1/133. Emergency cardiopulmonary bypass for cardiac arrest refractory to pediatric advanced life support.We report the application of emergent cardiopulmonary bypass (CPB) for three pediatric patients in the cardiac catheterization laboratory with cardiac arrest who did not respond to conventional resuscitation efforts. All three patients had return of baseline prearrest rhythms within minutes of the initiation of artificial cardiopulmonary support and the return of spontaneous circulation upon weaning CPB. Two patients had normal neurologic outcomes despite an interval of over 30 minutes from arrest to CPB. The continued judicious application and study of this technology in a small subpopulation of pediatric cardiac arrest patients is warranted.- - - - - - - - - - ranking = 1keywords = circulation (Clic here for more details about this article) |
2/133. Primary percutaneous transluminal coronary angioplasty performed for acute myocardial infarction in a patient with idiopathic thrombocytopenic purpura.A 72-year-old female with idiopathic thrombocytopenic purpura (ITP) complained of severe chest pain. electrocardiography showed ST-segment depression and negative T wave in I, aVL and V4-6. Following a diagnosis of acute myocardial infarction (AMI), urgent coronary angiography revealed 99% organic stenosis with delayed flow in the proximal segment and 50% in the middle segment of the left anterior descending artery (LAD). Subsequently, percutaneous transluminal coronary angioplasty (PTCA) for the stenosis in the proximal LAD was performed. In the coronary care unit, her blood pressure dropped. Hematomas around the puncture sites were observed and the platelet count was 28,000/mm3. After transfusion, electrocardiography revealed ST-segment elevation in I, aVL and V1-6. Urgent recatheterization disclosed total occlusion in the middle segment of the LAD. Subsequently, PTCA was performed successfully. Then, intravenous immunoglobulin increased the platelet count and the bleeding tendency disappeared. A case of AMI with ITP is rare. The present case suggests that primary PTCA can be a useful therapeutic strategy, but careful attention must be paid to hemostasis and to managing the platelet count.- - - - - - - - - - ranking = 77.21614757809keywords = coronary (Clic here for more details about this article) |
3/133. Profound ECG abnormalities during emergency cesarean section in a patient with pre-eclampsia.A case of severe ECG abnormalities occurring during pre-eclampsia is presented. Although these electrocardiographic changes were indicative of severe alterations of coronary flow, neither structural nor functional abnormalities could be documented during subsequent diagnostic workup. The pathogenetic pathways potentially involved in this case including coronary spasms are briefly discussed.- - - - - - - - - - ranking = 22.061756450883keywords = coronary (Clic here for more details about this article) |
4/133. Alkaptonuric aortic stenosis: a case report.alkaptonuria is a rare disease of phenylalanine, aromatic amino acids, and tyrosine metabolism. Because of a genetic deficiency of the enzyme homogentisic acid oxidase, an accumulation of homogentisic acid causes ochronotic pigment deposition. The most common clinical manifestations are arthropathy, urinary calculi and discoloration, cutaneous and cartilaginous pigmentation, and cardiac valvular disease. Arthropathy and aortic stenosis are the most debilitating manifestations of the disease. A case of alkaptonuric aortic stenosis is described. A 75-year-old woman with a history of alkaptonuria presented in the emergency department with complaints of progressive dyspnea. Upon examination, the patient was hypertensive, tachypneic, and tachycardic with premature ventricular contractions. She had pitting edema of the lower extremities and complaints of generalized weakness. Chest x-rays revealed congestive heart failure and pulmonary edema. diuretics were administered, and a continuous nitroglycerin infusion was initiated in the emergency department. The patient was admitted for further evaluation. The patient's respiratory status continued to decline. She was intubated endotracheally 1 day after admission. Subsequent cardiac evaluation revealed an ejection fraction of 35%, severe aortic stenosis, mild coronary artery disease, ischemic cardiomyopathy, and anteroapical akinesis. A dobutamine infusion was instituted for persistent hypotension, and renal dose dopamine was initiated for oliguric renal failure. The patient underwent an emergency operation for an aortic valve replacement with a Dacron patch 10 days after admission. cardiopulmonary bypass and mild hypothermia were used during the procedure. The patient's hemodynamic status remained tenuous throughout the procedure. Although the first attempt to wean off cardiopulmonary bypass failed, the second attempt was successful with the aid of an intra-aortic balloon pump, inotropic support, and atrioventricular pacing. These measures were maintained during transport to the surgical intensive care unit. In the intensive care unit, the patient did not have an audible blood pressure or a palpable pulse without the support of the intra-aortic balloon pump and atrioventricular pacing. Coarse atrial fibrillation was the underlying electrocardiogram rhythm in the absence of atrioventricular pacing. sodium bicarbonate was given without improvement. After discussion with the family, all life support measures were discontinued. The patient died 10 minutes after her arrival in the intensive care unit. alkaptonuria's pathogenesis is manifested as both local and systemic in nature. collagen vascular diseases share a similar pattern of multisystem involvement. Despite the negative outcome for the patient described, valuable insight can be obtained by studying this case and noting the anesthetic considerations specific to collagen vascular diseases in general.- - - - - - - - - - ranking = 11.030878225441keywords = coronary (Clic here for more details about this article) |
5/133. Spontaneous dissection of coronary artery in a patient with ascending aortic aneurysm and aortic valve regurgitation.Spontaneous coronary artery dissection is a rare cause of myocardial infarction associated with a significant high morbidity and mortality. It usually occurs in relatively young patients and it is frequently found at autopsy. We report a case of a 42-year-old woman, who underwent resection of subaortic diaphragm ten years earlier presenting with postero-lateral myocardial infarction. Coronary arteriography revealed a dissection of the left main stem extending distally to the left anterior descending artery (LAD) and circumflex artery (Cx); occlusion of the postero-lateral branch of the Cx; severe aortic valve regurgitation and ascending aortic aneurysm. She was successfully operated on in emergency and underwent myocardial revascularization and separate replacement of the aortic valve and the ascending aorta. In this specific case of coronary dissection and severe aortic regurgitation it is mandatory to perform surgery in emergency to limit infarction evolution and avert loss of life.- - - - - - - - - - ranking = 66.185269352648keywords = coronary (Clic here for more details about this article) |
6/133. Telemedical experiences at an Antarctic station.Wintering-over in Antarctica represents a physician's most remote and inaccessible scenario, apart from a space station. Because of the harsh and unpredictable winter weather, Antarctic stations are typically inaccessible for over six months of the year. telephone and fax communication, and recently other forms of telemedicine, have provided vital links to specialists. The author was the sole physician for more than 250 people wintering-over during the 1995 austral winter at McMurdo Station. There were several instances of serious or life-threatening illness where the author relied on teleconsultation. These cases included new-onset coronary artery disease, posterior hip dislocation, complicated colles' fracture and acute appendicitis. There were also numerous consultations for non-emergency clinical presentations normally managed by specialists. telemedicine was a crucial link to specialists from the remote and inaccessible environment of Antarctica.- - - - - - - - - - ranking = 11.030878225441keywords = coronary (Clic here for more details about this article) |
7/133. Successful resuscitation of a verapamil-intoxicated patient with percutaneous cardiopulmonary bypass.OBJECTIVE: To describe our experience with the use of percutaneous cardiopulmonary bypass as a therapy for cardiac arrest in an adult patient intoxicated with verapamil. DESIGN: Case report. SETTING: Emergency department of a university hospital. PATIENT: A patient with cardiac arrest after severe verapamil intoxication. INTERVENTIONS: Percutaneous cardiopulmonary bypass and theophylline therapy. CASE REPORT: A 41-yr-old white male had taken 4800-6400 mg of verapamil in a suicide attempt. On arrival of the ambulance physician, the patient was conscious with weak palpable pulses and was transported to a nearby hospital. The patient developed a pulseless electrical activity, and cardiopulmonary resuscitation was started. Despite all advanced life support efforts, the patient remained in cardiac arrest. Therefore, he was transferred under ongoing cardiopulmonary resuscitation to our department, where percutaneous cardiopulmonary bypass was initiated immediately (2.5 hrs after cardiac arrest). The first verapamil serum concentration obtained at admittance to our institution was 630 ng/mL. After several ineffective intravenous epinephrine applications, the administration of 0.48 g of theophylline as an intravenous bolus 6 hrs and 18 mins after cardiac arrest led to the return of spontaneous circulation. The patient remained stable and was transferred to an intensive care unit the same day. He woke up on the 12th day and was extubated on the 18th day. After transfer to a neuropsychiatric rehabilitation hospital, he recovered totally. CONCLUSION: In patients with cardiac arrest attributable to massive verapamil overdose, percutaneous extracorporeal cardiopulmonary bypass can provide adequate tissue perfusion and sufficient cerebral oxygen supply until the drug level is reduced and restoration of spontaneous circulation can be achieved.- - - - - - - - - - ranking = 2keywords = circulation (Clic here for more details about this article) |
8/133. Electrocardiographic manifestations: patterns that confound the EKG diagnosis of acute myocardial infarction-left bundle branch block, ventricular paced rhythm, and left ventricular hypertrophy.The 12-lead electrocardiogram (EKG), a powerful tool used in evaluating the chest pain patient, has its shortcomings. One such failing is encountered in a patient with one of the following electrocardiographic patterns: left bundle branch block (LBBB), ventricular paced rhythm (VPR), and left ventricular hypertrophy (LVH). These patterns reduce the ability of the EKG to detect acute coronary ischemic change and acute myocardial infarction (AMI). Several strategies are available to assist in the correct interpretation of these complicated electrocardiographic patterns, including a knowledge of the ST segment-T wave changes associated with these confounding patterns, performance of serial EKGs, and comparison with previous EKGs if available. This article suggests guidelines and interpretive tools for diagnosing AMI on EKG in patients with these confounding patterns.- - - - - - - - - - ranking = 11.030878225441keywords = coronary (Clic here for more details about this article) |
9/133. Stanford type A acute dissection developing acute myocardial infarction.A 75-year-old female, exhibiting epigastric pain and vomiting, underwent treatment for acute gastritis. She also experienced incontinence of urine and chest pain. A diagnosis of acute myocardial infarction was made upon examination of electrocardiographic findings and the patient was transferred to our hospital. Diffuse infarction of the left ventricle and acute aortic dissection (Stanford type A) were diagnosed by electrocardiographic and echo-cardiography. An emergency operation was performed. After induction of anesthesia, elevation of pulmonary artery pressure and fall of pulse pressure were observed, indicating acute cardiac tamponade. Transesophageal ultrasonography disclosed the entry of dissection in the descending aorta. dissection of the aorta extended proximally up to the annulus of the aortic valve and the right and left coronary arteries were compressed by its aneurysm. As aortic insufficiency was mild, only reconstruction of the ascending aorta was carried out. The patient was discharged in fair condition one month after operation under use of postoperative long-term administration of catecholamines.- - - - - - - - - - ranking = 11.030878225441keywords = coronary (Clic here for more details about this article) |
10/133. Myocardial perfusion scintigraphy (SPECT) in the evaluation of patients in the emergency room with precordial pain and normal or doubtful ischemic ECG. Study 60 cases.OBJECTIVES: To evaluate the diagnostic utility of myocardial perfusion by SPECT and Gated-SPECT in the diagnosis of acute coronary syndrome in patients with precordial pain associated with normal or doubtful ischemic ECG within the first 6 hrs of the last episode of pain. methods: Sixty such patients who sought attention in the Emergency room were included. Myocardial perfusion SPECT and Gated-SPECT (GSPECT) was performed in all patients using two distinct protocols. All patients underwent resting and pharmacological stress test. In 30 cases coronary angiogram were performed. RESULTS: Resting myocardial perfusion was abnormal or positive in 25 patients (42%) and normal or negative in 35 patients (58%). In the latter group perfusion became abnormal in 15 patients (43%) under stress with dipyridamole, while it remained normal in 19 (54%). The last subgroup presented no coronary events during the 12 months following their hospital discharge. In the group of 25 patients with resting perfusion abnormalities acute myocardial infarction was diagnosed in 7 patients, ischemia in 12 and reverse-reversibility in 6. Myocardial perfusion scintigraphy showed in the resting phase a low sensitivity of 61% (95% CI 39-74%), and negative predictive value of 71% (95% CI, 58-82%). During the stress phase, the utility of the test increased significantly, with a sensitivity of 97% (95% CI, 83-99%), specificity of 79% (95% CI, 57-92%), positive predictive value of 87% (95% CI, 72-95%) and, most outstanding, a negative predictive value of 95% CI, 73-99%). CONCLUSIONS: Myocardial perfusion studies have a sensitivity of 97% for identifying patients with acute coronary syndrome, with precordial pain and normal or doubtful ischemic ECG. For the intermediate or low risk patients with acute coronary syndrome the non-invasive diagnostic techniques of SPECT and GSPECT systems of evaluating myocardial perfusion achieve a high degree diagnostic accuracy, safety and reduces unnecessary admissions and costs.- - - - - - - - - - ranking = 55.154391127207keywords = coronary (Clic here for more details about this article) |
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