Percutaneous coronary intervention (PCI) is increasingly used in patients with high-risk baseline characteristics.^1–4 A prior stroke may identify patients who are at higher risk for post-PCI complications. However, no comparative data exist on post-PCI outcomes of patients with or without prior stroke. The benefits of PCI among these sub-groups may be partially offset by increased complication rates. Recent studies have reported improvements in angiographic and clinical success rates of PCI among high-risk groups, largely due to the availability of stents and glycoprotein IIb/IIIa (GPIIb/IIIa) receptor inhibitors.^5,6 Nevertheless, GPIIb/IIIa inhibitors are cautiously used in patients with prior stroke due to the fear of intracranial bleeding (ICH).

Unfractionated heparin is the primary anticoagulant administered prior to percutaneous coronary intervention (PCI) to prevent the generation of thrombin at the site of balloon-induced arterial injury and to reduce the thrombogenicity of the various types of equipment used during PCI.¹ Although glycoprotein IIb/IIIa receptor antagonists are proven to improve outcomes of PCI, approximately 50% of PCIs are performed only with heparin and without glycoprotein IIb/IIIa receptor antagonists in the United States.² Several clinical studies have demonstrated a strong inverse relationship between the degree of anticoagulation with heparin defined by the activated clotting time (ACT) and abrupt vessel closure.^3–7 The narrow window of therapeutic efficacy of heparin in patients undergoing PCI mandates that anticoagulation with heparin be administered accurately.

The current American College of Cardiology/American Heart Association guidelines recommend coronary angiography and revascularization for patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS) and high-risk clinical features.¹ This advantage of invasive approach is suggested by many contemporary randomized clinical trials demonstrating reduced death, myocardial infarction (MI), and recurrent angina in patients undergoing early angiography versus a conservative or ischemia driven strategy.^2–4 Based on these data and the widespread availability of cardiac catheterization, it is not surprising that more than 60% of hospitalized patients with NSTE-ACS in United States hospitals undergo angiography within one week of hospital presentation.⁵

Intracoronary radiation therapy, by virtue of its antiproliferative and favorable remodeling effects, reduces restenosis in both in-stent restenosis (ISR) and de novo lesions. While several large, randomized and non-randomised trials have demonstrated the efficacy of brachytherapy,^1–7 little is known about the lesion-specific characteristics that might determine the outcome of this modality. In this era of evidence-based medicine, this information may be important, specifically with respect to cost-effective resource utilization. Furthermore, with the advent of drug-eluting stents (DES), it has become imperative to further refine the indications of brachytherapy.

Transcatheter closure of single secundum atrial septal defects (ASDs) or patent foramen ovale (PFO) is a well-accepted alternative to surgical repair in selected patients,¹ and intracardiac echocardiography (ICE) has been demonstrated to be superior to conventional transesophageal echocardiography (TEE) monitoring for guiding device placement.²
On the contrary, perforated ASDs³ still remain a challenge for both sonographers and interventionists. This morphological variation has been successfully treated by percutaneous placement of two Amplatzer septal occluder devices^4,5 (AGA Medical Corporation, Golden Valley, Minnesota) or a single one after performing balloon atrial septostomy.⁶

A 43-year-old Chinese woman with eosinophilia and a swollen neck was found to have extensive aneurysmal dilatation of both carotid arteries. Although there were no anginal symptoms, cardiac investigation revealed an abnormal radionuclide perfusion study. Cardiac catheterization showed large coronary aneurysms with complete occlusion of the left circumflex (LCx) and right coronary arteries (RCA), and 90% stenosis of the mid-left anterior descending (LAD) artery with an ejection fraction (EF) of 25%. Discussion of this unusual form of eosinophilic arteritis and its treatment are presented.

Since we have entered the new “drug-eluting stent era,” managing drug-eluting stent (DES) failure has become a real issue for the interventionalists. So far, no approach has been recommended: intracoronary brachytherapy (IBT) might be efficacious, but concerns have been expressed regarding the combination of cytotoxic drugs and radiation, which may result in excessive inhibition of re-endothelisation, aneurysm and a high risk of thrombosis.^1–3
No data are yet available on the use of a DES to treat the failure of another one. We report on a patient with relapsing in-stent restenosis (ISR) after implantation of a paclitaxel DES who was successfully treated using two sirolimus drug-eluting stents.

Patients with chronic kidney disease have a high prevalence of heart failure. According to the United States Renal Data System, nearly 40% of incident dialysis patients had a clinical diagnosis of heart failure.¹ Furthermore, deterioration in renal function during an episode of cardiac decompensation is commonplace — some deterioration occurs in over 70% of all patients hospitalized for heart failure.² Renal vasoconstriction is the final common pathway for many factors such as drugs, contrast media, and poor pump function that contributes to acute renal insufficiency in hospitalized heart failure patients.

The major limitation of percutaneous therapy (PCI) for the treatment of chronic total occlusions (CTOs) is the inability to cross with a wire. We report successful recanalization of a CTO situated at the ostium of the left anterior descending artery. The lesion demonstrated several anatomical features known to be associated with an unsuccessful outcome, and attempts with conventional wires failed. However, recanalization was facilitated with the Intraluminal Wire,™ (Intraluminal Therapeutics, Inc., Carlsbad, California) a novel technology that combines guidance of the wire tip with the capability of radiofrequency ablation.

Although stent thrombosis is currently a rare complication of percutaneous coronary intervention (PCI), it can cause devastating clinical results such as acute myocardial infarction (AMI) and death.¹ The peak incidence of stent thrombosis usually occurs within the first 48 hours post-PCI, and is rarely encountered after the first week of stent implantation.¹ Late stent thrombosis (> 30 days) is an even more unusual phenomenon, and has been demonstrated to be associated with brachytheraphy² and radioactive or drug-eluting stents.³ Recently, late stent thrombosis more than one month after stenting has been reported in patients who underwent intracoronary brachyheraphy, perhaps due to a radiation-induced delay in the formation of an endothelial monolayer on the stent surface.²