Pseudoaneurysm of femoral artery after catheterisation: treatment by a mechanical compression device guided by colour Doppler ultrasound

A 28-year-old woman presented to the emergency department for evaluation of acute chest pain. She lacked risk factors for coronary artery disease and her initial electrocardiogram (ECG) was nondiagnostic. Within 45 minutes of presentation she developed nausea, vomiting, restrosternal chest pain, and ECG changes compatible with an acute inferoposterior myocardial infarction. Emergent cardiac catheterization revealed three-vessel coronary artery ectasia and two-vessel occlusion. She underwent emergency coronary artery bypass grafting. Her myocardial ischemia was believed to have been induced by methergine, which she had been taking over the preceding 3 days. The etiology and pathophysiology of coronary artery ectasia, as well as the cardiovascular effects of methergine and a related drug, ergotamine, are discussed.     

Acute aortic dissection complicated with acute myocardial infarction--a case report of successful operation for the case of DOA

A 61-year-old woman who suddenly manifested chest and back pain was admitted after the diagnosis of acute type A dissection complicated with acute inferior myocardial infarction at another hospital. While being transported to our hospital by ambulance, her ECG repeatedly demonstrated ventricular fibrillation of cardiac arrest. She was in the state of dead on arrival (DOA) when arrived at our hospital. ECG demonstrated complete A-V block and cardiac arrest alternately. However, soon after right ventricular pacing was done, her blood pressure increased and she recovered consciousness. We therefore performed an emergency operation. We performed reconstruction of the ascending aorta and right coronary bypass grafting, since she had aortic dissection and conus brach avulsion. The postoperative course was uneventful.     

Acute myocardial infarction during pregnancy caused by coronary artery spasm

A 33-year-old pregnant woman suffered from acute anteroseptal myocardial infarction at the 19th gestational week. Despite periodic attacks of myocardial ischaemia after admission, the coronary arteriograms under the use of nitroglycerin were normal. Thereafter, she remained free from the ischaemic events with diltiazem hydrochloride and delivered a healthy baby. The coronary arteriography at puerperium also showed no organic narrowing. However, the provocative test with acetylcholine chloride caused severe spasm of the left anterior descending coronary artery. These findings strongly suggest that acute myocardial infarction in this pregnant woman was caused by coronary artery spasm.     

Candida glabrata prosthesis infection following pyelonephritis and septicaemia

A 48-year-old woman with no cardiovascular risk factors was admitted to the hospital because of acute dyspnea. At 27-year-old, she developed Hodgkin's disease, that was successfully treated with splenectomy, combined chemotherapy (nitrogen mustard, vincristine, procarbazine, prednisone-MOPP regimen) and radiotherapy (4500 rads). At 43-year-old the lymphoma relapsed and she had further chemotherapy with doxorubicin, bleomycin, vinblastina and dacarbazine. After this treatment, she had an episode of pulmonary edema, attributed to doxorubicin acute cardiotoxicity. She responded to digitalis and diuretics and was discharged with an electrocardiogram (ECG) showing left bundle branch block and a normal echocardiogram. The patient enjoyed good health for several years and 4 months before the present admission the ECG and echocardiogram were unchanged. On this admission there were signs of left ventricular failure with acute pulmonary edema, and a new soft apical murmur (3-4 Levine). The patient required endotracheal intubation and high doses of diuretics, digitalis and vasodilators. The cardiac enzymes were negative, the serial ECGs confirmed left bundle branch block, while the echocardiogram showed moderate to severe mitral regurgitation, akinesia of the interventricular septum and inferior wall with dilation of the left ventricle. A previous silent myocardial infarction was suspected. After recovery, she underwent cardiac catheterization confirming akinesia of the interventricular septum and inferior wall with moderate mitral regurgitation, while coronary angiography showed a critical ostial stenosis of the right coronary artery. In view of a dipyridamole-thallium scan negative for myocardial viability, reperfusion was not attempted. With changes in radiotherapeutic techniques, the incidence of radiation-induced heart disease (pericarditis, myocarditis, conduction abnormalities and, rarely, occlusive coronary artery disease) is declining. Nevertheless, after irradiation of the chest and mediastinum a longterm cardiological follow-up is useful in selecting patients at higher risk of radiation-induced coronary artery disease, who will eventually require coronary angiography and reperfusion intervention.     

Venous and arterial gas embolism associated with positive pressure ventilation

We report a 53-year-old woman with ARDS who required positive pressure ventilation with positive end-expiratory pressure. She sustained an acute right ventricular myocardial infarction associated with cardiovascular instability. The next day she sustained a fatal cerebral arterial gas embolism. Intravascular gas was documented within the cerebral, coronary, and pulmonary arterial circulations. Clinicians need to be aware of venous and arterial gas embolism as a complication of mechanical ventilation.     

Spontaneous coronary artery dissection associated with oral contraceptive use

A 39-year-old woman presented with acute myocardial infarction due to spontaneous dissection of the left anterior descending artery. This was treated conservatively. She had been on combined oral contraceptive pills from the age of 22. Repeat coronary angiography 7 months later revealed spontaneous complete healing.     

Expression of p53 in reactive mesothelium

An arteriovenous fistula originating from halfway down the circumflex coronary artery, draining into the coronary sinus was first diagnosed in a patient of 81. For 10 years, she had had dyspnea on exertion, mild mitral regurgitation and permanent ventricular pacing for symptomatic bradyarrhythmia. She was treated medically and despite her age was offered transcatheter balloon embolization, but she refused to undergo such intervention.     

Development of 11 beta-hydroxysteroid dehydrogenase expression in the rat cochlea

Spontaneous coronary dissection is rare and the diagnosis is usually post-mortem. Less than 60 cases have been diagnosed at coronary angiography. The authors report, to the best of their knowledge, the first case of multiple spontaneous coronary artery dissections in a type IV Ehlers-Danlos syndrome in a young woman admitted to hospital for acute myocardial infarction. She had a previous history of regressive complete tetraplegia due to dissection of the basilar artery and episodes of dizziness related to a dissecting aneurysm of the left vertebral artery. The diagnosis of type IV Ehlers-Danlos syndrome was established after skin biopsy had shown typical histological changes. The patient died several months later after an acute abdominal syndrome probably related to dissection of the aorta. An autopsy was refused by her family. The authors believe this to be the first case of spontaneous coronary dissection related to a type IV Ehlers-Danlos syndrome.     

Elevation of plasma MB creatine kinase and the development of new Q waves in association with pericarditis

A 64-year-old woman with an acute exacerbation of chronic relapsing pericarditis had initial clinical and ECG features that were consistent with an acute anterior myocardial infarction. Transient Q waves were observed in the precordial leads, and she also exhibited elevated plasma MB creatine kinase (MB CK) activity. However, the overall clinical and laboratory data, including angiographic and radionuclide studies, suggest that the myocardial damage was secondary to pericarditis per se, rather than ischemic myocardial infarction. This case emphasizes that Q waves and elevated MB CK activity can be seen in association with pericarditis, and this must be differentiated from myocardial infarction secondary to coronary artery disease.     

Acute myocardial infarction in two adolescent males

Acute myocardial infarction in previously healthy children is rare in the absence of congenital anomalies. We describe two cases of acute anterior myocardial infarction in adolescent males with no congenital heart disease, without prior history of or risk factors for coronary heart disease, and with no history of drug abuse. These cases illustrate that myocardial infarction in the absence of systemic illness or coronary anomalies can occur in an adolescent population.     

A premenopausal woman presenting with acute myocardial infarction of three different coronary vessels within 1 year: role of lipoprotein(a)

A premenopausal female patient presented with acute myocardial infarction of 3 different coronary vessels at different times within 1 year. These events were caused not by restenotic lesions after balloon angioplasty but by new lesions, which were successfully treated by primary angioplasty. Although she had a history of hypertension, type IIB hyperlipidemia, and diabetes, they had been well-controlled on medication. An elevated serum lipoprotein(a) level may have played a role in this rapid angiographic progression.     

Linkage mapping of the Bra, Brb and Brg genes for rat protein phosphatase 2A 55 kDa B-regulatory subunit isotypes

We experienced a case with acute mitral regurgitation caused by complete posterior papillary muscle rupture as complication of acute inferior myocardial infarction, who underwent successfully emergency operation of mital valve replacement and coronary revascularization in acute stage. A 64-year-old woman developed sudden cardiogenic shock shortly after the onset of acute inferior myocardial infarction. The diagnosis of acute inferior myocardial infarction was based on the electrocardiographic findings. Under IABP support, preoperative coronary angiography visualized total occlusion of segment 3 of the right coronary artery, and preoperative left ventriculography showed akinesis of inferior wall and severe mitral regurgitation. At 6 hours after onset of papillary muscle rupture, emergency operation was performed. At operation, posterior papillary muscle was found to be totally ruptured. Coronary artery revascularization and mitral valve replacement were performed. Postoperative course was uneventful, with 4 days of IABP and 5 days of ventilatory support. She was discharged on the twentieth postoperative day in NYHA class I. Reports of successful emergency operation for total papillary muscle rupture following acute myocardial infarction are rare. Early diagnosis and surgical treatment are mandatory to save this group of patients.     

Peripartum management of a patient with Isaacs' syndrome

PURPOSE: To describe the peripartum management of a patient with Isaacs' syndrome with specific reference to the anaesthetic implications of the disease process. Associated medical problems included obesity, pregnancy induced hypertension and a difficult airway. CLINICAL FEATURES: This 30-yr-old gravida V para 0 woman presented to the anaesthesia consultation clinic at 37-wk gestation to discuss pain relief options for labour and delivery. She had a history of Isaacs' syndrome (a peripheral motor neuron disorder), congenital heart disease (ASD and VSD), treated Hashimotos thyroiditis, obesity and a family history of haemachromatosis. On the day of consultation, she was hypertensive and peripheral oedema was noted. Her urine showed trace protein. Four days later, she presented to the labour suite and her cervix was 9 cm dilated. An epidural anaesthetic was given without difficulty and she had an uneventful labour and delivery course. There were no subsequent neurological complications. CONCLUSION: Isaacs' syndrome is an extremely rare peripheral motor neuron disorder. This patient was successfully managed with epidural analgesia for labour and delivered a healthy child with no congenital anomalies.     

Implantable event recorder: a new aid for the diagnosis of arrhythmogenic syncope

HISTORY AND CLINICAL FINDINGS: A 52-year-old woman had for 31 years been experiencing occasional episodes of dizziness and syncope, as well as sudden attacks of "shaking" in the chest associated with cramp-like pain, nausea and weak spells, each lasting for up to 45 min. She had since childhood been suffering from atopy, with bronchial asthma and polyvalent allergies. On examination, which was otherwise unremarkable, her blood pressure was 140/100 mm Hg with a sinus tachycardia of 110/min. She was admitted for implantation of an event recorder to establish the etiology of the described symptoms. INVESTIGATIONS: The results of routine laboratory tests, including those of thyroid function, were within normal limits. The ECG showed sinus rhythm and minor left precordinal abnormalities of repolarization. The echocardiogram was normal and coronary angiography excluded coronary heart disease. TREATMENT AND COURSE: 3 weeks after ambulatory implantation of an event recorder (Reveal, Medtronic) she again had an attack. The recorded ECG indicated a supraventricular tachycardia (190/min), preceded by an atrial extrasystole, lasting 3 min 14 s. She was treated with digitalis and verapamil, her asthma contraindicating solatol. She had refused further invasive diagnostic measures. The appearance of an allergic rash required a change of drugs to propafenon. But as this, too, was poorly tolerated, electrophysiological testing was undertaken. It revealed an AV nodal reentry tachycardia which was treated with local ablation: supraventricular extrasystoles continued to occur frequently, but there were no further episodes of reentry tachycardia. CONCLUSION: In patients with recurrent syncopes, but otherwise unremarkable clinical findings, an implantable event recorder may provide important diagnostic information, especially relating to a possible arrhythmogenic cause.     

Sudden coronary death. Frequency of active coronary lesions, inactive coronary lesions, and myocardial infarction

BACKGROUND: The reported frequency of active coronary lesions (plaque rupture and coronary thrombosis) in sudden death due to coronary artery atherosclerosis (sudden coronary death) has varied from < 20% to > 80% of cases in previous series. In hearts lacking an active coronary lesion, sudden death has usually been attributed to a healed myocardial infarction. The purpose of the present study was to determine the frequency of active and inactive coronary lesions and myocardial infarction in individuals with sudden coronary death. METHODS AND RESULTS: The hearts of persons who died as a result of sudden coronary death underwent perfusion-fixation and postmortem angiography. An active coronary lesion was defined as a disrupted plaque, luminal fibrin/platelet thrombus, or both. We defined an inactive lesion as having a cross-sectional luminal stenosis of > or = 75% with neither plaque disruption nor luminal thrombus. Ninety hearts were examined (from 72 men and 18 women; mean age at the time of death, 51 +/- 10 years). Acute myocardial infarction was present in 19 (21% [acute myocardial infarction only in 9, both acute and healed myocardial infarction in 10]), healed myocardial infarction only in 37 (41%), and no myocardial infarction in 34 (38%). Active coronary lesions were identified in 51 (57%): acute thrombi plus disrupted plaques in 27, acute thrombi only in 21, and disrupted plaques only in 3. In hearts with acute myocardial infarction, active coronary lesions were significantly more prevalent than in hearts with only healed myocardial infarction or hearts lacking an acute or a healed myocardial infarction (89%, 46%, and 50%, respectively; P < .005). Hearts without acute or healed myocardial infarction and without active lesions were similar to hearts with active lesions with respect to heart weight and severity of epicardial coronary disease. CONCLUSIONS: Acute changes in coronary plaque morphology (thrombus, plaque disruption, or both) were found in 57% of cases of sudden coronary death. In hearts with myocardial scars and no acute infarction, active coronary lesions were identified in 46% of cases. Neither myocardial infarction (acute or healed) nor an active coronary lesion was present in 19% of hearts.     

Differential diagnosis in dementia

The results of an autopsy of a 78-year-old female patient with an occluded of the right internal carotid artery after a traffic accident are reported. She presented with consciousness disturbance, right conjugate deviation, left hemiparesis and left pathological reflex. Evidence of right skull and clavicular fractures seemed to suggest that severe hyperextension of her neck associated with contralateral lateral flexion had stretched her carotid artery. Although she was treated with antiplatelet therapy, her cerebral swelling due to right global infarction progressed and she died due to bilateral cerebral herniation three days after injury. The autopsy disclosed right dissecting carotid artery occlusion and subadventitial dissection was revealed histologically. When a hematoma dissect the media and adventitia of the carotid artery wall, the outer wall weakens and may dilate without narrowing the lumen of the carotid artery. In this case, the vessel occlusion was considered to be due to a primary intramural hematoma which developed and subsequently ruptured through the intima into the vessel lumen. Early diagnosis and treatment are necessary for improving the prognosis of this disease entity. A patient with poor colateral flow, such as in this case, will show a rapid progression of cerebral infarction. It is best to consider surgical treatment in this case if the other traumatic lesions are able to tolerate surgery.     

Interprosthetic fracture of the femoral shaft

Acute occlusion of the left main coronary artery is usually responsible for cardiogenic shock, severe arrhythmias or sudden death. Despite the widespread use of emergency coronary angiography in acute myocardial infarction, occlusion of the left main coronary artery is rarely observed and its treatment remains controversial. The authors report the case of a young man with a previous history of radiotherapy for Hodgkin's disease, admitted for acute myocardial infarction due to complete thrombosis of the left main coronary artery treated as an emergency by percutaneous transluminal angioplasty and implantation of a Palmaz Schatz stent. There were no complications of the procedure and the patient was asymptomatic one year later.     

Acute myocardial infarction related to cocaine use. Report of a case

Cocaine use has been associated with ischemic syndromes, especially angor pectoris, myocardial infarction, cardiac arrhythmias and sudden death. A significant number of persons suffering from myocardial infarction associated with cocaine abuse do not have significant coronary atherosclerosis, and the mechanism for infarction in these patients have remained obscure. This report describes a young man with angiographically normal coronary arteries in whom cocaine abuse probably produced coronary artery spasm leading to coronary thrombosis and infarction.     

Trends of back pain in eastern Finland, 1972-1992, in relation to socioeconomic status and behavioral risk factors

We report a 74-year-old woman with parkinsonism and dementia, who died 4 years after the onset of the disease. She was well until 70 years of the age (1993) when she noted slowness in the movement in her left hand. She also developed gait disturbance and the similar symptoms spread to the right upper and lower extremities. Two years after the onset, she had difficulty in walk, and was admitted to our hospital on March 9, 1995. Her daughter had the onset of hand tremor at 50 years of the age and gait disturbance at 52. Her gait improved after levodopa treatment, but her MRI revealed a liner T2-high signal lesion along the outer surface of each putamen. On admission, the patient was alert but slighted demented. Higher cerebral functions were normal. She had a masked face and small voice. Her gait was of small step without arm swing. Retropulsion was present. Rigidity was noted in the neck but not in the limbs. She was bradykinetic but tremor was absent. She was treated with levodopa/carbidopa, dops, and bromocriptine with considerable improvement and was discharged on March 30, 1995. On January 19, 1996, she developed fever and hallucination; she became more akinetic and admitted again. She showed marked dementia and stage IV parkinsonism. She was treated by supportive measures with improvement in the general condition, but she was found to have a gastric cancer for which a subtotal gastrectomy was performed on March 11, 1996. Post-operative course was uneventful, but her parkinsonism progressed to stage V. She was transferred to another hospital on May 13, 1996. In July 21, 1996, she developed dyspnea and fever and was admitted to our hospital again. She was somnolent. Rigidity was moderate to marked and she was unable to stand or walk. By supportive cares, her general condition improved and was discharged to home on November 4, 1996. She developed fever on June 13, 1997 and admitted to our service again. Her BP was 150/90 mmHg. She was alert but markedly demented. Laboratory examination revealed increases in liver enzymes (GOT 75 IU/l, GPT 101 IU/l) and renal dysfunction (BUN 68 mg/dl, creatinine 3.27 mg/dl). Subsequent hospital course was complicated by renal failure and thrombocytopenia (33,000/ml). She expired on July 1, 1997. The patient was discussed in a neurologic CPC, and a chief discussant arrived at the conclusion that the patient had diffuse Lewy body disease and her daughter striatonigral degeneration. Some participants thought both the patient and her daughter had diffuse Lewy body disease. Post-mortem examination revealed marked degeneration of the substania nigra and the locus coeruleus. The medial part of the nigra also showed marked cell loss. Lewy bodies were found in the remaining nigral and coeruleus neurons. Cortical Lewy bodies were very few and the striatum was intact. Pathologic diagnosis was Parkinson's disease. Dementia was in part attributed to the marked degeneration of the medial part of the substantia nigra.     

Myocardial contrast echocardiography versus dobutamine echocardiography for predicting functional recovery after acute myocardial infarction treated with primary coronary angioplasty

OBJECTIVES: We sought to compare myocardial contrast echocardiography with low dose dobutamine echocardiography for predicting 1-month recovery of ventricular function in acute myocardial infarction treated with primary coronary angioplasty. BACKGROUND: The relation between myocardial perfusion and contractile reserve in patients with acute myocardial infarction, in whom anterograde flow is fully restored without significant residual stenosis, is still unclear. METHODS: Thirty patients with acute myocardial infarction treated successfully with primary coronary angioplasty underwent intracoronary contrast echocardiography before and after angioplasty and dobutamine echocardiography 3 days after the index infarction. One month later, two-dimensional echocardiography and coronary angiography were repeated in all patients and contrast echocardiography in 18 patients. RESULTS: After coronary recanalization, 26 patients showed myocardial reperfusion within the risk area, although 4 did not. At 1-month follow-up, all patients had a patient infarct-related artery without significant restenosis. Both left ventricular ejection fraction and wall motion score index within the risk area significantly improved in the patients with reperfusion ([mean +/- SD] 38 +/- 8% vs. 48 +/- 12%, p < 0.005; and 2.35 +/- 0.5 vs. 2 +/- 0.6, p < 0.001, respectively), but not in those with no reflow. Of the 72 nonperfused segments before angioplasty, 27 showed functional improvement at follow-up. Myocardial contrast echocardiography had a sensitivity and a negative predictive value similar to dobutamine echocardiography in predicting late functional recovery (96% vs. 89% and 89% vs. 93%, respectively), but a lower specificity (18% vs. 91%, p < 0.001), positive predictive value (41% vs. 86%, p < 0.001) and overall accuracy (47% vs. 90%, p < 0.001). CONCLUSIONS: Microvascular integrity is a prerequisite for myocardial viability after acute myocardial infarction. However, contrast enhancement shortly after recanalization does not necessarily imply a late functional improvement. Thus, contractile reserve elicited by low dose dobutamine is a more accurate predictor of regional functional recovery after reperfused acute myocardial infarction than microvascular integrity.