Volume 18 - Issue 2 - February, 2006

Refractory Hypoxemia after Mitral Valve Surgery: An Unusual Cause and Its Successful Percutaneous Treatment

Alexander Sirker, MD, Jonathan Hyde, MD, David Hildick-Smith, MD

A variety of approaches are used for mitral valve repair and replacement operations. Rare complications specific to the surgical method may need to be considered if patients encounter unexplained problems postoperatively. We discuss such an example here. The operative approach to the mitral valve in this case was transseptal (from the right atrium), a method which has been widely used as an alternative to the more frequently employed left atriotomy.1,2 There are certain situations in which the transseptal approach may be particularly useful — for example, allowing better visualiza...

Bifurcation Intervention: Keep it Simple

James B. Hermiller, MD

The percutaneous treatment of bifurcation lesions remains suboptimal. A frequent problem, accounting for 10–20% of coronary lesions undergoing percutaneous coronary intervention (PCI), the bifurcation is plagued by acute technical challenges, long-term restenosis, and more recently, early and late stent thrombosis.1–4 Generally defined as a lesion which involves a side branch of 2.0 mm or greater, the bifurcation is in part so complex due to its variability. This variability results from inconsistent plaque distribution, unpredictable side branch angulation and large differences...

Fibromuscular Dysplasia and Acute Myocardial Infarction: Evidence for a Unique Clinical and Angiographic Pattern

Jose F. Huizar, MD, Ashish Awasthi, MD, Hani Kozman, MD

Myocardial infarction (MI) typically occurs in the setting of atherosclerotic coronary artery disease (CAD). However, there are other causes of MI unrelated to atherosclerosis that include spontaneous dissection of the coronary arteries, anomalous origin of coronary arteries, vasculitis, toxins such as carbon monoxide, medications (5-fluorouracil, sumatriptan, ergotamine) and hypercoagulable states.1–7 Fibromuscular dysplasia (FMD) is a condition typically involving small and medium-sized vessels. It has been rarely described in coronary arteries at autopsy8–13 in ass...

Early Ambulation and Variability in Anticoagulation during Elective Coronary Stenting with a Single Intravenous Bolus of Low-Do

Silvio Zalc, MD, Pedro A. Lemos, MD, Antonio Esteves, MD, Expedito E. Ribeiro, MD, Pedro Horta, MD, Jose C. Nicolau, MD, Jose A.F. Ramires, MD, Marc Cohen, MD, Eulogio E. Martinez, MD

Low-molecular weight heparin (LMWH), especially enoxaparin, and unfractionated heparin (UFH), is recommended in the early medical management of acute coronary syndromes.1,2 Compared to intravenous UFH, subcutaneous LMWH has a more predictable effect, a higher anti-Xa/anti-IIa ratio, does not require monitoring with an activated clotting time, and is resistant to inhibition by activated platelets.3–5 Earlier work by Collet and Montalescot,6 as well as the recent, large SYNERGY trial7 documented the efficacy of transitioning high-risk acute coronary ...

Percutaneous Coronary Intervention in Anomalous Right Coronary Arteries Arising from the Left Sinus of Valsalva: A Report of Tw

Konstantinos Spargias, MD, Panagiotis Kariofyllis, MD, Sophia Mavrogeni, MD

Congenital anomalies of the origin and distribution of the coronary arteries are infrequent and are found in 0.3–1.2% of patients undergoing coronary angiography.1–3 The prevalence is greater if the origin of a coronary artery from an ectopic ostium that is still in the correct sinus of Valsalva is included.4
The incidence of anomalous origin of the right coronary artery (RCA) out of the right sinus of Valsalva ranges from under 0.01–0.09%.1–6 It usually arises from the left sinus of Valsalva or the ascending aorta above it, and in most reported cases ...

Clinical and Economic Outcomes of Embolic Complications and Strategies for Distal Embolic Protection during Percutaneous Corona

Shaun R. Senter, MD, MS, Sandeep Nathan, MD, MS, Akshay Gupta, MD, Lloyd W. Klein, MD

Over 500,000 coronary artery bypass grafts in 314,000 cases were performed in the United States in 2000, however, over half of all vein grafts develop significant stenosis within 10 years.1,2 Percutaneous coronary intervention in saphenous vein grafts is consequently an increasingly common therapeutic modality utilized in the treatment of vein graft stenosis. In contemporary practice, vein grafts develop bulky lesions composed of loose atheroma and thrombotic material, and are often degenerated.3 This poses a significant risk for distal embolization and no-reflow, resulti...

Treatment of Spontaneous Coronary Dissection with Drug-Eluting Stents — Late Clinical, Angiographic and IVUS Follow Up

William J. van Gaal, III, MBBS, FRACP, Italo Porto, MD, Adrian P. Banning, MD, MRCP

Spontaneous coronary artery dissection (SCAD) is a rare condition which may result in sudden coronary occlusion, acute myocardial infarction (AMI) and sudden cardiac death.1–3 We previously reported a case of SCAD involving the left anterior descending (LAD) artery confirmed with coronary angiography and intravascular ultrasound (IVUS).4 After failure of medical management, the patient was successfully treated with implantation of drug-eluting stents (DES), achieving a good immediate angiographic and intravascular ultrasound (IVUS) result with resolution of symptoms. We...

Percutaneous Transvenous Mitral Commissurotomy Using Metallic Commissurotome: Long-Term Follow-Up Results

S. Harikrishnan, MD, Anil Bhat, MD, Jaganmohan Tharakan, MD, Thomas Titus, MD, Ajith Kumar, MD, S. Sivasankaran, MD, K.M. Krishnamoorthy, MD

Percutaneous transmitral commissurotomy (PTMC) has been established as an effective treatment for mitral stenosis (MS) and is now the procedure of choice.1–6 Of the procedures available to treat mitral stenosis, percutaneous valvotomy using the Inoue balloon is well established and carried out worldwide.
The miniaturized metallic commissurotome devised by Cribier et al. is reported to be a reliable and effective alternative to balloon mitral commissurotomy.7–11 The ease of resterilization and unchanged physical properties after multiple uses have made this device a p...

Late “Adult Form” Scimitar Syndrome Presenting with “Infant Form” Complications

*Brian Zagol, MD, *Scott Book, MD, Richard A. Krasuski, MD

Scimitar syndrome is a rare congenital cardiopulmonary anomaly that carries a poor prognosis for individuals who are diagnosed within their first year of life.1 These patients often present with pulmonary hypertension and right-sided congestive heart failure, presenting a challenge for medical and surgical management. Conversely, scimitar syndrome is generally asymptomatic and often an incidental finding for patients diagnosed after infancy.2 We describe a previously healthy elderly patient who presented with pulmonary hypertension and congestive heart failure, and was ev...

Glycoprotein IIb/IIIa Inhibitors during Rescue Percutaneous Coronary Intervention in Acute Myocardial Infarction

Luis Gruberg, MD, Mahmoud Suleiman, MD, Michael Kapeliovich, MD, Haim Hammerman, MD, Ehud Grenadier, MD, Monther Boulus, MD, Shlomo Amikam, MD, Walter Markiewicz, MD, Rafael Beyar, MD

Fibrinolytic therapy for acute myocardial infarction, even with the most efficient regimens available, is fraught with a substantial proportion of failures to re-establish normal blood flow in the occluded vessel.1,2 Failure to achieve prompt and complete restoration of TIMI 3 coronary blood flow after full-dose thrombolysis is associated with a poor prognosis.3 Although percutaneous coronary intervention (PCI), with or without stenting following full-dose thrombolytic therapy (rescue angioplasty), is a common procedure in these patients, data are scarce and there is ampl...

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