Aortic plaque dehiscence caused by rotational atherectomy with Kokeshi phenomenon in a patient with aortic stenosis successfully treated with transcatheter aortic valve replacement.

Rotational atherectomy (RA) is an important interventional technique to facilitate effective percutaneous coronary intervention of severely calcified lesions. Despite the improved probability of better procedural outcomes during angioplasty, the use of RA is associated with an inherent risk of complications. Here, we present a case of a woman in her mid-90s with severe aortic stenosis (AS) who underwent RA facilitated angioplasty of the right coronary artery (RCA), with the procedure complicated by the Kokeshi phenomenon. Manual traction to retrieve the burr resulted in dehiscence of an aortic plaque near the ostium of the RCA. Unfortunately, the patient's risk profile precluded surgery. After a multidisciplinary discussion, a self-expanding Core Valve Evolut R prosthesis (Medtronic, Minneapolis, Minnesota, USA) was successfully implanted, with improvement in the AS and stabilisation of the aortic plaque. This is the first reported case of successful non-operative management of a mobile-aortic plaque caused by RA with a transcatheter prosthesis.

Management of Heparin-Induced Thrombocytopenia Using Plasmapharesis in Patients Undergoing HeartMate 3 Left Ventricular Assist Device.

Heparin-induced thrombocytopenia (HIT) type-2 is a rare, but life-threatening complication that presents a unique challenge in patients undergoing cardiac surgery. Patients that require cardiac surgery with HIT present a dilemma between intraoperative anticoagulation, perioperative bleeding risk, and perioperative thrombotic events. We describe a case series of four patients who developed HIT in their hospital course before HeartMate 3 (HM3) left ventricular assist device implantation. Following a multidisciplinary approach, all patients did well intraoperatively with an approach of preoperative plasmapheresis, intraoperative unfractionated heparin (UFH), and postoperative conversion to bivalirudin with a bridge to warfarin. However, two patients had postoperative bleeding complications on bivalirudin. This case series details the therapeutic challenges encountered for HM3 implantation in patients with HIT and offers a therapeutic alternative to intraoperative bivalirudin in the effort to decrease perioperative complications in this challenging patient population.

Atrial myxoma presenting as acute ischaemic stroke and chronic right lower leg claudication.

A 48-year-old man presented with acute onset of left facial numbness, ataxic gait and double vision. He also complained of chronic right lower leg pain with acute onset a year prior to presentation. His vital signs were within normal limits. Physical exam was notable for right-sided intranuclear opthalmoplegia, decreased sensation to light touch on the left side of his body, left-sided dysmetria and ataxic gait. Neuroimaging showed evidence of acute stroke in the cerebellum and brainstem, for which he was treated with thrombolytics. An echocardiogram revealed a 5×3 cm left atrial myxoma, which was surgically resected. Subsequent imaging of his lower extremity revealed a chronic common iliac artery occlusion for which he underwent angioplasty. His claudication symptoms resolved, and he was without any neurological deficits at a 2-year follow-up visit.