Pritesh Parekh

Giant coronaries: coronary ectasia as an isolated cause of exertional angina and positive stress test

Coronary artery ectasia (CAE) is characterised by segmental or diffuse dilation of the coronary artery to more than 1.5 times its diameter.1 CAE has been classified by Markis on the basis of the extent of ectasia.2 More than half of CAE cases are related to atherosclerotic coronary artery disease. Ectasia is restricted to a single coronary in 75% cases and is usually segmental.2 We present an interesting case of a middle-aged patient with a history of exertional chest pain with a positive exercise ECG stress test. The patient was taken for a diagnostic coronary angiogram which revealed the presence of diffuse ectasia involving all three coronary arteries as …

Rare occurrence of a transient isolated unilateral partial third nerve palsy after angioplasty

We report a rare case of isolated unilateral partial oculomotor nerve palsy in an elderly woman a day after radial angioplasty presenting with diplopia and ptosis. A 65-year-old woman with diabetes and hypertension presented with the acute onset transient partial third cranial nerve palsy presenting as diplopia and ptosis after 1 day of undergoing a double vessel angioplasty which spontaneously improved after a day of its occurrence. The patient was in normal sinus rhythm and there was no echocardiographic evidence of any thrombus in the left-sided cardiac chambers. An ocular examination revealed ptosis with paresis …

Incidentally detected large idiopathic brachial artery aneurysm: a potentially life-threatening discovery

While peripheral artery aneurysms are rarely encountered, brachial artery aneurysms are even rarer. Most of those seen are usually dissecting aneurysms of infectious, post-traumatic or iatrogenic origin; true aneurysms of the brachial artery are even more unusual.1 ,2 There may be a cause of in situ thrombosis, which might occlude vessels. The risk of limb loss can be avoided by prompt diagnosis and early surgery.3 ,4 The best therapeutic option is operative repair or closure by covered stent, although there are no uniform guidelines regarding the timing and indications of intervention. We present an interesting case of a 58-year-old man who presented with symptoms of atypical chest pain with non-specific ST-T changes in the ECG. The patient was taken up for a …

Isolated RV myocardial infarction presenting with systemic hypertension minimally responsive to nitroglycerin.

Isolated right ventricular myocardial infarction (RVMI) is an uncommon entity and is seldom seen in routine cardiological practice. Isolated RVMI is often misdiagnosed especially where right-sided precordial ECG leads are not taken routinely in all cases of suspected myocardial infarction (MI). Conventionally RVMI is known to present with hypotension (which forms a part of the diagnostic triad) that is responsive to a bolus of intravenous fluid. RVMI is considered a contraindication for administration of nitroglycerin to which they are hypersensitive and can develop intractable shock due to dramatic reduction of preload to the left ventricle.1 We are describing an interesting case of a middle-aged man who presented to us with …

TCT-486 Clinical outcomes of a novel abluminal coated sirolimus eluting stent: 2 years results from en-ABL e-Registry

nos: 487 499

TCT-469 Clinical outcomes following novel abluminal coated sirolimus eluting stent implantation in small vessel vs. large vessel

METHODS In this multicenter, open-label, randomized, all-comers trials patients undergoing percutaneous coronary intervention (PCI) were randomly assigned in a 2:1 fashion to either BES or EES. The primary composite endpoint major adverse cardiac events (MACE) was defined as cardiac death, non-fatal myocardial infarction (MI), or target vessel revascularization (TVR). We defined SV as vessel with a pre-procedural reference vessel diameter (RVD) 2.75 mm at quantitative coronary analysis (QCA).

An atypical presentation of an extremely late stent thrombosis after more than 7 years (2634 days) of DES implantation in a patient without obvious risk factors on regular dual antiplatelet therapy.

Very late stent thrombosis is a rare complication of percutaneous coronary intervention in the era of dual antiplatelet therapy. The risk factors for stent thrombosis are drug default, age, diabetes, renal dysfunction, left ventricular dysfunction, smoking or procedure-related factors and complications. We are describing the case of a 55-year-old non-smoker patient without the conventional risk factors for stent thrombosis maintaining good compliance with dual antiplatelet (aspirin and clopidogrel) drugs in standard doses. The patient had a history of having received a Cypher stent more than 7 years (2634 days) ago in the left circumflex artery for the management of in-stent restenosis of a bare metal stent implanted previously. He was referred with acute stent thrombosis with an atypical presentation of non-ST elevation myocardial infarction having unexplainable spontaneous resolution of electrocardiographic changes. The patient was successfully managed with newer generation drug-eluting stents reimplantation. The presence of acute onset of symptoms and thrombus containing soft lesion as documented during intervention supported the diagnosis of acute stent thrombosis. To the best of our knowledge this case is one of the longest duration of presentation with acute stent thrombosis after stent implantation ever reported in literature and is also unique in its unusual mode of presentation.

An unusual and inexplicable ECG pattern in an ostial LAD occlusion.

Traditionally ECG has been the gold standard in culprit vessel localisation in cases with ST elevation myocardial infarction (STEMI). Anterior wall STEMI is most often characterised by the ST elevation in precordial leads which are most often used to diagnose and localise the site of occlusion of the left anterior descending (LAD) artery. We report an unusual ECG of a 29-year-old non-diabetic, non-hypertensive male smoker who presented with acute onset chest pain since the past 5 h. The ECG at presentation showed isolated ST elevation in leads I and aVL with reciprocal changes in the inferior leads. There was no ST elevation in any …

LBBB masking the ECG changes of inferior wall infarction: a caution to be vigilant

The occurrence of left bundle branch block (LBBB) is known to mask the ECG changes of anterior wall myocardial infarction (AWMI) because of the changes it causes in the ST-T segments of the precordial leads. The ECG changes of inferior wall infarction (IWMI) which affects the limb leads are usually unaffected by the intraventricular conduction abnormality caused by LBBB. The occurrence of an IWMI being completely masked by the presence of a pre-existent LBBB on the ECG is an important occurrence which needs to be highlighted and discussed.1–4 We present an interesting image of a middle aged man who presented to us with acute onset of severe chest pain with …

'Spear' through the right ventricle: pericardial tamponade caused by delayed pacemaker lead-related perforation of a normal thickness free wall which was managed percutaneously using the same lead.

Lead perforation is seen in around 0.1–1%1 ,2 of pacemaker implantation and is predominantly seen early in the course while occurrence after 1 month is much rarer. A 58-year-old patient who had undergone implantation of a single-chambered VVI pacemaker using an active fixation lead more than 3 months ago for the presence of intermittent complete atrioventricular block presented with symptoms of progressively increasing dyspnoea and fatigue since the past 3–4 days. The patient was diagnosed to have pericardial tamponade (video 1, figures 1 and 2) due to perforation of the normal thickness right ventricular (RV) free wall by the lead which appeared to have passed through the free wall like a ‘spear’ through the endocardium into …