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Dofetilide has been shown to be effective and safe in maintaining sinus rhythm in patients with persistent atrial fibrillation and congestive heart failure. Because of serious side effects of an increase in the QT interval causing torsades de pointes, dofetilide must be initiated with close monitoring of the QT interval in an inpatient setting. However, little has been reported about conditions surrounding the change in QT interval after the steady state is achieved that may have implications in the safety and efficacy of the drug. We report marked QT prolongation and torsades de pointes in a setting of flash pulmonary edema resulting from acute myocardial ischemia in a patient who was being treated with dofetilide for atrial fibrillation. Our case reminds the clinicians that the adverse and proarrhythmic effects of dofetilide can occur due to changes in the arrhythmic substrate during acute severe ischemia.

This article reviews cardiac and noncardiac complications encountered with various procedures used in cardiology practice. Some of the common complications associated with transesophageal echocardiography are hypoxia, laryngospasm, bronchospasm, and brady- or tachyarrhythmias. Death is a rare complication. The overall prevalence of complications associated with external cardioversion is low. Major complications include death, cardiac arrhythmias, pulmonary edema, systemic embolism, and cerebral embolism. The main indication for endomyocardial biopsy at present is to assess cardiac transplant rejection. Complications occurring most frequently are carotid artery puncture, arrhythmias, and conduction abnormalities. The most commonly occurring complications of electrophysiological studies are pneumothorax, venous thrombosis, and hypotension. Cardiac catheterization is an invaluable procedure in the assessment of patients with ischemic heart disease. Major complications include vascular complications, arrhythmias, complications due to contrast agents, and death. Central venous catheterization is used to deliver medication and parenteral nutrition and also in the hemodynamic monitoring of patients. Local infection, sepsis, noninfectious phlebitis, and catheter dislodgment are some of the more commonly occurring associated complications. Swan-Ganz catheters are indicated for the hemodynamic monitoring of critically ill patients. Major associated complications include pneumothorax, arterial puncture, air embolism, tracheal and esophageal puncture, arrhythmias, valvular damage, infection, thrombosis, and pulmonary infarction. The use of intra-aortic balloon pumps can be complicated by ischemia, bleeding, intraaortic balloon pump rupture, vascular complications (mainly limb ischemia), and death. Some of the common underlying mechanisms responsible for complications during interventional procedures are abrupt closure, noreflow phenomenon, coronary artery spasm, distal embolization, and side branch occlusion. The use of abciximab may be associated with an increased risk of major bleeding. Acute profound thrombocytopenia is another potential complication associated with abciximab use. Heparin usage may be associated with bleeding, thrombocytopenia, skin necrosis, osteoporosis and hypersensitivity reactions. Some of the more common complications of thrombolytic therapy are bleeding, myocardial rupture, hypotension, allergic reactions, anaphylaxis, thromboembolic complications, reperfusion arrhythmias, and splenic rupture.

Left internal mammary arteries (LIMA) are used routinely as grafts to the left anterior descending coronary artery (LAD) in selected patients undergoing coronary artery bypass graft (CABG) surgery because of better long-term patency rates. Pathology other than fibrointimal hyperplasia, accelerated atherosclerosis, or thrombus can sometimes cause obstructive lesions in such grafts. This report illustrates a kink in a LIMA graft to the LAD causing an obstructive lesion shortly after surgery and describes the subsequent management of this lesion with intracoronary stents. Cathet. Cardiovasc. Intervent. 46:223–226, 1999. © 1999 Wiley-Liss, Inc.

The precise diagnosis of the presence of significant left main coronary artery disease has profound prognostic and therapeutic implications. Coronary cineangiography has shown to be imprecise and inaccurate to determine the percent stenosis of the left main coronary artery. We report a case with significant left main coronary artery disease in whom coronary cineangiography was in discordance with the clinical data and intravascular ultrasonography. Based on the intravascular ultrasound findings, the patient underwent coronary artery bypass graft surgery. Therefore, the intravascular ultrasonography may be the procedure of choice for assessing indeterminant left main coronary artery lesions by coronary angiography. intravascular ultrasound, left main coronary artery, coronary cineangiography

Coronary artery vasculopathy (CAV) is one of the major factors that limit the long-term survival of heart transplant recipients. It is difficult to diagnose CAV, especially in the early stages. Traditional coronary angiography has been used for the diagnosis of CAV, but this method has limitations. Current literature suggests that intravascular ultrasound (IVUS) is a safe imaging technique that is beneficial for the early diagnosis of CAV; in comparison, IVUS with virtual histology (IVUS-VH) is an even more promising diagnostic utility. Despite its advantages, IVUS is currently not routinely utilized as the primary diagnostic modality for CAV in heart transplant recipients. In this review, we evaluate and summarize the clinical utility of IVUS in the early diagnosis of CAV, including its utility for assessing vessel remodeling, plaque composition, and prognostic value; morphometric analysis; and guiding therapy. After reviewing the relevant published literature, it is our recommendation that the use of IVUS be considered in all post-transplant CAV screening.

Marked bulging of the interventricular septum toward the left ventricle has been described as a reliable index of right ventricular systolic hypertension. We report a patient with Eisenmenger syndrome who has systolic aneurysmal protrusion of the interventricular septum into the left ventricular outflow tract. To our knowledge, this is the first report of systolic indentation of the left ventricular outflow tract in a patient with right ventricular pressure/volume overload.

In patients with significant left ventricular dysfunction and congestive heart failure despite optimal medical therapy, implantation of cardiac resynchronization therapy-defibrillation (CRT-D) devices has been shown to improve symptoms and mortality. In this report, we describe a case of a patient with ischaemic cardiomyopathy who developed incessant ventricular tachycardia (VT) after undergoing an upgrade from an implantable cardioverter defibrillator to a CRT-D device. The patient required multiple anti-arrhythmic agents, removal of the coronary sinus lead, and radiofrequency ablation to control VT. Thus, in rare patients, the CRT devices may potentially cause ‘proarrhythmia’ with serious consequences.

The influence of age on the clinical and angiographic outcome of directional coronary atherectomy is evaluated. Results demonstrate that DCA can be performed successfully in the vast majority (78.7-90%) of patients in all age groups. However, there is a non-statistical trend toward decreased success rates in the elderly (P > .05). Major ischemic complications and groin complications tend to be more common in the elderly (P > .05). Blood transfusions are required significantly more often in the elderly (P < .05). Directional coronary atherectomy is a useful method of coronary artery revascularization in all age groups, including the elderly.

8. cular hyperplasia: extension of the therapeutic outcome. Results of the University Hospital Zurich Cooperation Study on fibromuscular hyperplasia. Nephron 1986;44(suppl. 1):109-14. James TA, Froggatt P, Marshall TK. Sudden death in young athletes. Ann Intern Med 1967;67:1013-21. dames TA, Marshall TK. De subitaneis mortibus XVII. Multifocal stenoses due to fibromuscular dysplasia of the sinus node artery. Circulation 1976;53:736-42. Rossi L, Thiene G. Recent advances in clinicohistopathologic correlates of sudden cardiac death. AM HEART J 1981;102:47884. Nichols GR II, Davis GJ, Lefkowitz JB. Sudden death due to fibromuscuiar dysplasia of the sinoatrial nodal artery. KMA J 1989;87:504-5. Lie JT, Berg KK. Isolated fibromuscular dysplasia of the coronary arteries with spontaneous dissection and myocardial infarction. Hum Path01 1987;18:654-6.

Congenital coronary artery fistulas are important coronary artery anomalies. Bilateral coronary artery fistulas are very rare and coronary artery to left ventricular communications are even more infrequent. This report describes a patient with bilateral right and left coronary artery fistulas draining into a common channel and emptying into the left ventricular cavity.

Coronary artery bypass graft (CABG) surgery, performed for the control of angina pectoris, leads to postoperative relief from symptoms in most patients. Amelioration of ischemia and improvement in exercise capacity after CABG are well documented. However, patients currently undergoing CABG are more complex than in the past--they are older and are maintained on medical therapy for longer periods. A large number of these patients have had one or more previous myocardial revascularization procedures. The post-operative period would appear to be a time of vulnerability for coronary events. However, previous investigators have focused on the pre- and intraoperative aspects of peri-CABG ischemia. Outcome data suggest that the postoperative interval is at least equally important as a determinant of short- and long-term morbidity and mortality. We discuss the epidemiology, etiology, pathophysiology, and treatment of ischemic syndromes in the postoperative period after CABG. In addition, we review recent data from a series of 14 patients, observed at our institution, who underwent cardiac catheterization and, in some cases, angioplasty of the culprit vessel in the immediate postoperative period.

Newer developments in biotechnology and increasing operator experience have broadened the clinical applicability of percutaneous transluminal coronary angioplasty. These advances have allowed the treatment of patients with variant and anomalous coronary arteries and the treatment of an increasingly elderly population. A case of successful percutaneous transluminal coronary angioplasty in a 90-year-old man with unstable angina and an anomalous origin of the left main coronary artery is reported.

The influence of gender on the procedural outcome of directional coronary atherectomy (DCA) is controversial. This study of 373 consecutive patients (418 lesions) undergoing DCA demonstrates that the procedural success rate of DCA is significantly lower in women compared with men (72.7 vs. 82.9%, p = 0.011). Women have significantly smaller coronary arteries than men (2.5 mm vs. 2.7 mm, p = 0.028) and were older than men (66 vs. 61 years, p = 0.0001). Multivariate analysis identifies small coronary vessel size rather than female gender per se as an independent predictor of poor procedural outcome. Procedural success rates in women with coronary vessel sizeor = 2.5 mm is significantly higher (92.2%) than in women with coronary vessel size2.5 mm (73.1%), and parallels that in men with vessel sizeor = 2.5 mm (89.3%). Inability to engage the ostium of the coronary artery adequately with the guiding catheter and to cross the lesion with the atherectomy device is significantly more common in women compared with men. Major ischemic complication rates are similar in women and men (8.5 vs. 8.7%). Groin complications are significantly more common in women compared with men (13.5 vs. 2.9%). We conclude that procedural success rates in women may be improved by careful patient selection, with particular attention to small vessel size. DCA is best performed in vessels2.5 mm in diameter.

Percutaneous transluminal coronary angioplasty (PTCA) of heavily calcified rigid coronary arteries has decreased success and increased complication rates. Three cases are presented describing a new technique for the dilatation of severely calcified coronary arteries that were not dilatable by conventional angioplasty methods. This technique involves the use of a balloon dilatation catheter system parallel to a guide wire. © 1993 Wiley-Liss, Inc.

The glycoprotein (GP) IIb‐IIIa inhibitor eptifibatide (INTEGRILIN®, COR Therapeutics, Inc., South San Francisco, California, and Key Pharmaceuticals, Inc., Kenilworth, New Jersey) is a novel and highly potent antithrombotic agent indicated for the management of patients with non‐ST‐segment elevation acute coronary syndromes (ACS) and those undergoing percutaneous coronary intervention. The approval of eptifibatide for non‐ST‐segment elevation ACS was based on the positive results of the Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy (PURSUIT) trial. With enrollment of almost 11,000 patients, not only is the PURSUIT trial the largest trial of a GP IIb‐IIIa inhibitor to date, but it is also the largest clinical study ever conducted in patients with non‐ST‐segment elevation ACS. The key feature of the PURSUIT trial is that patient management closely resembled standard clinical practice, because decisions about the use and timing of invasive cardiac procedures were made by the individual physicians rather than being prespecified in the study protocol. Eptifibatide therapy was associated with a significant reduction in the incidence of the primary endpoint—a composite of death or myocardial infarction at 30 days (14.2 vs. 15.7% in the placebo group; p = 0.042). Of importance is the fact that the beneficial effect of eptifibatide was independent of the management strategy pursued during study drug infusion (invasive or conservative), and it was achieved with few major safety concerns. These findings demonstrate that the use of eptifibatide should be considered for all patients presenting with signs and symptoms of intermediate‐ to high‐risk non‐ST‐segment elevation ACS.

A patient of Middle-Eastern descent developed Kaposi’s sarcoma of the skin and lymph nodes after renal transplantation while receiving medical immunosuppression, including the use of cyclosporine. The clinical presentation of this patient resembled that of the HTLV-III-associated Kaposi’s sarcoma. The tumors totally regressed seven weeks after cessation of immunotherapy. This case, along with other recently reported cases of Kaposi’s sarcoma in postrenal transplant patients receiving cyclosporine, illustrates a rare complication of current immunosuppressive therapy.

The performance and results of PTCA have been shown to vary between men and women. However, the effect of PTCA on modifying quality of life (QOL) in men vs. women has not been fully evaluated. Therefore the Medical Outcome Study (MOS-3S), a well validated, quantitative tool to measure (QOL). was administered to 113 consecutive patients, (69% men and 31% women), prior to and 6 months after undergoing elective PTCA. The (MOS36) includes 8 individual indices including: physical role (RP), bodily pain (BP), social function (SF), emotional role (ER), general health, vitality, physical functioning, and mental health. Serial changes of the (MOS-36) indices, in men and women, were compared and statistically analyzed. Statistically significant changes were obtained by both groups in physical roles and bodily pain, men in social function, and women in emotional roles (p l 0,05). There were no significant differences in the other 4 indices. In conclusion, 1) (QOL) after PTCA can be quantitated by using the (MOS-36) in both men and women. 2) Gender differences do exist in (QOL) changes after PTCA. 3) Women have greater improvement in emotional roles, and men have greater improvement in social function. 4) Knowledge of gender differences in (QOL) changes after PTCA, may assist in patient care and outcome measurements. Download : Download high-res image (87KB) Download : Download full-size image