ABSTRACT: Variations in coronary anatomy are not uncommon. They are usually benign, but can be a cause of confusion to the angiographer and in most situations, have no clinical significance. In this report, we present an unusual case of a chronically occluded proximal right coronary artery with an anomalous separate right ventricular branch arising directly from the aortic root and serving as a large collateral to the area beyond the occlusion. To our knowledge, this is the first of such anatomic variations being reported. J INVASIVE CARDIOL 2008;20:E136–E137

ABSTRACT: Background. Percutaneous transmitral commissurotomy (PTMC) was first described by Inoue as an alternative to surgical closed mitral commissurotomy for severe rheumatic mitral stenosis. Two techniques — single- and double-balloon methods and percutaneous metallic devices — have been described for mitral dilatation. The Multi-Track system, a single-wire, double-balloon device was introduced by Bonhoeffer for mitral valve dilatation. We describe a case of mitral and tricuspid valve dilatation employing this double-balloon technique. Methods. A 25-year-old male with combined rheumatic mitral and tricuspid stenosis and severe pulmonary hypertension underwent simultaneous double-valve dilatation in a single setting using different sizes of the Multi-Track balloon catheter. Results. The patient’s transmitral gradient decreased from 15 to 2 mmHg and his mitral valve area increased from 1 cm2 to 2.2 cm2. Similarly, his tricuspid valve gradient dropped from 7 to 3 mmHg a

ABSTRACT: Percutaneous coronary intervention (PCI) of a chronic total occlusion (CTO) caused by in-stent restenosis (ISR) is sometimes very difficult due to the presence of hard occlusive components that prevent wire passage. We report a case of CTO caused by ISR (ISR-CTO) in which the occlusion was crossed with the wire subintimally along the outside of the stent and was successfully re-stented. Subintimal tracking along the outside of the stent can be considered as another approach for PCI of ISR-CTO in cases where conventional approaches fail. J INVASIVE CARDIOL 2008;20:E129–E132

ABSTRACT: Platypnea-orthodeoxia is an uncommon condition characterized by the development of hypoxia and breathlessness in the upright posture, relieved by resuming a supine position. First described in 1969, the condition has since been associated with intracardiac and intrapulmonary shunts, liver disease and a host of other conditions. We report an unusual case of episodic breathlessness and hypoxia cured by percutaneous cardiac intervention and discuss the evolving role of cardiac magnetic resonance imaging in the demonstration of functional distortions of cardiac and mediastinal anatomy that may not be as well characterized by other available imaging modalities. J INVASIVE CARDIOL 2008;20:197–198

ABSTRACT: Iatrogenic ostial coronary stenosis is a rare lifethreatening complication of aortic valve replacement, usually presenting after 2 to 6 months. Although it is rarely reported, its incidence has been estimated at 0.3%–5%. The most likely mechanism is posttraumatic fibrous intimal proliferation caused by coronary ostia cannulation for direct cardioplegia. We report a unique case of early occurrence of thrombotic obstruction of the left main stem following aortic valve replacement and its interventional management. J INVASIVE CARDIOL 2008;20:E124–E125

ABSTRACT: Stent thrombosis is a potentially catastrophic complication of coronary artery stenting. There have been particular concerns about the incidence of stent thrombosis following insertion of drug-eluting stents. We report a series of cases in which stent thrombosis occurred in association with malignancy and describe the potential mechanisms behind such an association. We speculate that this association merits further investigation as it raises the possibility that known malignancy may be a risk factor for stent thrombosis and that unexplained stent thrombosis, particularly if recurrent, should stimulate a search for occult malignancy. J INVASIVE CARDIOL 2008;20:E120–E123

ABSTRACT: Stroke is one of the leading causes of mortality, morbidity and serious disability in the developed world. Atrial fibrillation (AF), one of the most common cardiac arrhythmias, is a wellknown predisposing factor for stroke, raising the risk significantly. Oral anticoagulation with warfarin is currently the most effective therapy for stroke risk reduction; however, this therapy increases the risk of bleeding and is often underutilized, contraindicated, or when administered, often subtherapeutic. It has been documented that the left atrial appendage (LAA) is the main source of left atrial thrombus, especially in non-rheumatic AF. Therefore, LAA exclusion may reduce the risk of stroke in AF, and retrospective surgical data have demonstrated a reduced risk of embolic events if surgical LAA exclusion was also performed during mitral valve replacement. Recently, several less invasive percutaneous transcatheter techniques of LAA exclusion — the PLAATO device, the Watch

ABSTRACT: Objective. We sought to characterize the long-term outcomes of patients undergoing intracoronary brachytherapy using b- irradiation (b-BT). Background. b-BT is effective in reducing angiographic restenosis as well as target vessel revascularization (TVR) in patients with in-stent restenosis (ISR) after bare-metal stenting (BMS). Methods. Eighty-one consecutive patients undergoing b-BT for ISR (irradiated length 32 [32–54] mm) after BMS in native vessels (n = 79) or saphenous vein grafts (n = 2) between 2001 and 2003 were followed. Major cardiac events (MACE), including cardiac death, nonfatal myocardial infarction (MI), and TVR occurring < 1 year or > 1 year were assessed 5.2 (4.4–5.6) years after the index procedure. Results. During the entire follow-up period, the total MACE rate was 49.4%. Within the first year and at > 1 year, MACE rates were 25.9% and 23.5%, cardiac death occurred in 2.4% and 6.2%, and nonfatal MI in 6.2% and 12.3% for annual cardiac death/

ABSTRACT: Objectives. To determine the frequency and timing of B-type natriuretic peptide (BNP) and unbound free fatty acid (FFAu) elevation after percutaneous coronary intervention (PCI). Design and Methods. Blood samples were collected from 55 patients undergoing PCI within 1 hour prior to PCI, immediately after PCI, 6 hours and 18–24 hours after PCI, and were analyzed for BNP and FFAu. Results. There was a trend toward a rise in BNP levels at 18–24 hours post-PCI (65 vs. 45 pg/ml; p = 0.056). FFAu levels rose immediately after PCI and returned to baseline by 6 hours postprocedure (2.0 nM pre-PCI, 6.4 nM immediately post-PCI, 1.9 nM 6 hours post-PCI, and 2.2 nM 18-24 hours post-PCI; p < 0.0001). BNP and FFAu levels were elevated post-PCI in 17% and 82% of cases. Conclusions. PCI using short inflation times and coronary stenting are associated with a trend toward increased BNP levels at 18–24 hours post-PCI and a transient significant rise in FFAu levels. J INVASIVE CAR

ABSTRACT: Background and Objectives. Although the PercuSurge (PS) system is an efficient distal protection device, it has several limitations such as significant occlusion time causing myocardial ischemia and requirement of a large 7 or 8 Fr guiding catheter (GC). To address these problems, we developed a new method of use for the PS system using a deeply-engaged 5 Fr GC as an aspiration catheter instead of the Export aspiration catheter. Methods. We studied the initial feasibility and safety of 14 patients treated with a new PS procedure compared to 18 patients treated with the conventional method. Results. Clinical and demographic characteristics were similar between the two patient groups. Device success rate was also similar. The new method using a 5 Fr GC without the Export aspiration catheter significantly reduced fluoroscopic time, total procedure time, occlusion time and in-hospital costs. Conclusions. This method may be an important alternative procedure that co

ABSTRACT: Atrial septal defect (ASD) closure reduces symptoms and prevents ongoing congestive heart failure. However, little is known about device closure in the elderly (age > 60 years) and whether it is a safe and effective treatment. In this study, we report our results with ASD transcatheter closure in the elderly patient > 60 years of age using the Amplatzer Septal Occluder (ASO) device. Methods. Between September 1999 and March 2007, a total of 41 patients (24 females and 17 males) who were > 60 years of age (range 62–87.2 years) and had indications for ASD closure (right ventricular enlargement, clinically symptomatic dyspnea, fatigue, palpitations, exercise intolerance, transient ischemic attacks and/or stroke) underwent an attempt of transcatheter device closure using the ASO. Results. The median Qp/Qs ratio was 2.3 (range 1–7.5). The median mean pulmonary artery pressure was 26 mmHg (range 11–52 mmHg). The median size of the ASD as measured by intracardiac echoc

ABSTRACT: Background. The aim of vascular closure devices is to safely secure the arterial access site at the conclusion of catheterization procedures, thereby increasing patient comfort and decreasing time to hemostasis and ambulation. The FISH (femoral introducer sheath and hemostasis) device is novel in that the access sheath and closure component are incorporated onto the same system. Methods. The FISH pivotal investigation was conducted at 8 catheterization laboratories throughout the United States. Eligible diagnostic patients were randomized (2 to 1) to the FISH device versus manual compression and assessed for time to hemostasis and time to ambulation. Half of the participants underwent ultrasonographic evaluation at 30-day follow up. Enrollment for an interventional cohort is ongoing and will be reported at a later date; however, the interventional patients enrolled to date were combined with the diagnostic patients to comprise the safety data of the trial. Resu

ABSTRACT: Coronary artery aneurysm (CAA) often occurs after percutaneous coronary intervention, and it could be recognized more often in coronary intervention with directional coronary atherectomy (DCA). However, it has been uncertain and the natural history of CAA after DCA remains obscure. Thus, we examined the clinical course after DCA. This study included 792 lesions in which a follow-up angiogram was completed at mid- or long-term (3 months [mos.] or more than 1 year after DCA). The mean average of the angiographic follow-up period was 24.8 mos. (range 3–128 mo.), and clinical follow-up period was 45.6 mos. (range 3 to 144 mos.). CAA was defined as 1.5 > DCA site diameter / reference diameter by quantitative coronary angiography (QCA). CAAs were detected in 21 lesions (2.7%). There was no significant difference in the target lesion revascularization rate between CAA and non-CAA lesion (19.0% vs. 24.6%). More than twice as many follow-up coronary angiograms were perfor

ABSTRACT: Objectives. Stent thrombosis (ST) is a recognized complication of percutaneous coronary interventions (PCI). Due to the high thrombus burden present in ST, the use of thrombus aspiration (TA) may enhance the angiographic results by limiting distal embolization. Methods. Consecutive patients undergoing urgent PCI due to ST were studied, consisting of two groups according to the type of intervention (standard PCI [SP] or TA). TIMI flow, corrected TIMI frame count (cTFC), myocardial blush grade (MBG), thrombus score (TS), Yip’s adverse thrombus burden features, occurrence of angiographically evident distal embolization (DE) were evaluated offline. In-hospital outcomes were also recorded. Results. Twenty-eight patients entered the study. Baseline clinical and angiographic features were similar between patients treated by SP (n = 12) and those treated by TA (n = 16). After PCI, a trend in favor of TA as compared to SP was observed for post-PCI TIMI 3 flow rate (67%

ABSTRACT: Distal thrombus embolization during primary percutaneous coronary intervention occurs frequently and is associated with compromised long term outcomes. Apart from pharmacological agents, great interest has recently been shown in various mechanical devices aimed at either reducing the amount of thrombus present or preventing its distal migration. However, despite the intuitive appeal of such devices, their application remains uncertain given the results of emerging randomized trials. Data presently available show a significant discrepancy between softer clinical endpoints such as reperfusion markers and hard clinical outcomes. The purpose of this review is to summarize the current clinical evidence and provide guidelines for their use. J INVASIVE CARDIOL 2008;20:190–195 Key Words: distal protection; embolization myocardial infarction; thrombectomy