Ayse Colak

Intracoronary epinephrine in the treatment of refractory no-reflow after primary percutaneous coronary intervention: a retrospective study

BackgroundDespite the advances in medical and interventional treatment modalities, some patients develop epicardial coronary artery reperfusion but not myocardial reperfusion after primary percutaneous coronary intervention (PCI), known as no-reflow. The goal of this study was to evaluate the safety and efficacy of intracoronary epinephrine in reversing refractory no-reflow during primary PCI.MethodsA total of 248 consecutive STEMI patients who had undergone primary PCI were retrospectively evaluated. Among those, 12 patients which received intracoronary epinephrine to treat a refractory no-reflow phenomenon were evaluated. Refractory no-reflow was defined as persistent TIMI flow grade (TFG) ≤2 despite intracoronary administration of at least one other pharmacologic intervention. TFG, TIMI frame count (TFC), and TIMI myocardial perfusion grade (TMPG) were recorded before and after intracoronary epinephrine administration.ResultsA mean of 333 ± 123 mcg of intracoronary epinephrine was administered. No-reflow was successfully reversed with complete restoration of TIMI 3 flow in 9 of 12 patients (75%). TFG improved from 1.33 ± 0.49 prior to epinephrine to 2.66 ± 0.65 after the treatment (p < 0.001). There was an improvement in coronary flow of at least one TFG in 11 (93%) patients, two TFG in 5 (42%) cases. TFC decreased from 56 ± 10 at the time of no-reflow to 19 ± 11 (p < 0.001). A reduction of TMPG from 0.83 ± 0.71 to 2.58 ± 0.66 was detected after epinephrine bolus (p < 0.001). Epinephrine administration was well tolerated without serious adverse hemodynamic or chronotropic effects. Intracoronary epinephrine resulted in significant but tolerable increase in heart rate (68 ± 13 to 95 ± 16 beats/min; p < 0.001) and systolic blood pressure (94 ± 18 to 140 ± 20; p < 0.001). Hypotension associated with no-reflow developed in 5 (42%) patients. During the procedure, intra-aortic balloon pump counterpulsation was required in two (17%) patients, transvenous pacing in 2 (17%) cases, and both intra-aortic balloon counterpulsation and transvenous pacing in one (8%) patients. One patient (8%) died despite all therapeutic measures.ConclusionIntracoronary epinephrine may become an effective alternative in patients suffering refractory no-reflow following primary PCI.

[Coronary artery ectasia: its frequency and relationship with atherosclerotic risk factors in patients undergoing cardiac catheterization].

OBJECTIVE Coronary artery ectasia (CAE) is defined as local or generalized aneurysmal dilatation of the coronary arteries. We aimed to determine the frequency of CAE at our center and to compare clinical and angiographic characteristics between patients with isolated CAE and CAE with coronary artery disease (CAD). METHODS From February 2004 to December 2005, 12.514 patients were retrospectively analyzed by two independent operators who underwent coronary angiography. Coronary artery diameters were measured using qualitative computed angiography. CAD risk factors were recorded for all patients. Unpaired Students t-test and Chi-square test were used for statistical analysis. RESULTS CAE was diagnosed in 201 patients (1.59%). The majority (78%) were male. The mean age was 61±10.8 years (range, 25 to 82 years). The cases were divided into 2 groups as isolated CAE (Group 1) (14.9%) and CAE with CAD (Group 2) (85.1%). The risk factors of CAD were similar between two groups. The frequency of arterial involvement was: the right coronary artery (RCA) 54.3%; circumflex artery (Cx), 48.3%; the left anterior descending artery (LAD), 40.4%. CAE affected only one major vessel in 64.2% of cases and all 3 vessels in 9%. Isolated CAE was most commonly detected in Cx (47%). The type of CAE was determined according to Markis and Harikrishnan classification. The most prevalent involvement was Markis type 4 and Harikrishnan type 4a. Although atypical angina was the most common clinical presentation in both groups, acute coronary syndrome was more frequent in Group 2 (p=0.018). CONCLUSION The risk factors of CAD and the manner of clinical presentation were considerably similar in both groups and this situation was consistent with similar etiopathogenesis of two diseases.

Cardiac Involvement in Glycogen Storage Disease Type IV: Two Cases and the Two Ends of a Spectrum

Glycogen storage disease type IV (GSD IV) is an autosomal recessive disorder due to the deficiency of α 1,4-glucan branching enzyme, resulting in an accumulation of amylopectin-like polysaccharide in various systems. We describe two cases, a 23-year-old girl with dilated cardiomyopathy who presented with progressive dyspnea and fatigue and a 28-year-old girl with hypertrophic cardiomyopathy who was asymptomatic, secondary to the accumulation of amylopectin-like fibrillar glycogen, in heart. In both patients, the diagnosis was confirmed by enzyme assessment. Our patients showed that GSD IV is not only liver or skeletal muscle disease, but also it can be presented in different form of the spectrum of cardiomyopathy from dilated to hypertrophic and from asymptomatic to decompensated heart failure. Also, to our knowledge, this is the first hypertrophic cardiomyopathy case due to GSD IV in the literature.

Acute results of percutaneous mitral balloon valvuloplasty

OBJECTIVES We aimed to analyze acute clinical, echocardiographic, and hemodynamic results and long-term event-free survival of percutaneous mitral balloon valvuloplasty (PMBV) in the treatment of hemodynamically significant mitral stenosis (MS). STUDY DESIGN We retrospectively reviewed 577 patients (454 females, 123 males; mean age 38±11 years) who underwent PMBV for moderate or severe MS. Acute procedural success was defined as the achievement of mitral valve area (MVA) >1.5 cm2 and absence of grade 3-4 mitral regurgitation. In addition, 489 patients were interrogated by phone calls for event-free survival (death, redo PMBV, mitral valve replacement) after at least one year (mean 54 months) of the procedure. RESULTS The procedure was successful in 547 patients (94.8%) and unsuccessful in 30 patients (5.2%). Among baseline echocardiographic and hemodynamic parameters, MVA was significantly lower (p=0.0001) and moderate/severe tricuspid regurgitation was significantly more common (p=0.031) in patients with failure. The mean Wilkins scores were similar in the two groups (p>0.05). Failure was related to suboptimal valve opening (MVA <1.5 cm2) in 20 patients (66.7%), and grade 3-4 mitral regurgitation in 10 patients (33.3%). There were no in-hospital death, cardiac tamponade, or cerebrovascular accident. Acute complications included iatrogenic atrial septal defect (n=51, 8.8%) and groin hematoma (n=4, 0.7%). Inquiry for long-term outcomes showed that four patients had died, while 21 patients and six patients had undergone mitral valve replacement and redo PMBV, respectively. CONCLUSION Our data suggest that PMBV is a safe and effective treatment option in MS and preprocedural MVA and tricuspid regurgitation are associated with acute failure of the procedure.

Extraction of a large vegetation and ICD lead using the Evolution Mechanical Dilator Sheath

A 74-year-old male patient presented with complaints of fatigue, fever, and worsening health status. He had a 34-month history of cardioverter-defibrillator (ICD) implantation due to ischemic cardiomyopathy. Transthoracic and transesophageal echocardiography showed a mobile mass, 24 x 11 mm in size, consistent with a vegetation attached to the right ventricular ICD lead. Surgical removal of the electrode was considered to be highly risky for the patient, thus percutaneous removal was decided. Due to adhesions, manual traction of the lead with a standard stylet was ineffective. Complete lead extraction was accomplished using the Evolution Mechanical Dilator Sheath, which is a new mechanical sheath with a stainless steel bladed tip. No complications occurred during or after the procedure. Following a histopathologic diagnosis of vegetation, the patient received a six-week antibiotic therapy, after which a new ICD was implanted on the contralateral side. To our knowledge, this case represents the largest lead vegetation extracted by this new device. Although its safety should be validated by increasing number of cases, it seems that its simple use would make this device a new interesting tool among the instruments available for lead extraction.

Augmentation of vessel narrowing by nitroglycerine in a case with myocardial bridge

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