Transcatheter heart valve failure: a systematic review.

AIMS: A comprehensive description of transcatheter heart valve (THV) failure has not been performed. We undertook a systematic review to investigate the aetiology, diagnosis, management, and outcomes of THV failure. METHODS AND RESULTS: The systematic review was performed in accordance with the PRISMA guidelines using EMBASE, MEDLINE, and Scopus. Between December 2002 and March 2014, 70 publications reported 87 individual cases of transcatheter aortic valve implantation (TAVI) failure. Similar to surgical bioprosthetic heart valve failure, we observed cases of prosthetic valve endocarditis (PVE) (n = 34), structural valve failure (n = 13), and THV thrombosis (n = 15). The microbiological profile of THV PVE was similar to surgical PVE, though one-quarter had satellite mitral valve endocarditis, and surgical intervention was required in 40% (75% survival). Structural valve failure occurred most frequently due to leaflet calcification and was predominantly treated by redo-THV (60%). Transcatheter heart valve thrombosis occurred at a mean 9 ± 7 months post-implantation and was successfully treated by prolonged anticoagulation in three-quarters of cases. Two novel causes of THV failure were identified: late THV embolization (n = 18); and THV compression (n = 7) following cardiopulmonary resuscitation (CPR). These failure modes have not been reported in the surgical literature. Potential risk factors for late THV embolization include low prosthesis implantation, THV undersizing/underexpansion, bicuspid, and non-calcified anatomy. Transcatheter heart valve embolization mandated surgery in 80% of patients. Transcatheter heart valve compression was noted at post-mortem in most cases. CONCLUSION: Transcatheter heart valves are susceptible to failure modes typical to those of surgical bioprostheses and unique to their specific design. Transcatheter heart valve compression and late embolization represent complications previously unreported in the surgical literature.

Treatment of functional mitral valve regurgitation with the permanent percutaneous transvenous mitral annuloplasty system: results of the multicenter international Percutaneous Transvenous Mitral Annuloplasty System to Reduce Mitral Valve Regurgitation in Patients with Heart Failure trial.

OBJECTIVES: PTOLEMY-2 was a prospective multicenter phase I single-arm feasibility trial to evaluate the second-generation permanent percutaneous transvenous mitral annuloplasty (PTMA) device in reducing functional mitral regurgitation (MR). BACKGROUND: Percutaneous MR reduction has been performed through a direct method of clipping and securing the mitral leaflets together or an indirect approach of reducing mitral annular dimension via the coronary sinus. The PTMA device is the only coronary sinus mitral repair device without a static fixation element. METHODS: Patients with at least moderate functional MR, New York Heart Association functional class II to IV, and left ventricular ejection fraction of 20% to 50% were enrolled at 14 centers in 5 countries. Device effects on patients were assessed by serial echocardiography, quality of life (QOL), and exercise capacity metrics. RESULTS: A total of 43 patients were recruited, and 30 patients (70%) were implanted with a permanent PTMA device with a mean follow-up of 5.8 ± 3.8 months. The primary safety end point (freedom from death, myocardial infarction, stroke, or emergency surgery) at 30 days was met in 28 patients, whereas 2 patients died of device-related complications. The primary efficacy end point (MR reduction of at least 1.0 grade or reduction of regurgitant orifice area by 0.1 cm(2) or regurgitant volume by 15 mL or regurgitant fraction by 10% compared with baseline) was obtained in 13 patients. No significant changes were noted in MR parameters, ventricular volumes, or QOL. Distance walked on 6 minutes testing at 6-month follow-up increased from 331 ± 167 m to 417 ± 132 m (P = .65). Compared with nonresponders, responders had a higher baseline regurgitant orifice area >0.2 cm(2) (P = .001) and less prior history of myocardial infarction (P = .02), coronary artery bypass surgery (P = .03), and ischemic MR (P = .04). CONCLUSIONS: Overall, PTMA had mild impact on MR reduction, left ventricular remodeling, QOL, and exercise capacity. During follow-up, the risk/benefit ratio remained suboptimal.

Current percutaneous treatment strategies for saphenous vein graft disease.

Coronary artery bypass graft surgery remains one of the most widely performed surgical procedures in North America and aortocoronary saphenous vein grafts (SVG) are the most frequently used surgical conduits. SVG disease (SVGD) remains the leading cause of symptomatic coronary artery disease postcoronary artery bypass graft. When optimal medical therapy is ineffective, repeat surgery is associated with higher mortality combined with less favorable clinical and angiographic results, thus percutaneous revascularization on SVG is currently the standard of care for the revascularization of SVGD. Balloon angioplasty, bare metal stents, polytetrafluoroethylene-covered stents, and drug-eluting stents have been extensively investigated for SVG interventions. Multiple recent randomized trials and meta-analyses have confirmed the pathophysiologic and clinical differences between SVGD and coronary artery disease. Decisions such as patient selection, premedication, stent, and protection device characteristics should be carefully considered to achieve optimal procedural and clinical results. Acute coronary syndromes due to SVG involvement, chronic total occlusions, retrograde approaches, and SVG perforation management are newer fields requesting additional research.

Computer-assisted quantification of myocardial reperfusion after primary percutaneous coronary intervention predicts functional and contrast-enhanced cardiovascular magnetic resonance outcomes in patients with ST-segment elevation myocardial infarction.

OBJECTIVE: We investigated whether the Quantitative Blush Evaluator (QuBE) value predicts functional and contrast-enhanced cardiovascular magnetic resonance (CMR) outcomes at 4-6 months after primary percutaneous coronary intervention (PCI) inpatients with ST-segment elevation myocardial infarction (STEMI). BACKGROUND: QuBEis a computer-assisted open source program to quantify myocardial reperfusion.Although a higher QuBE value is associated with improved myocardial reperfusion measures and lower 1-year mortality, the association with intermediate functional parameters after STEMI has not yet been investigated. METHODS: QuBE values were quantified retrospectively on angiograms of patients enrolled in the ancillary CMR study of the proximal embolic protection in acute myocardial infarction and resolution of ST-elevation trial. QuBE en CMR outcomes were independently assessed by reviewers blinded to clinical data. RESULTS: A higher QuBE value was significantly associated with a smaller left ventricular (LV) end-diastolic and end-systolic volume, a higher LV ejection fraction and systolic wall thickening in the infarct area, and a smaller final infarct size and extent of transmural segments (P ≤ 0.008). In a multivariable model, including age, gender, infarct location, time to treatment, history of myocardial infarction, and postprocedural thrombolysis in myocardial infarction flow grade,only the QuBE value and infarct location remained as independent predictors of LV ejection fraction (P 5 0.018 for QuBE value). CONCLUSION: Higher QuBE values are independently associated with improved functional and contrast-enhanced CMR outcomes including LV ejection fraction at 4-6 months after primary PCI and may therefore aid in identifying high-risk patients who benefit most from adjunctive therapies sustaining myocardial function after PCI.

Feasibility and applicability of computer-assisted myocardial blush quantification after primary percutaneous coronary intervention for ST-segment elevation myocardial infarction.

OBJECTIVES: The aim of the study was to evaluate whether the "Quantitative Blush Evaluator" (QuBE) score is associated with measures of myocardial reperfusion in patients with ST-segment elevation myocardial infarction (STEMI) treated in two hospitals with 24/7 coronary intervention facilities. BACKGROUND: QuBE is an open source computer program to quantify myocardial perfusion. Although QuBE has shown to be practical and feasible in the patients enrolled in the Thrombus Aspiration during Percutaneous Coronary Intervention in Acute Myocardial Infarction Study (TAPAS), QuBE has not yet been verified on reperfusion outcomes of primary percutaneous coronary intervention (PCI) patients treated in other catheterization laboratories. METHODS: Core lab adjudicated angiographic outcomes and QuBE values were assessed on angiograms of patients who were enrolled in the PRoximal Embolic Protection in Acute myocardial infarction and Resolution of ST-Elevation (PREPARE) trial. ST-segment resolution immediately after PCI measured by continuous ST Holter monitoring was calculated by a blinded core lab. RESULTS: The QuBE score could be assessed on 229 of the 284 angiograms (81%) and was significantly associated with visually assessed myocardial blush grade (P < 0.0001). Patients with improved postprocedural Thrombolysis in Myocardial Infarction-graded flow, myocardial blush grade, ST-segment resolution immediately after PCI, or a small infarct size measured by peak CK-MB had a significant better QuBE score. CONCLUSIONS: QuBE is feasible and applicable at angiograms of patients with STEMI recorded at other catheterization laboratories and is associated with measures of myocardial reperfusion.

VEGF gene therapy fails to improve perfusion of ischemic myocardium in patients with advanced coronary disease: results of the NORTHERN trial.

Despite the promise of proangiogenic gene therapy most clinical trials have failed to show benefit for the primary end point analysis. The NOGA angiogenesis Revascularization Therapy: assessment by RadioNuclide imaging (NORTHERN) trial was a double-blind, placebo-controlled study of intramyocardial vascular endothelial growth factor (VEGF165) gene therapy versus placebo, involving seven sites across Canada, designed to overcome major limitations of previous proangiogenic gene therapy trials. A total of 93 patients with refractory Canadian Cardiovascular Society (CCS) class 3 or 4 anginal symptoms were randomized to receive 2,000 microg of VEGF plasmid DNA or placebo (buffered saline) delivered via the endocardial route using an electroanatomical NOGA guidance catheter. There was no difference between the VEGF-treated and the placebo groups in the primary end point of change in myocardial perfusion from baseline to 3 or 6 months, assessed by single photon emission tomography (SPECT) imaging, although a significant reduction in the ischemic area was seen in both groups. Also, similar improvements in exercise treadmill time and anginal symptoms were seen in the VEGF and the placebo groups at 3 and 6 months, although again there were no differences between these groups. Despite the intramyocardial administration of a high "dose" of plasmid DNA using a percutaneous guidance catheter system, there was no benefit of VEGF gene therapy at 3 or 6 months for any of the end points studied.

High energy excimer laser to treat coronary in-stent restenosis in an underexpanded stent.

Balloon refractory calcific coronary plaques remain a technical challenge. Stent underexpansion is known as a major cause of restenosis and thrombosis. We report a case of in-stent restenosis 5 months after stent suboptimal implantation in a noncompliant calcific atherosclerotic plaque which could not be disrupted by repeated prolonged high-pressure balloon inflations. High-energy excimer laser use altered underlying lesion morphology, allowing full stent apposition. Advances in equipment and technique have allowed more frequent use of high energy excimer laser technology during percutaneous coronary angioplasty with very low rates of complications. Laser technology represents a useful tool to overcome resistant lesions during percutaneous coronary interventions.

Left main coronary artery thrombectomy and stenting using a paclitaxel-eluting stent in the setting of acute myocardial infarction.

A 41-year-old man was referred to the Montreal Heart Institute, Montreal, Quebec, for primary angioplasty of an acute anterolateral wall myocardial infarction. Coronary angiography revealed the culprit lesion to be a subtotal left main coronary artery with Thrombolysis In Myocardial Infarction (TIMI) trial grade 1 flow associated with a filling defect compatible with an aggressive thrombotic process. The use of rheolytic thrombectomy and a drug-eluting stent for this distal left main target lesion are described.

Demographics, treatment and outcome of acute coronary syndromes: 17 years of experience in a specialized cardiac centre.

BACKGROUND: Epidemiological information on patients with acute coronary syndromes managed in specialized cardiac centres is limited. OBJECTIVE: To report the evolution of demographics, treatment and outcome of patients admitted to a tertiary coronary care unit (CCU) over a 17-year period. METHODS: A prospective database of 18,719 patients admitted from April 1986 to March 2003 in a 21-bed CCU was analyzed. RESULTS: From 1986 to 2003, the number of admissions increased from 937 to 1577 per year, while the length of stay declined from 7.5 to 3.5 days. The mean age increased from 58.4 to 63.4 years, and the proportion of men remained stable at approximately 70%. The use of coronary angiograms increased from 49.8% to 81.1% in all patients, while fibrinolysis dropped to 0.4%. In-hospital mortality decreased from 9% to 1.5%. The percentage of overall instrumentation (arterial line, central venous catheter, temporary pacemaker, Swan-Ganz catheter and intra-aortic balloon pump) decreased from 38% to 8.1%. From 1995 to 2003, the proportion of stenting during percutaneous transluminal coronary angioplasty increased dramatically from 0% to 86%. In the past five years, surgical revascularization has remained stable at approximately 20% of all admissions. The proportion of patients discharged with a noncoronary chest pain diagnosis has remained constant at approximately 4%. INTERPRETATION: There has been a tremendous increase in efficiency, with an approximate doubling of the admissions turnover rate in a tertiary CCU. Patients with acute coronary syndromes are stratified faster and treated more invasively. Therapeutic advances are reflected by an almost linear 0.5% per year decrease in in-hospital mortality.

Quantitative multi-slice computed tomography assessment of the mitral valvular complex for transcatheter mitral valve interventions part 2: geometrical measurements in patients with functional mitral regurgitation.

AIMS: Transcatheter mitral valve replacement (TMVR) is an emerging technology with the potential to treat patients with mitral regurgitation at excessive risk for mitral valve surgery. Geometrical measurements of the mitral valvular complex may have implications for the design of TMVR devices and for patient selection. This study sought to quantify the dynamic geometry of the mitral valvular complex in patients with significant functional mitral regurgitation (FMR) using multi-slice computed tomography (MSCT). METHODS AND RESULTS: MSCT images were acquired in 32 patients with symptomatic, significant FMR. Two independent observers analysed image sets using a dedicated software package and a standard measurement methodology. In patients with FMR, the mean mitral annulus intercommissural and aorto-mural diameters were, respectively, 41.5±5.2 mm and 38.7±5.9 mm in systole, and were 41.5±4.4 mm and 40.0±4.7 mm in diastole. In patients without MR, the diameters were, respectively, 33.6±5.1 mm and 28.8±8.0 mm in systole, and 36.2±4.5 mm and 31.6±7.9 mm in diastole. The obstacle-free zone below the mitral annulus averaged more than 20.0 mm and varied by less than 1 mm between systole and diastole, which is not statistically significant. The aorto-mitral angle was 129.7±10.5° in systole and 131.0±9.4° in diastole. CONCLUSIONS: The mitral annulus is larger in dimension, more circular, and less dynamic in patients with FMR. The obstacle-free zone below the mitral annulus is relatively constant during the cardiac cycle. Measurements of the mitral valvular apparatus vary considerably between patients, which suggests that tridimensional imaging will play an important role in the sizing of TMVR devices.

Quantitative multi-slice computed tomography assessment of the mitral valvular complex for transcatheter mitral valve interventions part 1: systematic measurement methodology and inter-observer variability.

AIMS: Transcatheter mitral valve replacement (TMVR) is an emerging technology with the potential to treat patients with severe mitral regurgitation at excessive risk for surgical mitral valve surgery. Multimodality imaging of the mitral valvular complex and surrounding structures will be an important component for patient selection for TMVR. Our aim was to describe and evaluate a systematic multi-slice computed tomography (MSCT) image analysis methodology that provides measurements relevant for transcatheter mitral valve replacement. METHODS AND RESULTS: A systematic step-by-step measurement methodology is described for structures of the mitral valvular complex including: the mitral valve annulus, left ventricle, left atrium, papillary muscles and left ventricular outflow tract. To evaluate reproducibility, two observers applied this methodology to a retrospective series of 49 cardiac MSCT scans in patients with heart failure and significant mitral regurgitation. For each of 25 geometrical metrics, we evaluated inter-observer difference and intra-class correlation. The inter-observer difference was below 10% and the intra-class correlation was above 0.81 for measurements of critical importance in the sizing of TMVR devices: the mitral valve annulus diameters, area, perimeter, the inter-trigone distance, and the aorto-mitral angle. CONCLUSIONS: MSCT can provide measurements that are important for patient selection and sizing of TMVR devices. These measurements have excellent inter-observer reproducibility in patients with functional mitral regurgitation.

Chronic arterial responses to polymer-controlled paclitaxel-eluting stents: comparison with bare metal stents by serial intravascular ultrasound analyses: data from the randomized TAXUS-II trial.

BACKGROUND: Polymer-controlled paclitaxel-eluting stents have shown a pronounced reduction in neointimal hyperplasia compared with bare metal stents (BMS). The aim of this substudy was to evaluate local arterial responses through the use of serial quantitative intravascular ultrasound (IVUS) analyses in the TAXUS II trial. METHODS AND RESULTS: TAXUS II was a randomized, double-blind study with 536 patients in 2 consecutive cohorts comparing slow-release (SR; 131 patients) and moderate-release (MR; 135 patients) paclitaxel-eluting stents with BMS (270 patients). This IVUS substudy included patients treated with one study stent who underwent serial IVUS examination after the procedure and at 6-month follow-up (BMS, 152 patients; SR, 81; MR, 81). The analyzed stented segment (15 mm) was divided into 5 subsegments in which mean vessel area (VA), stent area (SA), lumen area (LA), intrastent neointimal hyperplasia area (NIHA), and peristent area (VA-SA) were measured. NIHA was significantly reduced in SR (0.7+/-0.9 mm2, P<0.001) and MR (0.6+/-0.8 mm2, P<0.001) compared with BMS (1.9+/-1.5 mm2), with no differences between the two paclitaxel-eluting release formulations. Longitudinal distribution of neointimal hyperplasia throughout the paclitaxel-eluting stent was uniform. Neointimal growth was independent of peristent area at postprocedure examination in all groups. There were progressive increases in peristent area from BMS to SR to MR (0.5+/-1.7, 1.0+/-1.8, and 1.4+/-2.0 mm2, respectively; P<0.001). The increase in peristent area was directly correlated with increases in VA. CONCLUSIONS: Both SR and MR paclitaxel-eluting stents prevent neointimal formation to the same degree compared with BMS. However, the difference in peristent remodeling suggests a release-dependent effect between SR and MR.

Prospective, randomized evaluation of thrombectomy prior to percutaneous intervention in diseased saphenous vein grafts and thrombus-containing coronary arteries.

OBJECTIVES: We sought to determine whether routine thrombectomy prior to stent implantation in diseased saphenous vein grafts (SVGs) and thrombus-containing native coronary arteries would reduce peri-procedural myonecrosis and subsequently enhance event-free survival. BACKGROUND: Percutaneous coronary intervention in diseased SVGs and thrombotic native coronary arteries is complicated by a high rate of peri-procedural myocardial infarction (MI). Thrombectomy prior to intervention may enhance the safety of intervention and improve early and late outcomes in these high-risk patients. METHODS: At 60 centers in the U.S. and Canada, 797 patients with 839 diseased SVGs or thrombus-containing native coronary arteries were prospectively randomized to stent implantation with versus without prior thrombectomy with the X-SIZER device (ev3, Plymouth, Minnesota). RESULTS: Peri-procedural MI occurred in 15.8% of patients assigned to the X-SIZER device compared with 16.6% of control patients (p = 0.77), although the rate of large MI (pre-specified as the development of new pathologic Q waves or creatine phosphokinase-MB isoenzyme elevation >8 x upper limits of normal) was reduced with X-SIZER device use from 9.6% to 5.5% (multivariate risk ratio 0.35 [95% confidence interval 0.18 to 0.66], p = 0.002). Major adverse cardiac events (cardiac death, MI, or repeat target vessel revascularization) occurred in 16.8% of X-SIZER patients versus 17.1% of control patients at 30 days (p = 0.92), and in 31.3% of X-SIZER patients versus 28.2% of control patients at 1 year (p = 0.35). CONCLUSIONS: Thrombectomy with the X-SIZER device prior to stent implantation in high-risk diseased SVGs and thrombus-containing native coronary arteries may reduce the extent, but not the occurrence, of myonecrosis. Early and late event-free survival, however, were not improved by routine thrombectomy with this device.

Angiographic and clinical outcomes of polytetrafluoroethylene-covered stent use in significant coronary perforations.

Coronary perforations remain a rare but life-threatening complication of percutaneous coronary intervention. In the setting of complex coronary lesions, 14 of 25 consecutive perforations related to percutaneous coronary intervention were managed with stents covered with polytetrafluoroethylene (PTFE), and 11 were managed conventionally with reversal of anticoagulation and prolonged balloon inflation. Procedural success was achieved in 71.4% (10 of 14 perforations) of the PTFE arm compared with 27.3% (3 of 11 perforations) in the standard management arm (p = 0.047). Smaller final percent diameter stenosis and postprocedural cessation of dye extravasation were achieved with PTFE-covered stents. No delayed cardiac tamponade or in-hospital mortality was reported among patients in the PTFE group.

Effect of cholesterol lowering and cardiovascular risk factors on the progression of aortoiliac arteriosclerosis: a quantitative cineangiography study.

The post-Coronary Artery Bypass Graft (Post-CABG) trial has shown that aggressive compared to moderate lowering of low-density lipoprotein cholesterol (LDL-C) delayed the progression of obstructive disease in aortocoronary saphenous vein grafts and in the left main coronary artery. Patients had been allocated to high-and low-dose lovastatin therapy for a 4-5 year period. The present study evaluated the effect of LDL-C lowering and the role of cardiovascular risk factors on the progression of arteriosclerosis in the distal abdominal aorta and common iliac arteries. From one of the participating centers of the post-CABG trial, 145 patients who had adequate imaging of the aortoiliac arteries at baseline and follow-up were included. Angiographic outcomes, presumed to reflect progression of arteriosclerosis and obtained from lumen diameter (LD) measurements using quantitative cineangiography, were as follows: significant decrease of the minimum lumen diameter (LD) and increase of the maximum LD, percent lumen stenosis, and percent lumen dilatation. These outcomes were not significantly less frequent in patients randomly allocated to aggressive compared to moderate LDL-C lowering. Of 9 cardiovascular risk factors, only 2 were significantly related to progression of aortoiliac arteriosclerosis. Current smoking predicted both percent lumen stenosis increase and, to a lesser degree, percent lumen dilatation increase (p = 0.010 and p = 0.055, respectively). Abnormally high body mass index (BMI > or = 25 kg/m2) correlated with percent lumen dilatation increase (p = 0.006). Aggressive compared to moderate LDL-C lowering did not prevent or delay the progression of aortoiliac arteriosclerosis. Smoking predicted both lumen narrowing and dilatation presumably caused by arteriosclerosis. Abnormally high BMI, reflecting overweight or obesity, was strongly associated with vessel dilatation.

First-in-human experience with the Medtronic CoreValve Evolut R.

The CoreValve Evolut R with EnVeo R delivery catheter is a novel transcatheter heart valve (THV) system with enhanced features that have the potential to improve the safety of transcatheter aortic valve implantation (TAVI). The newly designed delivery catheter is 14 Fr-equivalent and thus expands the option of transfemoral TAVI to a greater proportion of patients. Most importantly, the EnVeo R delivery catheter allows the valve to be recaptured and repositioned during deployment, thus minimising the consequences of THV malposition. Furthermore, the nitinol frame of the CoreValve Evolut R has been redesigned for superior interaction, consistent radial force and optimised cover index across the sizing range, and conformability with the native annulus, thereby hypothetically reducing stress on the left bundle branch. Although large series with long-term follow-up are required to demonstrate the safety and efficacy of this device, we present the first human experience with the Evolut R system.

Saphenous vein graft perforation during percutaneous coronary intervention: a case series.

INTRODUCTION: The outcomes of perforation during aortocoronary saphenous vein graft (SVG) percutaneous coronary intervention (PCI) are poorly studied. METHODS: We reviewed all 12 SVG perforations that occurred between November 2005 and November 2011 at two tertiary referral centers. The acute and long-term outcomes of these patients were examined. RESULTS: The perforation was located in the SVG body (n = 6), aortic (n = 3), or distal (n = 3) anastomosis. Most perforations occurred after stent implantation (n = 5) or after stent postdilation (n = 3). The perforation was Ellis class I in 1 patient, II in 3 patients, III in 4 patients, and III with cavity spilling in 3 patients. The perforation spontaneously sealed without requiring further treatment in 3 patients. In the remaining 9 patients, the perforation was treated with prolonged balloon inflation (n = 2) or covered stent implantation (n = 5), but could not be treated in 2 patients who died during the procedure. Seven of the 10 survivors underwent follow-up angiography 5 months to 2 years after the perforation. The target SVG was occluded in 5 patients and had developed severe stenosis in the remaining 2 patients. CONCLUSIONS: SVG perforation during PCI carries a high mortality and frequently requires implantation of a covered stent. Perforated SVGs frequently occlude within 2 years post PCI.

Role of rheolytic thrombectomy in massive pulmonary embolism with contraindication to systemic thrombolytic therapy.

AIMS: Mortality of massive pulmonary embolism remains exceedingly high despite thrombolytic therapy. Despite initial encouraging results, rheolytic thrombectomy has not been considered the first choice of treatment in the current European Guidelines for massive pulmonary embolism, even in cases of major contraindication to thrombolysis. Our objective was to assess the efficacy of rheolytic thrombectomy in the specific treatment of massive pulmonary embolism with contraindication to systemic thrombolytic therapy. METHODS AND RESULTS: Between January 2003 and April 2008 a total of 10 patients with massive pulmonary embolism referred for rheolytic thrombectomy were included. Clinical data including medical history, haemodynamic status, procedural characteristic, in-hospital complications and survival were collected. Seven patients survived after undergoing the procedure, three patients died in during their initial hospitalisation however, two of these deaths were not attributable to the pulmonary embolism or the procedure. Rheolytic thrombectomy resulted in reduction of mean pulmonary artery pressures from 34.6+/-13.1 mmHg to 26.9+/-8.2 mmHg immediately following the procedure. Additionally, the Miller index improved from 22.4+/-2.8 to 9.8+/-2.7. There were no periprocedural bleeding complications associated with the procedure. CONCLUSIONS: Rheolytic thrombectomy might be an effective and safe treatment for massive pulmonary embolism when systemic thrombolytic therapy is contraindicated. These data form the basis for further clinical investigation of this novel therapy among patients with massive pulmonary embolism.

Comparison of usefulness of N-terminal pro-brain natriuretic peptide as an independent predictor of cardiac function among admission cardiac serum biomarkers in patients with anterior wall versus nonanterior wall ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention.

The purpose of the present study was to determine the prognostic value of N-terminal pro-brain natriuretic peptide (NT-pro-BNP), among other serum biomarkers, on cardiac magnetic resonance (CMR) imaging parameters of cardiac function and infarct size in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention. We measured NT-pro-BNP, cardiac troponin T, creatinine kinase-MB fraction, high-sensitivity C-reactive protein, and creatinine on the patients' arrival at the catheterization laboratory in 206 patients with ST-segment elevation myocardial infarction. The NT-pro-BNP levels were divided into quartiles and correlated with left ventricular function and infarct size measured by CMR imaging at 4 to 6 months. Compared to the lower quartiles, patients with nonanterior wall myocardial infarction in the highest quartile of NT-pro-BNP (> or = 260 pg/ml) more often had a greater left ventricular end-systolic volume (68 vs 39 ml/m(2), p <0.001), a lower left ventricular ejection fraction (42% vs 54%, p <0.001), a larger infarct size (9 vs 4 g/m(2), p = 0.002), and a larger number of transmural segments (11% of segments vs 3% of segments, p <0.001). Multivariate analysis revealed that a NT-pro-BNP level of > or = 260 pg/ml was the strongest independent predictor of left ventricular ejection fraction in patients with nonanterior wall myocardial infarction compared to the other serum biomarkers (beta = -5.8; p = 0.019). In conclusion, in patients with nonanterior wall myocardial infarction undergoing primary percutaneous coronary intervention, an admission NT-pro-BNP level of > or = 260 pg/ml was a strong, independent predictor of left ventricular function assessed by CMR imaging at follow-up. Our findings suggest that NT-pro-BNP, a widely available biomarker, might be helpful in the early risk stratification of patients with nonanterior wall myocardial infarction.

Cardiac hazard associated with eating habits. A case of infected intrapericardial foreign body due to an ingested toothpick.

An unusual case of a toothpick perforating the distal one-third of the duodenum, penetrating the inferior vena cava and thereafter migrating to the right atrium with extensive pericardial fibrosis is reported. A 60-year-old man was admitted to the emergency department because of epigastric pain, which had progressively worsened. After partial recovery, he was discharged. However, after four episodes of different gastrointestinal bacteria septicemias of unknown origin over a period of five months, the patient was transferred to Laval Hospital (Laval, Quebec) for clinical investigation. Cardiac echocardiography demonstrated a right atrial mass, suggestive of the presence of a thrombus. Thus, after exploratory thoracotomy was performed to remove the so-called thrombus, a toothpick was found in the right atrium.