Coverage of the left subclavian artery origin is required to achieve adequate proximal seal during up to 40% of TEVAR cases. The evidence regarding left subclavian artery revascularization in patients undergoing elective or emergent TEVAR with left subclavian artery coverage is weak, and there is ongoing debate whether revascularization should be performed routinely of selectively. Beyond this debate, there is a lack of data about left subclavian artery coverage during TEVAR in end-stage renal disease patients with a functional left upper limb atreriovenous fistula. We present the case of a patient with a left distal radiocephalic arteriovenous fistula who underwent emergent TEVAR with left subclavian artery coverage for ruptured type B aortic dissection. The arteriovenous fistula remains functional on a 3-month follow-up, and the patient did not develop symptoms related to posterior stroke, spinal cord ischemia, limb ischemia, or vertebrobasilar insufficiency.
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Introduction: Pathological Q waves are correlated with infarct size, and Q wave regression is associated with left ventricular ejection fraction improvement. There are limited data regarding the association between Q wave regression and clinical outcomes. Our main objective was to assess the association of pathological Q wave evolution after reperfusion with clinical outcomes after ST-elevation myocardial infarction (STEMI). Patients and Methods: Standard 12-lead electrocardiograms (ECGs) were recorded in 1553 patients, who presented to our hospital with chest pain and underwent primary percutaneous coronary intervention (p-PCI) with the diagnosis of STEMI and were retrospectively analyzed. ECGs were recorded before and 90 min after PCI, as well as at hospitalization discharge and 12 months of follow-up. The study population was divided into three groups as the Q wave regression group, the Q wave persistent group, and the non-Q wave MI group. Results: There were 502 (32%) patients with persistent Q waves (PQ group), 509 (33%) patients with Q wave regression (RQ group), and 542 (35%) patients with non-Q wave MI (NQ group). The degree of LVEF was significantly greater in the RQ group and NQ group than in the PQ group [(47.5 ± 10.1 vs. 49.2 ± 9.9) vs. 43.3 ± 10.5 respectively, p<0.01]. One-year mortality was significantly greater in the PQ group compared to the RQ and NQ groups [19 (3.78%) vs. 11 (2.16%) vs. 6 (1.1%) respectively, p<0.01]. Conclusion: In a population of STEMI patients, persistent Q waves defined according to the classic ECG criteria after reperfusion were associated with high one-year mortality, and low LVEF, while Q wave regression was associated with significantly lower risk of events.
A previously healthy 68-year-old woman presented to the outpatient clinic with a 2-month history of palpitation. Physical examination and laboratory findings were unremarkable. Her electrocardiogram showed sinus tachycardia with a heart rate of 115 beats/m. Transthoracic echocardiography (TTE) showed a normal ejection fraction with a huge mass in the left atrium (Figure 1a). Transesophageal echocardiography (TEE) and cardiac magnetic resonance imaging (MRI) were performed for further evaluation. TEE revealed a hyperechogenic, well-demarcated mass in the left atrium, that was attached to the interatrial septum and adjacent to the left pulmonary veins (Figure 1b, 1c,1d). Cardiac MRI revealed a heterogeneous left atrial mass located on the fossa ovalis, 58x52x54 mm in size and markedly hyperintense on a STIR sequence (Figure 1e). These findings were suggestive of a benign cardiac tumour such as myxoma or hemangioma. A decision for surgery was made and coronary angiography was performed which showed that the branch of the circumflex artery supplied and surrounded the mass in the form of a net (Figure 1e). The patient underwent complete excision of the mass (Figure 2a, 2b). Histopathological examination revealed a nested architecture of epitelioid cells, the nests are round or oval in shape and invested by an fibrovascular stroma. Tumor cells had centrally and eccentrically located round nuclei and cytoplasm ranging from finely granular to eosiniphilic. At immunohistochemical staining, the nests were positive for chromogranin A, negative for cytokeratin (Figure 2c, 2d, 2e, 2f). A diagnosis of paraganglioma was made. After an uneventful postoperative course, she was discharged home on postoperative day 6. Cardiac paraganglioma is a very rare neuroendocrine tumour and accounts for less than 1% of primary cardiac tumours (1,2). Approximately 10% of paragangliomas may be malignant, complete surgical resection remains the first-line treatment (3).
Successful reperfusion of myocardial tissue is the goal of primary percutaneous coronary intervention (pPCI) in patients with ST-segment elevation myocardial infarction (STEMI). We aimed to investigate the association between the De Ritis ratio (AST/ALT) and myocardial reperfusion in patients with STEMI who underwent pPCI. We retrospectively investigated 1236 consecutive patients who were hospitalized for STEMI and underwent pPCI. ST-segment resolution (STR) was defined as the return of the deviated ST-segment to baseline; poor myocardial reperfusion was defined as <70% STR. Patients were divided into 2 groups according to the median De Ritis ratio (.921); 618 patients (50%) were assigned to the De Ritis low group while 618 patients (50%) were assigned to the De Ritis high group. Stent size, neutrophil-to lymphocyte ratio (NLR), and the De Ritis ratio found to be associated with poor myocardial reperfusion (Odds ratio (OR) 1.45, 95% CI 1.07–1.98, P = .01, OR 1.22, 95% CI 1.01–1.48, P = .03 and OR 10.9, 95% CI 7.9–15, P < .001, respectively). A high De Ritis ratio was associated with poor myocardial reperfusion in STEMI patients who underwent pPCI. As an easily obtainable test in clinical practice, the De Ritis ratio may help identify patients at major risk for impaired myocardial perfusion.
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