Congenital coronary artery anomalies silent until geriatric age: non-invasive assessment, angiography tips, and treatment

Coronary artery anomalies (CAAs) may be discovered more often as incidental findings during the normal diagnostic process for other cardiac diseases or less frequently on the basis of manifestations of myocardial ischemia. The cardiovascular professional may be involved in their angiographic diagnosis, functional assessment and eventual endovascular treatment. A complete angiographic definition is mandatory in order to understand the functional effects and plan any intervention in CAAs: computed tomography and magnetic resonance imaging are useful non-invasive tools to detect three-dimensional morphology of the anomalies and its relationships with contiguous cardiac structures, whereas coronary arteriography remains the gold standard for a definitive anatomic picture. A practical idea of the possible functional significance is mandatory for deciding how to manage CAAs: non-invasive stress tests and in particular the invasive pharmacological stress tests with or without intravascular ultrasound monitoring can assess correctly the functional significance of the most CAAs. Finally, the knowledge of the particular endovascular techniques and material is of paramount importance for achieving technical and clinical success. CAAs represent a complex issue, which rarely involve the cardiovascular professional at different levels. A timely practical knowledge of the main issues regarding CAAs is important in the management of such entities

Multipoint pacing by a left ventricular quadripolar lead improves the acute hemodynamic response to CRT compared with conventional biventricular pacing at any site

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Ketamine and midazolam differently impact post-intubation hemodynamic profile when used as induction agents during emergency airway management in hemodynamically stable patients with ST elevation myocardial infarction

We investigated the incidence of post-intubation hypotension (PIH) in hemodynamically stable patients with STEMI requiring rapid sequences intubation (RSI) and medicated with ketamine or midazolam as induction agent. STEMI patients admitted between 1st January 2009 and 1st January 2017 who did not receive any type of inotropic support before the endotracheal intubation (ETI) was reviewed. PIH was defined as a reduction greater than 20% or a drop of systolic blood pressure (SBP) below 90 mmHg within 10 min from the administration of the induction agent [ketamine (1 mg/kg) or midazolam (0.3 mg/kg)]. Over the study period, 136 patients (66 male and 70 females, mean age 72.25 \ub1 7.33 years) met the inclusion criteria. Patients treated with midazolam and ketamine were 63 and 73, respectively. PIH was observed in 38 (27.9%) patients after 10 min from ETI. Midazolam patients had a significant lower SBP at both 5 and 10 min after induction (97.75 \ub1 8.06 vs 100.81 \ub1 8.08, p = 0.029 and 92.83 \ub1 7.53 vs 101.58 \ub1 7.29, p < 0.0001, respectively) (ANOVA p < 0.0001). Age (OR 1.91, 95% CI 1.87-1.97, p = 0.001), history of arterial hypertension (OR 2.27, 95% CI 2.21-2.35, p = 0.0001), multivessel coronary artery disease (OR 2.66, 95% CI 2.58-2.71, p = 0.001), SI 650.9 (OR 2.41, 95% CI 2.36-2.48, p < 0.0001) and anterior STEMI (OR 2.51, 95% CI 2.48-2.57, p = 0.0001) resulted independent predictors of PIH in STEMI patients treated with midazolam, as induction agent, before ETI. Midazolam was more likely than ketamine to cause significant PIH when used as an induction agent for RSI in hemodynamically stable patients with STEMI

Antiplatelet therapy in patients with glucose-6-phosphate dehydrogenases deficiency after percutaneous coronary intervention: A reappraisal for clinical and interventional cardiologists

Glucose-6-phosphate dehydrogenase (G6PD) deficiency represents one of the most common erythrocyte enzymopathy. In the era of drug-eluting stents (DESs), the use of prolonged dual antiplatelet therapy (DAPT) with aspirin (ASA) and thienopyridine (clopidogrel or ticlopidine) has become mandatory in the treatment of patients with acute coronary syndromes (ACS) and/or after percutaneous coronary intervention (PCI). However, the use of ASA, and more in general of antiplatelet drugs in patients with G6PD deficiency remains controversial, also for the absence of specific guidelines and scientific evidences. In the present manuscript, we reviewed the few cases available in medical literature, regarding patients with G6PD deficiency treated with percutaneous coronary artery intervention (PCI) and DAPT, with the aim to discuss and clarify the optimal treatment in these patients

Modified balloon aortic valvuloplasty in fragile symptomatic patients unsuitable for both surgical and percutaneous valve replacement

BACKGROUND: Balloon Aortic valvuloplasty (BAV) is considered as a bridge therapy to percutaneous valve implantation or a palliative treatment in patients with aortic valve stenosis (AVS). Potential risk of complications, in particular in fragile patients, is still not negligible. AIM: To describe the technique and outcomes of modified BAV in fragile symptomatic patients unsuitable for other treatments using no-pacing and minimally invasive approach. METHODS: Symptomatic fragile patients with severe aortic valve stenosis judged unsuitable by the heart team for surgical or percutaneous valve implantation from 1 September 2013 to 1 September 2017 were offered modified BAV. Simplified procedural protocol included a 4F right radial artery access for gradient check, a 8F compatible undersized balloons, two partial inflations-trial before a full inflation with no-pace maker back-up, final pressure gradient recording and aortography. RESULTS: Thirty-four symptomatic fragile patients (mean age 80.9\ub14.9, range 73 to 91years, 100% Katz >6, mean Euroscore I 30.0\ub111.7%) underwent modified BAV in the last 5years with immediate success in all (100%). Mean aortic valve area increased from 0.58\ub10.2cm2 to 1.1\ub10.2cm2 (p<0.01) whereas mean peak gradient decreased from 75.6\ub111.3 to 35.8\ub111.2mmHg (p<0.01). Procedural complications were 14.7%. Thirty-day mortality was 11.8%. On a mean follow up of 38.4\ub14.6months four patients successfully repeated the procedure, while global mortality was 23.5% (8 patients). The other 22 patients maintained a NYHA class of 2.1\ub10.7. CONCLUSIONS: No-pacing minimally invasive BAV seems to have acceptable outcomes in patients with severe AVS and no other treatment options

Air pollution and ST-elevation myocardial infarction treated with primary percutaneous coronary angioplasty: A direct correlation

Purpose The relationships between air pollutant concentration levels and admission for primary percutaneous coronary intervention (PCI) in patients with ST-elevation myocardial infarction (STEMI) have never been assessed. Methods We retrospectively reviewed 4 consecutive years of medical and instrumental data (1st January 2012 to 1st March 2016) to identify patients admitted with STEMI and subsequently treated with primary PCI in our third referral center. Daily atmospheric pressure data (in hectopascal [hPa]) and air pollutant concentration levels were obtained from the regional meteorological service which had a monitoring site in our city (Rovigo, Italy). Pollutants investigated were nitrogen dioxide (NO2), particulate matter â\u89¤Â 10 μm (PM10), ozone (O3), sulfur dioxide (SO2) and carbon monoxide (CO). Safety air concentration levels for the air pollutants were also considered. Results PCI in STEMI patients was more frequent when AP was higher than 1013.15 hPa (61.8% vs 38.2%, p < 0.001). The incidences of STEMI patients when NO2, PM10and O3levels overcame the safe threshold were 83.1%, 52% and 8.5%, respectively. A positive correlation was found between the daily number of STEMI subsequently treated with primary PCI and the air pollutant levels of the same day for NO2(r = 0.205, p = 0.001), PM10(r = 0.349, p < 0.0001) and O3(r = 0.191, p = 0.002). Conclusions A direct and significant correlation exists between the number of daily STEMI patients and the NO2, PM10and O3air concentration levels of the same day