T. Baillie

Multivessel coronary artery spasm.

Coronary spasm is increasingly recognised as an important aetiological mechanism causing myocardial ischaemia. Occasionally cases present with evidence of ST segment elevation myocardial infarction, usually secondary to spasm confined to a solitary coronary artery. We present the rare and life-threatening case of severe coronary spasm afflicting all three major epicardial arteries simultaneously. It describes the difficult emergency scenario and ongoing management dilemmas encountered by physicians confronted with multivessel coronary spasm. Moreover we discuss the malignant prognosis associated with this ailment and describe the potential insights provided by cardiac magnetic resonance imaging that might identify those at greatest risk after the index event.

Evaluation of human coronary vasodilator function predicts future coronary atheroma progression

Objective Coronary vasodilator function and atherosclerotic plaque progression have both been shown to be associated with adverse cardiovascular events. However, the relationship between these factors and the lipid burden of coronary plaque remains unknown. These experiments focus on investigating the relationship between impaired coronary vasodilator function (endothelium dependent (salbutamol) and endothelium independent (glyceryl trinitrate)) and the natural history of atheroma plaque progression and lipid burden using dual modality intravascular ultrasound (IVUS) and near-infrared spectroscopy (NIRS) imaging. Methods 33 patients with stable chest pain or acute coronary syndrome underwent serial assessment of coronary vasodilator function and intracoronary plaque IVUS and NIRS imaging. Coronary segmental macrovascular response (% change segmental lumen volume (ΔSLV)), plaque burden (per cent atheroma volume (PAV)), lipid core (lipid-rich plaque (LRP) and lipid core burden index (LCBI)) were measured at baseline and after an interval of 12–18 months (n=520 segments). Results Lipid-negative coronary segments which develop into LRP over the study time period demonstrated impaired endothelial-dependent function (−0.24±2.96 vs 5.60±1.47%, P=0.04) and endothelial-independent function (13.91±4.45 vs 21.19±3.19%, P=0.036), at baseline. By multivariate analysis, endothelial-dependent function predicted ∆LCBI (β coefficient: −3.03, 95% CI (−5.81 to −0.25), P=0.033) whereas endothelial-independent function predicted ∆PAV (β coefficient: 0.07, 95% CI (0.04 to 0.10), P<0.0001). Conclusions Epicardial coronary vasodilator function is a determinant of future atheroma progression and composition irrespective of the nature of clinical presentation. Trial registration number ACTRN12612000594820, Post-results.

The relationship between segmental wall shear stress and lipid core plaque derived from near-infrared spectroscopy

BACKGROUND AND AIMS Wall shear stress (WSS) has an important role in the natural history of coronary atherosclerosis. The aim of this study is to investigate the relationship between WSS and the lipid content of atherosclerotic plaques as assessed by near-infrared spectroscopy (NIRS). METHODS We performed serial NIRS and intravascular ultrasound (IVUS) upon Doppler coronary flow guidewire of coronary plaques at baseline and after 12-18 months in 28 patients with <30% angiographic stenosis, who presented with coronary artery disease. Segmental WSS, plaque burden and NIRS-derived lipid rich plaque (LRP) were evaluated at both time-points in 482 consecutive 2-mm coronary segments. RESULTS Segments with LRP at baseline (n = 106) had a higher average WSS (1.4 ± 0.6 N/m2), compared to those without LRP (n = 376) (1.2 ± 0.6 N/m2, p<0.001). In segments without baseline LRP, WSS was higher in those who subsequently developed new LRP (n = 35) than those who did not (n = 341) (1.4 ± 0.8 vs. 1.1 ± 0.6 N/m2, p=0.002). Conversely, in segments with baseline LRP, WSS was lower in those who had regression of lipid content (n = 41) than those who did not (n = 65) (1.2 ± 0.4 vs. 1.6 ± 0.7 N/m2, p=0.007). Segments with the highest tertile of WSS displayed greater progression of LCBI irrespective of baseline lipid content (p<0.001). Multivariate analysis revealed that baseline WSS (p=0.017), PAV (p<0.001) and LCBI (p<0.001) were all independent predictors of change in LCBI over time. CONCLUSIONS Coronary segments with high WSS associate with progression of lipid content over time, which may indicate transformation to a more vulnerable phenotype.

Sepsis and an Ischemic Toe—What’s the Diagnosis?

DESCRIPTION A54-year-oldmale dentist presented to our hospitalwith a diffuse skin rash with desquamation, fevers, rigors, lethargy, and a black left toe. Vital signs showed high-grade fever associated with tachycardia and borderline hypotension. He had a medical history relevant for an aortic coarctation repair with a Dacron graft at the age of 29 years and hyperlipidemia treated with atorvastatin 10 mg daily. He was otherwise previously fit and well and did not use illicit drugs. He was diagnosed and treated for sepsis with presumed septic emboli and staphylococcal scalded skin syndrome. Multiple subsequent blood cultures confirmed bacteremia with methicillin-sensitive Staphylococcus aureus. The presumed source was a fish bite incurred while free diving in the sea a week prior. He was admitted to the intensive care unit, and a transoesophageal

Magnetic resonance imaging in the diagnosis and surveillance of thoracic aortic perigraft seroma and its complications.

Computed tomography (CT) has been in clinical use for more than 20 years in the management of thoracic aortic disease and remains widespread due to its universal availability. Postoperative perigraft seroma formation is a poorly understood phenomenon that may be more prevalent than previously reported. In particular, cardiac magnetic resonance imaging (MRI) is emerging as an excellent complementary imaging modality in the follow-up of these patients and has several advantages over CT and echocardiography, lacking the hazards of frequent use of ionizing radiation and having the ability to image the thoracic aorta, its branches, and surrounding structures. We describe the use of MRI as the principle imaging modality for monitoring postthoracic aortic graft placement complicated by a large perigraft seroma. A patient with