Texas Heart Institute journal
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In this, the 1st part of a 2-part review, we discuss how plaque rupture is the most common underlying pathophysiologic cause of unstable angina and non-ST-segment-elevation myocardial infarction and how early risk stratification is vital in the timely diagnosis and treatment of acute coronary syndrome. Part 2 of this review (to be published in a later issue of this journal) will focus mainly on the various pharmacologic agents and treatment approaches (early invasive vs early conservative) to the management of unstable angina and non-ST-segment-elevation myocardial infarction.
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Transcatheter closure of congenital heart defects with the use of septal occluders has been widely accepted as a preferred treatment; however, the high cost of these devices limits their clinical application in some countries. Few clinical data are available regarding lower-cost products. Accordingly, we evaluated the efficacy and safety of the Chinese-made Shanghai Shape Memory Alloy (SHSMA) occluder in patients with congenital heart defects. ⋯ Six months postprocedurally, complete occlusion was associated with a significant decrease in the right ventricular Tei index in atrial septal defect patients (P < 0.05) and with improvement of body mass index in 11 children. These results suggest that the SHSMA occluder is a safe, effective device for the transcatheter closure of congenital heart defects. For confirmation, a randomized controlled trial with more patients and a longer follow-up period is warranted.
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Case Reports
Two scimitar veins in an adult: repair through a right thoracotomy without cardiopulmonary bypass.
Scimitar syndrome is a rare but serious congenital condition that consists of anomalous pulmonary venous drainage of the right lung to the inferior vena cava. The appearance on chest radiography resembles a curved Turkish sword, or scimitar. Scimitar syndrome is associated with other anomalies, including hypoplasia of the right lung, dextroposition of the heart, anomalous systemic arterial supply to the right lung, and atrial septal defect. ⋯ Classical surgical repair involves diversion of the scimitar venous flow into the left atrium with a baffle, requiring the use of cardiopulmonary bypass and deep hypothermic circulatory arrest. Herein, we report the case of a 42-year-old woman with 2 scimitar veins who underwent corrective surgery at our center without the use of cardiopulmonary bypass. We also comment on the importance of a patient's lung hypoplasia in the decision to repair the defect through a right thoracotomy.
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Reduced door-to-balloon time in primary percutaneous coronary intervention for the treatment of ST-elevation myocardial infarction has been associated with lower cardiac mortality rates. However, it remains unclear whether door-to-balloon time is predominantly a surrogate for overall peri-myocardial infarction care and is not independently predictive of outcomes, particularly when differences in door-to-balloon time have narrowed and previous studies have contained myocardial infarction-selection bias. We analyzed 179 consecutive patients who presented emergently at our cardiac catheterization laboratory with ST-elevation myocardial infarction within 12 hours of symptom onset and who underwent primary percutaneous coronary intervention within 3 hours of presentation. ⋯ Upon propensity-score analysis, door-to-balloon time remained a significant independent predictor of ln (AUC-creatine kinase) (beta=0.15, P=0.03). Upon use of a Cox regression model, ln (AUC-creatine kinase) independently predicted death (P=0.04) and recovery of left ventricular function (P=0.001) at follow-up (mean, 14 mo). Longer door-to-balloon time independently predicts increased myocardial cell damage, and ln (AUC-creatine kinase) predicts improvement in left ventricular systolic function and intermediate-term death after ST-elevation myocardial infarction.
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Comparative Study
Early outcomes of radial artery use in all-arterial grafting of the coronary arteries in patients 65 years and older.
We retrospectively evaluated early clinical results of coronary revascularization using none but arterial grafts in patients aged 65 years and older. The cases of 449 consecutive patients who had undergone isolated myocardial revascularization were divided into 2 groups: the arterial conduit group (n=107) received a left internal mammary artery (LIMA) graft and 1 or both radial arteries (RAs), while the mixed-conduit group (n=342) received a LIMA graft and 1 or more saphenous vein grafts (SVGs), with or without an RA. There was no significant difference between the groups' rates of mortality. ⋯ Angiography was performed postoperatively (mean, 24.9 +/- 16.3 mo; range, 11-65 mo) in 21 patients. In these patients, all LIMA grafts were patent, as were 86.9% of the SVGs and 90.9% of the RA grafts. Myocardial revascularization using all arterial grafts (at least 50% RAs) in patients aged 65 years and older is safe and reliable, produces short-term results equal to those of saphenous vein grafting, and can reduce graft-harvest-site infections.