A patient with variant angina presented complaining of frequent morning chest pain refractory to maximal doses of 5 vasodilator agents. His condition was complicated by a drug eruption due to a side effect of the calcium antagonist. Coronary angiography showed no organic stenosis, but a challenge test revealed multiple and diffuse coronary artery spasms at the right coronary artery and the left anterior descending artery. A total of 5 stents were implanted for full coverage of the spastic segments. Spasm could not be provoked by repeating the challenge test after stenting. He has been asymptomatic for 8 months since the procedure. J INVASIVE CARDIOL 2007;19:E320–E323

We report a case of a patient with exertional angina whose coronary angiography showed a severe stenosis at the ostium of the left coronary anterior descending artery. However, intravascular ultrasound imaging demonstrated only mild plaque burden and negative remodeling, with a 0.66 ratio of external elastic membrane area of the lesion to the distal site. The lesion was successfully treated with stenting. Therefore, our case suggests that negative remodeling at an ostial lesion could be the primary cause of myocardial ischemia. J INVASIVE CARDIOL 2007;19:E328–E330 Key Words: intravascular ultrasound; stenting

Coronary artery fistulae are rare anomalies that are most commonly congenital and rarely acquired. We present a first case of a vein graft to the left atrium fistula that occurred post coronary artery bypass grafting and was treated with percutaneous transcatheter embolization with coiling. The coil was initially lost in the left atrium, but was successfully retrieved and the fistula was closed. We review the pertinent literature on acquired coronary artery fistulae and their management. J INVASIVE CARDIOL 2007;19:E331–E334 Key Words: vein graft; left atrium; fistula

We report a case of an adult patient with patent ductus arteriosus (PDA), a large aortic ampulla and moderate pulmonary hypertension. The PDA was successfully closed using a Nit-Occlud® device designed for PDA closure. The day before the programmed procedure, the patient was admitted for signs and symptoms of cardiac heart failure and atrial fibrillation with rapid ventricular response. The procedure was postponed for 6 days, and in the meantime, she was successfully treated with diuretics, negative water balance and heart rate control. This device is frequently used in the pediatric population. The same procedure in an adult patient may present some technical difficulties, and the merging of pediatric and adult interventional cardiologists is necessary. The technique and management of the procedure are discussed here. J INVASIVE CARDIOL 2007;19:E325–E327 Key Words: PDA occlusion; pulmonary hypertension

Partial or total occlusion of septal perforator branches can occur during stenting of the proximal and mid portion of the left anterior descending artery, secondary to plaque snow plowing and/or stent “jailing”. Flow compromise in a sizeable septal branch can result in a myocardial infarction or in atrioventricular conduction abnormalities. Complete heart block has been described at the time of the procedure, and though it is usually transient, it may require temporary pacing. We report a case of delayed, symptomatic and permanent complete atrio-ventricular block that occurred 2 days after the index procedure, requiring implantation of a permanent pacemaker. J INVASIVE CARDIOL 2007;19:E324–E325 Key Words: left anterior descending artery; stenting complications

Percutaneous intervention for complex coronary chronic total occlusions (CTO) remains challenging in spite of the improvement in wiring techniques and devices available today. The antegrade wiring approach remains the most common method for crossing and intervening in chronic total occlusions. Distal intraluminal wire placement is the most critical step in accomplishing recanalization of a chronic total occlusion. Creation of multiple dissection planes with wires is not an uncommon occurrence prior to success. We describe the use of distal side branch entry to prove luminal entry and subsequent use of the contralateral injection technique to guide distal wire placement after utilization of the parallel wire technique to recanalize a long, calcified and complex chronic total occlusion. J INVASIVE CARDIOL 2007;19:E340–E342

Myocardial infarction during pregnancy is a rare event. The diagnosis and management of this pathology is not well established. We present an unusual case and a brief review of this topic. J INVASIVE CARDIOL 2007;19:E343–E345

Periprocedural hemodynamic stability is the cornerstone of success for complex percutaneous interventions. Percutaneous left ventricular assist devices (VSD) are increasingly being used to perform complex percutaneous coronary and non-coronary interventions. We report our experience in utilizing the TandemHeart®, a percutaneous VSD, to successfully perform complex tandem procedures; balloon aortic valvuloplasty and angioplasty. J INVASIVE CARDIOL 2007;19:E346–E349

Although stent thrombosis is a recognized complication of coronary intervention, recurrent stent thrombosis is rarely reported. We present a patient who suffered 3 ST-segment elevation myocardial infarctions associated with repeated stent thromboses within a month and a half. Although a potentially mechanical cause of thrombosis was identified in the only baremetal stent implanted in this case, no predisposing factors were seen for the 2 drug-eluting stents (DES). While recent worrisome data have suggested a slight increase in the incidence of late angiographic stent thrombosis (defined as occurring beyond 30 days) with drug-eluting stents (DES), their risk of subacute thrombosis (from 1 to 30 days) is reported to be equivalent to that of BMS. Therefore, this rare occurrence serves as a sobering reminder of the risks of subacute thrombosis with both BMS and DES. Marked neointimal inhibition, allergic reactions, as well as thienopyridine resistance, may all contribute to

We report an elective angioplasty of a left circumflex artery (LCx) bifurcation lesion treated by provisional stenting. With a “jailed” wire in the first obtuse marginal, we deployed a 3.0 x 28 mm drug-eluting stent into the main branch. The jailed wire was tangled up in a tortuous side branch. We were unable to retrieve the wire. Forceful wire removal led to an unintended extraction of the fully deployed stent from the main branch. J INVASIVE CARDIOL 2007;19:496–499 Key Words: coronary artery disease; angioplasty; stents; bifurcation

Although uncommon, significant postoperative residual leaks may occur after repair of any type of ventricular septal defect (VSD). Post-traumatic VSDs are even rarer, but can be occasionally seen after penetrating or blunt chest trauma. When these defects are associated with significant left-to-right shunting (Qp/Qs > 1.5) with persistent left ventricular volume overload, intervention is generally recommended. Surgical treatment requires cardiopulmonary bypass with its attendant morbidity, increased hospital stay and possible long-term neurological impairment. With the evolving experience of transcatheter closure of postinfarction and native perimembranous and muscular VSDs, this less invasive method became an attractive alternative to manage these postoperative and post-traumatic defects. In this paper, we report on 3 patients with such residual leaks after repair of a perimembranous defect, which was closed using a perimembranous Amplatzer VSD occluded after a failed at

Objectives. Neutrophils are activated and infiltrate the myocardium after ischemia and reperfusion. The involvement of neutrophils in irreversible reperfusion injury is suggested by numerous experimental studies. The aim of this study was to investigate markers of neutrophil activation following reperfusion of acute myocardial infarction (AMI) accomplished with percutaneous coronary intervention (PCI) and their relationship to markers of lipid peroxidation, cytokines and highly-sensitive C-reactive protein (hsCRP). Design. Non-consecutive patients with their first myocardial infarction were evaluated. Setting. University hospital as primary referral center, single center. Patients and Methods. Forty-nine patients with AMI were evaluated. All were treated with primary PCI and infusion of abciximab. Reperfusion was verified by angiography. Blood samples for analyses of myeloperoxidase (MPO), neutrophil gelatinase-associated lipocalin (NGAL), matrix metalloproteinase-9 (MMP

Background. Ostial disease of the left anterior descending (LAD) or circumflex (LCX) coronary artery is a challenge for the interventionalist. Focal ostial stenting may result in incomplete lesion coverage or plaque shift into the adjacent vessel, creating left main equivalent disease. The purpose of the present study was to address these concerns by using a left main bifurcation strategy with drug-eluting stents (DES) for the treatment of this problem. Methods. The study population consisted of patients with isolated unprotected ostial stenosis of the LAD or LCX artery. Coronary stenting was performed using a bifurcational technique in which DES were deployed from the distal left main artery across the stenosis into the main branch. Post-deployment kissing balloon inflation with provisional side branch stenting was then performed. Clinical and angiographic follow up was obtained to assess the primary endpoint of death, non-fatal myocardial infarction (MI) or target lesi

Background. The intravascular ultrasound (IVUS) findings during repeat intervention for drug-eluting stent (DES) restenosis have not been well described. Methods. We identified 62 consecutive DES restenosis lesions (45 sirolimus-eluting stents and 17 paclitaxel-eluting stents) undergoing repeat intervention with preand postintervention IVUS. Lumen, stent and intimal hyperplasia (stent minus lumen) areas were measured at the minimal lumen area (MLA) site and minimal stent area (MSA) site. Results. Repeat stent implantation was performed in 55 lesions (88.7%). Overall, MLA increased from 2.3 ± 0.7 mm2 preintervention to 4.6 ± 1.6 mm2 postintervention. Preintervention MLA was seen at exactly the preintervention MSA site in 42%, while 73% of postintervention MLAs were located at the preintervention MSA site. There was a strong correlation between the preintervention MSA and the postintervention MLA (r = 0.79; p < 0.001). Preintervention MSA was the strongest independent pred

Purpose. Consecutive patients with multivessel coronary artery disease treated with multiple drug-eluting-stent (DES) percutaneous coronary intervention (PCI) (111 patients) or coronary artery bypass graft (CABG) (95 patients) on the basis of clinico-anatomical judgment were examined to investigate mediumterm clinical results and initial and total costs. Methods. Clinical and procedural characteristics, duration of hospital stay, initial and total costs and 12-month follow-up events were considered in both groups. Results. Previous revascularization procedures and acute coronary syndromes were more frequent in the PCI group, while triple-vessel and left main disease occurred more often in the CABG group. The mean number of treated vessels in multiple DES PCI was 2.7/patient, with 2.8 DES/patient. Complete revascularization was achieved in 70% of cases. Inhospital events were postprocedural non- Q-wave acute myocardial infarction in 5.4%, and 2 retroperitoneal hemorrhages

Aortic stenosis is the most common valvular heart disease in the Western world and its prevalence is increasing with an aging population. Although medical therapy has little to offer in terms of prognosis or symptomatic relief, at least one-third of patients with severe aortic stenosis are denied valve surgery as a result of age and comorbidities. This review describes the development of the percutaneous aortic valve as an alternative therapy for such patients. The technique, initial results and the current limitations of the procedure are explained alongside the ongoing trials necessary in order that such therapy may eventually be made widely available. J INVASIVE CARDIOL 2007;19:478–483