Fatal derecruitment of occluded left anterior descending collaterals after left circumflex revascularization

Coronary arteries are not definitely functionally terminal arteries, as previously thought; indeed, they are linked and interconnected by a rich network of collaterals. Chronic total occlusions [CTOs] represent a subset of frequent lesions encountered in everyday catheterization laboratory practice, generally associated with a developed system of collateral connections. These latter have the capacity to prevent myocardial necrosis and may even uphold metabolic supply to the ischemic territory to maintain its contractile capacity. Authors have reported a rapid and progressive reduction of collateral function and their decline after antegrade flow restoration, resulting in higher myocardial susceptibility to ischemia in the CTO territory. Here, we report the case of a fatal derecruitment of collaterals for a left anterior descending CTO not reopened, after left circumflex subocclusion revascularization

Usefulness of SYNTAX score II in complex percutaneous coronary interventions in the setting of acute coronary syndrome

Background: SYNTAX score II [SS II] integrates anatomical SS with clinical characteristics allowing an individualized prediction of long-term mortality

Aims: We sought to assess to evaluate the usefulness of SS II in a real-world acute coronary syndromes [ACS] population with severe coronary artery disease [CAD] undergoing percutaneous coronary intervention [PCI]

Methods: From August 2011 to May 2013, out of 1591 consecutive patients admitted for ACS, 217 [13.6%] showed severe CAD [three-vessel disease and/or left main involvement]. Among the latter, 100 patients underwent PCI and were enrolled into the study. SS II was calculated in all patients. One-year clinical follow-up was performed; major adverse cardiac and cerebrovascular events [MACCE] were defined as a composite of death, nonfatal myocardial infarction, stroke, or repeat revascularization

Results: The median SS II was 29 [range, 14-59]. Overall, MACCE occurred in 25% of patients [cardiac death 4%, myocardial infarction 4%, stroke 0%, and repeat revascularization 17%]. The 1-year MACCE-free survival was significantly lower in patients with SS [>/=29], than in those with SS II [<29] [64.2% vs. 87.2%, respectively; p=0.007]. In multivariate Cox regression analysis, the presence of unprotected left main stenosis [hazard ratio 2.52, 95% confidence interval [CI]: 1.02-5.85; p=0.031] and SS II >/=29 [hazard ratio 2.74, 95% CI: 1.30-8.21; p=0.011] were the only predictors of MACCE at 1-year clinical follow-up. The c-index of SS score II was 0.70 [95% CI: 0.58-0.81]. For patients who experienced MACCE, the SS II reclassification improved by 36%, while in nonevent patients the reclassification improved by 22%. The net reclassification index was 0.24 [p=0.09]

Conclusion: SS II might represent a useful tool to predict clinical events in not only ideal stable patients, but also an unrestricted, real world population of patients with ACS and severe CAD undergoing PCI

Mechanical post-conditioning in STEMI patients undergoing primary percutaneous coronary intervention

Although early myocardial reperfusion via primary percutaneous coronary intervention [PCI] allows the preservation of left ventricular function and improves outcome, the acute restoration of blood flow may contribute to the pathophysiology of infarction, a complex phenomenon called reperfusion injury. First described in animal models of coronary obstruction, mechanical post-conditioning, a sequence of repetitive interruption of coronary blood flow applied immediately after reopening of the occluded vessel, was able to reduce the infarct size. However, evidence of its real benefit remains controversial. This review describes the mechanisms of post-conditioning action and the different protocols employed focusing on its impact on primary PCI outcome

Coronary perforation with tamponade successfully managed by retrograde and antegrade coil embolization

In recent years, retrograde approach for chronic total occlusions has rapidly evolved, enabling a higher rate of revascularization success. Compared to septal channels, epicardial collaterals tend to be more tortuous, more difficult to negotiate, and more prone to rupture. Coronary perforation is a rare but potentially life-threatening complication of coronary angioplasty, often leading to emergency cardiac surgery. We report a case of a retrograde chronic total occlusion revascularization through epicardial collaterals, complicated by both retrograde and antegrade coronary perforation with tamponade, and successfully managed by coil embolization

Invasive assessment modalities of unprotected left main stenosis

Among all coronary lesions, the decision-making process for the treatment of unprotected left main [ULM] stem lesions is still challenging. Indeed, the optimal therapeutic strategy for patients with ULM disease remains controversial: coronary artery bypass grafting was established as the gold standard, but it is without doubt that percutaneous coronary intervention [PCI] performed by experienced operators achieves good results at long term follow up, especially in cases where the ostium and/or shaft of ULM are treated. Thanks to the widespread use of invasive assessment of atherothrombotic ULM stenosis, improved selection of PCI cases and techniques of stenting, better outcomes are now possible. This review seeks to define the place of PCI in ULM disease by describing the different modalities of ULM stenosis assessment

Guideliner Catheter: a useful tool in the armamentarium of the interventional cardiologist

Regardless of the clinical setting, a good back-up represents one of the most important conditions to ensure guide wire and balloon advancement and stent delivery. As a "mother and child" system, the GuideLiner catheter [Vascular Solutions Inc., Minneapolis, MN, USA] provides an extension to the guide catheter with better coaxial alignment and stability. We report two didactic cases showing the usefulness of the GuideLiner device in everyday catheterization laboratory practice. The first case was a primary percutaneous coronary intervention [PCI] in a 71-year-old diabetic man admitted for inferior STelevation myocardial infarction, related to tight proximal stenosis in a dominant tortuous and calcified left circumflex. The second case was an elective PCI in a 76-year-old man admitted for stable angina [Canadian Cardiovascular Society [CCS] class III], related to focal intra-stent restenosis of a saphenous venous graft to the left anterior descending. In both cases, the GuideLiner catheter provided a good back-up insuring the success of PCI and drug-eluting stents implantation, with a good in-hospital outcome

Cardiac hydatid cyst revealed by ventricular tachycardia

Hydatid disease is a human parasitic infestation caused by the larval stage of Echinococcus Granulosus. The liver and the lungs are the most common locations. Cardiac involvement is rare and accounts for 0.5-2% of all hydatid disease. We report an unusual presentation of cardiac hydatid cyst revealed by ventricular tachycardia in a patient with a history of cerebral hydatid cyst

innovation of composite core dual coil coronary guide-wire technology: a didactic coronary chronic total occlusion revascularization case report

The treatment of coronary chronic total occlusions [CTO] continues to solicit technical innovations. As success primarily depends on crossing the lesion with a wire, all aspects regarding tip shape retention, torque precision, and penetration ability of the guide-wire have greatly influenced new techniques and strategies. The world of interventional cardiology has to look carefully at these developments, and to use them accordingly to improve the success rate in ordinary percutaneous coronary interventions. We present a didactical case report of a CTO revascularization treated with a new 'dual core' technology guide-wire