Effectiveness of Left Judkins Catheter as a Single Multipurpose Catheter in Transradial Coronary Angiography From Right Radial Artery: A Randomized Comparison With Conventional Two-Catheter Strategy.

OBJECTIVES: To investigate safety and efficacy of left Judkins (JL) catheter as a single multipurpose catheter in transradial coronary angiography (TRA). BACKGROUND: Most operators use standard femoral catheters instead of special multipurpose transradial catheters during TRA. METHODS: Patients undergoing TRA through right radial artery (RRA) were randomized into single-catheter approach with JL3.5 and two-catheter approach with JL3.5 and right Judkins 4.0 catheters. Primary outcome measures were rate of success in selective and stable engagement of both coronary arteries with JL catheter, procedure and fluoroscopy times. RESULTS: Of 314 patients enrolled, 206 patients (aged 60.3 ± 12.4 years, 36.9% female) were randomized. JL3.5 was successful in 66.0% of patients as a single catheter. Additional catheter was needed more frequently in single-catheter group (34 vs. 0.97%, P < 0.001). Single-catheter approach reduced procedure time significantly (6.7 ± 2.1 vs. 7.9 ± 3.3 minutes, P = 0.002). However on average there was 19.7% relative increase in fluoroscopy time (2.61 ± 1.38 vs. 2.18 ± 1.54 minutes, P = 0.035) with single-catheter approach. Radial artery spasm tended to develop more frequently in two-catheter group (22.3 vs. 12.6%, P = 0.067). In nearly half of the patients, procedure had been completed successfully with JL3.5 catheter within a fluoroscopy time similar to that of two-catheter group. CONCLUSION: In TRA from RRA, JL3.5 catheter can be very effective when dedicated multipurpose catheter is not available. As a single multipurpose catheter, JL works perfectly in nearly half of procedures without prolonging procedure and fluoroscopy times. However insisting on a single-catheter approach with JL could unnecessarily increase fluoroscopy time and, hence, radiation exposure. (J Interven Cardiol 2016;29:257-264).

Relation of epicardial fat thickness to subclinical right ventricular dysfunction assessed by strain and strain rate imaging in subjects with metabolic syndrome: a two-dimensional speckle tracking echocardiography study.

BACKGROUND: Right ventricular (RV) function is known to be impaired in the presence of metabolic syndrome (MetS). Epicardial adipose tissue is a metabolically active organ that generates various bioactive molecules, which might affect cardiac function and morphology. Thus, we hypothesized that RV dysfunction in patients with MetS may be related to increased epicardial fat thickness (EFT) in these patients. In patients with MetS, we aimed to assess the relation of EFT with RV function using two-dimensional speckle tracking echocardiography (2DSTE)-derived strain and strain rate imaging. METHODS: The study involved 76 subjects with MetS and 61 subjects without MetS. Biventricular structure and function together with EFT were evaluated by conventional echocardiography. RV free and septal walls strain (RVFW-S & RVSW-S), systolic and early diastolic strain rates (RVSRs & RVSRe) were evaluated by 2DSTE. RESULTS: Epicardial fat thickness was significantly higher in subjects with MetS (6.45 ± 1.48 mm vs. 5.49 ± 1.05 mm, P < 0.001). RVFW-S (-22.95 ± 4.97% vs. -24.96 ± 3.63%; P = 0.007), RVSRs (1.53 ± 0.33/sec vs. -1.70 ± 0.33/sec; P = 0.002), and RVSRe (1.40 ± 0.44/sec vs. 1.75 ± 0.49/sec; P < 0.001) were all lower in subjects with MetS, while RVSW-S did not differ. Multiple regression analysis showed that EFT was independently associated with RVFW-S (ß = -0.547, P < 0.001), RVSRs (ß = -0.332, P = 0.001), and RVSRe (ß = -0.187, P = 0.019) in subjects with MetS. CONCLUSIONS: Metabolic syndrome is associated with subclinical RV systolic and diastolic dysfunction. In subjects with MetS, increased EFT is independently related to RV systolic and diastolic dysfunction.

The value of plasma D-dimer level on admission in predicting no-reflow after primary percutaneous coronary intervention and long-term prognosis in patients with acute ST segment elevation myocardial infarction.

D-dimer is a final product of fibrin degradation and gives an indirect estimation of the thrombotic burden. We aimed to investigate the value of plasma D-dimer levels on admission in predicting no-reflow after primary percutaneous coronary intervention (p-PCI) and long-term prognosis in patients with ST segment elevation myocardial infarction (STEMI). We retrospectively involved 569 patients treated with p-PCI for acute STEMIs. We prospectively followed up the patients for a median duration of 38 months. Angiographic no-reflow was defined as postprocedural thrombolysis in myocardial infarction (TIMI) flow grade <3 or TIMI 3 with a myocardial blush grade <2. Electrocardiographic no-reflow was defined as ST-segment resolution <70%. The primary clinical end points were mortality and major adverse cardiovascular events (MACE). The incidences of angiographic and electrocardiographic no-reflow were 31 and 39% respectively. At multivariable analysis, D-dimer was found to be an independent predictor of both angiographic (p < 0.001), and electrocardiographic (p < 0.001) no-reflow. Both mortality (from Q1 to Q4, 5.7, 6.4, 11.3 and 34.1%, respectively, p < 0.001) and MACE (from Q1 to Q4, 17.9, 29.3, 36.9 and 52.2%, respectively, p < 0.001) rates at long-term follow-up were highest in patients with admission D-dimer levels in the highest quartile (Q4), compared to the rates in other quartiles. However, Cox proportional hazard model revealed that high D-dimer on admission (Q4) was not an independent predictor of mortality or MACE. In contrast, electrocardiographic no-reflow was independently predictive of both mortality [Hazard ratio (HR) 2.88, 95% confidence interval (CI) 1.04-8.58, p = 0.041] and MACE [HR 1.90, 95% CI 1.32-4.71, p = 0.042]. In conclusion, plasma D-dimer level on admission independently predicts no-reflow after p-PCI. However, D-dimer has no independent prognostic value in patients with STEMI.

Left atrial deformation parameters predict left atrial appendage function and thrombus in patients in sinus rhythm with suspected cardioembolic stroke: a speckle tracking and transesophageal echocardiography study.

The aim of this study was to evaluate left atrial deformations using speckle tracking echocardiography for predicting left atrial appendage (LAA) thrombus in patients with suspected cardioembolic stroke who were in normal sinus rhythm. A total of 153 ischemic stroke patients (89 males, 64 females) in sinus rhythm who were suspected of having cardioembolism were included in the study. The patients underwent conventional two-dimensional (2D) echocardiogram and 2D speckle tracking echocardiogram of the left atrium. Left atrial peak strain (LA-4C-RES) and left atrial precontraction strain (LA-4C-PUMP) were measured. Patients were divided into 2 groups according to the presence of thrombus in the LAA in transesophageal echocardiography. Both LA-4C-RES and LA-4C-PUMP values were found to be significantly lower in patients with LAA thrombus (11.8 ± 1.4% vs. 33 ± 12%, P < 0.001 and 5.8 ± 1.3% vs. 14.2 ± 5.3%, P < 0.001, respectively). A good inverse correlation was present between LA-4C-RES values and LAA morphologic parameters (with LAA area: r = -0.70, P < 0.001, with LAA length: r = -0.60, P < 0.001), and a good positive correlation was present with LAA emptying velocity with pulse Doppler (r = 0.74, P < 0.001). The area under the receiver-operating characteristic curve of the LA-4C-RES was 0.94 (0.90-0.98, P < 0.001), for the LA-4C-PUMP, the area was 0.92 (0.87-0.96, P < 0.001) to predict LAA thrombus. Left atrial deformation parameters measured by 2D speckle tracking method was found to predict impaired LAA functions and the presence of LAA thrombus in ischemic stroke patients with suspected cardioembolism, but who are in sinus rhythm.

Soluble CD40 ligand release in patients with stable coronary artery disease during elective stent implantation: effect of drug-eluting stent over bare metal stent.

OBJECTIVES: We aimed to determine the effect of drug-eluting stent (DES) implantation on soluble CD40 ligand (sCD40L) levels in patients with stable coronary artery disease undergoing stent replacement. STUDY DESIGN: Eighty-nine consecutive patients (33 women, 56 men; mean age 61±10 years) with stable coronary artery disease undergoing stent replacement were recruited. Pre- and post-procedural blood samples were collected for sCD40L analysis, and differences in plasma levels were calculated and expressed as delta sCD40L. Total size and length of implanted stents and pre- and post-dilatation procedures were recorded for each patient, for possible impact on sCD40L release. Patients were followed for one year following procedures for possible adverse cardiac events such as death, myocardial infarction and revascularization. RESULTS: Forty-nine patients received bare metal stent (BMS) and 40 patients received DES. There were no differences between BMS- and DES-implanted patients in terms of age, stent size and length, and delta sCD40L plasma levels. Delta sCD40L was correlated only with total implanted stent length (r=0.374, p<0.001). Delta sCD40L levels were divided into quartiles for better determination of the procedural parameters that are effective on biomarker release. Total stent length (p=0.008), stent size (p=0.038) and pre-dilatation procedure (p=0.034) were the statistically differing parameters between delta sCD40L quartiles. Although statistically non-significant, all three adverse events were observed in patients with the highest quartile (p=0.179). CONCLUSION: Procedural sCD40L release did not differ between DES- and BMS-implanted stable coronary artery disease patients. Total implanted stent length, stent size and pre-dilatation procedure were the influential parameters on procedural sCD40L release.

Relation of plasma matrix metalloproteinase-8 levels late after myocardial infarction with left ventricular volumes and ejection fraction.

OBJECTIVES: Enhanced matrix metalloproteinase-8 (MMP-8) activity in the early post-myocardial infarction (MI) period has been related to early remodeling. However, it has been demonstrated that plasma MMP-8 level has a biphasic profile, and the relation between the late plasma levels and remodeling is unclear. We evaluated the plasma MMP-8 levels and its correlates 20±3 months after acute MI. STUDY DESIGN: 58 post-MI patients and 26 control subjects underwent quantitative single-photon emission computed tomography (SPECT) and echocardiography. The plasma MMP-8 levels were measured and its correlates were investigated. RESULTS: The MMP-8 levels were significantly higher in post-MI patients [median 3.88 ng/ml, interquartile range (1.88-6.43) vs. 0.67 ng/ml (0.34-2.47); p<0.001]. Plasma MMP-8 levels were significantly correlated with left ventricular ejection fraction (LVEF) (ρ=0.34, p=0.009), end diastolic volume index (EDVi) (ρ=-0.39, p=0.002) and end systolic volume index (ESVi) (ρ=-0.40, p=0.002). CONCLUSION: Plasma MMP-8 levels were found to still be high in post-MI patients 20±3 months after the index event. The levels were significantly correlated with left ventricular volume indices and LVEF. We speculate that, in contrast to the relation between the higher early MMP-8 activity and the extent of cardiac remodeling, higher late levels may be associated with relative preservation of left ventricular systolic function.

Predictors and long-term prognostic significance of angiographically visible distal embolization during primary percutaneous coronary intervention.

OBJECTIVES: We aimed to identify the predictors of angiographically visible distal embolization (AVDE) during primary percutaneous coronary intervention (p-PCI) as well as to assess its impact on short- and long-term clinical outcomes in patients with acute ST-segment elevation myocardial infarction (STEMI). STUDY DESIGN: We retrospectively enrolled 2007 patients with STEMI who underwent p-PCI. We assessed the clinical and angiographic characteristics of patients in order to identify the predictors of AVDE and compared the outcomes of patients with and without AVDE during p-PCI. RESULTS: Distal embolization developed in 135 (6.7%) patients. Age (for each 10- year increase, Odds Ratio (OR) 1.34, 95% Confidence Interval (CI) 1.16-1.52, p<0.001), treatment of right coronary artery (OR 2.52, 95% CI 1.30-4.87, p=0.034), repeated balloon dilatation (OR 1.84, 95% CI 1.16-2.94, p=0.009), cut-off occlusion pattern (OR 2.17, 95% CI 1.38-3.42, p=0.001), lesion length >15 mm (OR 1.67, 95% CI 1.09-2.58, p=0.019), and reference vessel diameter >3.5 mm (OR 5.08, 95% CI 3.32-7.65, p<0.001) were independent predictors of AVDE. In-hospital (8.1% vs. 3.8%, p=0.014) and one-month (10.8% vs. 4.9%, p=0.004) all-cause mortality rates were higher in patients with AVDE. At the long-term follow-up (median: 42 months), both all-cause (21.5% vs. 10.4%, p<0.001) and cardiac mortality rates (18.4% vs. 8.0%, p<0.001) were higher in patients with AVDE. CONCLUSION: AVDE is associated with worse clinical outcome at both the short- and long-term follow-up of STEMI patients treated early with p-PCI.

Comparison of early and late clinical outcomes in patients >= 80 versus <80 years of age after successful primary angioplasty for ST segment elevation myocardial infarction.

OBJECTIVES: We aimed to compare the efficacy of primary percutaneous coronary intervention (p-PCI) in patients >=80 versus <80 years of age with ST-segment elevation myocardial infarction (STEMI). STUDY DESIGN: We retrospectively enrolled 2213 patients with acute STEMI. The patients were prospectively followed up for a median of 42 months. Early and late clinical outcomes were compared according to age. RESULTS: One-hundred and seventy-nine (8.1%) of the 2213 patients were aged >=80 years. Post-procedural TIMI grade 3 flow was significantly less frequent in the age >=80 years patients (82.1% vs. 91.1%, p<0.001). Rates of mortality (14.5% vs. 3.4%, p<0.001), heart failure (20.7% vs. 10.5%, p<0.001), major hemorrhage (9.5% vs. 3.3%, p<0.001), secondary VT/VF (10.1% vs. 4.2%, p=0.002) and atrial fibrillation (12.8% vs. 4.3%, p<0.001) during the early hospitalization period were significantly higher in the age >=80 years patient group. Overall rates of mortality (40% vs. 9.7%, p<0.001) and total stroke (5.6% vs. 1.1%, p=0.005) at long-term follow-up were also higher in the age >=80 years patient group. However, there was no difference between the two groups with respect to the reinfarction/revascularization rates. Analysis, using the Cox proportional hazards model, revealed that age >=80 to was an independent predictor of long-term mortality (hazard ratio 2.17, 95% CI 1.23-4.17, p=0.02). CONCLUSION: Age is an independent predictor of mortality after p-PCI for STEMI. Although it seems to improve early outcomes, the efficacy of p-PCI at long-term follow-up is limited in elderly patients.

Iliac Endovascular Intervention Without Procedural Anticoagulation.

BACKGROUND: Adequate antithrombotic therapy is essential to prevent thrombus formation during percutaneous endovascular interventions (PVI). We hypothesize that interventions for non-complex lesions of iliac arteries do not need procedural anticoagulation if patients are under dual antiplatelet therapy (DAPT). METHODS: Iliac PVIs performed without procedural anticoagulation were retrospectively screened between 2017 and 2021. Baseline characteristics of patients, in-hospital events and 30-day follow-ups were obtained from hospital records. Each PVI was reviewed for procedural details. Primary safety outcome was thromboembolic events during intervention. Secondary safety outcome was adverse vascular events at 30-day follow-up. Procedure times of iliac interventions were compared to peripheral angiography procedures of patients with similar demographic characteristics. RESULTS: We identified 108 iliac interventions without procedural anticoagulation, median age of 62 (interquartile range 56-68) years, 9 (8.3%) females. Median lesion length was 30 (19-50) mm. We observed a thrombotic finding in 4 (3.7%) procedures. Visible luminal thrombus was observed in 2 (1.9%) and introducer sheath thrombosis in 2 procedures (1.9%), all of which were in patients with in-stent lesions. No distal embolization was observed in final angiography of these procedures. At 30-day follow-up, acute limb ischemia was not observed and clinically driven target vessel revascularization was not required in any of the patients. Procedure time of iliac interventions was similar to that of lower extremity diagnostic procedures [18 (11-24) vs 18 (14-24) min, respectively, P = .364]. No major bleeding event was observed after iliac interventions. CONCLUSION: Non-complex lesions of iliac arteries can be managed within a time frame similar to that of lower extremity diagnostic procedures. These interventions can be performed safely without procedural anticoagulation, provided patient receives DAPT. Intervention of in-stent lesions should ideally be avoided without procedural anticoagulation.

Intracoronary bolus-only compared with intravenous bolus plus infusion of tirofiban application in patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention.

OBJECTIVES: The aim of this pilot study was to compare intracoronary bolus-only with standard intravenous bolus plus maintenance infusion of tirofiban with respect to improvement in myocardial reperfusion after primary percutaneous coronary intervention (p-PCI). BACKGROUND: Changes in clinical practice may obviate the need for a maintenance infusion of small molecule glycoprotein IIb/IIIa inhibitors in current practice. METHODS: Forty-nine patients undergoing p-PCI were randomized to either intracoronary bolus-only (n = 25) or intravenous bolus plus infusion (n = 24) of tirofiban. The primary end point was coronary hemodynamic indices of microvascular perfusion measured 4-5 days after p-PCI. The secondary end points were ST segment resolution at 90 min, the corrected TIMI frame count and myocardial blush grade. At 6 months, echocardiography and technetium-99m single-photon-emission computed tomography were performed. RESULTS: Microvascular perfusion did not differ significantly between the two treatment groups: index of microvascular resistance (27 ± 13 vs. 35 ± 15 U, P = 0.08) and coronary flow reserve (2.2 ± 0.7 vs. 1.9 ± 0.6, P = 0.25). The corrected TIMI frame counts assessed in the first (P = 0.13) and the second (P = 0.09) catheterization or the myocardial blush grades evaluated immediately (P = 0.23) and 4-5 days after MI (P = 1.00) were not significantly different between the two groups. At 6 months, there was no difference between the two groups in infarct size, left ventricular volumes, or ejection fraction. CONCLUSIONS: The standard intravenous bolus plus maintenance infusion of tirofiban in p-PCI is not superior to intracoronary bolus-only administration with respect to microvascular perfusion. Further, adequately powered randomized trials are warranted to evaluate the clinical outcomes associated with this strategy.

No harmful effect of dialysis-induced hypotension on the myocardium in patients who have normal ejection fraction and a negative exercise test.

BACKGROUND: We investigated the effects of dialysis-induced hypotension (DIH) on the myocardium of patients who have a normal ejection fraction and normal treadmill stress tests. METHODS: This study included 26 end-stage renal disease (ESRD) patients with DIH, 30 ESRD patients without DIH (non-DIH), and 30 control subjects. Mitral-myocardial systolic velocity (MSV), the mitral E'/A' ratio, the left ventricle filling pressure index (E/E' ratio), tricuspid-MSV, and the tricuspid E'/A' ratio were calculated. RESULTS: Biventricular systolic and diastolic functions were impaired in dialysis patients. The mitral and tricuspid MSV were similar between DIH and non-DIH patients (8.03 ± 0.90 cm/s vs. 8.31 ± 1.68 cm/s, p = 0.896, and 13.27 ± 2.97 cm/s vs. 13.15 ± 2.37 cm/s, p = 0.980). Mitral and tricuspid E'/A' were similar between DIH and non-DIH patients. (1.30 ± 0.53 vs. 1.16 ± 0.56, p = 0.695, and 0.70 ± 0.24 vs. 0.68 ± 0.33, p = 0.976). Likewise, the E/E' ratio was similar between DIH and non-DIH patients (8.20 ± 2.83 vs. 8.28 ± 2.53, p = 0.990). CONCLUSION: Although biventricular systolic and diastolic function is impaired in dialysis patients compared to controls, DIH episodes did not have an adverse effect on the myocardial functions.

In-hospital prognostic value of admission plasma B-type natriuretic peptide levels in patients undergoing primary angioplasty for acute ST-elevation myocardial infarction.

OBJECTIVES: We assessed in-hospital prognostic value of admission plasma B-type natriuretic peptide (BNP) levels in patients undergoing primary percutaneous coronary intervention (p-PCI) for acute ST-elevation myocardial infarction (STEMI). STUDY DESIGN: In a retrospective design, we evaluated 992 patients (801 males, 191 females; mean age 56 ± 12 years) treated with p-PCI for STEMI. The patients were divided into two groups according to the admission BNP levels, taking the cut-off value of BNP as 100 pg/ml; i.e, ≥ 100 pg/ml (n=334, 33.7%) and <100 pg/ml (n=658, 66.3%). Postprocedural angiographic and clinical in-hospital results were recorded. RESULTS: No-reflow (24% vs. 9%), heart failure (32.3% vs. 5.5%) and death (15.6% vs. 1.7%) were significantly more common in patients with BNP ≥ 100 pg/ml (p<0.001). In multivariate analysis, elevated baseline BNP level was identified as an independent predictor of no-reflow (OR=1.83; 95% CI 1.22-2.74, p=0.003), acute heart failure (OR=2.67; 95% CI 1.55-4.58, p<0.001), and in-hospital mortality (OR=3.28; 95% CI 1.51-7.14, p=0.003). In receiver operating characteristic curve analysis, the area under the curve and sensitivity/specificity of the cut-off value of BNP (100 pg/ml) for prediction of clinical endpoints were 0.741 and 58.6%/70.3% for no-reflow, 0.822 and 75%/73.3% for heart failure, and 0.833 and 82.5%/69.4% for death, respectively (p<0.001 for all). CONCLUSION: Elevated admission BNP level is an independent predictor of angiographic no-reflow, acute heart failure, and mortality in STEMI patients during in-hospital period, suggesting that it might be incorporated into traditional risk scoring systems to improve early risk stratification.

Primary angioplasty in a high-volume tertiary center in Turkey: in-hospital clinical outcomes of 1625 patients.

OBJECTIVES: We evaluated in-hospital results of primary percutaneous coronary intervention (PCI) in a high-volume tertiary center. STUDY DESIGN: We retrospectively evaluated 1625 patients (1323 males, 302 females; mean age 56.0 ± 11.6 years) who underwent primary PCI for acute ST-elevation myocardial infarction between January 2006 and April 2008. All coronary angiography procedures were performed using the femoral artery route. In-hospital clinical and angiographic results were recorded. RESULTS: On admission, 23% of the patients had diabetes mellitus, 49.6% had anterior myocardial infarction, and 4.9% had cardiogenic shock. The mean duration of pain was 171.2 ± 121.2 minutes, and the mean door-to-balloon time was 31.6 ± 7.2 minutes. Infarct-related artery was the left anterior descending artery in 49.7%, multivessel disease was present in 40.9%, TIMI 2/3 flow was present in 23.6%, and high-grade thrombus was observed in 66.8%. Primary PCI involved balloon dilatation (5.7%) and stent implantation (94.3%). The incidence of angiographic no-reflow was 11.9%. The mean hospital stay was 5.2 ± 3.3 days. All-cause mortality occurred in 71 patients (4.4%). Other in-hospital events were reinfarction (1.4%), target vessel revascularization (1.9%), hemorrhagic/ischemic stroke (0.6%), stent thrombosis (1.2%), major bleeding (3.8%), blood transfusion (4.8%), heart failure (10.5%), atrial fibrillation (4%), and ventricular tachycardia (3.9%). CONCLUSION: Primary PCI is an effective method in achieving complete revascularization of the infarct-related artery. Successful in-hospital results not only depend on the experience and equipment of the center, but also on how rapidly reperfusion is achieved.

Incidence and predictors of prolonged hemodynamic depression after carotid artery stenting: Yet another benefit of statins?

OBJECTIVES: We aimed to assess the incidence and predictors of prolonged hemodynamic depression (PHD) after carotid artery stenting (CAS). METHODS: We retrospectively analyzed data from 216 CAS procedures performed in 207 patients (156 male; median and interquartile range (IQR) of age 68 (62-73) yr) between July 2012 and October 2020. PHD was defined as hypotension (systolic blood pressure ≤ 90 mmHg) and/or bradycardia (heart rate < 60 bpm) lasting >1 h. RESULTS: The incidence of PHD was 25.9%. At multivariate analysis, asymptomatic lesions (OR: 2.43, 95% CI (1.16-5.06), p: 0.018), the stenosis proximity (<10 mm) to bifurcation (OR: 2.94, 95% CI (1.34-6.43), p: 0.007) and implantation of a Protege stent (OR: 2.93, 95% CI (1.14-7.53), p: 0.025) were independent risk factors, while statin usage (OR: 0.48, 95% CI (0.24-0.95), p: 0.036) was an independent protective factor for PHD after CAS. CONCLUSIONS: Patients with asymptomatic lesions and stenosis close to the bifurcation are more prone to PHD. The type of the stent selected significantly influences the risk of PHD. Further prospective randomized studies are warranted to investigate the possible protective role of statins against PHD after CAS.

Late bare metal stent thrombosis.

Late stent thrombosis is very rare in bare metal stents. We report on a 72-year-old male patient who developed late thrombosis of a bare metal stent implanted in the left main coronary artery (LMCA). The patient presented with cardiogenic shock 350 days after the first stent implantation. Coronary angiography showed total occlusion of the stent. Following the first balloon predilatation of the lesion, a flow in the LMCA was observed, but there was no flow in the left anterior descending (LAD) artery. Then, a bare metal stent was implanted into the LAD. Although the flow was maintained and all inotropic support continued, hypotension persisted. Angiography of the right coronary artery demonstrated 90% stenosis at the same location which had been observed as a noncritical lesion during the first percutaneous coronary intervention. As the patient was in shock, the right coronary artery was also stented and TIMI 3 flow was obtained. However, the patient developed cardiac arrest and died despite repeated efforts of cardiopulmonary resuscitation. It was learned that the patient had undergone an urological operation for bladder stone nine days before, for which both aspirin and clopidogrel were discontinued six days before the operation. Only aspirin was reinitiated three days after the procedure. He then presented to our hospital with cardiogenic shock on his first day after discharge.

Double-orifice mitral valve associated with bicuspid aortic valve: a rare case of incomplete form of Shone's complex.

Double-orifice mitral valve (DOMV) is a rare congenital malformation characterized by two separate valve orifices of varying sizes in association with the abnormalities of the subvalvular apparatus. It has been reported to be associated with a variety of other congenital malformations. We report a rare case of incomplete form of Shone's complex composed of a complete bridge-type DOMV and bicuspid aortic valve, well demonstrated by both transthoracic and transoesophageal echocardiography and cardiac magnetic resonance imaging.

Atherosclerosis in type IV dual left anterior descending artery and anomalous aortic origin of the left circumflex artery in association with rheumatic valve disease: a case report.

Double left anterior descending coronary artery arising from the left and right coronary arteries is a very rare congenital coronary artery anomaly. In this case, there was also a circumflex artery arising from the right sinus Valsalva and in association with severe rheumatic valve disease. Subsequently, the patient underwent mechanical aortic valve replacement with a 21-mm bileaflet mechanical aortic valve and coronary artery bypass grafting. We performed coronary artery bypass grafting of 3 vessels, including the left internal mammary artery to the large diagonal branch and the saphenous vein graft to the circumflex artery and the right coronary artery, under cardiopulmonary bypass. In this report, we describe an unusual case of this combination in association with both atherosclerosis and rheumatic aortic and mitral valve disease.

Influence of diurnal blood pressure rhythm on aortic elastic properties in hypertensive subjects.

OBJECTIVE: The aim of this study was to evaluate whether there is a relationship between aortic elastic properties and diurnal blood pressure rhythm in hypertensive subjects. METHODS AND RESULTS: This study included 41 hypertensive patients who were taking medical treatment and had undergone ambulatory blood pressure monitoring (ABPM). The patients were classified according to their night mean systolic blood pressure (Nm-SBP) fall. On the basis of Nm-SBP fall: 10 (24.4%) patients were dippers (with 10% but < 20% fall), 19 (46.3%) patients were nondippers (with 0% but <0% fall) and 12 (29.3%) patients were reverse dippers (with <0%). All subjects underwent echocardiographic examination. Internal aortic root diameters were measured at 3 cm above the aortic valve by the use of two-dimensional guided M-mode transthoracic echocardiography, and arterial blood pressure was measured simultaneously from the brachial artery by sphygmomanometry. Two indexes of the aortic elastic properties were measured which are aortic distensibility and aortic stiffness index. After subgroup analysis of the hypertensive patients, the highest aortic stiffness index value was found in reverse dipper patients (5.8 +/- 3.4) followed by nondipper patients (4.87 +/- 3.5) and the lowest in dipper patients (3.5 +/- 1.3) although clinical blood pressure values of hypertensive patients were similar. The aortic stiffness index value of reverse dippers and nondippers (5.6 +/- 3.4) was higher than in the (3.5 +/- 1.3) dippers group. CONCLUSION: In this study, we found a relation between diurnal blood pressure patterns and aortic elastic properties.

Inappropriate combination of warfarin and aspirin.

OBJECTIVE: A combination of warfarin and aspirin is associated with increased bleeding compared with warfarin monotherapy. The aim of the study was to investigate the incidence and appropriateness of the combination of warfarin and aspirin in patients with atrial fibrillation (AF) or mechanical heart valve (MHV). METHODS: This cross-sectional study included consecutive patients with AF or MHV on chronic warfarin therapy (>3 months) without acute coronary syndrome or have not undergone a revascularization procedure in the preceding year. Medical history, concomitant diseases, and treatment data were acquired through patient interviews and from hospital records. RESULTS: Three hundred and sixty patients (213 with AF, 147 with MHV) were included. In those with AF, a significantly higher warfarin-aspirin combination was observed with concomitant vascular disease (38.8% vs. 14.6%), diabetes (36.6% vs. 16.3%), statin therapy (40% vs. 16.9%), left ventricular systolic dysfunction (33.3% vs. 17.5%) (p<0.05 for all). The use of combination therapy was similar between different CHADS-VASc scores. In patients with MHV, higher combination therapy was observed in males (41% vs. 26.7% in females; p=0.070), concomitant vascular disease (47.8% vs. 29.8%; p=0.091), and AF (56.3% vs. 29.8%; p=0.033). Independent predictors of warfarin-aspirin combination were concomitant vascular disease, diabetes, and (younger) age in patients with AF and were concomitant AF and male sex in patients with MHV. Interestingly, the incidence of combination therapy was found to increase with a higher HAS-BLED score in both patients with AF and MHV (p<0.001). CONCLUSION: The combination of warfarin and aspirin was found to be prescribed to patients with AF mainly for the prevention of cardiovascular events, for which warfarin monotherapy usually suffices. On the other hand, co-treatment with aspirin appeared to be underused in patients with MHV.