A 65-year-old male who underwent coronary artery bypass graft surgery (CABG) 21 years ago and received a mitral valve annuloplasty 5 years ago presented with recurrent angina. Computed tomography showed an aneurysm of the saphenous vein graft (SVG), measuring approximately 43 x 33 mm with mural thrombus. Diagnostic catheterization showed that the SVG to the marginal branch of the left circumflex artery had a large aneurysm with mural thrombus, which measured 32 x 45 mm. The lesion was pretreated with a 5.5 x 47 mm Magic Wallstent (Boston Scientific, Maple Grove, Minnesota) followed by 4.0 x 26, 4. x 26, 4.0 x 19 and 4.0 x 16 mm PTFE-covered stents. Postdilatation was performed using a 5.0 x 20 mm balloon. Because of significant flow from the distal end of the PTFE-covered stents seen at coronary angiography after 6 months, we implanted another 4.0 x 26 mm PTFE-covered stent at the distal edge of the previous stent. Final angiography and intravascular ultrasound showed no

Takotsubo cardiomyopathy, also called transient left ventricular apical ballooning or “broken heart syndrome”, is a cardiac condition that mimics the clinical presentation of acute coronary syndrome but without any evidence of obstructive atherosclerotic coronary artery disease. An episode of intense emotional or physiologic stress, serving as the nidus for a catecholamine surge, has been reported prior to presentation and is presumed to be the triggering factor playing the pathogenic role. We report a unique case of Takotsubo cardiomyopathy without any known precipitating factors. After reviewing multiple case reports and review articles, the evidence supporting a “catecholamine surge” is empirically plausible; however, our case calls this theory into question. The “aborted MI” hypothesis is more convincing as an all-inclusive nidus for the pathogenesis and clinical presentation described in Takotsubo syndrome. More detailed studies and research are needed to ascertain

A 43-year-old male with mirror-image dextrocardia and severe rheumatic mitral stenosis was subjected to successful percutaneous transvenous mitral commissurotomy (PTMC).The standard Inoue technique was modified by transseptal catheterization via the left femoral vein, image inversion, delineation of the interatrial septal anatomy via levophase pulmonary angiography, septal contrast staining and pigtail catheter insertion in the noncoronary aortic sinus, interatrial septal puncture with the transseptal needle rotated to a 7 o’clock position and left ventricular entry with a reverse loop technique. There were no procedural complications. Intracardiac pressures and mitral valvular planimetry suggested a successful procedural outcome. This case illustrates that PTMC can be accomplished safely in patients with this unusual cardiac anatomy with a few modifications in the standard technique. J INVASIVE CARDIOL 2008;20:E33–E35 Key Words: percutaneous mitral commissurotomy; mitra

Stenting has emerged as a procedure associated with low mortality and morbidity for symptomatic renovascular disease. However, percutaneous revascularization of chronically occluded renal arteries has not been reported. We report a case of a patient with refractory hypertension and congestive heart failure with unilateral occlusion of the left renal artery. Renal radionuclide scintigraphy with Tc-MAG3 showed residual left renal function for which percutaneous revascularization and stenting were successfully performed with improvement in symptoms and blood pressure control. Following recanalization, the presence of collateral vessels through the capsule of the kidney was noted, possibly maintaining viability of the renal parenchyma. This is a case of percutaneous revascularization of a chronic total occlusion leading to improvement in hypertensive and congestive symptoms. J INVASIVE CARDIOL 2008;20:E26–E29 Key Words: renal artery stenosis; total occlusion; chronic; stenti

A 75-year-old Afro-Caribbean male presented with a non-ST-elevation myocardial infarction. Coronary angiography showed generally grossly dilated coronary arteries with a large lobular thrombus in the distal right coronary artery. We briefly review this case and discuss the definition, pathophysiology and treatment for coronary artery ectasia. J INVASIVE CARDIOL 2008;20:E23–E25 Key Words: percutaneous coronary intervention; thrombosis; acute coronary syndrome

Endovascular stent-grafts, prosthetic grafts placed over expandable stents, are an alternative therapy for the treatment of arterial aneurysms, pseudo-aneurysms, dissections, penetrating ulcers and coarctations. However, there are limitations to their applicability. Described here is a patient with Takayasu’s arteritis, an inflammatory disease of medium- to large-sized vessels, who developed a discrete pseudo-aneurysm in an open surgically placed aortic graft. She had previously undergone two separate surgeries for the treatment of thoracic aortic aneurysms. Due to the potential for reduced morbidity and mortality, endovascular stenting was a rational approach for a focal graft defect. Endovascular stent-graft repair could not be performed because the ratio of the required vascular sheath to peripheral vessel size was prohibitive in this patient. Instead, endovascular therapy using an Amplatzer patent foramen ovale occluder device was delivered within the pseudo-aneurysm

Coarctation of the aorta is a complex vascular lesion that usually originates distal to the left subclavian artery. It accounts for 5–10% of all congenital cardiovascular malformations and carries a high morbidity and mortality risk. Symptoms depend on the severity of the disease and other coexisting anomalies. Early in life, diagnosis is usually based on significant symptoms and physical findings. Many patients remain asymptomatic until adulthood, with most being diagnosed in the 2nd or 3rd decade. In this case report, we present a late diagnosis of aortic coarctation with a bicuspid aortic valve in a 52-year-old female. Our patient was relatively asymptomatic until she presented with chest discomfort, fatigue and dyspnea in her fifth decade of life. Based on the clinical presentation and the markedly elevated gradient, the patient was referred for corrective therapy. J INVASIVE CARDIOL 2008;20:35–36 Key Words: congenital malformation

ABSTRACT: The occurrence of myocardial infarction and revascularization by percutaneous coronary intervention (PCI) in children, though rare, has usually been reported to be due to secondary causes. Here, we report “real-world” revascularization by PCI in the youngest reported patient with atherosclerotic coronary heart disease, with excellent outcome after more than 30-month follow up. J INVASIVE CARDIOL 2008;20:37–40

Isolated coronary artery spasm without atherosclerotic obstruction is an unusual cause of myocardial infarction (MI). A middle-aged woman presented to our institution in 2001 with acute inferior MI due to coronary artery spasm at the mid segment of the dominant left circumflex coronary artery. After being well for 6 years, she was readmitted again in 2007 with the same type of severe retrosternal chest pain. Electrocardiography (ECG) showed ST-segment elevation over the inferior leads. The chest pain resolved with sublingual nitroglycerin and emergency diagnostic coronary angiography showed normal coronary arteries. Two months later, the patient developed another episode of severe retrosternal chest pain at home, followed by cardiac arrest. An onsite ECG showed ventricular fibrillation and immediate defibrillation was carried out. She was readmitted to the hospital and recovered over the next few days. In view of the recurrent coronary artery spasm causing myocardial inf

Objectives. This study was designed to evaluate the indications for performing multidetector computed tomographic coronary angiography (MDCTA) after catheter-based coronary angiography. Background. Appropriateness criteria for MDCTA apply exclusively to patient evaluation prior to catheterbased angiography. Methods. All MDCTA performed after catheterbased angiography at a tertiary referral center were reviewed. Results. Fourteen of a total of 2,000 MDCTAs (0.7%) fulfilled the criteria: 14 were performed after catheter-based angiography. The indications were: 1) inability to selectively cannulate a native vessel or graft; 2) severe pressure damping limiting safe angiography; 3) ostial disease; 4) course of anomalous vessels; 5) relationship of bypass grafts to the sternum; 6) graft morphology; 7) chronic total occlusions. In all cases, the MDCTA enabled definitive treatment. Conclusions. In a variety of scenarios, MDCT coronary angiography may provide essential

ABSTRACT: Background. Key insights into the role of platelets in acute myocardial infarction (AMI) and unstable angina have led to the development of the polymer-coated stent, Camouflage®. Coating of stents is an elegant method to minimize interactions between platelets and the stent surface and the vascular response following stent implantation. Methods. This single-center prospective registry was performed to estimate the in-hospital, 30-day and 180-day event rate (death, revascularization, reinfarction and pathological stress test at 180 days) in an everyday patient population with AMI with immediate percutaneous coronary intervention. There were 44 males (65.7%) and 23 females (34.3%); 53 patients (79.1%) had hypertension, 11 (16.4%) were diabetic, and 32 (47.8%) had elevated LDL cholesterol. The mean age was 60.7 ± 11.6 years. Results. Sixtyseven patients with AMI (STEMI: 56.7%, NSTEMI: 43.3%) were included. Clinical data at the 30-day and 180-day follow up were avai

Atherosclerotic disease of the vertebrobasilar vessels is an important cause of posterior circulation infarction. Commonly, the primary atheroma forms at the origin of the vertebral arteries. We have recently treated 12 high-risk patients with dilatation and stenting of symptomatic vertebral-origin disease and report our technique and results. Methods. Twelve patients with proximal vertebral stents placed between 1999–2005 were identified from a computerized registry of 3,046 records. All patients had high-grade origin stenoses, symptoms of cerebral ischemia and the following additional risk factors: 6 had contralateral vertebral occlusions; 1 had bilateral carotid occlusion; 2 had combined subclavian/vertebral-origin disease. After treatment, all patients were monitored with ultrasound and angiography and were aggressively managed for vascular disease risk factors. Results. Patients had: hyperlipidemia, 90%; hypertension, 80%; tobacco use, 70%; homocysteine > 10, 50%; co

Background. Despite the advances in interventional cardiology, stent expansion remains an important predictor of success, impacting restenosis and thrombosis rates after either bare-metal (BMS) or drug-eluting stent implantation. Especially for the treatment of complex lesions (e. g., calcified lesions, in-stent restenosis, etc.), adequate lesion preparation might help improve procedural results as well as clinical outcomes. We sought to investigate the safety, feasibility and mechanism of action of a new scoring-balloon catheter, the AngioSculpt®, comprised of a semicompliant balloon and a nitinol spiral cage designed to address complex lesions. Methods. A total of 60 consecutive patients at two centers were prospectively enrolled in this first-in-man coronary study and divided into two groups according to the type of lesion treated: Group I: patients with de novo coronary lesions (n = 47) as a pretreatment strategy before BMS implantation, and Group II: patients with BM

Background. The number of femoral artery catheterizations will increase over the next decade to more than 9 million worldwide. Accordingly, a new era of access site management with vascular closure techniques utilizing biologics are being developed and implemented. Glycerol mono-oleate (GMO) is one such biologic — a biodegradable compound that changes from a solid phase to a bioadhesive swollen semisolid phase when exposed to aqueous solutions and heat. We assessed whether GMO would: 1) achieve hemostasis more effectively than control when injected into a swine liver biopsy tract; and 2) inhibit common percutaneous procedure pathogens. M e t h o d s . During the hemostasis experiment, seven swine anticoagulated with heparin (ACT > 250) underwent 10 open-liver biopsies with a 14 gauge cutting needle; 5 injected with GMO (treatment) and 5 injected with nothing (control). Thirty seconds, 2 minutes, 5 minutes and 10 minutes after the procedure, bleeding was objectively grade

ABSTRACT: Objective. Is there a role for multivessel drug-eluting stenting alone in the treatment of patients with concomitant significant ischemic mitral regurgitation and coronary artery disease? Methods. In 2003, a single medical center in Honolulu, Hawaii, performed a total of 6 cases of coronary revascularization in patients with concomitant significant ischemic mitral regurgitation (MR). All 6 patients had at least 3–4+ grade MR by echocardiography. All 6 patients had clinical presentation of myocardial ischemia. Of the 6 patients, 2 underwent percutaneous coronary intervention (PCI) alone, 2 had coronary artery bypass graft surgery (CABG) alone, and 2 had combined CABG + mitral valve repair (MVR). The patients were followed for 4 years for cardiac death, myocardial infarction or target lesion revascularization. Results. Clinical follow up after the index procedure showed significant improvement in MR in all patients. Left ventricular ejection fraction improved in b