ABSTRACT: Restenosis after percutaneous intervention in the left main coronary artery may present as sudden cardiac death. Although drug-eluting stents have demonstrated promising results, there remains the question about appropriate length of the left main artery to be covered with the stent. We describe a patient who received two drug-eluting stents with the balloon crushing technique in the distal left main coronary artery. Three months later, this patient presented with a new lesion in the segment of the left main artery not covered with stent, but instead at the site where the balloon was inflated in the initial procedure.

ABSTRACT: We present the case of a 75-year-old female who developed restenosis after the deployment of “kissing” sirolimus-eluting stents at the left main coronary artery (LMCA) bifurcation. Restenosis occurred at the left circumflex (LCx) artery ostium, where a stent deployed from the LMCA to the LCx arteries overlapped another stent deployed from the LMCA to the left anterior descending (LAD) artery. We investigated the stent expansion and deformation after kissing stent implantation using a phantom three-dimensional model depicting a LMCA bifurcation. Stent overlap was detected at the distal LMCA whether the LAD stent was positioned over the left circumflex (LCx) stent or vice versa. Stent overlap created a gap beneath the overlapped portion of the stent. Thus, we found that kissing stent implantation using different-sized stents produced compression of the LCx stent at the distal LMCA. Incomplete stent apposition caused by stent overlap and stent deformation is thought to be

ABSTRACT: Acute occlusion of the left main coronary artery frequently causes cardiogenic shock and, when this occurs with an initial TIMI 0 flow, has an extremely poor prognosis. The use of a bifurcation system has not been described previously in this situation but has advantages that may result in a simpler and quicker solution then other strategies. This case describes a distal LMCA occlusion, 2 weeks post-stenting of the proximal LAD and proximal Cx, where this strategy was successfully used as a bridge to surgery. Such a strategy may be crucially beneficial in this commonly fatal condition.

ABSTRACT: Stent malapposition remains an important cause of complications following stent implantation. Stent underexpansion is a frequent cause of this. We describe a case of coronary stent malapposition as a result of a post-stenotic aneurysm. Both the malapposition and its etiology were clearly demonstrated by optical coherence tomography, a novel high-resolution imaging technology.

ABSTRACT: Objective. To evaluate the safety and efficacy of rotational atherectomy (RA) in patients with severe left ventricular (LV) dysfunction. Background. RA, using a rotating diamond-crystal burr, is most commonly used to open lesions with severe calcification or diffuse disease that may prove difficult to cross or dilate. However, RA generates microparticular debris that may attenuate the coronary microcirculation, inducing transient myocardial stunning and LV dysfunction. In fact, the manufacturer does not support RA use in patients with severe LV dysfunction. Methods. We retrospectively identified patients with a LV ejection fraction < 30% who underwent RA in our institution over a 4-year period. The medical records were reviewed and risk factors for cardiac disease were recorded. The procedural reports and subsequent hospitalization records were reviewed to identify predetermined positive and negative outcomes. Results. Twenty-three patients (17 males) who underwent RA

ABSTRACT: Background. Platelet glycoprotein IIb/IIIa inhibitors (GPI) are traditionally administered as a bolus followed by an infusion. In the current era of routine stenting, we hypothesized that a bolus-only GPI strategy can be used during percutaneous coronary intervention (PCI) in order to reduce bleeding complications, while preserving the benefits of inhibition of platelet aggregation at the time of device deployment. Methods. We retrospectively analyzed consecutive patients (n = 1,001) who underwent PCI and received an unfractionated heparin (UFH) and bolus-only GPI regimen, from January 2003 to August 2004 in a single institution. All patients received clopidogrel and aspirin prior to PCI. Post-procedure myocardial infarction (MI) was defined using the TIMI definitions, and bleeding complications were defined by the criteria used in REPLACE-2. Results. The most frequently used GPI was eptifibatide (58.3%), followed by abciximab (37.3%) and tirofiban (4.3%). The composit

ABSTRACT: Background. Patients with acute coronary syndromes (ACS) have been shown to have a local increase in culprit lesion temperature of at least 0.5ºC using a specialized thermography catheter. However, this device is unique, not clinically available and unable to provide information other than temperature. The 0.014-inch Radi™ PressureWire^® XT (RPW) contains a high-sensitivity thermistor in the sensor that has a sensitivity of 0.1ºC. We evaluated the ability of the RPW to detect an increase in plaque temperature in patients with ACS. Methods and Results. Patients with ACS and a culprit lesion of > 70% stenosis and who were candidates for percutaneous coronary intervention (PCI) were eligible (n = 20). Fractional flow reserve (FFR) post-adenosine administration and temperature estimations were performed prior to PCI. All demographic data are presented as mean ± SD, and temperature data (using delta temperature from baseline) as mean ± SEM. Fifteen men and

ABSTRACT: Objective. To determine echocardiographic characteristics that may identify patients likely to have residual right-to-left shunt after percutaneous closure of a patent foramen ovale (PFO). Background. Characteristics of the atrial septum and PFO may identify patients who are likely to have residual shunt following percutaneous closure. Methods. We reviewed 76 consecutive patients (42 women; 34 men) who underwent percutaneous PFO closure (AGA Amplatzer^® PFO occluder) for hypoxemia or paradoxical embolization who failed or were unable to receive systemic anticoagulation. Saline contrast echocardiography with and without the Valsalva maneuver was performed within 24 hours and after 6 months to assess for residual shunt. Results. 48 patients (63%) had early closure of the PFO with total elimination of the shunt. Residual shunt was detected in 28 patients (37%), although the severity had diminished significantly compared to baseline. All patients wi

ABSTRACT: Background. Myocardial infarction (MI) complicated by severe left ventricular (LV) dysfunction is associated with significant morbidity and mortality. The natural history of this population with contemporary revascularization and guideline-based medical therapies is poorly defined. We sought to determine the impact of contemporary treatment strategies on LV function and prognosis in patients with MI and severe LV dysfunction. Methods. Consecutive MI patients were prospectively followed as part of an ongoing internal database. The current report comprises 75 patients with first MI and severe LV systolic dysfunction (EF less than or equal to 30%). Initial demographic and clinical data were collected during hospitalization and at 1-, 3- and 6-month follow up. Results. Patients were 71% male, 36% diabetic and 51% had prior coronary disease with a mean (+ SD) age of 65 + 14 years. The average hospital stay was 5.7 days for ST-elevation (CPK range 424–5,250) an

ABSTRACT: Objectives. To demonstrate that fractional flow reserve (FFR) of vessels in patients with high left ventricular mass index (LVMI) should be similar to that of matched vessels in patients with normal LVMI. Background. FFR is a physiologic index of coronary lesion severity. It is not known whether FFR remains useful in the setting of increased LVMI, when microvascular abnormalities may be present. Methods. LVMI was calculated in 84 patients using contrast left ventriculography after validation with cardiac magnetic resonance imaging. Cardiac risk factors, LV ejection fraction (LVEF), minimal lumen diameter (MLD), percent diameter stenosis (%DS), lesion length and FFR were compared in 22 patients with high LVMI to 62 patients with normal LVMI and angiographically-matched vessels. Results. LVMI was 126 ± 21 g/m2 in the high LVMI group and 84 ± 21 g/m2 in the normal LVMI group. There were no differences in age, LVEF, diabetes, hypertension or dyslipidem

ABSTRACT: Background. Studies have revealed that stem cells improve clinical outcomes in patients with severe ischemic cardiomyopathy, but the role of bone marrow mesenchymal stem cells is not well understood. Methods. Twenty-two patients received an implantation of autologous bone marrow mesenchymal stem cell therapy; another 23 patients were placed in a control group after percutaneous coronary intervention (PCI) of the chronically occluded left anterior descending artery. Results. Reversible defect in the cell therapy group decreased from 16 ± 8% at baseline to 6 ± 2% at 12 months (p < 0.05), and this improvement was maintained throughout the entire follow-up period. Compared to the control group (5 ± 3 METS at baseline vs. 5 ± 3 METS at 3 months; p = NS), the level of exercise tolerance improved significantly 3 months after cell therapy (5 ± 2 METS at baseline vs. 7 ± 3 METS at 3 months; p < 0.05). The NYHA function class also improved in t

ABSTRACT: We report a series of 4 cases of percutaneous saphenous vein graft intervention on thrombus-containing occlusive lesions. After passing a 0.014-inch flexible coronary wire, primary thrombosuction was performed using an Export aspiration catheter (EAC). After removing the premounted delivery sheath, a 300-cm long FilterWire EZ was loaded into the aspiration lumen of the EAC. The EAC-FilterWire assembly was then advanced across the lesion; the filter sac was deployed after withdrawing the EAC. The coronary wire was removed, and angioplasty and stenting were performed in the usual manner over the FilterWire. Filter no-reflow developed in 2 cases, which was promptly reversed by repeated manual thrombosuction using the EAC. Finally, normal coronary blood flow was restored after filter retrieval. Visible thrombi or debris were detectable in 2 patients. This interventional strategy increases the efficiency of FilterWire delivery and also gives both active and passive embolic

ABSTRACT: The purpose of this paper is to review what is known regarding the anatomy of the coronary venous system, and the commonly used techniques for its selective catheterization. This is with regard to new innovative percutaneous techniques that have led to a burgeoning interest in methods of access to the coronary veins. Anatomical variation in the epicardial system exists, and the additional role of the Thebesian venous system may have important clinical implications. Catheter-based techniques for coronary vein retroperfusion may provide alternative treatment modalities for patients with “no option” for revascularization using conventional techniques. Furthermore, the use of the coronary venous system has now been reported for the regional delivery of drugs, cells and genes to protect and/or regenerate the myocardium. Finally, the use of the coronary venous system by the cardiac electrophysiologist is reviewed.