Miodrag Sreckovic

Coronary spasm that caused non-ST elevation myocardial infarction appeared in cath lab due to vasovagal reaction.

Coronary artery spasm is sometimes an unrecognized cause of myocardial ischemia. Myocardial ischemia is not always a product of fixed stenosis; it can also be induced by dynamic, transient stenosis. The angiogram represents the current state of vasculature at the time of examination and absence of stenosis does not mean disease absence. We present a case of right coronary artery spasm that caused non-ST elevation myocardial infarction and arrhythmias and was induced again in the cath lab due to vasovagal reaction.

Knuckle technique guided by intravascular ultrasound for in-stent restenosis occlusion treatment

One of the rarest lesions is in-stent restenosis chronic total occlusion (CTO). Limited data suggest that the treatment success rate is dependent on the possibility to cross into the lumen of an occluded stent, and the decision about what technique to use varies by operator preference. The knuckle technique is used to create a deliberate dissection plane in various CTO techniques. A guide wire is pushed until a complex loop is formed and advanced through the lesion. In this report we present a case where a knuckle wire guided by intravascular ultrasound control is used to penetrate the distal cap in an in-stent restenosis CTO lesion.

Extremely tortuous coronary arteries - when optical coherence tomography and fractional flow reserve did not help us much

Introduction. Extreme coronary tortuosity may lead to flow alteration resulting in a reduction in coronary pressure distal to the tortuous segment, subsequently leading to ischemia. Therefore the detection of a true cause of ischemia, i.e. whether a fixed stenosis or tortuosity by itself is responsible for its creation, with non-invasive and invasive methods is a real challenge. Case report. We presented a case of a patient with a history of stable angina [Canadian Cardiovascular Society (CCS class II)], an abnormal stress test and coronary tortuosity without hemodynamically significant stenosis. Due to suspected linear lesion between the two bends in proximal segment of Right coronary artery (RCA) we performed optical coherence tomography (OCT), minimum lumen area (MLA)-13.19 mm2) and fractional flow reserve (FFR) RCA (0.94). We opted for conservative treatment for stable angina. Conclusion. When tortuosities are associated with atherosclerosis in coronary artery for determination of true cause of ischemia invasive methods can be used, such as OCT and FFR.

Cardiorenal Syndrome Type 1: Definition, Etiopathogenesis, Diagnostics and Treatment

Abstract Cardiorenal Syndrome Type 1 (CRS-1) is defined as an acute worsening of heart function leading to acute kidney injury and/or dysfunction. It is an important cause of hospitalization which affects the diagnosis as well as the prognosis and treatment of patients. The purpose of this paper is to analyze causes that lead to the development of cardiorenal syndrome type 1 and its clinical consequences, as well as to emphasize the clinical importance of its early detection. The clinical studies and professional papers dealing with etiopathogenesis, diagnosis and treatment of cardiorenal syndrome type 1, have been analyzed. The most important role in the occurrence of cardio renal syndrome type 1 is played by hemodynamic mechanisms, activation of neurohumoral systems, inflammation and imbalance between the production of reactive oxygen species (ROS) and nitric oxide (NO). Diagnosis of cardiorenal syndrome type 1 involves biomarkers of acute renal injury among which the most important are: neutrophil gelatinaseassociated lipocalin (NGAL), cystatin C, kidney injury molecule 1 (KIM-1), liver-type fatty acid binding protein (L-FABP), IL-18 and the values of nitrogen compounds in serum. In addition to a pharmacological therapy, various modalities of extracorporeal ultrafiltration are applied in treatment of CRS-1, particularly if there is resistance to the use of diuretic therapy. As opposed to the experimental models, in clinical practice acute renal injury is often diagnosed late so that the measures taken do not give the expected results and the protective role shown in experimental conditions do not give the same results. For all these reasons, it is necessary to analyze the pathophysiology of renal impairment in cardiorenal syndrome as well as detect early indicators of kidney injury that could have clinical benefit and positive impact on reducing the cost of treatment.

Association of coronary ischemia estimated by fractional flow reserve and psychological characteristics of patients

Introduction Psychological characteristics of patients, depression, stress and anxiety are recognized as important confounding risk factors for ischemic heart disease. However, the impact of psychological characteristics on coronary ischemia and vice versa remain poorly understood. Aim To demonstrate the interplay of psychological characteristics, depression, stress and anxiety with coronary ischemia estimated with fractional flow reserve (FFR). Material and methods From 2014 to 2016, 147 patients who were planned for FFR measurement were included in this study. Psychological characteristics of patients were evaluated using the Depression, Anxiety and Stress Scale 21 items (DASS 21) self-report questionnaire. Results Comparing the FFR ischemic vs. FFR non-ischemic groups, a significant difference was observed regarding results achieved for the depression, anxiety and stress scales. Multivariate logistic regression analysis was used to model the correlation between FFR and the DAS scale. It was clear, when controlling for previous myocardial infarction, that FFR was significant in all analyses. However, when the Canadian Cardiovascular Society grading of angina pectoris (CCS) class was entered in the model, FFR was not a significant predictor of anxiety, but was significant in other analysis. Conclusions Higher degrees of the psychological characteristics depression, stress and anxiety were observed in the group of patients with coronary ischemia, corresponding to lower fractional flow values.

Renovascular Hypertension: Clinical Features, Differential Diagnoses and Basic Principles of Treatment

Abstract Renovascular hypertension is caused by renal artery stenosis. Its prevalence in populations of hypertensive patients is 1-8%, and in populations of patients with resistant hypertension, it is up to 20%. The two main causes of stenosis are atherosclerosis and fibromuscular dysplasia of the renal artery. The main clinical consequences of renal artery stenosis include renovascular hypertension, ischemic nephropathy and “flash” acute pulmonary oedema. Unilateral stenosis of the renal artery causes angiotensin II-dependent hypertension, and bilateral stenosis of the renal arteries produces volume-dependent hypertension. Renovascular aetiology of hypertension should be questioned in patients with resistant hypertension, hypertension with a murmur identified upon auscultation of the renal arteries, and a noticeable side-to-side difference in kidney size. Non-invasive diagnostic tests include the determination of concentrations of peripheral vein plasma renin activity, the captopril test, captopril scintigraphy, colour Doppler ultrasonography, computed tomography angiography, and nuclear resonance angiography. Renovasography represents the gold standard for the diagnosis of renovascular hypertension. The indications for revascularization of the renal artery include haemodynamically significant renal artery stenosis (with a systolic pressure gradient at the site of stenosis of - ΔP ≥ 20 mmHg, along with the ratio of the pressure in the distal part of the renal artery (Pd) and aortic pressure (Pa) less than 0.9 (Pd/Pa < 0.9)), resistant hypertension, loss of renal function after administration of ACE inhibitors or angiotensin receptor II blockers, and recurrent flash pulmonary oedema associated with bilateral renal artery stenosis. The contraindications for renal artery revascularization include a longitudinal diameter of the affected kidney that is less than 8.0 cm, the resistance index measured from the segmental arteries peak blood flow (RI) > 0.8, chronic kidney disease (GFR <30 ml/min/1.73 m2) and negative captopril scintigraphy (lack of lateralization).

Identifying culprit lesions in non-ST-elevation myocardial infarction: are new diagnostic tools always better?

Address for correspondence: Dr Miodrag J. Sreckovic, Clinical Centre Kragujevac, Interventional Cardiology, Faculty of Medical Sciences, Kragujevac, Serbia, tel: 381693371777, e-mail: sreckovic7@gmail.com Conflict of interest: none declared Kardiologia Polska Copyright

Grade III Coronary Artery Perforation Following PCI and Unusual Stent Graft Delivery System

ABSTRACT Coronary perforations are rare but vicious complications of PCI procedures. Ellis type III coronary artery perforation represents the most severe form and demands an urgent solution. It is often necessary to perform pericardiocentesis and utilizise multiple interventional techniques to seal the perforation. Polytetrafluoroethylene (PTFE)-covered stent implantation has become one of the most frequently used percutaneous solutions, but disadvantages of this intervention are its high profile and low device flexibility. In our case, we attempted to improve the deliverability of the PTFE stent graft alone by mounting it on a bare metal stent used as a stent graft carrier. SAŽETAK Koronarne perforacije su retke ali izuzetno neugodne komlikacije perkutanih intervencija. Perforacije koronarnh arterija trećeg stepena po Elisu predstvaljaju najozbiljniju formu perforacija i zahtevaju hitno zbrinjavanje. Često je neophodno uraditi perikardiocentezu i primeniti brojne interventne tehnike kako bismo rešili perforaciju. Stentovi prekriveni politetrafluoroetilenom(PTFE) postali su jedno od najčešće korišćenih perkutanih rešenja, ali su njihove mane visoki profil i slaba fleksibilnost. U našem slučaju, pokušali smo da poboljšamo plasiranje PTFE stenta montiranjem na metalni stent, koji smo iskoristili kao nosač.

Efficiency of IVUS guided procedures in center without previous experience

Introduction of IVUS procedures in the routine practice is not yet achieved nor there are significant studies that dealt with examining the success of IVUS guided PCI, showed a significant advantage over conventional angiography guided PCI. On the other hand a number of smaller studies give results for the benefit of IVUS. The aim of the research is to check the effectiveness of IVUS guided PCI in the center with no previous experience in performing intravascular ultrasound diagnostics.