A double right coronary artery arising from a single ostium in the right sinus of Valsalva is an extremely rare coronary artery variation. We report for the first time in the literature a case of inferior wall myocardial infarction due to a double right coronary artery occlusion that was successfully managed with percutaneous coronary intervention. The rarity of this unusual coronary artery anomaly, its angiographic diagnosis and an important diagnostic dilemma of a high takeoff of a large right ventricular branch are discussed here. J INVASIVE CARDIOL 2008;20:E37–E40

Primary cardiac non-Hodgkin’s lymphoma is defined as being exclusively located in the heart and/or pericardium, and is extremely rare. This disease occurs mainly in immunocompromised patients and rarely in the immunocompetent. To date, 35 cases of primary cardiac non-Hodgkin’s lymphoma have been reported in the literature by Chalabreysse et al in 2002, and 22 of these cases were diffuse, large B-cell lymphoma (DLBCL). We report a rare case of an immunocompetent female with no significant medical history who presented with dyspnea, chest pain and the beginnings of an SVC syndrome. The patient was initially diagnosed with primary cardiac Burkitt’s lymphoma when surgical pathology was reviewed. After further investigation by another pathology lab, the tumor was defined as DLBCL, which was confirmed by fluorescence in situ hybridization techniques. J INVASIVE CARDIOL 2008;20:E59–E60

Vascular complications are important and unfortunate sequelae of cardiac catheterization. We report a case of complex right subclavian artery dissection following attempted diagnostic cardiac catheterization of a right internal mammary artery (RIMA) coronary bypass graft. Subsequent dissection of the right subclavian artery involved the origin of the right vertebral and internal mammary arteries, as well as producing critical right upper limb ischemia. The anatomy dictated that therapy consist of conservative management of the proximal dissection involving the vertebral artery and the RIMA graft origins, with endovascular stent deployment at the distal site of the vessel occlusion. This example reinforces the need for prompt diagnosis and management of vascular complications, and emphasizes the need for available, appropriate skills relevant to the peripheral vascular interventions. J INVASIVE CARDIOL 2008;20:E61–E63

The presence of a residual systemic-to-pulmonary shunt following a bidirectional Glenn operation may be necessary in patients with an elevated pulmonary vascular resistance. It is often possible to perform percutaneous occlusion of these shunts once the resistance has fallen. We report on the use of an Amplatzer Ductal Occluder Device to occlude a residual Sano shunt in an infant with a variant of hypoplastic left heart syndrome. J INVASIVE CARDIOL 2008;20:E64–E65 Key Words: Amplatzer duct occluder; Sano shunt; hypoplastic left heart syndrome

Despite newer lower-profile stent technologies, placing coronary stents may still remain challenging when vessels are extremely tortuous. We describe a case of a tortuous, very largecaliber right coronary with a near-180º switchback “shepherd’s crook” turn, which could not be stented, and for which double balloon angioplasty was successfully performed. J INVASIVE CARDIOL 2008;20:E52–E53

Dual origin of the circumflex artery is an extremely rare anomaly. We report a rare case of a left circumflex artery arising from the left mainstem and an anomalous circumflex artery from a separate ostium in the right coronary sinus. Both these arteries supplied the circumflex territory. The potential pathological significance of the anomaly and pitfalls of the misdiagnosis are also discussed. J INVASIVE CARDIOL 2008;20:E54–E55

Objectives. To evaluate the radiofrequency energy and covered stents in the percutaneous reconstruction of an interrupted superior vena cava in patients needing endocardial lead implantation. Background. Patients with a history of multiple cardiac surgical procedures or with an history of infections of the pacemaker (PM) site and electrodes may develop iatrogenic occlusion of the venous access. Methods. Three patients (40, 48 and 74 years old, respectively) needing endocardial pacemaker implantation had complete obstruction of the superior vena cava. Recanalization of the superior vena cava (SVC) was undertaken under general anesthesia with orotracheal intubation. Results. A total of 7 balloonexpandable Cheatham-Platinum 8 Zig covered stents were implanted, with a median fluoroscopy time of 58 minutes. The connection between the SVC and the right atrium was obtained, and PMs were implanted successfully in all cases. The patients’ recovery was uneventful and they were dis

ABSTRACT: We report a unique combination of PDA stent placement and occlusion of a persistent cavo-atrial connection in an adult with complex cyanotic congenital heart disease. The unusual anatomy and physiology with prior palliative surgery were amenable to catheterization intervention and have resulted in marked clinical improvement. J INVASIVE CARDIOL 2008;20:E41–E43 Key Words: adults with congenital heart disease; Gianturco-Grifka vascular occlusion device; classic Glenn anastomosis; interventional catheterization

Stent detachment and loss from the balloon represents a dreaded complication of coronary angioplasty. Previously described techniques of stent retrieval include the distal small balloon technique,1 the wire braiding technique,2 the snare technique,3 the stent crush technique4 and a single report of retrieval with the PercuSurge distal embolic protection device.5 Partially expanded stents are potentially much more difficult to retrieve from the coronary circulation given their larger profile. We describe a new method of stent retrieval with the use of the SpideRX distal protection basket device to retrieve a partially expanded drug-eluting stent to the iliac artery and subsequent retrieval and externalization of this expanded stent and SpideRX unit in succession with an EnSnare device via a contralateral Balkin sheath. J INVASIVE CARDIOL 2008;20:E44–E47

Treatment of a coronary artery with a high burden of thrombus in the setting of myocardial infarction poses significant challenges to the operator. Furthermore, a high thrombus burden present in an abnormal aneurysmal artery poses an even greater obstacle. We report a unique case of a 30 year-old-male presenting with an acute myocardial infarction with a heavy thrombus burden in an aneurysmal right coronary artery. After using intravascular ultrasound to appropriately size the artery, thrombectomy and placement of a biliary stent were used to treat the lesion with excellent angiographic outcome. J INVASIVE CARDIOL 2008;20:E48–E51

Objective. To evaluate the long-term follow up of patients at high risk for coronary restenosis. Background. Drugeluting stents (DES) have been proven to reduce restenosis and reintervention compared with bare-metal stents (BMS). Although the safety of DES is not different from that of BMS in the short-tomedium term, concern has arisen about the potential for late stent thrombosis related to delayed endothelialization of the stent struts. Methods. Among 495 patients who underwent percutaneous coronary intervention between June 2004 and March 2005, we retrospectively identified a subset of 150 patients (30%) at high risk for coronary restenosis on the basis of angiographic characteristics who were treated with DES. We assessed the incidence of major adverse cardiac events (MACE) during a 2-year follow up period. The risk of MACE was estimated by computing the hazard ratio and the 95% confidence interval using the Cox regression method. Results. At baseline, 31% of the pat

Objectives. The objectives of the present study were to evaluate the feasibility and safety of implanting a prophylactic left ventricular (LV) assist device prior to high-risk percutaneous coronary intervention (PCI) and to assess the impact of suturemediated preclosure of the arteriotomy site on minimizing vascular complications. Background. Patients with multivessel disease, left main coronary artery disease (LMCA) or left main equivalent and/or moderate-to-severe LV dysfunction with elevated LV end-diastolic pressure are at increased risk of complications during PCI. The TandemHeart™ (TH) is a nonpulsatile percutaneous transseptal ventricular assist device (PTVA) that offers vital temporary hemodynamic support during high-risk PCI. Methods. Between April 2004 and November 2005, the TH was implanted in 20 patients undergoing high-risk PCI. Eight patients underwent unprotected LMCA stenting, and rotational atherectomy was used in 17 patients. Suturemediated femoral arte

Objectives. 1) Describe a quality improvement (QI) process to decrease door-to-balloon time (D2B); 2) Explain implementation of evidence-based strategies to improve D2B. Background. The ACC/AHA 2006 guideline target for ST-elevation myocardial infarction (STEMI) is a D2B of 90 minutes (min). QI methods can be used to identify areas for improvement, measure current processes, and provide rapid-cycle feedback about which strategies are effective. Methods. We studied all STEMI patients presenting to Vanderbilt University Medical Center from July 2005 through November 2006. A process flow chart was created and all D2B process steps were analyzed. In February 2006, evidence-based strategies were implemented to address bottlenecks and decrease D2B. Statistical process control (SPC) was used to monitor D2B time in real-time. Results. Targeted changes led to a 44 min decrease (p < 0.001) in overall median D2B time from 108 min (interquartile range [IQR] = 94–122 min) to 64 min (I

Background. Tirofiban administered at a bolus dose of 25 μg/kg is associated with a higher level of platelet inhibition compared to that associated with the standard 10 μg/kg tirofiban bolus dose. In our previous study on bolus-only glycoprotein IIb/IIIa receptor inhibition during percutaneous coronary intervention (PCI), the eptifibatide bolus-only group demonstrated similar efficacy, but significantly fewer bleeding complications compared to the abciximab bolus-only group. Objective. To compare the in-hospital outcomes of high-dose (25μg/kg) tirofiban bolusonly vs. eptifibatide double bolus-only during PCI. In addition, the degree of platelet inhibition achieved by this novel tirofiban dosing strategy was assessed. Methods. We retrospectively analyzed 876 consecutive patients who underwent PCI using a single high-dose bolus of tirofiban (25 μg/kg) or eptifibatide (180 μg/kg x 2, 10 minutes apart) from January 2003 to August 2005 in a single inst

The treatment of bifurcation coronary artery disease is a common challenge facing the interventional cardiologist. There have been major advances in techniques as well as more widespread use of drug-eluting stents; both appear to have contributed to the realization of single-digit target lesion revascularization rates as well as improvement in short-term complications such as stent thrombosis. Adequate treatment of the side branch ostium, the site most frequently described as being susceptible to restenosis, has become the focus of newer bifurcation techniques as well as dedicated devices for the treatment of this complex lesion subset. Since main branch reintervention rates are sufficiently low and silent restenosis of the side branch ostium is an all-too-common finding, there is no clear consensus on the optimal treatment strategy for bifurcation coronary disease. The following is a comprehensive review of those commonly used techniques as well as dedicated devices curr