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Query: UMLS:C0022116 (ischemia)
 91,303 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

We describe coronary-subclavian steal restricting flow to the left internal mammary artery (LIMA) associated with critical aortic stenosis treated with combined percutaneous transluminal stenting and minimally invasive aortic valve replacement (AVR). An 86-year-old patient had coronary artery bypass graft placement (CABG) seven years prior with the LIMA anastomosed to the left anterior descending coronary artery (LAD). At the time of CABG, the patient had mild aortic stenosis and normal left ventricular function. By the time of re-presentation with refractory angina and heart failure, the patient had developed critical aortic stenosis. Because repeat CABG with median sternotomy risked damaging the LIMA, pre-operative revascularization was planned to minimize the likelihood of peri-operative ischemia. Stenting of the subclavian artery was performed prior to minimally invasive AVR.
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PMID:Coronary-subclavian steal associated with severe aortic stenosis treated with combined percutaneous stenting and minimally invasive aortic valve replacement. 1074 61

Between January 1990 and December 1999, 20 patients underwent the valve surgery concomitant with coronary artery bypass grafting. There were 16 males and 4 females, their mean age was 66.5 years. Of the 20 patients, aortic stenosis was noted in 7, aortic regurgitation in 3, mitral stenosis in one, and mitral regurgitation in 9 patients. The cause of mitral regurgitation was considered to be an ischemic change in six patients, including ruptured papillary muscle due to myocardial infarction in two patients. On the contrary, LMT lesion was recognized in 5, LAD lesion in 17, LCX in 16, and RCA in 12 patients. Seven patients had preoperative myocardial infarction, three patients were required preoperative IABP support. AVR was performed in 10, MVR in 5, and MAP in 5 patients. The number of bypass was 1.9 +/- 0.85. Four patients died of LOS and MOF. The remaining 16 patients have been doing well. The significant difference between the survived and the not survived patients was recognized in the factor of emergency, preoperative IABP, papillary muscle rupture due to myocardial infarction, history of PTCA, LAD lesion, and the time of CPB. The factors regarding coronary artery had the influence on the outcome of a patients of valve surgery concomitant with CABG. Therefore, an appropriate myocardial protection and perioperative management for ischemia were mandatory.
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PMID:[Perioperative risk factors in valve surgery concomitant with coronary artery bypass grafting]. 1093 83

Early treatment of acute myocardial infarction (AMI) can improve the rate of coronary patency, salvage myocardium, and ultimately save lives; thus, rapid recognition of patients at a higher risk of developing AMI is very important. The clinical history in patients with documented AMI is sometimes atypical, and the initial cardiac enzyme levels often are within the normal range. Moreover, the typical ST-segment elevation is often absent on the initial electrocardiogram in patients who subsequently sustain an AMI. Stress-induced segmental wall motion abnormalities (SWMAs) in coronary artery disease patients can be readily detected by conventional two-dimensional echocardiography. Moreover, echocardiography is the only technique available that allows real-time assessment of stress-induced reduction in systolic wall thickening, a highly specific sign of myocardial ischemia. Echocardiography for the diagnosis of acute ischemia is most helpful in subjects with a high clinical suspicion but nondiagnostic electrocardiograms. Under these circumstances, reversible SWMA confirms the diagnosis of acute coronary syndrome. The location of regional SWMAs correlates well with the distribution of the artery involved and pathological evidence of infarction. A trained eye can easily recognize cardiac causes of acute chest pain other than coronary diseases such as aortic stenosis, hypertrophic cardiomyopathy, mitral valve prolapse, pericarditis, and aortic dissection. When echocardiography is performed soon after the patients arrival at the emergency department (ED) or during a chest pain episode, SWMAs are detected in 90-95% of transmural infarctions and in 80-90% of nontransmural or subendocardial infarctions, and the specificity of echocardiography is approximately 80-90%. Although stress echocardiography performed in the ED and interpreted at a distance through the use of telemedicine has the potential of being convenient, in our opinion, any form of stress echocardiography should be performed in the echocardiography laboratory only after an AMI has been completely ruled out. The detection of jeopardized myocardium early after AMI can identify patients at a higher risk to develop subsequent events. In conclusion, echocardiography is cost effective in the triage of patients presenting with acute chest pain when performed soon after ED admission or during a chest pain episode. However, echocardiography must be readily available, expeditiously performed, and skillfully interpreted. The clinical use of stress echocardiography in acute coronary syndromes has been greatly improved with the introduction of digital and second harmonics technology and further enhanced by the availability of contrast agents.
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PMID:Diagnostic and prognostic use of stress echo in acute coronary syndromes including emergency department imaging. 1097 25

The echocardiographic examination is generally performed in patients with heart failure and it often gives a significant contribution to the differential diagnosis. Firstly, the evaluation of left ventricular pump function by measuring the ejection fraction (EF) can distinguish patients with heart failure into two different groups, with depressed or preserved EF. The most frequent causes of heart failure and depressed EF are coronary artery disease, idiopathic dilated cardiomyopathy (DCM) and hypertensive heart disease. Although the echocardiographic features of coronary artery disease versus idiopathic DCM may be similar, the demonstration of inducible ischemia at dobutamine echocardiographic test suggests the presence of significant coronary artery disease and may be useful in the selection of cases for coronary arteriography. The association of left ventricular hypertrophy, hypokinesis and, sometimes, significant dilation is compatible with hypertensive heart disease or end-stage hypertrophic cardiomyopathy. No useful echocardiographic findings can identify the patients with genetic DCM or affected by myocarditis from other cases with idiopathic DCM. Some advanced cases of right ventricular dysplasia/cardiomyopathy may show a biventricular involvement and mimic DCM; these patients are usually characterized at echo by predominant right ventricular dilation and multiple a-dyskinetic bulges in the absence of pulmonary hypertension. Very difficult to manage are the patients with significant left ventricular dysfunction and severe valvular heart disease (such as aortic stenosis or mitral regurgitation). According to the literature, the left ventricular systolic function is relatively preserved (EF > 40%) in 30-40% of patients with heart failure. In these cases a diastolic dysfunction may be hypothesized. Echo-Doppler evaluation can be helpful in the recognition of signs of increased left ventricular stiffness ("restrictive filling pattern") and of increased filling pressures. In the differential diagnosis one must first consider the most frequent heart disorders that may present with this clinical syndrome, coronary artery disease and hypertensive heart disease. Furthermore, other less common diseases characterized by heart failure due to predominant diastolic dysfunction are the following: hypertrophic and restrictive cardiomyopathies, infiltrative heart diseases, such as amyloidosis, and constrictive pericarditis. Restrictive cardiomyopathy is characterized by heart failure and preserved left ventricular EF in the absence of significant ventricular dilation and hypertrophy; typical, although not pathognomonic, echocardiographic features are atrial enlargement ad restrictive filling pattern. In distinguishing constrictive pericarditis from restrictive cardiomyopathy useful Doppler signs are the wide respiratory variability in flow velocities at mitral and tricuspid levels, due to increased ventricular interdependence caused by the presence of an abnormally rigid pericardium.
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PMID:[Contribution of echocardiography to the diagnosis of patients with chronic heart failure]. 1106 13

We searched the medical literature for articles containing markers of cardiac ischemia and echocardiography in the evaluation of patients presenting to the emergency department to determine their combined clinical use. Several published articles indicate two-dimensional echocardiography is a useful and cost-effective imaging technique for the evaluation of patients with chest pain in the emergency department. New studies are emerging that evaluate ischemic markers in combination with echocardiography to assess patients presenting to the emergency department with chest pain. We searched the MEDLINE Database for English-language articles published from December 1980 to August 1998 using the key words troponin, echocardiography, myocardial infarction, and emergency. These key words were crossed referenced to determine publications in this area. Pertinent trials and reviews were selected from the database. There were six articles evaluating biochemical markers of ischemia and echocardiography to assess patients presenting with acute coronary syndromes in the emergency department. Very few studies combined the information obtained from novel ischemic markers and echocardiogram analysis to help delineate potential cardiac etiologies of acute coronary syndromes. However, the limited studies available indicate that echocardiography is both sensitive and specific for detecting acute myocardial infarction. The presence of regional wall motion abnormalities increases the chance of in-hospital complications and likelihood of developing congestive heart failure after admission for unstable angina. The combined use of troponin T levels and echocardiographic imaging was a more powerful predictor of adverse events than were isolated results. Myocardial scarring with ventricular wall thinning or aneurysm may allow for rapid diagnosis of 'occult' coronary artery disease in a patient presenting with chest pain who does not have a previous history of a cardiovascular event. Echocardiography may also help identify other cardiovascular causes of chest pain, such as aortic dissection, aortic stenosis, cardiac tamponade, pericarditis, and hypertrophic cardiomyopathy. The clinical use of combining ischemic markers of disease with echocardiographic imaging seems justified given their unique clinical advantages. Future clinical trials are needed to determine whether the combination of novel ischemic markers and echocardiography can provide for a more expedient and accurate diagnosis, resulting in improved patient care and a safe reduction in unnecessary hospitalization.
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PMID:Clinical Use of Ischemic Markers and Echocardiography in the Emergency Department. 1117 40

We describe two patients who underwent coronary artery bypass grafting complicated by postoperative hypoxemia due to a patent foramen ovale with right-to-left shunting. We discuss different hypotheses to explain the shunt: decreased right ventricular compliance, right atrial geometric changes due to septal distension or ischemia, exceeding filling pressure and localised haemorragic pericardial tamponade and low atrial pressure when correcting aortic stenosis. We emphasize the close interplay of pericardectomy and the four cardiac chambers including the distortion of the heart axis. The contrast echo produced by microbubbles of air is the safest and the most accurate procedure to detect the shunt. The two patients progressed positively with an extracorporeal circulation of short duration and without complications linked to the intervention. We conclude that postoperative unexplained hypoxemia must always exclude diagnosis of right-to-left shunting due to a patent foramen ovale (PFO).
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PMID:Patent foramen ovale: a cause of significant post-coronary artery bypass grafting morbidity. 1245 97

Aortic stenosis in the elderly is related to calcification of either a bicuspid valve or a morphologically normal tricuspid valve. There is increasing evidence that factors relating to atherosclerosis are involved in valvular calcification and that it is an actively regulated process rather than a degenerative one. With severe aortic stenosis left ventricular hypertrophy occurs, decreasing wall stress and supporting the left ventricular ejection fraction. However, with pathologic hypertrophy there is a dropout of myocardial cells, subendocardial ischemia, and fibrosis. Eventually, symptoms of angina, non-Q wave myocardial infarction, exertional syncope, and heart failure occur. Once symptoms begin, the prognosis is poor, with sudden death occurring in about one third of patients who die. In the elderly, symptoms can be recognized very late in the course of the disease since they can be attributed to other problems and since the elderly patient may have reduced physical activity to a minimum. The more comorbidities that exist, the greater the risk of valve replacement. Symptomatic patients with severe aortic stenosis even over age 80 can be operated upon with a relatively low mortality and morbidity. In patients over age 80, prolongation of life for any meaningful length of time is not as important as relief of symptoms and improvement in the quality of life. Thus, it is unlikely that any truly asymptomatic patient over age 80, even with severe aortic stenosis, should be sent to surgery.
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PMID:Pathophysiology of valvular aortic stenosis in the elderly. 1273 12

Williams syndrome is a complex syndrome comprising developmental abnormalities, craniofacial dysmorphic features, and cardiac anomalies. The most common cardiac anomaly is supravalvular aortic stenosis. We report a case of a 6-year-old girl with Williams syndrome who presented with decompensated heart failure due to ischemic cardiomyopathy. Her only significant cardiac anomaly was severe stenosis of the left main coronary artery. She subsequently died despite surgical revascularization. Isolated coronary anomalies are rare in Williams syndrome but should be considered especially in the presence of heart failure or ischemia.
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PMID:Severe coronary artery disease in the absence of supravalvular stenosis in a patient with Williams syndrome. 1554 15

Left ventricular (LV) hypertrophy and myocardial infarction play important roles in the progressive LV dysfunction. We hypothesized that the potassium-channel opener and nitrate-like vasodilator nicorandil prevents the development of LV hypertrophy and preserves myocardial viability. Twenty-four rats were subjected to aortic stenosis for 8 weeks to produce LV hypertrophy and assigned to non-treated and nicorandil-treated (3 mg/kg/d) groups. A third group (n = 12) without stenosis or treatment served as control. All 36 animals were subjected to reperfused infarction by 25-minute occlusion of the left coronary artery followed by 3 hours of reperfusion. Spin-echo magnetic resonance (MR) images were acquired to measure infarction size, LV mass, volumes, ejection fraction, and wall thickness. A necrosis-specific contrast agent, Gadophrin-3, was used to delineate necrotic myocardium. Aortic and LV pressures were measured invasively. At postmortem, LV mass and infarction size were determined and compared with MR findings. Nicorandil prevented the development of LV hypertrophy. Infarction size of nicorandil-treated animals was similar to control animals. Non-treated animals with aortic banding had higher LV mass (P < 0.001), lower ejection fraction (P = 0.006), and larger infarction size (P < 0.001) than treated and control animals. MR and postmortem data showed close agreement. Nicorandil therapy prevented the development of cardiac hypertrophy and protected myocardium against ischemia.
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PMID:Long-term oral treatment with nicorandil prevents the progression of left ventricular hypertrophy and preserves viability. 1577 22

A 39-year-old hypertensive man with severe aortic stenosis underwent aortic valve replacement monitored by intraoperative transesophageal echocardiography. Upon weaning the patient off extracorporeal circulation, hemodynamics became severely compromised, with hypotension, tachycardia, and elevated precordial electrocardiographic tracings. The echocardiographic images were instrumental during the episode to demonstrate that the anterior wall presented hypokinesis consistent with ischemia in the region but that there were also images of hyperrefringence highly suggestive of intracoronary air embolism. Intraoperative transesophageal echocardiography allowed us to diagnose the real cause of the ischemic event and rule out an atheromatous plaque as the source. Perfusion pressure was increased to treat the air embolism. The echocardiographic image demonstrated success, specifically restoration of left ventricular regional contractility. This experience revealed the usefulness of transesophageal echocardiography in intraoperative monitoring to diagnose ischemia, assess the cause, and guide treatment.
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PMID:[Intracoronary air embolism detected during intraoperative transesophageal echocardiography]. 1603 78


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