Recurrent minor strokes/TIA with a right to left shunt.

A patient came to our institution for evaluation and closure of suspected patent foramen ovale actively manifesting as cerebrovascular accident. Through further studies, we found the presence of a pulmonary arteriovenous fistula, which was subsequently and successfully closed through non-invasive percutaneous selective segmental pulmonary artery embolisation.

The safety and efficacy of peripheral vascular procedures performed in the outpatient setting.

OBJECTIVES: This study sought to evaluate the safety and efficacy of peripheral vascular interventions performed in a private, outpatient catheterization laboratory. BACKGROUND: Peripheral vascular interventions have been traditionally performed in the inpatient setting. However, there has been a recent shift away from hospital-based vascular interventions toward outpatient-based procedures. Data are scarce on the efficacy and safety of such procedures being performed in the outpatient setting. METHODS: We performed a retrospective chart review of the first 500 consecutive procedures that were performed at an outpatient catheterization laboratory from February 2012 through February 2013. We separated the procedures into arteriovenous fistula (AVF)-related procedures, peripheral arterial disease (PAD)-related procedures, and miscellaneous procedures. The primary endpoint was procedure success rate, defined as postintervention residual stenosis of <30% on angiography. The secondary endpoint was procedure-related adverse events. RESULTS: The success rate for AVF-related interventions was 90%, and 93% when including partially successful interventions. The success rate for PAD-related interventions was 82%, and 92% when including partially successful interventions. The procedure success rate for miscellaneous interventions was 89%. Five AVF-related procedures suffered an adverse event (1.49%). Two PAD-related procedures suffered an adverse event (1.3%), while no adverse events were noted among miscellaneous procedures. One patient required immediate postprocedure hospitalization due to iliac artery perforation. CONCLUSION: Peripheral vascular procedures performed in the outpatient setting are safe and effective. A comparison of outcomes between outpatient and inpatient facilities when performing similar peripheral vascular interventions is needed in order to determine whether a transition of further vascular procedures into an outpatient setting is justified.

Improved myocardial perfusion after transmyocardial laser revascularization in a patient with microvascular coronary artery disease.

We report the case of a 59-year-old woman who presented with symptoms of angina that was refractory to medical management. Although her cardiac catheterization revealed microvascular coronary artery disease, her symptoms were refractory to optimal medical management that included ranolazine. After undergoing transmyocardial revascularization, her myocardial ischemia completely resolved and her symptoms dramatically improved. This case suggests that combination of ranolazine and transmyocardial revascularization can be applied to patients with microvascular coronary artery disease.

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.

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.

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.

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 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.

Study to determine the clinical significance of HEmolysis During Orbital AtheRectomy (CLEAR study).

PURPOSE: To evaluate the incidence of clinically evident hemolysis associated with orbital atherectomy used to treat severe peripheral artery disease. METHODS: The observational CLEAR study enrolled 31 subjects (16 men; mean age 71 ± 10 years, range 44-92) with claudication (58.1%) or critical limb ischemia (38.7%) who underwent orbital atherectomy with the Diamondback 360 system at 4 US centers. The 42 lesions in 31 limbs were located in the superficial femoral (n = 19, 45.2%), popliteal (n = 8, 19.0%), and tibial arteries (n = 15, 35.8%). The majority of lesions (34, 81.0%) were de novo; moderate or severe calcification was identified in 90.5% of cases. Lesion and procedural parameters were analyzed at a core laboratory. Blood samples were collected during and post procedure and analyzed for markers of hemolysis. The primary endpoint was the occurrence of clinically significant hemolysis. The secondary endpoints included the occurrence of any clinical symptoms/signs potentially related to hemolysis. Statistical analysis was performed to identify predictors for hemolysis. RESULTS: Laboratory evidence of hemolysis was seen in 11 (35.5%) subjects. No one met the clinical event criteria, and so the primary endpoint of the study was not reached. The secondary endpoints were hypertensive crisis (1, 3.2%) and transient hemoglobinuria (3, 9.7%). Lower glomerular filtration rates, calcified plaque, long atherectomy runs, and solid crown selection were independent predictors of hemolysis. CONCLUSION: There was no clinically significant hemolysis after orbital atherectomy. The results of this study will enable users to predict conditions that predispose to high levels of red cell hemolysis following orbital atherectomy and to take appropriate measures to limit its occurrence.

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.

Review of vascular closure devices.

BACKGROUND: Vascular access-site complications are an important cause of morbidity following catheterization procedures. Manual compression is the "gold standard" in achieving hemostasis of an arteriotomy site; however, manual compression is limited by the need to interrupt anticoagulation, prolonged bed rest, patient discomfort and time demands for healthcare providers. Vascular closure devices (VCDs) improve patient comfort, free medical staff resources and shorten the time needed for hemostasis, ambulation and discharge. However, the safety of VCDs remains in question and they may increase the risks of infection and leg ischemia. Compared with manual compression, the rate of major complications appears to be increased with VasoSeal, decreased with Angio-Seal and decreased in diagnostic cases with Perclose. The safety of VCDs cannot be assumed due to "class effect," and nearly all individual trials are underpowered to detect differences in complication rates, so the safety of other individual VCDs is unclear. In the absence of puncture site-related risk factors, VCDs as a whole appear to have little influence on complication rates, and patients at high baseline risk for bleeding due to clinical factors may benefit from these devices. Screening with femoral angiography prior to VCD placement and avoidance of VCDs in the presence of puncture site-related risk factors might reduce the risk of vascular complications. This review describes the mechanism, efficacy and safety of VCDs including hemostasis pads, the FemoStop, Clamp Ease, Mynx, Duett, FISH, Boomerang, ExoSeal, Starclose, VasoSeal, Angio-Seal and Perclose devices.

When and why do heart attacks occur? Cardiovascular triggers and their potential role.

Coronary heart disease affects 7.6% of the population in the United States, where > 900,000 myocardial infarctions (MIs) occur annually. Approximately half of all MIs have an identifiable clinical trigger. Myocardial ischemia, MI, sudden cardiac death, and thrombotic stroke each occur with circadian variation and peak after waking in the morning. In addition, physical exertion and mental stress are common precipitants of MI. Waking in the morning, physical exertion, and mental stress influence a number of physiologic parameters, including blood pressure, heart rate, plasma epinephrine levels, coronary blood flow, platelet aggregability, and endothelial function. Upregulation of sympathetic output and catecholamines increase myocardial oxygen demand and can decrease myocardial oxygen supply and promote thrombosis. Ischemia ensues when myocardial oxygen demand exceeds supply. Increases in blood pressure and ventricular contractility increase intravascular shear stress and may cause vulnerable atherosclerotic plaques to rupture, forming a nidus for thrombosis that can precipitate MI. Numerous clinical triggers of MI have been identified, including blizzards, the Christmas and New Year's holidays, experiencing an earthquake, the threat of violence, job strain, Mondays for the working population, sexual activity, overeating, smoking cigarettes, smoking marijuana, using cocaine, and particulate air pollution. Avoiding clinical triggers or participating in therapies that prevent clinical triggers from precipitating cardiac events could potentially postpone clinical events by several years and improve cardiovascular morbidity and mortality. Direct or indirect evidence suggests that the risk of triggered MIs is reduced with ß-blockers, aspirin, statins, stress management, and transcendental meditation.

Use of a percutaneous left ventricular assist device for high-risk cardiac interventions and cardiogenic shock.

OBJECTIVE: We sought to describe the use of the TandemHeart percutaneous left ventricular assist device (PVAD) in a group of high-risk patients undergoing complex cardiovascular procedures. BACKGROUND: There is a substantial risk of acute decompensation and death in patients with cardiogenic shock or a reduced cardiac reserve undergoing high-risk cardiovascular interventions. The TandemHeart PVAD provides near-total hemodynamic support in this setting. METHODS: Thirty-seven high-risk patients underwent placement of the TandemHeart PVAD during 38 separate procedures between April 2007 and April 2009. PVAD insertion was considered emergent if a patient was not expected to survive more than 6 hours without PVAD support. Technical success was defined as successful initiation of the PVAD and completion of the intended interventional procedure. RESULTS: All 37 patients were in cardiogenic shock or undergoing complex coronary and valvular interventions with a high probability of hemodynamic collapse. The mean (+/- standard deviation) patient age was 73 +/- 14 years; 97% were in either NYHA class III-IV heart failure or cardiogenic shock; and the mean EuroSCORE was 11 +/- 3.4. Indications for ventricular assist device placement included critical aortic stenosis (n = 8), severe left main coronary stenosis (n = 18), severe multivessel coronary stenosis (n = 19) and severe cardiomyopathy (n = 23). Four patients were being managed for fulminant myocarditis, ventricular free-wall rupture, flail mitral valve or severe paravalvular leak. Despite their critical status and frequent (82%) need for post-procedure blood transfusion, this complex and high-risk patient population tolerated PVAD-supported intervention well and technical success was achieved in all patients. Seventy-one percent of patients survived to hospital discharge with improved functional status. Most deaths occurred in patients not expected to survive due to their moribund status and multiorgan failure. CONCLUSION: This experience demonstrates the utility and effectiveness of TandemHeart PVAD support in patients with advanced disease, critical clinical status and limited therapeutic options.

Peripheral chronic total occlusions treated with subintimal angioplasty and a true lumen re-entry device.

OBJECTIVE: We sought to verify how effective the Pioneer catheter (Medtronic, Inc., Minneapolis, Minnesota) is in overcoming the complexity of re-entry during subintimal angioplasty and provide a case series describing the technique. BACKGROUND: Subintimal angioplasty is effective in treating peripheral chronic total occlusions (CTO). However, this technique is often limited by the inability to re-enter the true lumen after subintimal crossing of the occluded segment. The Pioneer catheter was the first device to address this difficulty associated with subintimal angioplasty. METHODS: A retrospective review of 21 consecutive cases of peripheral CTOs requiring use of the Pioneer catheter were reviewed. The patients' demographics, indications for the procedure, location and extent of occlusion, lesion characteristics, technique, procedural success and complications were recorded. RESULTS: Twenty of 21 cases were procedurally successful (defined as < or = 30% post-procedure stenosis), for a rate of 95%. The most commonly occluded vessels were the common iliac artery and the superficial femoral artery. The average occlusion length was 107 mm (standard deviation = 87) with a range of 23-300 mm. Both antegrade and retrograde approaches were successful. There was only 1 complication in the study population. CONCLUSIONS: The Pioneer catheter is a re-entry device that is versatile and improves success rates of subintimal angioplasty, which may lead to improvement in the care of patients with CTOs. The cases series demonstrates the use of the Pioneer catheter in treating CTOs.

Use of high-frequency vibrational energy in the treatment of peripheral chronic total occlusions.

PURPOSE: Peripheral chronic total occlusions (CTO) are challenging lesions to treat. The CROSSER system (FlowCardia, Sunnyvale, CA) uses high-frequency low-amplitude vibrations to break through the cap of the CTO and had been shown to be successful in coronary CTOs. This is a case series demonstrating the use of the CROSSER system with peripheral CTOs. CASE REPORTS: Three patients with peripheral CTO of various lengths, locations, and complexities were treated with the CROSSER system. The device allowed placement of a guidewire across the area of occlusion, thus permitting further percutaneous intervention. The CROSSER system was effective with both ostial and distal lesions, tapered and abrupt lesion morphologies, and was used from both an ipsilateral (antegrade access) and contralateral approach. CONCLUSION: The CROSSER system is an additional device that may be used to treat peripheral CTOs.

Complication rate of diagnostic carotid angiography performed by interventional cardiologists.

OBJECTIVE: The aim of this study was to evaluate the complication rate of diagnostic carotid angiography performed by interventional cardiologists and compare it to previously published data. BACKGROUND: Percutaneous treatment for carotid artery stenosis is increasingly being performed. Previously published data describes the complication rate of diagnostic carotid angiography performed by radiologists and vascular surgeons, yet the information regarding interventional cardiologists is sparse. Currently in the United States, interventional cardiologists perform a great deal of diagnostic carotid angiograms. METHODS: A retrospective analysis was done on 333 patients who underwent diagnostic carotid angiography at a single medical center from January 2000 to February 2007. Medical records were reviewed for cardiovascular risk factors, indications for the procedure, angiography technique and in-hospital complications. Complications were categorized as neurological and non-neurological. Neurological complications were further grouped into transient (<7 days) or permanent. Non-neurological complications were grouped into major (requiring additional treatment) or minor. RESULTS: Three hundred and thirty-three patients underwent 347 diagnostic carotid angiograms. Twelve (3.5%) complications occurred in 12 patients. No cerebral vascular accidents occurred and only one (0.3%) transient ischemic attack occurred. Two patients required blood transfusions following the index procedure yielding a major non-neurological complication rate of 0.6%. Review of the literature revealed a transient neurological complication rate from 0 to 2.4% and a major non-neurological complication rate of 0.26-4.3%. CONCLUSIONS: Neurological and non-neurological complication rates for carotid angiograms performed by interventional cardiologists are low and compare well with the literature. Interventional cardiologists can safely perform diagnostic carotid angiography with low complication rates.

AngioJet Rheolytic thrombectomy during rescue PCI for failed thrombolysis: a single-center experience.

BACKGROUND: Previous studies have shown the efficacy of AngioJet Rheolytic Thrombectomy (RT) in reducing thrombus burden and improving coronary flow in acute myocardial infarction (MI). No study has specifically evaluated the use of AngioJet RT in patients undergoing rescue percutaneous coronary intervention (PCI) for failed thrombolysis, a setting that may be particularly beneficial given the extensive thrombus burden. The objective of this study was to evaluate the efficacy and safety of AngioJet RT during rescue PCI for failed thrombolysis. METHODS: 214 consecutive patients were transferred to Good Samaritan Hospital to undergo rescue PCI for failed thrombolysis from January 2000 to October 2004. From this cohort, 32 patients (age 57 +/- 9, 30% male) undergoing AngioJet RT for rescue PCI (RT group) were identified and matched by initial thrombolysis in MI (TIMI) flow and infarct related artery (IRA) location to 32 patients (age 60 +/- 12, 24% male) undergoing rescue PCI without AngioJet RT (Control group). TIMI frame count and TIMI thrombus grade were assessed at initial and final angiography. Angiographic success (TIMI 3 flow, < 50% residual stenosis) and in-hospital clinical events, including bleeding complications and major adverse cardiac events (MACE) such as death, recurrent MI, target vessel revascularization and emergent bypass surgery were evaluated. Clinical success was defined as angiographic success in the absence of MACE. RESULTS: Baseline clinical characteristics were similar in both groups, except patients undergoing AngioJet RT were more likely to be males and less likely to be intubated on transfer. 30/32 (94%) patients achieved a TIMI thrombus grade of 0 in the RT group, compared to 22/32 (69%) in the Control group. Final IRA TIMI frame count was similar in the RT compared to the Control group (33 +/- 21 vs. 38 +/- 23, p NS, respectively). The occurrence of no reflow was significantly lower in the RT compared to the Control group (13% vs. 56%, p < 0.001, respectively). There was a trend for higher angiographic success in the RT compared to the control group (93% vs. 78%, p = 0.07, respectively). Clinical success was higher in the RT compared to the Control group (91% vs. 71%, p = 0.05, respectively). There were no differences in bleeding complications or MACE between the groups. CONCLUSION: AngioJet RT in high-risk patients undergoing rescue PCI for failed thrombolysis is safe and more effective in decreasing thrombus burden and preventing no reflow than conventional PCI.

Rescue percutaneous coronary intervention for failed thrombolysis.

BACKGROUND: Previous studies of rescue percutaneous coronary intervention (PCI) for failed thrombolysis yielded conflicting results. In the current era of newer thrombolytic agents, coronary stents, glycoprotein IIb/IIIa inhibitors, and aggressive hemodynamic support, the outcome of this high-risk patient group has not been characterized. METHODS: From January 2000 to October 2004, 214 consecutive patients were transferred and underwent emergent coronary angiography following failed thrombolysis. One hundred and fifty five (72%) underwent immediate PCI, 23 (11%) underwent delayed PCI, and 36 (17%) received surgical revascularization or medical therapy. Medical records and angiograms for the entire PCI cohort (n=178) were reviewed for in-hospital events including bleeding complications, stroke, recurrent ischemia or myocardial infarction (MI), target vessel revascularization (TVR), and death. RESULTS: Time from symptom onset to thrombolysis (mean +/- standard deviation) was 5.6 +/- 11.9 hr, and time from thrombolysis to angiography was 7.0 +/- 5.5 hr. The study cohort was critically ill, with 9.6% experiencing cardiac arrest, 21% in cardiogenic shock, and 12% intubated prior to transfer. Coronary stents were placed in 88%, Rheolytic thrombectomy was used in 21%, an intraaortic balloon pump was placed in 17%, and a glycoprotein IIb/IIIa inhibitor was administered in 92%. Patients receiving delayed PCI had higher TIMI 3 flow grade at initial angiography than those receiving immediate PCI (83% vs. 34%, respectively, P < 0.0001). Angiographic success was 90% for the entire PCI cohort, 89% for the immediate PCI group, and 100% for the delayed PCI group. Clinical success (angiographic success and freedom from major adverse cardiac events) was 85% for the entire PCI cohort, 83% for the immediate PCI group, and 100% for the delayed PCI group. Severe and moderate bleeding complications occurred in 7.3%, stroke in 1.7%, recurrent ischemia or MI in 7.3%, and TVR in 3.4%. Overall, in-hospital mortality for the entire PCI cohort was 3.4%. CONCLUSIONS: This observational, consecutive, real-world study of contemporary rescue PCI for failed thrombolysis shows a high use of coronary stents, Rheolytic thrombectomy, glycoprotein IIb/IIIa inhibitors, and intraaortic balloon pump placement. Angiographic and clinical success was high with low bleeding complications and low in-hospital mortality, suggesting that prospective, randomized trials using contemporary interventional therapy for rescue PCI be considered.

Erectile dysfunction in the cardiac patient: how common and should we treat?

PURPOSE: Risk factors for erectile dysfunction (ED) (hypertension, diabetes, smoking, lipid abnormality) are also risk factors for coronary artery disease. However, most cardiologists do not routinely ask about ED and patients often are reluctant or embarrassed to discuss it. We determined how common ED was in a group of patients with chronic stable coronary artery disease. MATERIALS AND METHODS: We administered the validated Sexual Health Inventory for Men (SHIM) 5-item questionnaire, based on the International Index of Erectile Function questionnaire, to 76 men with chronic stable coronary artery disease during routine outpatient cardiology visits. Most of these men had not previously discussed ED with their cardiologist. RESULTS: The mean patient age was 64 years (range 40 to 82). The questionnaire took about 5 minutes to complete. Of the patients 47% were on beta blockers, 92% statins, 28% diuretics. SHIM score was 21 or less in 53 men (70%), which is indicative of ED. Of the patients 75% had some difficulty achieving erections (question 2) and 67% had some difficulty maintaining an erection after penetration (question 3). The questionnaire reflected successful sildenafil treatment in 4 patients (SHIM scores 23 to 25). If these 4 men are included as having had ED then 57 of 76 (75%) had ED or recent history of ED. CONCLUSIONS: ED is extremely common in men with chronic coronary artery disease (affecting approximately 75%) yet most cardiologists do not ask about it. The SHIM is a useful, quick and inexpensive tool for discussion and diagnosis of ED in this population. Although it is well established that cardiovascular risk factors are associated with erectile dysfunction, once it is present there is mixed information on whether treating the risk factors will treat the ED. Problems appear to be that lifestyle modification in midlife may simply be too late to effect a change, and some antihypertensive and lipid lowering drugs may actually exacerbate ED. Oral therapy for ED, namely the PDE5 inhibitors, is effective and safe in most cardiac and hypertensive patients. Organic nitrates such as nitroglycerin remain a contraindication to the concomitant use of these drugs. Guidelines for treatment of ED in the cardiac patient issued by the American College of Cardiology/American Heart Association and Princeton Guidelines may be useful in the approach to the cardiac patient with ED.