Objectives The aim of this study was to evaluate the rate of timely reperfusion for ST-elevation myocardial infarction (STEMI) with primary percutaneous coronary intervention (PPCI) in regional STEMI Receiving Center (SRC) networks.Background The American College of Cardiology Door-to-Balloon (D2B) Alliance target is a >75% rate of D2B <= 90 min. Independent initiatives nationwide have organized regional SRC networks that coordinate universal access to 9-1-1 with the pre-hospital electrocardiogram (PH-ECG) diagnosis of STEMI and immediate transport to a SRC (designated PPCI-capable hospital).Methods A pooled analysis of 10 independent, prospective, observational registries involving 72 hospitals was performed. Data were collected on all consecutive patients with a PH-ECG diagnosis of STEMI. The D2B and emergency medical services (EMS)-to-balloon (E2B) times were recorded.Results Paramedics transported 2,712 patients with a PH-ECG diagnosis of STEMI directly to the nearest SRC. A PPCI was performed in 2,053 patients (76%) with an 86% rate of D2B <= 90 min (95% confidence interval: 84.4% to 87.4%). Secondary analyses of this cohort demonstrated a 50% rate of D2B <= 60 min (n = 1,031), 25% rate of D2B <= 45 min (n = 517), and an 8% rate of D2B <= 30 min (n = 155). A tertiary analysis restricted to 762 of 2,053 (37%) cases demonstrated a 68% rate of E2B <= 90 min.Conclusions Ten independent regional SRC networks demonstrated a combined 86% rate of D2B <= 90 min, and each region individually surpassed the American College of Cardiology D2B Alliance benchmark. In areas with regional SRC networks, 9-1-1 provides entire communities with timely access to quality STEMI care. (J Am Coll Cardiol Intv 2009;2:339-46) (C) 2009 by the American College of Cardiology Foundation

BACKGROUND:Myocardial infarction with normal coronary arteries (MINCA) is a well-documented syndrome often associated with global left ventricular wall motion abnormalities (LVWMAs). Recent literature has emphasized the occurrence of Takotsubo cardiomyopathy associated with MINCA. What has not been reported is the incidence of MINCA in the general population and the relative frequency of other types of associated LVWMAs.METHODS AND RESULTS:Data were retrospectively collected on 165 consecutive patients with ST-elevation myocardial infarction (STEMI) and 244 patients with non-ST-elevation myocardial infarction (NSTEMI) who underwent cardiac catheterization at a single institution in Marin County, California. Thirty-two of the 409 (7.8%) patients had MINCA. Of the patients presenting with STEMI, 10.3% had MINCA, and 6.1% of the patients presenting with NSTEMI had MINCA. Females were more likely to present with MINCA than males, both for STEMI (21.6% vs. 5.3%; p < 0.001) and NSTEMI (12.1% vs. 2.6%; p < 0.001). Of the 32 patients who presented with MINCA, 7 (21.9%) females had Takotsubo cardiomyopathy, while 10 (31.3%) patients (9 females, 1 male) had other previously undescribed focal anterior and inferior LVWMAs. A recent stressful event was noted in 50% (47.8% of females, 55.6% of males) of the patients with MINCA.CONCLUSIONS:An unexpectedly high incidence of MINCA with newly-described focal anterior and inferior LVWMAs as well as Takotsubo cardiomyopathy was observed in our community hospital. This syndrome occurred predominantly in females and was often associated with a recent stressful event. As these results were from a community, rather than a referral hospital, this finding challenges the current thought about the incidence of this syndrome in the general population.

The normal posterior aortic wall echocardiogram shows anterior motion during left ventricular systole and predominantly posterior motion in three phases during left ventricular diastole. In six patients undergoing simultaneous left atrial angiograms and posterior aortic wall echocardiograms, there was excellent correlation between the posterior aortic wall motion and the change in the left atrial angiographic area showing the value of the posterior aortic wall echocardiogram in describing the left atrial volume curve.

Pulmonary vein isolation is becoming the treatment of choice for symptomatic atrial fibrillation (AF) that is refractory to drugs [1–3]. However, thromboembolic complications are an important limitation of this approach [4], occurring in up to 2.8% of the patients. Alternative energy sources such as cryoablation and ultrasound have the potential to improve the safety of the procedure by preventing disruption of the endothelial surface during energy delivery [5,6].

Introduction: Sick sinus syndrome is commonly associated with tachyarrhythmias and bradyarrhythmias that often are symptomatic. The aim of this study was to assess the effect of pulmonary vein isolation in patients with sick sinus syndrome and atrial fibrillation (AF).Methods and Results: Three hundred fourteen consecutive patients who underwent pulmonary vein isolation between December 2000 and January 2002 were included in the study. Thirty-one patients had sick sinus syndrome, which was defined as a preprocedural history of symptomatic sinus bradycardia or pauses. Endpoints included AF recurrence, change in the frequency of sinus pauses, and symptoms of presyncope or syncope, as well as mean heart rate and percentage of atrial pacing in patients with pacemakers implanted prior to the pulmonary vein isolation. Patients had AF for an average of 6 +/- 3 years. Patients were 58 +/- 8 years old and had ejection fractions of 55 +/- 4%. Sixty-one percent had implanted pacemakers. AF recurred within 6 months in 4 patients. Two had a successful second pulmonary vein isolation procedure. There were no recurrences of presyncopal events (P < 0.05) or documented sinus pauses (P < 0.05) after successful pulmonary vein isolation in the patients without permanent pacemakers. Patients with pacemakers had a 13-fold reduction in the percentage of atrial pacing (P < 0.05). Both groups showed a significant increase in average heart rates at 6-month follow-up.Conclusion: Cure of AF by pulmonary vein isolation helped resolve the clinical manifestations of sick sinus syndrome, suggesting that the occurrence of AF and/or the associated treatment could be partially responsible for sick sinus syndrome.