A case of 68-years-old male with sustained ventricular tachycardia resistant to pharmacological therapy with multiple cardiovascular diseases, after cardiosurgical mitral valve replacement and left internal mammary artery to left anterior descending coronary artery bypass, atrial fibrillation, mildly reduced ejection fraction of heart failure. A description of diagnostics step by step and invasive treatment in patient with multiple risk factors of cardio-vascular incidents.
A 37-year-old woman was admitted to the cardiology department because of a clinical suspicion of superior vena cava (SVC) syndrome. This suspicion was based on anamnesis of decreased physical effort tolerance with recurrent facial and eyelid oedema, resistant to an antiallergic treatment. At the age of 16, the patient had been diagnosed as having hypertrophic obstructive cardiomyopathy. After one year, a dual-chamber pacemaker was implanted to decrease the maximum left ventricular outflow tract gradient. Sixteen years later, an implantable cardioverter-defibrillator (ICD) was implanted as primary sudden cardiac death (SCD) prevention due to the following risk factors: recurrent non-sustained ventricular tachycardia, persistent massive interventricular septum hypertrophy, and a family history of SCD. The former pacemaker unit was removed, but the two leads were left with distal tips localised in the right atrium and right ventricle and proximally cut off and secured in the area of the primary pacemaker cavity. The implantation of a dual-chamber ICD was complicated by pneumothorax. Next, in order to verify the diagnosis of SVC syndrome, phlebography of the intrathoracic venous system was performed. This confirmed the obstruction of both left and right subclavian vein, as well as of the SVC (Figs. 1, 2). This caused a collateral circulation through the thoracic wall venous system to develop. Additionally, all four leads of both the former and the current implantable devices were visualised, two of them being actively fixated in the right atrium and the right ventricle (Fig. 3). In transthoracic echocardiography, there was no thrombus visible in the right heart cavities and the echoes of hyperechogenic atrial and ventricular leads were visualised (Fig. 4). Due to the final diagnosis of SVC thrombosis, antithrombotic treatment was initiated -starting with a therapeutic dose of low molecular weight heparin followed by a vitamin K antagonist with target international normalised ratio ranged 2.5-3.0. In conclusion, redundant leads of electrotherapy devices left in the venous system can generate significant health complications. Careful consideration of indications for electrotherapy devices implantation may help prevent future complications, especially in young patients.
A b s t r a c tCoronary artery fistula (CAF) is an abnormal connection between a coronary artery and a chamber of the heart (most often the right ventricle) or a large vessel. Most fistulas remain asymptomatic and are discovered accidentally during coronary artery diagnostics performed for other reasons. It is assumed that clinical symptoms and chest pain or exertional dyspnoea are caused by a steal phenomenon. In the case of coronary artery fistulas therapeutic management depends on clinical manifestation and the significance of haemodynamic consequences caused by the fistula. It should be noted that current guidelines of treatment are based on small retrospective studies.We present a case of a 45-year-old patient with CAF of a rare location draining from the left anterior descending artery into the left ventricle and accompanied by a myocardial bridge narrowing the lumen of this artery. The patient presented with symptoms of acute coronary syndrome.Key words: coronary artery fistula, acute coronary syndrome S t r e s z c z e n i e Przetoka tętnicy wieńcowej (CAF) jest nieprawidłowym połączeniem między tętnicą wieńcową a jamą serca (najczęściej prawą komorą) bądź dużym naczyniem. Większość przetok pozostaje bezobjawowa a rozpoznawane są przeważnie przy okazji diagnostyki naczyń wieńcowych przeprowadzanej z innych przyczyn. Uważa się, że objawy kliniczne takie jak ból w klatce piersiowej czy duszność wysiłkowa są spowodowane efektem podkradania. Postępowanie terapeutyczne w przypadku przetok tętnic wieńcowych jest zależne od manifestacji klinicznej i istotności następstw hemodynamicznych powodowanych przez przetokę. Należy dodać, że istniejące wytyczne postępowania zostały opracowane na podstawie niewielkich badań retrospektywnych.Przedstawiamy przypadek 45-letniego chorego z CAF o rzadkiej lokalizacji, łączącej gałąź międzykomorową przednią lewej tęt-nicy wieńcowej z lewą komorą, z towarzyszącym mostem mięśniowym zawężającym światło tego naczynia. Pacjent prezentował objawy ostrego zespołu wieńcowego.Słowa kluczowe: przetoka tętnicy wieńcowej, ostry zespół wieńcowy
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