Giant coronary aneurysm with ventricular fistula is rare. Due to the limited data from randomised clinical trials, therapeutic strategies for coronary aneurysms predominantly rely on on case series and anecdotal evidences. Reporting cases that provide practical experience in managing these aneurysms is therefore crucial. In this article, we report a rare case of a successful surgical management for a thrombosed giant left coronary aneurysm with right ventricular fistula, which is larger than any previously reported cases.

Coronary artery fistulas are rare, but one of the most common forms of congenital coronary abnormalities. These patients are often diagnosed incidentally undergoing coronary angiography, but with the advent of novel cardiac imaging tools, there is an increasing rate of detection as well as transcatheter management of these fistulas. Our case is unusual in a way that it involved a combination of two separate coronary artery fistulas arising from both the coronary systems draining into the same site.

Intercoronary communications are a very rare congenital coronary artery anomalies. We report a case of a man who underwent elective coronary angiography that showed a bidirectional direct intercoronary communication between right coronary and left circumflex arteries.

Lightning strike is an infrequent natural phenomenon with serious medical complications, like multiple organ damage, and it is associated with increased risk of mortality. Cardiovascular complications are among the most hazardous complications of lightning strike. Lightning strike can cause various serious consequences ranging from electrocardiographic changes to death. We reported a 21-year-old patient with no cardiovascular risk factors struck by lightning and presented by inferior ST elevated myocardial infarction (MI). The patient was followed up in the intensive care unit and MI complication did not develop during follow-up. The patient was lost due to multi-organ failure after 20 hours.

AydinF, Turgay YildirimO, DagtekinE, Huseyinoglu AydinA, AksitE. Acute Inferior Myocardial Infarction Caused by Lightning Strike. Prehosp Disaster Med. 2018;33(6):658–659.

Background: Coronary artery lesions in Kawasaki disease invasively assessed by coronary angiography. Evaluation of myocardial perfusion by single-photon emission computed tomography may identify the haemodynamic significance of coronary lesions. Objective: To evaluate diagnostic accuracy of dipyridamole stress technetium-99 m tetrofosmin, single-photon emission computed tomography as a possible alternative to invasive coronary angiography for detection and follow-up of myocardial ischaemia in patients with Kawasaki disease, and pre- and post-coronary bypass grafting. Patients and methods: Coronary angiography and single-photon emission computed tomography were performed on 21 patients who were classified into three groups – group I (stenosis), group II (giant aneurysms), and group III (small aneurysms). Of the 21 patients, 16 (groups I and II) patients with myocardial perfusion defects, who underwent coronary bypass grafting, were followed up with single-photon emission computed tomography. Result: In group I, all patients had significant coronary stenosis and 100% of them had perfusion defects in the anterior and septal walls. In group II, all patients had giant aneurysms and 83% of them had inferior and inferolateral perfusion defects. In group III, all patients had small aneurysms and 100% of them had normal perfusion. Pre-coronary bypass grafting myocardial ischaemic defects disappeared in all patients after surgery. Sensitivity, specificity, and accuracy of single-photon emission computed tomography were 94, 100, and 95%, respectively. Conclusion: Technetium-99 m tetrofosmin single-photon emission computed tomography can be applied as an accurate non-invasive diagnostic technique for detecting myocardial perfusion defects with coronary artery lesions, and to show improved or even normalised perfusion of the myocardium in patients after surgical revascularisation.

Objectives: Information on the impact of computed tomography coronary angiography (CTCA) on patterns of care is scarce. In particular, it is not clear if, and to what extent, its adoption actually leads to a reduction in the use of other diagnostics tools. The aim of this study was to evaluate whether the adoption of CTCA in Emilia-Romagna (an Italian region with a population of 4.4 million) had any effect on utilization rates of myocardial perfusion scintigraphy (MPS) and coronary angiography (CA).

Methods: Interrupted time series (ITS) were applied to monthly volumes of MPS and CA tests performed from 2003 to 2010, to assess trends in usage rates for those procedures before and after CTCA was adopted by all the healthcare organizations operating in the region.

Results: After an increase in the first year of CTCA introduction, its use remained stable over the study period. After September 2006, a significant decrease in MPS volumes (31 percent; p < .0001) and a much less tangible decrease in CA volumes (5 percent; p < .0001), were detected by ITS analyses.

Conclusions: This study demonstrates that the use of CTCA had a greater impact on MPS usage rates than on CA.

Objectives: Health technology assessment (HTA) programs influence practice on a broad scale through reimbursement decisions or national guidelines. Hospital-based HTA programs inform clinical decisions at the local level. Typically, they do this by adapting general HTA to their local setting, or by creating new HTA. However, unlike payer-based HTA organizations, hospital-based HTA organizations can also integrate local data into their reports.

Methods: We describe two examples of local data integrated into hospital-based HTA. In the first, qualitative data were used to select a new cardiac catheterization lab. In the second, quantitative data was used to inform a decision on whether to continue telemedicine services to critical care units. Local evidence sources included equipment service records, and interviews with physicians, technicians, and administrative staff in the first example, and the hospital's administrative and claims databases in the second example.

Results: In each case, there was little evidence from the peer-reviewed literature that could be applied to the decision. In the first example, staffing patterns and local preferences had considerable bearing on technology choices. In the second example, local outcomes data from administrative records were decisive.

Conclusions: Hospital-based HTA using local data can fill gaps in the published evidence, and also improve the generalizability of evidence to the local setting. To take advantage of local evidence, health systems should encourage the development of hospital-based HTA centers, seek out local preference data, and maintain databases of patient outcomes and utilization of services.

Objectives: The aim of this study was to analyze and describe process and outcomes of two pilot assessments based on the HTA Core Model, discuss the applicability of the model, and explore areas of development.

Methods: Data were gathered from HTA Core Model and pilot Core HTA documents, their validation feedback, questionnaires to investigators, meeting minutes, emails, and discussions in the coordinating team meetings in the Finnish Office for Health Technology Assessment (FINOHTA).

Results: The elementary structure of the HTA Core Model proved useful in preparing HTAs. Clear scoping and good coordination in timing and distribution of work would probably help improve applicability and avoid duplication of work.

Conclusions: The HTA Core Model can be developed into a platform that enables and encourages true HTA collaboration in terms of distribution of work and maximum utilization of a common pool of structured HTA information for national HTA reports.

Coronary angiograms were analyzed in 29 children after heart transplantation. Age at transplantation was one month to 14 years (mean 4.5 years) with follow-up from five months to six years (mean 2.9 years). Immunosuppression was based on cyclosporine and azathioprine; six patients also received maintenance steroids. Coronary angiograms were obtained after giving an intracoronary arterial bolus of nitroglycerin to avoid spasm. Coronary angiograms showed stenoses, luminal irregularities, loss of luminal diameter and obliteration of branches, and one example of myocardial bridging. The review of angiographic recordings in some patients showed a loss of normal motion of coronary arteries which, instead, appeared rigid. No abnormalities were seen in eight patients (28%). Coronary arterial changes were present between six months and four years after transplantation in 15 patients (52%). Isolated loss of normal motion of the coronary arteries was present in six patients (20%). The separate analysis of 15 patients who underwent more than one coronary angiogram showed a progression of lesions in eight cases. Coronary arterial disease is a frequent complication of heart transplantation in children and there is a progression of lesions in a large proportion of patients. Since there is no satisfactory therapy for this complication, heart transplantation should be reserved for children having no other reasonable therapeutic option.

A male patient with congenitally corrected transposition, with no associated cardiac malformations, was diagnosed in childhood and followed until his death at age 28. He underwent two cardiac gated single photon emission computed tomographies over a two year period, which demonstrated progression of ischaemia and reduction of systolic function. The findings suggest that, when the systemic ventricle is perfused by the morphologically right coronary artery, there may be inadequate perfusion to supply any subsequent extensive hypertrophy.

An eight-month-old girl with hypoplastic left heart syndrome, who underwent a modified Norwood operation at the age of two days, and a Hemifontan operation at five months of age, had severely impaired ventricular function and new electrocardiographic changes. Coronary angiography demonstrated a small adherent thrombus in the non-coronary sinus of Valsalva of the native aortic root, which may be the cause of unexplained ventricular dysfunction.

Aims: Coronary arterial abnormalities, congenital and acquired, may co-exist with structural congenital malformations of the heart. This study analyses information obtained from coronary angiography in grown-up patients with congenital cardiac disease undergoing cardiac catheterisation. Methods and Results: We studied 448 patients, of whom 181 (40%) had selective coronary angiography. This was undertaken as a routine measure in 165 (37%), and because of clinical indications in 16 (4%). Aortic root angiography was carried out in 107 (24%). Coronary arterial abnormalities were demonstrated in one-third of those undergoing selective angiography, and in 69% of those with a clinical indication for angiography, compared with 30% who had a routine procedure. In those patients undergoing aortography alone, abnormalities were recognized in 17%, while the angiographic images were inconclusive in 24%. In the remaining 59%, no abnormality was apparent, but only the proximal coronary arteries could be seen clearly. In total, congenital abnormalities of the coronary arteries were found in 11% of the patients, acquired lesions were demonstrated in 5%, and surgically acquired lesions in 2%. Conclusion: Routine coronary angiography during catheterization of grown-up patients with congenital heart disease revealed a high incidence of abnormalities of the coronary arteries. Selective injection into the arteries had a higher sensitivity than aortography. Consideration should be given to performing routine coronary arteriography during invasive investigation of patients with congenital cardiac disease, as it provides useful and often unexpected information, which may be valuable for the interpretation of symptoms and the planning of subsequent surgery.

Objectives: To examine determinants of use of cardiac procedures after acute myocardial infarction and identify variation factors.

Methods: Observational prospective cohort study of 2,519 patients in 48 centers with a two-level logistic-regression analysis.

Results: Elderly patients were less likely to undergo pre- and inhospital thrombolysis (odds ratios, 0.71 and 0.64; 95% CI, 0.62–0.81 and 0.58–0.69, respectively). The elderly, females, and patients with heart failure on admission were less likely to undergo noninvasive tests (0.74, 0.62, and 0.51; 95% CI, 0.67–0.81, 0.46–0.83, and 0.38–0.68, respectively) and coronary angiography (0.38, 0.53, and 0.67; 95% CI, 0.34–0.42, 0.38–0.74, and 0.52–0.86, respectively) but not revascularization. Hospital factors were more difficult to interpret.

Conclusions: Elderly, women, and heart failure patients underwent fewer cardiac procedures than lower-risk patients. Physicians should change their attitude toward these groups and use advanced procedures, bearing in mind the patients' needs rather than good procedural outcomes.

Objective: To describe the diffusion of cardiac catheterization technologies and time trends of their use according to setting and geographic region in Germany during a 13-year period. It is hypothesized that the cardiac catheterization technology has matured from an experimental state to a broadly accepted technology.

Methods: Data come from the annual survey of the German Society for Cardiovascular Research. All German cardiac catheterization units are requested to provide data on volume and type of catheterization procedures. Data are available from 1984 to 1996. Number and type of procedure, type of unit, diagnoses, and complications are all recorded. The overall response rate is 90%, on average.

Results: The total number of catheterization units was 324 in 1996, or an average of 3.69 units per 1 million population. In 1996, all of the East German Länder and districts were below average. Utilization of cardiac catheterization procedures increased exponentially during the study period. The number of angiographies rose from about 45,000 in 1984 to more than 450,000 in 1996; the number of angioplasties increased almost by a factor of 50 to 125,000 procedures in 1996. Inverse correlations between the rates per million population of either coronary angiographies or PTCAs and mortality rates from ischemic heart disease were observed at the level of the German Länder.

Conclusion: Further studies taking patient characteristics, long-term outcomes, and other factors in account are necessary to clarify the large geographic variations and the negative relationship between utilization rates and coronary heart disease mortality found in this study.