Search

Objectives: This study was designed to assess prospectively changes in serum lipid profile and myocardial perfusion with serial radionuclide single photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) during the first six months of pravastatin therapy.Background: Morbid coronary events occur despite statin therapy and lipid-lowering in patients with coronary artery disease (CAD). A reliable strategy to identify responders with effective treatment from nonresponders on statin therapy before clinical events is needed.Methods: Rest and stress SPECT MPI and lipids were assessed serially in 25 patients (36% women) with CAD and dyslipidemia during the first six months of pravastatin therapy.Results: Total cholesterol, low-density lipoprotein cholesterol, and triglycerides declined (26%, 32%, and 30%, respectively) by six weeks and remained reduced at six months. Mean stress perfusion defect (summed stress score [SSS]) was severe (13.3 +/- 6.0) at baseline, showed no change at six weeks, and improved significantly at six months (10.3 +/- 7.3, p < 0.01). The six-month study SSS improved in 11 (48%) patients, was unchanged in 10 (43%) patients, and worsened in 2 (9%) patients. Changes in lipid levels did not reliably predict changes in myocardial perfusion at six weeks or six months in this small pilot study.Conclusions: Serial SPECT MPI demonstrated improved stress myocardial perfusion in 48% of patients treated for six months with pravastatin. Time course of improved myocardial perfusion during pravastatin therapy is delayed compared to lipids. Direction and magnitude of changes in the myocardial perfusion vary and do not correlate closely with improvements in lipids. [ABSTRACT FROM AUTHOR]

We report the prospective use of an electrocardiographic sign--lead aVR ST-segment elevation greater than that seen in lead V(1)--in patients with an acute coronary syndrome as a method to prompt early angiography, to withhold clopidogrel therapy, and to perform urgent coronary bypass surgery leading to successful clinical outcomes. [ABSTRACT FROM AUTHOR]

Duplex ultrasonography of the vertebral artery is an integral part of extracranial cerebrovascular screening and provides noninvasive diagnostic clues for subclavian or vertebral artery stenosis. This review describes technique for the ultrasound examination of the vertebral and subclavian arteries. Duplex images from various patients are used to illustrate a spectrum of hemodynamic changes that occur in the vertebral artery Doppler signal caused by subclavian artery stenosis and subclavian-vertebral steal.

Cardiac tamponade is a common cardiac emergency requiring prompt diagnosis and intervention. A thorough understanding of the spectrum of clinical and hemodynamic changes in patients with pericardial effusion is vital for interventional cardiologists. This review discusses pathophysiology of cardiac tamponade with emphasis on hemodynamic aberrations. Specific clinical situations that lead to atypical hemodynamic presentations of cardiac tamponade are emphasized with a review of various diagnostic and therapeutic procedures., (2005 Wiley-Liss, Inc.)

Clinical examination and transthoracic echocardiography play a vital role in the management of patients with pericardial effusion and cardiac tamponade physiology. We report patients in advanced phase 3 cardiac tamponade with variant clinical and hemodynamic presentations. These atypical cardiac tamponade cases include: A patient with severe aortic valve regurgitation who lacked pulsus paradoxus; a patient with systemic sclerosis without hypotension; and a patient with pulmonary hypertension lacking right heart collapse on echocardiography. Recognition of these atypical clinical and hemodynamic manifestations of cardiac tamponade will avoid undue delay in the treatment.

A recent advance in technology permits the creation of sutureless proximal aortic anastomosis during coronary artery bypass graft surgery. This new tool has significant potential benefit by minimizing aortic manipulation with subsequent reduction in neuroembolization. Implantation of a nitinol-based proximal aortic connector (Symmetry) has a potential to elicit intimal hyperplastic reaction analogous to restenosis after coronary stent placement. We report cases of early vein graft stenosis in association with the use of the Symmetry device. Three patients suffered from severe ostial stenosis within 6 months of bypass surgery with symptomatic presentation. Of these three patients, two underwent successful percutaneous revascularization. Fluoroscopic star-shaped appearance of the metallic Symmetry allows device recognition during angiography. We review current data regarding graft patency with the use of Symmetry device and discuss technical issues to address specific problems during percutaneous revascularization., (Copyright 2004 Wiley-Liss, Inc.)

Totally occluded saphenous vein grafts are difficult to treat percutaneously with a higher likelihood of distal embolization and slow-flow or no-reflow during percutaneous interventions. The PercuSurge system, which utilizes a distal balloon occlusive device, has been shown to improve clinical outcomes during saphenous vein graft (SVG) interventions. This device may not be optimal in the setting of heavy thrombus or debris burden, a situation frequently encountered in totally occluded SVGs. Rheolytic thrombectomy facilitates percutaneous interventions by effectively removing intraluminal thrombus and debris but lacks distal embolization protection. We report our experience with the synergistic use of balloon-based distal embolization protection (PercuSurge) and rheolytic thrombectomy (AngioJet) to optimize percutaneous revascularization of totally occluded SVGs., (Copyright 2003 Wiley-Liss, Inc.)

Distal embolization protection devices are fast becoming an integral part of percutaneous vein graft interventions. The distal elastomeric balloon of the PercuSurge GuardWire system is supposed to be atraumatic to the vessel wall. We report the inadvertent dilation of a moderate distal stenosis at the site of GuardWire balloon inflation while intervening on a critical proximal saphenous vein graft stenosis. This case illustrates that plaque compression and potential vessel wall trauma might occur during the inflation of the PercuSurge GuardWire distal protection balloon., (Copyright 2003 Wiley-Liss, Inc.)

Patients with congenital heart disease are increasingly surviving to adulthood and present interesting challenges during cardiac catheterization. Situs inversus with dextrocardia is a type of cardiac malposition most likely to exist with a structurally normal heart. We present the case of a patient with complete situs inversus and bicuspid aortic valve stenosis, a hitherto unreported association. Prototypical findings in this cardiac malposition are illustrated for proper recognition with emphasis on technical tips for left and right heart catheterization.

Human coronary arteries occasionally course intramyocardially--a condition termed Myocardial Bridge. We review the anatomic and pathophysiological basis of the Myocardial Bridge and discuss clinical presentations, prognoses and the current treatment options for this interesting coronary angiographic variant., (Copyright 2002 Wiley-Liss, Inc.)

A 54-year-old man with end-stage cirrhosis of the liver presented for evaluation of dyspnea. Intrapulmonary arteriovenous shunting was suspected. Transthoracic echocardiography with agitated saline contrast injection from the right antecubital vein was performed. Late arrival of saline contrast bubbles in the left atrium by pulmonary veins leading to complete left heart opacification confirmed the diagnosis of significant intrapulmonary shunting. This case and images illustrate the use of agitated saline contrast in combination with transthoracic echocardiography for the diagnosis of intrapulmonary arteriovenous fistula.

Devices to prevent distal atheroembolization are an important addition to the armamentarium of an interventional cardiologist. We report the use of PercuSurge, a distal balloon occlusion device, in two patients with recent myocardial infarction of differing etiologies. The first case is a patient with an old degenerated vein graft with thrombotic occlusion of greater than 48-hr duration and the second case is a patient with an embolic myocardial infarction in a native coronary artery. In both cases, significant thromboembolic debris was aspirated with technical success and no complications. These cases illustrate use of the PercuSurge device in patients after a recent myocardial infarction for preserving distal myocardial perfusion and microvascular integrity., (Copyright 2002 Wiley-Liss, Inc.)

Primary angioplasty strategies have evolved dramatically, including increasing adjunctive use of stents and glycoprotein (GP) IIb/IIIa inhibitors. The purpose of this study was to examine the specific effects of these adjunctive therapies on long-term outcomes after primary angioplasty. From 1996 to 1998, 257 unselected, consecutive patients underwent primary PTCI at our institution. In-hospital mortality was 5.4% (2.9% for patients without cardiogenic shock). The remaining 243 patients were followed for 2.0 +/- 0.7 years. Adjunctive stenting was associated with increased late mortality (8.7% vs. 2.3%, P = 0.02). GP IIb/IIIa inhibitors were associated with reduced late mortality among patients receiving stents (6.9% vs. 21.4%, P = 0.07), but not in those patients treated with balloon angioplasty alone (2.9% vs. 0%, P > 0.20). Coronary stenting remained a significant predictor of late mortality (hazard ratio 5.6, 95% CI 1.5-21.2) after adjustment for other established risk factors. In this unselected series, adjunctive coronary stenting was associated with higher late mortality among hospital discharge survivors. Concomitant GP IIb/IIIa inhibitors partially corrected for this increase. These results are limited by the small sample size and retrospective design of this study. Additional long-term studies are required to test these findings and evaluate for possible mechanisms., (Copyright 2001 Wiley-Liss, Inc.)

Diabetes is an established risk factor for reinfarction and cardiac death in postinfarction patients. Since the underlying mechanism of diabetes-related risk is not fully understood we aimed to evaluate the association between lipids, thrombogenic factors and diabetes in postinfarction patients. The study population consisted of 1,045 postinfarction patients (846 non-diabetic, 125 non-insulin- and 74 insulin-requiring diabetics) with the following blood tests performed 2 months after an index myocardial infarction: lipoprotein (a), apolipoprotein-B, apolipoprotein-A, cholesterol, HDL cholesterol, triglycerides, insulin, von Willebrand factor (vWF), fibrinogen, factor VII, D-dimer, and plasminogen activator inhibitor (PAI-1). After adjustment for relevant clinical covariates, non-insulin-requiring diabetes was significantly (p < 0.05) associated with elevated levels of (odd ratios per 1 log unit increase in parenthesis) vWF (1.74) and PAI-1 (1.42) whereas insulin requiring diabetes was associated with even more elevated levels of vWF (4.68), but not with increased levels of PAI-1. No significant differences in lipid levels were observed among three groups. In conclusion, increased level of von Willebrand factor is significantly and independently associated with diabetes in postinfarction patients, suggesting that endothelial damage is the primary mechanisms contributing to an increased occurrence of vascular and cardiac events in diabetic postinfarction patients.

We describe two cases of late stent thrombosis (> 30 days postprocedure) following stenting without brachytherapy. Stent thrombosis was confirmed after successful treatment by catheter-based rheolytic thrombectomy. Predictors of stent thrombosis are reviewed and issues concerning the duration of combination antiplatelet therapy after stenting are discussed.

A 65-year-old male was referred for to our facility for right and left heart catheterization and coronary angiography for evaluation of a ventricular septal defect and to rule out significant coronary artery disease. During the procedure, the patient was diagnosed with a double-chambered right ventricle (DCRV). Most DCRV cases are diagnosed at a young age; presentation in an adult is extremely rare.

Cutaneous tuberculosis is an infrequent first sign of disseminated tuberculosis. We describe a patient with 2 cutaneous ulcerations that grew Mycobacterium tuberculosis. Despite an initial response to antimycobacterial therapy, the fever relapsed. After several months, biopsy of a single cervical lymph node showed a T cell-rich B cell lymphoma. Our patient had metastatic tuberculous abscesses (tuberculous gummas), which are secondary to disseminated tuberculosis, and an underlying occult lymphoma, both believed to be sequentially presenting as a fever of unknown origin.

Thrombosis contributes to recurrent coronary events in patients after acute myocardial infarction (AMI), but prognostic significance of thrombogenic factors by gender is unknown. This study aimed to determine gender-related differences in the prognostic significance of thrombogenic factors for predicting cardiac events (nonfatal reinfarction or cardiac death) in postinfarction patients. Blood levels of the following factors were measured 2 months after AMI in 791 men and 254 women: fibrinogen, von Willebrand factor, factor VII and VIIa, plasminogen activator inhibitor, D-dimer, cholesterol, apolipoprotein A-1, apolipoprotein B, lipoprotein(a), triglycerides, and high-density lipoprotein cholesterol. After adjustment for clinical covariates, levels of apolipoprotein A, high-density lipoprotein cholesterol, fibrinogen, and factor VIIa were significantly higher in postinfarction women than men. During a mean 26-month follow-up, there were 67 cardiac events (8.5%) in men and 14 (5.5%) in women (p = 0.11). In the multivariate Cox model, elevated levels of factor VIIa were a significant predictor of cardiac events in women (p = 0.022) but not in men (p = 0.80), with significant gender-related effect (hazard ratio 2.80 vs 0.92, respectively; p <0.05). D-dimer had prognostic value in men (p = 0. 006) but not in women (p = 0.36), although the difference between hazard ratios for men and women was not significant (2.35 vs 1.58, respectively; p = 0.49). In conclusion, elevated levels of factor VIIa are associated with an increased risk of recurrent cardiac events in postinfarction women, but not in men. D-dimer is more predictive for cardiac events in postinfarction men than women. These observations indicate possible gender-related differences in the pathophysiologic mechanisms of recurrent cardiac events.

Acute right ventricular dysfunction has been established both as a diagnostic and prognostic indicator in pulmonary embolism. This report illustrates the utility of thallium-201 scintigraphy as an adjunctive noninvasive test in the diagnosis of pulmonary embolism by demonstrating increases in regional right ventricular perfusion and its subsequent resolution with treatment presumably as a result of decreased pressure work.

Background: The appearance of ST-segment depression on the exercise electrocardiogram (ETT) generally indicates myocardial ischemia. Disorders that produce ST-segment depression on the resting electrocardiogram can confound the results of the ETT. The purpose of this study was to assess the reliability of exercise ST-segment depression as an indicator of ischemia in patients with a resting electrocardiographic ST depression, presumably caused by coronary disease., Methods: We studied 882 patients 1 to 6 months after a hospitalization for myocardial infarction or unstable angina as part of the Multicenter Study of Myocardial Ischemia. An ETT and thallium-201 perfusion scan were performed in all patients. For the purpose of this study, the perfusion scan was considered the "gold standard" for ischemia. We correlated the ETT ST-segment responses with the perfusion scan in a group with a normal electrocardiogram baseline ST segment (NO ST DEP group) and in a group with resting electrocardiographic ST depression > or =0.5 mm (ST DEP group)., Results: Although the frequency of ischemia by perfusion scan was similar in the ST DEP group (48%) to that in the NO ST DEP group (40%), the ST DEP group had a significantly higher (p = 0.03) sensitivity (54%) in detecting ischemia than the NO ST DEP group (35%). The ST DEP group, however, had a lower (58% vs 74%) specificity than the NO ST DEP group (p = 0.056). Baseline characteristics of the two groups probably account for these differences. The overall diagnostic accuracy is similar (58% vs 56%) in the two groups., Conclusion: We conclude that in a stable population with known coronary disease, the presence of ST depression on the resting electrocardiogram does not impair the detection of ischemia by the ETT, but may be associated with a higher false-positive rate.

To assess whether the presence of mitral regurgitation has a protective effect on left ventricular thrombus formation in a heterogeneous group of patients with dilated cardiomyopathy, a group of 103 patients with dilated cardiomyopathy identified by means of echocardiographic criteria was assembled over 1 year. The purpose of the study was to define a subgroup of patients with dilated cardiomyopathy from whom long-term anticoagulation might be withheld. Each echocardiogram was evaluated for the presence of left ventricular thrombus, presence and severity of mitral regurgitation, and ejection fraction. The role of clinical factors and clotting factors in left ventricular thrombus formation was assessed. Left ventricular thrombus was not present in 91 patients (group A) and was present in 12 patients (group B). Group B had larger left atrial and left ventricular systolic dimensions and decreased left ventricular systolic function. Mitral regurgitation jet area and ratio between mitral regurgitation jet area and left atrial area were lower (signifying less severe mitral regurgitation) among patients in group B. Although mitral regurgitation was equally present in group A and group B, severe mitral regurgitation was found only in group A patients ( 11 of 91 patients). Among patients with dilated cardiomyopathy, left ventricular ejection fraction is the factor most associated with left ventricular thrombus formation. The presence of severe mitral regurgitation may have a protective role in left ventricular thrombus formation.