarctation associated with a large dissected aneurysm (11cm). Complexity of pathology and high risk of rupture required immediate intervention. Open repair necessitates extensive surgery with a considerable risk of morbidity and mortality. We decided to perform an endovascular repair and subsequentially the patient was successfully treated with stent graft deployment, showing durable early-midterm results. Patient remains asymptomatic to this day and CT-scan at 3-year follow-up revealed a reduced and thrombosed aneurysm.

[Degeneration of atrioventricular nodal reentrant tachycardia into polymorphic ventricular tachycardia: a case report]. / Polimorfik ventrikül tasikardisine dönüsen atriyoventriküler nodal yeniden girisli tasikardi: Olgu sunumu.

Atrioventricular nodal reentrant tachycardia (AVNRT) is the most common form of paroxysmal supraventricular tachycardia and is usually treated successfully by radiofrequency catheter ablation. We report on a 38-year-old woman whose AVNRT attacks occasionally degenerated into polymorphic ventricular tachycardia (VT). The patient presented with a complaint of palpitations. The electrocardiogram was in sinus rhythm with a normal corrected QT interval. During Holter monitoring, narrow QRS complex tachycardia with a heart rate of 220 beats/min was noted at nighttime, that lasted for 90 minutes, during which two episodes of polymorphic VT were also seen. The diagnosis of AVNRT was confirmed on an electrophysiologic study and AVNRT was successfully treated by radiofrequency catheter ablation. The patient had no complaint during a follow-up of eight months, with no signs of arrhythmia on repeat Holter monitoring.

The beneficial effects of angiotensin-converting enzyme inhibitors on serum asymmetric dimethylarginine levels in the patients with cardiovascular disease.

ACEI and AT1 receptor antagonists are the drugs most consistently shown to reduce ADMA level in humans. Unfortunately, most of the human studies addressing the effect of pharmacotherapy on ADMA metabolism were accomplished on small patient subgroups and were relatively shortlasting. Besides, L-arginine was rarely measured in most studies, whereas L-arginine/ADMA ratio may be more important for NO synthase function than ADMA itself, and arginine concentration may be either increased or decreased by pharmacotherapy. We strongly believe that agents affecting ADMA more specifically (protein arginine methyltransferases inhibitors or dimethylarginine dimethylaminohydrolase inducers) deserve further investigation.

The small intestine: a critical linkage in pathophysiology of cardiac cachexia.

Impaired functioning of the gastrointestinal system may also contribute to malnutrition and cardiac cachexia (CC) in patients with chronic heart failure (CHF). Targets for future interventions include the deranged hormonal systems involved in energy balance as well as malabsorption from the gut and dietary supplementation. Other targets are the inhibition of proteasome-dependent protein degradation and the direct inhibition of pro-inflammatory pathways. The beneficial effects of ACE inhibitors, aldesterone inhibitors and beta-blockers in preventing or delaying the collagen deposition in the small intestine wall need to be elucidated. We strongly believe that by improving our understanding of the role of the gut in CC will lead to the development of novel therapeutic strategies in the near future.

Stent fracture: a new villain of the village.

Stent strut fracture (SSF) may be an important complication after drug-eluting stent (DES) implantation particularly in patients undergoing sirolimus-eluting stent (SES) implantation. The occurrence of SSF at 6 to 9 months after the SES implantation, which was relatively common, resulted in a higher rate of focal in-stent restenosis. Although this angiographic unfavorable outcome did not lead to an increased risk of adverse cardiac events in the current study, we believe that large-scale prospective studies are needed to elucidate the exact pathophysiology and clinical sequela of the stent strut fracture, including bare metal stents.

Metabolic syndrome and left ventricular dysfunction: new player of the game.

The metabolic syndrome (MS) is associated with impaired global left ventricular function. These preclinical cardiac abnormalities could be ascribed to the interplay of the metabolic components characterizing the MS. The MS can be clinically manifested in a variety of ways. A sizable number of metabolic changes thus occur in people with clinical evidence of the syndrome.We believe that the identification of these changes should provide a broader picture of the metabolic status of an affected individual.

Spontaneous dissection of left main coronary artery associated with hypertensive crisis: a probable fatal complication detected by intravascular ultrasound.

Spontaneous coronary artery dissection (SCAD) is a rare cause of acute ischemic coronary events with complex pathophysiology. It usually occurs in middle-aged women during pregnancy and postpartum period without traditional risk factors for coronary artery disease (CAD). Those patients over age 40 are more likely to have dissections associated with atherosclerosis. Several drugs and clinical conditions are associated with SCAD. It is frequently fatal and a great number of cases have been diagnosed at necroscopy. The quick recognition of SCAD and initiation of treatment may be life saving. In this report, we define a case of dissection of left main coronary artery, possibly triggered by hypertensive crisis, with no apparent atherosclerotic involvement detected by intravascular ultrasound (IVUS) and successfully treated with surgical revascularization.

Chill therapy in the patients with resuscitated cardiac arrest: a new weapon in the battle against anoxic brain injury.

Improved cooling technologies (such as newer intravascular cooling devices) may result in earlier attainment of target temperature and even more robust clinical benefits in the management of the survivors of cardiac arrest. Earlier cooling may also be facilitated by the introduction of cooled saline infusions in the emergency room setting, prior to induction of cooling in the intensive care unit. However, there is a need for studies of adjunctive therapies to minimize the risk of medical complications associated with hypothermia, the most serious of which is infection. We strongly believe that larger confirmatory studies might encourage more widespread adoption of therapeutic hypothermia for survivors of cardiac arrest and further studies are also needed to evaluate the utility of this procedure for more expanded indications, including asystole, pulseless electrical activity, and in-hospital arrest in patients without significant comorbidity.

The impact of admission C-reactive protein levels on the development of no-reflow phenomenon after primary PCI in patients with acute myocardial infarction: the role of inflammation.

The role of admission CRP levels on the prediction of poor myocardial perfusion grades after percutaneous coronary intervention (PCI) in patients with acute myocardial infarction (AMI) has not been clearly elucidated. Dynamic nature of acute coronary syndromes is usually associated with spontaneous ischemia-reperfusion injury in infarct related artery. So we considered that poor myocardial perfusion after primary PCI is not only related to procedural factors and clinical characteristics of the patients but may also be related to microvascular damage starting before coronary intervention. We suggested that CRP mediated complement activation and neutrophil plugging may be the factors contributing to the development of microvascular damage in patients with AMI.

Beta blockers for the prevention of atrial fibrillation after coronary artery bypass surgery: carvedilol versus metoprolol.

Although all beta blockers appear to be effective in the prevention of postoperative atrial fibrillation (AF) following coronary artery bypass surgery (CABG), carvedilol was found to be much more effective than metoprolol in this respect as the current study clearly delineated. We believe that the ongoing COMPACT trial will answer the question of whether or not carvedilol is more superior than metoprolol to prevent postoperative AF in patients undergoing CABG.

Culprit only versus multivessel coronary revascularization in patients presenting with acute ST elevation myocardial infarction: unending debate.

The optimal percutaneous interventional strategy for dealing with significant non-culprit lesions in patients with multivessel disease with acute myocardial infarction (AMI) at presentation remains to be controversial. For the time being, the current guidelines recommended that primary percutaneous coronary intervention (PCI) for non-culprit lesions should be limited to the infarct-related artery. We believe that decisions about PCI of the non-infarct vessel(s) should be individualized and guided by objective evidence of significant residual ischemia except in patients with multivessel disease showing hemodynamic compromise. Further large, randomized trials will help us solve this dilemma.

The clinical presentation of restenosis after bare metal stent implantation: behind a facade of benignity.

Contrary to common belief, bare metal in-stent restenosis (ISR) seems to be not a benign clinical entity. Thus,we believed that continued efforts are warranted to prevent bare metal ISR, including aggressive use of drug-eluting stent (DES) to decrease the incidence of acute coronary syndromes. However, despite improved outcomes with DES, bare metal stent (BMS) will continue to play a role for both clinical and economic reasons and we feel that there is still a future for BMS.

Impact of admission glomerular filtration rate on the development of poor myocardial perfusion after primary percutaneous intervention in patients with acute myocardial infarction.

AIMS: We aimed to investigate the impact of admission estimated glomerular filtration rates (eGFR) on the development of poor myocardial perfusion after primary percutaneous coronary intervention (pPCI) in patients presenting with acute ST-segment-elevation myocardial infarction (STEMI). MATERIALS AND METHODS: Study population consisted of 80 patients with STEMI (64 men, mean age=67.5+/-6.6 years) undergoing pPCI. Myocardial perfusion was evaluated by using thrombolysis in myocardial infarction (TIMI) myocardial perfusion grade (TMPG). Patients were divided into two groups according to TMPG after pPCI. Group 1 and 2 consisted of 40 patients with TMPGs 0-1 and 40 patients with TMPGs 2-3, respectively. GFR was calculated based on the abbreviated Modification of Diet in Renal Disease study equation. RESULTS: Admission serum creatine kinase-MB isoenzyme (CKMB) levels and the percentage of lower eGFR (<60 ml/min/1.73 m2) values of the patients with TMPGs 0-1 were significantly higher than those of the patients with TMPGs 2-3 after primary PCI (P=0.007, P<0.001, respectively). Univariate analysis identified pain-to-balloon time, eGFR lower than 60 ml/min/1.73 m2, peak CKMB, and TIMI flow grade 0/1 as the predictors of poor myocardial perfusion. In multivariate analysis peak CKMB, left ventricular ejection fraction less than 35%, admission TIMI flow grade 0/1, lower eGFR and pain-to-balloon time continued to have statistically significant independent association with poor myocardial perfusion in the model. Adjusted odds ratios were calculated as 12.05 for low eGFR [P=0.005; confidence interval (CI): 2.11-68.70], 8.10 for admission TIMI grade 0/1 (P=0.04; CI: 1.37-47.91), 7.04 for pain-to-balloon time (P<0.001; CI: 2.37-20.90), 6.76 for low left ventricular ejection fraction (P=0.03; CI: 1.12-40.61), and 1.02 for CKMB (P=0.01; CI: 1.00-1.04). CONCLUSION: Decreased GFR on admission in patients with STEMI is independently associated with the risk of poor myocardial perfusion following after primary PCI.

Metabolic agents in the management of diabetic coronary patients: a new era.

Modulation of myocardial free fatty acid metabolism is the key target for metabolic interventions in patients with coronary artery disease (CAD) with diabetes mellitus (DM). Because of its beneficial effects on heart metabolism at rest and on myocardial ischemia and left ventricular function, trimetazidine should be always combined with classical anti-ischemic treatment in patients with DM with CAD. We believe that, the new metabolic agents including L-carnitine, dichloroacetate, perhexiline and etomoxir will be added into our arsenal for the battle against CAD especially in patients with DM in the near future.

A physiologic approach to decreasing upward creep of the heart during myocardial perfusion imaging.

UNLABELLED: When body position changes from erect to supine, the effect of gravity on the organs also changes and is a possible underlying mechanism for upward creep of the heart during SPECT acquisitions. We hypothesized that if we provide enough time for the organs to settle after a positional change, the range of this vertical motion causing reconstruction artifacts can be decreased. Our aim was to evaluate the effect that a 5-min bed rest on the imaging table before both rest and stress SPECT acquisitions would have on upward creep of the heart. METHODS: Before both stress and rest SPECT acquisitions, the first 101 consecutive patients (group A) had a 5-min bed rest and the remaining 99 patients (group B) did not have any bed rest after they were positioned on the imaging table. Upward creep was detected by comparing the distance between the lower edge of the image and the lowest part of the heart silhouette on the last projection image of detector 2 and the first projection image of detector 1. RESULTS: Upward creep was found in 53% (54/101) and 55% (56/101) of patients in group A and in 89% (88/99) and 86% (85/99) of patients in group B in stress and rest SPECT studies, respectively. Upward creep of the heart was decreased prominently in group A, and this decrease was statistically significant (p < 0.001). CONCLUSION: We conclude that before SPECT acquisition, at least a 5-min bed rest on the imaging table significantly decreases vertical motion of the heart.