Histologic analysis of a covered stent implanted for pseudoaneurysm in a coronary artery.

Covered stents are the standard of care when coronary perforations complicate percutaneous coronary interventions and have also been utilized in the treatment of coronary aneurysms. We present the clinical and histologic features of a patient who developed a coronary perforation and pseudoaneurysm 4 years following deployment of intracoronary stents. Although the covered stent successfully sealed the perforation, subsequent thrombosis led to a fatal acute myocardial infarction.

Transcatheter closure of left ventricular pseudoaneurysm.

Left ventricular pseudoaneurysm is a rare complication of myocardial infarction, cardiovascular surgery, trauma, or infection. Untreated left ventricular pseudoaneurysm can have significant morbidity and mortality. Surgical treatment has generally been the standard of care. However, with a sicker and older population, surgical risks can sometimes be significant. We report a case of successful percutaneous closure of left ventricular pseudoaneurysm using coils and a vascular plug. We emphasize the role and importance of multimodality imaging for accurate diagnosis and therapy, and briefly review the literature on the various approaches used for percutaneous closure of left ventricular pseudoaneurysms.

Oral antiplatelet therapy in diabetes mellitus and the role of prasugrel: an overview.

Diabetics have a prothrombotic state that includes increased platelet reactivity. This contributes to the less favorable clinical outcomes observed in diabetics experiencing acute coronary syndromes as well as stable coronary artery disease. Many diabetics are relatively resistant to or have insufficient response to several antithrombotic agents. In the setting of percutaneous coronary intervention, hyporesponsiveness to clopidogrel is particularly common among diabetics. Several strategies have been examined to further enhance the benefits of oral antiplatelet therapy in diabetics. These include increasing the dose of clopidogrel, triple antiplatelet therapy with cilostazol, and new agents such as prasugrel. The large TRITON TIMI 38 randomized trial compared clopidogrel to prasugrel in the setting of percutaneous coronary intervention for acute coronary syndromes. The diabetic subgroup (n = 3146) experienced considerable incremental benefit with a 4.8% reduction in cardiovascular death, nonfatal myocardial infarction, and nonfatal stroke at 15-month follow-up with prasugrel treatment. Among diabetics on insulin this combined endpoint was reduced by 7.9% at 15 months. Major bleeding was not increased in the diabetic subgroup. This confirms the general hypothesis that more potent oral antiplatelet therapy can partially overcome the prothrombotic milieu and safely improve important clinical outcomes in diabetics.

Coronary artery spasm during angiography in a pediatric heart transplant recipient: subsequent prevention by intracoronary nitroglycerin administration.

Coronary artery spasm can occur during coronary angiography in pediatric heart transplant recipients. The angiographic appearance can suggest allograft vasculopathy. We report coronary artery spasm in a pediatric heart transplant recipient in whom intracoronary nitroglycerin administration prevented a repetition of spasm upon subsequent diagnostic coronary angiography. Additional studies of dose response, particularly in cardiac transplant recipients, may help determine whether lower doses of intracoronary nitrates, such as that administered to our patient, can be effective in preventing coronary artery vasospasm in pediatric heart transplant recipients.

Pretreatment with nitroprusside for microcirculatory protection in saphenous vein graft interventions.

OBJECTIVES: We hypothesized that the prophylactic administration of sodium nitroprusside (NTP) during saphenous vein graft (SVG) PCI would ameliorate the detrimental effects of distal embolization and reduce the frequency and magnitude of post-procedural myonecrosis. METHODS: Sixty-four consecutive patients with normal preprocedural cardiac enzymes underwent SVG PCI without embolic protection devices and received prophylactic intragraft NTP before initial device activation. For each case, 2 control patients were selected in reverse chronologic order and were matched for stent use, thromboatherectomy device use, clinical presentation, presence of thrombus and pre-PCI thrombolysis in myocardial infarction (TIMI) flow. RESULTS: Mean patient age was 66 +/- 10 years, 78% of whom were males. Stent and thromboatherectomy use was 95.3% and 3.1%, respectively in both groups (p = ns). Prior to intervention, TIMI < 3 flow was present in 26.6% of cases and in 24.2% of control patients (p = ns). Thrombus was present in 20.3% of cases and in 19.5% of controls (p = ns). Post-PCI creatinine kinase (CK)-MB elevation > 3 x the upper limit of normal (ULN) occurred in 6.3% of cases vs. 16.4% of controls (p = 0.049) and > 5 x ULN in 1.6% of cases vs.10.9% of controls (p = 0.022). In a multivariate regression model that included stent use, in-stent restenosis, thrombus presence, preprocedural TIMI 3 flow, MI as procedural indication, NTP and glycoprotein IIb/IIIa use, NTP was the only independent and significant predictor of reduced post-procedural CK-MB elevation > 5 x ULN. CONCLUSION: Prophylactic administration of intragraft NTP during SVG PCIs results in a lower frequency and magnitude of post-procedural cardiac enzyme elevation.

Saphenous vein graft-to-left atrium fistula treated with percutaneous transcatheter embolization with coils.

Coronary artery fistulae are rare anomalies that are most commonly congenital and rarely acquired. We present a first case of a vein graft to the left atrium fistula that occurred post coronary artery bypass grafting and was treated with percutaneous transcatheter embolization with coiling. The coil was initially lost in the left atrium, but was successfully retrieved and the fistula was closed. We review the pertinent literature on acquired coronary artery fistulae and their management.

Ruptured giant right coronary artery aneurysm percutaneously plugged.

The endovascular management of a patient with a ruptured giant coronary aneurysm presenting with chest pain followed by anterior chest wall ecchymosis and shock is described. The inflow to a large, acutely leaking right coronary aneurysm was successfully sealed with the Amplatzer Vascular Plug device. The patient was estimated to be at very high risk for surgical intervention. The use of this device to seal an acutely leaking coronary aneurysm has not been previously described.

The safety of bivalirudin during elective percutaneous coronary interventions in heart transplant patients.

BACKGROUND: Bivalirudin has been shown to be safe and effective during percutaneous coronary interventions (PCI) of native coronary arteries in the REPLACE 2 trial. The safety of bivalirudin during PCIs in heart transplant patients is not known. METHODS: Heart transplant patients who had undergone PCI of de novo lesions and received bivalirudin during the procedure were included in the study. Medical records were reviewed for the occurrence of death, myocardial infarction, target vessel revascularization or major bleeding up to 30 days after discharge. The results were compared with the REPLACE 2 trial and with a control group of heart transplant recipients who received heparin during their procedures. RESULTS: There were 51 separate PCIs performed in 30 patients in the study group. The mean age was 56 +/- 12 years and 6 (20%) were women. The control group consisted of 24 patients who had undergone 35 PCIs. There were no deaths, myocardial infarctions or target vessel revascularization during the follow-up period in the study group. The combined endpoint of death, myocardial infarctions, target vessel revascularization and major bleeding requiring two or more units of packed red blood cells occurred in 2 (3.9%) patients compared to 275 (9.2%) patients in the REPLACE 2 trial (p = 0.195) and 5 (14.3%) in the control group (p = 0.115). CONCLUSION: Bivalirudin is a safe antithrombotic medication to use during elective PCI in heart transplant patients with cardiac allograft vasculopathy. (Cardiol J 2007; 14: 458-462).

Cypher drug-eluting stent treatment of tibioperoneal obstructive disease: a case report.

Stent placement in a tibial artery for suboptimal angioplasty results has had a high rate of restenosis and occlusion due to neointimal hyperplasia. Drug-eluting stents may provide a new therapeutic option in this situation. We describe the use of a Cypher drug-eluting stent after suboptimal angioplasty result in a claudicant with a severe tibioperoneal trunk lesion and single-vessel runoff to the foot with 6-month follow-up.

Usefulness of live three-dimensional transthoracic echocardiography in the characterization of atrial septal defects in adults.

In this report we present 12 adult patients in whom surgical or percutaneous intervention was considered for repair of atrial septal defect (ASD). Location, size, and surrounding atrial anatomy of the ASD were assessed prior to intervention in all patients with standard and live three-dimensional transthoracic echocardiography (3D TTE). In the four patients in whom intraoperative three-dimensional transesophageal echocardiographic reconstruction (3D TEE) was done, 3D TTE measurements of maximum dimension, maximum circumference, and maximum area of ASD agreed well with 3D TEE. In the seven patients who underwent transcatheter closure device insertion, live 3D TTE measurements of maximum dimension, maximum circumference, and maximum area of ASD agreed well with the sizing balloon. Additionally, since the sizing balloon measures a stretched diameter and area, a live 3D TTE stretched ASD diameter and area (derived from the actual live 3D TTE maximum circumference) were calculated and demonstrated improved agreement with the sizing balloon measurements. In all patients, > or =5 mm of atrial tissue was visualized surrounding the ASD. Further, with the addition of contrast enhancement, characterization of a small patent foramen ovale (<5 mm) was possible in one patient. Live 3D TTE accurately defined ASD location, size, and surrounding atrial anatomy in all patients studied by us. ASD characterization by live 3D TTE agreed well with 3D TEE and sizing balloon measurements.

Quantification of mitral regurgitation by live three-dimensional transthoracic echocardiographic measurements of vena contracta area.

We evaluated 44 consecutive patients who underwent standard two-dimensional (2D) and live three-dimensional (3D) transthoracic echocardiography (TTE), as well as left heart catheterization with left ventriculography. Mitral regurgitant vena contracta area (VCA) was obtained by 3D TTE by systematic and sequential cropping of the acquired 3D TTE data set. Assessment of mitral regurgitation (MR) by ventriculography was compared to measurements of VCA by 3D TTE and to 2D TTE measurements of MR jet area to left atrial area (RJA/LAA), RJA alone, vena contracta width (VCW), and calculated VCA. VCA from 3D TTE closely correlated with angiographic grading (rs=0.88) with very little overlap. VCA of <0.2 cm2 correlated with mild MR, 0.2-0.4 cm2 with moderate MR, and >0.4 cm2 with severe MR by angiography. Ventriculographic grading also correlated well with 2D TTE measurements of RJA/LAA (rs=0.79) and RJA alone (rs=0.76) but with more overlap. Assessment of VCW and calculated VCA by 2D TTE agreed least with ventriculography (rs=0.51 and rs=0.55, respectively). Live 3D TTE color Doppler measurements of VCA can be used for quantitative assessment of MR and is comparable to assessment by ventriculography.

Long-term follow-up of brachytherapy for treatment of allograft in-stent restenosis.

The experience of brachytherapy in the treatment of in-stent restenosis of allograft arteries is limited. We present two cases of in-stent restenosis treated with brachytherapy with favorable angiographic follow-up at 10 months in one patient and at 17 months in the other.

Treatment of in-stent restenosis in a gastroepiploic artery coronary bypass graft with brachytherapy.

The pedicled right gastroepiploic artery is used as an arterial conduit in a select group of patients undergoing coronary artery bypass grafting with favorable patency and survival rates. Myocardial ischemia can occur, especially secondary to distal anastomotic stenosis. Percutaneous coronary interventions have been successful in treating these stenoses, precluding further challenging and higher risk operations. The restenosis rate of such interventions is unknown. We describe a case of distal right gastroepiploic graft anastomotic stenosis that was initially treated with percutaneous angioplasty, but later required stenting for restenosis. Subsequent in-stent restenosis was successfully treated with angioplasty and brachytherapy via the left axillary approach.