Giant left ventricular inferior wall aneurysm as a late complication after myocardial infarction: A case report.

A case of a 64-year-old patient who was referred to interventional cardiology unit in order to qualify her to mitral valve repair is presented. Transthoracic echocardiography revealed a giant inferior wall basal aneurysm of the left ventricle (44 mm × 31 mm, 57 ml) and coronary angiography revealed chronic total occlusion of the proximal right coronary artery. The patient refused surgical treatment and was treated with pharmacotherapy alone. At 1 year follow-up, clear progression of the disease was observed. Based on this case study, we would cautiously suggest that in similar cases of large inferobasal wall aneurysms causing severe MR, OMT may be insufficient to prevent disease progression, and that early surgical intervention may be preferred.

Long-term results of plaque excision combined with aggressive pharmacotherapy in high-risk patients with advanced peripheral artery disease (SAVE a LEG registry).

BACKGROUND: In United States alone there are more than 12 million people with peripheral artery disease (PAD). Long-term outcomes of plaque excision in high-risk population (patients with diabetes and patients with end stage renal disease on dialysis) are scarce. METHODS: Since November 2003, we treated 225 consecutive patients (138 male, mean age: 66.3 ± 12.4, range: 29-93) with SilverHawk(TM) plaque excision for critical limb ischemia or disabling claudication. A total of 367 procedures were performed treating 832 lesions (157 restenotic, 675 de novo). One hundred fifty-five patients (68.9%) were diabetics, 74 (32.9%) were on dialysis. All patients were treated with statins, clopidogrel, aspirin, and aggressive glycemic control. The primary endpoint for our study was target lesion revascularization (TLR), and the secondary endpoint was an assessment of major adverse events (all cause death, amputation, TLR). RESULTS: The average time of observation was 2.2 ± 1.2 years. Procedural success rate was 99.4% with <30% residual stenosis achieved in 818 (98.9%) lesions. SilverHawk was used alone in 86.7%. No acute limb loss or major perforation occurred. Sixty (26.6%) patients had TLR. Long-term mortality was 16.4%. Seven (3.1%) patients had to undergo major amputations and 7 (3.1%) minor amputations. Seventy (31.1%) patients had a major adverse event. Atorvastatin 80 mg was found to be independent predictor of survival, and major amputation was found to be independent predictor of mortality. CONCLUSIONS: SilverHawk Plaque Excision combined with aggressive pharmacotherapy in this presented high-risk population is associated with promising long-term outcomes that compare favorably with accepted standards of care.

Long-term results of cephalad arteries percutanoeus transluminal angioplasty with stent implantation (The CAPTAS registry).

INTRODUCTION: Carotid artery stenting (CAS) has become an alternative to carotid endarterectomy. Moreover, percutaneous transluminal angioplasty (PTA) allows other cephalad arteries revascularization. The aim of this study was to evaluate late outcomes of cephalad arteries PTA. METHODS: This is an international multicenter registry of 434 consecutive patients in which 497 PTAs were performed. Patients with symptomatic >50% stenosis or asymptomatic >70% stenosis were enrolled. Stenting of 577 internal carotid arteries (ICA) and 13 common carotid arteries was performed, 20.7% procedures were complex in which bilateral carotid stenoses or carotid and vertebral arteries stenoses were revascularized at one stage. In 15.9% patients, one-stage coronary intervention was carried out. Distal protection devices were used in 69.6% of cases. PTAs were divided into high (n = 330) and low (n = 167) risk of major adverse coronary and cerebral events (MACCE). RESULTS: At 30 days, there were 15 (3.5%) cases of MACCE [0.9% deaths, 2.1% strokes, and 0.9% myocardial infarction (MI)]. TIAs were observed in 15 (3.9%) patients. There was no significant difference in stroke incidence between procedures with or without neuroprotection (1.8 vs. 3%; P = 0.66) as well as in MACCE occurrence between high and low-risk groups (4.3 vs. 2%; P = 0.34). Bilateral stenoses increased while hypertension decreased the risk of MACCE. Left ICA lesions increased the risk of cerebrovascular accidents (CVA). At 4 years (1-11 years), the mortality rate was 11.5%, 6% of patients had stroke, and 3% MIs. Restenosis occurred in 3%. There was a trend toward higher mortality rate (13.3 vs. 6.9%; P = 0.07) and MACCE risk in high-risk group (23.5 vs.14.7% P = 0.06). Age > 65 y.o. and stent length < 24 mm increased, while the statin therapy on admission decreased the risk of long-term death. Structural valve disease and stent length <30 mm increased the risk of MACCE, while implantation of Acculink stent decreased the risk of CVA. CONCLUSIONS: CAS is safe and successful procedure with low early and long-term adverse events. Special attention should be put on patients with bilateral and left ICA stenoses. If possible, longer stents should be applied.

Cardiva Catalyst II vascular access management device in percutaneous diagnostic and interventional procedures with same-day discharge (Catalyst II trial).

PURPOSE: To present a prospective, single-center trial of the Cardiva Catalyst II, a vascular closure device that provides temporary hemostasis after the procedure and is removed under manual compression, leaving no material behind. METHODS: During a 16-month period between April 2008 and July 2009, 400 procedures (100 interventions, 300 diagnostic procedures) were performed on 351 nonconsecutive patients (185 men; mean age 60.2 ± 12.0 years, range 27-93). All interventions were performed utilizing bivalirudin for anti-thrombin therapy. Initial follow-up was done at a mean 1.3 ± 0.7 days after the index procedure in all patients. Final follow-up, for diagnostic procedures as well as interventions, was performed at a mean 15.4 ± 7.1 days. The primary and secondary endpoints were the rate of major and minor vascular complications, respectively. RESULTS: Successful deployment of the device was reported in 397 (99.3%) procedures, which were primarily in retrograde fashion (97.0%) from the right groin (92.5%). In most cases (309, 77.2%), a 5-F sheath was used. A major vascular complication occurred after 1 intervention; none was noted after diagnostic procedures. Minor vascular complications were recorded after 2 interventions and 5 diagnostic procedures. Overall vascular complication rates were 0.25% for major sequelae and 1.75% for minor events. Mean time to discharge after diagnostic procedures was 145.0 ± 21.2 minutes versus 295.1 ± 44.1 minutes after interventional procedures (p < 0.05). There was no death, stroke, myocardial infarction, or urgent hospital transfer in the study cohort. CONCLUSION: Cardiva Catalyst is safe and effective device in achieving local hemostasis after percutaneous diagnostic procedures and interventions performed under bivalirudin anticoagulation. The use of this device with an appropriate protocol facilitates same-day discharge.

Percutaneous versus surgical revascularization for multivessel coronary artery disease: a single center 10 year follow-up of SOS trial patients.

OBJECTIVES: To compare 10 year outcomes including death, left ventricular ejection fraction (LVEF), major adverse cardiovascular and cerebrovascular events (MACCE), repeat revascularization (RR), and severity of angina (CCS) after randomization to stent supported percutaneous coronary intervention (PCI) or surgical revascularization (CABG) in a single center participating in the SOS trial. BACKGROUND: Randomized studies show increased RR following PCI, but otherwise similar results to CABG in selected mutlivessel disease patients with up to 5 year follow up. There is no 10 year data available. MATERIALS AND METHODS: The analysis involved 100 patients randomized into the SOS study in Poland. RESULTS: Patients were well matched for baseline demographic and angiographic characteristics. During 9.6 +/- 0.85 year observation, there was no significant difference between groups for survival, CCS, and LVEF. Increased RR occurred following PCI; 21 (42%) vs. 9 (18%), P < 0.05. As a consequence, the MACCE was also significantly higher following PCI; 36 (72%) vs. 28 (56%), P < 0.05. Excess RR predominantly occurred in the first year and diminished over time with numerically less RR following PCI from year 5 to 10; 2 (4%) vs. 7 (14%), P = ns. CONCLUSIONS: These findings suggest that patients with multivessel coronary artery disease technically suitable for either stent supported PCI or CABG have very similar 10 year outcomes with respect to mortality, angina class, LVEF, and MACCE other than RR. Excess RR following PCI predominantly occurs in early years and is numerically lower following PCI in years 5-10. This underscores the need for longer-term follow up from randomized trials.

Safety of transesophageal echocardiography­guided electrical cardioversion in patients with atrial fibrillation and inadequate anticoagulation.

INTRODUCTION    Restoring sinus rhythm in patients with atrial fibrillation (AF)/atrial flutter (AFl) requires adequate oral anticoagulation prior to direct current cardioversion (DCC). Some patients eligible for DCC are not properly anticoagulated. OBJECTIVES    The aim of the study was to assess risk factors for thrombus and spontaneous echo contrast (SEC) in the left atrium (LA) as well as the safety profile of transesophageal echocardiography (TEE)-guided DCC in patients with inadequate anticoagulation. PATIENTS AND METHODS    From the cohort of 316 patients admitted for DCC, 139 patients (mean [SD] age, 63.4 [11.5] years) had inadequate anticoagulation; 91 patients were admitted urgently for acute coronary syndrome, heart failure (HF), or poor tolerance of arrhythmia. The mean (SD) CHA2DS2­VASc score was 3.0 (1.7). RESULTS    TEE revealed a left atrial appendage (LAA) thrombus in 16 patients (11.5%), and SEC in the LA in 63 patients (45.3%). In a univariate analysis, LAA thrombus was more common in patients after myocardial infarction (odds ratio [OR], 3.92; 95% CI, 1.34-11.48; P = 0.009), while SEC in the LA was more common in patients with HF (OR, 2.23; 95% CI, 1.1-4.53; P = 0.02) and left ventricular ejection fraction of less than 40% (OR, 3.65; 95% CI, 1.66-8.06; P = 0.001). In a multivariate model, the most powerful SEC­predicting factor was the LA size exceeding 45 mm (OR, 3.08; 95% CI, 1.3-7.29). DCC was performed in 105 patients. No complications of TEE or DCC were observed. CONCLUSIONS    AF/AFl inadequately treated with oral anticoagulation predisposes to thrombus formation and SEC in the LA. Once thrombus is excluded, DCC is a safe procedure. There were no predictors of LAA thrombus; therefore, TEE before DCC should be performed in all patients with AF/AFl in accordance with the guidelines.

Bipolar irrigated radiofrequency ablation of resistant ventricular tachycardia with a septal intramural origin: the initial experience and a description of the method.

Bipolar radiofrequency (RF) ablation is effective in treatment of ventricular tachycardia originating from thick interventricular septum. The RF generator and CARTO system can be used to precisely and safely perform ablation. Standard ablation catheter can be used with indifferent ablation electrode connected to the electrode receptacle in RF generator with custom-made cable.

Utilisation of bivalirudin and vascular closure devices for same-day discharge after percutaneous coronary and peripheral interventions.

BACKGROUND: Currently the majority of coronary and peripheral interventions are performed with an overnight stay. This increases the cost and does not reduce logistic constraints on hospital resources. We hypothesised that by combining bivalirudin with vascular closure devices we can safely discharge patients on the same day after percutaneous coronary intervention (PCI) and percutaneous transluminal angioplasty (PTA) without increasing their risk of bleeding. AIM: To evaluate the safety and the feasibility of same-day discharge after PCI and PTA using bivalirudin and vascular closure devices. METHODS: This is a retrospective analysis of 833 consecutive patients who underwent percutaneous procedures in our centre between January 2007 and February 2010. The population was divided into interventional and diagnostic arms. All interventions were done with use of bivalirudin for anticoagulation and vascular closure devices for achieving haemostasis. Haemostasis in the diagnostic cohort was achieved with standard manual compression. The mean time of observation was 30 days. The mean age of patients was 64.3 years. The primary endpoint was any bleeding event meeting GUSTO criteria. The secondary endpoints included local vascular complications, major adverse cardiac and cerebrovascular events, time to ambulation and discharge, as well as need for overnight hospitalisation. RESULTS: In 30-day observation the primary endpoint occurred in 4.0% of patients in the interventional group and in 2.6% of patients in the diagnostic group (p = 0.31). The frequency of local vascular complications was higher in the interventional group although it was not statistically significant (3.1% vs. 2.9%; p = 0.33). Patients from the interventional group were ambulated sooner compared to the diagnostic group (117.5 vs. 131 min; p = 0.003). Time to discharge was 316.4 ± 38.7 min and 214.2 ± 23.4 min for interventional and diagnostic procedures, respectively (p < 0.001). CONCLUSIONS: PCI and PTA in the selected group of patients, with use of bivalirudin and vascular closure devices, do not appear to have increased risk of post-procedural events when compared to diagnostic procedures, and can be done safely without the need for an overnight stay.