Coronary Artery Aneurysms and Acute Coronary Syndrome: An Interventionalist's Dilemma.

We report three cases of coronary artery aneurysm (CAA) in adults who presented with acute coronary syndrome. Two of these patients did not have traditional coronary artery disease risk factors. Management of CAA poses a significant challenge to interventionalists. We discuss the etiologic mechanisms, risk factors, pathophysiology, and diagnosis using angiography, intravascular ultrasound, and coronary computed tomography. We also highlight management options, including medical therapy and catheter-based interventions such as stenting, coil embolization, stent-assisted coil embolization, and surgical exclusion.

Wrapped Left Anterior Descending Artery Presenting As Inferior Myocardial Infarction: Case Report and Review of the Literature.

Acute occlusion of the left anterior descending (LAD) coronary artery generally results in ST-segment elevation in the anterior leads of the electrocardiogram and reciprocal ST-segment depression in the inferior leads. We present a case of LAD occlusion presenting as inferior wall ST-segment elevation myocardial infarction.

Variability in utilization of diagnostic imaging tests in patients with symptomatic peripheral artery disease.

AIM: Imaging can help guide management in peripheral arterial disease (PAD) with symptoms refractory to medical treatment. However, there are no set guidelines to determine when physicians should seek further imaging in patients with PAD for the assessment of new, persistent or worsening symptoms. This study describes the rates and variability in non-invasive and invasive imaging for patients presenting to vascular specialty clinics for symptomatic PAD. METHODS: Patients (n=1,275) with a new PAD diagnosis or exacerbation of PAD symptoms were enrolled from 16 vascular clinics. Hierarchical logistic regression models were used to estimate the referral rates for 1) non-invasive and 2) invasive imaging tests, after adjusting for patient demographics, disease characteristics, PAQ summary score, PAD performance measures and country. Median Odds Ratios (MOR) were calculated to examine the variability across sites and providers. RESULTS: Mean ABI was 0.67 ± 0.19. There were 690 (54.1%) patients who had imaging, of which 62 (9.0%) had invasive imaging. Imaging rates ranged from 8.6% to 98.6% across sites. The MOR for use of imaging for site was 3.36 (p < 0.001) and provider 3.49 (p < 0.001). The variability was explained primarily by (R2 = 29%) country followed by patient-level factors, provider and lastly site (R2 = 17%, 14%, and 13%, respectively). CONCLUSION: There is wide variation in the use of imaging for patients presenting with new onset or recent exacerbations of their PAD. Country, followed by provider and site, were most strongly associated with this variability after adjusting for patient characteristics.

Percutaneous coronary interventions on vein graft bifurcation lesions presenting as an acute coronary syndrome.

Interventions on graft bifurcation lesions are uncommon, especially in the setting of acute coronary syndromes (ACS). We described three cases of graft bifurcation intervention where we tailored our approach based on lesion characteristics, anatomy, and angulation to achieve excellent angiographic and clinical outcomes. In case 1, shared ostia of saphenous vein graft (SVG) to Diagonal (D) and Radial graft to Obtuse Marginal (OM) was severely stenosed. We prioritized the radial arterial graft as it is known to have a longer patency rate over a totally occluded SVG of an undetermined period. We performed provisional stenting of the ostium of the radial artery and balloon angioplasty of the SVG ostium, while stenting the body of the SVG. In case 2 (bifurcation lesion at the anastomosis of SVG to D1 and sequential jump graft to OM), we utilized a V stenting strategy after an embolization protection device (EPD) was deployed in the branch with a suitable landing zone. Kissing balloon dilatation of both the branches was performed both pre- and poststenting. In case 3 (bifurcation lesion at SVG to OM and Sequential "T" graft to diagonal), there was >90% angulation between both the grafts. We used "T" stenting strategy in this case. At 2-year follow-up, patients had no major adverse cardiovascular events since and remained symptom free.

Incidence of Left Ventricular Thrombus in Patients With Acute ST-Segment Elevation Myocardial Infarction Treated with Percutaneous Coronary Intervention.

Previous studies using 2-dimensional non-contrast echocardiography have reported a post-ST segment elevation myocardial infarction (STEMI) left ventricular (LV) thrombus incidence of 3% to 24%. However, these studies were not performed with ultrasound contrast agents (UCAs), which improve accuracy in the diagnosis of LV thrombus. We aimed to determine the early incidence and clinical correlates of LV thrombus in a large consecutive cohort of patients with STEMI. This study included consecutive patients admitted to Saint Luke's Mid America Heart Institute with STEMI who also underwent early percutaneous coronary intervention (PCI) and an echocardiogram. A total of 1,698 patients (1,205 men, mean age 61 ± 13 years) comprised the study group. Echocardiography was performed on hospital day 2, and a UCA was used in 1,292 patients (76%). LV thrombus was identified in 28 (1.6%) patients. A multivariable logistic regression model showed that left anterior descending intervention was independently associated with LV thrombus (odds ratio = 7.58, 95% confidence interval [CI] 2.20 to 26.19, p = 0.001), thrombolysis in myocardial infarction III flow was marginally associated with less LV thrombus (odds ratio = 0.41, 95% CI 0.16 to 1.04, p = 0.060), and higher LVEF was associated with less LV thrombus (odds ratio = 0.96, 95% CI 0.91 to 0.97, p <0.001). In conclusion, LV thrombus was identified in only 1.6% of patients in a large STEMI cohort, significantly lower than previous studies. A UCA was used in most echocardiograms, and it improves accuracy in the detection and exclusion of LV thrombus.

Posterior Reversible Encephalopathy Syndrome After Orthotopic Heart Transplantation: A Case Report.

BACKGROUND Calcineurin inhibitor-induced posterior reversible encephalopathy syndrome (PRES) is well described in liver and kidney transplant patients, but there is a paucity of data in heart transplant patients. PRES syndrome in the setting of heart transplantation can occur as early as 5 days following transplantation. CASE REPORT A 32-year-old woman who had recently undergone orthotopic heart transplantation developed headaches, visual disturbances, and generalized tonic clonic seizures 5 days after initiating anti-rejection therapy (tacrolimus, mycophenolate, and prednisone). No focal neurological deficits were noted on physical exam. Multifocal subcortical fluid attenuation inversion recovery (FLAIR) hyperintensity signals and areas of diffusion restriction with postcontrast enhancement, diagnostic of PRES, were found on MRI brain. Her symptoms resolved 2 days after tacrolimus was switched to cyclosporine. A follow-up MRI after 6 weeks demonstrated complete resolution of areas of flair hyperintensity signal. She was sent home on a short course of seizure prophylaxis, which was discontinued after the resolution of radiological findings. She had no further episodes of seizures for 6 months following discontinuation of her anti-epileptic regimen. CONCLUSIONS Tacrolimus-induced PRES can occur as early as 5 days after orthotopic heart transplantation. Early recognition of symptoms and management can prevent permanent neurological sequelae.

Safety With Echocardiographic Contrast Agents.

In October 2007, the Food and Drug Administration mandated significant revisions to product labeling for the commercially available echocardiographic contrast agents (ECA) Definity and Optison after spontaneous healthcare provider reports of 4 patient deaths and ≈190 severe cardiopulmonary reactions occurring in close temporal relationship to ECA administration. Since then, multiple large ECA safety studies have been published and have included outpatients, hospitalized patients (including the critically ill), patients undergoing stress echocardiography, and patients with pulmonary hypertension. In addition, the Food and Drug Administration has convened 2 Advisory Committee meetings and the product labels for Optison and Definity have been substantially revised with a softening of safety restrictions. In this review, we will address the safety of ECA use in patients with serious cardiopulmonary conditions, patients with intracardiac shunts, and special patient populations including pulmonary hypertension, pediatrics, and pregnancy. In addition, we will discuss the confounding role of pseudocomplication in attribution of adverse events during diagnostic testing, the current status of the ECA Black Box Warning, and recommended safety precautions during ECA administration.