Early surgical repair of an acute post-infarction left ventricular pseudoaneurysm complicated by second pseudoaneurysm formation.

We present a case of an acute myocardial infarction complicated by an acute left ventricular pseudoaneurysm (LVPA). Surgical correction in the subacute phase was complicated by development of a second larger LVPA due to tearing of the sutures of the first surgical repair. Our case demonstrates the difficult decision-making regarding the timing of surgical intervention, which remains a debatable issue. The literature on diagnostics, prognosis and treatment of the LVPA is also discussed.

Carcinoid crisis with fatal coronary spasm in a small localized peripheral bronchial carcinoid.

Presumptive coronary artery spasm, with characteristic ST-segment elevation followed by ventricular arrhythmia and cardiac arrest, is a very uncommon manifestation of the carcinoid crisis and has been shown on angiography only once in a patient with co-existing extensive atheromatous disease. We present the history of a 70-year-old man with angiographically documented fatal diffuse coronary spasm in the absence of significant atheromatosis, related to an unprovoked carcinoid crisis caused by a small peripheral atypical carcinoid tumour in the absence of metastasis.

Pulmonary oedema after percutaneous ASD-closure.

Although surgery is the gold standard, percutaneous closure of an atrial septal defect (ASD) is gaining popularity. Nonoperative device closure is applicable only to secundum defects with appropriate anatomic characteristics. A 27-year-old man was referred for closure of a symptomatic secundum type ASD and suffered from a dramatic change in his clinical status due to pulmonary oedema immediately after ASD-closure. The preexisting hypertrophic cardiomyopathy, not known at the moment of the closure procedure, was responsible for this dramatic evolution. Successful occlusion of the left-to-right shunt (resulting in a closure of an "escape mechanism") imparted an acute volume loading to the patient's poorly compliant left ventricle resulting in pulmonary oedema due to hyperacute diastolic heart failure. This case report tries to highlight the haemodynamic features related to ASD closure in the presence of hypertrophic cardiomyopathy. Implications for closure procedures in the presence of poorly compliant left ventricles are discussed.

Cardiac manifestation in Takayasu arteritis.

We present two case reports of young women with Takayasu arteritis and cardiovascular complications. The first case is a female patient suffering from significant aortic valve regurgitation, the second case is a woman who presents with amaurosis fugax and develops acute chest pain with heart failure. In this report we review cardiac involvement in Takayasu arteritis.

A randomized placebo-controlled study on the effect of nifedipine on coronary endothelial function and plaque formation in patients with coronary artery disease: the ENCORE II study.

AIMS: Endothelial dysfunction and plaque formation are features of atherosclerosis. Inhibition of L-type calcium channels or HMG-CoA pathway improves endothelial function and reduces plaque size. Thus, we investigated in stable coronary artery disease (CAD) the effects of a calcium antagonist on coronary endothelial function and plaque size. METHODS AND RESULTS: In 454 patients undergoing PCI, acetylcholine (10(-6) to 10(-4) M) was infused in a coronary segment without significant CAD. Changes in coronary diameter were measured and an intravascular ultrasound examination (IVUS) was performed. On top of statin therapy, patients were randomized in a double-blind fashion to placebo or nifedipine GITS 30-60 mg/day and followed for 18-24 months. Blood pressure was lower on nifedipine than on placebo by 5.8/2.1 mmHg (P < 0.001) as was total and LDL cholesterol (4.8 mg/dL; P = 0.495), while HDL was higher (3.6 mg/dL; P = 0.026). In the most constricting segment, nifedipine reduced vasoconstriction to acetylcholine (14.0% vs. placebo 7.7%; P < 0.0088). The percentage change in plaque volume with nifedipine and placebo, respectively, was 1.0 and 1.9%, ns. CONCLUSION: The ENCORE II trial demonstrates in a multi-centre setting that calcium channel blockade with nifedipine for up to 2 years improves coronary endothelial function on top of statin treatment, but did not show an effect of nifedipine on plaque volume.

Re-examining minimal luminal diameter relocation and quantitative coronary angiography--intravascular ultrasound correlations in stented saphenous vein grafts: methodological insights from the randomised RRISC trial.

AIMS: Angiographic parameters (such as late luminal loss) are common endpoints in drug-eluting stent trials, but their correlation with the neointimal process and their reliability in predicting restenosis are debated. METHODS AND RESULTS: Using quantitative coronary angiography (QCA) data (49 bare metal stent and 44 sirolimus-eluting stent lesions) and intravascular ultrasound (IVUS) data (39 bare metal stent and 34 sirolimus-eluting stent lesions) from the randomised Reduction of Restenosis In Saphenous vein grafts with Cypher stent (RRISC) trial, we analysed the "relocation phenomenon" of QCA-based in-stent minimal luminal diameter (MLD) between post-procedure and follow-up and we correlated QCA-based and IVUS-based restenotic parameters in stented saphenous vein grafts. We expected the presence of MLD relocation for low late loss values, as MLD can "migrate" along the stent if minimal re-narrowing occurs, while we anticipated follow-up MLD to be located close to post-procedural MLD position for higher late loss. QCA-based MLD relocation occurred frequently: the site of MLD shifted from post-procedure to follow-up an "absolute" distance of 5.8 mm [2.5-10.2] and a "relative" value of 29% [10-46]. MLD relocation failed to correlate with in-stent late loss (rho = 0.14 for "absolute" MLD relocation [p = 0.17], and rho=0.03 for "relative" relocation [p = 0.811). Follow-up QCA-based and IVUS-based MLD values well correlated in the overall population (rho = 0.76, p < 0.001), but QCA underestimated MLD on average 0.55 +/- 0.49 mm, and this was mainly evident for lower MLD values. Conversely, the location of QCA-based MLD failed to correlate with the location of IVUS-based MLD (rho = 0.01 for "absolute" values--in mm [p = 0.911, rho = 0.19 for "relative" values--in % [p = 0.111). Overall, the ability of late loss to "predict" IVUS parameters of restenosis (maximum neointimal hyperplasia diameter, neointimal hyperplasia index and maximum neointimal hyperplasia area) was moderate (rho between 0.46 and 0.54 for the 3 IVUS parameters). CONCLUSIONS: These findings suggest the need for a critical re-evaluation of angiographic parameters (such as late loss) as endpoints for drug-eluting stent trials and the use of more precise techniques to describe accurately and properly the restenotic process.

Rotational vs. standard coronary angiography: an image content analysis.

OBJECTIVE: To evaluate the clinical utility of images acquired from rotational coronary angiographic (RA) acquisitions compared to standard "fixed" coronary angiography (SA). BACKGROUND: RA is a novel angiographic modality that has been enabled by new gantry systems that allow calibrated automatic angiographic rotations and has been shown to reduce radiation and contrast exposure compared to SA. RA provides a dynamic multiple-angle perspective of the coronaries during a single contrast injection. METHODS: The screening adequacy, lesion assessment, and a quantitative coronary analysis (QCA) of both SA and RA were compared by independent blinded review in 100 patients with coronary artery disease (CAD). RESULTS: SA and RA recognize a similar total number of lesions (P = 0.61). The qualitative assessment of lesion characteristics and severity between modalities was comparable and lead to similar clinical decisions. Visualization of several vessel segments (diagonal, distal RCA, postero-lateral branches and posterior-descending) was superior with RA when compared to SA (P < 0.05). A QCA comparison (MLD, MLA, LL, % DS) revealed no difference between SA and RA. The volume of contrast (23.5 +/- 3.1 mL vs. 39.4 +/- 4.1; P = 0.0001), total radiation exposure (27.1 +/- 4 vs. 32.1 +/- 3.8 Gycm(2); P = 0.002) and image acquisition time (54.3 +/- 36.8 vs. 77.67 +/- 49.64 sec; P = 0.003) all favored RA. CONCLUSION: Coronary lesion assessment, coronary screening adequacy, and QCA evaluations are comparable in SA and RA acquisition modalities in the diagnosis of CAD however RA decreases contrast volume, image acquisition time, and radiation exposure.

Percutaneous revascularization strategies in a patient with previous coronary artery bypass surgery: technical and patho-physiological insights.

Occasionally, in post-coronary artery bypass patients multiple percutaneous revascularization choices (treatment of the native artery versus treatment of the bypass graft) are available in order to obtain adequate blood supply of the ischemic myocardial region and relief of the anginal symptoms. Once a strategy has been chosen, the possibility to switch to the alternative plan should be considered in case unpredictable complications occur during the first treatment choice. A step-by-step assessment and prediction of the possible acute and long-term outcomes and complications should always be performed in order to optimize the results.

Comparison of assessment of native coronary arteries by standard versus three-dimensional coronary angiography.

Vessel foreshortening is a major limitation of standard coronary angiography due to the 2-dimensional representation of 3-dimensional structures. Three-dimensional models may overcome it. The aim of this study was to compare measurements of coronary segments from quantitative coronary angiography (QCA) in an operator-selected "working view" of standard 2-dimensional coronary angiography with those from 3-dimensional coronary angiography (3D-CA) reconstruction models, which are automatically generated from software applied to rotational coronary angiographic acquisitions. Patients who underwent percutaneous coronary intervention were considered. Two or 3 segments of the artery needing treatment were prespecified, using bifurcations as edges. The operator selected a working view from standard angiography as the view best representing each segment. Rotational angiography was performed, allowing 3-dimensional reconstruction of the selected segments. Additionally a marker guidewire (with 4 markers 10 mm away from one another at the distal tip) was used to further measure segment length, and it was considered the "gold standard" reference. In 36 patients, 81 segments from 12 left anterior descending, 12 circumflex, and 12 right coronary arteries were evaluated. Three-dimensional coronary angiography was always feasible. Although reference vessel diameter was not different between 3D-CA and QCA (p >0.05), segment length measurements were on average 2.3 +/- 2.5 mm longer with 3D-CA than with QCA (p <0.001) and 0.4 +/- 1.8 mm longer than with marker guidewire measurement (p = 0.047). Marker guidewire measurements were 1.9 +/- 2.8 mm longer than QCA measurements (p <0.001). According to Bland-Altman plots, 3D-CA and marker guidewire measurements had the best agreement. In conclusion, 3-dimensional coronary modeling is highly feasible and yields more accurate assessments of the lengths of coronary segments than standard QCA.

Increased late mortality after sirolimus-eluting stents versus bare-metal stents in diseased saphenous vein grafts: results from the randomized DELAYED RRISC Trial.

OBJECTIVES: We sought to provide long-term follow-up data of sirolimus-eluting stents (SES) versus bare-metal stents (BMS) in saphenous vein grafts (SVG) from the RRISC (Reduction of Restenosis In Saphenous vein grafts with Cypher) trial. BACKGROUND: We have previously shown that, in SVG, the use of SES reduces 6-month restenosis and repeated revascularization procedures versus the use of BMS. These data are consistent with trials in native coronary arteries. However, recently published long-term follow-up data of these trials have revealed an increased risk of adverse events (particularly very late stent thrombosis) after SES. METHODS: A total of 75 patients with 96 SVG lesions were randomized to SES versus BMS. All patients underwent clinical follow-up up to 3 years. Specific outcomes assessed in this secondary post-hoc analysis were all-cause mortality, myocardial infarction, and target vessel revascularization. RESULTS: Thirty-eight patients received 60 SES for 47 lesions, whereas 37 patients received 54 BMS for 49 lesions. At a median follow-up time of 32 months (interquartile range 26.5 to 36 months), 11 deaths (7 cardiac, of which 1 was caused by very late stent thrombosis and, 3 were sudden) occurred after SES (29% [95% confidence interval (CI) 17% to 45%]) versus 0 after BMS (0% [95% CI 0% to 9%]) with an absolute difference of 29% ([95% CI 14% to 45%], p < 0.001). The rates of myocardial infarction and target vessel revascularization were not different: 18% and 34% after SES, respectively, versus 5% and 38% after BMS, respectively (p = 0.15 and p = 0.74, respectively). CONCLUSIONS: In this secondary post-hoc analysis, BMS were associated with lower long-term mortality than SES for SVG disease. Also, the 6-month reduction in repeated revascularization procedures with SES was lost at longer-term follow-up. (RRISC Study: Reduction of Restenosis In Saphenous Vein Grafts With Cypher Sirolimus-Eluting Stent; http://clinicaltrials.gov/ct/show/NCT00263263?order=1; NCT00263263).

Intravascular ultrasound comparison of sirolimus-eluting stent versus bare metal stent implantation in diseased saphenous vein grafts (from the RRISC [Reduction of Restenosis In Saphenous Vein Grafts With Cypher Sirolimus-Eluting Stent] trial).

The randomized Reduction of Restenosis In Saphenous Vein Grafts with Cypher Sirolimus-Eluting Stent trial compared angiographic outcomes of sirolimus-eluting stents (SESs) versus bare metal stents (BMSs) in saphenous vein grafts (SVG). Using intravascular ultrasound (IVUS) performed during 6-month follow-up angiography, we compared the vascular effects of the 2 types of stent on SVGs. Of 75 patients (96 lesions) included, 59 patients underwent IVUS in 61 SVGs; 29 patients received 40 SESs for 34 lesions, and 30 patients received 42 BMSs for 39 lesions. IVUS parameters (diameters, areas, and volumes) were compared in the 2 groups. A specific analysis was performed for overlapping SESs. Median neointimal volume was 1.3 mm(3) (interquartile range 0 to 13.1) in SESs versus 24.5 (7.8 to 39.5) in BMSs (p <0.001). Minimal incomplete stent apposition was detected at only 3 stent edges (2 BMSs, 1 SES) next to ectatic regions of the SVG. Compared with single SESs, overlapping SESs showed significant increases in neointimal reaction, with a neointimal volume of 0.6 mm(3)/mm of stent (0.1 to 1.8) versus 0 (0 to 0.4) in single SESs (p = 0.03), and this phenomenon was mainly localized in overlapping SES segments, where neointimal volume per millimeter of stent was 1.1 mm(3)/mm (0.6 to 4.4) versus 0 (0 to 1.3) in nonoverlapping segments (p = 0.05). In conclusion, SESs effectively inhibit neointimal hyperplasia volume compared with BMSs in diseased vein grafts, without evidence of increased incomplete apposition risk. The neointimal response to overlapping SES layers seems higher than to a single SES layer.

Acute and mid-term local vascular effects of compliant balloon inflation (GuardWire system) on saphenous vein bypass grafts: an angiographic analysis.

BACKGROUND: The GuardWire distal protection device reduces the incidence of periprocedural complications during percutaneous stenting of diseased saphenous vein grafts. Its mechanism of action is based on the occlusion of the vessel distal to the lesion with an inflated compliant balloon before the intervention, and the aspiration of embolized material after stent implantation. Although no safety issues related to the compliant balloon have been reported in vein graft treatment, concerns related to the potential injury of the balloon on the vessel wall have been raised. We thus evaluated the angiographic outcome of the vein graft segment where the compliant balloon of the GuardWire distal protection device was inflated during percutaneous interventions of diseased vein grafts. METHODS: Forty consecutive patients undergoing vein graft stenting, all with successful delivery of the GuardWire system, were enrolled. All patients underwent 6-months follow-up angiography. Quantitative coronary angiographic analysis of the vein graft segment where the balloon was inflated was performed before and after the procedure, as well as at 6-month follow-up. RESULTS: No differences in reference vessel diameter, minimal luminal diameter and diameter stenosis were evident between the three measurements. In particular, the difference between post-procedural and follow-up minimal luminal diameter (namely late loss) was 0.003+/-0.19 mm (95% confidence interval: -0.06-0.06). CONCLUSIONS: This prospective study supports for the first time the "angiographic safety" of low pressure inflations of a compliant balloon in saphenous vein grafts, suggesting the absence of acute and mid-term effects on the vein graft vessel wall.

Randomized double-blind comparison of sirolimus-eluting stent versus bare-metal stent implantation in diseased saphenous vein grafts: six-month angiographic, intravascular ultrasound, and clinical follow-up of the RRISC Trial.

OBJECTIVES: We sought to compare, in a randomized fashion, sirolimus-eluting stents (SES) versus bare-metal stents (BMS) in saphenous vein grafts (SVGs). BACKGROUND: Sirolimus-eluting stents reduce restenosis and repeated revascularization in native coronary arteries compared with BMS. However, randomized data in SVG are absent. METHODS: Patients with SVG lesions were randomized to SES or BMS. All were scheduled to undergo 6-month coronary angiography. The primary end point was 6-month angiographic in-stent late lumen loss. Secondary end points included binary angiographic restenosis, neointimal volume by intravascular ultrasound and major adverse clinical events (death, myocardial infarction, target lesion, and vessel revascularization). RESULTS: A total of 75 patients with 96 lesions localized in 80 diseased SVGs were included: 38 patients received 60 SES for 47 lesions, whereas 37 patients received 54 BMS for 49 lesions. In-stent late loss was significantly reduced in SES (0.38 +/- 0.51 mm vs. 0.79 +/- 0.66 mm in BMS, p = 0.001). Binary in-stent and in-segment restenosis were reduced, 11.3% versus 30.6% (relative risk [RR] 0.37; 95% confidence interval [CI] 0.15 to 0.97, p = 0.024) and 13.6% versus 32.6% (RR 0.42; 95% CI 0.18 to 0.97, p = 0.031), respectively. Median neointimal volume was 1 mm(3) (interquartile range 0 to 13) in SES versus 24 (interquartile range 8 to 34) in BMS (p < 0.001). Target lesion and vessel revascularization rates were significantly reduced, 5.3% versus 21.6% (RR 0.24; 95% CI 0.05 to 1.0, p = 0.047) and 5.3% versus 27% (RR 0.19; 95% CI 0.05 to 0.83, p = 0.012), respectively. Death and myocardial infarction rates were not different. CONCLUSIONS: Sirolimus-eluting stents significantly reduce late loss in SVG as opposed to BMS. This is associated with a reduction in restenosis rate and repeated target lesion and vessel revascularization procedures. (The RRISC Study; http://clinicaltrials.gov/ct/show; NCT00263263).

Sirolimus-eluting coronary stents in small vessels.

BACKGROUND: This prospective multicenter study compared angiographic in-lesion late lumen loss in de novo native coronary artery lesions (vessel diameter range 2.25-2.75 mm, length range > or = 15 to < or = 30 mm) 8 months after the implantation of a sirolimus-eluting stent with that of similar vessels with the same drug-eluting stent or a bare stent of the SIRIUS study (historical controls). METHODS AND RESULTS: One hundred one patients (study group) were matched and compared with 323 patients receiving the bare stent (bare control group) and with 350 receiving the Cypher stent (Cypher control group) in the SIRIUS trial. Mean in-lesion late loss in the study group was lower than that in the bare control group (0.20 versus 0.76 mm, P < .0001) and not inferior to that in the Cypher control group (0.27 mm, P = .3). Adverse event rates (death and myocardial infarction) were similar between groups. At 8 months, target lesion revascularization rates were 0% in the study group, 13.2% in the bare control group (P < .001), and 4.6% in the Cypher control group (P = .03). CONCLUSIONS: The Cypher Bx Velocity stent was confirmed to be superior to the bare Bx Velocity stent in small coronary vessels in terms of in-lesion late loss 8 months after implantation.

Randomized evaluation of polytetrafluoroethylene-covered stent in saphenous vein grafts: the Randomized Evaluation of polytetrafluoroethylene COVERed stent in Saphenous vein grafts (RECOVERS) Trial.

BACKGROUND: Treatment of lesions located in saphenous vein grafts (SVGs) is associated with increased procedural risk and a high rate of restenosis. METHODS AND RESULTS: We conducted a randomized, multicenter trial to evaluate the usefulness of a polytetrafluoroethylene (PTFE)-covered stent compared with a bare stainless steel (SS) stent for prevention of restenosis and major adverse cardiac events (MACE) in patients undergoing SVG treatment. The primary end point was angiographic restenosis at 6 months. Secondary end points were 30-day and 6-month MACE rates, defined as the cumulative of death, myocardial infarction (MI), and target lesion revascularization. Between September 1999 and January 2002, 301 patients with SVG lesions were randomized to either the PTFE-covered JoStent coronary stent graft (PTFE group, n=156) or the SS JoFlex stent (control group, n=145). Angiographic and procedural success rates were similar between the 2 groups (97.4% versus 97.9% and 87.3% versus 93.8%, respectively). The incidence of 30-day MACE was higher in the PTFE group (10.9% versus 4.1%, P=0.047) and was mainly attributed to MI (10.3% versus 3.4%, P=0.037). The primary end point, the restenosis rate at 6-month follow-up, was similar between the 2 groups (24.2% versus 24.8%, P=0.237). Although the 6-month non-Q-wave MI rate was higher in the PTFE group (12.8% versus 4.1%, P=0.013), the cumulative MACE rate was not different (23.1% versus 15.9%, P=0.153). CONCLUSIONS: The study did not demonstrate a difference in restenosis rate and 6-month clinical outcome between the PTFE-covered stent and the SS stent for treatment of SVG lesions. However, a higher incidence of nonfatal myocardial infarctions was found in patients treated with the PTFE-covered stent.