To evaluate the prognosis after local thrombolysis compared to systemic thrombolysis in high-risk pulmonary embolism. Observational study during 13 years which included 37 patients with high-risk pulmonary embolism treated with local thrombolysis and 36 patients with systemic thrombolysis (streptokinase, 250 000 UI/30 minutes followed by 100 000 UI/h). Cardiogenic shock has totally remitted in the group with local thrombolysis ( P = .002). The decrease in pressure gradient between right ventricle and right atrium was comparable in both groups in the acute period (the results being influenced by the higher in-hospital mortality after systemic thrombolysis), but significantly better in the next 24 months follow-up after in situ thrombolysis. Major and minor bleeding did not have significant differences. In hospital, mortality was significantly lower in the group with local thrombolysis ( P = .003), but for the next 24 months follow-up, the survival was comparable in both groups. Local thrombolysis, during the hospitalization, was associated with lower mortality rate comparing with systemic thrombolysis. In the next 24 months follow-up, the evolution of residual pulmonary hypertension was significantly better after in situ thrombolysis.

Critical lesion of the unprotected left main coronary disease carries a tremendous mortality burden, often associated with a diabetes status or multivessel disease, with coronary artery bypass grafting being the standard treatment for over 40 years. Percutaneous coronary intervention with drug eluting stents should be taken into consideration and could be a better option for patients with low SYNTAX score as validated by the recently published studies. This review summarizes the major randomized clinical trials and meta-analyses concerning the debate regarding percutaneous coronary intervention with drug eluting stents versus coronary artery bypass grafting for unprotected left main coronary disease, along with the latest European and American revascularization guidelines and tries to shed light on this matter. The most results advocate that there is no convincing difference in survival rate for both therapies, especially in patients with isolated left main disease but with fewer major ischemic events for coronary artery bypass grafting when compared with percutaneous coronary intervention in multivessel coronary artery disease, at the rate of a higher stroke incidence. The gaps in evidence are also highlighted, especially the lack of randomized clinical trials with new generation drug eluting stents versus coronary artery bypass grafting or those regarding the best revascularization strategy for an acute coronary syndrome when unprotected left main coronary disease is involved.

A 41-year-old female was referred to our clinic with progressive dyspnea and a syncope, preceded by angina. On admission she was in cardiogenic shock. ECG showed diffuse repolarization changes and cardiac enzymes were elevated. The echocardiogram revealed severe left ventricular dysfunction with basal and medium walls hypokinesia. After stabilizing the patient, a coronary angiography was performed which revealed normal epicardial arteries. In the next days her clinical status was marked by severe hypertensive episodes with flash pulmonary edema and low responsiveness to therapy. Cardiovascular magnetic resonance showed myocardial edema and intramyocardial late gadolinium enhancement. An abdominal ultrasound raised suspicion of a pheochromocytoma due to an abnormal mass with cystic areas found on the right suprarenal gland. Elevated urinary free catecholamines and fractionated metanephrines confirmed the diagnosis. Further on, a CT scan better identified the heterogeneous tumor and the patient was referred for a right laparoscopic adrenalectomy. Follow-up at 1 month reported full recovery of the sistolic function. The particularity of the case is represented by the difficulty of diagnosis of adrenergic myocarditis, as well as the management of cardiogenic shock induced by it.