Coronary angiography of the ex-situ beating donor heart in a portable organ care system.

OBJECTIVES: To determine safety and feasibility of ex-situ coronary angiography. BACKGROUND: To cater for the perpetually growing demand for heart donors, interest in donation following circulatory death (DCD) has been rekindled. Further pursuit of donor pool expansion has led to eligibility extension to "marginal" donors who are at higher risk of coronary artery disease (CAD). Excluding CAD in potentially eligible DCD donors, for whom ante-mortem angiography is commonly not permitted, is therefore challenging. Ex-situ coronary angiography serves as an ethical and feasible diagnostic tool to assess for preclusive CAD. METHODS: We undertook a systematic review of the published literature and institutional retrospective review of case experience with ex-situ coronary angiography of donor hearts, supported by a portable organ care system. RESULTS: Combined literature and institutional case review yielded nine total cases of ex-situ coronary angiography of donor human hearts plus one experimental porcine model. Of the eight cases of ex-situ coronary angiography performed at our institute, all were conducted without complication or injury to the allograft. Two thirds of reported human cases have proceeded to successful transplantation. CONCLUSIONS: Diagnostic coronary angiography of the ex-situ beating donor heart is safe, feasible, and demonstrates novel clinical utility in mitigating subsequent transplantation of unsuitable allografts. In the setting of suspected coronary atherosclerosis of the donor heart, which may preclude favorable transplantation outcomes, ex-situ coronary angiography should be considered at eligible transplant centers.

Primary percutaneous coronary intervention for inferior ST-segment elevation myocardial infarction in a patient supported by the HeartWare left ventricular assist device.

A 63-year-old man with an ischaemic cardiomyopathy, supported by the HeartWare left ventricular assist device (LVAD), presented with ventricular tachycardia and inferior ST-elevation myocardial infarction (STEMI) with associated acute right ventricular (RV) dysfunction. He underwent primary percutaneous coronary intervention with balloon angioplasty and placement of three drug-eluting stents in the proximal-to-mid right coronary artery. Post-procedure, ventricular arrhythmias abated, RV systolic dysfunction resolved and RV size normalised. Percutaneous coronary intervention (PCI) facilitated by the use of miniaturised percutaneous LVAD has become an increasingly available treatment option for high-risk patients. PCI in patients on established full mechanical circulatory support is not a common occurrence. Indeed, to our knowledge, this is the first case of primary percutaneous coronary intervention on an LVAD-supported heart reported in the medical literature. The case raises several specific issues that are of peculiar interest to clinicians involved in the care of patients supported by mechanical assist devices who experience an acute coronary syndrome requiring emergent revascularisation.

[Application of Mimics three-dimensional imaging in percutaneous left atrial appendage closure with Watchman system].

OBJECTIVE: The three-dimensional (3D) structure of left atrial appendage (LAA) in atrial fibrillation patients were reconstructed by Mimics 3D imaging system, aiming at guiding for selection of both the size and location of the closure devices and making preliminary risk assessment of LAA closure with Watchman system. METHODS: Inclusion criteria were: ten voluntary patients with both atrial fibrillation and indication for LAA closure aging from 40 to 85 years old with contraindication for oral anticoagulants or unwillingness to take long-term oral anticoagulation therapy from May to December 2014. 3D reconstruction of LAA was preoperatively made by Mimics 3D imaging system. With the Mimics 3D reconstruction model and the results of both transesophageal echocardiography (TEE) and LAA radiography, the size and location for the closure device were chosen. The devices were planted at the ostium of the LAA. RESULTS: Ten atrial fibrillation patients were enrolled (average age: (66.3±11.9) years old) and all successfully implanted with the Watchman LAA closure devices. Nine of them were with non-valvular atrial fibrillation with average CHADS2-VAS score (3.2±1.7) and HAS-BLED score (2.7±1.6). The rest one was a valvular atrial fibrillation patient with the history of the percutaneous balloon mitral valvuloplasty (PBMV) without surgical indications of mitral valve replacement (MVR). There was no blood leakage around the device by regular postoperative TEE and LAA radiography examinations. There were no complications of bleeding, embolism, or stroke through both at peri-operative period and at 1 month follow-up post procedure. CONCLUSION: Preoperative Mimics 3D reconstruction of LAA by Mimics 3D imaging system among atrial fibrillation patients provides essential information guiding the successful LAA closures.

Percutaneous left atrial appendage occlusion with a Watchman device following recurrent stroke on warfarin and rivaroxaban in patient with paroxysmal atrial fibrillation.

The optimal management of recurrent cardioembolic stroke in a patient on oral anticoagulation is controversial. Therapeutic strategies for secondary stroke prevention in such circumstances may include the intensification of oral anticoagulation, the addition of antiplatelet therapy to warfarin, or the use of a non-vitamin K antagonist instead of warfarin. However, there is no evidence to support these interventions, and indeed these strategies are not endorsed by the 2011 Guidelines on the Secondary Prevention of Stroke issued by the American Heart Association/American Stroke Association. Percutaneous occlusion of the left atrial appendage (LAA) has recently emerged as an acceptable non-pharmacological strategy to reduce the risk of cardioembolism in patients who cannot tolerate oral anticoagulation, but there is little evidence to support its use in the context of recurrent stroke despite oral anticoagulation. We present the case of a 66 year-old male with paroxysmal atrial fibrillation who experienced recurrent stroke despite treatment with warfarin initially, and rivaroxaban subsequently. After excluding non-cardioembolic causes of recurrent stroke, we proceeded with percutaneous occlusion of the LAA with a Watchman device. Nine months post-procedure he has not experienced recurrence of neurological symptoms. Our case provides anectodal evidence that catheter-based LAA occlusion can be beneficial in secondary stroke prevention where oral anticoagulation has been problematic.

1% Aspiration, 99% Perspiration: Acute Left Atrial Thrombus During Percutaneous Left Atrial Appendage Occlusion.

A 71-year-old man with chronic atrial fibrillation underwent insertion of a left atrial appendage occlusion device. Before release, a large thrombus was noted within the left atrium, attached to the left atrial appendage occluder delivery system. With continuous negative pressure, the device was deployed and thrombus successfully aspirated with no clinical sequelae. (Level of Difficulty: Intermediate.).

A novel buddy balloon technique to recross a T-stented bifurcation.

The T technique is not uncommonly used to stent bifurcation lesions. It requires recrossing into the side branch with a guidewire and balloon to perform final Kissing Balloon dilations, but recrossing can be difficult. We describe a case of bifurcation stenting where balloon recrossing following guidewire placement into the side branch proved very challenging, and was finally achieved via a combination of forward pressure on a low-profile balloon with its tip wedged at the stent struts along with simultaneous low-pressure inflation of a larger parallel balloon. This altered the stent architecture and also allowed for a more favorable vector of force transmission to allow recrossing and hence successful completion of the procedure.

Iatrogenic coronary arteriovenous fistula during percutaneous coronary intervention: unique insight into intra-procedural management.

We report the case of a 69-year-old man who presented with worsening exertional angina where subsequent percutaneous coronary intervention resulted in a coronary arteriovenous fistula. Attempts to occlude the fistula using a relatively conservative management approach with acute reversal of intraprocedural heparin and prolonged balloon inflation unfortunately resulted in extensive coronary artery thrombosis without immediate resolution of the arteriovenous fistula. However, follow-up at 6 months revealed resolution of the fistula. This case study emphasizes the uncommon but potentially life-threatening complications of percutaneous coronary interventions with implications not only relating to the hazards of managing iatrogenic arteriovenous fistula, but reversing intraprocedural heparin using protamine, during any coronary angiogram.

A New Era for Rotational Atherectomy: An Australian Perspective.

BACKGROUND: Rotational atherectomy (RA) has been used in percutaneous coronary intervention (PCI) for 30 years. With advances in technology, this observational study looks at how rates of RA have changed over the past decade in Australia in relation to PCI and coronary artery bypass graft (CABG) rates. METHODS: Retrospective analysis of RA, PCI, and CABG rates per Australian state from Australian Government Department of Human Services' data on Medicare items from 2007 to 2017 was carried out. RESULTS: There were 149 RA procedures in 2007, increasing to 452 in 2017. Rotational atherectomy accounted for 0.67% of PCI procedures in 2007, increasing to 1.48% in 2018 (+0.81%, 95% confidence interval [CI] = [0.64%-0.91%]; P < .001). Most of this increase has come from procedures in New South Wales (441% increase). Australian PCI rate increased from 22 301 to 30 480. Rate of CABG decreased from 5418 to 5206. CONCLUSIONS: From 2007 to 2017, rates of RA trebled in Australia. This is despite stable rates of PCI and a fall in rates of CABG. There are several clinical explanations for this trend.

Coronary artery aneurysms associated with a Paclitaxel coated stent.

Coronary artery aneurysm associated with the Paclitaxel drug eluting stent (Taxus) is a rare complication. We describe the case of a 71-year-old female, who developed two coronary artery aneurysms in her right coronary artery associated with the insertion of a Taxus stent. Although no adverse clinical outcome resulted, this case highlights a potential problem going forward.

Percutaneous coronary interventions without on-site cardiac surgery: a remote Australian experience.

BACKGROUND: The current American College of Cardiology (ACC) guidelines recommend that elective percutaneous coronary interventions (PCI) should not be performed in institutions without on-site cardiac surgery. We sought to determine the safety of PCI without cardiac surgical support on-site and specifically the safety of complex elective procedures. The results of the first 1000 procedures performed at our institution, which is a rural centre 80 km from the nearest cardiac surgical facility, are reported. METHODS: Between September 2002 and April 2006 a total of 1000 procedures were performed in 893 patients at our institution. Patients included both high and low risk cohorts. Clinical and procedural outcomes were recorded and analysed. RESULTS: Of the 921 elective and 79 emergency primary PCI procedures performed, 1138 vessels were treated and 1429 stents deployed. A 95% procedural success rate was recorded. Complex PCI was performed with multi-vessel PCI in 13%, bifurcation PCI in 8%, chronic total occlusions (CTO) in 5%, saphenous vein graft interventions in 5%, unprotected left main interventions in 0.8% and rotational atherectomy in 0.8% of all procedures performed. Of the cohort, 75.3% of the lesions treated were either American College of Cardiology (ACC)/American Heart Association (AHA) type B or C lesions. In the primary PCI group, three deaths and three sub-acute stent occlusions occurred. In the elective group, the following major complications occurred: one death, three sub-acute stent occlusions, one case of contrast nephropathy requiring short-term dialysis, two cases of cardiac tamponade, two significant femoral pseudo-aneurysms and one misplaced stent. Acute myocardial infarction occurred in 21 patients. There were no urgent transfers for CABG surgery to salvage a complication of PCI. CONCLUSION: PCI including high risk elective procedures can safely be performed without on-site cardiac surgery by experienced high volume operators.

Abciximab-induced thrombocytopenia: management of bleeding in the setting of recent coronary stents.

This case report and subsequent literature review describes the management difficulties in a patient who developed abciximab-induced thrombocytopenia and gastrointestinal bleeding. Abciximab was used to treat the no-reflow phenomenon, which occurred during insertion of three sequential Taxus coronary artery stents. Resuscitation of this bleeding patient with fluids, blood, and platelet transfusion, and the cessation of antiplatelet agents, was complicated by acute stent thrombosis. We discuss the risk factors for stent thrombosis and discuss abciximab-induced thrombocytopenia, looking at its incidence, pathophysiology, differential diagnosis, investigation, course, management, preventative strategies, and prognostic implications.

Retrograde application of the buddy wire technique.

We report the case of an 85-year-old man who presented with worsening exertional dyspnoea 18 months after coronary artery bypass surgery for critical three vessel coronary artery disease. Coronary angiography revealed an anastomotic stricture between a radial artery graft and the first diagonal branch. Percutaneous coronary intervention utilizing a retrograde application of the "buddy" wire technique was then performed.

"Backdoor" alternative approach to stenting of a post-anastomotic coronary artery lesion via a chronically obstructed right coronary artery after failure to stent through a tortuous free internal mammary graft.

We describe the case of a patient who previously had coronary artery bypass grafting including a free right internal mammary artery graft anastomosed to a chronic totally occluded right coronary artery (RCA) proximally and distally and who presented with a high-risk acute coronary syndrome. Coronary angiography revealed the graft to be patent with a distal post-anastomotic culprit lesion within the posterolateral branch of the native RCA. Because of technical challenges, PCI could not be performed through the graft and the lesion was stented via the chronically occluded RCA instead, in a "backdoor" approach with a good final result.

Very late [corrected] thrombosis of a sirolimus-eluting stent.

We report the case of a 67-year-old man who presented with a [corrected] non-ST-elevation acute myocardial infarction 41 months after implantation of a sirolimus-eluting stent in his left circumflex coronary artery. Coronary angiography revealed stent thrombosis.