Shmuel Rath

Review of echocardiographically diagnosed right heart entrapment of pulmonary emboli-in-transit with emphasis on management

2DE permits detection of thromboemboli transiently entrapped in the right heart chambers while en route to the pulmonary arteries. Review of the 49 cases recorded to date reveals that the supple elongated clot produces a 2DE picture--a mass of changing configuration and striking mobility--that is highly characteristic. Since emboli that become entrapped are large, when managed by medical measures alone they have an attendant mortality rate of 50%, usually soon after 2DE diagnosis, upon completion of pulmonary embolization. Death occurred in 8 of 16 patients treated with anticoagulants, thrombolytic agents, or antiaggregants and in 6 of 13 who received supportive measures only. Of 20 patients referred for surgery (cardiotomy and, in 17, pulmonary embolectomy), only three died, two of them failures of preceding anticoagulant treatment. These data indicate that thromboemboli entrapped in the right heart chambers are best handled as a surgical emergency.

Fate of nonobstructive aneurysmatic coronary artery disease: Angiographic and clinical follow-up report

The incidence of coronary aneurysmatic dilatation without coronary stenosis is rare, and the clinical course of such an entity is unknown. We present five adult patients, four men and one woman, with such an anatomic finding. The age range was 44 to 60 years. In four patients the aneurysmatic dilatations involved multiple coronary sites. The clinical course in all five patients was suggestive of coronary insufficiency. Despite no obstructive disease, two of the patients developed transient ischemic ECG changes accompanied by chest pain, and another two patients demonstrated ischemic exercise nuclear ventriculography response. In time, all five patients developed acute myocardial infarction and recatheterization revealed complete occlusion of a previously nonstenosed aneurysmatic vessel. More information is needed in order to guide therapy. However, prevention of thrombus formation and close follow-up is highly recommended.

Significance of ST segment elevations in posterior chest leads (V7 to V9) in patients with acute inferior myocardial infarction: application for thrombolytic therapy.

OBJECTIVES This study was designed to examine whether ST segment elevation in posterior chest leads (V7 to V9) during acute inferior myocardial infarction (MI) identifies patients with a concomitant posterior infarction and whether these patients might benefit more from thrombolysis. BACKGROUND Because the posterior wall is faced by none of the 12 standard electrocardiographic (ECG) leads, the ECG diagnosis of posterior infarction is problematic and has often remained undiagnosed, especially in the acute phase. METHODS Eighty-seven patients with a first inferior infarction who were treated with recombinant tissue-type plasminogen activator were stratified according to the presence (Group A [46 patients]) or absence (Group B [41 patients]) of concomitant ST segment elevation in posterior chest leads V7 to V9. RESULTS Patients in Group A had a higher incidence of posterolateral wall motion abnormalities (p < 0.001) on radionuclide ventriculography, a larger infarct area (as evidenced by higher peak creatine kinase levels) (p < 0.02) and a lower left ventricular ejection fraction (LVEF) at hospital discharge (p < 0.008) than those in Group B. ST segment elevation in leads V7 to V9 was associated with a higher incidence of at least one of the following adverse clinical events: reinfarction, heart failure or death (p = 0.05). Although patency of the infarct-related artery (IRA) in Group A resulted in an improved LVEF at discharge (p < 0.012), LVEF was unchanged in Group B, regardless of the patency status of the IRA. CONCLUSIONS ST segment elevation in leads V7 to V9 identifies patients with a larger inferior MI because of concomitant posterolateral involvement. Such patients might benefit more from thrombolytic therapy.

Early T wave inversion after thrombolytic therapy predicts better coronary perfusion: Clinical and angiographic study☆

OBJECTIVES This study was undertaken to test the hypothesis that early inversion of T waves after thrombolytic therapy for acute myocardial infarction predicts patency of the infarct-related artery with high Thrombolysis in Myocardial Infarction (TIMI) perfusion flow and better in-hospital outcome. BACKGROUND Although numerous studies have demonstrated a strong association between early resolution of ST segment elevation after acute myocardial infarction and successful thrombolysis, little is known about early changes in T waves after thrombolytic therapy. METHODS Ninety-four consecutive patients with acute myocardial infarction treated with recombinant tissue-type plasminogen activator (rt-PA) were studied with admission and predischarge radionuclide ventriculography and with coronary angiography within 72 h of admission. Patient stratification was based on the presence or absence of early (within 24 h) T wave inversion. RESULTS Early T wave inversion was associated with a higher patency rate of the infarct-related artery (90% vs. 65%, p < 0.02) and less severe residual stenosis ([mean +/- SD] 73 +/- 27 vs. 83 +/- 22, p = 0.06), and when only TIMI perfusion grade 3 was considered, the difference was even greater (77% vs. 41%, p < 0.001). Patients with early inversion of T waves had a lower peak creatine kinase value ([mean +/- SD] 678 +/- 480 vs. 1,076 +/- 620, p < 0.01), and although a similar percent of patients with and without early T wave inversion had a normal ejection fraction (> or = 55%) on admission, a higher percent of patients with early inversion had a normal ejection fraction at hospital discharge (71% vs. 44%, p < 0.03). Early T wave inversion anticipated a more benign in-hospital clinical course with a lower incidence of adverse cardiac events (10% vs. 33%, p < 0.02). CONCLUSIONS Early inversion of T waves in patients with acute myocardial infarction treated with thrombolytic therapy suggests patency of the infarct-related artery, better perfusion grade and left ventricular function and a more benign in-hospital course.

Two-dimensional echocardiographic analysis of proximal left main coronary artery in humans

The left main coronary artery (LMCA) was evaluated in 100 consecutive patients (88 men and 12 women; mean age 63 years) with anginal syndrome, all in New York Heart Association classes II and III. Each patient underwent two-dimensional echocardiography (2DE) from the parasternal short-axis and apical four-chamber views. Coronary angiography was subsequently performed within 24 hours. The LMCA was directly measured by 2DE and coronary angiography at its widest point. Each echocardiogram was blindly evaluated for LMCA aneurysm or obstruction. Eight patients (8%) were excluded because of inadequate visualization of the LMCA. The mean 2DE measurement was 4.4 +/- 0.9 mm vs 4.2 +/- 0.8 mm on coronary angiography (r = 0.86). Atherosclerotic aneurysms of the LMCA were correctly diagnosed in two patients by 2DE. LMCA stenosis (greater than 50%) was found in 11 patients on coronary angiography; three of them had ostial or proximal lesions, three had middle lesions, and five had distal lesions. 2DE correctly diagnosed all three ostial lesions, two of three middle lesions, but only two of five distal lesions. In four patients, dense echoes in the LMCA caused a false positive diagnosis. It was concluded that: the LMCA can be visualized and correctly measured by 2DE; atherosclerotic aneurysms can be detected; and 2DE is yet unable to screen patients for LMCA lesions; however, 2DE is a promising method for evaluating proximal and especially ostial LMCA stenosis.

Clopidogrel-induced systemic inflammatory response syndrome

Clopidogrel bisulfate, a widely used inhibitor of platelet aggregation, is considered at least as safe as aspirin. We describe a patient who developed a systemic inflammatory response syndrome consisting of high fever, tachycardia, cellulitis-like rash, impaired liver function, and mild leukopenia after receiving clopidogrel before coronary angiography and stent implantation. The reaction resolved promptly after withdrawal of the drug and recurred shortly after a rechallenge dose was administered, thus making the diagnosis of a clopidogrel-induced reaction highly probable. Recognition of this clopidogrel-induced syndrome is extremely important, both for rapid discontinuation of the offending drug and for avoidance of unnecessary drug therapy or invasive procedures.

Anomalous origin of the right coronary artery from the left anterior descending coronary artery

This is the first presentation of anomalous origin of right coronary artery (RCA) from mid-left anterior descending (LAD) coronary artery. A 77-year-old male was catheterized because of recent onset of fatigue during exertion. The LAD demonstrated 50-60% narrowing just proximal to the anomalous origin of the RCA. The patient was maintained on oral medication.

Subclavian Coronary Steal Syndrome: An Obligatory Common Fate between Subclavian Artery, Internal Mammary Graft and Coronary Circulation

The long-term patency of the left internal mammary artery (IMA) has made it the preferred conduit for myocardial revascularization. The proximal segment of the subclavian artery becomes functionally connected to the coronary circulation as a result of IMA implantation during coronary artery bypass surgery. The subclavian coronary steal syndrome results from stenosis in the left subclavian artery proximal to the IMA, compromising blood flow to the myocardium. We describe 7 patients, aged 55–75 years, 1.7–10.5 years after coronary bypass who presented with recurrent angina due to subclavian artery stenosis. The IMA graft was found open in each patient. A true steal mechanism was not demonstrated, casting doubt on the syndrome’s traditional name. Angioplasty and stenting of the subclavian artery resulted in the immediate disappearance of angina and continuous benefit at a follow-up of 3–32 months. The subclavian coronary steal syndrome, although rare, is a severe condition readily treated by angioplasty and stenting.

Frequency and Clinical Significance of Anomalous Origin of Septal Perforator Coronary Artery

Abstract The reported incidence of anomalous origin of coronary arteries ranges from 0.6 to 1.2%. 1–3 The most common variations reported are anomalous origin of the circumflex and conal arteries and, less often of the left anterior descending and right coronary arteries. 1–5 Anomalous origin of first septal perforator coronary artery (ASA) has been reported in only 3 living patients, 3 and its clinical significance is not known. We reviewed 2,100 consecutive angiograms from adult patients to determine the incidence of an ASA and its role as a collateral vessel in patients with obstructive coronary heart disease.

Left main coronary artery atresia : Extremely rare coronary anomaly in an asymptomatic adult and an adolescent soccer player

Left main coronary artery atresia is a very rare coronary anomaly with only 33 cases reported in the literature, of whom only 1 patient is asymptomatic. Pediatric patients are usually very symptomatic early in life (dyspnea, syncope, failure to thrive, ventricular tachycardia, and sudden death), whereas adult patients begin showing symptoms (angina or sudden death) only at an advanced age. Given the high risk related to the presence of left main coronary artery atresia, and in view of the good results obtained by coronary artery bypass surgery, coronary artery revascularization should always be considered as the possible treatment of choice for establishing adequate myocardial blood flow.