Vern Hsen Tan

Feasibility of Transradial Coronary Angiography and Intervention Using a Single Ikari Left Guiding Catheter for ST Elevation Myocardial Infarction

BACKGROUND Transradial coronary intervention (TRI) has been widely adopted in ST elevation myocardial infarction (STEMI) patients but there is limited literature on the use of a single catheter for both diagnostic angiography and intervention. We aim to evaluate the feasibility and outcomes of TRI with a single Ikari left (IL) guiding catheter in STEMI patients. METHODS This is a retrospective study of 362 consecutive STEMI patients from August 2007 to December 2008. We assessed the feasibility of TRI with a single IL and compared this strategy with conventional transfemoral intervention (TFI) on the following outcomes: (1) door to perfusion time, (2) total procedural duration, (3) total fluoroscopy duration, and (4) major adverse cardiac events (MACE) by intention to treat analysis. RESULTS TRI was attempted in 185 patients. There were no failed radial cannulations. Overall success rate of primary TRI with a single IL was 96.9% and there were only 2 failures that required conversion to TFI. Compared to TFI, TRI with IL tended to a shorter median door to perfusion time, 90 (IQR 76.0 - 119.5) versus 98 (IQR 80.8 - 120.5) minutes (P = 0.07) and a shorter median procedure duration of 34 (IQR 27.0 - 45.0) versus 37 (IQR 28.0 - 49.3) minutes (P = 0.06). The median fluoroscopy duration was longer in the TRI group. MACE were comparable between the 2 groups. CONCLUSION In experienced centers, TRI with a single IL catheter for STEMI is a feasible and effective approach and outcomes are comparable to conventional TFI.

Exercise-induced syncope in a 22-year-old man

Clinical introduction A 22-year-old man was referred to us for syncope during a game of Captains ball. There was no prodrome. His friends did not notice any ictal movements. He was otherwise well prior to passing out. He was not taking any medications or supplements. He was not usually physically active, but was otherwise well with no significant medical history. This is his first episode of syncope. There was no history of cardiac arrest or seizures. There is no family history of premature sudden cardiac death. Physical examination was normal. ECG at rest demonstrated sinus rhythm with corrected QT interval of 400 ms. Echocardiography revealed a structurally normal heart. Holter monitoring was normal. Treadmill exercise stress test demonstrated the following rhythm on figure 1 during stage 4 Bruce protocol. Stress test was terminated in view of sustained arrhythmia as illustrated. He felt light-headed during the period, but otherwise felt that he could carry on with the exercise. ECG during recovery was unremarkable. Figure 1 ECG recording of the patient during exercise stress test.

Late Ratchet syndrome involving isolated left ventricular lead dislodgement post-cardiac resynchronization therapy defibrillator generator change

Lead dislodgement following cardiac implantable electronic device (CIED) generator change is rare. We report a case including the postulate mechanism of an isolated left ventricular lead dislodgement 3 months after cardiac resynchronization therapy defibrillator pulse generator change.

Recurrent shocks from implantable cardiac defibrillator implanted 6 months ago. What is the mechanism

A 51yearold gentleman reported thumping sensations in the chest in the morning when he was preparing to go to work. He was diagnosed to have received appropriate shocks for ventricular tachycardia (VT) and was commenced on amiodarone. About 1 week later, the patient was admitted to our Centre for Palpitations. Device check revealed that he received five shocks from his implantable cardiac defibrillator (ICD) in a single morning 1 week ago. Patient had history of ischemic cardiomyopathy and received a dual chamber ICD (Boston Scientific Inogen) for primary prevention of sudden cardiac death 6 months ago. His baseline 12 lead ECG showed sinus rhythm with narrow QRS complex. ICD check showed stable and normal device parameters. VT zone was programmed 170199 beats per minute (BPM) with no therapies. Fast VT zone was programmed 200249 BPM with antitachycardia pacing (ATP) followed by 41J shocks. Ventricular fibrillation (VF) zone was programmed 250 BPM with ATP followed by 41J shocks. Figures 1 and 2 showed the device tracings of the events. What was the cause of his symptoms and how would you manage the patient?

Concealed conduction of premature ventricular complexes resulting in AV nodal block

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COMPARING UTILIZATION OF TIMI RISK INDEX VERSUS KILLIP CLASS AT PRESENTATION IN DETERMINING THE NEED OF ADMISSION TO CORONARY CARE UNIT FOR ACUTE ST ELEVATION MYOCARDIAL INFARCTION PATIENT AFTER SUCCESSFUL PRIMARY PERCUTANEOUS CORONARY INTERVENTION: SINGLE CENTRE STUDY

Background: With the ever-increasing number of acutely ill patients with cardiac disease that need intensive monitoring and limited resources in coronary care unit (CCU), there is a need to ensure appropriate admission to CCU. Studies have shown that Killip 1 patients who had successful primary percutaneous coronary intervention (PPCI) for ST Elevation Myocardial Infarction (STEMI) can be admitted safely to a step-down unit. However, Killip class was a subjective assessment. We attempt to compare TIMI risk index {TRI = [heart rate X (age/10)2]/systolic blood pressure} versus Killip Class at presentation in determining the need of admission to CCU for STEMI patient after successful PPCI. TRI was a robust predictor (for STEMI patients on irst arrival in hospital) and high discriminatory capacity of in-hospital events in each of the ive risk subgroups.

TRANSRADIAL PERCUTANEOUS INTERVENTION IN ACUTE ST ELEVATION MYOCARDIAL INFARCTION USING A SINGLE HEARTRAIL IKARI LEFT GUIDER

Methods: This is a single centre case series of 213 patients who underwent PTRI by a single radial interventionist between May 2007 and December 2008. In 171 patients, a 6F Heartrail IL guider was used first for diagnostic angiography of the contra-lateral artery followed by cannulation of the infarct related artery (IRA) for PTRI (IL group). In 4 patients (1.9%) the radial artery could not be cannulated. The remaining 38 patients (Non-IL group) had a diagnostic angiography done with a multipurpose catheter followed by a selective guider. The examined outcome included the rate of success of primary PTRI, door to balloon time, procedure duration and volume of contrast used between the 2 groups. Major adverse cardiac events were examined at in-hospital, 30 days and 6 months.