Feasibility and efficacy of the 2.5 L and 3.8 L impella percutaneous left ventricular support device during high-risk, percutaneous coronary intervention in patients with severe aortic stenosis.

OBJECTIVE: Assessment of the feasibility and outcomes of the 2.5 L and 3.8 L Impella cardiac pump in patients with severe aortic stenosis (AS) and left ventricular impairment undergoing percutaneous revascularization (PCI) with or without balloon aortic valvuloplasty (BAV). METHODS: We reviewed the clinical and procedural findings from a consecutive series of unselected patients with severe AS who underwent PCI during Impella support. In addition, we describe novel "balloon-assist" techniques that allowed implantation of Impella into the left ventricle (LV) when initial unassisted attempts failed. RESULTS: Five patients with severe AS were identified (four males, age 78.2 years, aortic valve area (AVA) 0.6 cm(2) , left ventricular ejection fraction (LVEF) 24 ± 5%, mean Society of Thoracic Surgeons (STS) mortality 11% (range 3-17%)). The Impella catheter traversed the aortic valve (AV) unassisted in only one patient, with four cases requiring balloon-assist techniques. All patients underwent planned revascularisation; mean procedure time 177 min (range 135-252 min), mean number of stents 3.4 (range 1-8), with three patients requiring rotational atherectomy. All procedures were well tolerated, with absence of arrhythmia, hypotension, pulmonary edema, stroke, or myocardial infarction. One patient died 48 hr post-PCI of multi-organ failure. The four remaining patients were well at 30 days. CONCLUSION: Implantation of the 2.5 and 3.8 L Impella appears feasible in patients with severe AS and left ventricle (LV) impairment. A balloon-assist technique may be used to facilitate device implantation when initial unassisted attempts fail. Improved hemodynamic stability may enhance the tolerability of lengthy and complex procedures.

Kissing drug eluting balloons for in-stent restenosis complicating bifurcations treated with drug-eluting stents.

The management of in-stent restenosis (ISR) complicating bifurcation lesions is technically challenging and implant of further stents may not be feasible. The use of drug-eluting balloons provides an attractive option for treatment of such lesions allowing a technically simple procedure without the need for further complex stenting. The SeQuent Please paclitaxel-eluting balloon (B. Braun, Berlin, Germany) has been shown to be superior to a paclitaxel eluting stent or balloon angioplasty for ISR complicating a bare-metal stent. However, there is no data on the efficacy of the SeQuent Please in ISR complicating drug-eluting stents or bifurcation lesions. We report two cases where the SeQuent Please was used in this setting with angiographic success and freedom from target vessel failure and angina at 24 months. In both cases the Sheathless Eau Cath guide (Asahi Intecc, Japan) was employed to perform a kissing-balloon dilatation with the SeQuent Please, so allowing treatment via radial access.

Successful implantation of the Edwards Sapien THV via direct aortic access in a patient with previous pneumonectomy and no other access.

The Edwards Sapien transcatheter heart valve (THV) is available for treatment of severe symptomatic aortic stenosis via transfemoral access or trans-apical access when ilio-femoral vessels are considered unsuitable. Some patients, however, may be unsuitable for access via either of these routes. We describe successful implantation of an Edwards Sapien THV via direct access of the ascending aorta in a patient with previous right pneumonectomy and pulmonary disease who was considered unsuitable for implantation via femoral vessels or via trans-apical approach. The potential advantages of this novel access route over trans-apical approach are discussed.

A noncompliant, high pressure balloon to manage undilatable coronary lesions.

Undilatable coronary lesions, due to coronary calcification, are encountered with increasing frequency. Percutaneous intervention of such lesions comes with the risk of stent underexpansion, which increases the risk of stent thrombosis and restenosis. A variety of techniques and devices are available to assist the interventionist in the treatment of calcified lesions. The OPN NC (SIS-Medical AG, Winterthur, Switzerland) is a high-pressure balloon (rated burst pressure 35 atm) that uses a novel, twin-layer balloon technology to ensure uniform balloon expansion, eliminating "dog-boning." We report four cases of successful treatment of calcified lesions with the OPN NC balloon after dilatation with standard noncompliant balloons to high-pressure failed.

Double-step invagination technique-A novel approach to retrieve embedded esophageal self-expanding metal stent.

Self-expanding metal stenting is an established treatment modality in the management of esophageal growth and stricture. Reactive tissue ingrowth at the uncovered portion of the self-expanding metal stent (SEMS) anchors it in position, preventing its migration. When removal of such an embedded SEMS is clinically indicated, the procedure of endoscopic retrieval is fraught with serious complications. Temporary deployment of a larger fully covered "rescue" SEMS within the embedded SEMS has been reported to be useful in the extraction of the embedded SEMS. When the regression of embedding tissue, is only partially achieved by such "rescue" fully covered SEMS, further extraction of the embedded SEMS can prove to be technically challenging. Here we report two cases where a novel technique, namely the "double-step invagination technique," was useful in retrieving such embedded esophageal SEMS.

Spectrum of small-bowel mucosal abnormalities identified by capsule endoscopy in patients with portal hypertension of varied etiology.

BACKGROUND: Bleeding from small intestinal ectopic varices and persistent anemia caused by portal hypertensive enteropathy (PHE) can be very challenging. Capsule endoscopy (CE) is one of the best noninvasive modalities in identifying such lesions. AIM: The aims of this study are to study the prevalence of small-bowel changes related to portal hypertension (PHT) and to correlate them with the observations related to the effects of portal hypertension in the esophagus, stomach, and colon. METHODS: Thirty-two patients with various etiologies of PHT with either anemia or gastrointestinal bleed were included along with age- and sex-matched controls without PHT. All patients underwent blood tests, gastroscopy, colonoscopy, and CE. The small-bowel findings by CE were categorized as inflammatory-like and vascular lesions. The small-bowel changes were analyzed to find out any association with various demographic, clinical, and endoscopic variables. RESULTS: Thirty-one out of 32 patients with PHT (96.8%) had PHE identified by CE. Of them, 31 (96.8%) had inflammatory-like appearance, 11 (34.4%) had vascular lesions, and 2 (6.2%) had small-bowel varices. Inflammatory-like appearance was noted in eight (25%) and angiodysplastic lesions in two (6.2%) controls. Findings compatible with PHE were detected in 96.8% of the patients and 25% of the controls (X 2 =34.72, p=0.000).The presence of PHE was not associated with any of the above-mentioned variables. CONCLUSIONS: Small-bowel mucosal changes were seen in significantly higher number of patients with PHT with anemia.

Acquired left ventricular to left atrial fistula--not mitral regurgitation! Transcutaneous closure with amplatzer device.

Acquired left ventricle (LV) to left atrial (LA) fistula is a very rare complication following aortic valve replacement (AVR). This can usually be surgically repaired but the risk of re-operation is high due to repeat sternotomy and also due to other comorbidities usually seen in this population. We report a case presenting with recurrent episodes of left ventricular failure 10 years following bioprosthetic aortic valve replacement and who was diagnosed to have a communication between the LV and the LA on transesophageal echocardiography (TEE). This was treated percutaneously with an Amplatzer duct occluder (ADO) device (AGA Medical Corp.) as she was considered to be a high surgical risk.

Intramural hemotoma presenting as acute coronary syndrome: the importance of intravascular ultrasound.

Intramural hematoma in major coronary epicardial vessels is a rare cause of chest pain. Afflicted individuals may present with acute coronary syndrome (ACS) or even sudden cardiac death. Spontaneous, isolated intramural hematoma may occur in the absence of associated intimal dissection. In this situation, lesions may be angiographically indistinguishable from ruptured atherosclerotic plaque. Intravascular ultrasound is important in the accurate diagnosis of isolated intramural hematoma. Although coronary stenting may be required in the presence of ongoing ischemia, intramural hematoma may be successfully managed medically. We describe the case of a middle-aged woman who presented with ACS due to an intramural hematoma and discuss the diagnosis and management of this rare illness.

Coronary stenting for iatrogenic stenosis of the left main coronary artery post-aortic valve replacement: an alternative treatment?

Iatrogenic coronary ostial stenosis after aortic valve replacement is a rare, life-threatening complication, which may follow implantation of either a mechanical or a biological prosthesis. Historically, this condition has been treated by urgent coronary bypass surgery but is associated with high morbidity and mortality, due to the hazards of early repeat sternotomy. We report a case of iatrogenic coronary ostial stenosis successfully treated with stenting and discuss the advantages of percutaneous intervention over coronary bypass surgery.

Don't rule out retroperitoneal bleeding just because the angiogram was done from the radial artery.

The use of radial artery for vascular access for cardiac catheterization and intervention has gained increasing acceptance over the last few years as result of the lower risk of vascular complications compared to use of the femoral artery. The strong evidence showing that major bleeding (commonly access site related) is an independent predictor of mortality in acute coronary syndrome patients undergoing intervention has only accelerated this change. This case highlights that although the risk of access site complications is reduced with the radial approach there remains a risk of spontaneous bleeding elsewhere due to the use of multiple potent antiplatelet and anticoagulant therapy in the treatment of acute coronary syndromes. Early recognition of bleeding is of the utmost importance as delay increases the likelihood complications of bleeding including death.

Lipomatous hypertrophy of the interatrial septum.

Lipomatous hypertrophy of the interatrial septum is a rare condition and it does not require any specific treatment. We present the transoesophageal echocardiogram findings of a 70-year-old lady demonstrating the appearances that were typical of lipomatous hypertrophy of the interatrial septum.