介入及手术联合治疗伴有体肺侧枝的法鲁氏四联症和肺动脉闭锁

目的评价介入栓堵侧枝合并手术矫治伴有体肺侧枝的重症法鲁氏四联症和肺动脉闭锁的临床结果,总结临床应用经验。方法回顾1992年至2006年我院介入加外科手术治疗25例伴有体肺侧枝的重症发鲁氏四联症和肺动脉闭锁,其中法四12例,肺动脉闭锁13例,年龄6月～17岁,体重7～55公斤,男性16例,女性9例,造影发现体肺侧枝共65支,平均2.6/例。外科根治手术23例,2例肺动脉闭锁行姑息手术,术前栓堵20例,术后栓堵5例,共栓堵侧枝53支,完全栓堵率86.8%。结果全组病例死亡6例,总死亡率24%,肺动脉闭锁根治术11例,死亡4例,死亡率36.4%,肺动脉闭锁姑息手术2例,死亡1例,法四根治术12例,死亡1例,死亡率8.3%。介入栓堵后根治术共18例,死亡3例,均为肺动脉闭锁,死亡率13%,根治术后介入栓堵5例,死亡2例,死亡率40%,其中法四4例死亡1例,肺动脉闭锁1例死亡1例。死亡原因为充血性心衰1例,低心排1例,肺出血1例,广泛肺渗出1例,肺缺血坏死1例,下腔静脉梗阻致多器官功能衰竭1例。结论介入栓堵体肺侧枝与外科手术联合治疗伴有体肺侧枝的重症法鲁氏四联症和肺动脉闭锁安全有效,可以减轻手术难度,减少术中出血,缩短手术时间,提高手术矫治成功率,减少手术创伤。术前栓堵侧枝对于手术成功尤为重要,术前明确体肺侧枝与固有肺动脉交通情况,对于单独供血的大体肺侧枝不宜拴堵,应于术中进行融合重建。与国外同期治疗结果比较我们的总死亡率较高。     

Stenting of a stenosed major aortopulmonary collateral artery in a baby with pulmonary atresia and a ventricular septal defect: Rescue from critical hypoxia in the immediate postoperative stage of unifocalization supported by extracorporeal membrane oxygenation

A 4‐month baby with pulmonary atresia, ventricular septal defect, major aortopulmonary collateral arteries (MAPCAs) and an extremely hypoplastic central pulmonary artery developed critical hypoxia following right unifocalization combined with a right Blalock‐Taussig shunt. To increase pulmonary blood flow we stented the left lower MAPCA during extracorporeal membrane oxygenation (ECMO) support. He was successfully weaned from ECMO 2 days after stenting. Percutaneous intervention for a stenosed MAPCA is an effective means of increasing pulmonary blood flow in critically hypoxic patients following unilateral unifocalization, even in the immediate postoperative stage. © 2008 Wiley‐Liss, Inc.     

肺血减少型复杂先天性心脏病合并的主要体肺动脉侧枝分布规律的临床研究

目的总结合并主要体肺动脉侧枝（MAPCAs）形成的复杂先天性心脏病（CHD）侧枝的分布规律。方法回顾分析1992年至2008年8月中国医学科学院阜外心血管病医院收治的65例合并MAPCAs形成的肺血减少型复杂CHD,总结复杂CHD的MAPCAs分布规律。年龄0．1～30岁（中位年龄1．9岁）,体重4～57．5kg（平均14．9±11．9kg）,其中法洛四联症40例,肺动脉闭锁20例,大动脉转位4例,右心室双出口1例。结果全组共发现体肺侧枝共160支,平均2．5支／例。全组共发现由胸主动脉上段发出62支（38．8％）侧枝血管,胸主动脉中段发出28支（17．5％）,腹主动脉发出11支（6．9％）,左胸廓内动脉发出10支（6．3％）,右胸廓内动脉发出10支（6．3％）,右锁骨下动脉发出7支（4．4％）,主动脉弓部发出7支（4．4％）,胸主动脉下段发出6支（3．8％）,头臂干根部发出5支（3．1％）,支气管动脉发出5支（3．1％）,左锁骨下动脉发出4支（2．5％）,膈下动脉发出4支（1．3％）,右肾动脉发出1支（0．6％）。供应左肺的侧枝为59支（36．9％）,供应右肺的侧枝为89支（55．6％）,同时供应两肺的侧枝为12支（7．5％）。全组有24支（15％）体肺侧枝开口出现不同程度的狭窄;43支侧枝在进入肺脏前呈现扭曲;13支为相应肺叶或肺段的单一供血血管。4例由较细且紊乱的体肺侧枝形成血管丛。结论肺血减少型复杂CHD合并的MAPCAs主要发自于降主动脉及其分支,以胸主动脉中上段最为多见,发自于升主动脉少见;部分侧枝开口可有不同程度的狭窄,给介入封堵带来一定的困难,单一血供侧枝应给予足够重视。     

Safety and efficacy of drug‐eluting stent for ST‐segment elevation myocardial infarction in an unselected consecutive cohort

Objective: The objective of this study is to investigate the clinical outcome of a large cohort of patients with ST‐segment elevation myocardial infarction (STEMI) treated with drug‐eluting stents (DES) compared to bare metal stents (BMS). Background: Several randomized controlled trials have demonstrated that PCI with the routine use of DES is safe and effective in patients with STEMI. However as randomized trials have strict inclusion criteria, further studies in unselected patient populations are needed. Methods: We performed a retrospective cohort analysis of the Mayo Clinic PCI database. A total of 552 consecutive STEMI patients who underwent a DES implantation between May 2003 and April 2006 were included in the study and compared to 557 who had BMS for STEMI earlier. No specific patient subsets were excluded. Results: Procedural success was achieved in 532 patients (96%). During initial hospitalization, 16 patients (2.9%) died and 8 (1.5%) suffered from a recurrent myocardial infarction. The median follow‐up was 23 months (IQR: 13–27 months). At 12 months post discharge, the rate of target lesion revascularization and death were 2.9% and 3.7%, respectively, and survival free of major adverse cardiac events (MACE) was 90.9%. These rates were similar to or lower than those of patients treated for STEMI with BMS prior to the availability of DES. Conclusion: DES are safe and effective in the treatment of STEMI in an unselected cohort; 90.9% of patients are free of MACE at 12 months post discharge. © 2008 Wiley‐Liss, Inc.     

Prognostic Value of Continuous ST‐Segment Monitoring in Patients with Non‐ST‐Segment Elevation Acute Coronary Syndromes

Background: Patients with non‐ST‐segment elevation acute coronary syndromes constitute a heterogeneous group concerning prognosis. The 12‐lead ECG at rest is recommended for early risk stratification but is unable to reflect the dynamic nature of myocardial ischemia and coronary thrombosis. This study investigated whether continuous ST‐segment monitoring provides early prognostic information in such patients. Methods: We prospectively studied 183 patients admitted due to chest pain at rest suggestive of an acute coronary syndrome. ST‐segment monitoring was performed continuously for 24 hours from admission. Cardiac‐specific troponin I levels were determined on admission and every 6 hours for the first 24 hours. The endpoint was defined as death or nonfatal myocardial infarction, whichever occurred first by 30 days follow‐up. Results: ST episodes, defined as transient ST deviations of at least 0.1 mV, were detected in 50 patients 27.3%) and associated with worse 30‐day outcome: 22.0% endpoint rate compared to 6.8% for patients without ST episodes (P = 0.003). In a multivariate analysis, the presence of ST episodes hazard ratio, 3.07; 95% Cl, 1.26 to 7.46; P = 0.014) and peak troponin I levels > 0.2 μg/L (hazard ratio, 2.65; 95% Cl, 1.01 to 6.95; P = 0.048) were independent predictors of prognosis. The combination of ST‐segment monitoring and peak troponin I identified patients at low (2.5%, n = 79), intermediate (14.5%, n = 76), and high (25.0%, n = 28) risk for the 30‐day endpoint. Conclusions: In patients with non‐ST‐segment elevation acute coronary syndromes, continuous ST‐segment monitoring provides on‐line early prognostic information, in addition to troponin I levels. A.N.E. 2002;7(1):29–39     

Selective drug‐eluting stent implantation for high‐risk patients with acute ST‐elevation myocardial infarction: Rationale and safety

Background : A selective policy of drug‐eluting stent (DES) implantation in ST‐elevation myocardial infarction (STEMI) patients at high risk of restenosis may maximize the benefit from restenosis reduction and minimize risk from late stent thrombosis (LaST). Objectives : We sought to prospectively determine the safety of selective DES implantation for long lesions (>20 mm), small vessels (<2.5 mm) and diabetic patients in patients with STEMI using a prospective single‐center registry. Methods : A total of 252 patients who underwent primary PCI between January 2005 and December 2006 were included: 126 consecutive patients receiving DES were compared with 126 age‐, sex‐, and vessel‐matched controls with STEMI who received bare‐metal stents. Composite major adverse cardiovascular events (MACE) (death, AMI, and target vessel revascularization) were used as the primary outcome measure. Results : Baseline clinical and angiographic characteristics and outcomes were similar between groups except for the prespecified diabetes, lesion length, and maximum stent diameter. Long‐term outcomes at a median follow up of 34 ± 6 months showed significant reductions in reinfarction (2% vs. 11%, P = 0.03), target vessel revascularization (TVR) (10% vs. 24%, P = 0.02), and composite MACE (18% vs. 31%, P = 0.03) with DES, with no excess of death (9% vs. 7%, P = NS) or LaST (2% vs. 1%, P = NS). In a Cox multivariate model, clopidogrel cessation at long‐term follow‐up was the most powerful predictor of hierarchical MACE (HR: 5.165; 95%CI: 2.019–13.150, P = 0.001). Conclusions : Selective DES implantation in patients with high‐risk STEMI appears safe, and exposes fewer patients to the risk of LaST. A randomized comparison of selective versus routine DES use in patients with STEMI should be considered. © 2010 Wiley‐Liss, Inc.     

Clinical impact of complete atrioventricular block in patients with ST‐segment elevation myocardial infarction

Complete atrioventricular block (CAVB) is a common complication of ST‐segment elevation myocardial infarction (STEMI). Although STEMI patients complicated with CAVB had a higher mortality in the thrombolytic era, little is known about the impact of CAVB on STEMI patients who underwent primary percutaneous coronary intervention (PCI). The study aimed at evaluating the clinical impact of CAVB on STEMI patients in the primary PCI era. We consecutively enrolled 1295 STEMI patients undergoing primary PCI within 24 hours from onset. Patients were divided into two groups according to the infarct location: anterior STEMI (n = 640) and nonanterior STEMI (n = 655). The outcomes were all‐cause death and major adverse cardiocerebrovascular events (MACCE) with a median follow‐up period of 3.8 (1.7–6.6) years. Eighty‐one patients (6.3%) developed CAVB. The incidence of CAVB was lower in anterior STEMI patients than in nonanterior STEMI (1.7% vs 10.7%, p < .05). Anterior STEMI patients with CAVB had a higher incidence of all‐cause deaths (82% vs 20%, p < .05) and MACCE (82% vs 25%, p < .05) than those without CAVB. Although higher incidence of all‐cause deaths was found more in nonanterior STEMI patients with CAVB compared with those without CAVB (30% vs 18%, p < .05), there was no significant difference in the incidence of MACCE (24% vs 19%). Multivariate analysis showed that CAVB was an independent predictor for all‐cause mortality and MACCE in anterior STEMI patients, but not in nonanterior STEMI. CAVB is rare in anterior STEMI patients, but remains a poor prognostic complication even in the primary PCI era.     

Comparison of procedural times,success rates,and safety between left versus right radial arterial access in primary percutaneous coronary intervention for acute ST‐segment elevation myocardial infarction

Objective: To evaluate if there are differences in procedural times, success rates, and safety between left and right radial approach (LRA and RRA, respectively) in primary percutaneous coronary intervention (PCI) for ST‐elevation myocardial infarction (STEMI). Background: Given conflicting reports of different procedural success with LRA vs. RRA, it is unclear if the side of radial access impacts in‐room procedural times and success rates in primary PCI. At our institution the LRA has been commonly used in certain STEMI patients. Our clinical database was reviewed to see if routine use of the LRA could generate favorable technical success and reperfusion times as compared to the RRA. Methods: We retrospectively analyzed 135 consecutive STEMI patients treated with primary PCI performed via the left and right radial approach at our institution. Results: There were 50 cases in the LRA group and 85 in the RRA group. There was no difference in median procedural times including total procedure time (LRA 53.5 mins vs. RRA 52 mins, P = 0.95), room‐to‐cannulation (LRA 12 min vs. RRA 13 min, P = 0.40) or room‐to‐balloon times (LRA 30 min vs. RRA 31 min, P = 0.74). There were no significant differences in procedural success rates (LRA 100% vs. RRA 97.6%, P = 0.27), or procedure‐related complications or death between the two groups. Conclusions: Left and right trans‐radial approach for primary PCI have similar in room procedural times, success rates, and comparable safety. Trans‐radial PCI through either arm is a feasible and safe approach in patients with STEMI. © 2010 Wiley‐Liss, Inc.     

Transcatheter closure of patent ductus arteriosus with Nit-Occlud coils.

The detachable coils have been successfully used for transcatheter occlusion of small- to moderate-sized patent ductus arteriosus (PDA). We report our experience regarding the use of the Nit-Occlud coils (NOCs) for transcatheter PDA and major aortopulmonary collateral (MAPCA) occlusion. Single NOCs were used to close PDA in 26 patients, and one small and two large MAPCAs in two patients. Mean age and weight of the patients were 7.7 +/- 5.4 years and 20.6 +/- 11.6 kg. Mean minimum duct diameter was 2.8 +/- 0.8 mm; ampulla, 8.7 +/- 2.4 mm; and PDA length, 9.3 +/- 4.4 mm. Mean pulmonary artery pressure ranged from 9 to 51 mm Hg and pulmonary/systemic flow ratio from 1.1 to 5.8. Ductal shape was conical in 24 patients. Route of approach was venous in 23 and arterial in 3. Successful coil implantation was achieved in 24/26 (92.3%). Mean procedure and fluoroscopy time were 67.2 +/- 22.1 and 14.9 +/- 6.5 min. The three MAPCAs were also successfully occluded using NOC Medium and Flex. Postimplantation angiograms revealed no leak in 3, a trace or small leak in 17, and a medium leak in 4 patients. Mean follow-up was 7 +/- 5 months. Complete occlusion was achieved in 17/24 (71%) at 24 hr, 19/24 (79%) by 1 month, 13/15 (87%) by 3 months, 14/15 (93%) by 6 months, and 10/11 (90%) by 12 months postprocedure. Hemolysis, late embolization, duct recanalization, and flow disturbances were not observed. Transcatheter occlusion of moderate-sized PDAs and MAPCAs using NOCs seems to offer a safe, simple, and controlled method in pediatric patients.     

Quality improvement in the door‐to‐balloon times for ST‐elevation myocardial infarction patients presenting without chest pain

Objective: To assess a quality improvement initiative aimed at minimizing door‐to‐balloon (DTB) times for ST‐elevation myocardial infarction (STEMI) patients presenting without chest pain. Background: Timely percutaneous coronary intervention (PCI) is the cornerstone of STEMI care. The absence of chest pain delays PCI. Improvements in DTB times may need to focus on atypical presentation patients. Methods: We compared DTB times on all STEMI patients admitted through the emergency department who underwent PCI before (Phase I; October 2004–June 2007) and after (Phase II; July 2007–October 2009) the quality improvement effort, which mandated rapid electrocardiogram (ECG) triage for an expanded list of presenting symptoms. Results: In Phase I (69 patient, 60 with chest pain), patients with chest pain had a shorter mean time to first ECG (ECG Interval) by 32.0 min (P < 0.01) and nonsignificantly faster mean DTB time by 42.0 min (P = 0.07) compared to patients who presented without chest pain. In Phase II (62 patients, 56 with chest pain) compared to Phase I, mean ECG interval decreased by 44 min (P = 0.02) and mean DTB time by 99 min (P = 0.01) in patients without chest pain, eliminating the differences in ECG intervals between typical and atypical presentations (12 min vs. 11 min, P = 0.91). Multivariable analysis controlling for on/off hours and patient characteristics confirmed these findings. Conclusions: A simple modification of emergency room ECG triage protocol, which expands indications for rapid ECG performance, was successful in improving rapid reperfusion for patients with STEMI presenting without chest pain. © 2011 Wiley‐Liss, Inc.     

Early versus delayed percutaneous coronary intervention for patients with non‐ST segment elevation acute coronary syndrome: A meta‐analysis of randomized controlled clinical trials

Background: Studies assessing the timing of percutaneous coronary interventions (PCI) in patients with Non‐ST segment elevation Acute Coronary Syndromes (NSTE‐ACS) have failed to generate a consensus on how early PCI should be performed in such patients. Purpose: This meta‐analysis compares clinical outcomes at 30 days in NSTE‐ACS patients undergoing PCI within 24 hours of presentation (early PCI) with those receiving PCI more than 24 hours after presentation (delayed PCI). Data Sources: Data were extracted from searches of MEDLINE (1990‐2010) and Google scholar and from scrutiny of abstract booklets from major cardiology meetings (1990‐2010). Study selection: Randomized clinical trials (RCTs) that included the composite endpoint of death and non‐fatal myocardial infarction (MI) at 30 days after PCI were considered. Data Extraction: Two independent reviewers extracted data using standard forms. The effects of early and delayed PCI were analyzed by calculating pooled estimates for death, non‐fatal MI, bleeding, repeat revascularization and the composite endpoint of death or non‐fatal MI at 30 days. Univariate analysis of each of these variables was used to create odds ratios. Data Synthesis: Seven studies with a total of 13,762 patients met the inclusion criteria. There was no significant difference in the odds of the composite endpoint of death or non‐fatal MI at 30 days between patients undergoing early PCI and those receiving delayed PCI (OR‐0.83, 95%CI 0.62‐1.10). Patients receiving delayed PCI experienced a 33% reduction in the odds of repeat revascularization at 30 days compared to those undergoing early PCI (OR‐1.33, 95%CI 1.14‐1.56, P=0.0004).Conversely, patients undergoing early PCI experienced lower odds of bleeding than those receiving delayed PCI (OR‐0.76, 95%CI 0.63‐0.91, P = 0.0003). Conclusions: In NSTE‐ACS patients early PCI doesn't reduce the odds of the composite endpoint of death or non‐fatal MI at 30 day. This strategy is associated with lower odds of bleeding and higher odds of repeat revascularization at 30 days than a strategy of delayed PCI. © 2012 Wiley Periodicals, Inc.     

Prospective randomized comparison of sirolimus‐ versus paclitaxel‐eluting stents for the treatment of acute ST‐elevation myocardial infarction

Objective: The aim of this study was to compare effectiveness of the Sirolimus‐ (SES) and Paclitaxel‐eluting stent (PES) in primary angioplasty for acute ST‐elevation myocardial infarction (STEMI). Background: It has been reported that SES and PES have been more effective than bare‐metal stents in reducing restenosis and cardiac events in a broad range of patients with coronary artery disease. However, it is unknown whether there may be differences between these two drug‐eluting stents in terms of efficacy in the setting of acute STEMI. Methods: Acute STEMI patients (n = 308) undergoing primary angioplasty were randomly assigned to SES (n = 154) or PES (n = 154) deployment. The routine angiographic follow‐up was performed at 6 months and clinical follow‐up data was obtained at 12 months. The primary end point was major adverse cardiac events (MACE) including death, reinfarction, stent thrombosis, and target lesion revascularization (TLR) at 12 months. Results: The baseline clinical, angiographic, and procedural characteristics were similar between the 2 groups. Two patients (all from the PES group) experienced stent thrombosis (1 acute and 1 subacute). The SES group revealed lower in‐segment restenosis (5.9% vs. 14.8%, P = 0.03) and in‐segment late loss (0.09 ± 0.45 vs. 0.33 ± 0.68 mm, P = 0.002) than PES group on follow‐up angiography. Twelve‐month TLR rates (2.6% vs. 6.5%, P = 0.17) were similar between two groups. MACE rates were lower in the SES group than in the PES group, but it did not reach statistical significance (5.8% vs. 11.7%, P = 0.07). Conclusion: In the setting of primary angioplasty for STEMI, there were no statistically significant differences between the SES and the PES in terms of 12‐month MACE. However, binary angiographic in‐segment restenosis and in‐segment late loss were significantly lower in the SES group. © 2008 Wiley‐Liss, Inc.     

Successful endoscopic hemoclipping of an esophageal perforation

We describe a case of esophageal perforation that resulted from a fishbone. A 71-year-old man had had a fishbone impacted in the lower esophagus for 2 days. At presentation, the bone was dislodged at endoscopy; one round opening in a deep ulceration was detected when the fishbone was removed. The perforation was closed by endoscopic hemoclipping, after the removal of the fishbone. A thoracic computed tomography revealed air around the esophagus, aorta and bronchus and the presence of a pleural effusion. These findings suggested mediastinal emphysema and mediastinitis due to the esophageal perforation after the removal of the fishbone. Esophagography revealed a focal esophageal defect and linear contrast leakage at the distal esophagus. The mediastinal emphysema and pleural effusion successfully resolved after the endoscopic hemoclip application and conservative management of the perforation.     

A Systematic Review of Transesophageal Echocardiography‐Induced Esophageal Perforation

A systematic review of transesophageal echocardiography (TEE)‐induced esophageal perforation was done using the MEDLINE (PubMed and OVID interfaces), Google Scholar and EMBASE databases. Thirty‐five cases of esophageal perforation from 22 studies were analyzed. TEE‐induced esophageal perforation occurs in elderly female patients, predominantly in an intra‐operative setting. Thoracic esophagus is the most commonly involved segment, especially, when TEE is performed intra‐operatively. Majority of the esophageal perforations occur in cases with a perceived low risk or smooth TEE exam and thus, screening for high risk factors may not eliminate the occurrence of a perforation. A delayed detection of perforation occurs when it is a thoracic esophageal perforation, performed intra‐operatively and when there are no known preoperative risk factors. Shock during the detection of the perforation is associated with mortality. Majority of the perforations can be repaired primarily.     

Simvastatin effects on portal‐systemic collaterals of portal hypertensive rats

Background and Aim: Portal‐systemic collateral vascular resistance and vasoconstrictor responsiveness are crucial in portal hypertension and variceal bleeding control. Statins enhance vasodilators production, but their influence on collaterals is unknown. This study aimed to survey the effect of simvastatin on collaterals. Methods: Partially portal vein‐ligated rats received oral simvastatin (20 mg/kg/day) or distilled water from ?2 to +7 day of ligation. After hemodynamic measurements on the eighth postoperative day, baseline perfusion pressure (i.e. an index of collateral vascular resistance) and arginine vasopressin (AVP, 0.1 nM–0.1 µM) responsiveness were evaluated with an in situ perfusion model for collateral vascular beds. RT‐PCR of endothelial NO synthase (eNOS), inducible NOS (iNOS), cyclooxygenase‐1 (COX‐1), COX‐2, thromboxane A₂ synthase (TXA₂‐S) and prostacyclin synthase genes was performed in parallel groups for splenorenal shunt (SRS), the most prominent intra‐abdominal collateral vessel. To determine the acute effects of simvastatin, collateral AVP response was assessed with vehicle or simvastatin. SRS RT‐PCR of eNOS, iNOS, COX‐1, COX‐2 and TXA₂‐S, and measurements of perfusate nitrite/nitrate, 6‐keto‐PGF1_α and TXB₂ levels were performed in parallel groups without AVP. Results: Acute simvastatin administration enhanced SRS eNOS expression and elevated perfusate nitrite/nitrate and 6‐keto‐PGF1_α concentrations. Chronic simvastatin treatment reduced baseline collateral vascular resistance and portal pressure and enhanced SRS eNOS, COX‐2 and TXA₂‐S mRNA expression. Neither acute nor chronic simvastatin administration influenced collateral AVP responsiveness. Conclusion: Simvastatin reduces portal‐systemic collateral vascular resistance and portal pressure in portal hypertensive rats. This may be related to the enhanced portal‐systemic collateral vascular NO and prostacyclin activities.     

Spontaneous circumferential intramural esophageal dissection complicated with esophageal perforation and esophageal‐pleural fistula: a case report and literature review

Spontaneous intramural esophageal dissection (IED) is a rare disease entity. There are few reports of spontaneous IED requiring surgical treatment. Hereby, we report a 37‐year‐old gentleman who was diagnosed to have spontaneous extensive circumferential IED complicated with esophageal perforation, empyema, and esophageal‐pleural fistula. Esophageal stenting and drainage of empyema were unsuccessful. Computed tomography and gastrografin contrast swallow demonstrated a leak to the pleural cavity, suggestive of esophageal‐pleural fistula. Subsequently, a two‐stage operation was performed: cervical esophagogastrostomy to bypass the perforated esophagus, followed by esophagectomy and decortication of the right lung. The patient recovered and was discharged home after a 3‐week hospitalization. The management principles and recent published literature related to IED were reviewed.     

Use of multislice CT for the evaluation of emergency room patients with chest pain: The so‐called “Triple rule‐out”

Recent advances in computed tomography (CT) technology have made high resolution noninvasive coronary angiograms possible. Multiple studies involving over 2,000 patients have established that coronary CT angiography (CCTA) is highly accurate for delineation of the presence and severity of coronary atherosclerosis. The high negative predictive value (>95%) found in these studies suggests that CCTA is an attractive option for exclusion of coronary artery disease in properly selected emergency department patients with acute chest pain. CT is also a well established and accurate tool for the diagnosis of acute aortic dissection and pulmonary embolism. Recent technical developments now permit acquisition of well‐opacified images of the coronary arteries, thoracic aorta and pulmonary arteries from a single CT scan. While this so called “triple‐rule out” scan protocol can potentially exclude fatal causes of chest pain in all three vascular beds, the attendant higher radiation dose of this method precludes its routine use except when there is sufficient support for the diagnosis of either aortic dissection or pulmonary embolism. This article provides an overview of CCTA, and reviews the clinical evidence supporting the use of this technique for triage of patients with acute chest pain. © 2008 Wiley‐Liss, Inc.