Objective. The present study evaluated the combined use of unfractionated heparin (UFH) and bivalirudin during ad hoc transradial interventional procedures. Background. As a result of its proven efficacy in recent clinical trials, the direct thrombin inhibitor bivalirudin is now increasingly utilized as the anticoagulant of choice for coronary interventions. However, it is currently not packaged for diagnostic procedures. Patients undergoing ad hoc transradial procedures thus need unfractionated heparin during the diagnostic catheterization to protect against radial occlusion. It is unclear how the transition to bivalirudin should be undertaken if a subsequent intervention were performed. Methods. A total of 117 patients underwent ad hoc transradial procedures. Fifty-one patients underwent diagnostic catheterizations receiving only 5,000 Units of UFH in divided doses: (1) Group 1H (n = 26), 2,500 U after sheath insertion and 2,500 U at conclusion; (2)

The compression of the left main coronay artery (LMCA) secondary to pulmonary artery trunk dilatation is a relatively new entity that has been associated with severe pulmonary hypertension. It is associated with acyanogen congenital cardiopathies or idiopathic pulmonary arterial hypertension. The natural history is unknown and its treatment has been based more on the severity of the angiographic compression than on the objective demonstration of myocardial ischemia. We report a case of a woman with severe pulmonary arterial hypertension due to an atrial septal defect with extrinsic compression of the LMCA and a physiopathologic approach to guide its treatment.

Provisional stenting of the side branch seems to be an attractive strategy even in the drug-eluting stent era. One of the technical problems in provisional side-branch stenting is how to deliver the stent through a stent strut. In this case presentation, we suggest a novel method for deploying a stent through the use of a 5 Fr guiding catheter. A 5 Fr guiding catheter within a 7 Fr guiding catheter was advanced to the lesion, through a stent strut, facilitating the deployment of the stent. This system permits negotiation of the stent strut that otherwise obstructs stent passage.

Stroke associated with percutaneous coronary intervention (PCI) is an infrequent, but devastating complication. Intra-arterial thrombolysis has been used with limited success, but there are no widely accepted strategies for acute ischemic stroke during PCI. We report a case in which the AngioJet rheolytic thrombectomy device was used in an attempt to re-establish patency of an occluded internal carotid artery in the setting of an acute stroke caused by thromboembolization from the right coronary artery during PCI.

Serious complications after percutaneous atrial septal abnormality closure are uncommon. We present a case of patent foramen ovale closure with early mobilization of the device and asymptomatic embolization into the descending aorta without sequels. Percutaneous retrieval of the device was successful down to the femoral artery from where it was extracted surgically.

We describe a 41-year-old woman with no cardiac risk factors, typical exertional angina and an abnormal noninvasive stress test. Coronary angiography demonstrated an ambiguous left main coronary artery (LMCA) stenosis. Intravascular ultrasound (IVUS) demonstrated no atheroma, but the minimum lumen diameter and area of the ostial LMCA were significantly reduced. Transesophageal echocardiography showed normal left ventricular function with a bicuspid aortic valve. Two-vessel coronary artery bypass grafting was subsequently performed. To our knowledge, this is the first IVUS-documented case of a congenital left main coronary artery stenosis associated with a bicuspid aortic valve.

We report a case of a healthy 23-year-old woman who presented with cardiogenic shock due to an extensive spontaneous coronary dissection that caused distal subocclusion of the left main and left circumflex artery with occlusion of left anterior descending artery. This spontaneous coronary dissection occurred during oral contraceptive therapy after a recent interruption of pregnancy. The patient was successfully treated with extensive primary stenting of the left coronary tree. Interruption of pregnancy followed by oral contraception should be added to the list of clinical conditions associated with spontaneous coronary artery dissection. The risk of coronary dissection may extend beyond the trigger event because of some not yet well-known alterations in the connective tissue of these patients. An interventional procedure, possibly with stenting, should be considered the first therapeutic option in patients with suitable anatomy.

Pulmonary arteriovenous fistulae, or malformations, are abnormal vascular connections between a pulmonary artery and a pulmonary vein. Clinical presentation may vary from asymptomatic patients to others showing a variety of symptoms such as cyanosis, dyspnea, high output heart failure, hemoptysis and paradoxical embolization. Initially, surgical treatment was the single method of therapy until several percutaneous embolization techniques using coils, coil bags, detachable balloons and devices were established. In this report, we describe a child in whom the new Amplatzer® Vascular Plug device was successfully used to close multiple, large pulmonary arteriovenous fistulae.

Background. Crossing chronic total occlusions (CTO) of coronary arteries continues to challenge interventional cardiologists. A clinical study was undertaken in four European centers to examine the feasibility of using the new CROSSER system that utilizes high-frequency mechanical vibration to penetrate atherosclerotic plaque material to cross CTOs in patients where conventional guidewire techniques had failed. The objective of the study was to determine whether the CROSSER system could safely cross such CTOs. Patients and Methods. A total of 55 CTO lesions in 53 patients were treated in two clinical phases: (1) Phase 1 feasibility study (30 CTOs), with a primary focus on device safety; and (2) Phase 2 pivotal study (25 CTOs) using an improved version of the device, with a primary focus on effectiveness. Results. The primary endpoint of device efficacy and the secondary endpoint of clinical success were both 76% (19/25) in the pivotal study phase. No major adverse cardiac events of dea

Objectives. We describe our experience in using the TandemHeart percutaneous ventricular assist device (pVAD) during high-risk percutaneous coronary intervention (PCI). Background. Coronary artery bypass grafting (CABG) is the preferred treatment for disease in an unprotected left main coronary artery or left main equivalent. However, severe comorbidities may preclude surgery in some patients. In these cases, PCI is also often a high-risk procedure. The pVAD is designed to provide circulatory support during high-risk PCI. Methods and Results. We used the pVAD for hemodynamic support during PCI in 5 consecutive patients who were ineligible for CABG because of severe comorbidities. In all 5 cases, the device was inserted and support initiated without complications. Percutaneous revascularization was successfully performed with pVAD support (approximately 3 L/minute). Four patients were supported for an average of 107 minutes, the pVAD being withdrawn shortly after PCI; all 4 patients rec

Objective. The aim of this study was to assess the safety and efficacy of a 90-minute bed rest protocol for patients undergoing elective 6 Fr coronary angiography via the femoral artery. Background. Following cardiac catheterization, reducing the period of immobilization has beneficial effects on patient comfort. Previously, immobilization times of up to 2 hours have been shown to be safe. Methods. One-thousand consecutive patients undergoing elective daytime coronary angiography were studied. We used a novel protocol with a commercially available compression device to mobilize patients after only 90 minutes of bed rest. Results. Of 1,000 patients, 1 had a minor bleed that was successfully treated with manual pressure followed by a pressure dressing. Two patients developed pseudoaneurysms, 1 of whom required a transfusion. No other patients required a transfusion or experienced hemodynamic instability. Thirteen patients had delayed discharge, most commonly due to a delay in obtaining u

Objective. The aim of this study was to evaluate the differences in 5-year outcomes among diabetic and nondiabetic patients undergoing saphenous vein graft (SVG) percutaneous coronary intervention (PCI) prior to the era of distal protection and drug-eluting stents. Background. PCI of native coronary arteries is known to be associated with higher rates of adverse outcomes in diabetic patients compared to nondiabetic patients. However, the impact of diabetes on long-term outcomes after SVG interventions is not as well established. We conducted an evaluation of 5-year outcomes after SVG PCI in the two decades prior to the availability of distal protection devices and drug-eluting stents. Methods. Data on 2,556 subjects (1,780 nondiabetic and 776 diabetic) undergoing SVG PCI at Emory Hospital from 1981 to 2001 were collected and entered into a computerized database and analyzed for adverse cardiovascular outcomes. Results. Compared to the nondiabetic group, the diabetic group had worse 1-y

Objectives. The purpose of this study is to compare the stent strut distribution between Cypher and Taxus stents by using optical coherence tomography (OCT) in a phantom model. Background. Previous studies demonstrated that the distribution of stent struts might affect amount of neointima proliferation after drug-eluting stent (DES) implantation. Methods. We developed experimental models made of silicon tubing angled at 0°, 30°, and 60°. Testing was performed on two types of stents, Cypher and Taxus, which represent current FDA-approved DES. After deployment, OCT was performed and measurements were obtained as follows at two cross sections; maximum and minimum numbers of visualized stent strut sites: (1) number of visualized stent struts; (2) angle between stent struts (interstrut angle); (3) mean interstrut angle; (4) the delta mean angle was defined as the margin between each value of the interstrut angle and mean interstrut angle. Results. In the Cypher s

In general, obesity is associated with better outcome in patients undergoing percutaneous coronary interventions (PCI). One small study has suggested that these patients do not achieve adequate platelet inhibition with clopidogrel and that this may shape clinical outcomes. We evaluated the relationship between body mass index (BMI) and clinical outcomes at 1 year following PCI in patients randomized to clopidogrel or placebo in the CREDO trial. Methods and Results. BMI, baseline clinical characteristics and clopidogrel regimen were assessed in 2,116 patients. The primary study endpoint was the 1-year composite of death, MI or stroke. A total of 342 patients had low or normal BMI (< 25 kg/m²), 847 were overweight (25–29.9 kg/m²), 810 were obese (30–39.9 kg/m²) and 113 were very obese (greater than or equal to 40 kg/m²). Obese patients were more likely to be young males with diabetes, hypertension and hyperlipidemia (p < 0.01). Bl

Objective. The objective of this retrospective chart review was to evaluate the safety and feasibility of using the direct thrombin inhibitor bivalirudin as the procedural anticoagulant in patients undergoing percutaneous peripheral intervention (PPI). Background. Patients with peripheral artery disease are in general a high-risk population that requires safe and reliable anticoagulation with complete thrombin inhibition. Bivalirudin, a direct thrombin inhibitor, has been shown to be as effective as heparin, but with fewer bleeding events in PCI trials, and recent data suggest that bivalirudin may provide the same benefits in PPI. Methods. This was a retrospective chart review of patients who underwent PPI with bivalirudin as the foundation anticoagulant. Bivalirudin was administered as a 0.75 mg/kg bolus, followed by a 1.75 mg/kg/hour infusion for the duration of the procedure. The primary endpoint was procedural success defined as residual stenosis less than or e

Angio-Seal™, a vascular hemostasis device, has been shown to be safe and effective in rapidly achieving hemostasis after cardiac catheterization or coronary intervention. We propose that similar results can be obtained with Angio-Seal when removing an intra-aortic balloon pump (IABP). We studied 16 patients in whom Angio-Seal was utilized in IABP removals. The primary safety endpoint was a composite of major complications such as retroperitoneal bleeding, vessel occlusion, loss of distal pulses, vascular surgery or death, and minor complications such as hematoma (> 10 cm), AV fistula or pseudoaneurysm by 7 days after removal. The time-to-hemostasis was 2–5 minutes (mean 3.3 minutes). There were no instances of major or minor complications by the seventh day in any patients.

Mechanical complications of acute myocardial infarction (AMI) are rare, but often fatal. Medical therapy does not provide adequate risk reduction, and surgical correction is recommended when feasible. Supplemental hemodynamic support utilizing intra-aortic counterpulsation with a balloon pump provides an improvement in morbidity and mortality when combined with a corrective surgical approach. We report a case of an elderly male with a progressive 2-week history of ischemic symptoms presenting with acute pulmonary edema, hypotension and an inferior wall ST-elevation MI. His hospital course was complicated by ischemic mitral regurgitation (MR) and cardiogenic shock, which resulted in a papillary muscle rupture/avulsion from the inferolateral myocardial wall, and a communication for blood from ventricle to pericardial space. Initial management included mechanical ventilation, pharmacologic inotropic support, percutaneous revascularization of the culprit lesion and intra-aortic balloon cou