A case of covered stent failure in sealing up a coronary perforation potentially related to intravascular lithotripsy treatment: insights from optical coherence tomography.

Background: Intravascular lithotripsy (IVL) is a new modality in treatment of calcified coronary lesions which improves procedural outcomes. Coronary perforation is an extremely uncommon but potentially catastrophic complication of percutaneous coronary intervention (PCI) and IVL therapy. Case summary: We report a case of an elective PCI to a calcified left anterior descending (LAD) and diagonal bifurcation lesion in a 65-year-old man. LAD was treated with two stents. Despite high pressure non-compliant balloon inflation, a focal area of under-expansion remained. IVL successfully treated the under-expansion but was complicated with a large coronary perforation. The perforation was successfully sealed with a PK-PAPYRUS covered stent sacrificing the diagonal branch. Patient remained stable until 3 hours later when he developed tamponade requiring urgent pericardial drainage. Repeat angiography demonstrated recanalization of the diagonal branch and ongoing contrast extravasation along its course. Optical coherence tomography intracoronary imaging was used to delineate the mechanism of ongoing bleeding. This demonstrated an interrupted elastic membrane of the covered stent, potentially caused by underlying fractured calcium. Therefore, a second overlying PAPYRUS stent was deployed which satisfactorily sealed the perforation. Discussion: IVL is an emerging less invasive treatment for calcified coronary stenosis but could be associated with drastic complications. This case highlights the importance of awareness of IVL-related coronary perforation and the potential limitation of new generation thinner-wall covered stents. Intracoronary imaging plays an important role in identifying mechanisms of stent failure, tailoring treatment, and optimizing outcomes.

Early Australian experience with intravascular lithotripsy treatment of severe calcific coronary stenosis: IVL in acute/chronic coronary syndromes.

Aims: Calcified coronary stenoses are a serious impediment to optimal stent expansion and can lead to stent failure and catastrophic adverse outcomes. We hereby present early Australian experience with intravascular lithotripsy for the treatment of calcific lesions in acute and chronic coronary syndromes. Methods and results: This was a single-centre retrospective study of all patients treated with intravascular lithotripsy (IVL) between October 2019 and June 2021. Patient demographics, procedural variables, and treatment safety/efficacy outcomes were evaluated. During this period, there were 40 patients and 41 coronary lesions with IVL-assisted percutaneous coronary intervention (PCI) (70% male; mean age 72.8±9.5 years). Indications for PCI were acute coronary syndromes in 25 patients (62.5%), and stable angina in 15 patients (37.5%). Upfront IVL usage occurred in 5% of cases with the rest being bailout procedures due to suboptimal initial balloon predilatation or stent underexpansion. Angiographic success (<20% residual stenosis) occurred in 37 cases (92.5%), with mean residual stenosis of 8.25%±8.5%. Two patients experienced procedural complications (5%). Conclusions: IVL appears to be a safe and effective modality in modifying coronary calcium to achieve optimal stent expansion in real-world practice. This device obviates the need for more complex lesion preparation strategies such as rotational or orbital atherectomy.

The effects of short-term omission of daily medication on the pathophysiology of heart failure.

AIMS: Pharmacological therapies for heart failure (HF) aim to improve congestion, symptoms, and prognosis. Failing to take medication is a potential cause of worsening HF. Characterizing the effects of short-term medication omission could inform the development of better technologies and strategies to detect and interpret the reasons for worsening HF. We examined the effect of planned HF medication omission for 48 h on weight, echocardiograms, transthoracic bio-impedance, and plasma concentrations of NT-proBNP. METHODS AND RESULTS: Outpatients with stable HF and an LVEF <45% were assigned to take or omit their HF medication for 48 h in a randomized, crossover trial. Twenty patients (16 men, LVEF 32 ± 9%, median NT-proBNP 962 ng/L) were included. Compared with regular medication, omission led to an increase in NT-proBNP by 99% (from 962 to 1883 ng/L, P < 0.001), systolic blood pressure by 16% (from 131 to 152 mmHg, P < 0.001), and left atrial volume by 21% (from 69 to 80 mL, P = 0.001), and reductions in transthoracic bio-impedance by 10% (from 33 to 30 Σ, P = 0.001) and serum creatinine by 8% (from 135 to 118 µmol/L, P = 0.012). No significant changes in body weight, heart rate, or LVEF were observed. CONCLUSIONS: The characteristic pattern of response to short-term medication omission is of increasing congestion but, in contrast to the pattern reported for disease progression, with a rise in blood pressure and improved renal function. In stable HF, weight is not a sensitive marker of short-term diuretic omission.

Tachycardia-induced cardiomyopathy in pregnancy.

Heart failure in pregnancy is rare, but usually ascribed to peripartum cardiomyopathy in the absence of other possible diagnoses. However, heart failure can develop solely due to a tachycardia, so-called 'tachycardia-induced cardiomyopathy'. The incidence of tachycardia-induced cardiomyopathy in pregnancy is unknown, but it is a treatable and potentially reversible cause of heart failure. Clinically, tachycardia-induced cardiomyopathy during pregnancy might present in a similar manner, but its management has to be individualized according to the arrhythmic substrate and usually involve multidisciplinary input from specialists in obstetrics, cardiac electrophysiology and heart failure.

Hydralazine and nitrates alone or combined for the management of chronic heart failure: A systematic review.

BACKGROUND: Hydralazine (H) and nitrates (Ns), when combined, reduced morbidity and mortality in some trials of chronic heart failure (CHF). It is unclear whether either agent used alone provides similar benefits. We aimed to evaluate the effects of H and/or N in patients with CHF. METHODS: A systematic review of randomised trials assessing the effects of H and N in CHF. For meta-analysis, only the endpoints of all-cause mortality and cardiovascular mortality were considered. RESULTS: In seven trials evaluating H&N in 2626 patients, combination therapy reduced all-cause mortality (OR 0.72; 95% CI 0.55-0.95; p=0.02), and cardiovascular mortality (OR 0.75; 95% CI 0.57-0.99; p=0.04) compared to placebo. However, when compared to angiotensin converting enzyme inhibitors (ACEIs), combination therapy was associated with higher all-cause mortality (OR 1.35; 95% CI 1.03-1.76; p=0.03), and cardiovascular mortality (OR 1.37; 95% CI 1.04-1.81; p=0.03). For N alone, ten trials including 375 patients reported all-cause mortality and showed a trend to harm (13 deaths in those assigned to nitrates and 7 to placebo; OR 2.13; 95% CI 0.88-5.13; p=0.09). For H alone, three trials showed no difference in all-cause mortality compared to placebo (OR 0.96; 95% CI 0.37-2.47; p=0.93), and two trials suggested inferiority to ACEI (OR 2.28; 95% CI 1.03-5.04; p=0.04). CONCLUSIONS: Compared to placebo, H&N reduces mortality in patients with CHF. Whether race or background therapy influences benefit is uncertain, but on direct comparison H&N appears inferior to ACEI. There is little evidence to support the use of either drug alone in CHF.

The utility of novel non-invasive technologies for remote hemodynamic monitoring in chronic heart failure.

Monitoring a patient's hemodynamic status may be a revolutionary way to aid a 'health maintenance' strategy in which the physician strives to therapeutically keep the patient in an ideal hemodynamic range. Currently, home telemonitoring employs a 'crisis-prevention' approach. This strategy is still based on easily acquired measures such as heart rate, weight and blood pressure--measurements that are useful to help implement guideline-directed therapy but provide little information about impending decompensation or the risk of hospitalisation. Current systems provide limited information to personalize and adapt medication therapy for heart failure. Several innovative technologies that can remotely monitor estimates of cardiovascular hemodynamics, such as cardiac index, systemic vascular resistance, augmentation index and added heart sounds may enable earlier detection of heart failure decompensation. This editorial presents an overview of the innovative technologies that are available for non-invasive hemodynamic monitoring and maybe adapted for home telemonitoring for chronic heart failure.

Acute blue finger: a diagnostic challenge.

The management of the acute blue finger is controversial with many regarding it as a benign condition. However, we would argue that it should always be considered as an emergency. We present a challenging case of a 43-year-old woman who presented with a 1-week history of sudden onset blue discolouration of the left fifth digit, and a 6-week history of episodic joint problems. Examination showed bilateral normal radial and ulnar pulses. Following blood investigations, an initial working diagnosis of early rheumatoid arthritis with associated Raynaud's phenomenon was made. Also, infective endocarditis was considered due to temporary misleading physical signs. Later, CT angiography of the left upper limb arteries showed a significant proximal left subclavian stenosis. Subsequently, a diagnosis of the left subclavian arteritis associated with digit ischaemia from embolic debris was made and the patient underwent a left subclavian angioplasty. However, delayed management resulted in a necrotic digit, which was left to autoamputate.