The number of patients receiving pacemaker and implantable cardioverter-defibrillator (ICD) implants is rapidly increasing. The number of permanent pacemaker implants in the United States increased from about 95,000 in 1990 to 250,000 in 2002, while the number of ICD implants increased from 10,000 in 1990 to 100,000 in 2002.¹
Improvements in resolution and greater utilization of transesophageal echocardiography (TEE) in clinical practice have led to increased detection of abnormalities on implanted leads. The reported incidence of such masses is highly variable, but fortunately appears to be relatively low.

Several clinical trials have demonstrated that platelet glycoprotein (GP) IIb/IIIa receptor inhibition reduces the ischemic complications of percutaneous coronary interventions (PCI).^1–4 Comparative data between agents, however, are very limited,⁵ and no large, randomized trials exist comparing the efficacy and safety of the two most commonly used agents, eptifibatide and abciximab. Based on clinical trials demonstrating a clear benefit of abciximab in high-risk patients^1,2,4 and a more modest benefit of eptifibatide use in the ESPRIT trial,⁴ a strategy for use of GP IIb/IIIa inhibitors during PCI with abciximab for high-risk patients and eptifibatide for lower-risk patients has been proposed.6 We previously reported results from a single-center observational study in acute coronary syndrome (ACS) patients undergoing PCI that early outcomes were superior with abciximab compared to eptifibatide.⁷

There is increasing evidence that the liberation of stem cells by use of granulocyte-colony stimulating factor (G-CSF) with or without their transcoronary transplantation is feasible and can improve cardiac function in humans after acute myocardial infarction (AMI).^1–3 However, patients with severe hemodynamic deterioration due to extensive loss of contractile tissue after AMI have not been enrolled in stem cell programs up to now. We report on the case of a patient with acute anterior wall myocardial infarction who suffered from cardiogenic shock despite successful primary percutaneous coronary intervention (PCI). After hemodynamic stabilization, pharmacological propagation of peripheral blood stem cells (PBSC) with G-CSF was initiated. Apheresis and transcoronary transplantation of the PBSC was performed 20 days after AMI.

Target Audience: Clinical Cardiologists, Interventional Cardiologists and Nurses.
Release Date: 12-01-06 Expiration Date: 11-30-07
Learning Objectives: Upon completion of this educational activity, participants should be able to: Educate clinicians about the latest pharmacological treatment options for ACS patients; Review proper utilization of thrombolytic and antiplatelet drugs; Discuss the risks and benefits of device treatment versus pharmacologic treatment.
Method of Participation: Read the journal supplement and complete the Post-Test and Evaluation form and send to: North American Center for CME, 83 General Warren Blvd. #100, Malvern, PA 19355. Fax: (610) 560-0501

(PART II)

Case Presentation. A 65-year-old female with squamous cell carcinoma of the uterus was admitted with acute dyspnea and hypotension. A computed tomography (CT) angiogram using the pulmonaryembolism (PE) protocol revealed evidence of multiple pulmonary emboli, with the largest thrombus in the left lower pulmonary artery branch (Figure 1A). A transthoracic echocardiogram (TTE) demonstrated evidence of right ventricular (RV) dilatation and dysfunction (Figure 1B). Her hemodynamic instability necessitated inotropic support. She had recently undergone resection of the cervix complicated by significant vaginal bleeding, and therefore was not deemed a candidate for thrombolytic therapy.

To the Editor:

Coronary fistulae are congenital or acquired communications between a coronary artery and either a chamber of the heart (coronary-cameral fistula) or any segment of the systemic or pulmonary circulation bypassing the myocardial capillary network. Coronary artery fistulae are a rare occurrence seen in only 0.1–0.2% of angiograms, but comprise about 14% of all congenital coronary anomalies.^1–3 Most fistulae are congenital in origin,^3–5 but acquired fistulae have been rarely reported as a consequence of trauma,^4,6 coronary artery bypass surgery,⁷ complication of percutaneous coronary intervention^8,9 and myocardial infarction.^10,11 These fistulae may be solitary or multiple, originating from one or more coronary arteries.¹ Spontaneous fistulae are extremely rare.^12,13

The precise role of patent foramen ovale (PFO) in causing stroke remains controversial. Clinical factors felt to support a diagnosis of paradoxical embolization through a PFO include presence of concurrent deep vein thrombosis (DVT) and onset of symptoms with a Valsalva maneuver.¹ Regarding the latter, sexual activity may be an often unrecognized Valsalva equivalent. The occurrence of stroke during sexual intercourse, therefore, may have important etiologic implications. We describe two cases of cerebrovascular events associated with sexual activity and strongly suggestive of paradoxical embolization through a PFO.

Since the introduction of drug-eluting stents (DES) during interventional procedures, several randomized studies have demonstrated a significant reduction in coronary restenosis and target vessel revascularizations.^1–4 However, despite the availability of long-term data, the safety of these devices remains an open question. Coronary stent thrombosis, not detected in the first series, has been recently reported in patients treated with DES.⁵ Furthermore, two controlled studies reported a higher incidence of subacute and late stent thrombosis with DES compared to bare-metal stents (BMS).^6,7 Clopidogrel cessation was strongly associated with this event at late follow up.^6–8