Calcified Coronary Lesions Treated With Intravascular Lithotripsy: One-Year Outcomes

Calcified lesions often increase the complexity of percutaneous coronary intervention (PCI) and risk of future adverse events. Shockwave intravascular lithotripsy (S-IVL; Shockwave Medical) has been shown to be an effective calcium-modification tool in preparing calcified coronary lesions prior to stent placement. Its circumferential, pulsatile soundwaves provide a different mechanism to fracture calcium compared with existing devices such as rotational atherectomy and cutting balloons. Although short-term safety outcomes have been positive, longer-term outcomes have yet to be reported. We previously described the first real-world series of PCI involving S-IVL, including use in acute coronary syndromes and left main interventions. We report the 1-year outcomes of patients treated with S-IVL during their PCI.

Treatment of Heavily Calcified Unprotected Left Main Disease With Lithotripsy: The First Case Series

We present the first case series using Shockwave Intravascular Lithotripsy (S-IVL; Shockwave Medical), a novel coronary calcium modification device, in patients with heavily calcified unprotected left main (LM) coronary artery disease (CAD). Decisions regarding surgical vs percutaneous revascularization in LM-CAD patients are based on anatomical complexity and perceived surgical risk. In this series, we present the use of S-IVL in a patient with LM-CAD with multivessel disease who declined surgery, a patient with an isolated LM-CAD and severe cardiomyopathy, and a late nonagenarian patient where surgical revascularization was not an option.

Shockwave Intravascular Lithotripsy of Calcified Coronary Lesions in ST-Elevation Myocardial Infarction: First-in-Man Experience

We present the first cases of Shockwave intravascular lithotripsy (S-IVL; Shockwave Medical), a novel coronary calcium modification device, being used in patients undergoing percutaneous coronary intervention for ST-elevation myocardial infarction (STEMI). The 3 presented cases include an upfront use of S-IVL in a right coronary artery, an in-stent restenosis, and a community cardiac arrest/STEMI equivalent where S-IVL was used as a bail-out technique to facilitate stent delivery in a tortuous calcified vessel.

Shockwave Intravascular Lithotripsy for Calcified Coronary Lesions: First Real-World Experience

BACKGROUND

Calcified coronary lesions often cause suboptimal stent expansion, which is one of the greatest predictors of adverse outcomes such as stent thrombosis and restenosis. Shockwave intravascular lithotripsy (S-IVL; Shockwave Medical, Inc) is a recently approved technique used in the treatment of heavily calcified coronary lesions. We present our early real-world experience with the S-IVL device.

METHODS

All patients treated with S-IVL between October 2018 and January 2019 during their percutaneous coronary intervention (PCI) at our center were included.

RESULTS

During this period, a total of 26 patients undergoing PCI were treated with S-IVL prior to stent deployment (69% male; age, 72 ± 8 years). Indications for PCI were acute coronary syndromes (ACS) in 14 patients (54%), stable angina in 11 patients (42%), and PCI before transcatheter aortic valve implantation in 1 patient (4%). Seventy-one percent of the ACS cases undergoing PCI with S-IVL were to the perceived ACS culprit lesion during the index procedure, while 29% were staged PCIs to severe non-culprit lesions. Upfront S-IVL usage occurred in 58% of cases; the rest were bail-out procedures due to suboptimal initial balloon predilation. S-IVL was used most commonly in the left anterior descending coronary artery (50%), with 1.3 ± 0.5 stents implanted/target vessel. Angiographic success (<20% residual stenosis) occurred in all cases, with no procedural complications.

CONCLUSION

S-IVL appears to be a useful modality in coronary calcium modification to optimize stent expansion. This device obviates the need for more complex lesion preparation strategies such as rotational atherectomy, except in severe undilatable cases where S-IVL is impossible. Further study is warranted to compare different calcium modification devices with conventional balloon angioplasty.

Extensive intracardiac thrombi in a patient with heart failure and hepatic congestion: a case report

Background

Left ventricular (LV) thrombi is a complication associated with anterior ST-elevation myocardial infarction, dilated cardiomyopathies, or LV aneurysms. Right sided intracardiac thrombi may be associated with other prothrombotic causes.

Case summary

A 66-year-old man admitted with congestive heart failure was found to have extensive intracardiac masses on transthoracic echocardiography and cardiac magnetic resonance imaging (MRI). This occurred in the absence of a recent myocardial infarction. During his hospital stay, he was found to have deranged liver enzymes and coagulation profile due to hepatic congestion. The patient was presumed to have intracardiac thrombi and was treated with warfarin therapy. There was complete resolution of the masses on repeat cardiac MRI after 4 weeks of treatment, confirming the diagnosis.

Discussion

Cardiac MRI is useful in the diagnosis of intracardiac thrombi. Clinicians should appreciate the prothrombotic risks associated with liver disease, despite the inability of standard coagulation tests to quantify this risk.

Diagnosis and Management of Post-myocardial Infarction Ventricular Septal Defects

As the treatment of acute myocardial infarction has evolved from conservative management to thrombolysis and, in more recent times, primary angioplasty, the incidence of ventricular rupture, in particular post-infarction ventricular septal defect (VSD), appears to have fallen. In this article we discuss the clinical presentation and investigation of post-infarction VSD, the natural history as well as surgical and percutaneous interventional management and outcomes. Very limited published information is available from small series reports with the inherent limitation of selection bias. Survival is clearly enhanced by surgical or percutaneous intervention. Overall outcomes remain suboptimal but do appear to be significantly better in the absence of cardiogenic shock and if the procedure can be deferred, factors which are clearly related. Further research is required in this difficult field.