Impact of diabetes mellitus on clinical characteristics, management, and in-hospital outcomes in patients with acute myocardial infarction (from the NCDR).

Patients with diabetes mellitus (DM) presenting with acute myocardial infarction (AMI) have worse outcomes versus those without DM. Comparative contemporary data in patients presenting with AMI with insulin-requiring diabetes mellitus (IRDM), noninsulin-requiring diabetes mellitus (NIRDM), and newly identified DM (hemoglobin A1C level >6.5%) versus patients without DM are limited. This observational study from the National Cardiovascular Data Registry (NCDR) Acute Coronary Treatment and Intervention Outcomes Network-Get with the Guidelines (ACTION Registry-GWTG consisted of 243,861 patients with AMI from 462 US sites identified from January 2007 to March 2011 entered into the registry. Clinical characteristics, management, and in-hospital outcomes were analyzed. Patients with DM with non-ST-segment elevation myocardial infarction (NSTEMI; n = 53,094, 35%) were less likely to undergo diagnostic angiography or revascularization, whereas those with ST-segment elevation myocardial infarction (STEMI) (n = 21,507, 23%) were less likely to undergo reperfusion therapy compared with patients without DM. There was an increased adjusted risk of in-hospital mortality in the DM group in both the NSTEMI (odds ratio [OR] 1.14, 95% confidence interval [CI] 1.06 to 1.22) and STEMI (OR 1.17, 95% CI 1.07 to 1.27) population. In patients with DM, the risk-adjusted in-hospital mortality was higher in patients with IRDM than those with NIRDM in the NSTEMI group (OR 1.12, 95% CI 1.01 to 1.24) but not in the STEMI group (OR 1.12, 95% CI 0.95 to 1.32). Newly diagnosed patients with DM presenting with AMI had similar unadjusted in-hospital outcomes compared with patients without DM. In conclusion, patients with DM presenting with AMI have a higher mortality risk than patients without DM. In patients with DM, those with IRDM presenting with NSTEMI had an increased mortality than those with NIRDM.

Use of the trellis device in the management of deep vein thrombosis: a retrospective single-center experience.

OBJECTIVES: The Trellis thrombectomy system (Covidien) is one of the newer devices that incorporates isolated pharmacomechanical thrombectomy and thrombolysis (PMT) for treatment of deep venous thrombosis (DVT). We conducted a retrospective review of patients with upper- and lower-extremity DVT managed with the Trellis thrombectomy system at our center. METHODS: All patients with symptomatic DVT who presented to our center between April 2010 and April 2011 who underwent PMT by the Trellis device were included in this retrospective review. RESULTS: Twenty-eight patients (mean age, 46.4 ± 21.2 years) presented with symptoms with a mean duration of 1.3 ± 1.8 months. Eighty-six percent had 100% occlusion on admission, while 14.3% had 70%-90% stenosis. The mean lytic dose used was tPA 20.7 ± 12 mg. The mean Trellis treatment time was 25.1 ± 11.5 minutes. Grade 3 lysis was achieved in 23 of 28 patients (85.8%), while grade 2 lysis was achieved in 14.2%. Mean total hospital stay was 2.6 ± 2.7 days. Postprocedure symptom resolution was 100%, and there was no reocclusion in 78.6% of patients at 1 year. At 12 months, the patency rate (primary or secondary) was 80% as determined by Doppler ultrasound. CONCLUSIONS: In patients with DVT involving the ilio-femoral and the upper-extremity vessels, the use of the Trellis device was associated with a high technical success rate as well as a satisfactory 12-month patency rate. Moreover, this strategy was associated with reduced lytic dose, shorter treatment time and hospital stay, and no bleeding complications.

Isolated right ventricular infarction after modified Cabrol operation.

We report the case of a 27-year-old woman with a rare presentation of right ventricular failure secondary to isolated right ventricular myocardial infarction, 3 weeks after an uncommon surgical procedure, the modified Cabrol operation. Her medical history also included a Ross procedure at the age of 12 years. On the basis of her subacute presentation and a consultation with cardiac surgeons, we decided on medical management. Follow-up echocardiography at 6 months revealed that the right ventricular systolic function remained severely impaired, but the patient was asymptomatic with excellent functional capacity.We review the surgical techniques of aortic graft replacement and their respective complications. We also discuss the impact of conservative and reperfusion strategies on prognosis and long-term outcomes in the setting of right ventricular infarction.

Use of a novel adjunctive kissing-balloon technique with the Trellis device to successfully prevent embolization across juxtaposed kissing aortoiliac stents.

The Trellis thrombectomy system (Covidien) has been used successfully to perform isolated pharmacomechanical thrombectomy of both venous and arterial thrombi. The device is designed to provide localized treatment while preventing both systemic spread of the thrombolytic agent and also distal embolization. However, when this device is utilized to remove thrombi at bifurcation lesions, embolization into the contralateral vessel can potentially occur. We describe a novel and simple technique of adjunctive kissing balloon inflation while using the Trellis device for the management of an aortoiliac occlusion that occurred in one of two juxtaposed stents previously placed in the distal aorta into the bilateral iliac arteries. This technique prevented distal embolization into the contralateral iliac artery.

Pharmacomechanical thrombolysis of acute and chronic symptomatic deep vein thrombosis: a systematic review of literature.

Pharmacomechanical thrombolysis (PMT) is an emerging treatment option for symptomatic deep vein thrombosis (DVT). This may obviate the need for systemic or catheter-directed thrombolysis. PubMed, EMBASE, and Cochrane database search of PMT in acute and chronic symptomatic DVT was undertaken. Baseline demographic and clinical characteristics, procedural details, DVT characteristics, and procedural and clinical outcomes are presented. A total of 8 case series (n = 2528; 1998-2009) qualified for inclusion. Lower extremity symptomatic DVTs constituted the majority of the cases (>80%). Both acute (<14 days) and chronic (>14 days) DVTs were included. Procedural success was 59% to 100% and catheter-directed thrombolysis was used as an adjunct in 16% to 53%. No deaths or major bleeding complications were reported. Pharmacomechanical thrombolysis leads to the immediate resolution of clinical symptoms of DVT in the majority of patients. Pharmacomechanical thrombolysis may be a safe and novel method, when appropriate expertise and resources are available, for the treatment of symptomatic acute and chronic DVT.

Re-entry devices in the treatment of peripheral chronic occlusions.

Chronic occlusions are present in up to 40% of patients who undergo treatment for symptomatic peripheral arterial disease. The primary difficulty encountered during the treatment of chronic occlusions is inability to re-enter the true lumen after subintimal crossing of the occlusion. Two devices have been designed to mitigate this limitation via controlled re-entry. Herein, we report our experience with the Outback LTD catheter and the Pioneer Plus Catheter PPlus 120 in re-entering the true arterial lumen during percutaneous intentional extraluminal revascularization for peripheral chronic occlusions involving the superficial femoral artery. In reviewing our peripheral interventions performed from February 2006 through February 2009, we evaluated angiograms, patients' characteristics, presentations, types of lesions, procedural successes, complications, and symptom-free intervals. The total study population consisted of 23 patients. The Outback catheter was used in 15 patients and the Pioneer catheter in 8 patients.The procedure was successful in all 8 Pioneer cases (100%) and in 13 of the 15 Outback cases (87%). All 8 (100%) of the patients in the Pioneer group and 12 of the 14 patients in the Outback group (86%) remained asymptomatic at an average of 12 months. Overall, there were no procedural complications, amputations, or deaths. This single-center experience demonstrates that the Outback and Pioneer re-entry catheters are safe and effective in managing peripheral chronic occlusions, with an average symptom-free interval of 12 months. This management strategy proves to be reasonable when standard techniques fail to achieve true lumen re-entry.

Retrograde access via the popliteal artery to facilitate the re-entry technique for recalcitrant superficial femoral artery chronic total occlusions.

Subintimal recanalization is beneficial in selected patients with peripheral chronic total occlusions (CTO). However, in complex cases, re-entry into the true arterial lumen may prove to be unsuccessful with a conventional guidewire or a re-entry catheter when using standard femoral artery access. Our case series describes these technical dilemmas along with strategies that can be utilized to overcome these challenges.

Effect of statin therapy on contrast-induced nephropathy after coronary angiography: a meta-analysis.

BACKGROUND: Although the pleiotropic effects of statins are postulated to be renoprotective, clinical studies have demonstrated conflicting results. We undertook a meta-analysis of published trials to evaluate the impact of statin therapy on the incidence of contrast-induced nephropathy (CIN) in patients undergoing coronary angiography. METHODS: We searched MEDLINE and EMBASE databases through December 2010 for articles evaluating the effect of statins on the incidence of CIN in patients undergoing coronary angiography. Odds ratios (OR) with 95% confidence intervals (CI) were calculated using random effects modeling. RESULTS: Three randomized controlled trials involving 770 patients (330 in the statin group and 340 in the control group) and 7 non-randomized studies involving 31,959 patients (11,936 statin-pretreated and 20,023 statin-naïve). The definition of CIN varied somewhat among the studies. Based on the pooled estimate across the 3 randomized controlled trials, statin therapy did not significantly reduce the incidence of CIN compared to control (OR=0.76, 95% CI: 0.41-1.41, p=0.39). No significant heterogeneity was found in the randomized studies (I(2)=0%, p=0.48). The pooled analysis of the non-randomized studies showed a marginally significant benefit associated with statin therapy (OR=0.60, 95% CI: 0.36-1.00, p=0.05). There was significant heterogeneity among the non-randomized studies (I(2)=88%, p<0.00001). CONCLUSIONS: Our meta-analysis suggests that statin therapy might be associated with a significant reduction in the incidence of CIN in patients undergoing coronary angiography. Further studies are warranted to clarify this issue.

Rapidly evolving coronary aneurysm in a patient with rheumatoid arthritis.

Coronary artery aneurysm (CAA) formation in the setting of an acute inflammatory state due to connective tissue disease is rare. We report a case of rapid progression from an ectatic to an aneursymatic left circumflex coronary artery leading to an acute coronary event in a patient with rheumatoid arthritis (RA). We report the accelerated growth of the aneurysm as it was temporally related to the lapse in treatment and the management strategies involved with this entity.

Acute stent thrombosis associated with heparin-induced thrombocytopenia and abciximab-induced profound thrombocytopenia.

Heparin-induced thrombocytopenia (HIT) is a wellknown complication after exposure to heparin products. Profound thrombocytopenia has also been reported with the use of abciximab, a glycoprotein IIb/IIIa receptor antagonist, which is used during percutaneous coronary intervention. Acute stent thrombosis is a rare but serious complication of HIT. We report an unusual case of acute stent thrombosis with concomitant heparin- and abciximab-induced profound thrombocytopenia and discuss the subsequent treatment strategies. Prompt identification and management of this disorder is critically important to avoid devastating complications.

Isolated pharmacomechanical thrombectomy for the management of chronic DVT.

Thrombo-reduction in the setting of deep vein thrombosis (DVT) to prevent the postthrombotic syndrome has not been traditionally managed by interventional cardiologists. We report a case series of successful chronic DVT management with pharmacomechanical thrombectomy utilizing the Trellis device.

AngioSculpt PTCA Balloon Catheter entrapment and detachment managed with stent jailing.

The AngioSculpt PTCA Scoring Balloon Catheter is an FDA-approved device for plaque modulation. We describe the first case of AngioSculpt EX catheter entrapment and detachment in the right coronary artery during PCI that was successfully managed with stent jailing of the entrapped balloon catheter and its shaft against the vessel wall.

Bifurcated aortic endograft limb occlusion managed with a novel method of isolated pharmacomechanical thrombectomy.

Limb occlusion of an aortic endograft is uncommon, however, it can result in permanent sequelae if management is delayed. We report the first case utilizing the Trellis device to achieve localized and prompt isolated pharmacomechanical thrombectomy (PMT) for the treatment of acute limb thrombosis of a bifurcated aortic endograft.

Giant splenic artery aneurysm: managed in the cardiovascular catheterization laboratory using the modified neck remodeling technique.

We report the first case of coil embolization using the "modified neck remodeling technique" in the management of a splenic artery aneurysm. This technique was feasible due to the unique and complex anatomy of the aneurysm. This condition has been largely treated by vascular surgeons and interventional radiologists; however, this patient was referred to the interventional cardiologists for endovascular coiling.

Activating autoantibodies to the beta-1 adrenergic and m2 muscarinic receptors facilitate atrial fibrillation in patients with Graves' hyperthyroidism.

OBJECTIVES: We studied activating autoantibodies to beta-1 adrenergic receptors (AAbeta1AR) and activating autoantibodies to M2 muscarinic receptors (AAM2R) in the genesis of atrial fibrillation (AF) in Graves' hyperthyroidism. BACKGROUND: Atrial fibrillation frequently complicates hyperthyroidism. Both AAbeta1AR and AAM2R have been described in some patients with dilated cardiomyopathy and AF. We hypothesized that their copresence would facilitate AF in autoimmune Graves' hyperthyroidism. METHODS: Immunoglobulin G purified from 38 patients with Graves' hyperthyroidism with AF (n=17) or sinus rhythm (n=21) and 10 healthy control subjects was tested for its effects on isolated canine Purkinje fiber contractility with and without atropine and nadolol. Immunoglobulin G electrophysiologic effects were studied using intracellular recordings from isolated canine pulmonary veins. Potential cross-reactivity of AAbeta1AR and AAM2R with stimulating thyrotropin receptor (TSHR) antibodies was evaluated before and after adsorption to Chinese hamster ovary cells expressing human TSHRs using flow cytometry and enzyme-linked immunosorbent assays. RESULTS: The frequency of AAbeta1AR and/or AAM2R differed significantly between patients with AF and sinus rhythm (AAbeta1AR=94% vs. 38%, p<0.001; AAM2R=88% vs. 19%, p<0.001; and AAbeta1AR+AAM2R=82% vs. 10%, p<0.001). The copresence of AAbeta1AR and AAM2R was the strongest predictor of AF (odds ratio: 33.61, 95% confidence interval: 1.17 to 964.11, p=0.04). Immunoglobulin G from autoantibody-positive patients induced hyperpolarization, decreased action potential duration, enhanced early afterdepolarization formation, and facilitated triggered firing in pulmonary veins by local autonomic nerve stimulation. Immunoadsorption studies showed that AAbeta1AR and AAM2R were immunologically distinct from TSHR antibodies. CONCLUSIONS: When present in patients with Graves' hyperthyroidism, AAbeta1AR and AAM2R facilitate development of AF.

Ureteroarterial fistula: a rare cause of hematuria managed in the cardiac cath lab.

Ureteroarterial fistulae (UAFs) are rare but potentially life-threatening entities that require a high degree of suspicion for diagnosis followed by prompt intervention. This case report describes the successful management of the oldest woman to-date presenting with intermittent hematuria, secondary to a fistula between the ureter and internal iliac artery, which was subsequently resolved by coil embolization. Morbidity and mortality associated with UAFs can be decreased by increasing awareness of this rare but fatal complication. Our review of the medical literature indicates that this is the oldest woman reported to have developed a UAF after radiation therapy and chronic ureteral stent exchange, as well as the first reported management of a UAF by interventional cardiologists.

Anterolateral myocardial infarction induced by coronary-subclavian-vertebral steal syndrome successfully treated with stenting of the subclavian artery.

A female patient with graft-dependent coronary circulation presented with vertebrobasilar insufficiency and NSTEMI (Non-ST-Elevation Myocardial Infarction) related to a 100 percent stenosis of the left subclavian artery. Our review of the medical literature indicates that this is the first reported case in which a patient presented with an anterolateral NSTEMI and dizziness with subsequent angiographic evidence of both coronary subclavian and vertebral subclavian steal syndromes successfully treated with angioplasty and stenting of the left subclavian artery without any intervention in the coronary arterial tree.