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Volume 20 - Issue 2 - February, 2008

Double Balloon Angioplasty for Unstentable Large-Caliber Right Coronary Stenosis

Scott B. Baron, MD, Clifford Nielson, CVT

Despite newer lower-profile stent technologies, placing coronary stents may still remain challenging when vessels are extremely tortuous. We describe a case of a very large-caliber right coronary artery (RCA) with a “shepherd’s crook” configuration, which could not be stented, and for which double balloon angioplasty was successfully performed.
Case Report. A 69-year-old Caucasian male was hospitalized for an acute coronary syndrome. Diagnostic heart catheterization revealed a 90% eccentric stenosis past the genu of the right coronary artery. The...

Prophylactic, Standby, or Rescue Support for High-Risk PCI: Who Knows?

*,§Fayaz Shawl, MD and *,£Robert J. Lederman, MD

This series from Mount Sinai Hospital extends the reported experience with prophylactic deployment of a percutaneous transseptal cardiopulmonary bypass system during high-risk elective coronary angioplasty. These highly experienced operators employed a dual-“preclose” technique in the majority of patients, implanting arterial sutures before pump deployment that permitted immediate postprocedure arterial closure. The short-term outcome was excellent, reported complications minimal, and intermediate-term outcomes reasonable for the high-risk patient cohort described.
How sh...

Twin Circumflex Arteries: A Rare Coronary Artery Anomaly

M.N. Attar, MD, MRCP, Roger K. Moore, MD, MRCP, Sarfraz Khan, FRCP, FCPS

Case Report. A 62-year-old Caucasian male presented with recurring angina. He was experiencing angina attacks on walking 10 to 20 yards. The patient had suffered a myocardial infarction in the past and had undergone percutaneous intervention to his left anterior descending artery (LAD). Following the procedure, he remained relatively angina-free until recently. He was diabetic and hypertensive. There was a strong family history of premature coronary artery disease. He was unable to perform an exercise stress test due to peripheral neuropathy. In view of a positive...

Effects of B-Type Natriuretic Peptide (Nesiritide) on Coronary Epicardial Arteries, Systemic Vasculature and Microvessels

*Gui Fu Wu, MD, PhD, §Joanna J. Wykrzykowska, MD, £Jamal S. Rana, MD, §Duane S. Pinto, MD,
§C. Michael Gibson, MD, §Jian Li, MD, §Frank W. Sellke, MD, §Roger J. Laham, MD

Nesiritide (Natrecor®, Scios Inc., Fremont, California) is a recombinant form of human B-type (brain) natriuretic peptide (BNP) that has beneficial vasodilatory, diuretic and neurohormonal effects.1 It activates membrane-bound guanylyl cyclase A-receptor, resulting in accumulation of intracellular cGMP, which in turn mediates the vasodilatory effects in vascular smooth muscle cells.23 Nesiritide is manufactured from E. coli using recombinant DNA technology with a molecular weight of 3,464 g/mol with the same 32 amino acid sequence as th...

Use of Radiofrequency Energy and Covered Stents in Patients with an Occluded Superior Vena Cava and Requiring Endocardial Pace

Gianfranco Butera, MD, PhD, Ezio Aimè, MD, Mario Carminati, MD

Obstructions of the caval veins may develop in various clinical settings in subjects with tumoral lesions, after surgery on the caval veins — as in the Mustard/Senning operation, after radiation therapy, or due to central lines, dialysis catheters and pacing wires.1–4 In particular, patients with a history of multiple cardiac surgical procedures or with a history of infections of the pacemaker site and electrodes may easily develop an iatrogenic occlusion of the venous access.2 Various kinds of interventions have been performed in these subjects, including ...

February 2008

Richard E. Shaw, Phd, FACC, FACA

This issue of the Journal of Invasive Cardiology includes original research articles, a review article, selections from the journal special section Clinical Images and online case reports which can be found in the archive section on our website, as well as in the new Digital JIC at: www.invasivecardiology.com. I encourage you to visit the website to read these interesting and informative case reports.
In the first research article, submitted by Dr. Robert Huang and colleagues from the Vete...

Primary Cardiac Diffuse, Large B-Cell Lymphoma in an Immunocompetent Patient

Kevin P. Cohoon, DO, William Howe, MD, Thomas Mc Kiernan, MD

Primary cardiac non-Hodgkin’s lymphoma is defined as being exclusively located in the heart and/or pericardium, and is extremely rare. This disease occurs mainly in immunocompromised patients and rarely in the immunocompetent. In a series of over 12,000 autopsies, only 7 primary tumors were identified for an incidence of less than 0.1%.1 Primary cardiac lymphoma comprises only 2% of all cardiac tumors, and may obstruct valvular orifices and even cause hypertrophic cardiomyopathy when heavy tumorous lesions infiltrate the ventricular septum, as described by Roberts et ...

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 ...

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