A rare complication of cerebral venous thrombosis during simple percutaneous coronary intervention: A case report.

RATIONALE: Cerebrovascular accidents (CVAs) after percutaneous coronary intervention (PCI), although rare, are associated with high in-hospital morbidity and mortality rates. Cerebral venous thrombosis (CVT) is an uncommon cause of CVAs compared with arterial disease but is associated with favorable outcomes in most cases. We present a rare case of CVT following a simple PCI procedure with stent implantation, which has not been previously reported in the literature. PATIENT CONCERNS: A 78-year-old woman with hypertension, hyperlipidemia, and coronary artery disease received simple PCI with stent implantation. After PCI, she developed a throbbing headache with nausea and vomiting, with her blood pressure increasing to 190/100 mmHg. Drowsiness, disorientation, and neck stiffness were noted. Neurological complication due to the PCI procedure was highly suspected. DIAGNOSIS: Noncontrast brain computed tomography was performed along with emergency neurological consultation, and the patient was diagnosed as having acute CVT. INTERVENTIONS: The patient was treated with anti-intracranial pressure therapy and anticoagulation therapy through low-molecular-weight heparin and was subsequently treated with warfarin. OUTCOMES: After treatment, the patient's symptoms and signs gradually subsided, and her clinical condition improved. She was discharged with full recovery thereafter. LESSONS: A case of acute CVT, a rare, and atypical manifestation of venous thromboembolism and CVA, complicated simple PCI with stent implantation. During PCI, identifying patients with a high risk of a CVA is critical, and special care should be taken to prevent this devastating complication.

Automatic Detection of Atherosclerotic Plaque and Calcification From Intravascular Ultrasound Images by Using Deep Convolutional Neural Networks.

Atherosclerosis is the major cause of cardiovascular diseases (CVDs). Intravascular ultrasound (IVUS) is a common imaging modality for diagnosing CVDs. However, an efficient analyzer for IVUS image segmentation is required for assisting cardiologists. In this study, an end-to-end deep-learning convolutional neural network was developed for automatically detecting media-adventitia borders, luminal regions, and calcified plaque in IVUS images. A total of 713 grayscale IVUS images from 18 patients were used as training data for the proposed deep-learning model. The model is constructed using the three modified U-Nets and combined with the concept of cascaded networks to prevent errors in the detection of calcification owing to the interference of pixels outside the plaque regions. Three loss functions (Dice, Tversky, and focal loss) with various characteristics were tested to determine the best setting for the proposed model. The efficacy of the deep-learning model was evaluated by analyzing precision-recall curve. The average precision (AP), Dice score coefficient, precision, sensitivity, and specificity of the predicted and ground truth results were then compared. All training processes were validated using leave-one-subject-out cross-validation. The experimental results showed that the proposed deep-learning model exhibits high performance in segmenting the media-adventitia layers and luminal regions for all loss functions, with all tested metrics being higher than 0.90. For locating calcified tissues, the best result was obtained when the focal loss function was applied to the proposed model, with an AP of 0.73; however, the prediction efficacy was affected by the proportion of calcified tissues within the plaque region when the focal loss function was employed. Compared with commercial software, the proposed method exhibited high accuracy in segmenting IVUS images in some special cases, such as when shadow artifacts or side vessels surrounded the target vessel.

Comparison of ejection fraction calculation between CT and SPECT at high heart rate: A dynamic cardiac phantom study.

The purpose of this study is to compare the ejection fraction (EF) calculation of CT and SPECT at high heart rate. A dynamic cardiac phantom with programmable end-systolic volume (ESV), end-diastolic volume (EDV), and heart rate was used to compare CT, which has high spatial resolution (< 1 mm) and modest temporal resolution of 175 msec, and SPECT, which has high temporal resolution of 16 bins per cardiac cycle but poor spatial resolution (> 1 cm) in EF, ESV, and EDV at the heart rates ≤ 100 bpm for EF = 30 (disease state) and EF = 60 (healthy state). EF calculations for SPECT were accurate in 2% for 40 to 100 bpm for both EF = 30 and EF = 60, and were not heart rate dependent although both ESV and EDV could be underestimated by 18-20%. EF calculations for CT were accurate in 2.2% for 40 and 60 bpm. Inaccuracy in EF calculations, ESV and EDV estimates increased when the heart rate or EF increased. SPECT was accurate for EF calculation for the heart rates ≤ 100 bpm and CT was accurate for the heart rates of ≤ 60 bpm. CT was less accurate for the high heart rates of 80 and 100 bpm, or high EF = 60.

The Utilization of Stress Tests Prior to Percutaneous Coronary Intervention for Stable Coronary Artery Disease in Taiwan.

BACKGROUND: Ischemia shown in non-invasive tests is considered to be a fundamental requirement for treating patients with stable coronary artery disease (CAD) with a percutaneous coronary intervention (PCI). In a nationwide cohort, we investigated the utilization of stress tests, including myocardial perfusion imaging (MPI), treadmill exercise test (TET) and stress echocardiography (SE) prior to elective PCI. METHODS: This retrospective study used the Longitudinal Health Insurance Database 2000 (LHID2000) of the National Health Insurance program in Taiwan. The LHID2000 is comprised of one million randomly sampled beneficiaries. We enrolled patients receiving elective PCI for stable CAD from 2000 to 2013. Stress tests performed within 90 days prior to PCI and patient characteristics correlated with the utilization of stress tests were investigated. RESULTS: During the investigation period, 3,163 patients received elective PCI for stable CAD and 1,847 (58.4%) patients had at least one stress test within 90 days prior to PCI. Among them, 1,461 (79.1%) had MPI, 1,228 had TET (66.4%) and only 1 had SE (0.05%). Age < 80 years, regional hospital and hyperlipidemia were independently associated with an increased likelihood of receiving stress tests. On the other hand, Charlson-comorbidity index score ≥ 1, prior catheterization and heart failure were independently associated with a decreased likelihood of receiving stress tests. CONCLUSIONS: In the setting of stable CAD, almost 60% of our patients received stress tests within 90 days prior to elective PCI, and MPI was the most commonly used test.

Percutaneous Transluminal Angioplasty and Stenting for Hepatic Vessel Stenosis after Orthotopic Liver Transplantation.

BACKGROUND: This study aimed to evaluate the efficacy of vascular intervention in percutaneous transluminal angioplasty (PTA) for the treatment of hepatic artery and hepatic vein stenosis after liver transplantation (LT), including thrombotic total occluded lesions. METHODS: Percutaneous transluminal angioplasty after orthotopic liver transplantation was performed to re-open hepatic vessel lesions. We daily used routine Doppler ultrasound during admission for early detection of graft hepatic vessel lesions, including hepatic artery and vein lesions. In outpatients, Doppler ultrasound was performed every month. Urokinase was delivered with a dose of 150,000-300,000 IU by catheter before PTA for thrombotic total occlusion of the graft for hepatic artery patients. Laboratory data were collected to evaluate the effects of the PTA procedure. RESULTS: The study involved a total of seven patients, six of whom were successfully treated by a first PTA procedure. Thrombolysis use of urokinase in totally occluded donor hepatic arteries post-LT following stenting was successful in three patients. One complication occurred, an arterial dissection and perforation, finalizing the success rate at ~86% and the complication rate at ~14%. Therefore, our study has a primary patency rate of 100% at 1 and 3 months. Also, the graft survival rate was 100 % and 86 % in the first and third months, respectively. CONCLUSIONS: PTA with stenting is an effective treatment for hepatic vessel stenosis, including hepatic arteries and hepatic veins, after a liver transplantation without an increase in the complication rate. In addition, thrombolysis using urokinase intra-artery infusion in graft thrombotic total occluded patients is a good treatment strategy as well. KEY WORDS: Angioplasty; Complication; Liver transplantation.

Prognostic Value of Functional Variables as Assessed by Gated Thallium-201 Myocardial Perfusion Single Photon Emission Computed Tomography for Major Adverse Cardiac Events in Patients with Coronary Artery Disease.

PURPOSE: Gated single photon emission computed tomography (SPECT) using thallium-201 (Tl-201) has the capacity to evaluate the earlier post-stress (PS) function compared to technetium-99m labeled tracers, and may be more sensitive in detecting transient ventricular dysfunction caused by stress-induced ischemia. The purpose of this study was to assess the prognostic value of functional variables obtained from Tl-201 gated SPECT as a predictor of major adverse cardiac events (MACE). METHODS: Four hundred and thirty-eight subjects who had known or suspected coronary artery disease and underwent clinically indicated dipyridamole-stress electrocardiography-gated Tl-201 SPECT were included in this study. Functional variables, including PS-ejection fraction (EF), PS-end systolic volume (ESV), PS-regional wall motion abnormality (RWA), reversible RWA and EF worsening, were generated to study the correlation with MACE (cardiac death, nonfatal infarction, unstable angina and coronary revascularization). RESULTS: Sixty-eight of the total 438 patients (15.5%) had MACE during the period of follow-up (a median time of 31 months), including 2 cardiac deaths, 9 non-fatal infarctions, 9 unstable angina and 48 coronary revascularizations. These events occurred significantly more frequently in patients with reversible RWA (28.8% vs. 7.1%, p < 0.0001), EF worsening (34.8% vs. 12.1%, p < 0.0001), PS-RWA (29.9% vs. 11.4%, p < 0.0001) and PS-EF < 45% (27.8% vs. 14.4%, p = 0.034). Using the Cox proportional hazards regression analysis, reversible RWA and EF worsening were two independent predictors of MACE, providing incremental prognostic value over clinical and perfusion-alone information. CONCLUSIONS: The functional assessment with Tl-201 gated SPECT was a useful prognosticator for patients who had known or suspected coronary artery disease. KEY WORDS: Coronary artery disease; Gated SPECT; Major adverse cardiac events; Tl-201.

Stress-induced myocardial ischemia is associated with early post-stress left ventricular mechanical dyssynchrony as assessed by phase analysis of 201Tl gated SPECT myocardial perfusion imaging.

PURPOSE: In (201)Tl SPECT myocardial perfusion imaging (MPI) data are acquired shortly after the stress injection to assess early post-stress left ventricle (LV) function. The purpose of this study was to use (201)Tl SPECT MPI to investigate whether stress-induced myocardial ischemia is associated with LV mechanical dyssynchrony. METHODS: Enrolled in the study were 75 patients who were referred for dipyridamole stress and rest (201)Tl gated SPECT MPI. The early post-stress scan was started 5 min after injection, and followed by the rest scan 4 h later. The patients were divided into three groups: ischemia group (N = 25, summed stress score, SSS, ≥5, summed rest score, SRS, <5), infarct group (N = 16, SSS ≥5, SRS ≥5) and normal group (N = 34, SSS <5, SRS <5). LV dyssynchrony parameters were calculated by phase analysis, and compared between the stress and rest images. RESULTS: In the ischemia group, LV dyssynchrony was significantly larger during stress than during rest. On the contrary, LV dyssynchrony during stress was significantly smaller than during rest in the normal and infarct groups. LV dyssynchrony during rest was significantly larger in the infarct group than in the normal and ischemia groups. There were no significant differences in LV dyssynchrony during rest between the normal and ischemia groups. CONCLUSION: Stress-induced myocardial ischemia caused dyssynchronous contraction in the ischemic region, leading to a deterioration in LV synchrony. Normal myocardium had more synchronous contraction during stress. The different dyssynchrony pattern between ischemic and normal myocardium early post-stress may aid the diagnosis of coronary artery disease using (201)Tl gated SPECT MPI.

Stent graft used to rescue coronary rupture during percutaneous coronary intervention for myocardial bridge.

Myocardial bridge (MB) is a congenital variation of the coronary arteries and the segment of the coronary artery through myocardium is compressed during systole. Although it is relatively asymptomatic, percutaneous coronary intervention (PCI) may be necessary to relieve symptoms. Perforation or frank rupture of coronary arteries occurs rarely in patients undergoing percutaneous coronary intervention. We report the coronary rupture in a case with myocardial bridge which occurred during percutaneous coronary intervention. We deployed a stent graft to successfully rescue the rupture of the distal segment of left anterior descending coronary artery (LAD-D) with myocardial bridge (MB).

Vegetation on patent foramen ovale presenting as a cryptogenic brain abscess.

This paper describes a case of 51-year-old man with a vegetation on his patent foramen ovale presenting with a cryptogenic brain abscess. He received surgical evacuation and was successfully managed with septal occlusion. This is the first reported case of cryptogenic brain abscess caused by a vegetation on a patent foramen ovale directly documented with transesophageal echocardiography.