Urgent Pericardiocentesis Is More Frequently Needed After Left Circumflex Coronary Artery Perforation.

Background: Coronary artery perforation (CAP) is a rare but potentially life-threatening complication of percutaneous coronary interventions (PCIs) due to the risk of cardiac tamponade. Strikingly, in contrast to numerous analyses of CAP predictors, only few studies were focused on the predictors of tamponade after PCI, once iatrogenic CAP has occurred. Our aim was to search for clinical and periprocedural characteristics, including the coronary artery involved, associated with the development of acute cardiac tamponade among patients experiencing CAP. Methods: From the medical records of nine centers of invasive cardiology in southern Poland, we retrospectively selected 81 patients (80% with acute myocardial infarction) who had iatrogenic CAP with a visible extravasation jet during angiography (corresponding to type III CAP by the Ellis classification, CAPIII) over a 15-year period (2005-2019). Clinical, angiographic and periprocedural characteristics were compared between the patients who developed acute cardiac tamponade requiring urgent pericardiocentesis in the cathlab (n = 21) and those with CAPIII and without tamponade (n = 60). Results: CAPIII were situated in the left anterior descending artery (LAD) or its diagonal branches (51%, n = 41), right coronary artery (RCA) (24%, n = 19), left circumflex coronary artery (LCx) (16%, n = 13), its obtuse marginal branches (7%, n = 6) and left main coronary artery (2%, n = 2). Acute cardiac tamponade occurred in 24% (10 of 41), 21% (4 of 19) and 37% (7 of 19) patients who experienced CAPIII in the territory of LAD, RCA and LCx, respectively. There were no significant differences in the need for urgent pericardiocentesis (37%) in patients with CAPIII in LCx territory (i.e., the LCx or its obtuse marginal branches) compared to CAPIII in the remaining coronary arteries (23%) (p = 0.24). However, when CAPIII in the LCx were separated from CAPIII in obtuse marginal branches, urgent pericardiocentesis was more frequently performed in patients with CAPIII in the LCx (54%, 7 of 13) compared to subjects with CAPIII in an artery other than the LCx (21%, 14 of 68) (p = 0.03). The direction of this tendency remained consistent regardless of CAP management: prolonged balloon inflation only (n = 26, 67% vs. 13%, p = 0.08) or balloon inflation with subsequent stent implantation (n = 55, 50% vs. 24%, p = 0.13). Besides LCx involvement, no significant differences in other characteristics were observed between patients according to the need of urgent pericardiocentesis. Conclusions: CAPIII in the LCx appears to lead to a higher risk of acute cardiac tamponade compared to perforations involving other coronary arteries. This association may possibly be linked to distinct features of LCx anatomy and/or well-recognized delays in diagnosis and management of LCx-related acute coronary syndromes.

[Pseudo-Wellens syndrome in a patient with vasospastic angina]. / Rzekomy zespól Wellensa u pacjenta z dlawica naczyniowo−skurczowa.

Wellens syndrome is characterised by negative or biphasic T waves in V2-V4 leads and critical stenosis of proximal part of the left descending coronary artery. These ECG changes without atherosclerotic changes in coronary angiography, i.e. coronary artery spasm are called pseudo-Wellens syndrome. We describe a patient with acute coronary syndrome and pseudo-Wellens syndrome as a cause of vasospastic angina. These ECG abnormalities need differentiation with acute pulmonary embolism.

[Acute coronary syndrome with minimal electrocardiographic changes as a manifestation of large, first diagonal branch occlusion]. / Ostry zespól wiencowy z minimalnymi zmianami elektrokardiograficznymi jako manifestacja zamkniecia duzej, pierwszej galezi diagonalnej.

A case of a 61-year-old patient with acute coronary syndrome (ACS) and minimal ECG changes is presented. The patient was admitted to a community hospital, where non-ST-segment elevation ACS was diagnosed. He was given standard pharmacotherapy and was transferred very early to an invasive facility, where coronarography and percutaneous coronary intervention of the large diagonal branch were performed. We stress the importance of non-invasive assessment with ECG and echocardiography, in addition to coronary angiography, for diagnosis and treatment decisions in complex cases.

[Transient left ventricular apical ballooning syndrome--a case report]. / Zespól tako-tsubo--tajemnicza kardiomiopatia--wariant ostrego zespolu wiencowego z przetrwalym uniesieniem odcinka ST.

We present a case of a 78-year-old female who was admitted to the hospital due to clinical and electrographic features of ST-elevation acute myocardial infarction. Coronary angiography revealed normal coronary arteries and severe left ventricular contractility abnormalities, detected initially by echocardiography, which resolved within 20 days from hospital admission. Because of these findings and typical echocardiographic picture, a transient left ventricular apical ballooning syndrome (the tako-tsubo syndrome) was diagnosed.