Drug-coated balloon angioplasty, intraoperatively through left anterior descending arteriotomy access, a novel hybrid revascularization strategy: a case report.

Background: Patients undergoing coronary artery bypass graft (CABG) sometimes have critical proximal lesion in left anterior descending (LAD) artery or chronic total occlusion followed by either skip lesions or diffuse disease of late mid-to-distal LAD artery. Such lesions require endarterectomy or atheroma bridging via long venous or arterial patch (patch-plasty), for which clinical outcomes are conflicting in studies due to a more thrombogenic milieu created by patch-plasty as well as incomplete endarterectomy. We present a hybrid approach with drug-coated balloon (DCB) angioplasty of mid-to-distal LAD through LAD arteriotomy followed by left internal mammary artery (LIMA) insertion to LAD. Case summary: A 35-year-old man who was thrombolyzed for anterior wall myocardial infarction in another city, reported to our hospital four weeks later with persistent angina. Coronary angiography showed severe multivessel coronary artery disease. There was diffuse disease in LAD distal to potential site of LIMA insertion and needed patch-plasty. We carried out a hybrid procedure by performing DCB angioplasty of mid-to-distal LAD through the LAD arteriotomy site during CABG followed by LIMA insertion to the LAD. The patient remained asymptomatic post procedure with a 6-month follow-up computerized tomography scan showing patent LIMA and mid-to-distal LAD. Discussion: This case shows a novel technique, first in the world, of performing angioplasty during CABG through arteriotomy followed by graft insertion.

It's a Trap: A Case of Strangulated Coronary Guidewire and Longitudinal Stent Deformation in the Right Coronary Artery.

BACKGROUND Strangulation of the coronary guidewire is an infrequent complication of percutaneous coronary intervention (PCI), and it can lead to disastrous outcomes of stent thrombosis, vessel occlusion, and vessel damage. CASE REPORT Early-generation stents were made from stainless steel and had a bulky design as compared to cobalt-chromium or platinum chromium alloys, which have superior trackability at the cost of a thin core and low-strength struts, resulting in increased incidence of longitudinal stent deformation. We present a case of a 62-year-old active smoker with effort angina of Canadian Cardiovascular Society (CCS) class III. His coronary angiogram revealed a totally occluded right coronary artery (RCA). After placing 2 coronary guidewires (Run-through and Balanced middle-weight), Xience Xpedition (3.25×48 mm) and Promus Element (2.75×32 mm) were deployed through the whole length of the RCA. While placing the distal stent, the guidewire securing the posterior left ventricular (PLV) was trapped between 2 stents and all attempted maneuvers were unsuccessful in retrieving the wire. The stents sustained longitudinal deformation by the guide catheter, and subsequent arteriotomy for stent and wire retrieval and coronary artery bypass graft surgery were (CABG) performed. CONCLUSIONS Despite the remarkable safety profiles of the percutaneous equipment, complications still occur even with experienced operators. Calcified and tortuous vessels are primarily at risk for wire strangulation between stents or side-branches, and better deliverability of newer drug-eluting stents (DES) comes at the cost of reduced longitudinal strength.

Coronary Artery Calcium Score: Assessment of SYNTAX Score and Prediction of Coronary Artery Disease.

Background With the advent of modern imaging technologies, non-invasive assessment of the coronary system is not only possible but its complexity and plaque burden can be quantified. This study aims to determine whether calcium score on computed tomography coronary angiography (CTCA) can be associated with the complexity of coronary artery disease (CAD), which is determined by the SYNTAX score on coronary angiography, as well as to determine which cut-off value of coronary artery calcium (CAC) score can predict severe CAD in our population. Methodology This was a cross-sectional study conducted at the Rawalpindi Institute of Cardiology, Pakistan from January 2019 to March 2020. The calcium score of all patients with low-to-intermediate pretest probability of CAD was calculated on CTCA. All patients who had significant disease on CTCA were subjected to conventional coronary angiography and SYNTAX score was calculated, which was later used to determine the association between calcium and SYNTAX score. Results A total of 90 patients were included in the study. CAC and SYNTAX score were found to be positively correlated (Pearson coefficient [r] = 0.354; p = 0.001). The total CAC score with a cut-off value of 212 recognized patients with the SYNTAX score of >27. The sensitivity was 66.7% and specificity was 70.5% with an area under the curve of 0.743. The mean calcium score of patients in our study group was 223, with the maximum score of 1,216 and the minimum score of zero. Conclusion A CAC score greater than 212 is associated with a high SYNTAX score indicating complex disease. Only age is an independent predictor of calcium score.

Elevated D-Dimers and Right Ventricular Dysfunction on Echocardiography for Diagnosis of Pulmonary Embolism: A Validation Study.

Background There is an increasing need to explore other non-invasive techniques for the diagnosis of pulmonary embolism in resource-limited countries. Objective To assess the validity of elevated D-dimer levels and right ventricular (RV) dysfunction on echocardiography in predicting definite massive pulmonary embolism among patients diagnosed with massive pulmonary embolism using computed tomography (CT) pulmonary angiography as the gold standard. Methods The patients with acute massive pulmonary embolism on CT pulmonary angiography were included. The participants underwent 12-lead electrocardiography, assessment of D-dimer levels, and bedside echocardiography to determine right ventricular dysfunction. The data were recorded on a proforma and analyzed using IBM SPSS software version 26.0 (IBM Corp., Armonk, NY). Results There were 160 patients in the study. The mean age was 49.19 ± 14.89 years. Elevated D-dimer levels were seen in 80.60% of the patients whereas ventricular dysfunction on echocardiography was seen in 90.00% of the patients. The sensitivity and specificity of elevated D dimer levels were 78.99% and 14.60%, respectively. The positive predictive values (PPV) and negative predictive values (NPV) for elevated D-dimer levels were 72.87% and 19.35%, respectively. In contrast, the sensitivity of ventricular dysfunction was 94.96% and specificity 24.39%. PPV was found to be 78.47% and NPV was 62.50%. Conclusion Positive D-dimer levels and ventricular dysfunction on echocardiography are sensitive enough to consider the diagnosis of massive pulmonary embolism but lack adequate specificity, thus, necessitating the presence of other noninvasive tests.

Adverse Events in Primary Percutaneous Coronary Angioplasty With Drug-Eluting Stents Compared With Drug-Coated Balloons: A Retrospective Outlook.

Objective To compare drug-eluting stents (DES) with drug-coated balloons (DCBs) in terms of major adverse cardiovascular and cerebrovascular events (MACCE) in patients who have undergone primary percutaneous coronary intervention (PPCI). Methodology Out of 210 angioplasties in six months, 80 patients were included; 40 in DES and 40 in DCB, respectively. All had a successful PPCI. It was defined as the achievement of thrombolysis in myocardial infarction (TIMI) grade II/III with <20% residual stenosis for the DES and TIMI grade II/III with <30% residual stenosis for the DCB. Any subsequent MACCE during the ensuing six months were assessed from emergency/outpatient records during their subsequent hospital visits, hospital registry, and telephonic interviews. Results The mean age in the DES group was 54.83 + 8.72 years while it was 56.8 + 8.9 years in the DCB group. The left anterior descending artery (LAD) was the culprit artery in the majority of the cases in both groups. The mean diameter of DES and DCB was 3.17 + 0.38 mm and 2.75 + 0.53 mm, respectively. Overall, 15 adverse events were seen in the DES group and 16 in the DCB group. The difference was insignificant (P-value = ≥ 0.999). There were nine hospitalizations due to chest pain in the DES group and eight in the DCB group. Total vessel revascularization (TVR) was seen in two patients in the DES group and three patients in the DCB group. None of the patients suffered a stroke. All variables of MACCE were non-significant (P-value = ≥ 0.999). Conclusion DCB appears to be non-inferior to DES in PPCI at a median follow-up of six months.

Everolimus-eluting bioresorbable coronary scaffold in Asian patients: A 2-year follow-up.

Indo-Pakistan population has one of the highest risk of coronary artery disease (CAD) in the world. Percutaneous interventions with the use of stents has been the mainstay of treatment for CAD, evolving from balloon angioplasty to bare metal stents and then to drug eluting stents. However, there are a few drawbacks related to the metal implant in the coronary, leading to the development of bio-resorbable vascular scaffolds (BVS). This case series studies the implantation techniques and 24 month clinical outcome of bioresorbable stent Absorb at Rawalpindi Institute of Cardiology. From November 1, 2013 till June 30, 2018. Fifty patients undergoing angioplasty with Absorb BVS as elective or primary PCI were enrolled. Case selection was at the discretion of the operator. Patients were followed up clinically. Repeat angiogram was conducted if clinically indicated. The study population involved patients with mean age of 42±8.82. Fourty three (86%) were male and most had single or double vessel disease. The most common treated coronary was left anterior descending. Most of the lesions were predilated with 1:1 sizing. Most scaffolds were post dilated with 0.5mm larger diameter non-compliant balloon at nominal pressure. Angiographic success rate was 92%. On follow up, 4% had stent thrombosis (ST) (compared to <1% for latest generation drug eluting stents (DES) as per available literature). No death was reported. Majority of those with ST had longer median treated lesion length than those without stent thrombosis (32mm versus 28mm). Stent thrombosis occurred in 7.7% of cases with overlapping BVS while 2.8% in single BVS patients. To conclude, current generation Biovascular scaffold has higher thrombosis rates as compared to latest generation DES. Procedure/lesion related risk factors may predispose in addition to the thick stent struts.

Correction to: Caregiver Voices: Cross-Cultural Input on Improving Access to Autism Services.

Please note that the middle name of coauthor Francisco Reinosa Segovia was misspelled (as "Rienosa") is this article as originally published.

Caregiver Voices: Cross-Cultural Input on Improving Access to Autism Services.

Decades of research have established that racial ethnic minority, low-income, and/or non-English speaking children with autism spectrum disorder (ASD) are diagnosed later than white children, and their families experience greater difficulty accessing services in the USA. Delayed access to timely diagnosis and early intervention may impact child outcomes and family quality of life. Despite their cognition of these disparities and their significant impact on the lives of those affected, explanations for the barriers experienced by underserved families are elusive, likely due to the complex interaction between structural and family factors. This study used qualitative methods to gather family and provider perspectives of perceived barriers and facilitators to obtaining an ASD diagnosis and accessing ASD-related services for underserved families. Themes from focus groups and interviews with families from three cultural groups (black, Hispanic/Latino, and Korean) and three primary languages (English, Korean, and Spanish) highlight specific barriers related to family, community, and systemic challenges as well as facilitators to accessing care for these populations. Family experiences are expanded upon with viewpoints from the providers who work with them. Recommendations are made for reducing disparities in the existing ASD service system including increasing professional, family, and community education; increasing culturally responsive care; improving provider-family partnerships; and addressing practical challenges to service access.

Clinical profile of patients presenting with acute ST elevation myocardial infarction.

OBJECTIVE: To identify risk factors and clinical profile of the patients presenting with acute ST Elevation Myocardial Infarction (STEMI). METHODS: This prospective observational study was carried out from April to September 2005. The 300 consecutive patients presenting with typical electrocardiographic changes of acute ST elevation myocardial infarction to the Emergency Department of our hospital were recruited in the study. The physician (a fellow) on duty assessed the patients and documented the predefined independent variable and patients characteristics. The clinical history revealed information about age, gender, risk factors, modes of presentation and duration of symptoms. The details of physical examination including anthropometric data, vital signs and complete systemic evaluation were recorded. The regions of infarction and rhythm disturbances were also documented. RESULTS: This study was predominantly male dominated 234 (78%) patients, with a mean age of 58 +/- 11 years. Cigarette smoking was identified as a major risk factor in 138 (46%) patients. The least common risk factor i.e. obesity (BMI >25) was present in 12 (4%) patients. Majority of the patients, 282 (94%) presented with typical chest pain and within first six hours of onset of symptoms 216 (72%). Most of the patients 240 (80%) had normal examination at presentation and 60 (20%) had signs of Left Ventricle Failure. Isolated inferior and anterior myocardial infarction was noted in 138 (46%) and 48 (16%) patients respectively. Normal electrocardiographic rhythms at presentation were observed in 282 (94%) patients. CONCLUSION: Acute myocardial infarction was more common in adult males with smoking being the major risk factor. Most of the patients presented with typical chest pain and within six hours of onset of symptoms. The majority of patients demonstrated normal physical examination and cardiac rhythm. Inferior myocardial infarction was the most common lesion.

Control of severe bleeding episode in case of Glanzmann's thrombasthenia refractory to platelet transfusion therapy by administering recombinant factor VIIa.

Glanzmann's thrombasthenia is an autosomal recessive inherited platelet function defect. Though, quantitatively normal, the aggregation ability of platelets is reduced leading to bleeding episodes requiring transfusion of platelet concentrates. We describe a case of 13-year-old girl who had recurrent episodes of epistaxis since birth and was managed with multiple platelet concentrate transfusions and recently admitted with severe epistaxis refractory to platelet transfusion. At this stage administration of recombinant activated factor VII (fVIIa) was considered, which was initially given at 90 microg/kg dose with little control of bleeding but subsequent second dose of 120 microg/kg was administered with excellent response and immediate control of bleeding.

N-butyl-2-cyanoacrylate and lipoidol pulmonary embolism (glue embolism).

Glue embolisation is a rare happening and many clinicians who evaluate patients for post sclerotherapy problems may be unaware of this complication. We present a case of pulmonary embolism in a patient of cirrhosis liver secondary to gastric variceal sclerotherapy with N-Butyl-2-cyanoacrylate and lipoidol solution. This is also called glue embolism.

Pulmonary embolism at high altitude and hyperhomocysteinemia.

This case report describes pulmonary embolism in a patient as a complication of extended stay at high altitude. He also had increased plasma homocysteine levels. Hypercoagulability at high altitude along with hyperhomocysteinemia is a risk factor for arterial and venous thrombosis.