Anticoagulation for percutaneous coronary intervention: a contemporary review.

PURPOSE OF REVIEW: Optimal anticoagulation is needed to prevent ischemic complications during percutaneous coronary interventions (PCIs). The efficacy and safety of new anticoagulants to support PCI in different clinical scenarios have been evaluated in large clinical trials. This review summarizes the major issues and current practices for anticoagulation during PCI. RECENT FINDINGS: It is known that thrombotic events during PCI correlate with poor prognosis. However, the prognostic impact of bleeding is similar or even worse compared with ischemic complications. Therefore, the use of more predictable anticoagulants and safe practices in the catheterization laboratory to balance ischemia and bleeding is an important goal. Mindful of this notion, new anticoagulants with a safer profile, such as bivalirudin, have become popular to avoid bleeding. However, this paradigm shift has resulted in increased rates of acute stent thrombosis after primary PCI. SUMMARY: Individual factors associated with increased bleeding risk should be considered in the choice of anticoagulants during PCI. It is now known that the higher bleeding risk observed with heparin-based regimens can be attributed to excessive doses or concomitant use of glycoprotein IIbIIIa inhibitors. In addition to the right anticoagulant choice, operators can avoid bleeding by implementing transradial access and ultrasound-guided and fluoroscopic-guided vascular access.

Association between anti-human heat shock protein-60 and interleukin-2 with coronary artery calcium score.

INTRODUCTION: Based upon evidence suggesting that concentrations of anti-heat shock protein-60 (anti-HSP60) and interleukin-2 (IL-2) are associated with atherogenesis, we tested the hypothesis that anti-HSP60 and IL-2 are associated with coronary artery calcium (CAC) score, a marker of subclinical atherosclerosis. METHODS: We evaluated 998 asymptomatic adults, age 45-84 years, without known coronary disease from the Multi-Ethnic Study of Atherosclerosis (MESA), who had anti-HSP60 measured at baseline. Tertiles of serum anti-HSP60 were evaluated. The associations of IL-2 and anti-HSP60 with CAC were assessed using multivariate analyses, with adjustments for coronary risk factors and Framingham risk score. RESULTS: Patients' demographics, diabetes, hypertension, obesity, or dyslipidaemia did not show differences in levels of anti-HSP60. The median (IQR) Framingham risk score was 11 (5-22), 8 (5-16), and 9 (5-18) for the first, second, and third tertiles, respectively (p=0.043). IL-2 and tumour necrosis factor α (TNF-α) were associated with increased CAC (IL-2: OR 3.70, p<0.001; TNF-α: OR 4.63, p<0.001). In multivariate regression, the highest tertiles of anti-HSP60 and IL-2 were associated with increased risk of CAC (HSP60 T3: OR 1.49, p=0.022; IL-2: OR 2.49, p<0.001). After adjustment, significant progression of CAC was observed in patients with higher baseline levels of anti-HSP60 (estimate 31.73, p=0.016) and IL-2 (estimate 34.39, p=0.024). CONCLUSIONS: Increased concentrations of inflammatory markers (IL-2 and anti-HSP60) are associated with an increased CAC at baseline and follow-up in healthy asymptomatic adults. Future studies should be carried out to assess its association with early development of atherosclerosis.

Management of transcatheter aortic valve embolization into the left ventricle.

Embolization of transcatheter aortic valve replacement (TAVR) prostheses is a rare and serious procedural complication. While embolization into the aorta can sometimes be managed by transcatheter techniques, embolization into the left ventricle (LV) often requires immediate open heart surgery. We report three TAVR cases complicated by LV embolization. In each case, successful implantation of a second transcatheter prosthesis was accomplished, followed by surgical removal of the first embolized device.

Transfemoral aortic valve replacement in failing aortic root homografts.

Transcatheter aortic valve implantation (TAVI) for failing aortic root and valve homografts has been described primarily via a transapical approach. We report the successful treatment of two patients with failing homografts by transfemoral (TF) TAVI. In both cases, TF TAVI was accomplished without technical difficulty and with good clinical outcomes.

Takotsubo cardiomyopathy: utility of cardiac computed tomography angiography for acute diagnosis.

Takotsubo (stress) cardiomyopathy may present as acute cardiovascular collapse, simulating an acute coronary syndrome or other emergencies such as pulmonary embolism or aortic dissection. The diagnosis relies on demonstration of characteristic wall motion abnormalities in the absence of obstructive coronary lesions and is typically diagnosed with cardiac catheterization. Cardiac computed tomography angiography is well suited to use in the emergency setting to diagnose or exclude thoracic cardiovascular events. We describe a case of Takotsubo cardiomyopathy that occurred during induction of anesthesia, in which emergent cardiac computed tomography angiography confirmed the diagnosis and excluded other potential etiologies of disease.