Transvenous Temporary Cardiac Pacing

Transvenous temporary cardiac pacing is a rather old but still contemporary life-saving technique, with a unique value in the treatment of critically ill patients suffering from rhythm disturbances and associated hemodynamic compromise. Physicians involved in the management of such patients should always keep in mind the indications and contraindications of transvenous temporary cardiac pacing, and should be at least familiar with the insertion technique and the post-insertion care

An Underexpanded Stent Does not Forgive

Resistant coronary lesions regularly challenge physicians performing percutaneous coronary interventions (PCI) and specific techniques may be required to achieve procedural success. Underestimation of a resistant lesion may result in implanting an underexpanded stent due to insufficient plaque modification. Stent underexpansion is a risk factor for stent thrombosis and particularly difficult to treat. We present herein a case of a resistant right coronary artery lesion, insufficiently modified before stenting and finally treated with an underexpanded stent which could not be expanded by balloon post-dilatation at the initial intervention. Two inferior wall myocardial infarctions ensued one and three years later, both due to stent thrombosis despite intensive dual antiplatelet therapy and both treated by primary PCI. The stent could only be expanded by aggressive non-compliant balloon dilatation at the last procedure. The case presentation is followed by a brief discussion concerning techniques to successfully treat resistant coronary lesions and underexpanded stent

An Underexpanded Stent Does not Forgive

Resistant coronary lesions regularly challenge physicians performing percutaneous coronary interventions (PCI) and specific techniques may be required to achieve procedural success. Underestimation of a resistant lesion may result in implanting an underexpanded stent due to insufficient plaque modification. Stent underexpansion is a risk factor for stent thrombosis and particularly difficult to treat. We present herein a case of a resistant right coronary artery lesion, insufficiently modified before stenting and finally treated with an underexpanded stent which could not be expanded by balloon post-dilatation at the initial intervention. Two inferior wall myocardial infarctions ensued one and three years later, both due to stent thrombosis despite intensive dual antiplatelet therapy and both treated by primary PCI. The stent could only be expanded by aggressive non-compliant balloon dilatation at the last procedure. The case presentation is followed by a brief discussion concerning techniques to successfully treat resistant coronary lesions and underexpanded stents

CryoAblation of Atrial Fibrillation: New Technique/ New expectations

A 53-year-old gentleman with frequent episodes of idiopathic paroxysmal atrial fibrillation (AF) who had failed rhythm control with two antiarrhythmic drugs was initially submitted to an ablation procedure during which pulmonary vein (PV) isolation was performed with use of a cryothermic balloon in September 2012. After a 3-month blanking period, he remained free of symptoms for over a year. However, over the last one month he has had frequent arrhythmia recurrences with almost weekly episodes. He returned for a repeat ablation procedure... (excerpt

The Current Role of Glycoprotein IIb/IIIa Inhibitors in Percutaneous Coronary Intervention

The central role of platelets in acute coronary syndromes (ACS) and percutaneous coronary interventions (PCI) is well appreciated. The various platelet activation mechanisms finally lead to the expression and activation of surface glycoprotein IIb/IIIa receptors that mediate platelet aggregation and thrombus formation. Glycoprotein IIb/IIIa inhibitors (GPIs) are the most potent antiplatelent agents and their role in ACS treatment and PCI has been dominant in the recent past. The advent of stents and thienopyridines minimized ischemic complications and in parallel the role of GPIs in low risk PCI. Despite being effective in decreasing PCI-related ischemic complications, the major drawback of GPI use is a relative increase of hemorrhagic complications that can unfavorably affect prognosis. The availability of bivalirudin, which is regarded as an equally effective but safer antithrombotic agent when compared to the combination of heparin and GPIs, despite an ongoing controversy, has also led to a decrease of GPI use in PCI for ACS. Finally the advent of novel potent antiplatelet agents (prasugrel, ticagrelor and soon cangrelor) further contained GPI use in patients with ischemic – thrombotic risk that clearly exceeds bleeding risk and mainly for bail-out in case of a thrombotic event during PCI. A concise overview of accumulated data regarding optimal use of GPIs as determined by large clinical trials and recent guidelines is herein attempted

Late Tricuspid Regurgitation as a Result of Rheumatic Tricuspid Disease in a Patient With Prosthetic Mitral Valve. Combined Two-Dimensional and Real-Time Three-Dimensional Transthoracic Echocardiographic Assessment

We herein present the case of a 65-year-old lady with late tricuspid regurgitation 15 years after successful mitral valve replacement due to severe mitral stenosis of rheumatic origin. She presented to our department complaining of fatigue which worsened over the last 6 months. Transthoracic echocardiographic examination including both 2D and real time 3D modalities revealed severe tricuspid regurgitation and the patient was scheduled for tricuspid annuloplasty. A propos with this case, a brief review of the literature is provided highlighting the key points of this topic

Echocardiographic Findings in Carcinoid Syndrome

A 57-year-old Caucasian female was referred to our Cardiology department due to hypertension, flushing, and diarrhea. She had a medical history of hypertension and paroxysmal atrial fibrillation. On physical examination, the patient had a heart rate of 70 bpm and a respiratory rate of 12 breaths/min. Her temperature was 37°C and her blood pressure was 120/80 mmHg. Cardiac examination revealed a left parasternal holosystolic murmur, and a palpable right ventricular heave. Lung auscultation was unremarkable. From the initial biochemical exam she had no specific abnormalities. The ECG showed sinus rhythm, negative T-waves in leads III, V1-5. The transthoracic echocardiography study revealed a left ventricle with normal size and normal systolic function and dilatation of the left atrium, whereas the right cardiac chambers were dilated with thickened, immobile leaflets of the tricuspid and pulmonic valve, leading to malcoaptation and severe tricuspid and pulmonic regurgitation. (Figures 1-5) The clinical and echocardiographic findings raised the suspicion of carcinoid heart disease. Abdominal CT demonstrated hepatic metastases and the patient was treated with chemotherapy and with the somatostatin analog octreotide... (excerpt

Diagnosis and Treatment of Inappropriate Sinus Tachycardia

Inappropriate sinus tachycardia (IST) is a syndrome of cardiac and extracardiac symptoms characterized by rapid sinus heart rate at rest (>100 bpm) or with minimal activity and disproportionate to the physiologic demands. Patients with this unique and puzzling arrhythmia may require restriction from physical activity. The responsible mechanisms for IST are not completely understood. IST and postural orthostatic tachycardia syndrome (POTS) are the 2 sides of the same coin. It is important to distinguish IST from so-called appropriate sinus tachycardia and from POTS, with which an overlap may occur. As the long-term outcome seems to be benign, treatment may be unnecessary, or may be as simple as physical training. However, for patients with intolerable symptoms, therapeutic measures are warranted. Beta-adrenergic blockers, considered a first-line therapy, are usually ineffective even at high doses; the same applies for most other medical therapies. Ivabradine seems to be more effective than beta-blockers especially in the non- hypertensive patients. In rare instances, catheter- or surgically- based right atrial or sinus node modification may be helpful, but even this is fraught with limited efficacy and potential complications. Overtreatment, in an attempt to reduce symptoms, can be difficult to avoid, but is discouraged. In this report, we will be review IST, explore its mechanisms and evaluate possible management strategies

Percutaneous Extraction of Chronically Implanted Left Ventricular Lead Aided by Telescopic Sheaths Spares Patient Major Cardiac Surgery

A 70-year-old patient sustained a severe pocket infection of a biventricular pacemaker system implanted 4 years ago. Patient opted for a percutaneous approach to lead extraction over open heart surgery. However, use of special locking stylets to facilitate lead traction was hampered by inability to insert the stylets due to mechanical lumen blockage and/or uncoiling and fracture of lead conductors. Hence, the procedure was finally carried out successfully only with use of telescoping sheaths, which facilitated extraction by freeing leads from multiple adhesions along their intravascular and intracardiac course, sparing patient major open cardiac surgery which would have been the only alternative should the percutaneous technique have failed