Outcomes following PCI in patients with previous CABG: a multi centre experience.

BACKGROUND: Limited data is available to guide operators as to the optimal revascularisation strategy in patients with previous CABG representing with angina. METHOD: Retrospective analysis of 161 patients with prior CABG undergoing PCI in two centres between September 2005 and April 2008. RESULTS: 161 patients (132 male, 68 ± 8 years) underwent PCI at 126 ± 65 months after index CABG. Clinical presentation of recurrent ischaemia was stable in 59.7% and as an acute coronary syndrome in 40.3% of patients. Mean follow-up after PCI was 13.5 ± 4.8 months. About 62.7% of patients underwent native vessel PCI, 32.9% had a graft only PCI, and 4.4% having a combination of both. Drug eluting stents were used in 84.9% of cases. There was one cardiac death and one case of redo CABG during follow-up. Mean CCS angina class decreased from 2.87 to 0.67 (P < 0.0001) in the follow-up group. About 13.6 % of all patients had a MACE at follow up. This was higher in the graft PCI group (21.6% vs. 8.9%, P = 0.048). About 12.4% of the total cohort underwent repeat PCI although 30% of these required PCI for a de-novo lesion. TVR rate was significantly higher in patients undergoing graft PCI than native vessel PCI (15% vs. 4.9%, P = 0.031). Graft PCI was an independent predictor (HR 3.73, 1.27-10.87 [95%CI], P = 0.016) of MACE in these patients. CONCLUSION: PCI significantly improved angina in these patients with low overall rates of TVR. However TVR rate was significantly higher in patients undergoing graft PCI than those undergoing native vessel PCI.

Early multicenter experience of Melody valve implantation in India.

BACKGROUND: Transcatheter valves provide a safe and effective alternative to surgery for treating dysfunctional right ventricular outflow tracts (RVOTs). We present our early multicenter experience of percutaneous pulmonary valve implantation (PPVI) using Melody valve (Medtronic Inc., Minneapolis, MN). METHODS: Patients with stenosed conduits or degenerated bioprosthetic valves in RVOT with combined stenosis and regurgitation were evaluated for suitability of Melody valve implantation. After undergoing an initial structured training, PPVI using Melody transcatheter pulmonary valve (TPV) was guided by an approved proctor. Conduits were serially dilated and prestented with careful coronary interrogation, and bioprosthetic valves were dilated with high-pressure balloons. Clinical and echocardiographic follow-up was performed at 6 monthly intervals. RESULTS: Fifteen patients (three females) aged 23.1 ± 9.5 years in NYHA Class II-III underwent Melody TPV implantation in four Indian centers. The underlying anatomy comprised surgically implanted bioprosthetic valves for pulmonary regurgitation (n= 5), conduit repair for pulmonary atresia (n = 4), Rastelli repair (n = 3), truncus (n = 1), and Ross procedure (n = 2). Twelve patients had more than one previous surgery. Doppler gradient decreased from 74.2 ± 21.5 mmHg to 10.2 ± 4.5 mmHg after the PPVI. At a median follow-up of 14 months (1-39 months), all the patients were in NYHA Class I with echocardiographic gradients of 8 ± 5.7 mmHg with no evidence of pulmonary regurgitation. There were no major procedural adverse events or deaths. CONCLUSIONS: Our early experience shows encouraging results of the PPVI program in India with proctored case selection and meticulous planning. It also confirms the safety and efficacy of Melody TPV for treating dysfunctional RVOT in postoperative patients.

Telescoping catheter technique for enlarged aortas.

Selective coronary angiography in severely dilated ascending aorta is technically challenging and sometimes impossible. The Terumo "five-in-six" system uses an extra long 5Fr guide catheter in a standard 6Fr guide catheter, so that the tip of the 5Fr guide catheter protrudes beyond the tip of the 6Fr catheter allowing an extra reach. This system has been used successfully to advance balloon catheters across chronic total occlusions (Takahashi et al, Catheter Cardiovasc Interv 2004;63:452-456) and stent delivery beyond proximal obstruction point (Mamas et al, Catheter Cardiovasc Interv 2008;71:358-363). We describe the successful use of this system in an atraumatic manner for selective coronary angiography in a patient with a severely dilated ascending aorta.

MitraClip and mitral annuloplasty device as a bridge to transplantation.

A 42-year-old man with dilated cardiomyopathy and endstage heart failure was evaluated for heart transplantation. He received a MitraClip and Carillon annuloplasty device for functional mitral regurgitation as palliation for his heart failure. Subsequently, he underwent successful heart transplantation.

Percutaneous closure of symptomatic large tricuspid paravalvular regurgitation using two muscular VSD occluders.

Paravalvular leaks are common following valve replacement surgery. Majority are benign and do not require any active intervention. However, occasionally severe paravalvular regurgitation can produce heart failure and/or hemolysis, needing closure of the defect. It is more commonly associated with aortic and mitral prosthesis, symptomatic tricuspid paravalvular regurgitation being a rare entity. In this report we present the successful percutaneous transcatheter closure of a large paravalvular tricuspid regurgitation in a 59-year old lady with history of multiple previous operations. The elongated crescent-shaped defect was closed using two muscular VSD devices without any residual leak and without hampering the bio-prosthetic tricuspid valve function. Patient had transient complete heart block during the procedure which recovered later. There was marked improvement in the symptomatic status of the patient at discharge (NYHA IV to NYHA II), which was sustained at follow-up.

Spontaneous coronary artery dissection in men presenting with acute coronary syndrome, successfully managed by intravascular ultrasound-guided percutaneous coronary intervention.

Spontaneous coronary artery dissection is a rare cause of acute coronary syndrome. It is most commonly seen in young women, without atherosclerosis, in the peripartum period. Management options include conservative medical treatment, percutaneous coronary intervention or a surgical approach depending on the presentation, extent of dissection and luminal stenosis. We describe three unusual cases of spontaneous coronary artery dissection occurring in young/middle-aged men-the first in association with heavy mechanical work, the second in association with high levels of anxiety and emotional distress and the third in association with intense physical exercise. In each case we report the use of coronary angiography and intravascular ultrasound in the diagnosis of the condition, and their successful management using percutaneous coronary intervention.

Use of IABP in contrast media-induced anaphylactic shock: the ultimate lifesaver.

Anaphylactic reaction to contrast media during selective coronary angiography is a rare occurrence. It can be occasionally resistant to medical treatment leading to cardiovascular collapse and death. The use of intra-aortic balloon pump (IABP) counter-pulsation when the supportive medical treatment fails during anaphylactic shock is not well documented in the literature. We report a case of a severe contrast media-induced anaphylactic shock which failed to respond to the supportive medical management and the timely insertion of IABP for further circulatory support that prevented death in a patient who had an elective diagnostic coronary angiography. The clinical diagnosis of anaphylaxis was challenging at the onset of shock as the typical rash developed after a few minutes.

Combined catheter ventricular septal defect closure and multivessel coronary stenting to treat postmyocardial infarction ventricular septal defect and triple-vessel coronary artery disease: a case report.

Ventricular septal defect following acute myocardial infarction is a rare but life-threatening complication. Early surgical closure improves survival but carries a considerable risk. Percutaneous transcatheter closure is an alternative but experience to date is limited. We report a case of successful transcatheter closure of postmyocardial infarction ventricular septal defect (VSD) in a 55-year-old male with the Amplatzer muscular VSD occluder device and complete percutaneous revascularization with successful multivessel coronary stenting for three-vessel disease as a staged procedure. The technique and its potential use as an alternative to surgical approach for treatment of acute myocardial infarction and its complication (VSD) are discussed.