Andrea Farina

Safety, Efficacy, and Complications of Pericardiocentesis by Real-Time Echo-Monitored Procedure

Pericardiocentesis is useful in the diagnosis and treatment of pericardial effusive disease. To date, a number of methods have been developed to reduce complications and increase the success rate of the procedure. The aim of the present study was to evaluate the efficacy and the safety of echocardiography-guided pericardiocentesis under continuous echocardiographic monitoring in the management of pericardial effusion. We prospectively performed 161 pericardiocentesis procedures in 141 patients admitted from 1993 to 2015 in 3 centers. This procedure was performed for tamponade or large pericardial effusion in 157 cases and for diagnosis in 4 cases. A percutaneous puncture was performed where the largest amount of fluid was detected. To perform a real-time echo-guided procedure, a multi-angle bracket was mounted on the echocardiographic probe to support the needle and enable its continuous visualization during the puncture. The procedure was successful in 160 of 161 cases (99%). Two major complications occurred (1.2%): 1 mediastinal hematoma that required surgical drainage in a patient on anticoagulant therapy and 1 pleuropericardial shunt requiring thoracentesis. Seven minor complications occurred (4.3%): 1 pleuropericardial shunt, 1 case of transient AV type III block, 3 vasovagal reactions (1 with syncope), and 2 cases of acute pulmonary edema managed with medical therapy. No punctures of any cardiac chamber occurred, and emergency surgical drainage was not required in any case. In conclusion, echocardiography-guided pericardiocentesis under continuous visualization is effective, safe, and easy to perform, even in hospitals with low volumes of procedures with or without cardiac surgery.

Capecitabine-induced cardiotoxicity: when to suspect? How to manage? A case report.

We present a case of capecitabine-induced cardiac toxicity manifested by chest pain, ST-segment elevation and ventricular tachycardia. Symptoms and ECG alterations were completely reversible after withdrawal of the drug. Coronary angiography demonstrated the absence of epicardial coronary spasm. We suggest cardiac monitoring with ECG Holter and effort ECG during the first days of drug administration. Prompt evaluation of chest pain in this setting is of paramount importance.

Emergent transvenous cardiac pacing using ultrasound guidance: a prospective study versus the standard fluoroscopy-guided procedure:

Aims: To compare time to active pacing and complication rates associated with temporary transvenous pacemaker (TTVPM) insertion between a fully echo-guided approach of vein access and lead placement, and standard placement of TTVPM under fluoroscopic guidance. Methods and results: We performed a prospective single-center observational study enrolling all consecutive patients from 1 January 2008 to 31 December 2012 needing emergent TTVPM placement. According to personal experience and clinical setting, the operators could choose between a fully echo-guided approach of TTVPM placement through the jugular vein and a standard fluoro-guided approach through the femoral vein. Safety and efficacy endpoints were pre-specified, registered, and compared. A total of 113 patients were treated using the echo-guided approach, and 90 via the fluoro-guided approach. The two groups differed with regard to clinical setting at presentation: an acute coronary syndrome was more frequent in the fluoro-guided approach group (39.7% vs. 16.8%, p<0.001), whereas asystole was more frequent in the echo-guided approach group (9.7 vs. 0%). Median time from decision to active pacing was significantly shorter in the echo-guided approach group (22 vs. 43 minutes, p<0.01). The overall complication rates were significantly lower in the echo-guided approach group (15.0% vs. 28.8%, p 0.02), because of lower rates of infections (2.7% vs. 11.1%, p 0.02) and puncture-related hematomas (0 vs. 3.3%, p=0.08). There were no deaths related to TTVPM, but one heart perforation requiring emergent pericardiocentesis occurred in the fluoro-guided approach group. One pneumothorax treated conservatively occurred in the echo-guided approach group, while no differences were observed with regard to sustained tachyarrhythmias (1.8% vs. 2.2%) or malfunctions requiring reposition of the catheter (8.8 vs. 8.9%). Overall, complications delaying permanent pacemaker implant for >48 hours were observed less often in the echo-guided approach group (6.8 vs. 20.7%, p = 0.03). Conclusion: Echo-guided insertion of TTVPM through the jugular vein is a feasible and safe alternative to fluoroscopic guidance and may reduce complications and time to active pacing in patients who are not candidates for emergent cardiac catheterization.

Three-dimensional intraoperative echographic monitoring for endovascular stent-graft repair in a patient with type B aortic dissection.

To the Editor The preferred treatment for most patients with Stanford type B dissection is medical therapy. Specific cases that are complicated by progression of dissection, impending rupture, refractory hypertension, localized false aneurysm, unremitting chest pain or end-organ ischemia are typically treated with emergency surgery. Recent clinical experience indicates that most of the cases are potentially amenable to minimally invasive therapy with endovascular stent-graft repair as an effective alternative to open surgery.

Simultaneous acute occlusion of right and anterior descending coronary arteries in acute myocardial infarction.

To the Editor Acute ST segment elevation myocardial infarction (STEMI) is usually caused by the abrupt complete occlusion of a single epicardial coronary artery due to rupture or erosion of an unstable coronary atherosclerotic plaque. Simultaneous acute total occlusion of more than one epicardial vessel is quite rare and it has been described in only a few cases in the current literature; it is always life threatening because of rapid hemodynamic deterioration leading to cardiogenic shock. The incidence of simultaneous occlusion of more than one major coronary arteries is not known and, to our knowledge, the most numerous series (five cases) reported in the literature is the one by Maagh et al.

Malignant Cough Syncope from Idiopathic Vagal Inflammation

We describe the case of a patient with malignant vasodepressive cough syncope. We demonstrated a vaso-vagal mechanism related to left vagal neuritis, by means of laryngoscopy and laryngeal electromyography. The condition resolved with steroid therapy. LEARNING POINTS Left vagal neuritis should be considered in the differential diagnosis of recent onset repetitive loss of consciousness, in particular if cough related. Steroids were used to successfully treat recent onset cough-related syncope. Relatively simple trials of drug therapy can sometimes avoid intensive investigations; in our case, the use of a systemic steroid would probably have avoided many radiological and endoscopic examinations.

Sinoatrial Blocks in Hyperthyroidism Treated with Beta-Blockers: A Case of Paradoxical Treatment

We describe an interesting case of a 52 year-old patient affected by thyrotoxicosis crisis, in whom sinoatrial blocks were associated with syncope and treated effi ciently with beta-blockers.

Massive left ventricular ischemia in a patient with anterior ST elevation myocardial infarction and anomalous origin of the circumflex artery.

A 41-year-old man with no risk factors for coronary disease presented with chest pain for 90 min. His ECG showed a wide QRS with ST elevation in leads V1–4, aVR, aVL and inferior ST depression (Fig. 1). Echocardiography showed severe left ventricular dysfunction with akinesia of anterior wall, apex and interventricular septum and severe lateral hypokinesia. Before angiography, ventricular fibrillation occurred that required six Direct Current (DC) shocks for defibrillation. Angiography revealed an isolated left anterior descending artery (LAD) with proximal subocclusive stenosis (Fig. 2a). The anomalous circumflex artery was hypoplasic and

Dalla unità di cura coronarica alla terapia intensiva cardiologica: l’evoluzione del Dipartimento Cardiovascolare dell’Ospedale di Lecco

BACKGROUND Substantial changes have occurred over time in the diagnoses, procedures and characteristics of patients admitted to coronary care units (CCU). Following the introduction of cardiac surgery activity in our hospital in December 2009, the aim of this study was to evaluate the changes in activity, processes of care and outcomes of patients consecutively admitted to our CCU after the reorganization of the Cardiovascular Department. METHODS All 1674 consecutive patients admitted to the CCU from January 2009 to December 2010 were enrolled in this retrospective registry. RESULTS In 2010, the number of patients referred from other hospitals or wards significantly increased (from 17.2% to 28.3%; p<0.001). Significant was also the increase of patients with ST-elevation myocardial infarction (n=190 to n=230, p<0.001), shock (n=20 to n=50, p<0.001), pulmonary edema (n=47 to n=64, p<0.05), cardiac arrest (n=2 to n=8, p<0.05), aortic dissection (n=0 to n=12; p<0.001). Conversely, the number of patients admitted for acute coronary syndromes without ST-segment elevation and GRACE risk score <140 significantly decreased (n=169 to n=52, p<0.001). In parallel, a significant increase in the use of intra-aortic balloon pump (2.0% to 5.6%, p<0.001), continuous hemofiltration (0.3% to 3.1%, p>0.001), non-invasive ventilation (5.6% to 10.5%, p<0.001) and mechanical ventilation (0% to 4.1%, p<0.001) was observed. Intensive care devices were more frequently used in the subgroups affected by shock, acute coronary syndromes without ST-segment elevation and GRACE risk score >200, and heart failure. Interestingly, despite the increase in high-risk clinical conditions the intra-CCU mortality did not change (3.1 vs 2.9%). CONCLUSIONS Patients admitted to the CCU have high-risk acute clinical conditions. A model based on the sharing of cardiological, cardiac anesthesiological and surgical expertise is effective in increasing admission appropriateness and improving standards of care in a short period of time.

Aborted sudden death from Epstein-Barr myocarditis.

To the Editor Ventricular fibrillation is the most common ECG pattern of presentation in adult cardiac arrest and usually has an ischemic origin. Cardiomyopathy and channelopathy are more frequent in the youngest adult group. Among the transient causes of ventricular fibrillation one should also keep viral myocarditis in mind. Epstein–Barr has rarely been reported as a cause of acute myocarditis, accounting for about 1% of cases, but has been associated with complete heart block, ventricular arrhythmias, myocardial infarction-like patterns and sudden death. The infection may occur with the typical mononucleosis syndrome characterized by the triad of fever, pharyngitis and lymphadenopathy, but cardiac manifestation may be the first sign of virus diffusion and can include any of the following: chest pain, dispnea, palpitation or sudden cardiac death.