Feasibility of in vitro calcification plaque disruption using ultrasound-induced microbubble inertial cavitation

Percutaneous transluminal coronary angioplasty (PTCA) is a clinical method in which plaque-narrowed arteries are widened by inflating an intravascular balloon catheter. However, PTCA remains challenging to apply in calcified plaques since the high pressure required for achieving a therapeutic outcome can result in balloon rupture, vessel rupture, and intimal dissection. To address the problem with PTCA, we hypothesized that a calcified plaque can be disrupted by microbubbles (MBs) inertial cavitation induced by ultrasound (US). This study proposed a columnar US transducer with a novel design to generate inertial cavitation at the lesion site. Experiments were carried out using tubular calcification phantom to mimic calcified plaques. After different parameters of US + MBs treatment (four types of MBs concentration, five types of cycle number, and three types of insonication duration; n = 4 in each group), inflation experiments were performed to examine the efficacy of cavitation for a clinically used balloon catheter. Finally, micro-CT was used to investigate changes in the internal structure of the tubular plaster phantoms. The inflation threshold of the untreated tubular plaster phantoms was > 11 atm, and this was significantly reduced to 7.4 ± 0.7 atm (p = 5.2E-08) using US-induced MBs inertial cavitation at a treatment duration of 20 min with an acoustic pressure of 214 kPa, an MBs concentration of 4.0 × 108 MBs/mL, a cycle number of 100 cycles, and a pulse repetition frequency of 100 Hz. Moreover, micro-CT revealed internal damage in the tubular calcification phantom, demonstrating that US-induced MBs inertial cavitation can effectively disrupt calcified plaques and reduce the inflation threshold of PTCA. The ex vivo histopathology results showed that the endothelium of pig blood vessels remained intact after the treatment. In summary, the results show that US-induced MBs inertial cavitation can markedly reduce the inflation threshold in PTCA without damaging blood vessel endothelia, indicating the potential of the proposed treatment method.

Pseudoaneurysm of the mitral-aortic intervalvular fibrosa: a rare case after percutaneous transluminal coronary angioplasty

BACKGROUND

Pseudoaneurysm of the mitral-aortic intervalvular fibrosa (P-MAIVF) is an uncommon but potentially life-threatening condition. The most common pathogenic factors of P-MAIVF are infective endocarditis and surgical valve operation. Here, we report a rare case of P-MAIVF which occurred one year after percutaneous transluminal coronary angioplasty (PTCA).

CASE PRESENTATION

A 31-year-old man developed a P-MAIVF one year after PTCA. Transthoracic echocardiography (TTE) revealed a pseudoaneurysm between the aortic root and the left atrium. Three-dimensional transesophageal echocardiography (3D-TEE) clearly demonstrated the orifice of the pseudoaneurysm. This case was initially diagnosed by ultrasound, and the prognosis was good after surgical repair.

CONCLUSIONS

We report a rare case of P-MAIVF that occurred one year after PTCA.

Crystalline sirolimus-coated balloon (cSCB) angioplasty in an all-comers, patient population with stable and unstable coronary artery disease including chronic total occlusions: rationale, methodology and design of the SCORE trial

BACKGROUND

A decade ago, the iopromide-paclitaxel coated balloon (iPCB) was added to the cardiologist's toolbox to initially treat in-stent restenosis followed by the treatment of de novo coronary lesions. In the meantime, DES technologies have been substantially improved to address in-stent restenosis and thrombosis, and shortened anti-platelet therapy. Recently, sirolimus-coated balloon catheters (SCB) have emerged to provide an alternative drug to combat restenosis.

METHODS

The objective of this study is to determine the safety and efficacy of a novel crystalline sirolimus-coated balloon (cSCB) technology in an unselective, international, large-scale patient population. Percutaneous coronary interventions of native stenosis, in-stent stenosis, and chronic total occlusions with the SCB in patients with stable coronary artery disease or acute coronary syndrome were included. The primary outcome variable is the target lesion failure (TLF) rate at 12 months, defined as the composite rate of target vessel myocardial infarction (TV-MI), cardiac death or ischemia-driven target lesion revascularization (TLR). The secondary outcome variables include TLF at 24 months, ischemia driven TLR at 12 and 24 months and all-cause death, cardiac death at 12 and 24 months.

DISCUSSION

Since there is a wealth of patient-based all-comers data for iPCB available for this study, a propensity-score matched analysis is planned to compare cSCB and iPCB for the treatment of de novo and different types of ISR. In addition, pre-specified analyses in challenging lesion subsets such as chronic total occlusions will provide evidence whether the two balloon coating technologies differ in their clinical benefit for the patient.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Identifier: NCT04470934.

Release of MMP-2 in the circulation of patients with acute coronary syndromes undergoing percutaneous coronary intervention: Role of platelets

INTRODUCTION

Matrix metalloproteinases (MMPs) of atherosclerotic tissue contribute to plaque rupture triggering acute coronary syndromes (ACS). Several MMPs, including MMP-2, are also contained in platelets and released upon activation. An increase in circulating levels of MMP-2 has been reported in patients undergoing percutaneous coronary interventions (PCI), but its time-course and origin remain unclear. Aims of our study were to assess the time-course of MMP-2 release in blood of stable and unstable coronary artery disease patients undergoing PCI and to unravel the possible contribution of platelets to its release.

METHODS

Peripheral blood samples were drawn immediately before, 4 and 24 h after PCI from patients with ACS (NSTEMI or STEMI, n = 21) or with stable angina (SA, n = 21). Platelet-poor plasma and washed platelet lysates were prepared and stored for subsequent assay of MMP-2 and β-thromboglobulin (β-TG), a platelet-specific protein released upon activation.

RESULTS

Plasma MMP-2 and β-TG increased significantly 4 h after PCI and returned to baseline at 24 h in ACS patients, while they did not change in SA patients. Platelet content of MMP-2 and β-TG decreased significantly 4 h after PCI in patients with ACS, compatible with intravascular platelet activation and release, while they did not change in patients with SA.

CONCLUSIONS

PCI triggers the release of MMP-2 in the circulation of ACS patients but not in that of patients with SA. Platelets activated by PCI contribute to the increase of plasma MMP-2 releasing their MMP-2 content. Given that previous mechanicistic studies have shown that MMP-2 may sustain platelet activation and unstabilize downstream-located plaques and in the long term favour restenosis and atherosclerosis progression, these data may encourage the search for therapeutic agents blocking MMP-2 release or activity in ACS.

The effect of sexual counseling on depression, anxiety, stress, sexual knowledge and sexual quality of life in men who have undergone invasive coronary interventions: An RCT

Background

Sexual dysfunctions are common in men with ischemic heart disease, especially in men undergoing therapeutic interventions.

Objective

This study intended to assess the effect of counseling on depression, anxiety, stress, sexual knowledge and sexual quality of life in men after invasive coronary interventions in the post catheterization department of Kashan Shahid Beheshti Hospital during 2018.

Materials and Methods

The study population consisted of 54 male participants who had undergone an invasive coronary intervention. The intervention group received counseling and the control group underwent the standard ward routine. Data were collected using the depression anxiety stress scales, Abraham's sexual quality of life, and the Yi-Hung Sexual Knowledge questionnaires before discharge and also two months later.

Results

Within two months, the intervention group's mean score of sexual knowledge significantly increased, compared with the control group, from 12.37 to 14.81 (p ≤ 0.001). The intervention group's mean score of sexual quality of life also significantly increased, compared with the control group, from 48.2 to 60.7 (p ≤ 0.001). Moreover, the mean anxiety score changed in the intervention group from 11.18 to 5.25, again a significant difference compared with the control group (p = 0.01). But, the differences in the depression and stress scores were not significant.

Conclusion

Our findings suggest that sexual counseling may improve sexual knowledge, sexual quality of life and anxiety in men following invasive coronary intervention, but might not reduce their stress or depression. Further studies are needed to confirm these findings.

Added burden of major depressive disorder on cardiovascular morbidity and mortality among patients with cardiovascular disease and the modifying effects of antidepressants: A national retrospective cohort study

BACKGROUND

To evaluate the likelihood of a future cardiovascular event (i.e., in-hospital mortality or cardiovascular disease [CVD] complications/interventions) among patients with CVD and major depressive disorder (MDD) compared to those without MDD, and the antidepressant use on future cardiovascular events between the two groups.

METHODS

This is a retrospective cohort with propensity score matching with 8941 patients with CVD and MDD, and 8941 non-MDD patients using data from the Longitudinal Health Insurance Database from 1999 to 2013 in Taiwan. The outcome was in-hospital mortality and the incidence of revascularization (i.e., percutaneous transluminal coronary angioplasty [PTCA] and coronary artery bypass graft surgery [CABG]).

RESULTS

Patients with CVD and MDD were more likely to need revascularization (an adjusted hazard ratio [aHR]: 1.26 and 95% CI: 1.12-1.43) than those without MDD, regardless of whether PTCA (aHR: 1.23 and 95% CI: 1.07-1.40) or CABG (aHR: 1.60 and 95% CI: 1.16-2.21) had occurred. Antidepressant use was associated with a tendency of reduced risk of mortality (aHR: 0.92 and 95% CI: 0.84-1.00). Although the magnitude of aHR ranged from 0.92 to 0.95 with revascularization, they did not reach significant levels.

LIMITATIONS

Some covariates could not be controlled because they were not included in the national register dataset, and the causality is limited in an observational study.

CONCLUSIONS

Patients with CVD with MDD are more likely to experience a cardiovascular complication requiring intervention than CVD patients without MDD. Antidepressant use is associated with reduced in-hospital mortality.

Depression anticipates patients at risk of poor exercise stress test performance after percutaneous coronary angioplasty: A short-term longitudinal study

AIMS

The exercise stress test is commonly used to assess physical capacity and recovery in coronary artery disease (CAD) patients after percutaneous transluminal coronary angioplasty (PTCA). Despite depressive symptoms have been consistently associated with adverse outcomes in CAD patients, they are rarely considered as risk factors of poor exercise test. The present study investigated the influence of depressive symptoms, along with anxiety, sleep problems and perceived health on exercise test in PTCA patients.

METHODS

One hundred and sixty-five patients who underwent PTCA completed the Beck Depression Inventory-II (BDI-II), the Beck Anxiety Inventory, the Sleep Condition Index and the 12-item Short-Form Health Survey and, after 20 days, underwent exercise stress test.

RESULTS

Higher BDI-II scores significantly predicted lower maximal workload measured in metabolic equivalents (METs; β = -0.13; p = .030), shorter total exercise duration (β = -5.23; p = .034) and the inability to reach maximum heart rate during exercise test (OR = 1.07; p = .032), even after controlling for relevant sociodemographic and biomedical risk factors.

CONCLUSIONS

Depressive symptoms specifically predicted worse exercise stress test performance in patients after PTCA, controlling for common risk factors. Focusing on the assessment of depressive symptoms, in addition to sociodemographic and biomedical risk factors, is essential to anticipate patients at risk of poor physical capacity after PTCA.

Optimal Medical Treatment vs. Invasive Approach in Patients with Significantly Obstructive Coronary Artery Disease and Ischemia

INTRODUCTION

Stable ischemic heart disease (SIHD) is a condition that develops in subjects after myocardial infarction. Evidence suggests that optimal medical treatment (OMT) is not inferior to intervention (INT) using percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG).

AIM

To compare clinical outcomes in subjects with SIHD who only received OMT and those who received INT+OMT.

METHODS

We retrospectively examined subjects with SIHD who underwent myocardial perfusion study-SPECT/CT in a reference center in Mexico. We assigned two branches: INT+OMT (subjects with previous PCI or CABG) and OMT (subjects with antiplatelet drugs, β-blockers, renin-angiotensin-system blockade, nitrates, calcium-channel blockers, and aggressive lipid-lowering therapy). Clinical outcomes at follow-up were angina relief, functional class improvement, hospitalization, myocardial reinfarction and death from any cause.

RESULTS

We included 100 subjects; 51 with OMT and 49 with INT+OMT. 54 subjects had 1 affected vessel and 46 more than 2. INT+OMT group had up to 14 fold likelihood (95% CI: 3.38-63.35) of achieving angina relief and 2.2 fold likelihood (95% CI: 0.92-5.57, p = 0.077) for functional class improvement. No differences were found in hospitalization, myocardial infarction and death from any cause compared to OMT.

CONCLUSIONS

Subjects with OMT have no higher risk of adverse clinical outcomes compared to INT+OMT. However, the INT+OMT provides angina relief and functional class improvement compared to OMT.

Contrast agent dose and slow/no-reflow in percutaneous coronary interventions : A case-control study of patients with non-ST-segment elevation acute coronary syndromes

BACKGROUND

The angiographic slow/no-reflow phenomenon after primary percutaneous coronary intervention carries a poor prognosis for patients with non-ST-segment elevation acute coronary syndrome (NSTEACS). There is evidence that contrast agents cause endothelial dysfunction, myocardial cell damage, and coronary spasms. We hypothesized that the contrast agent dose may be related to slow/no-reflow in patients with NSTEACS undergoing percutaneous transluminal coronary angioplasty and stent (PTCA + stent).

PATIENTS AND METHODS

We enrolled 3369 patients with NSTEACS who underwent PTCA + stent only in the culprit vessel for the first time from September 2007 to May 2017 in this study. Coronary blood flow of ≤TIMI grade 2 after PTCA + stent was defined as slow/no-reflow. The relationship between the contrast agent dose and slow/no-reflow phenomenon was analyzed by multivariate conditional logistic regression and smooth curve fitting.

RESULTS

In multivariable conditional logistic regression analysis, the contrast agent dose was found to be an independent risk factor for slow/no-reflow after adjusting for the number of stents and the thrombus burden (OR: 1.0112; 95% CI: 1.0049-1.0176; p < 0.0001), and after adjusting for type 2 diabetes mellitus, NSTEACS risk stratification, application of platelet glycoprotein (GP) IIB/IIIA receptor antagonists, type of contrast agent, number of balloon dilatations, number of stents, and thrombus burden (OR: 1.0113; 95% CI: 1.0036-1.0191; p = 0.004). Further, the risk of slow/no-reflow increased significantly with the contrast agent level up to the inflection point of 160 ml.

CONCLUSION

The contrast agent dose may be a risk factor for slow/no-reflow phenomenon after PTCA + stent in patients with NSTEACS. When the dose was greater than 160 ml, the risk of slow/no-reflow increased significantly.

A Case of Severe Advanced Takayasu Arteritis with Acute Myocardial Infarction as First Manifestation

We present the case of a 53-year-old female who presented in the emergency room accusing chest pain, dyspnea to moderate physical strain and physical asthenia. The clinical exam highlighted the absence of pulse in the left upper limb, weak pulse at upper right and lower limbs. The angiography revealed severe coronary lesions, bilateral subclavian occlusion, bilateral renal artery occlusion, infrarenal aortic occlusion. The patient was diagnosed with Takayasu's disease. Sequential interventional revascularization was performed. Takayasu arteritis is a rare disease that can easily be overlooked. It can present with severe coronary lesions which require a complex interventional and medical management.

[Initial management of ST-elevation myocardial infarction in 2014: From guidelines to practices, survey of 176 French interventional cardiologists]

BACKGROUND

Real life management of myocardial infarction has not recently been evaluated in France.

AIMS

To describe ST-elevation myocardial infarction management in France in 2014 and to compare it with current guidelines.

METHODS

A multicentre study was performed. An e-mail questionnaire was sent to French interventional cardiologists. Demographic data of interventional cardiologists, procedural aspects of percutaneous coronary intervention, antithrombotic treatments and patient rehabilitation have been investigated.

RESULTS

One hundred and seventy-six answers were analysed. Most of centres realized more than 600 annual angioplasties. An average of 209 myocardial infarctions were managed per centre in 2014, more often in academic than in general or private centres (respectively 51, 32 and 17% of infarctions). Anti-GPIIbIIIa (34% of the cases) and thromboaspiration were not systematic but depend on patient's characteristics, according to guidelines. Radial access was favoured in 85% of the cases and increased for the last decade. Drug eluting stents were used in 62% of cases. Unfractionated heparin and enoxaparine accounted for more than 80% of anticoagulants treatments. Overall, use of clopidogrel was as high as that of prasugrel or ticagrelor although clopidogrel is recommended in second-line. Cardiovascular rehabilitation was proposed to more than 50% of patients.

CONCLUSION

In spite of heterogeneity of ST-elevation myocardial infarction management in 2014, real-life practices generally comply with current guidelines.

Large hematoma over the puncture site of percutaneous transluminal coronary angioplasty as a presenting sign of severe dengue infection

Dengue fever is a common arboviral infection all over the world. It is endemic in the tropical and subtropical areas of the world with periodic epidemics in these areas. In its severe form dengue patients may develop life-threatening bleeding manifestations. We report here a case of large hematoma formation precisely located over the puncture site of percutaneous transluminal coronary angioplasty as a presenting sign of severe dengue infection for its unusual occurrence. <Learning objective: Severe dengue including dengue shock syndrome is a potentially life-threatening condition. Dengue virus-induced coagulopathy and thrombocytopenia may further complicate cardiological interventions like percutaneous transluminal coronary angioplasty or coronary artery bypass grafting as such patients are already on antiplatelet drugs. Performing any cardiovascular intervention in an endemic area of dengue needs proper vigilance to avoid such potentially life-threatening complications.>.

Self-management of coronary heart disease in older patients after elective percutaneous transluminal coronary angioplasty

OBJECTIVE

To explore how older patients self-manage their coronary heart disease (CHD) after undergoing elective percutaneous transluminal coronary angioplasty (PTCA).

METHODS

This mixed methods study used a sequential, explanatory design and recruited a convenience sample of patients (n = 93) approximately three months after elective PTCA. The study was conducted in two phases. Quantitative data collected in Phase 1 by means of a self-administered survey were subject to univariate and bivariate analysis. Phase 1 findings informed the purposive sampling for Phase 2 where ten participants were selected from the original sample for an in-depth interview. Qualitative data were analysed using thematic analysis. This paper will primarily report the findings from a sub-group of older participants (n = 47) classified as 65 years of age or older.

RESULTS

78.7% (n = 37) of participants indicated that they would manage recurring angina symptoms by taking glyceryl trinitrate and 34% (n = 16) thought that resting would help. Regardless of the duration or severity of the symptoms 40.5% (n = 19) would call their general practitioner or an emergency ambulance for assistance during any recurrence of angina symptoms. Older participants weighed less (P = 0.02) and smoked less (P = 0.01) than their younger counterparts in the study. Age did not seem to affect PTCA patients' likelihood of altering dietary factors such as fruit, vegetable and saturated fat consumption (P = 0.237).

CONCLUSIONS

The findings suggest that older people in the study were less likely to know how to correctly manage any recurring angina symptoms than their younger counterparts but they had fewer risk factors for CHD. Age was not a factor that influenced participants' likelihood to alter lifestyle factors.

[Is the introduction of innovative methods in cardiovascular diagnostics and therapy to quick?]

Andreas Grüntzig can be regarded as the pioneer of modern cardiology. Based on the previous experiences of Charles Dotter in Portland, Oregon, and after many years of preparation as a young 38-year-old physician and consultant he carried out the first percutaneous transluminal coronary angioplasty (PTCA) in a 38-year-old patient in Zurich in 1977, supported by the cardiac surgeons A. Senning and M. Turina. Despite high ranking publications and early preparedness to share his experiences the development of PTCA stagnated and was met with great scepticism. The technique was new, technically difficult and aimed at aortocoronary bypass surgery, which was itself still in its infancy 10 years after the introduction in Cleveland in 1968. Even after several years only two patients per week were admitted for treatment in Zurich. In a similar way the young cardiac surgeon H.R. Andersen was a pioneer in Denmark whose ideas and own experiments with a balloon catheter-assisted aortic valve implantation were not initially taken up by the leading companies of the time and publication of the data suffered lengthy delays. It took 10 years before Prof. A. Cribier in Rouen followed up his ideas and carried out the first valve implantation again in pioneer work after many years of preparation in 2002. Again, the new method for treatment of very old and high risk patients needed many years before it was accepted. The breakthrough only became possible when this new technique began to be used in cardiac surgery after the introduction of hybrid cardiac catheter operating rooms. Despite evidence-based studies innovative methods are not subject to the same criteria throughout Europe with respect to the timely introduction of innovative and validated procedures also in consideration of reimbursement and this has become an important initiative of the European Society of Cardiology (ESC).

Cerebrovascular, cardiovascular and renal hypertensive disease after hypertensive disorders of pregnancy

BACKGROUND

Strong associations have been established in nationwide registry studies between hypertensive disorders of pregnancy (HDP) and later vascular morbidities and mortality. The aim of this case-control study is to examine the interdependent relationships of different predictive factors for vascular disease and HDP, because they are not clearly elucidated due to lack of detail in registries.

METHODS AND RESULTS

We assembled three different case groups of women who had cerebrovascular, cardiovascular, or hypertensive kidney disease before the age of 55. The control group consisted of age-matched women who underwent hysterectomy for benign reasons. We assessed the occurrence of HDP in previous pregnancies. The strength of the association with vascular morbidities was tested with multivariable logistic regression in comparison with classic vascular risk factors. In all case groups, previous HDP occurred more frequent than in the control group. In logistic regression analysis, previous HDP were the strongest predictor in the cerebrovascular group (OR 4.2; 95% confidence interval [CI] 1.6-11.0). In the cardiovascular group and the kidney failure group a similar association was found, however, this was not statistically significant (OR 4.4 (95% CI 0.82-4) and 2.9 (95% CI 0.61-14), respectively).

CONCLUSIONS

Previous hypertensive disorders of pregnancy are a strong predictor for later vascular morbidity. This is partially mediated through the presence of classic vascular risk factors, but our data suggest it is also an independent predictor.

The impact of side branch predilatation on procedural and long-term clinical outcomes in coronary bifurcation lesions treated by the provisional approach

INTRODUCTION AND OBJECTIVES

It is uncertain whether side branch predilatation before main vessel stenting is necessary. We evaluated the effect of side branch predilatation on outcomes in percutaneous coronary intervention for true nonleft main bifurcation determined by the Medina classification using the provisional approach.

METHODS

Target vessel failures (composite of cardiac death, myocardial infarction, or target vessel revascularization) were compared between patients who underwent side branch predilatation (predilatation group, n = 175) and those who did not (nonpredilatation group, n = 662).

RESULTS

Final kissing-balloon inflation (57.1% vs 35.8%; P < .001) was performed more frequently and the cross-over rate to a 2-stent technique (14.9% vs 5.1%; P < .001) was higher in the predilatation group. During a median follow-up of 21 months, the predilatation group had a higher incidence of target vessel failures (14.3% vs 6.8%; P = .002) and target vessel revascularization (12.0% vs 5.6%; P = .003), but not of cardiac death or myocardial infarction compared with the nonpredilatation group. On multivariate analysis, side branch predilatation was associated with a higher occurrence of target vessel failures (adjusted hazard ratio = 2.11; 95% confidence interval, 1.27-3.50; P = .004). These results remained consistent after a propensity score-matched population analysis (for target vessel failures, adjusted hazard ratio = 2.63; 95% confidence interval, 1.09-6.34; P = .0031) and they were also constant among the various subgroups, according to the bifurcation angle, calcification, and diameter stenosis of the side branch.

CONCLUSIONS

Side branch predilatation before main vessel stenting may be associated with an increased risk of repeat revascularization in patients with true nonleft main bifurcation treated by the provisional approach.

TRIAL REGISTRATION

ClinicalTrials.gov number: NCT00851526.

Optical coherence tomography guided PCI - initial experience at Apollo Health City, Jubilee Hills, Hyderabad

Background

The capability of OCT to examine the structure of the arterial wall before or after PCI is superior to those of other imaging modalities. Therefore the application of OCT during PCI seems logical and has the potential to enhance our performance during the PCI procedures.

Methods

OCT was performed in fifty-two patients out of which, 45 patients underwent PCI. Out of these 45 patients, in 25 patients both pre and post PCI OCT assessment was done. In 20 patients only post PCI OCT assessment was done. In seven patients PCI was not done due to nonsignificant obstruction, these seven patients were not included in final analysis.

Results

Over all OCT leads to management changes in 65% of the time it was used. Alteration of stent length was done in 56% of the cases when evaluated pre PCI. Alteration of stent diameter was done in 36% cases when evaluated pre PCI. Treatment of malapposition was done in 24% of total cases. Further balloon dilatation for vessel expansion was done in 15% of total cases. In one case left main stenting was done after proximal edge dissection.

Conclusion

OCT makes better visualization of plaque, thrombus, stent malapposition, dissection, plaque prolapse and helps in optimization of PCI results. More extensive, long-term studies will be needed to assess the prognostic implications of these findings.

Simultaneously Presented Acute Ischemic Stroke and Non-ST Elevation Myocardial Infarction in a Patient with Paroxysmal Atrial Fibrillation

Although atrial fibrillation is the most frequent cause of embolic stroke, coronary embolism from atrial fibrillation is a very rare cause of acute myocardial infarction. Therefore, simultaneously presented acute ischemic stroke and acute myocardial infarction due to atrial fibrillation in the same patient has not been documented. The present report describes the case of a 58-year-old man with paroxysmal atrial fibrillation who initially presented with a large cerebral infarction due to embolic occlusion of the left middle cerebral artery. Four hours after the diagnosis of cerebral embolism, he was subsequently diagnosed with acute myocardial infarction due to concurrent coronary embolism. He underwent successful coronary revascularization with a drug-eluting stent. The possibility of combined coronary embolism as a rare etiology should be kept in mind when a patient with acute embolic stroke presents, especially when there is evidence of acute myocardial infarction.

Effects of low dose pioglitazone on restenosis and coronary atherosclerosis in diabetic patients undergoing drug eluting stent implantation

PURPOSE

Thiazolidinediones are insulin-sensitizing agents that reduce neointimal proliferation and the adverse clinical outcomes associated with percutaneous coronary intervention (PCI) in patients with diabetes mellitus (DM). There is little data on whether or not low dose pioglitazone reduces adverse clinical outcomes.

MATERIALS AND METHODS

The study population included 121 DM patients with coronary artery disease and they were randomly assigned to 60 patients taking 15 mg of pioglitazone daily in addition to their diabetic medications and 61 patients with placebo after the index procedure with drug-eluting stents (DESs). The primary end points were rate of in-stent restenosis (ISR) and change in atheroma volume and in-stent neointimal volume. The secondary end points were all-cause death, myocardial infarction (MI), stent thrombosis and re-PCI.

RESULTS

There were no statistical differences in the clinical outcomes and the rate of ISR between the two groups [all-cause death; n=0 (0%) in the pioglitazone group vs. n=1 (1.6%) in the control group, p=0.504, MI; n=2 (3.3%) vs. n=1 (1.6%), p=0.465, re-PCI; n=6 (10.0%) vs. n=6 (9.8%), p=0.652, ISR; n=4 (9.3%) vs. n=4 (7.5%), p=1.000, respectively]. There were no differences in changes in neointimal volume, percent neointimal volume, total plaque volume and percent plaque volume between the two groups on intravascular ultrasonography (IVUS) study.

CONCLUSION

Our study demonstrated that low dose pioglitazone does not reduce rate of ISR, neointimal volume nor atheroma volume in DM patients who have undergone PCI with DESs, despite the limitations of the study.

Atrial coronary artery occlusion during elective percutaneous coronary angioplasty

BACKGROUND

Atrial arteries arise from the right and left circumflex coronary arteries and they may be accidentally occluded during percutaneous coronary angioplasty; however, this complication is not well known. The aim of our study was to analyze the incidence and risk factors of accidental atrial branch occlusion (ABO) during elective angioplasty.

METHODS AND MATERIALS

Clinical records and coronary angiography of 200 patients undergoing elective angioplasty were retrospectively analyzed. Atrial branches were identified and in each vessel we measured the luminal diameter, flow grade, and the location of atherosclerotic plaques. Patients were allocated either into the ABO group if atrial branch flow fell from TIMI grades 2-3 to 0-1 after procedure or in the non-ABO group if TIMI flow was preserved.

RESULTS

Atrial branch occlusion occurred in 43 (21.5%) patients. The atrial branch diameter was larger in non-ABO than in ABO group (1.29mm, SD 0.33 versus 0.97mm, SD 0.22, p=<0.0001). Plaques at atrial branch origin were present in 93% of ABO group, only in 31.8% of non-ABO (p≤0.0001). Predictors of ABO were a cut-off vessel diameter of 1.00mm (ROC 77% sensitivity and 67.5% specificity, p≤0.0001), the presence of atherosclerotic plaque at the ostium of atrial branch and maximal inflation pressure during stenting.

CONCLUSIONS

The occurrence of ABO is frequent after elective angioplasty of right or circumflex coronary arteries in an experienced interventional center. Risk factors were the diameter and the presence of ostial plaques in the atrial branches, and the maximal inflation pressure during stenting.

Early and long-term outlook of percutaneous coronary intervention for bifurcation lesions in young patients

BACKGROUND

Coronary artery disease is most common in older patients, but may occur in younger subjects. The outlook of young patients after percutaneous coronary intervention (PCI) of challenging lesion subsets such as coronary bifurcations, is not established. We thus aimed to appraise the early and long-term results of PCI for bifurcations in young patients.

METHODS

A multicenter, retrospective study was conducted enrolling consecutive patients undergoing bifurcation PCI between 2002 and 2006 in 22 Italian centers. Patients were divided in 2 groups: age ≤ 45 years, and age > 45 years. The primary end-point was long-term rate of major adverse cardiac events (MACE).

RESULTS

4,314 patients were included: 195 (4.5%) in the younger group, and 4119 (95.5%) in the older group. 30-day outcomes did not show significant differences in MACE rates, with 1.0% in the ≤ 45 years group and 2.1% in the >45 years group (p=0.439), with death in 0.5% and 1.2% (p=0.388). At long-term follow-up (24.4 ± 15.1 months), younger patients showed similar rates of MACE, (12.8% vs. 16.6%, p=0.161), myocardial infarction (3.1% vs. 3.7%, p=0.633), target lesion revascularization (11.3% vs. 12.5%, p=0.627), or stent thrombosis (1.5% vs. 2.8%, p=0.294), despite an increased risk of death in older patients (1.0% vs. 5.0%, p=0.012). Even at extensive multivariable analysis, younger patients still faced a similar risk of MACE (HR=0.78 [0.48-1.27], p=0.318).

CONCLUSIONS

Despite their low age, young patients undergoing PCI for bifurcation face a significant risk of early and late non-fatal adverse events. Thus, they should not be denied careful medical management and follow-up.

Successful retrieval of intravascular stent remnants with a combination of rotational atherectomy and a gooseneck snare

Stent migration from the delivery balloon catheter is a rare but serious complication during percutaneous coronary intervention, particularly when a part of the stent stretches into the aorta. We report an unusual case of stent migration treated with a combination of a gooseneck snare and rotablation. A part of the stent was overstretched and unrolled into the aorta and the rest of the stent remained implanted in the coronary artery. The stent was captured with a gooseneck snare but could not be retrieved because it was connected to a stent remnant implanted in the coronary artery. The stent strut was cut with rotablation, and the stent was successfully removed through the femoral sheath.

Ruptured Splenic Abscess following Percutaneous Transluminal Angioplasty in a 40-Year-Old Man

The incidence of splenic abscesses is currently 0.14–0.7% with a reported mortality of 0–47%. The diagnosis of splenic abscess which has ruptured into the abdomen is often overlooked because of its rarity and its misleading clinical presentations. Percutaneous coronary interventions (PCIs) and coronary stenting procedures increased from 184,000 to 885,000 (from 335 to 1,550) and from 3,000 to 770,000 (from 5 to 1,350 per one million inhabitants), respectively. A 40-year-old Asian male presented to our emergency department with upper abdominal pain 5 days after a percutaneous transluminal coronary angioplasty. Clinical examination raised the possibilities of acute pancreatitis and intraabdominal sepsis. An initial ultrasound of the abdomen and blood tests were negative. A computed tomography scan of the abdomen revealed a splenic abscess that had ruptured into the abdomen. Pus culture revealed a multidrug-resistant strain of Klebsiella pneumoniae that was sensitive to meropenem. The patient recovered quickly after open surgical drainage and antibiotic therapy. As this is the second case of splenic abscess and the first case report of a ruptured splenic abscess following a PCI, it will be rational to administer a short course of antibiotic prophylaxis for high-risk immunocompromised patients who are undergoing percutaneous transluminal coronary intervention.

Fatal delayed coronary artery perforation after coronary stent implantation

Most type I and II perforations are predominately caused by hydrophilic and stiff wires, often presented in the delayed form, and do not require pericardial drainage or surgical interventions. However, we report a type III delayed coronary artery perforation at the site of stent implantation after intervention without any evidence of immediate perforations. To the best of our knowledge, this is the first case report of angiographic documentation and treatment of delayed coronary perforation at the site of stent, presented as a cardiac arrest.

Successful primary percutaneous coronary intervention in a patient with acute myocardial infarction and single coronary artery ostium

One of the single anomalous origins of coronary artery that has rarely been reported is a congenital anomaly of coronary circulation that occurs in the left coronary artery originating from the right coronary sinus of valsalva. We report a 49-year-old male patient with non-ST segment elevated myocardial infarction that was identified to have an anomalous origin of the left coronary artery from the right coronary artery (RCA) with thrombotic total occlusion of RCA by coronary angiography and cardiac computed tomography. The patient underwent successful percutaneous coronary intervention in total occlusion of the RCA and was discharged after uneventful recovery.

Successful retrieval of a fractured and entrapped 0.035-inch terumo wire in the femoral artery using biopsy forceps

A 0.035-inch guide wire fracture and entrapment in a peripheral artery is a very rare complication, but when it does occur it may lead to life-threatening complications, such as perforation, thrombus formation, embolization, and subsequent limb ischemia. We describe our experience of successfully retrieving a fractured 0.035-inch Terumo guide wire in the external iliac artery using a biopsy forcep.

Periprocedural myocardial infarction after retrograde approach for chronic total occlusion of coronary artery: demonstrated by cardiac magnetic resonance imaging

A retrograde approach through the collateral channels was recently proposed as one of the most promising current techniques for percutaneous coronary intervention of chronic total occlusion in coronary arteries (CTO). This report describes the case of a 68-year-old man in whom CTO was successfully crossed with a wire by the retrograde approach using septal collateral, but the patient suffered from a complication with septal myocardial infarction demonstrated by cardiac magnetic resonance imaging.

The impact of moderate to severe renal insufficiency on patients with acute myocardial infarction

Background and Objectives

Renal insufficiency (RI) has been reported to be associated with unfavorable clinical outcomes in patients undergoing percutaneous coronary interventions (PCI). However, little data is available regarding the impact of moderate to severe RI on clinical outcomes in patients with acute myocardial infarction (AMI) undergoing PCI.

Subjects and Methods

Between March 2003 and July 2007, 878 patients with AMI who underwent PCI were enrolled. Based on estimated glomerular filtration rate (eGFR) using the Modification of Diet in Renal Disease (MDRD) equation, patients were divided into two groups: eGFR <60 mL/min·m² (moderate to severe RI, group A) and eGFR ≥60 mL/min·m² (normal to mild RI, group B). The primary endpoint was all-cause mortality at 1-year after successful PCI. The secondary endpoints were non-fatal myocardial infarction (MI), target lesion revascularization (TLR), target vessel revascularization (TVR), stent thrombosis (ST) and major adverse cardiac events (MACE) at 1-year.

Results

In group A, patients were more often male and older, with diabetes and hypertension. Compared to patients in group B, group A showed significantly higher incidences of all-cause mortality, cardiac mortality, non-fatal MI and MACE. The needs of TLR and TVR, and the incidence of ST were not significantly different between the two groups. Independent predictors of 1-year mortality were eGFR <60 mL/min·m², male gender, older age and a lower left ventricular ejection fraction.

Conclusion

In patients with AMI, moderate to severe RI was associated with mortality and MACE at 1-year after successful PCI. In addition, eGFR <60 mL/min·m² was a strong independent predictor of 1-year mortality.

Recanalization of an accidentally crushed coronary stent by intravascular ultrasonography catheter entrapment

Intravascular ultrasonography (IVUS) imaging is a user-friendly technique widely used during coronary interventions. An 80-year-old man was admitted with chest pain, and successful percutaneous coronary intervention was performed with stent implantation. One week later, the patient complained of further chest pain. Urgent coronary angiography showed total occlusion of the middle left anterior descending artery and the aspiration of thrombi was high. IVUS imaging showed inadequate stent strut apposition and distal dissection. We attempted another stent implantation but the IVUS catheter was stuck on the 0.014 inch wire. Therefore, we tried to pass the wire across the lateral side. After the wire was successfully passaged, the sprinter balloon was passed through the crushed stent to expand it. After 4 days later, the patient was discharged with no symptoms or electrocardiographic change.

Stenting of the Left Main Coronary Artery in a Patient With Takayasu's Arteritis

Management of Takayasu's arteritis of the left main coronary artery (LMCA) is difficult because of the possibility of restenosis. Clinically significant stenotic lesions must be considered anatomical correlation. Many studies have reported that the management of stenotic lesions of the LMCA with endoluminal stenting and balloon angioplasty and de-novo stenting is safe and effective for patients with Takayasu's arteritis. We report the case of a patient with Takayasu's arteritis of the LMCA. The patient had undergone two consecutive percutaneous coronary interventions because of recurrent restenosis of in-stent lesions, and eventually underwent coronary artery bypass graft (CABG) surgery for myocardial infarction in the same lesion. We suggested treatment with CABG because the pathophysiology of Takayasu's arteritis is different from that of atherosclerotic stenosis.

Evaluation of Cardiac Function by Transthoracic Echocardiography in Subjects with ST-Segment Elevation Myocardial Infarction Following Primary Percutaneous Coronary Intervention according to Valsartan Dose: The Valsartan One Center Trial

BACKGROUND

The aim of this study was to evaluate the mid-term changes in cardiac function by transthoracic echocardiogram (TTE) in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI) according to valsartan dose.

METHODS

Between April 2006 and February 2009, 78 subjects (mean age: 57 ± 12 years, M : F = 74 : 4) with STEMI who underwent primary PCI were enrolled. Fifty three patients received low dose valsartan (40 or 80 mg) and 25 patients received high dose valsartan (160 or 320 mg). Follow-up TTE was done approximately 2 years later. We evaluated the changes in left ventricular (LV) function between initial and final TTE after primary PCI and compared the changes between low and high dose valsartan group.

RESULTS

The mean follow-up TTE duration was 24 ± 8 months. Deceleration time (188.6 ± 56.3 msec vs. 221.5 ± 71.3 msec, p = 0.01), E/e' (12.24 ± 5.2 vs. 10.1 ± 4.9, p = 0.002), ejection fraction (52.7 ± 8% vs. 55.2 ± 8.4%, p < 0.01), and wall motion score index (1.45 ± 0.30 vs. 1.33 ± 0.32, p < 0.01) showed significant changes during the follow-up period. Wall motion improvement in injured myocardial segments was more frequently observed in the high-dose valsartan group compared to the low-dose group [18/25 (72%) vs. 24/53 (43.7%), p = 0.03]. There was no significant difference in the changes in cardiac dimensions and function between the low and high dose valsartan group.

CONCLUSION

In patients with STEMI who undergoing primary PCI, high-dose valsartan treatment may be more helpful than low-dose in improving wall motion in the injured myocardium.

A case of coronary artery dissection after aortic replacement in acute type a aortic dissection

A 59-year-old woman was transferred to our institution with a diagnosis of acute type A aortic dissection. During aortic replacement surgery, the dissection had not extended to the orifice of the left coronary artery. However, ST segment elevation was observed on an electrocardiogram monitor immediately postoperatively. An emergent coronary angiogram showed almost complete collapse of the lumen of the left coronary artery due to pulsatile compression of the false lumen, which was caused by extension of the aortic dissection. Percutaneous coronary intervention (PCI) was performed with placement of stents in the left anterior descending artery (LAD) and left circumflex artery. Coronary angiography and intravascular ultrasound performed 45-days after PCI showed significant instent restenosis (ISR) at the proximal portion of the LAD and residual coronary artery dissection of the diagonal branch. Repeat balloon angioplasty was performed at the site of the ISR. A follow-up coronary angiogram 8-months after the PCI showed no evidence of ISR.

Therapeutic strategy for in-stent restenosis based on the restenosis pattern after drug-eluting stent implantation

BACKGROUND AND OBJECTIVES

The aim of this study was to evaluate the outcomes of repeated percutaneous coronary intervention (PCI) based on the restenosis pattern in drug-eluting stent (DES) failure.

SUBJECTS AND METHODS

From April 2003 to March 2006, all 67 patients (67 lesions) at our 3 centers who had DES in-stent restenosis (ISR) were enrolled. The patients were divided into 3 groups: group I had focal edge restenosis, group II had focal body restenosis, and group III had non-focal restenosis. All patients were treated with conventional PCI including plain old balloon angioplasty (POBA), cutting balloon angioplasty (CBA), and repeated DES implantation (Re-DES). Angiographic and clinical one year follow-up results for the 3 groups were evaluated.

RESULTS

Sixteen patients were enrolled in group I, 36 in group II, and 15 in group III. Baseline clinical and angiographic characteristics and the proportion of patients in each group receiving each type of treatment strategy were not significantly different among the groups. Within each group, a comparison of angiographic and clinical outcomes for each therapeutic modality revealed that restenosis rates were not statistically different. Although rates of major adverse cardiac events (MACE) were not statistically different between groups I and II, in group III, MACE were 3-fold higher for the POBA (4/4, 100.0%) and CBA (4/4, 100.0%) subgroups than for Re-DES (1/3, 33.3%) (p=0.06), but the differences did not reach statistical significance.

CONCLUSION

THE PRESENT STUDY SUGGESTS THAT TREATMENT OF DES ISR SHOULD BE INDIVIDUALIZED ACCORDING TO RESTENOSIS PATTERN: any PCI strategy appears appropriate for focal ISR patterns, while Re-DES might be a better choice for non-focal ISR patterns.