The importance of excluding coronary artery vasospasm before percutaneous transluminal coronary angioplasty. A case report

CITATION: Przybojewski, J. Z. 1986.The importance of excluding coronary artery vasospasm before percutaneous transluminal coronary angioplasty. A case report. South African Medical Journal, 70(10), 495-499.The original publication is available at http://www.samj.org.zaENGLISH ABSTRACT: It is important to exclude coronary vasospasm, the mechanism responsible for so-called 'dynamic' coronary stenosis, when selecting of patients for percutaneous transluminal coronary angioplasty (PTCA). Although cine angiographic demonstration of this frequently fleeting entity can sometimes be difficult, a strong suspicion should be aroused by a carefully taken history. The danger of PTCA in these cases of Prinzmetal's variant angina, as well as the frustration often encountered in drug management, is highlighted.AFRIKAANSE OPSOMMING: Geen opsomming beskikbaarPublisher’s versio

Multiple coronary vasospasm: a cause of repeated myocardial infarction and symptomatic 'torsade de pointes' (atypical ventricular tachycardia) A case presentation and review

A middle-aged Coloured man had a 6-year history of chest pain induced by effort and also experienced at rest. Quite dramatic episodes of associated arrhythmias, specifically 'torsade de pointes' (atypical ventricular tachycardia) and syncope were experienced by the patient, despite the use of numerous anti-arrhythmic and anti-anginal agents. Transmural anteroseptaI and non-transmural. anterolateral myocardial infarctions were documented in the presence of a normal left coronary artery (LCA). Severe reversible vasospasm of the right coronary artery (RCA) was provoked with the use of ergonovine (ergometrine) maleate at cardiac catheterization. It is postulated that the cause of the previous myocardial infarctions was significant vasospasm of the LCA branches, and that he was subject to multiple coronary vasospasm, as was highlighted by the visualization of spasm superimposed on atheromatous plaque within the RCA. Furthermore, it is strongly suggested that the potentially lethal ventricular arrhythmias, including 'torsade de pointes', were a direct result of coronary vasospasm which in turn gave rise to his presyncope and syncope attacks. No evidence of sinoatrial node disease could be found. The only risk factor for ischaemic heart disease which applied in his case was heavy cigarette smoking. Control of his disabling symptoms seems to have been achieved by' the use of maintenance nifedipine (a calcium-blocking agent), long-acting nitrates (isosorbide dinitrate) and quinidine gluconate, confirming the probable vasospastic aetiology of the 'torsade de pointes'. At no stage was there dangerous prolongation of the QT interval, an oftquoted prerequisite for this·arrhythmia. Some of the more important aspects of coronary vasospasm are discussed; as far as I am aware this is the first patient documented in the literature with 'torsade de pointes' associated with angiographically demonstrated coronary artery spasm

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Hepatitis B-vaksien - wie behoort dit te kry?Acquired immunodeficiency syndrome (AIDS)Coronary vasospas

Hypertrophic non-obstructive apical cardiomyopathy : a case presentation and review of the literature

CITATION: Przybojewski, J. Z. & Blake, R. S. 1984. Hypertrophic non-obstructive apical cardiomyopathy : a case presentation and review of the literature. South African Medical Journal, 66:492-498.The original publication is available at http://www.samj.org.zaA 20-year-old coloured man gave a history of atypical chest pain, palpitations after strenuous exercise and a single episode of post-exertional presyncope. The diagnosis of hypertrophic non-obstructive apical cardiomyopathy (HNOAC) was established by means of electrocardiography, echocardiography (both M-mode and two-dimensional) and left ventricular cine angiography. This variant of hypertrophic cardiomyopathy is most unusual and has been encountered most frequently in Japan, although a few cases have been diagnosed in the USA. The present case is the second reported from the Republic of South Africa. Important aspects of HNOAC are reviewed.Publisher’s versio

Hyperkalaemic complete heart block : a report of 2 unique cases and a review of the literature

The original publication is available at http://www.samj.org.zaTwo White male patients with temporary complete heart block (CHB) secondary to hyperkalaemia are presented. One, a 40-year-old man, developed CHB with ensuing shock within the first 24 hours of repeat aortic valve replacement for a paraprosthetic leak caused by previous endocarditis. This patient experienced iatrogenic hyperkalaemia. The second was an 81-year-old man who had chronic renal failure and presented with Stokes-Adams attacks. This patient was initially thought to have degenerative CHB and nearly underwent inadvertent permanent pacemaker insertion. Both patients were initially treated with emergency temporary cardiac pacing with subsequent successful management. Temporary CHB secondary to hyperkalaemia, from whatever cause, has very rarely been documented in the literature. A review of this potentially lethal complication is undertaken and the significance of unifascicular and bifascicular conduction block as a consequenc of hyperkalaemia is discussed.Publishers' versio

Primary cardiac hydatid disease : a case report

The original publication is available at http://www.samj.org.zaA young Coloured man whose only symptom was that of minimal dyspnoea on exertion, on examination had signs of infundibular stenosis which were confirmed by cardiac catheterization. Additional features were left anterior hemiblock and cardiomegaly as delineated radiologically. Cross-sectional echocardiography revealed a very large cystic mass located within the interventricular outflow tract. This cystic mass was further delineated by cardiac cine angiography. It is postulated that this mass was a primary cardiac echinococcal cyst and was directly responsible for the complications of left anterior hemiblock and the infundibular obstruction. The patient declined surgery and a definitive pathological diagnosis could therefore not be made. If this is a hydatid cyst then it is the second case reported in the literature diagnosed by two-dimensional echocardiography and in which left anterior hemiblock has been recorded. The clinical features, complications and surgical correction are briefly outlined.Publishers' versio

Iatrogenic aortocoronary vein fistula : a case presentation and review of the literature

The original publication is available at http://www.samj.org.zaA patient underwent aortocoronary saphenous bypass grafting to the left anterior descending coronary artery (LADA) and its first diagonal branch for the relief of severe angina pectoris. There was difficulty in exposure of the LADA, which was covered by a thick layer of epicardial adipose tissue. Post-operatively the patient continued to experience severe retrosternal pain which prompted early repeat coronary angiography. This revealed an aortocoronary vein fistula (AVF) secondary to the inadvertent anastomosis of one of the saphenous vein grafts to the left anterior descending coronary vein (LADV). It was only after this procedure that clinical examination revealed a grade 2/6 high-frequency continuous murmur best heard in the 2nd and 3rd left intercostal spaces. The persistance of severe angina pectoris at rest and on effort led to performance of revision operation. The LADV was then transected and ligated, and an extended saphenous vein reimplanted into the LADA proper. This provided complete relief from angina. This is the first such case reported in South Africa and the sixth documented. In all the aortosaphenous vein grafts had been inserted into the LADV; all exhibited the classic continuous murmur postoperatively, apart from 1 patient who had an ejection systolic murmur. None of the other 5 patients complained of postoperative angina and only 3 were subjected to revision surgery. The literature is reviewed, with emphasis on the rationale for performing the first elective aortocoronary vein anastomosis in 1968. Clinical features of iatrogenic AVF are detailed and an attempt is made to assess when re-operation is indicated. It is easy to fail to notice this complication; however, its correction can have a dramatic effect on the patient's symptoms. It is the author's belief that many more such cases exist but are not being detected, probably because of lack of appreciation of the possibility of this iatrogenic condition occurring.Publishers' versio

Pseudo-myocardial infarction pattern after aortocoronary saphenous vein bypass graft surgery : a case report

ArticleThe original publication is available at http://www.samj.org.zaIn a 51-year-old medical colleague with symptomatic atherosclerotic coronary artery disease, coronary arteriography delineated significant left mainstem, left anterior descending and left circumflex coronary artery lesions and cine angiography demonstrated normal left ventricular contractility. Aortocoronary saphenous vein bypass grafting was successful. The postoperative appearance of QS waves on the ECG suggested the possible complication of an acute transmural anteroseptal and anterolateral myocardial infarction (MI). However, this possibility was excluded by resting technetium-99m and thallium-201 scintiscans, as well as by a technetium-99m-gated blood pool scintiscan. The occurrence of acute pericarditis approximately 2 weeks after surgery made clinical evaluation more difficult. The ECG may represent a pseudo-MI pattern, the patient having suffered a post-pericardiotomy syndrome. The importance of excluding postoperative acute MI is stressed. The causes of the appearance of new Q waves after aortocoronary saphenous vein bypass graft surgery are briefly outlined.Publishers' versio

Asymptomatic iatrogenic right coronary artery dissection with spontaneous resolution. A case report

CITATION: Przybojewski, J.Z. 1987. Asymptomatic iatrogenic right coronary artery dissection with spontaneous resolution: A case report. S Afr Med J, 71(4):255-256.The original publication is available at http://www.samj.org.zaENGLISH ABSTRACT: A young woman with angiographically normal coronary arteries had asymptomtic iatrogenic catheter-induced dissection of her right coronary artery which was managed conservatively. Because of continuing chest pain despite therapy, over a year later she again underwent selective coronary arteriography; a Softip cardiovascular catheter (Angiomedics Inc., Minneapolis) was used without complication. This may be the first report of use of this catheter after previous iatrogenic coronary artery dissection caused by a more conventional type. It is also the first time that this catheter was employed in the RSA. The use of a Softip cardiovascular catheter may significantly reduce this complication of a common coronary angiography.Publisher’s versio

Arrhythmia

The original publication is available at http://www.samj.org.zaA 42-year-old White man suffered from recurrent symptomatic ventricular tachycardia but not angina pectoris. Cardiac catheterization demonstrated a normally contracting left ventricle and coronary angiography delineated significant atherosclerotic obstructions in the left circumflex (LC) coronary artery and the first diagonal branch of the left anterior descending (LAD) coronary artery. Coronary artery bypass graft (CABG) surgery was carried out on the anterolateral and mid-lateral branches of the LC coronary artery as well as the first diagonal branch of the LAD coronary artery. Frequent postoperative Holter monitoring as well as maximum-exercise stress testing has failed to show any recurrence of the ventricular arrhythmia, and the patient has remained asymptomatic and medical therapy has been discontinued. Some 30 months after operation left ventricular cine angiography demonstrated normal contractility. Selective coronary arteriography indicated that the CABG to the anterolateral branch of the LC coronary artery was occluded at its proximal aortic anastomosis. However, the CABGs to the mid-lateral branch of the LC and LAD coronary arteries were still patent. Repeat serial resting ECGs failed to show any evidence of postoperative myocardial infarction. It is concluded that CABG surgery was responsible for eliminating the episodes of life-threatening ventricular tachycardia, presumably by correcting myocardial ischaemia. The role of CABG surgery in the control of medically unresponsive and dangerous ventricular arrhythmias is reviewed.Publishers' versio