How I do it: directional atherectomy for in-stent restenosis of a PTFE arteriovenous graft.

We describe the use of directional atherectomy (DA) to restore patency of a thrombosed polytetrafluoroethylene arteriovenous graft with an in-stent restenosis at the venous anastomosis. Technically, the procedure described is not an atherectomy per se, but rather the removal of fibrosis and intimal hyperplasia with sharp endoluminal dissection. Certainly, the operator must be cautious when performing DA directly adjacent to a previously deployed stent. Nevertheless, our report suggests that there may be a role for DA in the treatment of severe, resistant in-stent stenosis. Further investigation is necessary to evaluate the safety and efficacy of the described technique.

Delayed complete heart block secondary to jailed first septal perforator.

Partial or total occlusion of septal perforator branches can occur during stenting of the proximal and mid portion of the left anterior descending artery, secondary to plaque snow plowing and/or stent "jailing". Flow compromise in a sizeable septal branch can result in a myocardial infarction or in atrioventricular conduction abnormalities. Complete heart block has been described at the time of the procedure, and though it is usually transient, it may require temporary pacing. We report a case of delayed, symptomatic and permanent complete atrio-ventricular block that occurred 2 days after the index procedure, requiring implantation of a permanent pacemaker.

Rationale for targeted rather than population based screening with C-reactive protein using the National Health and Nutrition Examination Survey (1999 to 2002).

C-reactive protein (CRP) is the most well-studied inflammatory marker for the prediction of coronary artery disease. It was hypothesized that population-wide screening would have minimal impact but that a target population might be identified for whom CRP testing could be appropriate. The National Health and Nutrition Examination Survey (NHANES; 1999 to 2002) included 7,399 subjects who represented 171 million United States residents aged 20 to 79 years. Subjects were risk stratified according to National Cholesterol Education Program Adult Treatment Panel III guidelines. Subjects with CRP levels >3 mg/L then had their risk profiles adjusted by adding 1 risk factor and multiplying their Framingham risk scores by 1.5. Subjects had their low-density lipoprotein (LDL) cholesterol goals adjusted as necessary and were then recategorized as above or below their CRP-adjusted LDL cholesterol goal. LDL cholesterol goals were met initially by 67.8% (116 +/- 8 million) of United States residents, and 64.8% (111 +/- 8 million) achieved their LDL cholesterol goals after CRP adjustment. Thus, 5.3 +/- 1.1 million of the population (3.1 +/- 0.1%) had their risk modified in a clinically meaningful way by CRP adjustment. Targeting the screening to 2 groups, those with 1 risk factor and LDL cholesterol levels 130 to 159 mg/dl and those with moderately high risk and LDL cholesterol levels 100 to 129 mg/dl, we were able to identify all 5.3 million by screening only 14.8 million, achieving a screening yield of 35%. In conclusion, population-based screening with CRP provided a clinical impact for only 3.1% of United States residents. Patients with 1 risk factor and LDL cholesterol levels of 130 to 159 mg/dl and those with moderately high risk and LDL cholesterol levels of 100 to 129 mg/dl represent high-yield subgroups for routine CRP screening.

Platelet-derived growth factor receptor antagonist STI571 (imatinib mesylate) inhibits human vascular smooth muscle proliferation and migration in vitro but not in vivo.

BACKGROUND: Cell-specific inhibition of vascular smooth muscle cells, the primary constituent of neointima following arterial injury, without deleterious effects on vascular endothelial cell function may be a critical requirement for drug-eluting stents that are not prone to excess late thrombosis. We hypothesized that imatinib mesylate (Gleevec, Glivec, formerly known as STI571), a relatively selective inhibitor of protein tyrosine kinases including platelet-derived growth factor receptor (PDGFR), would inhibit hCASMC proliferation and migration in vitro with little effect on endothelial cell proliferation and prevent restenosis in a swine balloon injury model. METHODS: Proliferation and migration of stimulated human vascular smooth muscle and endothelial cells were quantified in cell culture in the presence of imatinib (0.001 to 10 M). Imatinib-loaded drug-eluting stents were implanted in swine coronary arteries after predilatation with an oversized balloon, and neointimal proliferation was measured by quantitative angiography and histopathology. RESULTS: Increasing doses of imatinib-inhibited autophosphorylation of the PDGFR and its downstream effects of proliferation and migration of human CASMC in a dose-responsive manner, yet had no effect on stimulated human aortic endothelial cells. However, imatinib-eluting stents had no effect on neointimal proliferation and restenosis in a standard porcine in-stent restenosis model compared to bare-metal or unloaded polymer-coated stents. CONCLUSION: We conclude that imatinib is a potent inhibitor of proliferation and migration of human vascular smooth muscle cells in vitro, but has no effect on human vascular endothelial cell proliferation. However, the lack of an in vivo effect on neointimal proliferation in a standard porcine coronary overstretch model does not support the use of imatinib mesylate for localized drug delivery in the prevention of in-stent restenosis.

Transient left ventricular apical ballooning: a review of the literature.

Transient left ventricular apical ballooning is a newly defined syndrome characterized by sudden onset of chest symptoms, electrocardiographic changes characteristic of myocardial ischemia, transient left ventricular dysfunction-particularly in the apical region, low-grade troponin elevation, and no significant coronary stenosis by angiogram. This syndrome is also referred to as Takotsubo cardiomyopathy, "Ampulla" cardiomyopathy, Human Stress cardiomyopathy, and Broken Heart Syndrome. Emergency physicians, family physicians, general internists, and cardiologists may all encounter this syndrome at the point of contact. The similarity to acute coronary syndrome requires all clinicians who may potentially care for these patients to familiarize themselves with this newly recognized disease. We provide a recent case and review the current literature surrounding this syndrome.