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Uvod: Extrakorporalni membranova oxygenace (ECMO) je metoda mimotělniho oběhu se vzrůstajicim užitim u kardiogenniho soku nebo refrakternich srdecnich zastav. Pece o tyto pacienty je vesměs vazana na centra s kardiochirurgii. Technický vývoj usnadil zavedeni okruhu bez chirurgicke asistence a pro management oběhove podpory neni nutna přitomnost perfuzionisty.

Bifurkacni leze tvoři 15-20 % vsech intervenovaných koronarnich lezi a jejich osetřovani je i přes výrazný pokrok v intervencni kardiologii i nadale spojeno s technickými obtižemi a horsi klinickou efektivitou. Zakladnim doporucovaným postupem pro osetřovani bifurkacnich lezi je "provisional stenting". Jako alternativni postup lze zvažit některou z dvoustentových technik. V nasem registru jsme se rozhodli posoudit bezpecnost, technickou a klinickou uspěsnost při použiti dedikovaneho bifurkacniho stentu Tryton Side Branch. Do registru bylo zařazeno 201 pacientů neselektovane populace osetřených v obdobi mezi cervnem 2012 a dubnem 2016 v Kardiovaskularnim centru Krajske nemocnice Liberec, u kterých bylo zvažovano užiti bifurkacniho stentu Tryton. Uspěsnost osetřeni bifurkacnich lezi při užiti stentu Tryton byla 85,07 %. Pacienty jsme pote sledovali v obdobi sesti měsiců od osetřeni. K infarktu myokardu doslo u tři pacientů, k revaskularizaci bylo nutno přistoupit pouze u tři pacientů, z toho vsak ani jednou nebylo potřeba osetřit cilovou tepnu nebo lezi. Otazka osetřovani bifurkacnich lezi zůstava do budoucna stale otevřena, jako možna alternativa se jevi užiti dedikovaných bifurkacnich stentů. Bifurkacni stent Tryton ma výhodu v ochraně bocni větve, jejiž osetřeni může být u větsiny standardnich technik problematicke. Stent Tryton lze dle nasich dat s výhodou použivat zejmena u bifurkacnich lezi s velkou bocni větvi (≥ 2,5 mm). Data z naseho registru tak svědci pro vysokou bezpecnost a uspěsnost osetřovani tohoto typu bifurkacnich lezi pomoci stentu Tryton. © 2019, CKS.

We report the case of a patient with acute anterolateral myocardial infarction without ST segment elevations and incipient cardiogenic shock due to complex high grade left main (LM) stenosis and tight calcified ostial left anterior descending (LAD) artery stenosis. Rotablation followed by stent deployment achieved a successful angiographic outcome with no associated clinical complications. During 30 days follow-up, the patient remains stable. An acute interventional approach in unprotected LM coronary stenosis is associated with high procedural risk. Combining that procedure, i.e., rotational atherectomy, with stent placement enhanced procedural success and clinical outcome in this case.

OBJECTIVE To assess long-term results after deferring coronary intervention (percutaneous coronary intervention (PCI)) of an intermediate lesion with a value of myocardial fractional flow reserve (FFR) > or = 0.75 in a 'real life' patient population with no respect to results of stress tests (if performed) or coronary disease extent. METHODS PCI of an intermediate lesion was deferred in a group of 85 consecutive patients (54 men, 61+/-10 years) on the basis of the result of FFR > or = 0.75 (mean FFR, 0.89+/-0.06%). FFR was measured in 111 stenoses (mean diameter stenosis, 54+/-8%, left anterior descending coronary artery, 65 (58%), left circumflex coronary artery, 24 (22%), right coronary artery, 22 (20%). Multi-vessel disease (defined as visually assessed diameter reduction of more than 50% in at least two arteries of more than 1.5 mm diameter, supplying at least two of the three major coronary artery perfusion territories) was present in 67% of patients (one-vessel disease, 28 patients (33%), two-vessel disease, 39 patients (46%), three-vessel disease, 18 patients (21%). Recorded events during follow-up were as follows: all-cause death, cardiac death, non-fatal myocardial infarction, ischemia-driven target lesion transcatheter revascularization (TLR) and coronary artery bypass graft (CABG). Angina class (Canadian Cardiovascular Society (CCS) classification) and the need for anti-anginal drugs were recorded. RESULTS Follow-up was completed in 85 patients (100%). Mean duration of follow-up was 22.6+/-6.6 months (range 4-33 months). Events occurred in 11 patients (13%). Seven patients died; this included two cardiac deaths. A non-fatal myocardial infarction occurred in one patient, one patient needed TLR and three patients underwent CABG. Estimated 33 month cardiac-event-free survival (Kaplan-Meier) was 91+/-4%. Angina class decreased [1.6+/-1.2 compared with 0.8+/-0.8 (P < 0.0001)] without difference with respect to the use of anti-anginal drugs (1.7+/-0.8 compared with 1.7+/-0.9, P = NS). CONCLUSIONS Deferring coronary interventions of intermediate stenosis based on FFR measurement is safe with respect to long-term follow-up, irrespective of the extent of coronary artery disease.

An elevated plasma level of endothelin-1 was reported in several cardiovascular conditions including unstable angina pectoris and myocardial infarction. The present study was designed to evaluate the time course of the endothelin-1 release in unstable angina pectoris and to assess its relationship to the development of myocardial infarction and coronary vessel occlusion. The cohort studied included 32 patients with the clinical diagnosis of unstable angina pectoris who had been admitted to the coronary care unit and subsequently underwent coronary angiography (group A). Fourteen patients with chronic stable angina pectoris referred to routine diagnostic coronary angiography served as the control group (group B). A significant difference in the endothelin-1 plasma level was found between both groups, the values being 10.2 ± 5.3 and 6.0 ± 3.1 pg/ml (p < 0.01), respectively. There were, however, no significant differences between the following subdivisions of group A: patients with and without subsequent myocardial infarction; those with angiographically documented occlusion of at least one major branch of the coronary artery and no occlusion; and finally, those with persisting symptoms of angina pectoris and with favorable response to treatment. Neither was there any difference found among the subgroups differing in the time interval between the onset of chest pain and blood sampling. The time course of endothelin plasma concentrations showed elevated values lasting for more than 96 h after the index episode of prolonged chest pain. No correlation with the subsequent clinical course could be inferred. Thus, plasma endothelin level was elevated in patients with unstable angina pectoris and myocardial infarction and the increase persisted for several days after the onset of symptoms.

Fig. 1 – Schema of the loop of the diagnostic catheter and procedures for its removal. Case report: A 76-year-old female presented with a history of intermittent chest pain at rest during the previous two days. She had no significant past medical history and was on no medication. Chest X-ray was unremarkable, but her 12-lead electrocardiogram revealed lateral ST depressions of 2 mm. Coronary angiography was performed via her right radial artery. The radial artery puncture was straightforward, and a TIG 5F catheter was used to attempt left coronary angiography. Unfortunately, while struggling to pass through the severe tortuosity of the brachiocephalic artery, the catheter made a loop high in the radial artery close to the brachial bifurcation. Despite gentle attempts to rotate the catheter to undo the kinking, the catheter became stuck in the artery due to spasm, and even gentle manipulation was very painful for the patient. A cocktail of nitroglycerin and verapamil was repeatedly administered intra-arterially, and this relieved the spasm. We were unable to cross through the kinked portion, even with a coronary guide wire. An attempt was made to snare the tip of the catheter with the coronary loop via the right femoral artery and straighten the catheter. This was unsuccessful due to the severe tortuosity of the brachiocephalic artery. We considered vascular surgery to remove the catheter. Prior to going to the surgical department, however, we decided to make one last attempt to straighten the catheter. We cut off the end of the catheter, removed the 6F