Volume 20 - Issue 2 - February, 2008

Using Quality Improvement Methods to Improve Door-to-Balloon Time at an Academic Medical Center

a-eRobert L. Huang MD, MPH, dAnderson Donelli, MD, dJeannie Byrd, RN, eMarc A. Mickiewicz, MD,
eCorey Slovis, MD, a-c,fChristianne Roumie, MD, MPH, a-c,fTom A. Elasy, MD, MPH,
a-c,fRobert S. Dittus, MD, MPH, a-cTed Speroff, PhD, dTom DiSalvo, MD, MPH, dDavid Zhao, MD

An estimated 500,000 patients per year in the United States1 experience a ST-elevation MI (STEMI) with a shortterm mortality rate of 5–10%.2 Percutaneous coronary intervention (PCI) is the preferred approach for treating STEMI1 and timely reperfusion in patients with STEMI has been shown to increase the likelihood of survival.3 Time-toreperfusion is commonly measured by door-to-balloon time, which measures the time between a patient’s arrival at the hospital to when a balloon is inflated in the coronary artery. Door-to-balloon time for...

Complex Right Subclavian Artery Dissection during Diagnostic Cardiac Catheterization

*Nicholas J. Collins, BMed, FRACP, §J. Robert Beecroft, MD, FRCPC,
*Eric M. Horlick, MD, CM, FRCPC

Management of vascular complications remains an important component of both diagnostic cardiac catheterization and percutaneous coronary intervention. We report a unique case of extensive right subclavian artery dissection following attempted diagnostic cardiac catheterization of a right internal mammary artery (RIMA) coronary bypass graft. This resulted in complex dissection of the right subclavian artery involving the origin of the right vertebral and internal mammary arteries, as well as critical right upper limb ischemia. Therapy consisted of both conservative management of the proximal...

High-Dose Tirofiban Administered as Bolus-Only during Percutaneous Coronary Intervention

Jonathan D. Marmur, MD, Shyam Poludasu, MD, Ajay Agarwal, MD, Nagarathna Manjappa MD,
Erdal Cavusoglu, MD

Inhibition of platelet glycoprotein IIb/IIIa receptors during percutaneous coronary intervention (PCI) using tirofiban, eptifibatide and abciximab has been associated with improved outcomes.1 The only head-to-head comparison to these agents was provided by the “do Tirofiban And Reopro Give similar Efficacy outcomes Trial (TARGET)”, in which patients were randomized to tirofiban or abciximab.2 In this study tirofiban offered less protection from major ischemic events compared to abciximab. However, the dose of tirofiban used in the TARGET trial (bolus of 10 ...

Occlusion of a Sano Shunt Using the Amplatzer Duct Occluder

Mark A. Walsh, MD, Colin J. McMahon, MD, Kevin P. Walsh, MD

Many centers are currently adopting the Sano modification of the Norwood operation for infants with hypoplastic left heart syndrome.1 The insertion of a right ventricle-to-pulmonary artery conduit may increase aortic diastolic pressure and coronary artery perfusion.2 In the face of an unexpectedly elevated pulmonary vascular resistance prior to the bidirectional Glenn operation, an additional source of pulmonary blood flow may be required. This situation may arise either intraoperatively, prohibiting shunt takedown, or postoperatively, requiring reoperation and s...

High-Dose, Bolus-Only, Glycop rotein IIb/IIIa Inhibitors for Elective Coronary Intervention: Logical, Safe, Cost-Effective, an

Tim A. Fischell, MD

Platelet-mediated thromboembolic events are believed to cause the majority of non-Q-wave myocardial infarctions (MI) observed after an otherwise uncomplicated percutaneous coronary intervention (PCI).1
Activation of the platelet-surface glycoprotein IIb/IIIa (GP IIb/IIIa) receptor is the final common pathway in the process leading to platelet aggregation, and thrombus formation after PCI.1,2 The use of weight-adjusted bolus, plus prolonged infusion of IIb/IIIa inhibitors has been shown to reduce the risk of non-Q-wave MI (CPK-MB leaks) after PCI.3–9...

Two-Year Clinical Follow Up of Coronary Drug-Eluting Stent in Patients at High Risk for Coronary Restenosis

Salvatore Azzarelli, MD, Francesco Amico, MD, *Alfredo R. Galassi, MD, Michele Giacoppo, MD,
Vincenzo Argentino, MD, Antonio Fiscella, MD

Drug-eluting stents (DES), compared with bare-metal stents (BMS), have shown a clear superiority in the prevention of restenosis and the need for further revascularization in randomized, controlled trials.1–5 Accordingly, the superiority of DES over BMS was confirmed in large registries.6,7 A major finding regarding the use of DES is that although the safety of DES is not different from that of BMS in the shortto- medium term, concern has arisen about the potential for late stent thrombosis related to delayed endothelialization of the stent struts.8,9 ...

Clinical Application of Prophylactic Percutaneous Left Ventricular Assist Device (Tandem Heart™) in High-Risk Percutaneous Cor

Sanjay Rajdev, MD, Prakash Krishnan, MD, Adil Irani, MD, Michael C. Kim, MD,
Pedro R. Moreno, MD, Samin K. Sharma, MD, Annapoorna S. Kini, MD

Introduction of novel devices for cardiac support during complex percutaneous coronary intervention (PCI) has revolutionized the treatment of coronary artery disease (CAD) and has led to an increasing number of high-risk PCI procedures. Traditionally, the intra-aortic balloon pump (IABP) has been used to provide hemodynamic stability during coronary interventions in high-risk patients. However, the mortality rate continues to be high (30–75%) despite the use of IABPs in the setting of acute myocardial infarction complicated by cardiogenic shock; insertion of a percutaneous transseptal...

Bifurcation Coronary Artery Disease: Current Techniques and Future Directions (Part 1)

David G. Rizik, MD, Kevin J. Klassen, MD, James B. Hermiller, MD

Published randomized trials of drug-eluting stents (DES) have shown reduced rates of restenosis and target lesion revascularization (TLR) in noncomplex lesions compared to bare-metal stents (BMS).1 Given this documented success of the antiproliferative therapies in relatively simple lesions, interventional cardiologists have developed techniques and devices hoping to demonstrate similarly durable results in more complex lesion subsets.2–6 Bifurcation coronary artery disease (CAD) comprises an important subset of lesions inadequately studied and thus far unapproved f...

Double Inferior Vena Cava Filter Implantation in a Patient with a Duplicate Inferior Vena Cava

Rizwan A. Siddiqui, MD and Sachinder Hans, MD*

Case Presentation. A 79-year-old female presented with pain and swelling of the left lower extremity. Physical examination revealed a swollen left calf and 1+ pitting edema over both ankles. There was no evidence of calf tenderness and Homan’s sign was negative bilaterally. A venous duplex Doppler study revealed the presence of occluding thrombi in the left popliteal, as well as the right popliteal and posterior tibial veins. She was also found to have microcytic hypochromic anemia. Upper gastrointestinal endoscopy revealed the presence of erosive esophagitis and ant...

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