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Combined coronary angioplasty and aortic valvuloplasty
1184
BRIEF REPORTS
left anterior descending and left circumflex coronary arteries. Angioplasty of the ramus intermedius coronary artery was performed using 8Fr FL4 guiding catheter, 0.018-inch floppy guidewire and a 3.0 mm standard balloon catheter (ACS). Three balloon inflations were performed to 8 atm and for a maximum duration of 90 seconds. The dilation was angiographitally successful with no complications (Fig. I]. A treadmill stress test 36 hours later was normal. The patient was discharged taking aspirin 80 mg daily, diltiazem 240 mg daily and dipyridamol225 mg daily. However, he was readmitted to the hospital 5 months later (April 1987) with recurrent chest pain at rest and his electrocardiogram revealed ischemic ST and Twave changes in the anterolateral leads. Repeat cardiac catheterization while the patient was receiving intravenous nitroglycerin revealed a new 85% diameter stenosis involving the LM coronary artery, 99% diameter stenosis of the ramus intermedius artery at the site of previous dilation [Fig. 2). To exclude local spasm, intracoronary nitroglycerin (400 pg) and sublingual nifedipine (20 mg] were administered and a repeat nonselective injection of the LM coronary artery confirmed the initial findings. The patient underwent an uneventful coronary bypass surgery. Of 800 patients who underwent PTCA during the last 12 months at our institution, angiographic restenosis or obstruction occurred at the dilated site in 223
CombinedCoronary Angioplasty and Aortic Valvuloplasty NIDAL HAMAD, MD AUGUST0 PICHARD, MD JOSEPH LINDSAY, Jr, MD
R
ecently, percutaneous balloon valvuloplasty for acquired valvular aortic stenosis has been performed in elderly patients with good immediate results and a low complication rate .Q We describe 4 patients who underwent combined aortic valvuloplasty and percutaneous transluminal coronary angioplasty (PTCA]. Of 32 patients who underwent aortic valvuloplasty at our hospital, 4 patients had critical I-vessel coronary artery disease contributing to their symptoms and poor functional
status (Table I). Two of these 4
patients had PTCA performed just before valvuloplasty during the same visit to the laboratory (Fig. 1 and 2) From the Washington Hospital Center and George Washington University School of Medicine, Washington, DC 20010. Manuscript received June 18,1987; revised manuscript received June 29,1987, accepted July 1,1987.
(28%) The patient reported here was the only one to be observed with a new critical stenosis of a previously normal LM coronary artery. Five patients have been previously described with such a late and rare complication involving the LM artery 3 to 14 months after successful dilation of a proximal left anterior descending artery segment.2-4Of these 5 patients, 4 had preexisting minimal LM narrowing. At necropsy, Waller et al4 observed fibrocellular tissue proliferation in a LM coronary artery similar to that at the site of previous PTCA of the anterior descending artery. Histologic analysis of LM coronary arteries from 11 patients who died within 72 hours of PTCA of left anterior descending or left circumflex arteries disclosed local loss of luminal endothelium in 9 patients5
1. Meir B, King SB, Gruentzig AR, Douglas IS, Hollman J, Ischinger T, Galan K, Tankersley R. Repeat coronary angioplasty. IACC 1964;4:463-466. 2. Graf RH, Verani Ms. Left main coronary artery stenosis: a possible complication of tronsluminal coronary angioplasty. Cathet Cardiovasc Diagn 1984: l&163-166.
3. Slack \D, Pinkerton CA. Subacute left main coronary stenosis: an unusual but serious complication of percutaneous transluininal coronary angiopiasty. Angiology 1985;36:130-136. 4. Waller BF, Pinkerton CA, Foster LN. Morphologic evidence of accelerated left main coronary artery stenosis: a late complication of percutaneous transfuminal balloon angioplasty of proximal left anterior descending artery. rACC 1987;9:1019-1023. 5. Wailer BF, Gorfinkel HJ, Dillon JC. Splitting or stretching differingmechanisms in percutaneous transluminal ongioplasty of stenotic coronary arteries, sophenous vein bypass grafts and superior vena cave post-mustard procedure. Morphologic analysis of 14 patients. Circulation 72;suppJ III:III-398.
TABLE I
Clinical
Characteristics
and Hemodvnamic
Peak Systolic Valve Gradient (mm I-b) Pt
Age W)
1
67
2 3 4
80 80 81
Symptoms AP, D, S AP, PE AP, PE AP
Data
Valve Area (cm?
Before
After
Before
60 80 90 120
25 25 47 40
0.70 0.36 0.35 0.40
After
1.20 1.10 0.85 0.90
AP = angina pectoris; D = dyspnea; LAD = left anterior tery; PE = pulmonary edema; S = syncope.
Coronary Artery LAD Right Right Right
descending
ar-
and the other 2 patients had PTCA 3 and 6 weeks after valvuloplasty, having demonstrated continued angina (Fig. 3 and 4). We think that if PTCA is to be performed in a patient who will undergo valvuloplasty, it may be desirable to proceed with PTCA first to reduce the hypoxic insult to the hypertrophic myocardium during the stress of valvuloplasty. The limited available data have indicated poor early prognosis in patients with significant coronary artery disease despite the acceptable hemodynamic results obtained after aortic valvuloplasty. Coronary
November
FIGURE 1. Left anterior descending (left) antd after (right) angioplasty.
FIGURE 2. Right coronary after (rif TM) angioplasty.
arte !ry before
artery before
3. Right coronary artery before (/efr) an Id after (right) angioplasty.
?ft) and
15, 1987
THE AMERICAN
JOURNAL
OF CARDIOLOGY
Volume SO
1185
BRIEF REPORTS
1186
FIGURE 4. Right coronary artery before (leff) anId after (right) angioplastl Y-
angioplasty in the subset of patients with obstructive coronary artery disease limited to 1 or 2 arteries might add to the hemodynamic benefit and the improvement in the functional status of these patients.
Torsades de Pointes Precipitated by a Chinese Herbal Remedy MICHAEL BRYER-ASH, MB, MRCP JAMES ZEHNDER MD PAUL ANGELCHIK, MD ALAN MAISEL, MD
T
orsades de pointes (TdP] is a form of ventricular tachycardia first described in 1966 by Dessertenne.* The term is used to describe a form of the arrhythmia in which the amplitude of the complexes and their vector continually changes in a twisting motion around the isoelectric line. Although the precise underlying pathophysiologic basis is unknown, TdP has been described in association with a number of predisposing factors, most commonly the presence of a previously prolonged QT interval. We describe an unusual case of TdP precipitated by a nonprescription “herbal” remedy, and emphasize that early recognition and appropriate management of this specialized form of ventricular tachyarrhythmia may be lifesaving.
From the Department of Medicine, Stanford University Medical Center, Stanford, the Department of Medicine, University of California, San Diego, and the Veterans Administration Medical Center, La Jolla, California. Manuscript received April 17, 1987; revised manuscript received and accepted July 20,1987.
1. Cribier A, Savin T, Berland J, Rocha P, Mechmeche R, Saoudi N, Behar P, Letac B. Percutaneous transluminol balloon valvuloplasty of adult aortic stenosis; report of 92 cases. fACC 1987;9:381-389. 2. McKay RG, Safian RD, Lock JE, Diver DJ, Berman AD, Warren SE, Come PC, Bairn DS, Mandell VE, Royal HD, Grossman W. Assessment of left ventricular and aortic valve function afteraortic balloon valvuloplasty in adult patients with critical aortic stenosis. Circulation 1987;75:192-20%
A 69-year-old CQmbOdiQnwoman presented to the Stanford Hospital Emergency Room with a history of 4 episodes of acute syncope over the preceding 24 hours lasting up to 25 minutes. Each of these episodes had been witnessed by her family, and consisted of abrupt collapse of the patient without prior complaints and independent of posture. There was no evidence of seizure activity. Shortly after reawakening she was able to resume normal activity. She denied palpitations, dyspnea, chest pain or other cardiorespiratory symptoms. She took no prescribed medications, but her family stated that she had taken several tablets daily for several days of a traditional Chinese herbal
FIGURE 1. Chui-Feng-%-Ho-Wan.
BRIEF REPORTS
left anterior descending and left circumflex coronary arteries. Angioplasty of the ramus intermedius coronary artery was performed using 8Fr FL4 guiding catheter, 0.018-inch floppy guidewire and a 3.0 mm standard balloon catheter (ACS). Three balloon inflations were performed to 8 atm and for a maximum duration of 90 seconds. The dilation was angiographitally successful with no complications (Fig. I]. A treadmill stress test 36 hours later was normal. The patient was discharged taking aspirin 80 mg daily, diltiazem 240 mg daily and dipyridamol225 mg daily. However, he was readmitted to the hospital 5 months later (April 1987) with recurrent chest pain at rest and his electrocardiogram revealed ischemic ST and Twave changes in the anterolateral leads. Repeat cardiac catheterization while the patient was receiving intravenous nitroglycerin revealed a new 85% diameter stenosis involving the LM coronary artery, 99% diameter stenosis of the ramus intermedius artery at the site of previous dilation [Fig. 2). To exclude local spasm, intracoronary nitroglycerin (400 pg) and sublingual nifedipine (20 mg] were administered and a repeat nonselective injection of the LM coronary artery confirmed the initial findings. The patient underwent an uneventful coronary bypass surgery. Of 800 patients who underwent PTCA during the last 12 months at our institution, angiographic restenosis or obstruction occurred at the dilated site in 223
CombinedCoronary Angioplasty and Aortic Valvuloplasty NIDAL HAMAD, MD AUGUST0 PICHARD, MD JOSEPH LINDSAY, Jr, MD
R
ecently, percutaneous balloon valvuloplasty for acquired valvular aortic stenosis has been performed in elderly patients with good immediate results and a low complication rate .Q We describe 4 patients who underwent combined aortic valvuloplasty and percutaneous transluminal coronary angioplasty (PTCA]. Of 32 patients who underwent aortic valvuloplasty at our hospital, 4 patients had critical I-vessel coronary artery disease contributing to their symptoms and poor functional
status (Table I). Two of these 4
patients had PTCA performed just before valvuloplasty during the same visit to the laboratory (Fig. 1 and 2) From the Washington Hospital Center and George Washington University School of Medicine, Washington, DC 20010. Manuscript received June 18,1987; revised manuscript received June 29,1987, accepted July 1,1987.
(28%) The patient reported here was the only one to be observed with a new critical stenosis of a previously normal LM coronary artery. Five patients have been previously described with such a late and rare complication involving the LM artery 3 to 14 months after successful dilation of a proximal left anterior descending artery segment.2-4Of these 5 patients, 4 had preexisting minimal LM narrowing. At necropsy, Waller et al4 observed fibrocellular tissue proliferation in a LM coronary artery similar to that at the site of previous PTCA of the anterior descending artery. Histologic analysis of LM coronary arteries from 11 patients who died within 72 hours of PTCA of left anterior descending or left circumflex arteries disclosed local loss of luminal endothelium in 9 patients5
1. Meir B, King SB, Gruentzig AR, Douglas IS, Hollman J, Ischinger T, Galan K, Tankersley R. Repeat coronary angioplasty. IACC 1964;4:463-466. 2. Graf RH, Verani Ms. Left main coronary artery stenosis: a possible complication of tronsluminal coronary angioplasty. Cathet Cardiovasc Diagn 1984: l&163-166.
3. Slack \D, Pinkerton CA. Subacute left main coronary stenosis: an unusual but serious complication of percutaneous transluininal coronary angiopiasty. Angiology 1985;36:130-136. 4. Waller BF, Pinkerton CA, Foster LN. Morphologic evidence of accelerated left main coronary artery stenosis: a late complication of percutaneous transfuminal balloon angioplasty of proximal left anterior descending artery. rACC 1987;9:1019-1023. 5. Wailer BF, Gorfinkel HJ, Dillon JC. Splitting or stretching differingmechanisms in percutaneous transluminal ongioplasty of stenotic coronary arteries, sophenous vein bypass grafts and superior vena cave post-mustard procedure. Morphologic analysis of 14 patients. Circulation 72;suppJ III:III-398.
TABLE I
Clinical
Characteristics
and Hemodvnamic
Peak Systolic Valve Gradient (mm I-b) Pt
Age W)
1
67
2 3 4
80 80 81
Symptoms AP, D, S AP, PE AP, PE AP
Data
Valve Area (cm?
Before
After
Before
60 80 90 120
25 25 47 40
0.70 0.36 0.35 0.40
After
1.20 1.10 0.85 0.90
AP = angina pectoris; D = dyspnea; LAD = left anterior tery; PE = pulmonary edema; S = syncope.
Coronary Artery LAD Right Right Right
descending
ar-
and the other 2 patients had PTCA 3 and 6 weeks after valvuloplasty, having demonstrated continued angina (Fig. 3 and 4). We think that if PTCA is to be performed in a patient who will undergo valvuloplasty, it may be desirable to proceed with PTCA first to reduce the hypoxic insult to the hypertrophic myocardium during the stress of valvuloplasty. The limited available data have indicated poor early prognosis in patients with significant coronary artery disease despite the acceptable hemodynamic results obtained after aortic valvuloplasty. Coronary
November
FIGURE 1. Left anterior descending (left) antd after (right) angioplasty.
FIGURE 2. Right coronary after (rif TM) angioplasty.
arte !ry before
artery before
3. Right coronary artery before (/efr) an Id after (right) angioplasty.
?ft) and
15, 1987
THE AMERICAN
JOURNAL
OF CARDIOLOGY
Volume SO
1185
BRIEF REPORTS
1186
FIGURE 4. Right coronary artery before (leff) anId after (right) angioplastl Y-
angioplasty in the subset of patients with obstructive coronary artery disease limited to 1 or 2 arteries might add to the hemodynamic benefit and the improvement in the functional status of these patients.
Torsades de Pointes Precipitated by a Chinese Herbal Remedy MICHAEL BRYER-ASH, MB, MRCP JAMES ZEHNDER MD PAUL ANGELCHIK, MD ALAN MAISEL, MD
T
orsades de pointes (TdP] is a form of ventricular tachycardia first described in 1966 by Dessertenne.* The term is used to describe a form of the arrhythmia in which the amplitude of the complexes and their vector continually changes in a twisting motion around the isoelectric line. Although the precise underlying pathophysiologic basis is unknown, TdP has been described in association with a number of predisposing factors, most commonly the presence of a previously prolonged QT interval. We describe an unusual case of TdP precipitated by a nonprescription “herbal” remedy, and emphasize that early recognition and appropriate management of this specialized form of ventricular tachyarrhythmia may be lifesaving.
From the Department of Medicine, Stanford University Medical Center, Stanford, the Department of Medicine, University of California, San Diego, and the Veterans Administration Medical Center, La Jolla, California. Manuscript received April 17, 1987; revised manuscript received and accepted July 20,1987.
1. Cribier A, Savin T, Berland J, Rocha P, Mechmeche R, Saoudi N, Behar P, Letac B. Percutaneous transluminol balloon valvuloplasty of adult aortic stenosis; report of 92 cases. fACC 1987;9:381-389. 2. McKay RG, Safian RD, Lock JE, Diver DJ, Berman AD, Warren SE, Come PC, Bairn DS, Mandell VE, Royal HD, Grossman W. Assessment of left ventricular and aortic valve function afteraortic balloon valvuloplasty in adult patients with critical aortic stenosis. Circulation 1987;75:192-20%
A 69-year-old CQmbOdiQnwoman presented to the Stanford Hospital Emergency Room with a history of 4 episodes of acute syncope over the preceding 24 hours lasting up to 25 minutes. Each of these episodes had been witnessed by her family, and consisted of abrupt collapse of the patient without prior complaints and independent of posture. There was no evidence of seizure activity. Shortly after reawakening she was able to resume normal activity. She denied palpitations, dyspnea, chest pain or other cardiorespiratory symptoms. She took no prescribed medications, but her family stated that she had taken several tablets daily for several days of a traditional Chinese herbal
FIGURE 1. Chui-Feng-%-Ho-Wan.