Contrast media injection into right coronary artery caused thrombus extraction to aorta that may have resulted in left main trunk thrombosis.

A 59-year-old man with inferior acute myocardial infarction underwent an urgent coronary angiography and as a result a total occlusion of the ostial right coronary artery (RCA) was observed. Interestingly, the thrombus in the RCA clearly shortened within 2.3 s during the contrast media injection. While we prepared for percutaneous coronary intervention (PCI) of the RCA, ventricular fibrillation occurred and pulseless electrical activity continued in spite of repeated cardioversion. Despite no stenosis in the left main trunk (LMT) in the initial coronary angiography, the LMT was totally occluded. Following aspiration therapy on the LMT with percutaneous cardiopulmonary support, PCI of the RCA was performed. A coronary angiography should be carefully performed if a lot of thrombi exist in the coronary ostium because LMT embolism may have been caused by thrombus extraction from the RCA by contrast media injection.

Hyperuricemia as a risk factor for progressive renal insufficiency after coronary intervention in patients with chronic kidney disease.

The development of renal insufficiency after percutaneous coronary intervention (PCI) is associated with increases in morbidity and mortality. Recent studies have reported that hyperuricemia (HU) results in hypertension, intrarenal vascular disease, and renal injury. We postulated that HU contributes to progressive renal disease after PCI. We studied 139 patients with chronic kidney disease (CKD) undergoing elective PCI including 59 HU patients. We assessed the relationship between HU and the development of renal insufficiency after PCI by estimating traditional contrast-induced nephropathy (CIN) and persistent postprocedural nephropathy (PPN) defined as an increase in creatinine ≥0.2 mg/dl of the baseline value 2 weeks after procedure. CIN and PPN were seen in 6.5 and 28.8% respectively. The incidence of PPN was higher in HU patients than in non-HU patients (p < 0.001) although the incidence of CIN was not significantly different between the two groups. PPN was more frequently observed in hyperuricemic patients irrespective of association with hypertension (with and without hypertension, p < 0.001 and p = 0.034, respectively). By univariate analysis, HU and hypertension are associated with PPN although there was no significant predictor of CIN in this study. Multivariate analysis showed HU and hypertension were independent predictors of PPN. HU is a predictor of slow and mild development of renal insufficiency after PCI in patients with CKD.

Prognostic values of perfusion-metabolic mismatch in Tl-201 and BMIPP scintigraphic imaging in patients with chronic coronary artery disease and left ventricular dysfunction undergoing revascularization.

OBJECTIVES: The aim of this study was to assess the prognostic value of the amount of perfusion-metabolic mismatch in revascularized patients with left ventricular (LV) dysfunction by means of Thallium (Tl)-201 and BMIPP imaging. METHODS: Seventy-six patients with LV dysfunction and coronary artery disease underwent Tl-201 and BMIPP imaging. They were revascularized with either coronary artery bypass graft or balloon angioplasty and were entered into this study. To quantify the amount of perfusion-metabolic mismatch, SPECT images were displayed as polar maps and analyzed semiquantitatively. The patients were followed up for a mean period of 32 months for cardiac mortality and non-fatal cardiac events. Standard follow-up left ventriculography was performed 6 to 12 months after revascularization. RESULTS: Thirty-two patients exhibited a large amount of perfusion-metabolic mismatch (> 7 segments, group A), 28 patients had a small amount of perfusion-metabolic mismatch (2 to 6 segments, group B), and 16 patients were found to have no perfusion-metabolic mismatch (group C). Similar pre-revascularization LVEF of 35 +/- 5%, 34 +/- 8% and 36 +/- 6% increased to 45 +/- 8% (p < 0.0001), to 38 +/- 8% (p < 0.05), and to 36 +/- 3% (n.s.), respectively, after revascularization. The functional improvement after revascularization in group A was accompanied by a low rate of cardiac events during follow-up and better cardiac event free survival as judged by the Kaplan-Meier method (p < 0.05, vs. group B and C). CONCLUSION: In revascularized patients with severe LV dysfunction, the presence of a large amount of perfusionmetabolic mismatch evaluated by Tl-201 and BMIPP imaging identifies patients with the best prognosis.