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Clinical update. Computed Tomography — an Emerging Tool for Triple Rule-Out in the Emergency Department. A Review

Abstract

New imaging tools have been developed in recent years to rapidly and accurately diagnose life-threatening diseases associated with high mortality rates, such as acute coronary syndromes, acute aortic dissection, or pulmonary embolism. The concept of using computed tomographic (CT) assessment in emergency settings is based on the possibility of excluding multiple acute pathologies within one scan. It can be used for patients complaining of acute chest pain of unclear etiology with the possible association of acute coronary dissection or pulmonary embolism, but only a low to moderate risk of developing an acute coronary syndrome. One of the benefits of this protocol is the possibility of decreasing the number of patients who are hospitalized for further investigations. The technique also allows the rapid triage of patients and the safe discharge of those who show negative results. The aim of this review is to summarize the current medical literature regarding the potential use of CT for the triple rule-out (TRO) of coronary etiologies.

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Original research. The Assessment of Epicardial Adipose Tissue in Acute Coronary Syndrome Patients. A Systematic Review

for unstable angina/non-ST elevation MI: a method for prognostication and therapeutic decision making. JAMA. 2000;284:835-842. doi: 10.1001/jama.284.7.835. 66. de Lemos JA, Braunwald E. ST segment Resolution as a Tool for Assessing the Efficacy of Reperfusion Therapy. J Am Coll Cardiol. 2001;38:1283-1294. doi: 10.1016/S0735-1097(01)01550-9. 67. Opincariu D, Chitu M, Rat N, Benedek I. Integrated ST Segment Elevation Scores and In-hospital Mortality in STEMI Patients Undergoing Primary PCI. Journal of Cardiovascular Emergencies. 2016

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Bilateral Coronary Ostial Stenosis after Bentall Procedure in a Patient with Marfan Syndrome

Abstract

Introduction: The majority of patients with Marfan syndrome undergo Bentall procedure. Several periprocedural complications may arise; cardiac complications play the most dominant role.

Case presentation: A patient with Marfan syndrome developed symptoms two years after the Bentall procedure. Coronary CT angiography revealed bilateral coronary ostial stenosis. Percutaneous coronary intervention was performed, and two drug-eluting stents were implanted.

Conclusions: Coronary CT angiography is a valuable tool for the examination of symptomatic patients following surgical aortic root replacement.

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The Use of Biomarkers for the Early Detection of Vulnerable Atherosclerotic Plaques and Vulnerable Patients. A Review

Abstract

Acute coronary syndromes represent the most severe consequences of atherosclerosis, most often triggered by the rupture of a coronary plaque, which, for various reasons, has become unstable. In many cases, these rupture-prone vulnerable plaques are difficult to diagnose, because they do not always cause significant obstruction noticeable by coronary angiography. Therefore, new methods and tools for the identification of vulnerable plaques have been proposed, many of which are currently under study. Various biomarkers have been suggested as predictors of a vulnerable plaque, as well as indicators of an increased inflammatory status associated with higher patient susceptibility for plaque rupture. Integration of such biomarkers into multiple biomarker platforms has been suggested to identify superior diagnostic algorithms for the early detection of the high-risk condition associated with an unstable plaque. The aim of this review is to summarize recent research related to biomarkers used for the early detection of vulnerable plaques and vulnerable patients.

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Modern Technology for Prevention of Sudden Cardiac Death – a Clinical Update on Device Therapy in Children with Congenital Heart Diseases

Abstract

Sudden cardiac death in children is one of the most devastating conditions that can be encountered in acute cardiac care. Intracardiac device therapy, providing prompt and effective treatment in malignant ventricular arrhythmia or in severe conduction abnormalities, is a promising tool to reduce the incidence of this fatal condition. However, the implementation of device-based therapy in the pediatric population is currently limited by the lack of clinical studies on large number of subjects. As a result, indications for device therapy in pediatric patients are still unclear in many circumstances. There are also several particularities related to device implantation in pediatric age, such as the somatic growth leading to a mismatch between chamber size and lead length, or the difficulties of implantation technique in children with small body weight. This study aims to present an update on the current advantages and limitations of device-based therapy for treating severe malignant arrhythmia or conduction disorders in children at risk for sudden cardiac death.

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Role of Multidetector Computed Tomography in Transcatheter Aortic Valve Implantation – from Pre-procedural Planning to Detection of Post-procedural Complications

Abstract

Transcatheter aortic valve implantation (TAVI) is an effective treatment option for patients suffering from symptomatic, severe aortic valve stenosis. Previously, only patients with prohibitive or high surgical risk were TAVI candidates; however, current guidelines already recommend TAVI as a treatment alternative for patients with intermediate surgical risk. Multidetector computed tomography (MDCT) has gained great importance in the periprocedural assessment of patients who undergo TAVI. Due to the three-dimensional image visualization, MDCT allows the evaluation of anatomical structures in a more comprehensive manner compared to echocardiography, the traditional tool used in TAVI patient work-up. By providing accurate measurements of the aortic root, MDCT helps to avoid potential patient-prosthesis mismatch throughout transcatheter valve sizing. Moreover, MDCT is also a feasible tool for access route evaluation and to determine the optimal projection angles for the TAVI procedure. Although the routine MDCT follow-up of patients is currently not recommended in clinical practice, if performed, it could provide invaluable information about valve integrity and asymptomatic leaflet thrombosis. Post-procedural MDCT can provide details about the position of the prosthesis and complications such as leaflet-thrombosis, aortic regurgitation, coronary occlusion, and other vascular complications that can represent major cardiac emergencies. The aim of the current review is to overview the role of MDCT in the pre- and post-procedural assessment of TAVI patients. In the first part, the article presents the role of pre-TAVI imaging in the complex anatomical assessment of the aortic valve and the selection of the most appropriate device. The second part of the review describes the role of MDCT in patients who underwent TAVI to assess potential complications, some of them leading to a major cardiovascular emergency.

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Assessment of Coronary Plaque Vulnerability in Acute Coronary Syndromes using Optical Coherence Tomography and Intravascular Ultrasound. A Systematic Review

Abstract

The aim of this systematic review was to analyze studies characterizing vulnerable coronary plaques using optical coherence tomography (OCT) and intravascular ultrasound (IVUS), in order to identify the most efficient invasive technique permitting plaque characterization in patients with acute myocardial infarction.

Method: A total number of 432 studies were identified, 420 through database searching and 12 through manual searching. Eight duplicate studies were removed, leaving a total number of 424 studies to be screened. Twenty-six studies only available in Abstract-only form were excluded, resulting in 398 studies checked for eligibility. Eleven studies fulfilled the eligibility criteria and were included in this systematic analysis. Plaque vulnerability was investigated in plaques with thin cap fibroatheroma (TCFA) versus those with thick cap fibroatheroma, in ruptured coronary plaques versus non-ruptured coronary plaques, in culprit versus non-culprit lesions and in lipid-rich versus non-lipid-rich plaques.

Results: A total of 1,568 coronary plaques in 1,225 patients with acute coronary syndromes (ACS) who underwent both IVUS and OCT for analysis of plaque features were included in the final analysis. The review identified the following IVUS-derived features as significantly correlated with plaque vulnerability: plaque burden (p <0.001), remodeling index (p <0.001), external elastic membrane cross-sectional area (p <0.001), and the amount of necrotic core (p <0.001), while OCT-derived features characterizing unstable plaque were TCFA (p <0.001), lipid arch (p <0.001), accumulation of macrophages (p = 0.03), and presence of intracoronary thrombus (p <0.001).

Conclusion: Both IVUS and OCT are invasive imaging techniques able to provide relevant information on the vulnerability of coronary atheromatous plaques, identifying, as they do, various plaque features significantly associated with unstable plaques. Information provided by the two techniques is complementary, and both methods can serve as a useful clinical diagnostic tool, especially in cases of ACS patients undergoing a revascularization procedure.

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Pre-selection of primary intubation technique is associated with a low incidence of difficult intubation in patients with a BMI of 35 kg/m2 or higher

Abstract

Background: The incidence of difficult intubation (DI) in obese patients may reach a two-digit figure. No studies have assessed the effect of primary use of special intubation devices on lowering the incidence of DI. We assessed the effect of primary selection of special intubation techniques on the incidence of DI in patients with a BMI of 35 kg/m2 or higher. Patients and methods: Data from 546 patients with a BMI of 35 kg/m2 or higher who underwent bariatric surgery at Wolfson Medical Center from 2010 through 2014 was retrospectively extracted and analyzed for demographics, predictors of DI and intubation techniques employed. Difficult intubation was defined as the presence of at least one of the followings: laryngoscopy grade 3 or 4, need for >1 laryngoscopy or intubation attempt, need for changing the blade size, failed direct laryngoscopy (DL), difficult or failed videolaryngoscopy (VL-Glidescope), difficult or failed awake fiberoptic intubation (AFOI) and using VL or awake AFOI as rescue airway techniques. Primary intubation techniques were direct DL, VL and AFOI. We correlated the predictors of DI with the actual incidence of DI and with the choice of intubation technique employed. Results: The overall incidence of DI was 1.6% (1.5% with DL vs. 2.2 with VL + AFOI, p = 0.61). With logistic regression analysis, age was the only significant predictor of DI. Predictors of DI that affected the selection of VL or AFOI as primary intubation tools were Mallampati class 3 or 4, limited neck movement, age, male gender, body mass index and obstructive sleep apnea syndrome. Conclusion: The lower incidence of DI in our study group may stem from the primary use of special intubation devices, based on the presence of predictors of DI.

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Inflammation in Acute Cardiac Care

- Inducible Factor 1-Alpha Release After Intracoronary Versus Intramyocardial Stem Cell Therapy in Myocardial Infarction. J Cardiovasc Transl Res. 2010;3:114-121. doi: 10.1007/s12265-009-9154-1. 15. Lazar E, Benedek T, Korodi Sz, et al. Stem cell-derived exosomes - an emerging tool for myocardial regeneration. World J Stem Cells. 2018;10:106-115. doi: 10.4252/wjsc.v10.i8.106. 16. Tang J, Cui X, Caranasos TG, et al. Heart Repair Using Nanogel- Encapsulated Human Cardiac Stem Cells in Mice and Pigs with Myocardial Infarction. ACS Nano. 2017

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