Search

Percutaneous coronary intervention (PCI) is increasingly used for unprotected left main coronary artery disease (UPLMS) revascularization. Data regarding long-term mortality in this subset of patients remain sparse. We aim to present our outcome data on all comers who had UPLMS PCI. Methods: Retrospective dataset analysis of prospectively collected data evaluating all UPLMS PCI performed in a large tertiary cardiac centre, between September 2003 and December 2012. Long-term mortality data were available over a median duration of 21 months (IQR 10 months to 43 months). Results: In total there were 483 procedures performed. The cohort consisted of 58% with non ST elevation myocardial infarction (NSTEMI), 17% with STEMI and 25% with stable angina (SA). The overall in-hospital and long-term mortality were 7% and 22% respectively. The in-hospital mortality was 23%, 6%, and 1.6% in STEMI, NSTEMI, and SA respectively. Long-term mortality was 31% in STEMI patients, 26% in NSTEMI and 10% in SA. The use of drug eluting stents (DES) [adjusted RR 0.40 (95% CI, 0.23-0.69)] and Intravascular ultrasound (IVUS) [adjusted RR 0.17 (95% CI 0.04-0.72)] were independently associated with improved long-term survival. Conclusion: UPLMS PCI is associated with favourable long-term survival. The use of DES and IVUS guided PCI appear to be associated with improved long-term outcome and should be considered in the routine management of this cohort of patients. [ABSTRACT FROM AUTHOR]

Abstract: Despite the improvement in pharmacologic treatment of heart failure, many patients continue to have severe persistent symptoms, and their prognosis remains poor. One of the most recent advances in heart failure management is the concept of cardiac resynchronization therapy (CRT) with right and left ventricular pacing. Large clinical trials have demonstrated morbidity and mortality benefits of CRT in patients with moderate to severe drug refractory heart failure (New York Heart Association (NYHA) functional class III or IV), and ejection fraction ≤35% with QRS duration ≥120 ms. Despite the documented benefits, 20–30% of patients selected to have CRT do not respond to this treatment. Echocardiography will probably play a more important role in better selecting patients with mechanical dyssynchrony who are more likely to respond to CRT. This article reviews the available evidence for CRT as well as the way to select responders to this rather invasive therapy. [Copyright &y& Elsevier]

Abstract: Background: The different levels of deoxyhemoglobin in the ischemic myocardium, induced by stressors such as dipyridamole, can be detected by blood oxygen level-dependent (BOLD) MRI and may be used to diagnose myocardial ischemia. The aim of this study was to assess the signal change in the myocardium on BOLD MRI as well as wall thickening between rest and dipyridamole stress images in ischemic and non-ischemic myocardium as identified on SPECT imaging. Methods: Twelve patients with stress-induced myocardial ischemia on SPECT underwent rest and dipyridamole stress MRI using a double breath-hold, T2⁎-weighted, ECG-gated sequence to produce BOLD contrast images as well as cine-MRI for wall thickening assessment in 10 of the 12 patients. Signal change on BOLD MRI and wall thickening were compared between rest and stress images in ischemic and non-ischemic myocardial segments as identified on SPECT. In each patient, two MRI slices containing 16 segments per slice were analysed. Results: In total, there were 384 segments for BOLD analysis and 320 for wall thickening. For BOLD signal 137 segments correlated to segments with reversible ischemia on SPECT and 247 to normal segments, while for wall thickening 112 segments correlated to segments with reversible ischemia and 208 to normal segments. The average BOLD MRI signal intensity change was −13.8 (±16.3)% in the ischemic segments compared to −10.3 (±14.7)% in the non-ischemic segments (p =0.05). The average wall thickening was 6.4 (±3.4) mm in the ischemic segments compared to 8.7 (±3.8) mm in the non-ischemic segments (p <0.0001). Conclusion: Stress-induced ischemic myocardium has a different signal change and wall thickening than non-ischemic myocardium and may be differentiated on BOLD MRI. Larger studies are needed to define a threshold for detection and to determine the sensitivity and specificity of this technique. [Copyright &y& Elsevier]

Cardiopulmonary exercise testing (CPET) has become an important clinical tool to evaluate exercise capacity and predict outcome in patients with heart failure and other cardiac conditions. It provides assessment of the integrative exercise responses involving the pulmonary, cardiovascular and skeletal muscle systems, which are not adequately reflected through the measurement of individual organ system function. CPET is being used increasingly in a wide spectrum of clinical applications for evaluation of undiagnosed exercise intolerance and for objective determination of functional capacity and impairment. This review focuses on the exercise physiology and physiological basis for functional exercise testing and discusses the methodology, indications, contraindications and interpretation of CPET in normal people and in patients with heart failure. [ABSTRACT FROM AUTHOR]

Cardiopulmonary exercise testing (CPET) has become an important clinical tool to evaluate exercise capacity and predict outcome in patients with heart failure and other cardiac conditions. It provides assessment of the integrative exercise responses involving the pulmonary, cardiovascular and skeletal muscle systems, which are not adequately reflected through the measurement of individual organ system function. CPET is being used increasingly in a wide spectrum of clinical applications for evaluation of undiagnosed exercise intolerance and for objective determination of functional capacity and impairment. This review focuses on the exercise physiology and physiological basis for functional exercise testing and discusses the methodology, indications, contraindications and interpretation of CPET in normal people and in patients with heart failure. [ABSTRACT FROM AUTHOR]

Cardiopulmonary exercise testing (CPET) has become an important clinical tool to evaluate exercise capacity and predict outcome in patients with heart failure and other cardiac conditions. It provides assessment of the integrative exercise responses involving the pulmonary, cardiovascular and skeletal muscle systems, which are not adequately reflected through the measurement of individual organ system function. CPET is being used increasingly in a wide spectrum of clinical applications for evaluation of undiagnosed exercise intolerance and for objective determination of functional capacity and impairment. This review focuses on the exercise physiology and physiological basis for functional exercise testing and discusses the methodology, indications, contraindications and interpretation of CPET in normal people and in patients with heart failure. [ABSTRACT FROM AUTHOR]

Percutaneous closure of atrial septal defect (ASD) and patent foramen ovale (PFO) has become increasingly utilized. The indications and results of percutaneous closure are diverse. Aim: To assess the indications, results, and complications of percutaneous closure of ASD and PFO in our tertiary center. Method: Case note review and retrospective analysis of all consecutive patients undergoing percutaneous closure over a 3-year period from January 2003 to October 2005 with a mean follow-up of 19 months (4–36). Results: There were 185 consecutive patients. The mean age was 44.9 years (SD 12.9) and 53% (n = 98) were males. There was 59% (n = 109) PFO and 41% (n = 76) ASD. The predominant indication for PFO closure was cerebrovascular accident (CVA) (42.2%, n = 46)- and for ASD, dilated right ventricle (68.4%, n = 52). Of all procedures, 94.6% (n = 175) were first time and 5.4% (n = 10) were redo for residual shunt. Overall, the success rate was 96.8% (n = 179) with two patients referred for surgical closure due to the large size of ASD and unsuitability for percutaneous closure, two procedures abandoned due to pericardial effusion, and two abandoned because the PFO was too small to cross. The Amplatzer device was used in 92.7% (n = 166) and the Starflex in 7.3% (n = 13). Minor complications were recorded in 10 patients (5.4%), of which 4 (2.2%) had minor venous access bleeding, 1 patient (0.5%) had retroperitoneal hematoma, and 2 patients (1.1%) had transient atrial fibrillation. One patient (0.5%) had transient inferior ST elevation during the procedure, one patient (0.5%) reported chest pain postprocedure, and one patient (0.5%) developed septicemia 3 weeks postprocedure. Major complications were recorded in three patients (1.5%), one patient (0.5%) with retroperitoneal hematoma requiring blood transfusion and two patients (1%) with pericardial effusion following transseptal puncture, requiring aspiration. No death, stroke, or device embolization was recorded. Conclusion: Our experience with percutaneous closure in adults demonstrates excellent results and safety with few complications. Percutaneous device closure will replace surgical closure for many ASDs and PFOs. [ABSTRACT FROM AUTHOR]

Abstract: Background: Blood oxygen level-dependent (BOLD) MRI relies on changes in deoxyhaemoglobin level in tissues under stress for signal variation and may be used for detection of ischaemic myocardium. Methods: 15 patients with stress induced myocardial ischaemia on PET scanning underwent rest and dypiridamole stress MRI using a double breath-hold T2⁎-weighted, ECG gated sequence to produce BOLD contrast images and cine-MRI for wall thickening assessment. Signal change on BOLD MRI and wall thickening were compared between rest and stress images in ischaemic and non-ischaemic myocardial segments. Results: Using PET, 156 segments were identified with reversible ischaemia and 324 as non-ischaemic. The ischaemic segments were found on BOLD MRI to have an average signal change between rest and stress of −16.7% compared to −14% in the non-ischaemic segments (p =0.04). The average wall thickening was 7.8 mm in the ischaemic segments compared with 9.5 mm in the non-ischaemic segments (p <0.0001). Conclusion: BOLD MRI with wall thickening assessment may differentiate ischaemic from non-ischaemic myocardium in patients with stress induced myocardial ischaemia. Larger studies with improved spatial resolution would help define a threshold for detection of ischaemia as well as determine this technique''s sensitivity and specificity. [Copyright &y& Elsevier]

Abstract: Background: Blood oxygen level dependent (BOLD) T2* MRI detects signal variance within the myocardium based on changes in the deoxyhaemoglobin level following pharmacological stress, and it has the potential to identify areas of myocardial ischemia. The aim of the present study was to assess the utility of BOLD T2* MRI in the detection of myocardial ischemia in patients with an existing diagnosis of coronary artery disease. Method: Twenty-one patients with established three-vessel coronary artery disease on coronary angiography underwent rest and dipyridamole stress MRI using a double breath-hold T2* weighted ECG gated sequence. Analysis was performed on multiple short-axis slices of the heart, projected as a bull''s eye. The myocardium was divided into three coronary territories, yielding 63 territories in total. A signal change between rest and stress of more than ±4% was significant, implying a change in deoxyhaemoglobin concentration. A signal decrease or no changes denote the presence of ischemia, while a signal increase indicates no ischemia. Results: All images were of sufficient quality for signal intensity analysis. In 12/63 territories (19%), a significant signal increase following stress was detected. A significant signal decrease was detected in 34/63 territories (54%), and in 17/63 territories (27%) there was a non-significant change. The presence of a perfusion defect was identified, therefore, in 51/63 (81%), based on the signal difference between rest and stress. Conclusion: Changes in myocardial oxygen level appear to be detectable by BOLD T2* MRI without using contrast media. Further, larger comparative studies are required to evaluate the diagnostic and prognostic impact of this technique and to compare it to the gold standard methods for the detection of myocardial ischemia. [Copyright &y& Elsevier]

Although myocardial infarction (MI) mainly occurs in patients older than 45, young men or women can suffer MI. Fortunately, its incidence is not common in patients younger than 45 years. However, the disease carries a significant morbidity, psychological effects, and financial constraints for the person and the family when it occurs at a young age. The causes of MI among patients aged less than 45 can be divided into four groups: (1) atheromatous coronary artery disease; (2) non-atheromatous coronary artery disease; (2) hyper-coagulable states; (4) MI related to substance misuse. There is a considerable overlap between all the groups. This article reviews the literature and highlights the practical issues involved in the management of young adults with MI. [ABSTRACT FROM AUTHOR]

Cocaine is the second commonest illicit drug used and the most frequent cause of drug related deaths. Its use is associated with both acute and chronic complications that may involve any system, the most common being the cardiovascular system. Cocaine misuse has a major effect in young adult drug users with resulting loss of productivity and undue morbidity with cocaine related cardiac and cerebrovascular effects. Many cocaine users have little or no idea of the risks associated with its use. Patients, health care professionals, and the public should be educated about the dangers and the considerable risks of cocaine use. This review concentrates on the cardiovascular effects of cocaine and their management. [ABSTRACT FROM AUTHOR]

Background: The identification of viable myocardium in patients with impaired left ventricular contraction secondary to coronary heart disease is important clinically as such myocardium is likely to benefit from revascularisation. Blood oxygen level dependent (BOLD) magnetic resonance imaging (MRI) relies on changes in deoxyhaemoglobin concentration under stress for signal generation and could be used for the differentiation between scarred and viable myocardium.Aim: To assess the signal change on BOLD MRI in viable and scarred myocardium as identified by positron emission tomography (PET).Method: 19 patients with impaired left ventricular contraction and at least one akinetic area were enrolled. They underwent rest and dipyridamole stress MRI, using a double breath hold T2* weighted, ECG gated sequence to produce BOLD contrast images, and cine-MRI for wall thickening assessment. Dynamic perfusion and metabolic PET images followed the MRI. Signal change on BOLD MRI and the wall thickening were compared between rest and stress images in hibernating and scarred segments identified by PET on two short axis slices of mid ventricle, with eight segments each.Results: Using PET, 68 segments were identified as hibernating and 42 as scarred. The hibernating segments were found on BOLD MRI to have an average signal change between rest and stress of -9.53%, compared with -2.15% in the scarred segments (p = 0.008). The average wall thickening was 8.7 mm in the hibernating segments compared with 5.9 mm in the scarred segments (p < 0.0001).Conclusions: BOLD MRI with wall thickening may differentiate scarred and viable myocardium and help identify suitable patients for revascularisation. Further larger studies are needed to establish a threshold for detection, sensitivity, and specificity. [ABSTRACT FROM AUTHOR]

Systemic emboli are important clinically and have a high morbidity and mortality. The identification of the source of embolisation is crucial for further treatment and management. The aorta harbours the source of emboli in a small but significant number of cases. However, it is usually underestimated as the source of systemic embolisation. The use of transoesophageal echocardiography facilitates establishing the diagnosis and guiding management decisions. [Copyright &y& Elsevier]

Abstract: Warfarin is used extensively in clinical practice for numerous indications. It is generally safe. Bleeding is the major risk of warfarin; several uncommon adverse skin manifestations may also be associated with its use. These range from ecchymoses and purpura, haemorrhagic necrosis and maculopapular vesicular urticarial eruptions to cutaneous necrosis, purple digit syndrome and warfarin-induced skin necrosis. Early recognition and diagnosis of these adverse reactions are important to avoid morbidity and possible mortality. All health professionals should be aware of these complications. [Copyright &y& Elsevier]

Quadricuspid aortic valve and sinus of Valsalva fistula are rare congenital anomalies. We report the first case of association of these two congenital anomalies in an adult patient and the important role of Magnetic Resonance Imaging (MRI) in establishing and confirming the correct diagnosis and helping in planning the treatment. [Copyright &y& Elsevier]

This article presents the case study of a 30 year old insulin dependent diabetic man, who was treated for severe diabetic ketoacidosis. He was a smoker with a 15 year history of diabetes mellitus. Eight hours following admission, ST segment elevation was noted on the monitor and an inferolateral acute myocardial infarction pattern was confirmed by ECG. Hyperkalaemia may produce multiple ECG abnormalities, including ST segment elevation and pseudoinfarct pattern with resolution of these abnormalities on correcting the hyperkalaemia. When faced with a patient with hyperkalaemia, ST segment elevation may pose a diagnostic and management dilemma regarding the use of thrombolysis.

A 66 year old man with two previous coronary bypass surgeries underwent coronary angiography and grafts restudy for recurrent angina. A vein graft to the left anterior descending artery (LAD) severe stenosis before its insertion with an aneurysmal dilatation of the LAD at the site of the graft insertion. With the help of an interventional radiologist, authors proceeded to percutaneous embolisation of the aneurysm using metal wires, which are usually used for cerebral aneurysms, under fluoroscopy. The aneurysm was obliterated completely using 30 wires. Angioplasty with stent insertion was then carried out at the graft stenosis with an excellent result. Repeat angiography six weeks later showed no flow in the aneurysm and no restenosis.

Objective: To assess the impact of diabetes on 2-year mortality in current PCI practice. Background: In patients with coronary artery disease undergoing revascularization, diabetes mellitus is associated with higher mortality. Methods: A retrospective analysis was done of all patients undergoing PCI at our tertiary center between January 2000 and December 2004. There were 6,160 PCI procedures performed in 5,759 patients who received at least one stent. Of these patients, 801 (13.9%) were diabetic and 4,958 (86.1%) were nondiabetic. The primary outcome measure of the study was all-cause mortality. All patients were followed up for a period of 2 years. Multivariate logistic regression analysis was used to test for a potential independent association between diabetic status and follow-up mortality. Results: Before adjustment, a trend toward higher mortality was observed in diabetic patients compared to non-diabetics at 1 year (3.2% vs 2.4%) and 2 years (5.1% vs 3.8%), P = 0.12. Independent predictors for mortality were increasing age, renal dysfunction, peripheral vascular disease, NYHA class >2, urgent PCI, treating left main stem lesions, vessel diameter ≤ 2.5 mm, and 3-vessel disease. The use of drug-eluting stent was associated with a reduction in mortality. Diabetes was found to have no independent impact on mortality following PCI (odds ratio = 1.08; 95% confidence intervals = 0.73–1.60; P = 0.71). Conclusion: The presence of diabetes was not an independent predictor of mortality following PCI. A diabetic patient that does not require insulin treatment and has no evidence of macro- or microvascular diabetic disease could enjoy a PCI outcome similar to nondiabetic subjects. [ABSTRACT FROM AUTHOR]