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PP-049 POLYARTERITIS NODOSA PRESENTING AS ACUTE INFERIOR MYOCARDIAL INFARCTION WITH CORONARY DISSECTION
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Cardiology Posters / International Journal of Cardiology 140, Supplement 1 (2010) S1–S93
the exercise testing negative group. Coronary angiography was performed to all of the patients in the exercise testing positive group. Results: There were no difference between the levels of hs-CRP, SAA and NT-pro-BNP before and after exercise testing in both of the exercise testing positive and negative groups. Conclusions: Serum levels of hs-CRP, SAA and NT-proBNP can not predict the occurrence of reversible myocardial ischemia during exercise. Large scaled clinical studies are needed for clarifying the status of hs-CRP, SAA and NT-proBNP and exercise.
PP-049 POLYARTERITIS NODOSA PRESENTING AS ACUTE INFERIOR MYOCARDIAL INFARCTION WITH CORONARY DISSECTION Ugur Canpolat, Ahmet Hakan Ates, Hamza Sunman, Kadri Murat Gurses, Hikmet Yorgun, Kudret Aytemir, Giray Kabakci, Ali Oto Department of Cardiology, Hacettepe University, Ankara, Turkey Objective: Polyarteritis nodosa (PAN) is a necrotizing vasculitis of smallmedium sized vessels. Coronary artery involvement (76%) ranks second in frequency behind the renal arteries (85%). Aneurysms, thrombosis and arteritis of the coronary vessels are known complications of the disease. The diagnosis of PAN is made by biopsy or angiographic demonstration of the involved organ. Methods: A 23 year old woman presented with typical chest pain. On admission, there was electrocardiographic and biochemical evidence of acute inferior and right ventricular myocardial infarction (MI) and complete AV block. Due to hemodynamic stability of patient, there was no need for external pacemaker implantation. The patient’s past medical history was significant for a 15 year history of polyarteritis nodosa and due to chronic renal failure renal transplantation from her mother 8 years ago. Her physical examination on presentation with acute MI revealed a blood pressure of 110/65mmHg and unremarkable systemic findings. Biochemical analysis showed an elevated creatinine kinase (206.4ng/ml) and troponin T (10.62ng/ml) level. Liver and renal function tests were normal. Electrocardiogram showed 3° AV block with an acute inferior and right ventricular MI. Initial treatment consisted of aspirin, clopidogrel, unfractioned heparin, beta-blocker, ACE inhibitor and statin. The patient was referred for cardiac catheterization due to her age and ongoing chest pain. Coronary angiography revealed ectsia and slow flow at left coronary system. The right coronary artery (RCA) was totally occluded from proximal segment. No blood flow throughout the vessel was provided after placement of 0.014 inch soft guidewire. After predilatation of proximal RCA with 3.0×20mm Bonnie (Schneider GmbH, Germany) balloon, TIMI III flow was provided and coronary dissection was seen at distal RCA. Also there were 2 consecutive lesions at proximal and mid portions of the vessel. First, 3.5×23mm bare metal stent was deployed to the distal segment, than 3.5×13mm bare metal stents were deployed to the 2 consecutive lesions at proximal and mid portions. There was no complication occured during procedure. The remaining hospital course was uneventful. Results: PAN involving coronary arteries can lead to vessel occlusion and myocardial infarction. Rarely these patients can present as acute MI. Due to coronary vessel arteritis, aneurysm, thrombosis, dissection and stenosis can be seen in PAN. Conclusions: Although there are no published guideline for coronary angiography or angioplasty for vasculitis patients who present with acute MI, it seems rational to perform this procedure early in symptomatic patients.
PP-050 MASSIVE LINGUAL HEMATOMA: A RARE COMPLICATIONS OF THROMBOLYTIC THERAPY Adem Bekler 1 , Tezcan Peker 1 , Zeynep Sayar 2 , Mustafa Yilmaz 1 , Fehmi Doner 2 1 Department of Cardiology, Bursa Yuksek Ihtisas Education and Research Hospital, Bursa, Turkey 2 Department of Otorhinolaryngology, Bursa Yuksek Ihtisas Education and Research Hospital, Bursa, Turkey Objective: Thrombolytic agents are commonly used for the treatment of acute myocardial infarction. Although thrombolytic therapy decreases mortality in acute myocardial infarction, it may lead to serious side effects. Bleeding is the major complication associated with the administration of
thrombolytics. Lingual hematoma is a rare complications of thrombolytic therapy but potentially fatal cause of upper airway obstruction. Methods: A case of a 66-year-old woman who developed massive lingual hematome after tissue plasminogen activator (alteplase) administration for an acute myocardial infarction that necessitated nasotracheal intubation for tracheostomy in general anesthesia. Results: A 66-year-old female was hospitalized at the emergency room of our hospital with a restrosternal chest pain which was showing progression for the last three hours. There was no characteristic history of this patient excluding hypertension which was kept under control with medical treatment. For this patient who had a short and thick neck and an obese appearance. Physical examination was normally. Her blood pressure was 110/70 mmHg and pulse 82 beats/minute. Electrocardiography showed ST elevations at D2, D3, aVF, V4-V6 derivations and ST depression at D1, aVL and V1-V3 derivations. The patient was taken to coronary intensive care unit with diagnose of acute inferolateral myocardial infarction. Since there was no contraindication for thrombolytic therapy, 100 mg tissue plasminogen activator (alteplase) treatment was started on the patient together with other conventional myocardial infarction treatments (beta blockers, nitrates, heparin, aspirin). After thrombolytic therapy, chest pain of the patient was reduced and ST resolution was achieved in the electrocardiography series that followed. 4 hours after the thrombolytic therapy, massive lingual hematoma developed in the patient, that filled the oral cavity and oropharynx causing upper airway obstruction. Heparin and aspirin medications were stopped. She was consulted by otorhinolaryngology department and it was decided to perform tracheostomy. Since it was not possible to apply orotracheal intubation, tracheostomy was performed under general anesthesia with nasotracheal intubation. Three days after this operation, lingual hematoma was resolved and tracheostomy was closed. No lingual pathology was detected in the 2nd month check of the patient. Conclusions: Lingual hematoma is a rare complication of thrombolytic therapy but potentially fatal cause of upper airway obstruction. Clinicians need to be vigilant for this complication even if it is seldom encountered.
PP-051 A 48 YEAR OLD PATIENT WITH CHEST PAIN AND BILATERAL SPONTANEUS HEMOTHORAX - CASE REPORT Mertay Boran 1 , Ertay Boran 2 , Levent Mavioglu 3 Cankiri State Hospital, Department of Thoracic Surgery, Turkey 2 Izmir Ataturk Training and Research Hospital, Department of Anesthesiology and Reanimation, Turkey 3 Evliya Celebi Hospital, Department of Cardiovascular Surgery, Kutahya, Turkey 1
Objective: Spontaneous hemothorax (SH) is a rare disease manifestation and most of the data about SH consist of case reports and case series. Bilateral SH is much more rare entity. Majority of the reported causes of SH include, adhesions with pneumothorax, tumors, vascular ruptures, miscelleneous diseases and hematologic diseases. Undiagnosed and untreated aortic disection (AoD) is often fatal. Hemothorax complicating AoD occurs usually on the left hemithorax. We present a case of bilateral SH due to ruptured acute Stanford type B AoD (STBAoD) in a patient with no pre-existing risk factors for AoD. Methods: A 48-year-old nonsmoker man with no medical and surgical history, complaining of sharp chest pain, was admitted to a tertiary hospital and was treated for myalgia 24 hour before he was taken to our hospital after a syncope episode at home. Angina pectoris was ruled out by cardiologist following a normal electrocardiogram and troponin I levels. The patient was transferred to our Thoracic Surgery Unit for further investigation of left pleural effusion seen in transthoracic echocardiography. Patient described a sudden onset of pain on the left chest started 24 hours before and atypical abdominal pain and two sincope episodes seen during last 4 hours. At the physical examination 100/70 mmHg of blood pressure and 76 beats/min of heart rate were detected. The left anterior hemithorax and abdomen were tender to palpation. Lung sounds were diminished at the left side. Results: The laboratory showed leukocytosis, mild renal failure, elevated transaminase, creatinine kinase and D dimer levels. Chest X-ray revealed a marked opacity of lower zone at the left hemithorax and a minimal opacity on costodiaphragmatic sinus at the right side. Thorax CT showed an intimal flap at decending aorta, fluid extravasation around decending aorta and into mediastinum and pericardium, besides hemothorax on the left side and right side. Maximum aortic diameter was 46 mm. Abdominal
Cardiology Posters / International Journal of Cardiology 140, Supplement 1 (2010) S1–S93
the exercise testing negative group. Coronary angiography was performed to all of the patients in the exercise testing positive group. Results: There were no difference between the levels of hs-CRP, SAA and NT-pro-BNP before and after exercise testing in both of the exercise testing positive and negative groups. Conclusions: Serum levels of hs-CRP, SAA and NT-proBNP can not predict the occurrence of reversible myocardial ischemia during exercise. Large scaled clinical studies are needed for clarifying the status of hs-CRP, SAA and NT-proBNP and exercise.
PP-049 POLYARTERITIS NODOSA PRESENTING AS ACUTE INFERIOR MYOCARDIAL INFARCTION WITH CORONARY DISSECTION Ugur Canpolat, Ahmet Hakan Ates, Hamza Sunman, Kadri Murat Gurses, Hikmet Yorgun, Kudret Aytemir, Giray Kabakci, Ali Oto Department of Cardiology, Hacettepe University, Ankara, Turkey Objective: Polyarteritis nodosa (PAN) is a necrotizing vasculitis of smallmedium sized vessels. Coronary artery involvement (76%) ranks second in frequency behind the renal arteries (85%). Aneurysms, thrombosis and arteritis of the coronary vessels are known complications of the disease. The diagnosis of PAN is made by biopsy or angiographic demonstration of the involved organ. Methods: A 23 year old woman presented with typical chest pain. On admission, there was electrocardiographic and biochemical evidence of acute inferior and right ventricular myocardial infarction (MI) and complete AV block. Due to hemodynamic stability of patient, there was no need for external pacemaker implantation. The patient’s past medical history was significant for a 15 year history of polyarteritis nodosa and due to chronic renal failure renal transplantation from her mother 8 years ago. Her physical examination on presentation with acute MI revealed a blood pressure of 110/65mmHg and unremarkable systemic findings. Biochemical analysis showed an elevated creatinine kinase (206.4ng/ml) and troponin T (10.62ng/ml) level. Liver and renal function tests were normal. Electrocardiogram showed 3° AV block with an acute inferior and right ventricular MI. Initial treatment consisted of aspirin, clopidogrel, unfractioned heparin, beta-blocker, ACE inhibitor and statin. The patient was referred for cardiac catheterization due to her age and ongoing chest pain. Coronary angiography revealed ectsia and slow flow at left coronary system. The right coronary artery (RCA) was totally occluded from proximal segment. No blood flow throughout the vessel was provided after placement of 0.014 inch soft guidewire. After predilatation of proximal RCA with 3.0×20mm Bonnie (Schneider GmbH, Germany) balloon, TIMI III flow was provided and coronary dissection was seen at distal RCA. Also there were 2 consecutive lesions at proximal and mid portions of the vessel. First, 3.5×23mm bare metal stent was deployed to the distal segment, than 3.5×13mm bare metal stents were deployed to the 2 consecutive lesions at proximal and mid portions. There was no complication occured during procedure. The remaining hospital course was uneventful. Results: PAN involving coronary arteries can lead to vessel occlusion and myocardial infarction. Rarely these patients can present as acute MI. Due to coronary vessel arteritis, aneurysm, thrombosis, dissection and stenosis can be seen in PAN. Conclusions: Although there are no published guideline for coronary angiography or angioplasty for vasculitis patients who present with acute MI, it seems rational to perform this procedure early in symptomatic patients.
PP-050 MASSIVE LINGUAL HEMATOMA: A RARE COMPLICATIONS OF THROMBOLYTIC THERAPY Adem Bekler 1 , Tezcan Peker 1 , Zeynep Sayar 2 , Mustafa Yilmaz 1 , Fehmi Doner 2 1 Department of Cardiology, Bursa Yuksek Ihtisas Education and Research Hospital, Bursa, Turkey 2 Department of Otorhinolaryngology, Bursa Yuksek Ihtisas Education and Research Hospital, Bursa, Turkey Objective: Thrombolytic agents are commonly used for the treatment of acute myocardial infarction. Although thrombolytic therapy decreases mortality in acute myocardial infarction, it may lead to serious side effects. Bleeding is the major complication associated with the administration of
thrombolytics. Lingual hematoma is a rare complications of thrombolytic therapy but potentially fatal cause of upper airway obstruction. Methods: A case of a 66-year-old woman who developed massive lingual hematome after tissue plasminogen activator (alteplase) administration for an acute myocardial infarction that necessitated nasotracheal intubation for tracheostomy in general anesthesia. Results: A 66-year-old female was hospitalized at the emergency room of our hospital with a restrosternal chest pain which was showing progression for the last three hours. There was no characteristic history of this patient excluding hypertension which was kept under control with medical treatment. For this patient who had a short and thick neck and an obese appearance. Physical examination was normally. Her blood pressure was 110/70 mmHg and pulse 82 beats/minute. Electrocardiography showed ST elevations at D2, D3, aVF, V4-V6 derivations and ST depression at D1, aVL and V1-V3 derivations. The patient was taken to coronary intensive care unit with diagnose of acute inferolateral myocardial infarction. Since there was no contraindication for thrombolytic therapy, 100 mg tissue plasminogen activator (alteplase) treatment was started on the patient together with other conventional myocardial infarction treatments (beta blockers, nitrates, heparin, aspirin). After thrombolytic therapy, chest pain of the patient was reduced and ST resolution was achieved in the electrocardiography series that followed. 4 hours after the thrombolytic therapy, massive lingual hematoma developed in the patient, that filled the oral cavity and oropharynx causing upper airway obstruction. Heparin and aspirin medications were stopped. She was consulted by otorhinolaryngology department and it was decided to perform tracheostomy. Since it was not possible to apply orotracheal intubation, tracheostomy was performed under general anesthesia with nasotracheal intubation. Three days after this operation, lingual hematoma was resolved and tracheostomy was closed. No lingual pathology was detected in the 2nd month check of the patient. Conclusions: Lingual hematoma is a rare complication of thrombolytic therapy but potentially fatal cause of upper airway obstruction. Clinicians need to be vigilant for this complication even if it is seldom encountered.
PP-051 A 48 YEAR OLD PATIENT WITH CHEST PAIN AND BILATERAL SPONTANEUS HEMOTHORAX - CASE REPORT Mertay Boran 1 , Ertay Boran 2 , Levent Mavioglu 3 Cankiri State Hospital, Department of Thoracic Surgery, Turkey 2 Izmir Ataturk Training and Research Hospital, Department of Anesthesiology and Reanimation, Turkey 3 Evliya Celebi Hospital, Department of Cardiovascular Surgery, Kutahya, Turkey 1
Objective: Spontaneous hemothorax (SH) is a rare disease manifestation and most of the data about SH consist of case reports and case series. Bilateral SH is much more rare entity. Majority of the reported causes of SH include, adhesions with pneumothorax, tumors, vascular ruptures, miscelleneous diseases and hematologic diseases. Undiagnosed and untreated aortic disection (AoD) is often fatal. Hemothorax complicating AoD occurs usually on the left hemithorax. We present a case of bilateral SH due to ruptured acute Stanford type B AoD (STBAoD) in a patient with no pre-existing risk factors for AoD. Methods: A 48-year-old nonsmoker man with no medical and surgical history, complaining of sharp chest pain, was admitted to a tertiary hospital and was treated for myalgia 24 hour before he was taken to our hospital after a syncope episode at home. Angina pectoris was ruled out by cardiologist following a normal electrocardiogram and troponin I levels. The patient was transferred to our Thoracic Surgery Unit for further investigation of left pleural effusion seen in transthoracic echocardiography. Patient described a sudden onset of pain on the left chest started 24 hours before and atypical abdominal pain and two sincope episodes seen during last 4 hours. At the physical examination 100/70 mmHg of blood pressure and 76 beats/min of heart rate were detected. The left anterior hemithorax and abdomen were tender to palpation. Lung sounds were diminished at the left side. Results: The laboratory showed leukocytosis, mild renal failure, elevated transaminase, creatinine kinase and D dimer levels. Chest X-ray revealed a marked opacity of lower zone at the left hemithorax and a minimal opacity on costodiaphragmatic sinus at the right side. Thorax CT showed an intimal flap at decending aorta, fluid extravasation around decending aorta and into mediastinum and pericardium, besides hemothorax on the left side and right side. Maximum aortic diameter was 46 mm. Abdominal