Asghar Ali

The safety of preoperative vardenafil in patients undergoing coronary artery bypass graft surgery.

Abstract: Phosphodiesterase 5 inhibitors are cardioprotective against myocardial reperfusion ischemic injury in animal models but are contraindicated in patients with coronary disease who take nitrates because of a risk for hypotension. We investigated the safety of vardenafil in patients undergoing coronary artery bypass grafting (CABG) surgery. A single dose of vardenafil was given to 10 patients before CABG surgery. The postoperative course of these 10 patients was compared with the postoperative course of 47 patients who did not receive vardenafil before CABG surgery. There were no perioperative deaths and no episodes of hypotension in the group receiving vardenafil. The clinical and operative characteristics of the 2 study groups were similar. There were no significant differences in postoperative serum troponin levels (9.1 ± 8.3 vs 12.5 ± 9.3 ng/mL; P = 0.29, respectively), duration of postoperative intubation (21.4 ± 10.1 vs 27.4 ± 15.2 hours; P = 0.14, respectively), or length of hospital stay (11.1 ± 13.2 vs 10.0 ± 4.7 days; P = 0.8, respectively) between the group receiving vardenafil and the control group. This pilot study of 10 patients suggests that vardenafil use is safe in patients before CABG surgery. A larger study is needed to explore the myocardial protective effect of the drug.

Septic Pulmonary Embolism in a Patient with Defibrillator Lead Endocarditis

and a boil on his jaw. Computerized tomography (CT) scan of chest showed inflammatory changes along the pacemaker leads and thrombus in the left innominate and jugular veins (Figure 1a). Ultrasound of the left arm and neck veins showed venous thrombosis (Figure 1b). Transesophageal echocardiography showed a vegetation attached to the right atrial lead (Figure 1c). The ICD was explanted percutaneously. Four days later the patient developed fever with pleuritic chest pain. Follow-up CT angiography showed interval development of multiple pulmonary emboli (Figure 1d). The patient was treated with nafcillin, coumadin, and a life vest defibrillator until ICD re-implantation. The incidence of cardiac device endocarditis is 1–7% of those who receive a cardiac device, and 27% of cardiac device endocarditis is associated with septic pulmonary embolism. Both cardiac device endocarditis and septic pulmonary embolism have high morbidity and mortality (1). The risk factors for cardiac device endocarditis are recent device manipulation, diabetes mellitus, corticosteroid medication, anticoagulation, cancers, chronic renal failure, and bacteremia (2). Septic pulmonary embolism is a rare disorder associated with cardiac device implants, intravascular catheters, intravenous drug use, suppurative process in head and neck, thrombophlebitis, and immunocompromised state (3).

Contemporary antiplatelet therapy in patients undergoing percutaneous coronary intervention

The proper use of antiplatelet agents in the cardiac catheterization laboratory is important for ensuring optimal results in patients undergoing percutaneous revascularization. Understanding the mechanisms by which these drugs exerts their effects is important for both interventional and non-interventional cardiologists. The effects of these agents on platelet function can be assessed and monitored using a variety of commercially available laboratory assays but so far these tests have not been adopted in routine clinical practice. Currently, aspirin, thienopyridines and glycoprotein IIb/IIIa inhibitors are the primary types of antiplatelet drugs being utilized. The use of these drugs and of several newer antiplatelet drugs in the treatment of patients undergoing percutaneous revascularization in the cardiac catheterization laboratory will be discussed, especially in the light of the recently published guidelines.

Contemporary anticoagulation therapy in patients undergoing percutaneous intervention.

The proper use of anticoagulants is crucial for ensuring optimal patient outcomes post percutaneous interventions in the cardiac catheterization laboratory. Anticoagulant agents such as unfractionated heparin, a thrombin inhibitor; low-molecular weight heparins, predominantly Factor Xa inhibitors; fondaparinux, a Factor Xa inhibitor and bivalirudin, a direct thrombin inhibitor have been developed to target various steps in the coagulation cascade to prevent formation of thrombin. Optimal anticoagulation achieves the correct balance between thrombosis and bleeding and is related to optimal outcomes with minimal complications. This review will discuss the mechanisms and appropriate use of current and emerging anticoagulant therapies used during percutaneous interventions.

Pneumopericardium and pneumomediastinum after esophageal bolus impaction.

A 74-year old-man presented with difficulty swallowing for one day after eating a pork chop. The patient had neck pain. Chest radiography showed pneumopericardium, pneumomediastinum, and subcutaneous emphysema of the neck (Figure 1A). Urgent esophagogastroduodenoscopy showed a large bolus of food obstructing the distal esophagus and a superficial laceration of the distal esophagus. In the interim, the patient vomited out the food bolus. A computed tomography scan of the chest demonstrated air along the pericardium, trachea, lesser curvature of the stomach, and cervical prevertebral soft tissue, with small bilateral pleural effusions (Figure 1B). The patient remained afebrile with stable vital signs and no crepitations in the neck or chest. He was managed conservatively with intravenous fluids, intravenous antibiotics, and close observation. He was discharged home after 3 days, and was doing well when seen as an outpatient 3 months later.

Spontaneous Coronary Artery Dissection in a Young Man with a Factor V Leiden Gene Mutation: A Case Report and Review of the Literature

Spontaneous coronary artery dissection is a rare but increasingly recognized cause of acute myocardial ischemia in young adults, especially in women. We report a case of spontaneous coronary dissection in a young healthy man who was also a carrier of the factor V Leiden gene mutation.