Erhan Babalik

Radiation-induced coronary artery disease.

Wir berichten von einem 36-jährigen Patienten der wegen neu auftretender Angina-Symptomatik aufgenommen wurde. Er hatte keine Risikofaktoren für koronare Herzkrankheit (KHK). Anamnestisch auffällig war ein Morbus Hodgkin im Alter von 10 Jahren die mit Bestrahlung von Mediastinum behandelt worden war. Koronarangiographie ergab eine zwei Gefäßerkrankung mit komplettem Verschluss von RIA und 70% Stenose der rechten Koronararterie. Beide Verschlüsse wurden erfolgreich wiedereröffnet (Ballondilatation und Stent-Implantation). Kontrollangiographie nach einem Jahr ergab keine Restenose und der Patient war auch klinisch beschwerdefrei. Bei jedem Patienten mit kardialen Beschwerden und anamnestisch bekannter Bestrahlung im Bereich von Mediastinum soll an strahlenbedingte Herzerkrankung gedacht werden. Strahlenschaden kann zur Myokard-, Perikard-, Klappenerkrankungen oder Rythmusstörungen führen. Eine andere Manifestation ist früh ansetzende KHK. In dieser Hinsicht soll Bestrahlung im Bereich von Mediastinum als Risikofaktor für KHK angenommen werden. Da heutzutage Strahlentherapie die Behandlungsmethode für mehrere mediastinale Malignitäten ist, optimale Beschirmung während der Therapie und regelmäßige Kontrolluntersuchungen sind erforderlich um die kurz- und langfristige Komplikationsrate möglichst niedrig zu halten und Komplikationen, besonders KHK früh zu erkennen. Die bevorzugte Behandlungsmethoden für Strahlenbedingte KHK sind Ballondilatation mit Stent-Implantation oder aortakoronare By-pass-Operation. Die Mammaria-Arterien sollen preoperativ kontrolliert werden. Radiation-induced heart disease must be considered in any patient with cardiac symptomatology who had prior mediastinal irradiation. Radiation can affect all the structures in the heart, including the pericardium, the myocardium, the valves and the conduction system. In addition to these pathologies, coronary artery disease following mediastinal radiotherapy is the most actual cardiac pathology as it may cause cardiac emergencies requiring interventional cardiological or surgical interventions. A 36- year-old man was admitted to the clinic with unstable angina pectoris of one month duration. The patient had no coronary artery disease risk factor. The history of the patient revealed that he had mediastinal radiotherapy due to Hodgkin’s disease at 10-year of age. Coronary arteriography showed total occlusion of the left anterior descending artery and 70% stenosis of the proximal right coronary artery. Both arteries are dilated with placement of two stents. Control coronary arteriography at the end of the first year showed patency of both stents and the patient is free of symptoms. Previous radiotherapy to the mediastinum should be considered as a risk factor for the development of premature coronary artery disease. Percutaneous transluminal coronary angioplasty with stent placement or surgical revascularization are the preferred methods of treatment. Preoperative assessment of internal thoracic arteries should be considered prior to surgery. As the radiation therapy is currently the standard treatment for a number of mediastinal malignancies, routine screening of these patients and optimal cardiac prevention during radiotherapy are the only ways to minimize the incidence of radiation-induced heart disease.

Unusual case of aortic valve involvement in patient with Löffler's endomyocarditis: management, follow-up and short review of the literature.

Idiopathic hypereosinophilic syndrome (IHES) is an uncommon systemic disease which is characterised by blood eosinophilia and multiple clinical presentations. Cardiac involvement is the major cause of mortality and morbidity. Here we describe a 59-year-old man with symptoms of progressive dyspnea on exertion, and productive cough as an unusual case of Löffler endomyocarditis with a mass on the aortic valve which showed regression with treatment.

Increased secretion of insulin during oral glucose tolerance test can be a predictor of stent restenosis in nondiabetic patients

Insulin is known to stimulate proliferation and migration of vascular smooth muscle cells. As the predominant mechanism of restenosis after stent implantation is neointimal tissue proliferation, one can expect a relationship between hyperinsulinemia and restenosis in these patients. The aim of this study was to determine whether hyperinsulinemia during oral glucose tolerance test is a predictor of the development of restenosis after stent implantation in nondiabetic patients. We prospectively studied 52 nondiabetic patients with effort angina who underwent elective stent implantation for single‐vessel coronary artery disease. In order to increase the statistical power of the study, numerous exclusion criteria were applied. All patients were subjected to a 75 g oral glucose tolerance test a day before the stent implantation and underwent follow‐up angiography 6 months later. Plasma insulin levels in fasting (6.77 ± 1.57 vs. 5.36 ± 1.35 μU/ml; P = 0.005), at 30 min (102.48 ± 10.6 vs. 47.74 ± 12.75 μU/ml; P = 0.001), 1 hr after (120.23 ± 14.1 vs. 63.08 ± 12.62 μ/ml; P = 0.001), 2 hr after (63.58 ± 8.64 vs. 34.88 ± 6.82 μ/ml; P = 0.001), and 3 hr after (25.71 ± 5.65 vs. 23.02 ± 4.61 μ/ml; P = 0.04) loading were significantly higher in patients with stent restenosis than in patients without stent restenosis. Insulin area and insulin area/glucose area were also significantly higher in patients with stent restenosis than in patients without (219.5 ± 23.8 vs. 118.9 ± 21.8, P = 0.001, and 0.62 ± 0.09 vs. 0.33 ± 0.06, P = 0.001, respectively). By multiple logistic regression analysis, insulin area during oral glucose tolerance test was found to be an independent predictor of stent restenosis (OR = 1.12; 95% CI = 1.01–1.25; P = 0.031). In conclusion, nondiabetic patients with hyperinsulinemia during oral glucose tolerance test have a high risk for restenosis after stent implantation, and performing this simple test before intervention may be useful for the prediction of stent restenosis. Cathet Cardiovasc Intervent 2003;58:306–312.

ω-3 fatty acid treatment in cardiac syndrome X: a double-blind, randomized, placebo-controlled clinical study.

ObjectiveWe conducted a clinical trial to examine the effect of &ohgr;-3 fatty acids in patients with cardiac syndrome X (CSX). We aimed to evaluate the potential impact of &ohgr;-3 fatty acids on endothelial function, oxidative stress, and symptom relief in the CSX. Methods and resultsEighteen patients with CSX were enrolled according to a double-blind, randomized, placebo-controlled design. Patients were randomized to &ohgr;-3 fatty acids (1440 mg/day, n=8) or placebo (n=10) for 4 months. We assessed plasma levels of malondialdehyde (MDA), endothelium-dependent vasodilatation [flow-mediated dilatation (FMD)], endothelium-independent vasodilatation [nitroglycerin-mediated dilatation (NMD)], and status of symptom [score with Seattle Angina Questionnaire (SAQ)] before and after the treatment. After 4 months, patients who were treated with &ohgr;-3 fatty acids showed significant increases in the FMD (from 47±48 to 104±23%, P<0.05) and NMD (from 51±53 to 93±35%, P<0.05) values, and significant decreases in the plasma MDA levels (4.4±0.86 to 3.35±0.33 µmol/l, P=0.012). SAQ scores were increased significantly in both groups (from 60±14 to 73±15%, P<0.05 placebo, from 67±10 to 81±9%, P<0.05 treatment group). NMD was correlated negatively with the plasma MDA levels. ConclusionFour months of therapy with a moderate dose of &ohgr;-3 fatty acids improved the endothelial function and reduced oxidative stress in patients with CSX.

Thrombolysis with Streptokinase During Cardiopulmonary Resuscitation: A Single Center Experience and Review of the Literature

Objective: To report our experience with use of thrombolysis with streptokinase during cardiopulmonary resuscitation of patients with cardiac arrest due to myocardial infarction.Design: A case series.Methods: Thrombolytic therapy (streptokinase) was administered during cardiopulmonary resuscitation of 4 patients with suspected myocardial infarction as the cause of cardiac arrest.Results: 3 of the 4 patients survived and were discharged from the hospital without any major complications or neurological sequela.Conclusion: Thrombolysis with streptokinase during cardiopulmonary resuscitation of patients with suspected acute myocardial infarction is associated with reduced mortality and favorable neurological outcome.

Verification and uniformity control of doses for 90 Sr/ 90 Y intravascular brachytherapy sources using radiochromic film dosimetry

Intravascular brachytherapy (IVBT) is a useful treatment modality for the recurrence of in-stent restenosis following drug-eluting stents (DES) or IVBT failure. The objective of this study was to measure the dose rate of 90Sr/90Y IVBT sources for comparison with that given by the manufacturer and to control the dose uniformities of these sources along the source axis. The dose rates of 90Sr/90Y beta sources were measured with a radiochromic film in a custom-made phantom. The films for calibration were irradiated using 60Co photon beams. The results for the three sources were 4.5%, 2.3%, and 3.5% higher than the corresponding certificate values. Maximum and minimum of the dose rates varied within ±10% of those at source center; and maximum dose discrepancy for the first 90Sr/90Y source train was 8.2%; for the second source train, 7.1%; and for the third source train, 5.1%. Our study showed that the dose rates given by the manufacturer for the three 90Sr/90Y IVBT sources were reliable and dose uniformities were within ±10% along two thirds of the treatment length.

Revascularization of chronic coronary artery occlusions using laser debulking followed by stent implantation.

Objective — Chronic total occlusions are considered unfavourable for percutaneous balloon angioplasty because of the low rate of success and the high rate of restenosis. Stent implantation after recanalization of chronic total occlusions has been shown to reduce restenosis and reocclusion rates compared with balloon angioplasty in recently published randomized trials. However, it is not well known whether laser debulking before stent implantation would improve the benefit of stenting in chronic total occlusions. Methods and results — We analysed procedural and long-term clinical and angiographic followup results of 48 patients who underwent laser angioplasty followed by stent implantation for chronic total occlusions. The procedure was completed successfully in 46 patients (95.8%) in whom the lesion was crossed with a guidewire.We implanted 51 stents in 46 chronic total occlusions following laser debulking. During in-hospital follow-up 1 patient (2.1%) had Q wave, and 4 patients (8.7%) had non-Q wave myocardial infarction. Nine patients (19.5%) had repeat angioplasty for restenosis and one (2.1%) underwent coronary bypass operation at 6 months follow-up. Death or Q wave myocardial infarction did not occur during 6-month follow-up.Thirty-nine patients (85%) had angiographic follow-up at 6 months, and stent restenosis was found in 17 (44%) patients. Conclusion — These high rates of restenosis and target vessel revascularization in our study suggest that laser debulking before stent implantation does not improve clinical and angiogragic outcomes in chronic total occlusions.

Micro channels within chronic total occlusion: a true way

A 44-year-old man presented with Canadian Cardiovascular Society (CCS) class II exertional angina. Both the physical examination and resting electrocardiogram were unremarkable. Depression of the ST segment in anterolateral derivations was observed during the exercise test, and coronary angiography revealed chronic total occlusion (CTO) of the proximal right coronary artery (RCA) with collateral flow from the distal left anterior descending artery (LAD) …