Marcello Dominici

Operator exposure to x-ray in left and right radial access during percutaneous coronary procedures: OPERA randomised study

Objective Left radial access (LRA) and right radial access (RRA) have been shown to be safe and effective for coronary arteries catheterisation. However, the differences between the two approaches in terms of radiation exposure are still unclear. The aim of the present investigation is to evaluate in a randomised study, the dose of radiation absorbed by operators using either LRA or RRA. Design Randomised, prospective, double arm, single centre study. Setting University Hospital. Patients Male or female subjects with stable, unstable angina and silent ischaemia. Interventions The present study is a comparison of LRA and RRA for coronary artery catheterisation in terms of operators’ radiation exposure. Main outcome measures The primary outcome measure was the radiation dose absorbed by operators; secondary outcome measures were fluoroscopy time, dose-area product and contrast delivered. Results A total of 413 patients were enrolled; 209 were randomly selected to undergo diagnostic procedures with RRA and 204 with LRA. The operators radiation exposure was significantly lower in the left radial group (LRA 33±37 μSv vs RRA 44±32 μSv, p=0.04). No significant differences were observed in fluoroscopy time (LRA 349±231s vs RRA 370±246 s p=0.09) and dose-area product (LRA 7011.42±3617.30 μGym2 vs RRA 7382.38±5226.61 μGym2, p=0.80), even though in both there was a trend towards a lower level in the LRA. No differences were observed in contrast medium delivered (LRA 89.92±32.55 ml vs RRA 88.88±35.35 ml, p=0.45). Conclusions The LRA was associated in the present report with a lower radiation dose absorbed by the operator during coronary angiography.

ST-elevation during surgery in a young male: who would bet on inverted takotsubo syndrome?

We report the case of a 21-year old man active smoker, admitted to hospital for acute scrotal pain suspicious of testicular torsion. He underwent an emergency surgical exploration complicated by extreme sinus bradycardia (~20 bpm), successfully treated with atropine; neither epinephrine nor any other adrenergic agent was administered. After restoring the normal heart rate the ECG revealed an ST-segment elevation in the anterolateral leads. Transthoracic echocardiography showed reduced left ventricular ejection fraction (LVEF; 40%) due to diffuse severe hypokinesis except for the apex that appeared hyperkinetic. Emergency coronary angiography revealed normal coronary arteries (Fig. 1, Video 1). Left ventriculography showed akinesia of the mid and basal segments with concomitant hyperkinesis of the apex, resembling to the contractile pattern of apical sparing takotsubo cardiomyopathy (TTC) (Fig. 1, Video 2–3). Troponin peak was 31.60 ng/ml (upper limit of normal 1.20 ng/ml). We diagnosed inverted type of TTC occurred in a young male triggered by a physical stress. Patient was treated with Beta-blockers and ACE Inhibitors. At discharge five days later, the patient was asymptomatic and the ECG was unremarkable. Echocardiography disclosed improved LVEF (55%) but residual hypokinesis of the mid segments. At 2-weeks

Idiopathic, Serial Coronary Vessels Dissection in a Young Woman with Psychological Stress: A Case Report and Review of the Literature

Spontaneous coronary artery dissection (SCAD) is a very rare disease, associated with high mortality rate, whose etiology and pathogenesis are poorly understood. Its sporadic nature and the varied angiographic extent make firm recommendations regarding revascularization impossible. The case described is that of a young, otherwise healthy woman, without a known underlying condition which may lead to SCAD, but with a history of intense psychological stress. We managed the patient with a conservative approach based on watchful waiting, medical therapy, and plain old balloon angioplasty (POBA) with low inflation atmospheres.

A Giant Coronary Artery Aneurysm with Coronary Arteriovenous Fistula in Asymptomatic Elderly Patient

Coronary Arteriovenous Fistula (CAF) is a rare defect that occurs in 0.1-0.2% of patients undergoing coronary angiography; Coronary Artery Aneurism (CAA) also occurs in approximately 15–19% of patients with CAF. It is usually congenital, but in rare occasions it occurs after chest trauma, cardiac surgery, or coronary interventions. The case described is that of a 72-year-old woman, without previous history of cardiovascular disease, who presented a huge cardiac mass. A multimodal approach was necessary to diagnose a giant CAA with CAF responsible for compression and displacement of cardiac structures. Due to likely congenitally origin of the lesion and the absence of symptoms correlated to the CAA and to the CAF we decided to avoid invasive interventions and to treat the patient with medical therapy.

An Unusual Case of Congenitally Corrected Transposition of the Great Arteries in the Elderly

A 56-year-old man1–4 with a history of mild dyspnea for several years and without cardiovascular risk factors was referred to our institution for coronary angiography. Before he was admitted to the hospital, a transthoracic 2-dimensional echocardiogram (TTE) was performed. The TTE was not diagnostic enough because of a suboptimal acoustic window and a technetium-99m single photon emission computed tomography pharmacological (dipyridamole) stress test that showed a mild, reversible left ventricular septal perfusion defect. On admission to our institution, the patient was asymptomatic and had no signs of heart failure on physical examination; however, a mild systolic (grade 2) murmur was heard on cardiac auscultation. An ECG at rest showed a sinus rhythm with normal PR interval and complete left bundle-branch block …

Spontaneous-Idiopathic Left Anterior Descending Artery Dissection: Is Watchful Waiting Better Than Immediate Stenting?

Spontaneous coronary artery dissection (SCAD) is a rare, complex disease, nowadays poorly understood yet. The lack of firm recommendations about this issue is a great limitation which makes any therapeutic decision controversial. The case described is that of a young, otherwise healthy woman, who presented with an ostial dissection of the left anterior descending (LAD) artery. Due to patients stable clinical and hemodynamic parameters, we used a cautious approach based on watchful waiting and medical therapy, postponing stenting in order to achieve a partial vessel reopening with a more comfortable access to PCI.

Interplay between Oxidative Stress and Platelet Activation in Coronary Thrombus of STEMI Patients

Background: Platelet activation and oxidative stress seem to play a key role in coronary thrombus formation and are associated with thrombus burden in ST-elevation myocardial infarction (STEMI). However, the interplay between oxidative stress and platelet activation has not been fully elucidated. Materials and Methods: For 32 patients with STEMI undergoing primary percutaneous coronary intervention (PPCI) and 10 patients with stable angina (SA) and oxidative stress, as assessed by NADPH isoform 2 activity (soluble Nox2-derived peptide, sNox2-dp), levels of oxidized low-density lipoproteins (oxLDLs) and platelet activation markers such as soluble CD40 Ligand (sCD40L) and soluble P-selectin (sP-selectin) were measured in the retrieved material (coronary thrombi plus blood waste) of STEMI patients and in intracoronary blood of SA patients, respectively, and in peripheral blood samples of both groups. Results: In aspirated thrombi and blood waste of STEMI patients we found higher serum levels of sNox2-dp, oxLDLs, sCD40L, and sP-selectin, as compared to the intracoronary blood samples of SA patients. Moreover, in thrombi and blood waste of STEMI patients, a direct correlation between markers of oxidative stress and of platelet activation was found. Also, in STEMI patients a progressive increase of oxidative stress and platelet activation markers was observed according to the thrombus score burden. STEMI patients showed higher peripheral blood Nox2 activity and oxLDL levels as compared to SA patients. Conclusion: This study shows a close relationship between oxidative stress and platelet activation in the intracoronary blood waste and aspirated thrombi of STEMI patients, suggesting a role of oxidative stress in promoting thrombus formation and growth.