When clopidogrel is added to background aspirin therapy, it reduces the composite of cardiovascular death, myocardial infarction (MI) or stroke in patients with acute coronary syndromes (ACS)1 or percutaneous revascularization.2 The most consistent reduction is observed in MI and lasts for at least 1 year after initiation of therapy. Because dual antiplatelet therapy with aspirin and thienopyridines also reduces the incidence of acute and subacute stent thrombosis,3,4 it may be construed that the reduction in adverse ischemic events is the result of prevention of the need for revascularization in these patients. Nevertheless, little has been reported about the need for (repeat) revascularization and the relationship, if any, between ischemic events and revascularization.

Conflicting opinions exist regarding the optimal dose of acetyl salicylic acid (ASA) to be given after percutaneous coronary intervention (PCI) with drug-eluting stents (DES). The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy suggested a daily dose of 75–100 mg of ASA with concomitant clopidogrel, without differentiating between bare-metal and DES.¹ Recent PCI guidelines state that patients without ASA allergy, resistance or increased risk of bleeding should receive a daily dose of 325 mg for 3 to 6 months depending on the type of DES implanted.² However, higher doses of ASA in combination with clopidogrel are proven to increase the risk of bleeding.³ Hence, despite the recent PCI guidelines,² the optimal dose of ASA at the time of discharge is still a matter of debate.

Patent ductus arteriosus (PDA) can cause congestive cardiac failure, repeated pneumonia, pulmonary hypertension and an increased risk for endocarditis. Transcatheter closure of PDA is currently the preferred therapeutic alternative to surgical ligation^1–3 in infants, children and adults. During the last decade, clinical experience has widened extensively and several occlusive devices have been used for this purpose. These include Rashkind’s double umbrella, the Sideris buttoned device, Gianturco spring coils, Cook’s detachable coils and, most recently, the Amplatzer duct occluder.^{3– 5} In the present era, surgical ligation is reserved for large symptomatic PDAs in very small infants and premature babies, unfavorable morphology of the duct^5,6 or due to cost factors, since surgical ligation may be a cheaper alternative.

Patent ductus arteriosus (PDA) may be an isolated lesion or may be present in association with other defects. Isolated PDA constitutes 6–11% of all congenital heart defects. The configuration of PDA varies considerably, but most often it has a conical or funnel shape. The aortic end (ampulla) is wide and gradually narrows towards the pulmonary end. The narrowest segment is usually at the pulmonary end. PDA morphology can vary and the ductus may be short and tubular, have multiple constrictions, or have a bizarre configuration. Some order was brought to classifying the PDAs by the work of Krichenko and his colleagues.¹

Although stenting has improved clinical outcomes of patients undergoing percutaneous coronary intervention (PCI), bare-metal stents are associated with a considerable risk of restenosis.^1,2 The main cause of in-stent restenosis is excessive neointimal hyperplasia formation resulting from proliferation and migration of smooth muscle cells and extracellular matrix production.^3–5

Lately, drug eluting-stents (DES) have markedly reduced neointimal hyperplasia (NIH) via local delivery of antiproliferative agents.^6–8 Several clinical studies have shown that sirolimus- and paclitaxel-eluting stents significantly reduce neointimal hyperplasia and the need for repeat coronary revascularization compared to bare-metal stents.^9–11 However, concerns about long-term safety of these two DES12 have stimulated the search for new DES with comparable efficacy and an improved safety profile.

Interatrial septal defects (IASD) have been associated with an increased incidence of cryptogenic strokes.^1–7 Percutaneous closure of these defects is now widely performed and the safety of this procedure has been established. It is unclear, however, which is the best anticoagulant to use during IASD closure. Bivalirudin has been shown to have lower bleeding complication rates in patients undergoing percutaneous coronary intervention.^8–12 These patients involved primarily an arterial access in contrast to percutaneous closure of IASD that primarily involves venous access, but larger venous sheath sizes. In this study, we retrospectively reviewed our own experience with the use of various anticoagulants in IASD closure and its relationship to in-hospital frequency of major adverse events.

Methods

Introduction of drug-eluting stent (DES) has led to a marked reduction in the problem of in-stent restenosis across all patient subsets and lesions complexities.⁷ Recently, several case reports of aneurysm formation after DES implantation have been reported in the literature. We report a unique presentation of coronary aneurysm following DES implantation.

Variant angina is a distinct clinical entity first described by Prinzmetal and associates in 1959.¹ The classic presentation is characterized by chest pain occurring at rest, and is more frequent in young women. Unlike true angina, the chest pain in variant angina is usually not triggered by physical exertion or emotional stress. Coronary spasm can occur in apparently normal vessels, but more frequently affects atherosclerosis- afflicted segments in the coronary tree.^2,3 It frequently occurs in focal zones, and diffuse multivessel spasm is rarely reported. We report such a case of diffuse, unprovoked triple-vessel vasospasm misdiagnosed as atherosclerotic obstructive coronary artery disease resulting in coronary bypass graft surgery (CABG).

Rupture of atherosclerotic plaque leading to exposure of highly thrombogenic material to the blood pool with subsequent thrombus formation is the principal mechanism associated with acute coronary syndromes.^1,2 Percutaneous coronary intervention (PCI) with distal embolization of thrombus is associated with an increased incidence of death, myocardial infarction (MI), abrupt closure, and emergency coronary artery bypass graft surgery.^3–5 Various pharmacologic, mechanical, and barrier strategies have been studied to avoid the adverse consequences related to PCI on lesions with visible thrombus. Unfortunately, the optimal treatment of thrombus-containing lesions is not yet defined.

Coronary artery fistulae are uncommon vascular anomalies. The incidence of these anomalies is low, ranging from 0.2 to 0.25%.¹ The fistulae frequently drain into one of the ventricles, the pulmonary arteries, the coronary sinus and the superior vena cava or pulmonary veins. The etiology of fistulae is mostly congenital,² however, fistulae may occur secondary to other conditions such as cardiac trauma,³ coronary angioplasty,^4–6 repeated endomyocardial biopsies after heart transplantation,⁷ and following aortic valve replacement.⁸

We report a case of an iatrogenic arteriovenous (AV) fistula between the left anterior descending coronary artery (LAD) and the anterior interventricular vein (AIV) that occurred after stenting of the LAD. To the best of our knowledge, this is the first case of iatrogenic AV fistula between the LAD and AIV that occurred following stenting of the LAD.