Predisposing Factors, Demographics, Angiographic Features, and the Possible Role of Inflammation in Coronary Perforations-A 10-year Single-center Experience.

BACKGROUND: Coronary perforation during percutaneous coronary intervention is a rare but dreaded complication. The risk factors, optimal management, and outcome remain obscure. OBJECTIVES: To determine the predisposing factors, optimal management, and preventive strategies. We retrospectively looked at coronary perforations at our catheterization laboratory over the last 10 years. We reviewed patient charts and reports. Two independent operators, in a blinded approach, reviewed all procedural cineangiograms. Data were analyzed by simple statistical methodology. RESULTS: Nine patients were treated conservatively and six patients were treated with prolonged balloon inflation. Six patients were treated with polytetrafluoroethylene (PTFE)-covered stents. One patient required emergency coronary artery bypass graft. No deaths were reported. Subjects with perforations also had a significantly higher total white blood cell count (means 12,134 versus 6,155, 95 % confidence interval [CI], p< 0.0001, n=22), total absolute neutrophil count (means 74.2 % versus 57.1 %, 95 % CI, p<0.0001, n=22), and neutrophil:lymphocyte ratio (means 3.65 versus 1.50, 95% CI, p<0.0001, n=22). CONCLUSIONS: Coronary perforations are rare but potentially fatal events. Hypertension, small vessel diameter, high balloon:artery ratio, use of hydrophilic wires, and presence of myocardial bridging appear to be possible risk factors. Most perforations can be treated conservatively or with prolonged balloon inflation using perfusion balloons. Use of PTFE-covered stents could be a life-saving measure in cases of large perforations. Subjects with perforations also had greater systemic inflammation as indicated by elevated white cell counts.

Isolated and significant left main coronary artery disease: demographics, hemodynamics and angiographic features.

Left main coronary artery disease carries a poor prognosis. The etiology of isolated and significant left main coronary artery (ILMCA) disease is not well understood. Studies so far were limited by small numbers. The authors identified 46 patients with ILMCA disease from their database over 10 years (group I) and compared them with 83 consecutive patients undergoing catheterization (group II). They also compared patients with ostial vs distal ILMCA disease. Group I represented 0.1% of catheterization patients. The demographic profile and atherosclerotic risk factor profile of the 2 groups as well as ostial and distal ILMCA disease were compared. This is the largest study of ILMCA disease. Risk factors for atherosclerosis were commonly seen. Nonatherosclerotic causes of ILMCA disease were not seen. This study suggests coronary atherosclerosis as the predominant cause of ILMCA disease. ILMCA disease is more common in women. Diabetes is more commonly associated with distal ILMCA lesion. There is a trend suggesting that ostial ILMCA lesion is more common in smokers and women.

Prediction of left main coronary artery obstruction by 12-lead electrocardiography: ST segment deviation in lead V6 greater than or equal to ST segment deviation in lead V1.

BACKGROUND: Acute coronary syndrome (ACS) resulting from culprit lesion in left main coronary artery (LMCA) can cause rapid hemodynamic deterioration. It is important to identify these patients early to facilitate timely revascularization. ST segment elevation in aVR greater than or equal to V(1) (aVR-V(1)>or= 0) has been suggested as a sensitive predictor of LMCA disease. As a result of balanced forces, we hypothesized that ST deviation in V(6) greater than or equal to ST deviation in V(1) (V(6)-V(1)>or= 0) might be a good determinant of LMCA disease. METHODS: We compared admission 12-lead ECGs of ACS resulting from culprit LMCA lesion (n = 75, group I) with ACS resulting from culprit left anterior descending lesion (n = 81, group II). Group I was selected over a period of 10 years. We compared V(6)-V(1)>or= 0 to aVR-V(1)>or= 0 in both groups. We also looked at ratios of ST deviations in V(6),V(1) (V(6)/V(1)>or= 1) and aVR,V(1) (aVR/V(1)>or= 1) in patients where ST segment in V(1) was not isoelectric (group I = 54 and group II = 55). RESULTS: ST deviation in V(6) was significantly greater in group I as compared to group II (P < 0.001). The reliabilities of V(6)-V(1)>or= 0, V(6)/V(1)>or= 1, aVR-V(1)>or= 0, and aVR/V(1)>or= 1 in predicting LMCA disease were determined. CONCLUSION: This is the largest series of ECG analysis on ACS resulting from culprit LMCA lesion. V(6)-V(1)>or= 0 and V(6)/V(1)>or= 1 were more sensitive in predicting LMCA as culprit vessel in comparison to previously reported greater ST segment elevation in aVR than V(1).

Risk stratification for sudden cardiac death in patients with non-ischemic dilated cardiomyopathy.

Non ischemic dilated cardiomyopathy (NIDCM) is a disorder of myocardium. It has varying etiologies. Albeit the varying etiologies of this heart muscle disorder, it presents with symptoms of heart failure, and rarely as sudden cardiac death (SCD). Manifestations of this disorder are in many ways similar to its counterpart, ischemic dilated cardiomyopathy (IDCM). A proportion of patients with NIDCM carries a grave prognosis and is prone to sudden cardiac death from sustained ventricular arrhythmias. Identification of this subgroup of patients who carry the risk of sudden cardiac death despite adequate medical management is a challenge. Yet another method is a blanket treatment of patients with this disorder with anti arrhythmic medications or anti tachyarrhythmia devices like implantable cardioverter defibrillators (ICD). However this modality of treatment could be a costly exercise even for affluent economies. In this review we try to analyze the existing data of risk stratification of NIDCM and its clinical implications in practice.