How to Do It: Transbrachial Impella Placement to Facilitate Percutaneous Coronary Intervention.

A 64-year-old man with diffusely diseased iliofemoral vessels and an ejection fraction of 20% to 25% presented with a non-ST elevation myocardial infarction and proximal left anterior descending (LAD) and left circumflex (LCx) coronary artery disease, with a chronically occluded right coronary artery. The iliofemoral system was not suitable for Impella placement, and bilateral axillary arteries were heavily calcified. The proximal left brachial artery was chosen for placement of both an Impella CP (Abiomed, Danvers, MA, USA) and percutaneous coronary intervention (PCI) sheath through a graft sewn to the brachial artery in this single-access technique. A 6 mm graft was sewn to the brachial artery, through which the Impella CP was placed. The Impella CP sheath was then used to introduce a 7F sheath for PCI. Successful PCI with drug-eluting stents was carried out to the LAD and LCx arteries, the Impella was weaned and removed, and the graft was stapled. The patient was discharged without any access or PCI complications. This report demonstrates the feasibility of the single-access Impella technique through a brachial artery cutdown approach.

Coronary no reflow.

The no-reflow phenomenon has been studied extensively in the basic science laboratory and has entered the clinical arena. No-reflow, which develops largely within the first 2h of reperfusion, is primarily the result of ischemic endothelial cell injury that obstructs the capillary lumen. Additional contributing mechanisms in experimental models include neutrophil accumulation, reactive oxygen species, and the coagulation cascade. Atherosclerotic- and thromboembolism also contribute to no-reflow during percutaneous coronary intervention and clinical myocardial infarction. No-reflow is assessed using tracers, electrocardiography (ST segment resolution), angiography (thrombolysis in myocardial infarction [TIMI] flow grading and myocardial blush grading), Doppler guidewires, myocardial contrast echocardiography, and cardiac magnetic resonance imaging. No-reflow is a poor prognosticator for left ventricular remodeling and function, and acute and long-term clinical events and survival. No-reflow benefits from therapies initiated during coronary occlusion or during early reperfusion. Potential therapies include vasodilators, statins, antiplatelet agents, thrombus aspiration, distal protection devices, ischemic preconditioning, remote ischemic preconditioning and postconditioning, pharmacologic preconditioning, and hypothermia. This comprehensive review will cover the underlying mechanisms, methods of assessment, prognostic implications, and potential therapies for the no-reflow phenomenon. This article is part of a Special Issue entitled "Coronary Blood Flow".

Acute and Subacute Triggers of Cardiovascular Events.

Inability to predict short-term cardiovascular (CV) events and take immediate preemptive actions has long been the Achilles heel of cardiology. However, certain triggers of these events have come to light. Although these triggers are nonspecific and are part of normal life, studying their temporal relationship with the onset of CV events provides an opportunity to alert high-risk atherosclerotic patients who may be most vulnerable to such triggers, the "vulnerable patient". Herein, we review the literature and shed light on the epidemiology and underlying pathophysiology of different triggers. We describe that certain adrenergic triggers can precipitate a CV event within minutes or hours; whereas triggers that elicit an immune or inflammatory response such as infections may tip an asymptomatic "vulnerable patient" to become symptomatic days and weeks later. In conclusion, healthcare providers should counsel high-risk CV patients (e.g., in secondary prevention clinics or those with coronary artery Calcium >75th percentile) on the topic, advise them to avoid such triggers, take protective measures once exposed, and seek emergency care immediately after becoming symptomatic after such triggers. Furthermore, clinical trials targeting triggers (prevention or intervention) are needed.

Thrombolysis After Protamine Reversal of Heparin for Acute Ischemic Stroke After Cardiac Catheterization: Case Report and Literature Review.

BACKGROUND: Patients with an acute ischemic stroke (AIS) following cardiac catheterization (CC) generally do not receive intravenous thrombolysis [intravenous tissue plasminogen activator (IV-tPA)] as it is contraindicated due to the coagulopathy related to the heparin used during the procedure. We report a case of AIS successfully treated with IV thrombolysis following protamine reversal of heparin effect. CASE REPORT: An 87-year-old man with diabetes mellitus, hypertension, neurofibromatosis, and hyperlipidemia underwent elective transradial CC following an abnormal stress test. He had 2 drug-eluting stents for severe stenosis of mid-circumflex and right coronary arteries and received heparin 13,000 IU during procedure. He developed acute left hemiparesis with initial NIH stroke scale (NIHSS) of 4. Computed tomographic scan of the brain and computed tomographic angiogram of head and neck were unremarkable. Bedside activated clotting time was 181. Protamine 40 mg was administered and 30 minutes later, the activated clotting time level was normalized. IV-tPA was administered at 4 hours 25 minutes from his last known well. Within 15 minutes, his NIHSS was 0. Magnetic resonance imaging of brain showed no acute infarction 24 hours after stroke. CONCLUSIONS: There are limited reports of protamine reversal of heparin before IV-tPA administration. To our knowledge, there are only 6 AIS cases including ours. Three cases received 0.6 mg/kg of tPA dose. All have favorable outcomes and no intracranial hemorrhage was reported. Protamine reversal of heparin for AIS after CC seems to be safe. Further studies are needed to confirm the therapeutic safety and efficacy of this strategy.

Relation of Total and Cardiovascular Death Rates to Climate System, Temperature, Barometric Pressure, and Respiratory Infection.

A distinct seasonal pattern in total and cardiovascular death rates has been reported. The factors contributing to this pattern have not been fully explored. Seven locations (average total population 71,354,000) were selected where data were available including relatively warm, cold, and moderate temperatures. Over the period 2004 to 2009, there were 2,526,123 all-cause deaths, 838,264 circulatory deaths, 255,273 coronary heart disease deaths, and 135,801 ST-elevation myocardial infarction (STEMI) deaths. We used time series and multivariate regression modeling to explore the association between death rates and climatic factors (temperature, dew point, precipitation, barometric pressure), influenza levels, air pollution levels, hours of daylight, and day of week. Average seasonal patterns for all-cause and cardiovascular deaths were very similar across the 7 locations despite differences in climate. After adjusting for multiple covariates and potential confounders, there was a 0.49% increase in all-cause death rate for every 1°C decrease. In general, all-cause, circulatory, coronary heart disease and STEMI death rates increased linearly with decreasing temperatures. The temperature effect varied by location, including temperature's linear slope, cubic fit, positional shift on the temperature axis, and the presence of circulatory death increases in locally hot temperatures. The variable effect of temperature by location suggests that people acclimatize to local temperature cycles. All-cause and circulatory death rates also demonstrated sizable associations with influenza levels, dew point temperature, and barometric pressure. A greater understanding of how climate, temperature, and barometric pressure influence cardiovascular responses would enhance our understanding of circulatory and STEMI deaths.

Super Bowl outcome's association with cardiovascular death.

BACKGROUND: A previous analysis from Los Angeles showed that death rates increased among hometown fans after losing the Super Bowl in 1980 and decreased after a win in 1984. Data are unavailable in the era of drug-eluting stents, dual antiplatelet therapy, statins, and modern medical therapy. METHODS: Two high drama and intense Super Bowls were analyzed: NYC beat New England (Massachusetts) in 2008 and Pittsburgh defeated Arizona in 2009. Daily death certificate data were obtained. The case period included eight consecutive days beginning Super Bowl day. The control period included eight consecutive days beginning Super Bowl day in non-case period Super Bowls from 2005 to 2009. RESULTS: After Massachusetts' defeat, circulatory deaths increased by 20 % (p = 0.0004) and ischemic heart disease deaths increased by 24 % (p = 0.01) in Massachusetts. After Pittsburgh's victory circulatory deaths decreased by 25 % (p = 0.046), ischemic heart disease deaths decreased by 31 % (p = 0.03), and myocardial infarction deaths decreased by 46 % (p = 0.01) in Pittsburgh. Cardiovascular death rates did not change in Arizona (all p > 0.19). Massachusetts and Pittsburgh show stronger support for their home teams compared with Arizona. CONCLUSIONS: A Super Bowl with high drama/intensity can be associated with changes in cardiovascular death rates among a fan base with a strong attachment to the team even in the contemporary era. An increase in death rates can be associated with a loss and a decrease in death rates can be associated with a win.

Phosphodiesterase type 5 inhibitors improve endothelial function and may benefit cardiovascular conditions.

The effects of phosphodiesterase type 5 inhibitors on vasodilation mediated via nitric oxide-cyclic guanosine monophosphate are well described. Less is known about other mechanisms through which phosphodiesterase type 5 inhibitors benefit endothelial function, including normalization of serum biomarkers, increased levels of endothelial progenitor cells, ischemia-reperfusion protection mechanisms, and other actions specific to patients with diabetes. These various mechanisms are reviewed. Their impact on several cardiovascular diseases, including erectile dysfunction, pulmonary hypertension, heart failure, high-altitude pulmonary edema, Raynaud's phenomenon, coronary artery disease, diabetes, and atherosclerosis, is presented.

Impella-assisted balloon aortic valvuloplasty.

The Impella LP 2.5 left ventricular assist device (Abiomed) is safe and effective for assisting high-risk percutaneous interventions. A 77-year-old woman with severe aortic stenosis, severe coronary artery disease, an ejection fraction of 20%, severe peripheral vascular disease, and other comorbidities presented to a private, tertiary referral hospital with shortness of breath that had been worsening over 2 weeks. The patient underwent a successful, Impella-assisted balloon aortic valvuloplasty (BAV) without complications. Impella support may be considered during BAV in high-risk patients with contraindications for a TandemHeart device (CardiacAssist, Inc.).

Treating peripheral arterial disease percutaneously with atherectomy.

PURPOSE: To determine clinical outcomes of patients who underwent percutaneous revascularization (PR) with multiple devices. METHODS: PR cases at a private, tertiary referral hospital were reviewed retrospectively. Limb salvage and patency rates were calculated by the Kaplan Meier method. Historical and procedural factors were analyzed by multivariate Cox proportional hazards models. RESULTS: We identified 66 patients and 87 limbs with 261 lesions, including 38 patients with critical limb ischemia (CLI) (51 limbs, 171 lesions). PR incorporated multiple devices (2.0 ± 1.2 devices/lesion, 2.4 ± 1.6 devices/procedure), including balloon angioplasty (57%), excisional atherectomy (54%), orbital atherectomy (44%), and stenting (13%). Last imaged patency was at 18 ± 13 months and last clinical follow-up was 22 ± 12 months. Thirty-five of 87 limbs had ≥1 repeat PR. In 51 limbs with CLI, limb salvage was 75% at 3 years. Independent predictors of amputation were higher creatinine (P=.01; hazard ratio [HR], 1.4), Rutherford category (P=.03; HR, 3.5), and history of coronary artery bypass graft (CABG) (P=.03; HR, 8.9). Overall patency remained 75% through 3 years. Loss of patency or primary patency (patency without repeat PR) was predicted by higher creatinine, Rutherford category, chronic total occlusion, history of CABG, female gender, current and past smoking. Use of excisional atherectomy maintained overall patency (P=.01; HR, 0.36). CONCLUSIONS: An aggressive approach to PR with frequent use of atherectomy resulted in high rates of limb salvage and patency. Smoking cessation and excisional atherectomy may improve patency rates.

Cardiac uses of phosphodiesterase-5 inhibitors.

Phosphodiesterase-5 inhibitors (PDE5Is) improve erectile function by enhancing nitric oxide availability in the penis and its supplying vasculature, resulting in vasodilation and increased blood flow. PDE5Is might benefit cardiovascular diseases because phosphodiesterase-5 is also located elsewhere in the body, including the pulmonary and systemic vasculature and in hypertrophied myocardium. PDE5Is are approved for pulmonary arterial hypertension, given that they improved several hemodynamic and clinical parameters in large randomized trials. Initial evidence suggests that PDE5Is benefit patients with congestive heart failure and secondary pulmonary hypertension. PDE5Is seem to improve hemodynamic and clinical parameters in patients with high-altitude pulmonary edema (HAPE) and high-altitude pulmonary hypertension. In climbers with prior episodes of HAPE, PDE5Is prevented HAPE in 2 small randomized trials. In small randomized trials of PDE5Is, patients with Raynaud's phenomenon demonstrated improved blood flow, fewer symptoms and frequency of attacks, and resolution of digital ulcers. In addition to enhancing vasodilation, PDE5Is seem to protect the myocardium through complex pathways that involve nitric oxide, cyclic guanosine monophosphate, protein kinase G, extracellular-signal-regulated kinase, B-cell lymphoma protein-2, and Rho kinase inhibition. In animal models of acute myocardial infarction, PDE5Is consistently reduced infarct size indicating cardioprotection and PDE5Is also promote reverse remodeling and reduce myocardial apoptosis, fibrosis, and hypertrophy. PDE5Is might also benefit patients with treatment-resistant hypertension, preeclampsia, or peripheral arterial disease. This review presents the pathophysiology and trial data with regard to the use of PDE5Is for cardiac diseases.

Treating Refractory Cardiogenic Shock With the TandemHeart and Impella Devices: A Single Center Experience.

BACKGROUND: Patients with cardiogenic shock (CS) are routinely treated with intra-aortic balloon pumps (IABPs). The utility of 2 new percutaneous left ventricular assist devices (PLVADs), the Impella and TandemHeart, is unknown. The objective of this study was to describe the use of PLVADs for patients with CS at our institution. METHODS: All cases involving PLVADs in patients with CS between between January 1, 2008 and June 30, 2010 at a private, tertiary referral hospital were reviewed retrospectively. RESULTS: All 76 cases were identified (50 IABP only, 7 Impella, 19 TandemHeart). Most Impella (5/7) and TandemHeart (10/19) patients were initially treated with an IABP before "upgrading" for increased hemodynamic support. All 76 devices (100%) were initiated successfully. Percutaneous revascularization was attempted in 63 patients with angiographic success in 57 (90%). The incidences of major complications were similar between groups, except bleeding occurred less frequently with the IABP. Mean ejection fraction on presentation was 30.4±16.5% and increased by a mean of 6.6±11.4% (P < 0.001). With the institutional approach of treating patients with CS initially with vasopressors and IABPs, then upgrading to an Impella or TandemHeart device for patients refractory to IABP therapy, the overall mortality rate was 40%. CONCLUSION: The Impella and TandemHeart devices can be initiated successfully in patients with CS, are associated with high rates of angiographic success during high risk percutaneous interventions and may benefit the myocardium during myocardial infarction. Randomized trials are warranted investigating use of the Impella and TandemHeart devices in patients with CS and in patients refractory to conventional IABP therapy.

Therapeutic hypothermia for acute myocardial infarction and cardiac arrest.

This report focuses on cardioprotection and describes the advantages and disadvantages of various methods of inducing therapeutic hypothermia (TH) with regard to neuroprotection and cardioprotection for patients with cardiac arrest and ST-segment elevation myocardial infarction (STEMI). TH is recommended in cardiac arrest guidelines. For patients resuscitated after out-of-hospital cardiac arrest, improvements in survival and neurologic outcomes were observed with relatively slow induction of TH. More rapid induction of TH in patients with cardiac arrest might have a mild to modest incremental impact on neurologic outcomes. TH drastically reduces infarct size in animal models, but achievement of target temperature before reperfusion is essential. Rapid initiation of TH in patients with STEMI is challenging but attainable, and marked infarct size reductions are possible. To induce TH, a variety of devices have recently been developed that require additional study. Of particular interest is transcoronary induction of TH using a catheter or wire lumen, which enables hypothermic reperfusion in the absence of total-body hypothermia. At present, the main methods of inducing and maintaining TH are surface cooling, endovascular heat-exchange catheters, and intravenous infusion of cold fluids. Surface cooling or endovascular catheters may be sufficient for induction of TH in patients resuscitated after out-of-hospital cardiac arrest. For patients with STEMI, intravenous infusion of cold fluids achieves target temperature very rapidly but might worsen left ventricular function. More widespread use of TH would improve survival and quality of life for patients with out-of-hospital cardiac arrest; larger studies with more rapid induction of TH are needed in the STEMI population.

High-risk percutaneous coronary intervention with the TandemHeart and Impella devices: a single-center experience.

BACKGROUND: Intra-aortic balloon pumps (IABPs) are indicated during high-risk percutaneous coronary intervention (HR-PCI) to reduce major procedural complications. The clinical utility of the newer Impella and TandemHeart devices is not clear. This study determined the baseline characteristics, hemodynamics, and outcomes of patients treated with prophylactic percutaneous left ventricular assist devices (PLVADs) during HR-PCI. METHODS: A retrospective analysis at a private, tertiary referral hospital was conducted of all cases involving prophylactic PLVAD during HR-PCI between January 1, 2008 and June 30, 2010. General practice in this institution involves a tiered approach to PLVAD whereby patients with the least, intermediate, and highest risk of left ventricular failure are treated with an IABP, Impella, or TandemHeart, respectively. RESULTS: Fifty cases were identified (5 IABP, 13 Impella, 32 TandemHeart). Mean ejection fraction was 31 ± 17%. All devices (100%) were initiated successfully. Angiographic success was achieved in 96% (80% IABP, 100% Impella, 97% TandemHeart). Of the 38 patients not in cardiogenic shock, death occurred in 1 (2.6%), recurrent ischemia in 3 (8%), and stroke in 0%. Shortly after device removal, systolic blood pressure (mean increase, +5 ± 22 mmHg) and ejection fraction (mean increase, +7.4 ± 11%; p = 0.0006) increased in all 3 groups, suggesting a beneficial effect on the myocardium. CONCLUSIONS: In patients undergoing HR-PCI with Impella and TandemHeart support, angiographic success was high and major complication rates were low. A tiered approach where patients with the least, intermediate, and highest risk of left ventricular failure are treated with an IABP, Impella, or Tandem- Heart, respectively, theoretically maximizes appropriate hemodynamic support and minimizes complications. Further studies are warranted.

Rotational Atherectomy and Stent Implantation for Calcified Left Main Lesions.

BACKGROUND: Left main coronary artery (LMCA) bifurcation and heavily calcified lesions are common and challenging to treat percutaneously. Rotational atherectomy (RA) may be beneficial in this setting to facilitate stent placement though direct supporting evidence is lacking. This study sought to analyze patients who underwent RA of the LMCA. METHODS: Consecutive cases involving RA of the LMCA between 1/1/2004 and 12/31/2009 at a private, tertiary referral hospital were reviewed retrospectively. Medical records, angiograms and clinically driven follow-up were reviewed. RESULTS: Thirty-one cases were identified (20 protected, 11 unprotected), including 23 with stent implantation (21 drug-eluting, 2 bare metal). All 31 lesions had moderate to severe calcification, 84% involved the distal segment. Mean burr-to-vessel ratio was 0.43. Overall angiographic success was 90% (28/31) and was higher with a drug-eluting stent versus no stent (100% vs. 62%; P = 0.0153). In-hospital major adverse cardiovascular events (MACE) occurred in 1 patient (3%). Mid-term MACE occurred in 6 patients (26%) and tended to occur less frequently in patients with protected LMCAs (P = 0.0697). At final follow-up, patients were more likely to be alive and free from angina with a protected LMCA (94% vs. 57% unprotected; P = 0.0564) and with a drug-eluting stent (89% vs. 50% with no stent; P = 0.0281). CONCLUSIONS: RA of the LMCA to facilitate stent implantation appears to be safe and effective with favorable mid-term outcomes. In the setting of severe calcification and distal LMCA involvement RA and drug-eluting stent implantation should be considered.

Rotational atherectomy in the drug-eluting stent era: a single-center experience.

BACKGROUND: In heavily calcified lesions, rotational atherectomy (RA) improves procedural success and facilitates stent deployment. Reports on RA in the drug-eluting stent (DES) era are limited. The objective of this study was to determine the presenting characteristics, procedural and in-hospital clinical outcomes of patients who underwent RA at our institution in the DES era. METHODS: Consecutive cases involving RA between January 1, 2004 and December 31, 2009 at a private, tertiary referral hospital were reviewed retrospectively. RESULTS: A total of 158 patients (236 lesions) who underwent RA are described, including 112 patients (158 lesions) with subsequent DES implantation, 19 patients (28 lesions) with bare-metal stent (BMS) implantation, and 27 patients (50 lesions) with no stent. RA was utilized to modify heavily calcified plaque (84%), as bail-out therapy (16%), to preserve the patency of sidebranches (25%) and as debulking therapy for chronic total occlusion (13 lesions) and in-stent restenosis (7 lesions). DES were not placed in 46 patients (23%) due to reference vessel diameter < 2.25 or > 3.75 mm, inability to deliver DES, or desire to avert clopidogrel therapy. Angiographic and procedural success rates were significantly higher in the DES and BMS groups compared with the no stent group (angiographic success: 99.1% for DES versus 95% for BMS versus 63% for no stent; p < 0.05; procedural success: 96.4% for DES versus 95% for BMS versus 63% for no stent; p < 0.05). CONCLUSION: In the DES era, RA remains utilized primarily to modify heavily calcified plaque. In unadjusted analysis, procedural success appears high with subsequent stent placement (DES or BMS) versus RA alone. However, 1 in 4 are not candidates for stent placement, and the lower procedural success rate in this population should be considered prior to embarking on RA.