Takotsubo cardiomyopathy after microwave ablation for metastatic liver lesions.

Takotsubo cardiomyopathy (TCMP) is characterized by transient and reversible left ventricular regional wall motion abnormalities triggered by acute and intense emotional or physical stress. We present a case of a 79 year old woman with a hypertensive crisis after microwave ablation (MWA) for metastatic liver lesions. Initial evaluation suggested an acute coronary syndrome with an ST segment elevation and with elevated serum troponin T. No associated chest pain or dyspnea was present. Further evaluation with ECG, echocardiography, coronarography with left ventricle angiogram and MRI was consistent with an apical ballooning syndrome. She was managed medically and the abnormalities resolved in the next 8 weeks during her follow up. The association between MWA and TCMP has been only reported once in the literature. We would like to emphasize one of the risks of MWA in or near the thoracic region potentially leading to TCMP.

Anomalous right coronary artery in a middle-aged patient: A case report and review of the literature.

BACKGROUND: An anomalous right coronary artery originating from the left sinus of Valsalva is a rare, but often incidental, finding in middle-aged to elderly people. Prevalence is difficult to define, as well as determining potential harmful hemodynamic consequences. Moreover, the optimal treatment remains debatable. CASE SUMMARY: The authors present a case of a middle-aged patient diagnosed with an anomalous right coronary artery causing ischemia, who was treated surgically. CONCLUSION: By reviewing literature, the authors conclude that choice of treatment depends on age, symptoms, and certain anatomic features of this anomaly. However, there are no randomized trials available in this field.

Loss and retrieval of a coronary angioplasty stent balloon.

A case is presented in which a breakage of the coronary stent delivery catheter occurred as retrieval of the stent balloon was attempted after stent implantation. The broken distal balloon shaft with its stuck balloon was retrieved by controlled pulling on the guiding catheter in which a new balloon was inflated, thus trapping the distal shaft. The case underscores the importance of adequate lesion assessment and preparation.

In-hospital outcomes of percutaneous coronary intervention in patients with chronic total occlusion: insights from the ERCTO (European Registry of Chronic Total Occlusion) registry.

AIMS: In comparison with non-occlusive lesions, percutaneous coronary intervention (PCI) of chronic total occlusions (CTO) represents a greater challenge for the interventionalist, due to lower procedural success rates, relatively higher incidence of procedural complications and the increased rate of restenosis. The European Registry of Chronic Total Occlusion (ERCTO) was created with the goal of evaluating the real impact of CTO PCI in the European context, trying to analyse the rates of procedural success, technical information from the CTO procedures and patient outcome. METHODS AND RESULTS: Data collection was carried out in 16 centres across Europe, starting from the beginning of January 2008. In two years of activity, a total of 1,914 patients with 1,983 CTO lesions were consecutively enrolled in the registry. Overall procedural success was achieved in 1,607 lesions (82.9%); anterograde procedures obtained higher procedural success of retrograde ones (83.2% versus 64.5%, p<0.001). Coronary perforation occurred more frequently in patients who underwent retrograde approach (4.7% versus 2.1%, p=0.04). Although no differences were observed in terms of 30-day major adverse cardiac events between anterograde and retrograde treated patients, a trend toward higher periprocedural non-Q-wave myocardial infarction was found in patients in which the retrograde approach was attempted (2.1% versus 1% p=0.08). Moreover, retrograde approach was related with longer procedural and fluoroscopy times (156.9±62.5 min vs. 98.2±52.8 min and 73.3±59.9 min vs. 38.2±43.9 min respectively, p<0.001) and higher contrast load administration (402±161 cc vs. 302±184 cc, p<0.001). CONCLUSIONS: The first report of the ERCTO registry by the EuroCTO club shows a high procedural success rate obtained by expert European operators in a "real-world" consecutive series of patients, comparable with those reported by Japanese registries. The rate of observed procedural adverse events was low and similar to the non-CTO PCI series. In this registry, retrograde procedures were associated with extended fluoroscopy exposure and procedural time, increased contrast load administration as well as a higher incidence of coronary perforations. Such outcomes should become the standard of care that all centres undertaking CTO PCI should aspire to.

Early- and long-term intravascular ultrasound and angiographic findings after bioabsorbable magnesium stent implantation in human coronary arteries.

OBJECTIVES: This study aimed to evaluate the degradation rate and long-term vascular responses to the absorbable metal stent (AMS). BACKGROUND: The AMS demonstrated feasibility and safety at 4 months in human coronary arteries. METHODS: The PROGRESS-AMS (Clinical Performance and Angiographic Results of Coronary Stenting) was a prospective, multicenter clinical trial of 63 patients with coronary artery disease who underwent AMS implantation. Angiography and intravascular ultrasound (IVUS) were conducted immediately after AMS deployment and at 4 months. Eight patients who did not require repeat revascularization at 4 months underwent late angiographic and IVUS follow-up from 12 to 28 months. RESULTS: The AMS was well-expanded upon deployment without immediate recoil. The major contributors for restenosis as detected by IVUS at 4 months were: decrease of external elastic membrane volume (42%), extra-stent neointima (13%), and intra-stent neointima (45%). From 4 months to late follow-up, paired IVUS analysis demonstrated complete stent degradation with durability of the 4-month IVUS indexes. The neointima was reduced by 3.6 +/- 5.2 mm(3), with an increase in the stent cross sectional area of 0.5 +/- 1.0 mm(2) (p = NS). The median in-stent minimal lumen diameter was increased from 1.87 to 2.17 mm at long-term follow-up. The median angiographic late loss was reduced from 0.62 to 0.40 mm by quantitative coronary angiography from 4 months to late follow-up. CONCLUSIONS: Intravascular ultrasound imaging supports the safety profile of AMS with degradation at 4 months and maintains durability of the results without any early or late adverse findings. Slower degradation is warranted to provide sufficient radial force to improve long-term patency rates of the AMS.

Safety of direct stenting with the Endeavor stent: results of the Endeavor II continued access registry.

AIMS: The safety and efficacy of direct stenting with the Endeavor stent is unknown. The acute and 9 month outcome after direct stenting vs. predilatation was tested in a multicentre, prospective, single-arm study. METHODS AND RESULTS: 300 patients were treated with the Endeavor stent for a single, previously untreated coronary artery stenosis (vessel diameter 2.25 to 3.75 mm; lesion length 14 to 27 mm). Predilatation was at discretion of the operator for lesions < 20 mm in length but mandatory for lesions > 20 mm. Angiographic follow-up at 8 months was prespecified for the first 150 consecutive patients. Out of 296 patients, 126 (42.6%) underwent direct stenting and 170 (57.4%) predilatation. Patients in the direct stenting group were younger (62.9 years vs 65.3 years, P=0.04) and lesions were predictably more proximally located and shorter (14.29 mm vs 18.16 mm, P<0.0001), with larger pre-procedural minimum lumen diameter. Success rate was 92.9% with direct stenting vs. 95.3% with predilatation (P=0.45). At 8 months, late loss was not significantly different between groups. The rate of MACE at 9 months was 10.6% with direct stenting vs. 10.2% with predilatation (P=1.00). There were no occurrences of stent thrombosis in either group. CONCLUSION: Direct stenting with the Endeavor stent as deemed feasible by the operator, was safe and effective, and comparable to the results of implantation following predilatation.

Relative lack of depressive cognitions in post-myocardial infarction depression.

BACKGROUND: Depression has been associated with adverse clinical events in myocardial infarction (MI) patients, but many questions about the nature of post-MI depression remain unanswered. We examined whether depressive cognitions characteristic of depression in psychiatric patients are also present in post-MI patients with major depression (MD). METHODS: Non-depressed (n=40) and depressed (n=40) post-MI patients, and psychiatric outpatients (n=40) treated for clinical depression, matched on age and sex, were interviewed using a structured clinical interview to diagnose DSM-IV MD. All patients also completed the Beck Depression Inventory (BDI) and the Beck Cognition Checklist-Depression subscale (CCL-D). RESULTS: Mean levels of depressive cognitions were considerably higher in depressed psychiatric patients compared with depressed post-MI patients (34.9 versus 28.0; p=.013), and higher in depressed post-MI patients compared with non-depressed post-MI patients (28.0 versus 17.8; p<.0001), adjusted for age, sex, educational level, and marital status. Younger age (p=.024), absence of a partner (p=.016) and depressed psychiatric status (p=.016) were independently associated with depressive cognitions. Psychiatric patients also had higher mean levels of depressive symptoms as compared to depressed post-MI patients (25.1 versus 17.8; p=.001). LIMITATIONS: This study is based on a cross-sectional design. CONCLUSIONS: The symptom presentation of MD in post-MI patients is both quantitatively and qualitatively different from that seen in psychiatric patients, suggesting that depressive symptoms in post-MI patients differ in content from those in psychiatric patients. These findings could have important consequences for the design and contents of therapeutic programs for treating depression in post-MI patients.

The effect of variable dose and release kinetics on neointimal hyperplasia using a novel paclitaxel-eluting stent platform: the Paclitaxel In-Stent Controlled Elution Study (PISCES).

OBJECTIVES: The aim of this study was to evaluate the effect of variable dose and release kinetics of paclitaxel on neointimal hyperplasia. BACKGROUND: Conventional paclitaxel-eluting stents use a durable polymer coating as a vehicle for drug delivery. The Conor stent (Conor Medsystems, Menlo Park, California) with intra-strut wells and erodable polymer is specifically designed for drug delivery with programmable pharmacokinetics. METHODS: Two hundred and forty-four patients with single vessel disease received either a bare metal Conor stent (n = 53) or one of six different release formulations that varied in dose (10 or 30 microg) and elution release kinetics (first order, zero order), direction (abluminal, luminal), and duration (5, 10, and 30 days). End points at six months (bare stent group) and at four months (eluting stent groups) were angiographic late loss and neointimal tissue volume by intravascular ultrasound and the rate of major adverse cardiac events (MACE). RESULTS: The lowest in-stent late loss (0.38 mm, p <0.01, and 0.30 mm, p <0.01) and volume obstruction (8%, p <0.01, and 5%, p <0.01) were observed with the 10-microg and 30-microg doses in the 30-day release groups respectively, whereas the highest in-stent late loss (0.88 mm), volume obstruction (26%), and restenosis rate (11.6%) were observed in the bare stent group. The overall MACE rate of the eluting stent group was 8.6%: death 0.5%, myocardial infarction 2.7%, and target lesion revascularization (TLR) 5.3%. Sub-acute thrombosis was 0.5%. The TLR rates in the two 30-day release groups were 0% and 3.4%. CONCLUSIONS: This novel eluting stent platform, using an erodable polymer with complete elution of low doses of paclitaxel, is safe. The inhibition of the in-stent neointimal hyperplasia was best in the long release groups.

One-year clinical outcome of various doses and pharmacokinetic release formulations of paclitaxel eluted from an erodable polymer - Insight in the Paclitaxel In-Stent Controlled Elution Study (PISCES).

AIMS: The one year clinical benefit of various doses and release durations of paclitaxel eluted from an erodable polymer has not been evaluated so far. METHODS AND RESULTS: Conor paclitaxel-eluting stents have intra-stent wells in which drug and polymer are deposited. Stents with six different release formulations (dose: 10 microg or 30 microg, duration: 5, 10 or 30 days, direction: mural or bidirectional) were implanted in 6 patient cohorts. Clinical follow-up was conducted at 4 and 12 months. Quantitative angiography and IVUS were performed at 4 months, and additional angiographic and IVUS follow-up were performed for groups D5 (10microg/30days/mural) and D6 (30microg/30days/mural), as they had shown the most favorable results at 4 months. At one year, the lowest major adverse cardiac event rates were observed in the slow release (30 day) group (5.1% in D5 and 6.9% in D6). One-year in-stent late loss was 0.52+/-0.34 mm in D5 and 0.36+/-0.50mm in D6 (p=0.20) while neointimal area was 0.99+/-0.54 mm2 in D5 and 0.77+/-0.92 mm2 in D6 (p=0.42). Corresponding in-stent binary restenosis at one year was 0% and 5.6% respectively (p=0.36). CONCLUSIONS: Patients who received the slow release formulation stent had better clinical outcome at one year than those who received the fast release formulation. However, the effect on neointimal suppression requires investigation in a larger population to determine whether the high dose formulation confers an additional clinical benefit.

One-year clinical outcome of various doses and pharmacokinetic release formulations of paclitaxel elutedfrom an erodable polymer - Insight in the PaclitaxelIn-Stent Controlled Elution Study (PISCES)

The one year clinical benefit of various doses and release durations of paclitaxel eluted from an erodablepolymer has not been evaluated so far.Methods and results: Conor paclitaxel-eluting stents have intra-stent wells in which drug and polymer aredeposited. Stents with six different release formulations (dose: 10 μg or 30 μg, duration: 5, 10 or 30 days,direction: mural or bidirectional) were implanted in 6 patient cohorts. Clinical follow-up was conducted at4 and 12 months. Quantitative angiography and IVUS were performed at 4 months, and additional angiographicand IVUS follow-up were performed for groups D5 (10μg/30days/mural) and D6(30μg/30days/mural), as they had shown the most favorable results at 4 months. At one year, the lowestmajor adverse cardiac event rates were observed in the slow release (30 day) group (5.1% in D5 and 6.9%in D6). One-year in-stent late loss was 0.52±0.34 mm in D5 and 0.36±0.50mm in D6 (p=0.20) whileneointimal area was 0.99±0.54 mm2 in D5 and 0.77±0.92 mm2 in D6 (p=0.42). Corresponding in-stentbinary restenosis at one year was 0% and 5.6% respectively (p=0.36).Conclusions: Patients who received the slow release formulation stent had better clinical outcome at oneyear than those who received the fast release formulation. However, the effect on neointimal suppressionrequires investigation in a larger population to determine whether the high dose formulation confers anadditional clinical benefit.

The effect of variable dose and release kinetics on neointimal hyperplasia using a novel paclitaxel-eluting stent platform

The aim of this study was to evaluate th effect of variable dose and release kinetics of paclitaxel on neointimal hyperplasia.Conventional paclitaxel-eluting stents use a durable polymer coating as vehicle for drug delivery.The Conor stent (Conor Medsystem, Menlo Park, Califórnia) with intra-strut wells and erodable polymer is specifically designed for drug delivery with programmable pharmakocinetics.Two hundred and forty-four patients with single vessel disease received either a bare metal Conor stent(n=53) or one of six different release formulations that varied in dose (10 or 30yg) and elution release kinetics (first order, zero oder), direction (abluminal, luminal), and duration (5, 10, and 30 days)...

Percutaneous coronary intervention or bypass surgery in multivessel disease? A tailored approach based on coronary pressure measurement.

The optimal revascularization strategy, percutaneous coronary intervention (PCI) or coronary artery bypass graft surgery (CABG), for patients with multivessel coronary artery disease (MVD) remains controversial. The aim of the present study was to compare the long-term outcomes after selective PCI of only hemodynamically significant lesions (fractional flow reserve, or FFR < 0.75) to CABG of all stenoses in patients with MVD. In 150 patients with MVD referred for CABG, FFR was determined in 381 coronary arteries considered for bypass grafting. If the FFR was less than 0.75 in three vessels or in two vessels including the proximal left anterior descending (LAD) artery, CABG was performed (CABG group). If only one or two vessels were physiologically significant (not including the proximal LAD), PCI of those lesions was performed (PCI group). Of the 150 patients, 87 fulfilled the criteria for CABG and 63 for PCI. There were no significant differences in the angiographic or other baseline characteristics between the two groups. At 2-year follow-up, no differences were seen in adverse events, including repeat revascularization (event-free survival 74% in the CABG group and 72% in the PCI group). A similar number of patients were free from angina (84% in the CABG group and 82% in the PCI group). Importantly, the results in both groups were as good as the surgical groups in previous studies comparing PCI and CABG in MVD. In patients with multivessel disease, PCI in those with one or two hemodynamically significant lesions as identified by an FFR < 0.75 yields a similar favorable outcome as CABG in those with three or more culprit lesions despite a similar angiographic extent of disease.

Randomized comparison of balloon angioplasty versus silicon carbon-coated stent implantation for de novo lesions in small coronary arteries.

The objectives of this study were to compare the short- and long-term clinical and angiographic outcomes of conventional balloon angioplasty versus elective silicon carbide-coated stent implantation in de novo lesions in small coronary arteries (<3.0 mm). Angioplasty of small coronary arteries is associated with high restenosis rates. The beneficial effects of stent implantation on restenosis rates and clinical outcomes have been suggested by observational studies. However, randomized trials comparing balloon angioplasty with stenting show conflicting results. A total of 496 patients with a de novo stenosis in a coronary artery, with a diameter between 2.0 and 3.0 mm, were randomly assigned to balloon angioplasty (n = 246) or stent implantation (n = 250). One-year clinical and 6-month angiographic follow-up were performed. Baseline characteristics were similar for the 2 groups, with 16% having diabetes and 77% complex lesions (type B or C). Crossover to stents occurred in 29% of patients randomized to balloon angioplasty. At 6 months, angiographic restenosis rates were 25% versus 21% for the angioplasty and stent groups, respectively (p = NS). One-year clinical follow-up showed no difference in occurrence of major adverse cardiac events. Elective silicon carbon-coated stent implantation in small coronary arteries is safe and effective, with no beneficial effect on angiographic or clinical outcome compared with balloon angioplasty with provisional stenting.

Clinical and angiographic outcomes after Tsunami coronary stent placement.

STUDY AIM: The aim of this study was to determine six months restenosis rate measured by off-line quantitative coronary angiography, and to assess the efficacy and safety of newly developed six cells Tsunami stent system for the treatment of symptomatic, de novo, native coronary artery lesions. STUDY DESIGN AND METHODS: Between January and August 2001, 100 patients with 120 lesions were included at four clinical sites in this prospective, non-randomized, single arm study. In 35% of the patients two or more stents were implanted, 15% of the lesions were stented with more than one stent and 46% of the lesions were in small vessels (

Randomized study to compare balloon angioplasty and elective stent implantation in venous bypass grafts: the Venestent study.

The aim of the study was to compare acute and long-term angiographic and clinical outcome of balloon angioplasty and elective stenting in de novo lesions in the body of a saphenous vein graft (SVG). A total of 150 patients, with de novo lesions in SVG, were randomly assigned to balloon angioplasty or elective Wiktor I stent implantation. The angiographic restenosis rate at 6-month follow-up was 32.8% in the balloon group and 19.1% in the stent group (P = 0.069). At 1-year follow-up, target vessel revascularization rate was 31.4% vs. 14.5% (P < 0.05), and event-free survival was 60.0% vs. 76.3% (P < 0.05) for the balloon and stent group, respectively. Elective stent implantation in de novo SVG lesions is associated with a significant lower target vessel revascularization rate and a significant higher event-free survival at 1-year follow-up as compared to balloon angioplasty.

Direct coronary stenting through left and right internal mammary artery grafts.

We describe a case of successful direct coronary stenting of two tight lesions, one at the site of the left internal mammary artery (LIMA) graft anastomosis with left anterior descending coronary artery and the other at the site of the anastomosis between the right internal mammary artery (RIMA) graft and the right coronary artery. To our knowledge, this is the first reported case of successful direct stent implantation through the LIMA and RIMA.

Coronary pressure and FFR predict long-term outcome after PTCA.

Although coronary stents have been the most important improvement in percutaneous coronary interventions in the last 10 years, it is well known to interventionalists that many patients after percutaneous transluminal coronary angioplasty (PTCA) have a favourable outcome without stenting. Coronary angiography, however, is not sensitive enough to identify those particular patients and it has been suggested that a combination of angiographic and functional criteria would be more suitable to distinguish patients with a low restenosis chance after plain balloon angioplasty. In the present study, the authors investigated the value of coronary pressure measurement for conditional stenting in 85 patients. It was demonstrated that in patients in whom a high fractional flow reserve (FFR) was present (> 0.90), the incidence of coronary events at two-year follow-up was almost three times lower than in those patients with an FFR below 0.90. Such high FFRs could be obtained in approximately 45% of all patients. In an additional group of patients, it was demonstrated by intravascular ultrasound (IVUS) studies that the mechanism of a high FFR after plain balloon angioplasty is most likely the result of a larger lumen compared with patients with a suboptimal FFR. This means that, in patients in whom both the angiographic and the functional result after PTCA is optimal, a restenosis rate is achieved similar to that achieved by stenting. Obviously, in such patients, additional stenting and a number of problems in the long-term possibly related to stenting can be avoided. Therefore, coronary angiography and coronary pressure measurement have a complementary value in the evaluation of PTCA results and such information can be easily obtained by using a pressure wire instead of a regular guidewire.

Guidelines for indications for coronary revascularization in The Netherlands.

In 1996 the Minister of Public Health, Welfare and Sports in The Netherlands published a 'Planning Decree Special Interventions in the Heart'. She requested from the professional organizations guidelines for the indications for interventions in the heart. A working group was formed with representatives from the Dutch professional organizations for cardiology and thoracic surgery, to address this issue for patients with coronary artery disease. The working group confirmed the need to discuss all patients who are considered for either elective or emergency revascularization during a multidisciplinary consultation in (or with) one of the specialized Dutch hospitals. During this meeting of the 'heart team', at least one interventional cardiologist and one thoracic surgeon should be present. There are three possible outcomes of the heart team's consultations for each patient: drug therapy only ('conservative management'), coronary surgery or catheter intervention. For each case, the team should indicate the expected benefit, the risk of the intervention, the urgency and the estimated waiting time. The guidelines presented in this paper address these issues for three patient categories: stable angina pectoris, unstable angina pectoris and acute myocardial infarction.

Initial results and long-term clinical follow-up of an amorphous hydrogenated silicon-carbide-coated stent in daily practice.

The hemocompatibility and biocompatibility of a stent are determined by the physical and electrochemical properties of the stent surface. The aim of this study was to determine the feasibility, safety and efficacy of implantation of a stent coated with silicon carbide. Baseline characteristics were collected prospectively. The occurrence of cardiac adverse events and the angina score were assessed at clinical follow-up. A total of 193 Tensum stents were implanted in 174 patients. In hospital, one patient experienced stent thrombosis and in 6% of the patients a creatinine kinase elevation to 240 U/l or more occurred. Long-term follow-up was performed in 172 patients, with a mean follow-up of 454 +/- 181 days. Ninety-seven per cent were still alive, 15% had undergone target-vessel revascularization, and 2% had angiographic restenosis and were treated with medication only. Seventy-one per cent of the patients were free of anginal complaints, and 20% had anginal complaints in Canadian Cardiac Society class I or II. The Tensum coronary stent showed to be a safe and efficacious device in this study, with a high primary success rate and favorable long-term clinical followup.