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A 25-year-old woman presented with sudden severe left-sided chest pain. Her co-morbidities include systemic lupus erythematosus, antiphospholipid antibody syndrome, four prior strokes, patent foramen ovale (closed percutaneously), and an abdominal aortic aneurysm repair. Upon admission, her INR was 3 (on coumadin). A chest CT scan ( Panel A ) showed a large mediastinal haematoma (asterisk) and active extravasation (arrow) …

In a 25-year-old patient treated with covered stents for a giant aneurysm of the LAD post-Kawasaki (arrowhead in Panel A ), intravascular ultrasound was used to confirm the size and characteristics of a smaller aneurysm in the mid-RCA ( Panels B and C ). No treatment was performed as the maximal aneurysm …

Background Atrial septal aneurysm has been considered a potential source of cardiogenic embolism for many years. The present study evaluated the prevalence and characteristics of atrial septal aneurysm in a patient population with stroke and normal carotid arteries compared to a control population without stroke. Methods A total of 606 patients were enrolled between November 1990 and December 1996. The study group included 245 patients who had experienced cerebral ischaemic attack but had normal carotid arteries. The control group included 316 age- and sex-matched patients undergoing transoesophageal echocardiography for indications other than a search for a cardiac source of embolism. The prevalence and morphological characteristics of atrial septal aneurysm were evaluated and compared. Results We reported a higher prevalence of atrial septal aneurysm in the group with cerebral ischaemia; 68 patients (27·7%) vs 36 patients (9·9%) from the control group; P

A 61-year-old gentleman underwent coronary computed tomography (CT) angiography (CCTA) for atypical chest pain, which revealed partially ectatic, diffusely diseased coronary arteries and a giant, eccentric, and partially thrombosed aneurysm in the proximal segment of the right coronary artery (RCA) (size: 7 × 5.5 × 6 cm; Panels A and B , arrows). On invasive angiography, the true size of the aneurysm …

Aim Vessel size adapted PTCA results in the use of larger balloons with an increased incidence of severe vascular dissections. The aim of our trial was (a) to evaluate the effect of severe dissections on the acute outcome and (b) to study the natural history of dissections after 1 year. Methods and Results One hundred and seventy-eight patients with 195 lesions underwent vessel size adapted PTCA using intravascular ultrasound. Clinical and angiographic 1 year follow-up was obtained for all patients. Intravascular ultrasound was performed before PTCA to measure the external elastic membrane diameter at the lesion site so that the balloon size could be adopted (external elastic membrane−10%) and post-interventionally to determine the procedural success and the incidence of intracoronary dissections. Stent implantation was reduced to persistently flow limiting dissections (TIMI I, II). Dissections were detected by intravascular ultrasound in 128/195 (66%) lesions (by angiography in 111/195 [58%] lesions) and classified by intravascular ultrasound criteria into four groups: group I: no dissection (67 lesions [34%]), group II: mild dissections (21 lesions [11%]), group III: medium dissections (19 lesions [10%]) and group IV: severe dissections (88 lesions [45%]). Because of threatened vessel closure, GPIIb/IIIa antagonists were used in eight (4·5%) patients and a stent was implanted in two (1·1%) patients. The cumulative event rate after 1 year was 12% and the global angiographic restenosis rate was 19%. The post-interventional evidence of severe dissections was associated with a decrease in clinical events during long-term follow up (group I: 13 events [19%] vs group IV: seven events [7%]; P =0·03). This was also true for the occurrence of restenosis which was significantly lower in patients with severe dissections (group I: 19 [28%] lesions vs group IV:10 [11%] lesions; P =0·01). Conclusions According to the theory of ‘therapeutic dissections’, our data suggest that substantial dissections following PTCA, which do not diminish antegrade blood flow, do not lead to an increase in acute or long-term events. The natural history of vessel injury seems to provide favourable wound healing without increase of restenosis. Thus, stenting for treatment of large dissections without flow limitation does not seem to be mandatory.

Few reports are available regarding the natural history of coronary aneurysms. The consensus is that they may enlarge overtime and eventually rupture. The possibility of a catastrophic evolution supports invasive management, but this is mostly based on autoptical reports. We present the case of a 56-year-old male, smoker and affected by hypertension. He was admitted for an anterior ST-elevation myocardial infarction (STEMI) in three-vessel disease. Thrombotic occlusion of proximal left anterior descending artery (LAD) was apparent (Supplementary material online, Video S1 ). Successful percutaneous thrombus aspiration and bare-metal stent (BMS) implantation (3.5 × 23 mm) was performed (Supplementary material online, Video S2 ). A small …

A 59-year-old Filipino man without previous illness was admitted for heart failure (HF). Chest X-ray demonstrated an enlarged cardiac silhouette, with a prominent bulge on the third arch of the left heart border ( Panel A ). Echocardiography detected dilated cardiomyopathy with decreased left ventricular ejection fraction (LVEF 30%), and three large cystic aneurysmal structures: one at the level of the …

A 32-year-old woman suffering from load-dependent chest pain since 2 months was referred to our institution to rule out coronary heart disease. Nicotine abuse and hyperlipidaemia were stated in medical history. Exercise electrocardiogram generated reproducible and typical angina pectoris starting at a stress-level above 75 Watt. However, significant ST-deviation did not occur ( Panel A ). Echocardiography displayed normal biventricular function without regional …

Aims To evaluate safety and effectiveness of clopidogrel reloading in patients on chronic clopidogrel therapy undergoing percutaneous coronary intervention (PCI). Methods and results Five hundred and three patients on >10 days clopidogrel therapy (41% with non-ST-segment elevation acute coronary syndrome, ACS) randomly received 600 mg clopidogrel loading 4–8 h before PCI ( n = 252) or placebo ( n = 251). Primary endpoint was 30-day incidence of major adverse cardiac events (MACE). In the overall population primary endpoint occurred in 6.7% of patients in the reload vs. 8.8% in the placebo arm [odds ratios (OR) 0.75, 95% confidence intervals (CI) 0.37–1.52; P = 0.50]. In stable angina patients, 1-month MACE were not significantly different (7.0 vs. 3.9%; OR 1.84, 0.60–5.88; P = 0.36), whereas ACS patients had significant clinical benefit with reloading (6.4 vs. 16.3%; OR 0.34, 95% CI 0.32–0.90, P = 0.033 at multivariable analysis; interaction test: P = 0.01). There was no excess bleeding in the reload arm (6% in both groups). Conclusion ARMYDA-4 RELOAD reveals no overall benefit from reloading patients on chronic clopidogrel therapy prior to PCI; the benefit observed in ACS patients is a hypothesis-generating finding that needs to be confirmed by larger studies.

A previously healthy 45-year-old woman complained of worsening chest pain, which occurred mainly during exercise, was oppressive in nature and resolved after a few minutes of rest. The patient had no risk factors for coronary artery disease, no family history of cardiovascular disease or sudden death, and no recent pregnancy. According to the European Guidelines, this patient had low probability of obstructive coronary artery disease (5–20%) and should be referred to a non-invasive ischaemia test. Despite recommendations, the patient underwent directly an invasive coronary angiography (ICA) procedure …

A 48-year-old Caucasian woman developed a ‘ripping’ chest pain and shortness of breath while skiing off-piste at high altitude (>3300 m). She had dynamic ST changes on the electrocardiogram, an intermittent left bundle branch block, and a subsequent troponin I release (7.5 µg/L). She had no coronary risk factors or history of oral contraceptive use. Concerns …

A 57-year-old woman with history of hypertension was admitted to the coronary care unit with acute coronary syndrome without ST-segment elevation. Coronary angiography showed an eccentric and severe lesion at the mid-segment of the left anterior descending (LAD) coronary artery. Intravascular ultrasound (IVUS) showed a spontaneous dissection with intramural haematoma (Panel A), which was treated with a 3.0 × 28 mm paclitaxel eluting-stent direct implantation. After stent placement, an angiographically severe …

A 28-year-old woman was referred to our department with a syncopal sustained ventricular tachycardia with right bundle branch morphology. She was diagnosed with a pericarditis when she was 2 years old, and related an episode of palpitations five years ago. After electrical cardioversion of ventricular tachycardia, her 12-lead electrocardiogram revealed a normal sinus rhythm at 70 beats/min without any sign of myocardial ischaemia, no sign for arrhythmogenic right ventricular dysplasia or Brugada disease, or …

A 60-year-old man who underwent bypass surgery using saphenous vein conduits 18 years ago was admitted with a non-ST-elevation acute coronary syndrome. The patient was referred to the cath-lab and the angiography showed severe stenosis in the proximal left anterior descending (LAD) and in the …

A 72-year-old male with a history of chest pain presented to the ER with left-side motor weakness. Brain MRI revealed acute infarction of right anterior cerebral artery territory, and echocardiography showed normal ejection fraction and no visible thrombus. However, coronary angiography revealed left main coronary artery saccular aneurysm (8 × 10 mm2) originating at the distal segment of the left main between LAD and LCX. IVUS examination showed similar size and …

A 34-year-old man visited our institution for an abnormal chest radiograph with greatly enlarged cardiac silhouette (Panel A) found before his wedding. Detailed medical history revealed a febrile episode and a strawberry-like tongue and some ‘flu-like symptoms’ for >1 week when he …

Aims Coronary artery dissections are common findings following percutaneous transluminal coronary angioplasty and occur with an incidence of approximately 20% to 40%. The purpose of this study was to evaluate the impact of intravascular ultrasound for the prediction of severe dissections by pre-interventional analysis of lesion morphology and plaque composition. Methods and Results Pre- and post-interventional intravascular ultrasound was performed in 197 patients with 205 lesions. Using intravascular ultrasound criteria, 24 lesions were classified as soft (hypo- or iso-echogenic), 73 as intermediate (hyper-echogenic) and 108 as calcified (calcific arc >900 of the vessel circumference). Additionally, calcium localization was defined as subendothelial, central or deep. The incidence of dissections was 37·5% in patients with soft lesions, 24·7% in patients with intermediate and 36·1% in patients with calcified lesions. In calcified lesions, the occurrence of severe dissections was not dependent on the localization of calcium deposits. The procedural parameters were similar in all patients. The minimal inflation pressure, however, was significantly higher in calcified lesions ( P

Objective To describe the morphological changes occurring in the months following percutaneous transluminal coronary angioplasty (PTCA) of unstable plaques. Background Coronary angioscopy is a relatively new technique to assess plaque morphology. Previous angioscopic studies have shown that unstable coronary lesions are characterized by complex morphology, evidence of plaque rupture, and intraluminal thrombi. No serial angioscopic studies have investigated the effects of PICA on plaque morphology at such lesions. Methods We studied 15 patients who underwent successful PTCA for an unstable coronary syndrome (unstable angina: n=5; recent myocardial infarction: n=10). Angioscopy was performed immediately before PTCA in 14 patients, immediately after PTCA in 13 patients, and at follow-up (225 ± 62 days after PTCA) in all patients. Results Pre-PTCA, plaque morphology was defined as complex in 18%, ulcerated in 27%; the vessel was totally occluded in 18% of cases. Plaque colour was yellow in 75% of patients. A thrombus was identified at the lesion site in 71% of patients. Immediately post-PTCA, small surface disruptions and dissections were observed in 62% of patients. Plaque colour was yellow in 85% of cases. Seventy-seven percent of patients had an angioscopically visible thrombus at the PTCA site. At follow-up, however, plaque shape was almost uniformly classified as smooth concentric (93%); plaque colour was white in 93%; no thrombus was observed. Conclusions These results demonstrate the healing of unstable plaques in the months following PTCA. The angioscopic appearance at 6 months is that of a stable plaque (smooth concentric, white, without thrombus). Whether this stable angioscopic appearance predicts long term clinical stability remains to be determined. (Eur Heart J 1996; 17: 1554–1559)

To study the immediate effects of prolonged total balloon inflation during PTCA, 41 patients (44 lesions) with chronic stable angina were randomized for prolonged sequential inflations (three to five inflations of 3 to 5 min each, for a total duration ofor = 12 min, group 1, n = 20 lesions) or 'standard' sequential inflations (three to five inflations ofor = 1 min each, for a total duration ofor = 3 min, group 2, n = 24 lesions). The mean duration of total balloon inflation time was 958 +/- 129 s in group 1 vs 205 +/- 46 s in group 2. Results of angioplasty were assessed on both angiography and percutaneous transluminal coronary angioscopy performed immediately after the procedure. High quality imaging of the coronary lumen and lesion morphology was possible on angioscopy in all patients without any complications. Post-PTCA angiographic percent diameter stenosis was significantly less in group 1 compared to group 2: 26 +/- 10% vs 36 +/- 8% (P0.05). On angioscopy, flaps were seen in 16 patients in group 2, but in only six in group 1 (P0.02). There was no difference in the incidence of thrombi on angioscopy between the two groups (group 1: nine cases, group 2: 10 cases). Sensitivity of angiographic detection of flaps and thrombi was poor: 10% and 12% respectively. One patient in each group developed a longitudinal dissection, detected on both angiography and angioscopy.(1) prolonged sequential balloon inflations lead to less residual luminal stenosis after PTCA, with a decreased incidence of intimal flaps in comparison with standard inflations. (2) Post-PTCA transluminal coronary angioscopy is safe and offers better assessment of luminal effects of PTCA than angiography.

A 25-year-old female was admitted with chest distress, and a chest X-ray showed a giant heart ( Panel A ). A transthoracic echocardiogram showed a huge coronary artery aneurysm (CAA) and a fistula between the aneurysm and the right atrium ( Panel B , the arrow points to fistula see Supplementary material online, Videos S1 and S2 ). A computed tomographic scan demonstrated the CAA (14.4 cm × 12.0 cm …

An exceptional combination of three major coronary anomalies: a single coronary artery, a congenital coronary-right ventricular fistula and a large proximal coronary aneurysm were found in a living 66-year-old patient suffering from post-myocardial ischaemic heart disease. Each coronary anomally and their influence on the clinical situation of the patient are briefly discussed.

A 64-year-old male presented for pre-operative assessment prior to orthopaedic surgery, with a history of hypertension, hyperlipidaemia, was a lifelong non-smoker, and reported no cardiac symptoms. Clinical examination was unremarkable; with electrocardiography demonstrating sinus rhythm with small, non-pathological inferior lead Q-waves. Transthoracic echocardiogram showed normal left ventricular size and function, without regional …

A 71-year-old woman presented with stable angina pectoris. On coronary angiography, a giant aneurysm of the left anterior descending artery (LAD) measuring 70 × 40 mm was seen. The aneurysm was lined with thrombus ( Panel A : aneurysm indicated by large arrows and lumen indicated by small arrows; see Supplementary material online, Video S1 ). Proximal and distal to the aneurysm, the LAD was …

A 69-year-old woman carrying the hepatitis C virus was admitted to our hospital because of atypical chest pain. Electrocardiogram was normal, except for right axis deviation. Trans-thoracic echocardiography revealed a tumour-like image behind the left atrium ( Panel A , asterisk) and a flow towards the inferior wall of the left ventricle …