A rare combination of coronary anomalies.

Coronary anomalies are found in less than 1% of diagnostic coronary angiograms. The clinical relevance of these anomalies varies from insignificant to potentially lethal. The major role of coronary angiography in interventional cardiology and coronary surgery underscores the importance of having knowledge of the variations in coronary anatomy and their clinical relevance. We report a rare case of a patient with a combination of coronary anomalies: coronary fistulae, a double circumflex coronary artery and anomalous origin of a circumflex artery from the proximal right coronary artery. (Neth Heart J 2008;16:387-9.).

[In favour of performing coronary balloon dilatation in 'smaller' hospitals]. / Vóór dotteren in 'kleinere' ziekenhuizen.

Until now, the permission to set up a centre for percutaneous coronary intervention (PCI) has been governed by Dutch law to ensure the availability and quality of PCI procedures. Recently, the Minister of Health proposed abolishing this law for PCI procedures. The Dutch Society of Cardiology has issued stringent guidelines for PCI centres. Even small hospitals should be able to start a PCI programme by following these stringent guidelines.

Pseudonormalisation of the T wave: old wine?: A fresh look at a 25-year-old observation.

A 74-year-old woman with documented coronary artery disease presented with symptoms of angina at rest. During these episodes of angina, the initial abnormal terminal negative T waves converted to normal positive T waves. In this article the significance of pseudonormalisation as a sign of ischaemia is reviewed. The underlying electropathological basis of this phenomenon is discussed as well. (Neth Heart J 2007;15:257-9.).

Coronary tortuosity: a long and winding road.

Coronary tortuosity is a phenomenon often encountered by cardiologists performing coronary angiography. The aetiology and clinical importance of coronary tortuosity are still unclear. Coronary tortuosity without fixed atherosclerotic stenosis in patients with angina pectoris and an abnormal exercise stress test has never been described in the literature.This article describes three cases of patients with anginal complaints, an abnormal exercise stress test and coronary angiography without the presence of a fixed atherosclerotic lesion.It is hypothesised that coronary tortuosity leads to flow alteration resulting in a reduction in coronary pressure distal to the tortuous segment of the coronary artery, subsequently leading to ischaemia. Future studies will be necessary to elucidate the actual mechanism of coronary tortuosity and its clinical significance. (Neth Heart J 2007;15:191-5.).

Posterior myocardial infarction: the dark side of the moon.

The clinical presentation of posterior myocardial infarction is not always easy, not even for the cardiologist. In this article a 70-year-old woman who presented with chest pain is described. The electrocardiogram at presentation showed marked ST-segment depression in leads V(1) to V(5) and slight ST-segment depression in leads I and aVL. There was ST-segment elevation in the posterior leads V(7) to V(9). Elevation of specific cardiac enzymes confirmed the diagnosis of myocardial infarction. True posterior myocardial infarction is difficult to recognise because the leads of the standard 12-lead electrocardiogram are not a direct representation of the area involved. Only with indirect changes in the precordial leads as such the diagnosis can be suspected. This review will highlight the electrocardiographic fine-tuned diagnosis of posterior myocardial infarction by using the posterior leads V(7) to V(9) leading to easier and faster recognition with consequences for treatment and improved prognosis. (Neth Heart J 2007;15:16-21.).

Be smart, don't kick the heart.

Blunt chest trauma is a rare cause of cardiac pathology. Nevertheless, a variety of life-threatening cardiac diseases can be caused by blunt chest traumas. In this case report we describe a myocardial infarction associated with kickboxing. We also review the literature describing myocardial infarction associated with blunt chest trauma.

Arteriovenous fistula after intervertebral disk surgery at L4-L5.

We describe a 34-year-old woman who had symptoms of heart failure due to an arteriovenous fistula between the right iliac artery and the inferior vena cava caused by surgery for a herniated intervertebral disk. The literature is reviewed. An intra-arterial placed covered stent was successfully used to close the fistula.

[International and Dutch reanimation guidelines]. / Internationale en nationale reanimatierichtlijnen.

The 'Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care' have been published in a number of journals by a group of international experts. Although these guidelines are not dictated or imposed, their implementation would necessitate changes to the curriculum 'Basic Life Support' instruction for laymen. The recall of all persons ever instructed to inform them about the new Guidelines is also necessary. However, in view of the present lack of solid scientific basis, the wisdom of implementing the present guidelines in Dutch practice in an unrestricted manner has to be questioned, due to financial and human impact that would be involved.

[Resuscitation: CAB versus ABC]. / Reanimatie: CAB versus ABC.

In the resuscitation guidelines revised by the Netherlands Resuscitation Council, the decision has been made to conform with the resuscitation flowchart used elsewhere in the world, and to use the ABC sequence: 'airway-breathing-circulation'. This implies that the CAB sequence ('circulation-airway-breathing'), which has been in use since 1981, has been abandoned. Intrinsic arguments in favour of the CAB scheme are based on animal experiments and observations in humans. They come down to time-saving in the various diagnostic and therapeutic steps, whereby the chance of successful recovery of the circulation increases, and the convalescence phase and the risk of brain damage probably are reduced. In addition, this scheme is better suited to the relatively large group of patients with a cardiac cause underlying their loss of consciousness, and to the preference of lay people to limit themselves to heart massage when attending the patient. Intrinsic arguments in favour of the ABC scheme are not based on scientific data. They concern improvement of the ventilation-perfusion ratio with the first heart massage, oxygenation of the blood in the lung capillaries, improvement of the circulation and the palpability of pulses.

Between the devil and the deep blue sea: an unusual kind of late cardiac tamponade with a therapeutic dilemma.

A 67-year-old patient underwent a left pneumectomy because of a moderately differentiated squamous cell carcinoma. Two weeks later, while still in hospital, he suddenly experienced an acute increase in dyspnoea. Pulmonary embolism was considered. However, echocardiography showed compression of the right ventricle and right atrium by an intrapericardial mass, confirmed by computed tomography. Following signs of a large thrombus in the inferior vena cava, pericardiocentesis was considered undesirable due to possible dislocation resulting from the sudden changes in intrapericardial pressure. Re-thoracotomy was equally undesirable because of the recent operation and status of the patient. After stabilisation and extensive consulting the patient was referred for pericardiocentesis by sternotomy. Huge blood clots were removed from the pericardial space. No thrombus mass was found in the inferior vena cava. The patient recovered uneventfully.

Ventricular fibrillation and rhabdomyolysis after administration of succinylcholine.

Succinylcholine is a depolarising muscle relaxant. Because of its quick onset of action, it is particularly used in situations which require urgent intubation. However, there have been several reports of cardiac arrest after administration of succinylcholine. We describe the case of a young woman who developed ventricular fibrillation and rhabdomyolysis following succinylcholine administration. Possible mechanisms and treatment are discussed.

Friction and fluid: correlating pericardial effusion and pericardial friction rub.

BACKGROUND: In this study the relationship between pericardial friction rub (PFR) and the degree of pericardial effusion was investigated. METHODS: A retrospective study was performed involving all patients for whom the diagnosis pericarditis was made on clinical grounds (type of chest pain, fever, laboratory findings and/or electrocardiographic signs) in the period 1990-1999. In this patient group (n=138) the presence of PFR was correlated against the amount of pericardial effusion measured echocardiographically. RESULTS: No statistically significant correlation between the presence of PFR and the amount of pericardial effusion was observed. It is, therefore, a misconception that the presence of a PFR signifies absence or only a small volume of pericardial effusion. Our results are in line with the literature. CONCLUSION: Based on this study and results presented in the literature, we postulate that the friction rub associated with pericarditis is not caused by friction of the 'roughened' pericardial layers, as is commonly propagated. Instead fibrin strands caused by the inflammation, connecting the two pericardial layers, may function as snares and generate, through the movements of the heart, the typical triphasic pericardial friction rub.

Temporal arrest.

Two patients are presented in which documented periods of asystole were caused by temporal epilepsy. Pacemaker implantation prevented total collapse but episodes of near collapse continued. After institution of anti-epileptic drug treatment both patients are free of symptoms.