Anomalous coronary arteries are rare and usually incidental angiographic findings. Their clinical importance lies in the potential risk for sudden cardiac death, especially if the course is interarterial (between the aorta and pulmonary artery). In these situations, coronary bypass surgery is the recommended treatment. When percutaneous interventions are undertaken, however, the nontraditional locations and frequently angulated ostia of these vessels can pose technical challenges. We hereby report a case of percutaneous intervention in an anomalous circumflex artery arising acutely from the right coronary ostium. Despite the use of an anchor wire in the patient’s right coronary artery, access into the circumflex artery was possible only with a steerable guidewire. We believe that this is a potentially useful tool in percutaneous intervention of anomalous as well as other angulated coronary anatomies. The technical advantages of this wire, as well as a review of the litera

Severe functional mitral regurgitation associated with myocardial ischemia is conventionally a Class I indication for cardiac surgery. Mitral annuloplasty or mitral valve replacement are performed during coronary bypass surgery with the aim of improving the patient’s ventricular function and symptoms. With the advancement of stent technology, sustained myocardial perfusion and improvement of ventricular function could be achieved by revascularization alone, leading to a reduction in the severity of mitral regurgitation. The purpose of this case is to review the role of transcatheter coronary revascularization in the management of myocardial ischemia associated with severe functional mitral regurgitation and heart failure. J INVASIVE CARDIOL 2007;19:E286– E289

Percutaneous coronary intervention (PCI) of complex coronary lesions in patients with severely depressed left ventricular (LV) function may increasingly constitute an alternative to surgical revascularization. The availability of hemodynamic support devices offers a promising option to reduce PCI-related complications in such high-risk procedures. We report the case of successful distal left main coronary artery T-stenting supported by the Impella Recover LP 2.5 assist device in a patient with severe LV dysfunction. J INVASIVE CARDIOL 2007;19:E294–E296

Early stent occlusion after myocardial infarction is associated with increased morbidity and mortality, and antiplatelet drugs are applied to prevent these complications. We report on 3 patients with gastrointestinal bleeding or who were scheduled for emergency surgery and who received donor platelet transfusion early in the course after stenting. These patients had symptomatic coronary artery stenoses and were treated with antiplatelet therapy. Stent occlusion was diagnosed 6–17 hours after donor platelet transfusion, suggested by electrocardiographic and, in 1 patient, angiographic findings. One patient died of intractable bleeding from the gastrointestinal tract. Our observations emphasize the risks involved in platelet transfusion, and support withholding such therapy, unless vitally indicated, in patients who have undergone recent bare-metal coronary artery stent implantation. J INVASIVE CARDIOL 2007;19:E297–E299

A 25-year-old semiprofessional soccer player was referred to our hospital because of intermittent claudication of the right leg. He had right limb trauma while playing soccer, and a selfexpandable stent was implanted for the occluded femoropopliteal artery. One month later, he complained of acute recurrence of claudication. Angiography revealed an occlusion of the stent due to cross-sectional stent squeeze and partial fracture. The occlusion was successfully revascularized with additional stenting. The patient was asymptomatic at 5-month follow up. Early self-expandable stent squeeze is quite rare. The forces exerted in the popliteal artery while playing soccer may have caused this phenomenon. J INVASIVE CARDIOL 2007;19:300–302

A 75-year-old male developed late coronary stent infection with symptoms presenting months after the initial procedure. This presentation was notably different than that of other cases in the literature, which typically presented days to a few weeks after stent implantation. Persistently unendothelialized stent struts may be a nidus for late infection. J INVASIVE CARDIOL 2007;19:E307–E308

This report describes the use of intracoronary adenosine and transvenous pacemaker backup as an adjunct to intra-aortic balloon pump use and glycoprotein IIb/IIIa inhibition to accomplish high-risk multivessel coronary angioplasty in an 87-year-old female with profound cardiogenic shock. Myocardial preconditioning may further enhance microvascular perfusion in this critical state. J INVASIVE CARDIOL 2007;19:E309–E312 Key Words: cardiogenic shock; multivessel angioplasty; preconditioning; adenosine

We report the successful transcatheter closure of a large persistent left superior vena cava draining into a left upper pulmonary vein in a patient who suffered 2 transient ischemic attacks after intravenous (IV) injection of saline flush solution into a left arm peripheral IV line utilizing an Amplatzer Vascular Plug. J INVASIVE CARDIOL 2007;19E313–E316 Key Words: Amplatzer vascular plug; venous anomaly

In order to avoid distal embolization in patients undergoing emergency percutaneous coronary intervention for STelevation myocardial infarction, both thrombectomy and distal protection devices have been evaluated with conflicting effects on myocardial perfusion. However, the removal of massive coronary thrombus is always problematic, and failure of standard approaches might result in severe microvascular damage. We report a case of the unusual use, in a “Fogarty-like” fashion, of the Spider™ filter to trap and remove a large thrombus that was refractory to aspiration and balloon dilatation before stent implantation in a proximal, infarct-related coronary artery. J INVASIVE CARDIOL 2007;19:E317–E319

A 5-year-old female presented with anasarca secondary to protein-losing enteropathy after fenestrated extracardiac Fontan. There was no response to digoxin, furosemide, spironolactone and captopril. She had coarctation of the aorta and left pulmonary artery stenosis resistant to multiple surgical and balloon interventions. Stent expansion of these lesions resulted in the patient’s recovery from protein-losing enteropathy. J INVASIVE CARDIOL 2007;19:444–446

Background. Although the increased utilization of drug-eluting stents is well supported by multiple studies with clinical trial data for many patient and lesion subsets, their use to treat diseased saphenous vein graft (SVG) lesions is much less well substantiated. We sought to ascertain and compare 12-month target vessel revascularization (TVR) rates for sirolimus-eluting Cypher™ stents and bare-metal stents (BMS) when utilized to treat stenoses in diseased SVGs. Methods. Therefore, we conducted a multicenter matched-control study in patients treated for de novo SVG lesions with Cypher or BMS, matching for reference vessel diameter, stent length, diabetes and number of stents utilized. The primary study endpoint was TVR at 12 months. Results. Three hundred and fifty patients were matched, with patient age = 69 ± 9 years, 77% male, 39% diabetics, SVG age = 119 ± 75 months, reference vessel diameter = 3.3 ± 0.4 mm, target lesion length = 17.4 ± 8.4 mm (p = NS for all betw

Background. Intravascular ultrasound (IVUS) can detect atherosclerotic compromise in coronary segments where conventional angiography cannot. However, IVUS is more invasive, expensive and laborious than angiography. We compared the detection of stenosis by IVUS and angiography and identified angiographic predictors of severe luminal stenosis on IVUS in patients with angiographically-intermediate coronary lesions. Methods. Fifty-six patients with myocardial ischemia and intermediate stenosis by quantitative coronary angiography (QCA) underwent IVUS assessment of the culprit artery. The results from IVUS and QCA were compared using the two-tailed unpaired t-test. Multiple regression analysis was performed to identify QCA parameters that could predict the presence of severe stenosis on IVUS, defined as a minimum luminal area (MLA) ≤ 4 mm2. Results. A total of 63 stenotic coronary lesions were classified as intermediate by QCA; 68% of these were found to be severe on I

Background. Primary percutaneous coronary intervention (PCI) is the treatment of choice following ST-elevation myocardial infarction (STEMI). There is limited adoption and a paucity of data on outcomes following primary PCI in developing countries. The objective of this study was to describe the procedural and clinical outcomes of patients undergoing PCI for STEMI at a Joint Commission International Accreditation (JCIA) certified hospital in Pakistan and make a comparison with outcomes from the West. Methods. We conducted a retrospective cohort study at a tertiary care university hospital in Karachi, Pakistan. A total of 277 consecutive patients undergoing primary PCI between January 2001 and December 2005 were reviewed. Exclusion criteria included preceding fibrinolytic therapy and STEMI due to stent thrombosis. Cox proportional hazards models were constructed. The primary outcome was mortality. Results. Procedural success was 97.1%. Inhospital mortality was 8.3% (43.9%

Background. Postconditioning has been shown to reduce infarct size during reperfusion (< 72 hours). However, it is unknown whether the infarct size reduction with postconditioning is a long-term effect after clinical percutaneous coronary intervention (PCI). The present study tested the hypothesis that postconditioning during primary PCI preserves global cardiac function and reduces infarct size in patients after prolonged reperfusion. Methods. Fortyone patients undergoing PCI were randomly assigned to a control (n = 18) or postconditioning (n = 23) group within 90 minutes after admission. After predilatation, in the Control group, no intervention was applied in the first 3 minutes of reperfusion, while in the Postconditioning group, three cycles of 30-second angioplasty balloon deflation and 30-second inflation were repetitively applied. Results. There was a trend toward increased ejection fraction quantified by echocardiography in the Postconditioning group compared to

Background. In clinical practice, the use of clopidogrel loading doses higher than the standard 300 mg dose is becoming more common in percutaneous coronary intervention (PCI) despite a paucity of clinical evidence to support such a strategy. Objective. This study sought to assess whether patients with acute coronary syndromes (ACS) undergoing PCI would receive additional benefit from higher-than-standard (300 mg) loading d o s e s of clopidogrel. Methods.We performed a retrospective analysis of outcomes in 2,484 patients with ACS undergoing PCI who received either standarddose (300 mg, n = 1,199) or high-dose (> 300 mg, n = 1,285) clopidogrel loading at 1 of 14 study hospitals between January 2003 and September 2004. Results. At 60 days after discharge, the rate of the combined endpoint of myocardial infarction (MI), stroke, coronary revascularization or death was higher in the high-dose group (37.1% vs. 20.5%; p < 0.0001), primarily because of a higher rate of MI in the

The heart failure epidemic is predominantly an effect of widespread coronary disease, better treatment of coronary heart disease and an aging population. While coronary intervention prevents left ventricular systolic dysfunction (LVSD) by preventing or limiting myocardial damage, it can also be a cause of (iatrogenic) LVSD. Limiting myocardial damage during coronary intervention may well be the next important step that interventional cardiologists need to take by qualifying each procedure as high or low risk for the induction of LVSD and using an appropriate strategy that minimizes the risk of LVSD. This article discusses the various options of limiting LVSD during coronary intervention. J INVASIVE CARDIOL 2007;19:440–443