Measurement of cardiac troponins has gained a leading position in the field of biochemical diagnosis of myocardial necrosis, as compared with conventional creatine kinase-MB (CK-MB) measurement. Data reported during the past decade have indicated superior efficacy, high sensitivity and specificity for troponin I (cTn-I), and cardiac troponin T (cTn-T) in the diagnosis of myocardial damage.^1–6 After percutaneous coronary intervention (PCI), cTn-I, cTn-T and CK-MB elevation is not rare and several studies have showed an association with adverse late outcomes.^4–8 Although the underlying pathophysiologic mechanism of post-procedural increase of three markers is quite similar, there are still discussions on the value of each marker in detecting “clinically significant” myocardial damage and defining the predisposition to long-term cardiac events.

Transseptal puncture has recently been a very important therapeutic technique in the treatment of mitral stenosis1,2 and radiofrequency ablation of a left-sided accessory pathway.3 It has increased in importance since ablation for atrial fibrillation is performed in the left atrium by this technique. However, occasional puncture of the atrial free wall may result in bleeding into the pericardial space, which limits this method and increases the difficulty in mastering this technique. We present an improved method for the transseptal approach using a guidewire technique.

Methods
Patients. Eight patients were included in this study from October 1997 to October 1998. We performed percutaneous tranvenous mitral commissurotomy (PTMC) in all of the patients. One patient had PTMC and ablation for left Kent bundle at the same time. All patients provided written informed consent.

Transseptal puncture of the interatrial septum was introduced in 1960 by Brockenbrough.¹ The technique relied on fluoroscopic landmarks to identify anatomical boundaries.

Hypertrophic cardiomyopathy (HCM) is a genetically transmitted disease of the sarcomeres, characterized phenotypically by an inappropriate thickness of the interventricular septum and less frequently, of the free left ventricular wall of a nondilated ventricle.^1,2 Anginal symptoms and signs of ischemia occur frequently in patients with HCM without detectable lesions of the major epicardial coronary arteries,^3–6 suggesting that the presence of ischemia is the result of abnormalities of the coronary microcirculation. Furthermore, coronary flow reserve has been reported to be decreased in patients with hypertrophic cardiomyopathy without evidence of structural and/or functional stenoses of the epicardial vessels.^3–6 Thrombolysis In Myocardial Infarction (TIMI) frame count is a simple clinical tool for assessing quantitative indexes of coronary blood flow.

The transradial artery approach (TRA) for coronary interventions is now well accepted as a safe and cost-effective alternative to the traditional transfemoral approach (TFA).^1,2 In our center, more than 90% of coronary interventions are performed today by TRA. However, in some cases, this approach cannot be used. As an alternative to TRA, we have evaluated the transulnar artery approach (TUA) in 122 consecutive cases.

Methods

Contrast nephropathy (CN) is a recognized complication following cardiac catheterization. Ongoing advances in catheter-based technologies have resulted in an increased number of procedures performed which, in turn, could be related to an increase in in-hospital morbidity and mortality.^1,2 Important risk factors for acute renal failure related to contrast agents are pre-existing renal dysfunction — particularly diabetic nephropathy, reduced intravascular volume, administration of a high volume of contrast, and the use of high-osmolality agents.^3,4

Clinical Trials of Direct Thrombin Inhibitors
The 2 direct thrombin inhibitors that have been studied most extensively are hirudin and bivalirudin. The earlier trials focussed on hirudin in the setting of acute coronary syndromes, MI and PCI and the recent trials are exploring the role of bivalirudin as a replacement of heparin and/or GP IIb/IIIa antagonists and as an adjunct to GP IIb/IIIa receptor antagonists in acute coronary syndromes and PCI.

Acute coronary occlusion following radiofrequency catheter ablation has previously been reported as a very rare complication in the treatment of accessory pathways.¹ We report a case of acute coronary occlusion following a routine atrial flutter ablation. Previously, there has been only one case of acute coronary occlusion following atrial flutter ablation reported in the literature.⁴ To our knowledge, such a case has never been reported in a patient without known prior coronary disease.

Vascular brachytherapy using beta and gamma radiation was the standard for percutaneous reintervention in patients with in-stent restenosis.^1–4 While its beneficial effect has been excellent, the development of new lesions at the proximal and distal edges of the irradiated segments — the “edge effect” — necessitates additional care during such interventions.^5,6 Clinical trials utilizing beta sources have shown that at least a 10 mm or more safety margin of radiation from the balloon-injured segment is required to minimize this phenomenon.⁷ However, this strategy requires irradiation of uninjured, often “normal” areas of the artery, with little known about the potential damage of radiation to “normal” coronary artery tissue. The following case describes the development of new and significant disease in proximal, normal-appearing coronary vascular segments irradiated during a procedure for more distal in-stent restenosis.

Recent studies have demonstrated that in the setting of acute coronary syndrome (ACS), with either intractable symptoms, acute left ventricular failure, acute mitral regurgitation, cardiac enzyme rise or electrocardiogram (ECG) change, percutaneous coronary intervention (PCI) is prognostically advantageous over conservative therapy.^1,2 The benefits of this treatment modality, both in the short term (in terms of procedural success) and in the longer term, is enhanced further by the use of aggressive anticoagulant strategies, including the use of aspirin, clopidogrel, heparin and glycoprotein IIb/IIIa inhibitors. However, the use of aggressive anticoagulation is associated with a higher incidence of access site complications, although several studies have shown that these can be reduced to nearly zero by the use of radial artery access.