The initial interest in the late 1980s in balloon aortic valvuloplasty (BAV) for adults with calcific aortic stenosis (AS) was subsequently tempered by multiple studies demonstrating high rates of restenosis and lack of a favorable impact on long-term survival.^1–3 Currently, few centers have continued to perform BAV regularly, and the number of operators trained in performing BAV has dramatically fallen. With the development of percutaneous valve replacement therapies, there has been a resurgence in BAV.^4,5 A technically-successful BAV is required for delivery of the catheter-mounted valve conduit in all of the percutaneous aortic valves currently being developed and investigated. It is likely that the initial population studied for percutaneous aortic valve replacement will be those at high risk for surgical valve replacement due to comorbid conditions.

There has been growing interest in transradial coronary procedures due to the rare incidence of complications at this puncture site, elimination of the need to limit the patient’s activity and the possibility of early patient discharge.^1,2 Furthermore, use of the radial artery as a vascular access route is expected to expand due to the miniaturization and improvement of the devices, improvement of the techniques and increasing experience by operators with transradial coronary procedures. However, unlike the femoral approach, patients who undergo transradial coronary procedures complain primarily of wrist pain at the puncture site.

Recently, it was reported that aggressive and optimal directional coronary atherectomy (DCA) using intravascular ultrasound (IVUS) can be performed with favorable outcomes.^1–4 The benefit of DCA is thought to be the debulking of plaques in the main vessel without affecting the side branch. Proximal left anterior descending artery (LAD) stenosis and bifurcating lesions are therefore suitable lesions for this technique. The Flexi-Cut™ (Guidant Corporation, Indianapolis, Indiana) is a new atherectomy catheter that was used in our center from July 2001 to October 2004, with good results. This study examined the acute and chronic results (about 6 months after the procedure) of DCA for LAD proximal lesions using the Flexi-Cut and the effects of this device on the left circumflex (LCx) ostium.

Methods

Electrocautery has long been described to generate electromagnetic interference (EMI) and oversensing by implanted pacemakers and defibrillators. Electrocautery is commonly used during surgical procedures involving implantation and explantation of pacemakers and implantable cardioverters-defibrillator (ICDs). However, ventricular tachycardia (VT) or ventricular fibrillation (VF) occurring as a result of electrocautery has only been sporadically reported. We present 4 cases of electrocautery-associated VT or VF during either implantation or explantation of ICDs and pacemakers. The etiology of VT/VF is unclear in these circumstances.

Methods

Secundum atrial septal defect (ASD) is the most common congenital heart defect first diagnosed in adults, even late in life,¹ and it may be successfully closed percutaneously. Patent foramen ovale (PFO) is a remnant of fetal circulation present in about 20% of the normal adult population² and may require closure in cases of cryptogenic stroke due to possible paradoxical emboli.³ Since the prevalence of coronary artery disease (CAD) is increasing with age,⁴ the association of CAD and ASD or PFO may be encountered in adult patients. An adult patient may present with numerous risk factors for CAD and/or symptoms and signs of suspected coronary ischemia. Although both conditions may be successfully treated percutaneously, the techniques of ASD closure and coronary intervention are completely different.

Standard therapy for cryptogenic stroke in the setting of patent foramen ovale (PFO) includes antiplatelet medications and long-term anticoagulation with warfarin. Oral anticoagulation increases the risk of bleeding complications and may not prevent recurrent ischemic neurological events.¹ Therapy for recurrent cryptogenic stroke with PFO includes surgical closure or percutaneous transcatheter closure of the PFO. Surgical closure is associated with significant morbidity with no proven benefits.² Since the first report of percutaneous PFO closure,³ advances in device design have led to facilitated delivery and improved PFO occlusion rates. Recent studies report success rates of deployment with complete closure, as assessed by transesophageal echocardiography (TEE), of more than 90% six months after device implantation.^4–17

The discipline of catheter-based closure of patent foramen ovale (PFO) is still in its “childhood”. Ushered in by the seminal paper from Bridges et al in 1992,¹ it is still hampered by amateurism, ghosts of old misconceptions, apprehension about new methods requiring permanent implants and, most of all, lack of adequate exposure to the discipline in the professional world. The paper prompting this commentary is a step in the right direction. The fact is, catheter-based closure of a PFO is the most simple and innocuous therapeutic intervention in invasive cardiology, shy of, perhaps, the insertion of a temporary cardiac pacemaker. Hence, the old saying “see one, do one, teach one” fits as closely as ever.

Percutaneous coronary intervention (PCI) in bifurcations represents 15–18% of all lesions treated¹ and has traditionally been associated with more complexity and restenosis. It has been demonstrated with bare-metal stents (BMS) that the strategy of provisional stenting provides better outcomes than the implantation of 2 stents.²
The progressive utilization of drug-eluting stents (DES) has increasingly led to treating bifurcations with 2 stents. Colombo described the crushing technique³ and later, Lim⁴ published in-hospital results with the balloon-crushing technique. The balloon-crushing technique involves a modification of the crushing technique in which 2 stents are implanted with the use of a 6 Fr guiding catheter, which may be especially important for radial access procedures.

Trifurcating coronary artery disease is a complex atherosclerotic process involving the origin of one or more of three side branches (SB) arising from a main coronary artery vessel or trunk (MT), with or without involvement of the MT itself. Percutaneous treatment of this disease is often challenging and time-consuming, even with the most experienced operators. With the emergence of drug-eluting stents, interventional cardiologists have become more aggressive in treating complex coronary artery disease including unprotected left main disease in trifurcating vessels.¹ Small case reports have been reported or presented at national meetings with apparently good outcomes.^2–5

Carotid artery stenting (CAS) is now widely utilized as a less invasive alternative to carotid endarterectomy for the prevention of stroke caused by extracranial bifurcation carotid artery stenosis. The procedure involves diagnostic angiography, the extent of which is determined by the anatomic information obtained by preprocedural noninvasive studies, but which should include an accurate evaluation of lesion severity, the carotid bifurcation, ipsilateral intracranial anatomy and the anatomy of the common carotid artery (CCA). The interventional aspects of the procedure then follow.