Non-Cardiac Sudden Death in a Patient With Arrhythmogenic Right Ventricular Cardiomyopathy

We herein present the case of a 70-year old lady with arrhythmogenic right ventricular cardiomyopathy (ARVC) and recurrent episodes of syncope. She was referred to our department due to an episode of sustained ventricular tachycardia (VT) which caused haemodynamic collapse and was converted electrically. During diagnostic investigation, echocardiography revealed evidence of right ventricular dysfunction. She underwent risk stratification and sustained monomorphic VT was easily induced during electrophysiology study. An implantable cardioverter-defibrillator (ICD) device was subsequently implanted, but she died suddenly three months later. ICD device interrogation did not reveal any arrhythmic event and death was attributed to carbon monoxide poisoning

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

Echocardiographic Criteria for CRT Patient Selection: Is There Still a Role?

Cardiac resynchronization therapy (CRT) is a relatively new therapeutic option for patients with systolic heart failure (HF) and electrocardiographic evidence of dyssynchrony. However, with current selection guidelines, still a proportion of patients do not respond to this interventional therapy. Several echocardiographic criteria have been proposed to address this issue, but research so far has failed to provide a single and simple measurement with adequate accuracy for CRT candidate selection. While investigation for this subject is still under way, new possible roles of echocardiography in CRT implementation arise, such as assistance in selecting the site of left ventricular (LV) pacing lead and optimizing CRT device programming during follow up visits

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

Beware of the Ailments of Vitamin B12 Deficiency

Vitamin B12 or cobalamin deficiency is a common problem in adult patients, which is however frequently missed. The most common cause of cobalamin deficiency is the food cobalamin malabsorption syndrome (> 60% of all cases). Neuropsychiatric manifestations can be the presenting and only early sign of cobalamin deficiency even in the absence of hematologic abnormalities. The deficiency can occur despite serum cobalamin levels at low normal values; thus, normal vitamin B12 levels have been revised upward to >350 pg/ml. Early detection and treatment are important to prevent structural and irreversible damage. The causes and ailments of vitamin B12 deficiency are herein overviewed and a diagnostic and therapeutic strategy is outlined

Vieussens’ Arterial Ring Attenuates the Consequences of an Otherwise Large Anterior Myocardial Infarction

A 55-year-old patient, with a history of a recent ST-elevation myocardial infarction (STEMI) diagnosed elsewhere but not treated due to patient’s refusal, was urgently admitted to our hospital with symptoms of post-infarction angina over the last 48 hours. The patient, who remained hemodynamically stable, underwent urgent coronary angiography via a transradial access. Total occlusion of the left anterior descending (LAD) coronary artery was visualized right after the first diagonal branch, while the periphery of the LAD was opacified through collaterals from the proximal right coronary artery (RCA), an anatomic variation also knows as the Vieussens’ ring. Decision was taken not to proceed with revascularization, until viability in the territory of the LAD could be documented. Rhythmos 2016;11(4):98-99

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