Itzhak Herz

Thrombolysis is an effective and safe therapy in stuck bileaflet mitral valves in the absence of high-risk thrombi

OBJECTIVESnWe sought to evaluate the effectiveness and safety of thrombolytic therapy in stuck mitral bileaflet heart valves in the absence of high-risk thrombi.nnnBACKGROUNDnCurrent recommendations for the thrombolytic treatment of stuck prosthetic mitral valves are partially based on older valve models and inclusion of patients in whom high-risk thrombi were either ignored or not sought for. The feasibility and safety of thrombolysis in bileaflet models may be affected by the predilection of thrombi to catch the leaflet hinge.nnnMETHODSnWe studied 12 consecutive patients (men/women = 5/7, age 58.8 +/- 14.9 years) who experienced one or more episodes of stuck bileaflet mitral valve over a 33-month period and received thrombolytic therapy with streptokinase, urokinase or tissue-type plasminogen activator. Transesophageal echocardiography was performed in all patients. Patients with mobile or large (>5 mm) thrombi were excluded. Functional class at initial episode was I-II in 4 patients (33.3%) and III-IV in 8 patients (66.6%).nnnRESULTSnPatients receiving thrombolytic therapy achieved an overall 83.3% freedom from a repeat operation or major complications (95% confidence interval 51.6-97.9%). Minor bleeding occurred in three patients (25%) and allergic reaction in one (8.3%). Transient vague neurologic complaints, without subjective findings, occurred in four patients (33.3%). Three patients had one or more relapses within 5.2 +/- 3.1 months from the previous episode, and readministration of thrombolytics was successful.nnnCONCLUSIONSnIn clinically stable patients with stuck bileaflet mitral valves and no high-risk thrombi, thrombolysis is highly successful and safe, both in the primary episode and in recurrence. The best thrombolytic regimen is yet to be established.

Importance of the Conal Branch of the Right Coronary Artery in Patients With Acute Anterior Wall Myocardial Infarction: Electrocardiographic and Angiographic Correlation

OBJECTIVESnThis study assessed prospectively the correlation between the conal branch of the right coronary artery and the pattern of ST segment elevation in leads V1 and V3R during anterior wall acute myocardial infarction (AMI).nnnBACKGROUNDnThe traditional electrocardiographic (ECG) definition of anteroseptal AMI-ST segment elevation in leads V1 to V3-has recently been challenged. The significance of ST segment elevation in lead V1 during anterior wall AMI is unclear.nnnMETHODSnThe admission 12-lead ECG with additional lead V3R and the coronary angiograms performed within 10 days of hospital admission were evaluated in 28 consecutive patients (mean age +/- SD 62 +/- 9 years) admitted to the coronary care unit with anterior wall AMI. Patients were classified into two groups according to the magnitude of ST segment elevation in lead V1: group A (elevation > or = 1.5 mm, n = 12) and group B (elevation < 1.5 mm, n = 16). Two types of conal branch were identified: small (not reaching the interventricular septum [IVS]) and large (reaching the IVS).nnnRESULTSnST segment elevation in lead V3R was found in 11 (92%) and 6 (37%) patients from group A and group B, respectively (p < 0.001); a small conal branch was seen in 10 (83%) and 3 (19%) patients, respectively (p < 0.001). Ten patients (all from group B) had a large conal branch.nnnCONCLUSIONSnST segment elevation in lead V1 in the admission ECG of patients with anterior wall AMI is strongly related to ST segment elevation in lead V3R and is associated with a small conal branch. Our findings suggest that lead V1 reflects the right paraseptal area supplied by the septal branches of the left anterior descending coronary artery (LAD), alone or together with the conal branch. The absence of ST segment elevation in lead V1 during anterior AMI suggests that the IVS is protected by a large conal branch in addition to the septal branches of the LAD (double circulation).

Electrocardiographic criteria for predicting the culprit artery in inferior wall acute myocardial infarction

Two patterns of the QRS complex in the lateral lead aVL on the admission electrocardiograms of patients with inferior wall acute myocardial infarction (AMI) were correlated with the culprit artery. S/R wave ratio < or =1/3 with ST depression < or =1 mm was found to be a sensitive and specific marker for left circumflex artery AMI, whereas S/R-wave ratio >1/3 with ST-segment depression >1 mm was suggestive of right coronary artery AMI.

Coronary air embolism treated by bubble aspiration

We describe a case of coronary air embolism following cardiac catheterization, with all the signs and symptoms of an acute coronary event. Thanks to the rapid and effective aspiration of the air bubble from the distal artery, blood flow was restored and the clinical picture was resolved. Cathet. Cardiovasc. Intervent. 49:452–454, 2000.

Coronary stenting without predilatation (SWOP) : Applicable technique in everyday practice

To evaluate the feasibility of stenting without predilatation, we registered all interventional procedures over a 6‐month period. Six hundred patients were registered, and 684 lesions were treated. Interventions were divided into four groups: stenting without predilatation (SWOP), 221 lesions (32.4%); primary stenting with predilatation (PDS), 161 lesions (23.5%); provisional stenting (PRS), 131 lesions (19.2%); and plain‐old balloon angioplasty (POBA), 171 lesions (25%). Interventional strategy was at the discretion of the operator based on few simple angiographic criteria and his clinical judgment. Procedural success was similar in all stent groups. We conclude that when primary stenting is planned, about 60% of lesions can be treated by SWOP effectively with excellent procedural results and considerable cost saving. Cathet. Cardiovasc. Intervent. 49:384–388, 2000.

Iodide‐induced sialadenitis complicating coronary angiography

Sialadenitis is an uncommon complication of intravenous administration of iodinated contrast medium. We present two cases of iodide‐induced sialadenitis following coronary angiography. Clinical features and clues to differentiation from suppurative sialadenitis are discussed. The mechanism for aseptic iodide‐induced sialadenitis remains unclear, but prognosis with conservative treatment is apparently good. Sialadenitis may recur with subsequent administration of contrast medium. Cathet Cardiovasc Intervent 2002;57:50–53.

Persistent ST Segment Depression in Precordial Leads V5-V6 After Q-Wave Anterior Wall Myocardial Infarction Is Associated With Restrictive Physiology of the Left Ventricle

OBJECTIVESnTo examine the relationship between the persistence of ST segment depression in leads V5-V6 after Q-wave anterior wall myocardial infarction (MI) and the filling pattern of the left ventricle (LV).nnnBACKGROUNDnPrecordial ST segment depression predominantly in leads V5-V6 is associated with increased in-hospital morbidity and mortality after acute myocardial ischemia, perhaps due to reduced diastolic distensibility of the LV.nnnMETHODSnWe prospectively studied 19 patients after Q-wave anterior wall MI (>6 months). All patients underwent 12-lead ECG recording, symptom-limited treadmill exercise testing with single photon emission computed tomography thallium-201 imaging, transthoracic Doppler echocardiography, cardiac catheterization and measurement of circulating atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP) levels. Patients were classified based on the presence of ST segment depression in leads V5-V6: Group I = ST segment depression <0.1 mV (n = 10); Group II = ST segment depression > or =0.1 mV (n = 9).nnnRESULTSnPatients in Group II had greater LV end diastolic pressures (32.4 +/- 6.5 mm Hg vs. 14.8 +/- 6.1 mm Hg; p = 0.0001), higher plasma ANP (44.4 +/- 47.1 pg/ml vs. 10.7 +/- 14 pg/ml; p = 0.04) and BNP levels (89.4 +/- 62.7 pg/ml vs. 23.6 +/- 33.1 pg/ml; p = 0.01), greater left atrium area (20.6 +/- 3.1 cm2 vs. 17.8 +/- 2.4 cm2; p = 0.05), lower peak atrial (A), higher early (E) mitral inflow velocities, a higher E/A ratio and a lower deceleration time (167 +/- 44 ms vs. 220 +/- 40 ms; p = 0.05). Lung thallium uptake during exercise was more common in Group II (78% vs. 10%, p = 0.04).nnnCONCLUSIONSnPersistent ST segment depression in leads V5-V6 in survivors of Q-wave anterior wall MI is associated with increased LV filling pressure and a restrictive LV filling pattern.

Early Development of High-Degree Atrioventricular Block in Inferior Acute Myocardial Infarction Is Predicted by a J-Point/R-Wave Ratio above 0.5 on Admission

This study assessed the ability of simple clinical and electrocardiographic (ECG) variables routinely obtained on admission to identify patients with inferior myocardial infarction who are at high risk of developing high-degree atrioventricular (AV) block within the first 24 h of hospitalization in 205 patients. The admission ECGs were classified into two patterns based on the J-point to R-wave amplitude ratio: pattern 1: those with J-point/R-wave ratio <0.5; pattern 2: patients with J-point/R-wave ratio ≥0.5 in ≥2 inferior leads (II, III and aVF). High-degree AV block was found in 10.2% of the patients (21 of 205 patients; 5 and 16% of the patients with initial patterns 1 and 2, respectively, p = 0.014). Multivariate logistic regression analysis revealed that the only variables independently associated with high-degree AV block were the initial ECG pattern 2 versus 1 (odds ratio, OR, 4.47, 95% confidence interval, CI, 1.18–16.9; p = 0.0276), age (OR 1.06, 95% CI 1.01–1.12; p = 0.0254); Killip class >1 (OR 2.33, CI 0.83–6.54; p = 0.1065) and thrombolytic therapy (OR 0.32, 95% CI 0.11–0.93; p = 0.037).