Right coronary artery diastolic perfusion pressure on outcome of patients with left heart failure and pulmonary hypertension

Aims

Right ventricle adaptation to prolonged exposure against pulmonary hypertension (PH) includes structural and functional abnormalities, translated into modifications of blood flow pattern through the right coronary artery. Given these changes, we investigate the relationship between right coronary artery diastolic perfusion pressure (RCDPP) and clinical outcome, in patients with PH secondary to left‐sided heart failure (HF).

Methods and results

We studied 108 HF patients who underwent right heart catheterization. PH was present in 75 (69.4%). Mean RCDPP was lower in patients with PH (59.4 ± 14.0 mmHg) as compared with no PH patients (65.5 ± 11.6 mmHg) (P = 0.03). Aortic diastolic pressure accounted for 79% of RCDPP variability explained by the model (P < 0.0001). During a median follow‐up of 26 months, the RCDPP 1st tertile (<55 mmHg) [hazard ration (HR) 5.19, 95% confidence interval (CI) 1.08–25.12, P = 0.04] and left ventricular ejection fraction <45% [HR 7.26, 95% CI 1.77–29.73, P = 0.006] were independent predictors of mortality.

Conclusions

Right coronary artery diastolic perfusion pressure is a strong independent haemodynamic maker of mortality in left‐sided HF and PH. Excessive reduction of aortic diastolic pressure may be detrimental. Future research is necessary to determine the therapeutic approach to blood pressure in this population.

Fatal association of mechanical valve thrombosis with dabigatran: a report of two cases

Several new oral anticoagulants have been approved for thromboembolism prevention in patients with nonvalvular atrial fibrillation. However, they are not yet approved for anticoagulation use in patients with prosthetic mechanical valves, and no randomized data have been published so far on their safety of use in these patients. We present two cases of patients with prosthetic mechanical mitral valves who were switched from warfarin and acenocoumarol to dabigatran and within 1 month experienced severe valve complications resulting in death. One patient experienced stroke and later cardiogenic shock and death, and the other experienced pulmonary edema, cardiogenic shock, and subsequent death.

Oxidative stress and inflammation due to peripheral polymorphonuclear leukocytes after coronary angiography vs percutaneous coronary intervention

AIM

Percutaneous coronary intervention (PCI) as an invasive procedure includes inflation of a balloon and/or implantation of an endovascular prosthesis (stent) in an atherosclerotic coronary vessel at a level where the plaque narrows its cross-sectional area by more than 75%. Various reports have demonstrated that balloon inflation or stent implantation trigger inflammation and subsequent growth of smooth muscle cells. Both oxidative stress (OS) and inflammation parameters worsen, increasing the risk of complications. The polymorphonuclear leukocyte (PMNL) is one of the inflammatory cells releasing reactive oxygen species contributing to OS, inflammation and endothelial injury. The aim of this study was to study the contribution of PMNLs during coronary intervention.

METHODS

Patients enrolled in this study were randomized into two groups, namely nine patients undergoing PCI procedure, compared to 11 undergoing diagnostic coronary angiography. PMNLs were separated from patient blood, before and following PCI. PMNL priming was measured by rate of superoxide release from PMNLs and flow cytometry analysis of CD11b levels. PMNL-related inflammation was estimated by white blood cells (WBC) and PMNL count. Systemic inflammation was monitored by C-reactive protein (CRP) and fibrinogen.

RESULTS

Tested patients were divided into patients undergoing PCI procedure, compared to those undergoing diagnostic coronary angiography; already at time ''0'', OS and inflammation parameters were higher in the PCI group of patients. OS parameters decreased significantly following PCI procedure. PCI itself induces increased OS and inflammation. Significant positive correlation was found between serum creatine phosphokinase and rate of superoxide release from PMNLs, indicating correlation between PMNL priming and the severity of cardiac disease. Systemic inflammation parameters, such as fibrinogen and CRP, showed significant decrease in the PCI group after the procedure, while those related to PMNLs did not.

CONCLUSION

PMNL contribution to OS and inflammation is lower in patients undergoing diagnostic coronary angiography, compared to the PCI group. This research adds new facet to evaluation of cardiac patients whether they will undergo PCI procedure or diagnostic coronary angiography.

"Burning tongue" sensation during routine coronary angiography--a phenomenon related to a rare coronary anomaly

We present the case of rare coronary circulation anomaly discovered during the routine coronary angiography that was associated with unusual "burning" sensation reported by the patient.

Bilateral coronary fistulae to pulmonic valve in presence of severe three-vessel coronary artery disease

A 62-year-old man was admitted to the coronary care unit due to anginal pain and palpitations--coronary angiography revealed three-vessel coronary artery disease. The unexpected finding was the presence of coronary to pulmonary artery fistulae bilaterally, from both the proximal RCA and the proximal LAD. Right heart catheterization revealed normal right ventricular and pulmonary artery pressure and absence of hemodynamically significant left to right shunt. The patient underwent a triple coronary bypass including the closure of bilateral fistulae, which were draining into the left sinus of the pulmonary valve. One month after the operation he was in good health and had no complaints. Bilateral coronary artery fistulae is a rare anomaly diagnosed in 0.002-0.0013% of adult coronary angiograms. (Int J Cardiovasc Intervent 1999; 2: 249-251).

[The clinical significance of postictal electrocardiographic changes mimicking acute myocardial infarction]

The electrocardiogram (ECG) is of critical importance in the diagnosis of acute myocardial infarction. Clinical conditions such as acute pericarditis, esophageal rupture, pancreatitis, subarachnoid hemorrhage, perforated duodenal ulcer, pneumothorax and status following elective DC cardioversion result in ECG changes that include ST elevation and T wave inversion. This report aims to increase the awareness of non-cardiac syndromes, with ECG abnormalities mimicking acute myocardial infarction, and thus to avoid unjustified thrombolytic therapy. We describe the case of a patient after epileptic seizures and pathological EEG pattern. The ECG showed repolarization abnormalities suggestive of evolving acute myocardial infarction. The cardiac enzymes (except normal Troponin I) were severely elevated and coronary angiography was normal.

Uneventful 25-year course of an intracardiac intravenous catheter fragment in the right heart

We describe a patient with an intracardiac intravenous catheter fragment in the right heart that was found during fluoroscopy. The catheter fragment had broken off from an intravenous catheter inserted 25 years previously when the patient was admitted after a road accident. There were no complications during these years. The fragment was removed during coronary bypass surgery. Other cases of intracardiac foreign bodies have been described, some causing complications even after many years. Uninfected, these can be removed easily with local interventional techniques. Removal of an infected foreign body per cardiotomy has a much higher mortality risk.

An awl inflicted chest wound causing acute myocardial infarction

Penetrating chest wounds are frequent. When involving the heart, they usually cause tamponade. In our case, caused by an awl, laceration of the LAD occured without intrapericardial bleeding. The coronary angiography demonstrates the damage to the wall of the LAD.

Doppler echocardiographic study of the pulmonary artery and its branches in 114 normal neonates

It has been shown that there are pressure gradients between the main pulmonary artery (MPA) and its two branches in infants undergoing catheterization. This study investigated the blood flow velocities and pressure gradients in the right and left pulmonary arteries (RPA and LPA, respectively) in normal neonates. The MPA and its two branches were examined echocardigraphically in 114 term consecutive healthy neonates aged 1-6 days. The pressure gradients between the MPA and RPA or LPA were calculated. Thirty neonates with pressure gradients above 2.5 mmHg were followed by 3-6 months. The peak velocities in the RPA and LPA (1.16 +/- 0.19 and 1.01 +/- 0.18 m/s) were significantly higher than that in the MPA (0.84 +/- 13 m/s) (both p < 0.001), with that in the RPA slightly higher than in the LPA (p < 0.001). There was an estimated pressure gradient of 2.5-8.3 mmHg between the MPA and RPA in 43% and of 2.5-6.6 mmHg between the MPA and LPA in 16.7% of all neonates. The gradients disappeared within 3-6 months in 12 (40%) of the 30 neonates with an initial gradient above 2.5 mmHg. The differences in blood flow velocities or pressure gradients in the RPA or LPA were probably attributable to the variations in pulmonary arterial pressure, cardiac output, age, and birth weight and can be considered physiologically characteristic in neonates.

Comparison of patients with acute myocardial infarction with and without ventricular fibrillation

Among 1,590 patients with acute myocardial infarction from 1990 to 1994, the rate of primary ventricular fibrillation was 3.6%. The prevalence of smoking, complete left bundle branch block, hypokalemia, and decreased left ventricular function was higher in patients with ventricular fibrillation while those on thrombolytic therapy and those with non-Q-wave myocardial infarction were significantly lower.

Left ventricular function in patients with acute myocardial infarction, acute pulmonary edema, and mechanical ventilation: relationship to prognosis

OBJECTIVES

To evaluate the relationship between left ventricular function and prognosis in patients treated with mechanical ventilation for severe, persistent pulmonary edema as a consequence of acute myocardial infarction.

DESIGN

A prospective study.

SETTING

A nine-bed coronary care unit in a 900-bed teaching hospital.

PATIENTS

Sixty-nine successive patients.

INTERVENTIONS

All patients had acute pulmonary edema not responding to classical treatment and were treated with mechanical ventilation.

MEASUREMENTS AND MAIN RESULTS

The inhospital mortality rate was 67%. Thirteen of 23 patients surviving hospitalization died during follow-up, a mean of 5.8 +/- 7.7 months after infarction. Six of ten long-term survivors are in functional capacity class 1 or 2 (New York Heart Association) and four survivors are in class 3. Echocardiographic examination indicated that severe left ventricular dysfunction was present in most patients during the time of mechanical ventilation. Repeat echocardiographic examination performed 14.2 +/- 8.1 months after infarction showed a remarkable improvement in left ventricular function among the survivors. Multivariate analysis indicated that the small group of patients with a good long-term prognosis could not be separated prospectively from the larger group dying during or after hospitalization using variables obtained at the time of mechanical ventilation.

CONCLUSIONS

The mortality rate is high in this group of patients. Left ventricular function of survivors is severely diminished at the time of infarction but improves markedly during follow-up. The small subgroup of patients with a good long-term prognosis cannot be identified prospectively when evaluated during the acute stage of infarction and the provision of mechanical ventilation.