Volume 17 - Issue 11 - November, 2005

Rescue Percutaneous Coronary Intervention: A Review

Umesh K. Arora, MD and Meeney Dhir, MD

The primary goal of therapy for acute myocardial infarction (AMI) is rapid, complete and sustained restoration of infarct-related artery (IRA) blood flow and myocardial perfusion, with a consequent positive impact on the patient’s outcome. Both fibrinolytic and mechanical restoration of anterograde coronary blood flow in patients suffering AMI have shown to improve left ventricular function, reduce infarct size and reduce mortality.1–10 The benefits of myocardial reperfusion, including the prevention of infarct expansion and improvement of electrical stability, are amplified whe...

The “Zipper” Lesion: A Rare but Serious Guiding Catheter-Induced Complication of a PCI Procedure

Stéphane Cook, MD and David Tueller, MD

A 42-year-old man presented with heavy chest pain of four hours’ duration. Physical examination was unremarkable. The ECG showed an acute septoapical infarction. Nitroglycerin, aspirin, clopidogrel and heparin were administered, and an emergency coronary angiography was performed from the right femoral artery (Figures 1 A and B). The left anterior descending artery was occluded distally. The left main trunk ostium was deeply intubated by a slightly too large Q4 6 French intervention catheter. There was, however, no damping or ventriculization of pressure. The occlusion was crossed with a ...

Transcatheter Fenestration of Autologous Pericardial Extracardiac Fontan via the Transhepatic Approach

Michael R. Recto, MD, Walter L. Sobczyk, MD, Erle H. Austin III, MD

The Fontan operation was first described for management of univentricular heart disease in 1971. Since it was first described, there have been several modifications to the original operation.1 In 1988, de Laval2 first proposed the concept of total cavopulmonary anastomosis (construction of an intra-atrial lateral tunnel to connect the inferior vena cava to the pulmonary artery together with a bidirectional cavopulmonary shunt) as an alternative to atriopulmonary connection. The extracardiac approach remains popular because it eliminates the need for aortic cross-clamping,...

Acute Myocardial Infarction during Puerperium. Report of Two Cases of Multivessel Involvement Treated with Primary Coronary Inte

Santiago Jiménez Valero, MD, Eulogio García, MD, Juan Luis Delcán, MD

Acute myocardial infarction (AMI) is a rare event in pre-menopausal women, with only 0.7% of the total number of AMIs appearing in young women.1 The incidence of AMI in the Framingham study for women 35 to 44 years of age was 5.2 cases per 1,000 over a 10-year follow-up period.2
AMI is also an exceptional occurrence during pregnancy, delivery or puerperium, with a prevalence of approximately 1 out of every 10,000–30,000 pregnancies.1–3 Since the first description in 1922 by Katz,4 less than 200 cases have been reported. The condition is associa...

Feasibility Assessment of Aortic Valve Area in Patients with Aortic Stenosis Using a Pressure Wire through a 4 French System and

Stefan C. Bertog, MD, Andrew Smith, MD, Carmelo J. Panetta, MD

Symptomatic aortic stenosis can be associated with significant morbidity and mortality.1 Accurate assessment of the severity is important both to determine the association of symptoms with aortic stenosis and for optimal timing of surgical repair. In the majority of patients, the aortic valve area can be assessed noninvasively with accuracy by transthoracic echocardiography. However, due to poor images or other technical limitations with echocardiography, cardiac catheterization is occasionally necessary for valve area assessment. Calculation of the aortic valve area (AVA) relies on...

Release and Elimination of Soluble Vasoactive Factors during Percutaneous Coronary Intervention of Saphenous Vein Grafts: Analys

Joseph Salloum, MD, Carter Tharpe, MD, Douglas Vaughan, MD, David X. Zhao, MD

The no-reflow phenomenon is defined as a severe reduction in antegrade coronary flow in the absence of epicardial vessel obstruction.1 The presence of no-reflow substantially increases the risk of major adverse clinical events (MACE) in percutaneous coronary artery interventions (PCI), particularly in saphenous vein grafts (SVG).2,3 Mechanisms underlying no-reflow are not completely understood. Several hypotheses have been proposed, including microvascular spasm, in situ thrombosis and distal embolization. Distal protection devices are designed to prevent no-reflow...

Inadvertent Detachment of an Entrapped Cutting Balloon from the Balloon Catheter during Treatment of In-Stent Restenosis

Daniel Blackman, MD and Vladimir Dzavik, MD

The Cutting Balloon® (CB) (Interventional Technologies, Letterkerry, Ireland) employs three to four longitudinally mounted microblades that produce clean incisions into plaque or neointima, enhancing lesion dilatation.1 Its use has been advocated specifically for heavily calcified lesions, aorto-ostial disease, and in-stent restenosis (ISR).2–4 However, the microblades also render the current version of the balloon bulky and stiff. Several recent reports have described CB entrapment following dilatation for ISR, leading to inadvertent extraction of th...

Sirolimus-Eluting Stent Treatment for Complex Proximal Left Anterior Descending Artery Stenoses: 7-Month Clinical and Angiograph

Ahmed A. Khattab, MD, Andreas Otto, MD, Ralph Toelg, MD, Volker Geist, MD, Lothar Klatt, MD, Gert Richardt, MD

Proximal left anterior descending artery (LAD) stenoses are considered to have special prognostic implications.1 Medically treated patients with isolated proximal LAD stenosis have a significantly worse prognosis than patients with lesions in other locations.2 Stenting is an accepted treatment with excellent short-term results, yet previous studies have shown that proximal LAD stenoses per se have higher rates of restenosis than stenoses in other coronary segments after angioplasty,3 as well as after stenting.4,5
Bypass surgery utilizing the interna...

Intravascular Ultrasound to Guide Stenting of an Anomalous Right Coronary Artery Coursing between the Aorta and Pulmonary Artery

Italo Porto, MD, Simon T. MacDonald, BM BCh, MRCP, Joseph B. Selvanayagam, MBBS, FRACP Adrian P. Banning, MD, FRCP, FESC

Anomalous coronary arteries arising from the opposite sinus of Valsalva (ACAOS) are a rare anomaly associated with increased mortality, particularly when the right coronary artery (RCA) courses between the aorta and pulmonary trunk.1–4 An anomalous right coronary artery arising from the left coronary sinus under these conditions may give rise to an estimated mortality rate higher than 25%, and anomalous coronary arteries have been thought to be the second leading cause of sudden death in competitive athletes.2,3,5 Bypass surgery has been suggested as the preferred meth...

Soluble Mediators of Microvascular Dysfunction — Identifying the Invisible Culprits?

Pedro Martinezclark, MD and Joseph P. Carrozza Jr., MD

Percutaneous intervention of saphenous vein grafts is associated with approximately 20% risk of major adverse cardiovascular events secondary to decreased antegrade flow or “no-reflow” during the procedure.1 The mechanism of this phenomenon is probably multifactorial and involves microvascular dysfunction and potentially platelet-mediated loss of capillary autoregulation. Since the typical vein graft lesion is friable with large plaque volume, it may be that embolization of thrombotic and atheromatous material during the intervention is the trigger that starts a cascade of event...

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