Eustachian valve, interatrial shunt, and paradoxical embolism.

Randomized clinical trials demonstrate that percutaneous closure of the patent oval foramen is a safe and effective treatment for secondary prevention of cryptogenic stroke in selected patients. The Eustachian valve is generally considered an incidental finding without any significant pathophysiological consequences in adults. However, a persistent Eustachian valve, particularly a prominent one, is significantly more prevalent in patients with patent oval foramen and cryptogenic stroke, and is associated with adverse outcomes following percutaneous closure. Therefore, the Eustachian valve may not be an incidental finding or an innocent bystander. By directing the blood flow from the inferior caval vein to the interatrial septum, the persistence of a Eustachian valve may prevent spontaneous closure of the oval foramen, and predispose to paradoxical embolism during adulthood. The Eustachian valve should be considered an adjunctive risk factor for paradoxical embolism in patients with patent oval foramen. Furthermore, the Eustachian valve has been included in several risk prediction models to identify patients at the highest risk of paradoxical embolism and such patients may benefit the most from an intervention.

Three-dimensional echocardiography assessment of carcinoid valvular heart disease: Images of each and all.

A 54-year-old male was found to have neuroendocrine carcinoma with hepatic metastasis. Two-dimensional (2D) transthoracic echocardiography (TTE) demonstrated dilated right ventricle and right atrium, and severe tricuspid and pulmonary regurgitation. Three-dimensional (3D) TTE en-face views showed thickened, retracted, and fixed tricuspid valve and pulmonic valve which remained widely open throughout the cardiac cycle. 3D TTE, particularly en-face views, demonstrates incremental value over 2D TTE by providing precise valvular anatomic details comparable to surgical findings. 3D TTE also offers a unique opportunity to assess all four valves simultaneously with en-face views to delineate their relationships with surrounding structures.

Left Ventricular Dyssynchrony by Three-Dimensional Echocardiography: Current Understanding and Potential Future Clinical Applications.

Left ventricular mechanical dyssynchrony is an important prognostic factor for patients with symptomatic systolic heart failure and has emerged as a therapeutic target for cardiac resynchronization therapy (CRT). However, approximately one-third of patients fail to improve after CRT based on current guideline recommendations and electrocardiographic criteria. Two-dimensional echocardiography and tissue Doppler-based techniques have shown variable results in assessment of left ventricular (LV) dyssynchrony and have limited value in clinical practice. Three-dimensional echocardiography (3DE) is an appealing novel imaging modality that has been recently used in quantitative evaluation of global and regional LV function. There is accumulating evidence that 3DE measurement of LV systolic dyssynchrony index may potentially play a role in predicting the short- and long-term response to CRT and further improve patient selection for CRT. New developments in 3DE speckle tracking technique and strain analysis may further improve the accuracy of LV mechanical dyssynchrony assessment in this population. In addition, recent studies suggest that mechanical dyssynchrony is present in patients with LV hypertrophy and diastolic heart failure. Three-dimensional echocardiographic assessment of dyssynchrony may aid in diagnosis and in predicting long-term outcome in these patients. We will summarize current understanding of 3DE techniques and parameters in assessment of LV mechanical dyssynchrony in the population of patients with systolic heart failure, LV hypertrophy, and diastolic heart failure. A number of the novel 3DE techniques described in this review are early in their stage of development, and they will continue to evolve and need further testing in large multicenter studies.

The left bundle-branch block puzzle in the 2013 ST-elevation myocardial infarction guideline: from falsely declaring emergency to denying reperfusion in a high-risk population. Are the Sgarbossa Criteria ready for prime time?

Prompt and accurate identification of ST-elevation myocardial infarction (STEMI) in the presence of left bundle-branch block (LBBB) remains difficult. The 2004 STEMI guideline recommended emergent reperfusion therapy to patients with suspected ischemia and new or presumably new LBBB. These recommendations have led to frequent false catheterization laboratory activation and inappropriate fibrinolytic therapy because most patients with suspected ischemia and new or presumably new LBBB do not have acute coronary artery occlusion on angiography. The new 2013 STEMI guideline makes a drastic change by removing previous recommendations. Therefore, patients with suspected ischemia and new or presumably new LBBB would no longer be treated as STEMI equivalent. The new guideline fails to recognize that some patients with suspected ischemia and LBBB do have STEMI, and denying reperfusion therapy could be fatal. The Sgarbossa electrocardiography criteria are the most validated tool to aid in the diagnosis of STEMI in the presence of LBBB. A Sgarbossa score of ≥3 has a superb specificity (98%) and positive predictive value for acute myocardial infarction and angiography-confirmed acute coronary occlusion. Thus, we propose a diagnosis and triage algorithm incorporating the Sgarbossa criteria to quickly and accurately identify, among patients presenting with chest pain and new or presumably new LBBB, those with acute coronary artery occlusion. This is a high-risk population in which reperfusion therapy would be denied by the 2013 STEMI guideline. Our algorithm will also significantly reduce false catheterization laboratory activation and inappropriate fibrinolytic therapy, the inevitable consequence of the 2004 STEMI guideline.

Doxorubicin Detoxification in Healthy Organs Improves Tolerability to High Drug Doses for Enhanced Antitumor Therapy.

With its well-documented toxicity, the use of doxorubicin (Dox) for cancer treatment requires trade-offs between safety and effectiveness. This limited use of Dox also hinders its functionality as an immunogenic cell death inducer, thus impeding its usefulness for immunotherapeutic applications. Here, we develop a biomimetic pseudonucleus nanoparticle (BPN-KP) by enclosing GC-rich DNA within erythrocyte membrane modified with a peptide to selectively target healthy tissue. By localizing treatment to organs susceptible to Dox-mediated toxicity, BPN-KP acts as a decoy that prevents the drug from intercalating into the nuclei of healthy cells. This results in significantly increased tolerance to Dox, thereby enabling the delivery of high drug doses into tumor tissue without detectable toxicity. By lessening the leukodepletive effects normally associated with chemotherapy, dramatic immune activation within the tumor microenvironment was also observed after treatment. In three different murine tumor models, high-dose Dox with BPN-KP pretreatment resulted in significantly prolonged survival, particularly when combined with immune checkpoint blockade therapy. Overall, this study demonstrates how targeted detoxification using biomimetic nanotechnology can help to unlock the full potential of traditional chemotherapeutics.

Three-dimensional echocardiography in valvular heart disease.

Two-dimensional echocardiography (2DE) with color Doppler has been the standard tool for assessing valvular heart disease. However, this requires conceptualizing three-dimensional (3D) valvular anatomy from individual 2D slices, which is inadequate for complex valvular abnormalities. Similarly, Doppler-based methods are inherently limited by several assumptions and are influenced by hemodynamics and concomitant valvular disease. 3DE has improved both morphological and functional assessment of valvular heart disease. It provides additional morphological information, which leads to better understanding of the mechanism of valvular dysfunction and surgical planning. 3D planimetry has proven to be accurate in the evaluation of valvular stenosis. This direct assessment eliminates measurement errors and could potentially serve as new gold standard. The continuity equation for aortic stenosis can be simplified by directly measuring left ventricular outflow tract area and stroke volume. In patients with valvular regurgitation, vena contracta area can be directly measured by using 3D color Doppler which is more accurate than the standard 2D methods. By applying hemi-elliptical formula or directly measuring isovelocity surface area, 3DE has significantly improved the accuracy in regurgitant severity assessment. This is particularly useful in patients with eccentric jets. 3DE has an advantage over 2DE in assessment of tricuspid valve due to its complex geometry. Direct planimetry of orifice area in tricuspid stenosis, or vena contracta area in tricuspid regurgitation are promising although validation studies are needed before they can be applied for clinical decision making. 3DE has not been widely studied in pulmonic valve disease but preliminary data indicate that it is feasible.

Three-dimensional echocardiography in evaluation of left ventricular indices.

Accurate determination of left ventricular mass, volume, ejection fraction, and wall motion is important for clinical decision making. Currently, M-mode and two-dimensional echocardiography (2DE) have been routinely used for this purpose. Although these 1D or 2D modalities provide excellent diagnostic and prognostic information, they have a number of technical limitations including the time required to perform the procedure and operator-dependent image acquisitions. In addition, they are inherently limited by geometric assumption of three-dimensional (3D) left ventricular structures based on 2D slices. With the improvement in transducer technology and software development, 3D echocardiography (3DE) has become widely available. Left ventricular quantitation by 3DE has been demonstrated to be accurate by multiple studies that compared 3DE with reference techniques. In addition, 3DE measurements were found to be more reproducible and less variable than 2DE. Real time 3DE imaging has potential advantages in stress echocardiography including rapid acquisition, unlimited number of planes, avoidance of foreshortening, and precise segment matching. This is a major step forward in our diagnostic armamentarium for the evaluation of ischemia. In this review, we summarized the current evidence of 3DE for left ventricular evaluation.

Diabetic conditions promote binding of monocytes to vascular smooth muscle cells and their subsequent differentiation.

Diabetes is associated with significantly accelerated rates of atherosclerosis, key features of which include the presence of excessive macrophage-derived foam cells in the subendothelial space. We examined the hypothesis that enhanced monocyte-vascular smooth muscle cell (VSMC) interactions leading to subendothelial monocyte retention and differentiation to macrophages under diabetic conditions may be underlying mechanisms. Human aortic VSMCs (HVSMCs) treated with diabetic stimuli high glucose (HG) or S100B, a ligand of the receptor for advanced glycation end products, exhibited significantly increased binding of THP-1 monocytic cells. Diabetic stimuli increased the expression of the adhesive chemokine fractalkine (FKN) in HVSMCs. Pretreatment of HVSMCs with FKN or monocyte chemoattractant protein-1 (MCP-1) neutralizing antibodies significantly inhibited monocyte-VSMC binding, whereas monocytes treated with FKN showed enhanced binding to VSMC. Mouse aortic VSMCs (MVSMCs) derived from type 2 diabetic db/db mice exhibited significantly increased FKN levels and binding to mouse WEHI78/24 monocytic cells relative to nondiabetic control db/+ cells. The enhanced monocyte binding in db/db cells was abolished by both FKN and MCP-1 antibodies. Endothelium-denuded aortas from db/db mice and streptozotocin-induced diabetic mice also exhibited enhanced FKN expression and monocyte binding, relative to respective controls. Coculture with HVSMCs increased CD36 expression in THP-1 cells, and this was significantly augmented by treatment of HVSMCs with S100B or HG. CD36 mRNA and protein levels were also significantly increased in WEHI78/24 cells after coincubation with db/db MVSMCs relative to control MVSMCs. These results demonstrate that diabetic conditions may accelerate atherosclerosis by inducing key chemokines in the vasculature that promote VSMC-monocyte interactions, subendothelial monocyte retention, and differentiation.

Streptococcus anginosus purulent pericarditis with cardiac tamponade after coronary artery bypass surgery.

Purulent pericarditis caused by Streptococcus anginosus is extremely rare. A 66-year-old man underwent elective coronary artery bypass surgery. This was complicated by sternal wound dehiscence with drainage. Subsequently, he developed fever, progressive dyspnoea and presyncope. Echocardiography showed a large pericardial effusion with evidence of tamponade. He underwent emergent pericardiocentesis. The pericardial fluid culture grew S. anginosus He was treated with 4 weeks of intravenous ceftriaxone with complete clinical recovery. The source of infection was most likely the sternal wound which was overlooked during debridement and rewiring surgery.

A leaking spontaneous coronary artery pseudoaneurysm.

A 78-year-old man presented with chest pain and ST segment elevation. Coronary angiography showed no significant coronary artery disease. A saccular pocket of contrast material was found outside of the distal right posterior descending coronary artery consistent with a pseudoaneurysm. Echocardiography showed a pocket of pericardial fluid behind the left atrium concerning for a hemopericardium. The pseudoaneurysm was treated urgently with two coils successfully deployed to obtain complete exclusion of the pseudoaneurysm sac and occlusion of the distal portion of the posterior descending coronary artery.

Two in One: Echocardiographic Features of Right-Ventricular Diverticulum and Left-Ventricular Aneurysm in the Same Patient.

Ventricular diverticulum is a rare congenital heart defect that is usually found incidentally upon imaging, such as 2-dimensional transthoracic echocardiogram. We report a case in which an isolated right-ventricular diverticulum and a left-ventricular aneurysm were both found on transthoracic echocardiogram in the setting of a pulmonary embolism. This case highlights how to distinguish between an aneurysm and a diverticulum based on wall motion on echocardiogram, as well as potential complications that may arise from either anomaly.

La présence d'un diverticule ventriculaire est une malformation cardiaque congénitale rare qui est habituellement détectée par accident lors d'un examen d'imagerie, par exemple une échocardiographie transthoracique bidimensionnelle. Nous exposons le cas d'une patiente présentant un diverticule ventriculaire droit isolé et un anévrisme ventriculaire gauche qui ont été décelés lors d'une échocardiographie transthoracique en contexte d'embolie pulmonaire. Nous expliquons comment faire la distinction entre un anévrisme et un diverticule en se fondant sur le déplacement de la paroi à l'échocardiographie, ainsi que les complications qui peuvent découler de ces deux anomalies.

Enhanced proatherogenic responses in macrophages and vascular smooth muscle cells derived from diabetic db/db mice.

Diabetes is associated with enhanced inflammatory responses and cardiovascular complications such as atherosclerosis. However, it is unclear whether similar responses are present in cells derived from experimental animal models of diabetes. We examined our hypothesis that macrophages and short-term cultured vascular smooth muscle cells (VSMCs) derived from obese, insulin-resistant, and diabetic db/db mice would exhibit increased proatherogenic responses relative to those from control db/+ mice. We observed that macrophages from db/db mice exhibit significantly increased expression of key inflammatory cytokines and chemokines as well as arachidonic acid-metabolizing enzymes cyclooxygenase-2 and 12/15-lipoxygenase that generate inflammatory lipids. Furthermore, VSMCs derived from db/db mice also showed similar enhanced expression of inflammatory genes. Expression of inflammatory genes was also significantly increased in aortas derived from db/db mice. Both macrophages and VSMCs from db/db mice demonstrated significantly increased oxidant stress, activation of key signaling kinases, and transcription factors cAMP response element-binding protein and nuclear factor-kappaB, involved in the regulation of atherogenic and inflammatory genes. Interestingly, VSMCs from db/db mice displayed enhanced migration as well as adhesion to WEHI mouse monocytes relative to db/+. Thus, the diabetic milieu and a potential hyperglycemic memory can induce aberrant behavior of vascular cells. These new results demonstrate that monocyte/macrophages and VSMCs derived from db/db mice display a "preactivated" and proinflammatory phenotype associated with the pathogenesis of diabetic vascular dysfunction and atherosclerosis.

Predictors of periprocedural creatine kinase-myocardial band elevation complicating elective percutaneous coronary intervention.

Limited data are available regarding the predictors of periprocedural creatine kinase-MB (CK-MB) isoenzyme increase after elective percutaneous coronary intervention (PCI) in the stenting era. We explored the predictors of periprocedural CK-MB increase in 882 consecutive patients with normal preprocedural CK-MB who underwent 919 angiographically successful elective PCIs with (n = 814) or without (n = 105) stenting. Patients were categorized into 3 groups based on their peak CK-MB levels after PCI: (1) normal CK-MB (n = 761), (2) minor CK-MB increase (CK-MB 1 to 3 times normal, n = 112), and (3) major CK-MB increase (CK-MB >3 times normal, n = 46). By logistic regression analysis, independent predictors for minor CK-MB increase included thrombus (odds ratio [OR] 5.09, p = 0.001), platelet IIb/IIIa antagonist use (OR 0.53, p <0.01), number of lesions treated (per additional lesion, OR 1.54, p <0.01), maximum balloon size (per millimeter increase, OR 1.57, p <0.05), American College of Cardiology/American Heart Association type C lesion (OR 1.68, p <0.05), sustained chest pain during procedure (OR 1.94, p <0.05), dissection (OR 2.05, p <0.05), and transient side branch occlusion (OR 4.54, p <0.05). Independent predictors for major CK-MB increase were chest pain at end of procedure (OR 9.66, p <0.001), type C lesion (OR 2.42, p <0.05), Canadian Cardiovascular Society angina class III to IV (OR 3.32, p <0.05), thrombus (OR 5.09, p = 0.001), and abrupt closure (OR 5.30, p <0.05). In conclusion, baseline clinical and angiographic characteristics and procedural complications were associated with minor and major CK-MB increases. Patients with chest pain at the end of the procedure were at the highest risk for major CK-MB increase.

[Intervention effects of oral active AdipoRon on liver oxidative stress in type 2 diabetic mice].

OBJECTIVE: To explore the intervention effects of oral active AdipoRon on liver oxidative stress in type 2 diabetic mice, which provides basic data for clinical application. METHODS: Thirty-two healthy male C57BL/6 mice were divided into 4 groups:normal group (NC, n=8), diabetes mellitus group (DM, n=8), high dose AdipoRon treatment group (DM + H, n=8) and low dose AdipoRon treatment group (DM + L, n=8). Following six weeks high fat feed, mice of DM, DM + H and DM + L were intraperitoneally injected with 40 mg/kg streptozocin (STZ), leading to type 2 diabetes. Afterwards, DM + H group and DM + L group were continuously treated with high dose and low doses of oral AdipoRon respectively for 10 days, following which, related biochemical indicators were detected. Western blot method was used to detect the p-IRS-1 protein expression in liver tissue and RT-PCR method to detect PDX-1 mRNA expression in the pancreas. RESULTS: The blood glucose of DM group was obviously higher than that of NC group (P < 0.05). Compared to that of DM group, blood glucose of DM + H group as well as DM + L group was significantly lower. Activity of superoxide dismutase (SOD), catalase (CAT) in liver tissue of DM mice was significantly lower than that of NC group (P < 0.05); activity of malondialdehyde (MDA) and nitric oxide synthase (NOS) in DM group significantly higher than that of NC group (P < 0.05); activity of SOD and CAT in DM + L group and DM + H group obviously higher than DM group (P < 0.05); activity of MDA and NOS in DM + L group and DM + H group significantly lower than DM group (P < 0.05). And the p-IRS-1 protein expression in liver tissue and PDX-1 mRNA level in pancreas increased significantly (P < 0.05). CONCLUSIONS: Oral active Adi-poRon which reduced the blood glucose levels of mice had a certain intervention effect on liver tissue oxidative stress in type 2 diabetes mice.

Interaction of monocytes with vascular smooth muscle cells regulates monocyte survival and differentiation through distinct pathways.

OBJECTIVE: Vascular smooth muscle cells (VSMCs) may regulate monocyte functions within atherosclerotic lesions. We investigated the impact of VSMC/monocyte interactions on monocyte apoptosis and scavenger receptor CD36 expression, key events related to monocyte survival and differentiation. METHODS AND RESULTS: Serum deprivation significantly increased THP-1 and human peripheral blood monocyte apoptosis. However, this was significantly reversed by physical binding to human VSMCs (HVSMCs). On binding to HVSMCs, antiapoptotic kinase Akt and its downstream targets were phosphorylated, and Bcl-2 expression was enhanced. Binding-mediated suppression of apoptosis and Akt phosphorylation were attenuated by a phosphoinositide 3-kinase inhibitor and also by an antibody to vascular cell adhesion molecule-1. CD36 expression was also significantly increased in THP-1 cells and in human peripheral blood monocytes after binding to HVSMCs, and this was mediated by both direct contact and soluble factors. Extracellular signal-regulated kinase 1/2 (ERK1/2) mitogen-activated protein kinase phosphorylation was increased in THP-1 cells after HVSMC coculture. Furthermore, an ERK1/2 inhibitor blocked monocyte CD36 upregulation. Contact-dependent CD36 induction and ERK1/2 phosphorylation in monocytes were inhibited by blocking vascular cell adhesion molecule-1 on HVSMC, whereas soluble factor-induced CD36 expression was attenuated by a monocyte chemoattractant protein-1 neutralizing antibody. CONCLUSIONS: These data provide evidence of novel VSMC-dependent local regulation mechanisms for monocyte survival and differentiation in atherosclerosis.

Multimodality imaging and transcatheter coil embolization of an iatrogenic subclavian artery-internal jugular vein fistula.

A 69-year-old man was found to have a loud continuous bruit in the neck. Duplex carotid ultrasound showed high-velocity turbulent flow in the dilated and pulsatile right internal jugular vein. Computed tomography angiogram demonstrated markedly enlarged right internal jugular vein with a posteriorly located arteriovenous communication. Invasive angiography revealed an arteriovenous fistula originating from the right subclavian artery draining into the dilated and tortuous right internal jugular vein. An endovascular coil was successfully deployed in the fistula tract. Subclavian artery-internal jugular vein fistula is rare. Our case is most likely iatrogenic towing to previous central venous cannulation during coronary bypass grafting. The anatomic challenge of this fistula, being located in the thoracic outlet, makes endovascular repair particularly favourable.

Retrospective analysis of percutaneous transluminal coronary angioplasty and coronary stenting.

OBJECTIVE: To examine long-term efficacy of percutaneous transluminal coronary angioplasty (PTCA), coronary stenting and to assess the factors affecting its efficacy. METHODS: A total of 790 patients who underwent successful PTCA and PTCA + stent in this hospital were followed by direct interview or letter. The rate of follow-up was 84.2% and the period of follow-up was 0.9 - 12.7 (3.5 +/- 2.4) years. RESULTS: During follow-up, 4 (0.5%) patients died, 22 (2.8%) had nonfatal acute myocardial infarction, 10 (1.3%) had coronary artery bypass surgery, and 98 (12.4%) had repeat PTCA. The rate of recurrent angina pectoris was 31.1%. The cardiac event-free survival rate calculated by the Kaplan-Meier method was 88.2% at 1 year and 80.6% at 12.7 years. Cox regression analysis showed that there was a positive correlation between AMI history, stent implantation and the risk of cardiac events, and there was a negative correlation between the number of diseased arteries and the risk of cardiac events. Compared to the PTCA group, patients with PTCA + stent had significantly lower rates of total cardiac events. CONCLUSION: The long-term efficacy of PTCA, especially PTCA + stent in Chinese patients was very satisfactory, suggesting that PTCA + stent therapy should be the major treatment for revascularization in patients with coronary heart disease.

Coronary artery disease in patients with chronic kidney disease: a clinical update.

Chronic kidney disease (CKD) is an independent risk factor for coronary artery disease (CAD). Coronary artery disease is the leading cause of morbidity and mortality in patients with CKD. The outcomes of CAD are poorer in patients with CKD. In addition to traditional risk factors, several uremia-related risk factors such as inflammation, oxidative stress, endothelial dysfunction, coronary artery calcification, hyperhomocysteinemia, and immunosuppressants have been associated with accelerated atherosclerosis. A number of uremia-related biomarkers are identified as predictors of cardiac outcomes in CKD patients. The symptoms of CAD may not be typical in patients with CKD. Both dobutamine stress echocardiography and radionuclide myocardial perfusion imaging have moderate sensitivity and specificity in detecting obstructive CAD in CKD patients. Invasive coronary angiography carries a risk of contrast nephropathy in patients with advanced CKD. It should be reserved for those patients with a high risk for CAD and those who would benefit from revascularization. Guideline-recommended therapies are, in general, underutilized in renal patients. Medical therapy should be considered the initial strategy for clinically stable CAD. The effects of statins in patients with advanced CKD have been neutral despite a lipid-lowering effect. Compared to non-CKD population, percutaneous coronary intervention (PCI) is associated with higher procedure complications, restenosis, and future cardiac events even in the drug-eluting stent era in patients with CKD. Compared with PCI, coronary artery bypass grafting (CABG) reduces repeat revascularizations but is associated with significant perioperative morbidity and mortality. Screening for CAD is an important part of preoperative evaluation for kidney transplant candidates.

The use of echocardiography in Wolff-Parkinson-White syndrome.

Endocardial mapping and radiofrequency catheter ablation are well established modalities for the diagnosis and treatment of patients with Wolff-Parkinson-White (WPW) syndrome associated with tachyarrhythmias. However, the electrophysiologic techniques are invasive, require radiation exposure, and lack spatial resolution of cardiac structures. A variety of echocardiographic techniques have been investigated as a non-invasive alternative for accessory pathway localization. Conventional M-mode echocardiography can detect the fine premature wall motion abnormalities associated with WPW syndrome. However, it is unable to identify the exact site of accessory pathway with sufficient accuracy. 2D, 2D-guided M-mode, and 2D phase analysis techniques are limited by image quality and endocardial border definition. Various modalities of tissue Doppler echocardiography significantly increase the accuracy of left-sided accessory pathway localization to 80-90% even in patients with poor acoustic window. However, right-sided pathways remain a diagnostic challenge. Strain echocardiography by speckle tracking has recently been evaluated and appears promising. Different cardiac abnormalities have been detected by echocardiography in WPW patients. Patients with WPW syndrome and tachyarrhythmias have impaired systolic and diastolic function which improves after radiofrequency ablation. Echocardiography is useful in identifying patient with accessory pathway-associated left ventricular dyssynchrony and dysfunction who may benefit from ablation therapy. Transesophageal and intracardiac echocardiography have been used to guide ablation procedure. Ablation-related complications detected by routine echocardiography are infrequent, rarely clinically relevant, and of limited value.

Very Late Development of Coronary Artery Aneurysm with Total Occlusion following Sirolimus-Eluting Stent Implantation.

A 41-year-old African American woman presented with chest pain and was found to have non-ST segment elevation myocardial infarction with a peak cardiac troponin I of 28.5. Elective cardiac catheterization revealed a 70% ostial left anterior descending (LAD) artery stenosis. The patient underwent percutaneous coronary intervention and a sirolimus-eluting stent (Cypher, Miami, FL, 3.5 × 8 mm) was successfully deployed. Three years after stent implantation, the patient presented with recurrent angina. Repeat coronary angiography revealed a large aneurysm involving the proximal portion of the stent with a total occlusion at the mid to distal portion of the stent with collaterals to LAD from left circumflex artery. The patient underwent coronary artery bypass surgery with left internal mammary artery graft to LAD and ligation of LAD at its origin proximal to the aneurysm.