Triple-Guidewire Technique for Treating Stent Underexpansion in Severely Calcified Coronary Artery Lesions.

Stent underexpansion, a potential complication of percutaneous coronary intervention in severely calcified and stenotic coronary arteries, may result in in-stent thrombosis and restenosis. Different balloon-based and atheroablative techniques have been proposed to reduce the risk of these complications. We describe a simple triple-guidewire technique that we used to treat stent underexpansion in 2 elderly men.

Dietary Supplement Use in Patients with Cardiovascular Disease.

IMPORTANCE AND OBJECTIVE: Dietary supplements and herbs (called naturoceuticals) are commonly used by Americans, but little is known about their use in cardiovascular disease patient populations. The objective was to evaluate naturoceutical use in a sample population of cardiovascular disease patients in the U.S. DESIGN, SETTING AND PARTICIPANTS: A non-blinded, single medical center clinic open questionnaire was delivered to cardiovascular clinic patients with known cardiovascular diseases. MAIN OUTCOMES AND MEASURES, AND RESULTS: Estimation of naturoceutical usage prevalence and frequency in the sample population of cardiovascular disease patients. A total of 163 patients (n = 99 males, 64 females) participated (mean age: males, 66 years; females, 64 years). Overall, 76.7 percent of participants reported using naturoceuticals. Of them, about 63.2 percent took more than one type, and 90.3 percent reported daily usage. Of the naturoceuticals reportedly being taken, multivitamins containing vitamin K were the most commonly consumed (32.3 percent male, 29.7 percent female), followed by vitamin D (23.2 percent male, 31.3 percent female) and fish oil (24.2 percent male, 15.6 percent female). CONCLUSIONS AND RELEVANCE: The present study revealed that naturoceutical use was very popular in cardiovascular disease patients, largely due to the belief that they could reduce and/or prevent symptoms and disease in general. The benefits and hazards of those naturoceuticals being used concurrent with other prescription medications were discussed.

Orbital Atherectomy and Heavily Calcified Saphenous Vein Graft Intervention.

Percutaneous coronary intervention in the diseased saphenous vein graft differs significantly from that in the diseased native coronary artery. After being exposed to arterial pressures over time, vein grafts have substantially different plaque characteristics, with more inflammatory cells, more diffuse disease, and less calcification. Severe calcification of saphenous vein grafts, although uncommon, poses a high risk of stent underexpansion. Orbital atherectomy for treatment of de novo calcified coronary lesions has been associated with better outcomes at 5-year follow-up. However, there are no published data on the use of orbital atherectomy to treat severely calcified saphenous vein graft lesions. We present the case of a 77-year-old woman with non-ST-segment-elevation myocardial infarction who underwent successful orbital atherectomy to prepare a severely calcified saphenous vein graft lesion for stent implantation.

Ultra-Low Contrast Volume Technique for Coronary Angiography - Successful Application in Clinical Setting.

Iodinated contrast media used during cardiac catheterization predispose patients to develop contrast-induced nephropathy. Reducing contrast volumes without impairing the quality of angiographic imaging appears to be a viable solution. We present three cases of patients with chronic kidney disease in which we used an ultra-low contrast volume technique to help minimize contrast exposure risk. This technique uses an automated contrast injection system that can be used during diagnostic or coronary interventional cases and reduces the risk of iatrogenic kidney disease without compromising imaging quality.

Frequency Domain-optical Coherence Tomography of Coronary Arteries Using a Diluted Iodinated Contrast-saline Mix with 5-Fr Guide Catheters.

Background Optical coherence tomography (OCT) is currently mostly performed using 6-Fr coronary guide catheters via femoral access. Catheters with such large internal diameters are necessary to deliver viscous contrast media and achieve sufficient red blood cell washout. Currently, undiluted iodinated contrast media (15 mL/injection) is used to clear the coronary arteries of red blood cells (RBCs). This leads to an increase in the total amount of contrast used and often the need for femoral artery access. Our objective is to assess the feasibility of performance of OCT using a 5-Fr guide catheter via radial access using diluted iodinated contrast. Methods We present a case series of 11 patients where second-generation frequency domain (FD)-OCT was used to assess the coronary arteries using a novel 70:30 dilution mixture of iodinated contrast medium with heparinized normal saline. All procedures were performed with a 5-Fr coronary guide catheter via the radial artery approach. Results All procedures were successfully performed vial radial access with good quality imaging obtained. The target vessel was the left anterior descending artery in eight patients, the right coronary artery in two patients, and the left main coronary artery in one patient. OCT resulted in a change in management in 7/11 (64%) patients; no complications were reported with OCT. On average, 10 mL of contrast was used per injection. Conclusions The current study demonstrates the feasibility of FD-OCT using 5-Fr guide catheters and diluted iodinated contrast media. This approach lowers contrast exposure and potentially decreases vascular complications without sacrificing image quality.

Recurrent Ischemic Stroke: A Manifestation of a Sinus of Valsalva Pseudoaneurysm.

An 83-year-old female presented to the emergency department with bilateral eye pain, dizziness, and acute shortness of breath. Her blood pressure (BP) at presentation was 184/93 mmHg. She was admitted for hypertensive emergency and her symptoms improved with BP control. However, during hospitalization, she developed left-sided paresthesia which on investigation was found to be secondary to ischemic stroke. She had two previous aortic mechanical valve replacements for aortic stenosis. Transthoracic echocardiogram revealed a large pseudoaneurysm of the non-coronary sinus of Valsalva that we believe was the cause of her recurrent stroke. A sinus of Valsalva pseudoaneurysm is an uncommon complication of aortic valve replacement surgery which in turn has been associated with aortic rupture, myocardial infarction, and stroke. Our case identifies a situation where sinus of Valsalva pseudoaneurysm predisposed our patient to recurrent ischemic strokes and this should be kept in mind when evaluating a patient with ischemic stroke.

Single Coronary Artery Arising from the Right Sinus of Valsalva and the Role of Coronary Computed Tomography Angiography.

There are many variations of coronary anatomy encountered during coronary angiogram. Anatomy demonstrating a single coronary artery is a rare congenital coronary artery anomaly. The entire heart is supplied solely by a coronary artery with single coronary ostium. We present a rare case of single coronary artery arising from the right sinus of Valsalva. The patient had presented with atypical chest pain and a stress test was performed, which was abnormal. We proceeded with coronary angiography which showed a common ostium of the right and left coronary artery coming from the right coronary cusp. The coronary computed tomography angiography revealed the left main had a pre-pulmonic course, crossing the base of the heart and passing anterior to the pulmonary artery and then branching into the left anterior descending artery and left circumflex artery. Patients with single coronary artery usually has benign prognosis; however, a specific coronary anomaly may result in myocardial ischemia and sudden cardiac death if the anomalous coronary artery takes an intra-arterial course, running between the aorta and the pulmonary artery. Coronary computed tomography angiography is a useful imaging modality to identify anatomical course of coronary anomaly.

Clinical factors associated with physician choice of femoral versus radial access: A real-world experience from a single academic center.

OBJECTIVES: To analyze clinical factors associated with operator's preference in selection of femoral versus radial access for angiography and percutaneous intervention (PCI) procedures. BACKGROUND: There has been an increase in radial access in cardiac catheterization and PCI in the last few decades. METHODS: Data from 11 226 consecutive cardiac catheterization procedures were collected from Sanford University Medical Center (University of South Dakota, Sanford School of Medicine) from 2011 to 2015. RESULTS: In the overall cases, clinical factors that favored upfront femoral access include patients presenting as ST-elevation myocardial infarction (STEMI) or emergent, coronary artery bypass graft, body mass index (BMI) <30 kg/m2 and age ≥70 years, whereas morbidly obese patients (BMI ≥35) and age <70 favored upfront radial access. Radial access in the overall group had lower fluoroscopy time (6.5 vs 8.4 min, P < 0.0001) and lower contrast use (68.8 vs 80.6 cc, P < 0.0001). In the PCI group, efficacy of upfront radial access is less evident with radial fluoroscopy time (10.1 vs 11.0 min, P < 0.0028) and contrast use being higher in radial group (113.8 vs 108.2 cc, P < 0.037). Interventional cardiologists were more efficient in diagnostic cases than non-interventional cardiologists. CONCLUSION: STEMI or emergent cases and elderly patients favor upfront femoral access. As BMI increases and age decreases, radial access is progressively favored. In diagnostic cases, radial access appears to be superior to femoral access in efficacy, but the distinction is less obvious in PCI and STEMI or emergent cases.

A Fish Mouth Appearing Perforation of the Native Aortic Valve Due to Streptococcus infantarius subspecies coli.

Infective endocarditis due to Streptococcus infantarius with the subspecies (subsp.) coli is infrequently encountered in healthy humans. This entity is associated with hepatobiliary malignancies and colorectal neoplasia. Here, we report on a unique case of endocarditis associated with S. infantarius subsp. coli in an 80-year-old male with no known risk factors of the infective endocarditis.

Multiple Pulmonary Arteriovenous Malformations: An Unusual Cause of Shortness of Breath and Recurrent Strokes.

OBJECTIVE: To discuss an uncommon case of a patient with multiple pulmonary arteriovenous malformations (PAVMs) presenting with dyspnea on exertion and recurrent strokes. BACKGROUND: A 79-year-old woman with recent onset recurrent cerebrovascular accidents (CVAs) was referred to cardiology for evaluation of dyspnea on exertion. Clinical examination was unrevealing. METHODS: A transthoracic echocardiogram (TTE) with agitated saline was suggestive of an extra-cardiac shunt. Subsequent chest computed tomographic angiography (CTA) demonstrated five large PAVMs. RESULTS: The patient underwent transcatheter coil embolization of the five PAVMs, resulting in marked improvement in dyspnea and resolution of the shunt on bubble study echocardiography. CONCLUSIONS: Although PAVMs are rare, they remain an important entity to consider when evaluating patients with extracardiac shunts. They may present with nonspecific features such as dyspnea on exertion and recurrent CVAs. All patients with multiple PAVMs should undergo thorough skin screening for telangiectasia as well as radiologic imaging to screen for additional AVMs in the liver and brain in order to exclude hereditary hemorrhagic telangiectasia (HHT).

Incidental Finding of Giant Left Ventricular Aneurysm: Case Report and Literature Review.

Left ventricular aneurysms and pseudoaneurysms are complications of myocardial infarction. With advances in percutaneous coronary intervention, development of thrombolytic agents, and early initiation of treatment with angiotensin-converting enzyme inhibitors to decrease afterload and inhibit left ventricular remodeling, these complications have become much less common. Here, we report an incidental finding of a giant aneurysm of the left ventricle with associated thrombus and mural calcifications in an elderly male patient who presented to his primary care physician for abdominal pain and denied any prior coronary artery disease. In addition, a potential inflammatory mass at the rectosigmoid junction was also found by computed tomography scanning for his abdominal problem.

A Novel Technique of Stenting of the Renal Artery In-Stent Restenosis with GuideLiner® through Radial Approach.

In-stent restenosis of the renal arteries is relatively common and its management is not well studied. An 83-year-old female with bilateral renal artery stenosis and balloon angioplasty and stenting bilaterally one year ago was found to have recurrent severe elevations in the blood pressure despite medical management. Renal artery duplex showed 60-99% stenosis of the right renal artery and 20-59% stenosis of the left renal artery. A subsequent angiography of the right renal artery revealed 80% in-stent restenosis at the ostium. We describe a new approach of balloon angioplasty and stenting through radial access site with the assistance of a GuideLiner in a complex in-stent restenosis of the renal artery.

Kansas City Cardiomyopathy Questionnaire Utility in Prediction of 30-Day Readmission Rate in Patients with Chronic Heart Failure.

Background. Heart failure (HF) is one of the most common diagnoses associated with hospital readmission. We designed this prospective study to evaluate whether Kansas City Cardiomyopathy Questionnaire (KCCQ) score is associated with 30-day readmission in patients hospitalized with decompensated HF. Methods and Results. We enrolled 240 patients who met the study criteria. Forty-eight (20%) patients were readmitted for decompensated HF within thirty days of hospital discharge, and 192 (80%) patients were not readmitted. Compared to readmitted patients, nonreadmitted patients had a higher average KCCQ score (40.8 versus 32.6, P = 0.019) before discharge. Multivariate analyses showed that a high KCCQ score was associated with low HF readmission rate (adjusted OR = 0.566, P = 0.022). The c-statistic for the base model (age + gender) was 0.617. The combination of home medication and lab tests on the base model resulted in an integrated discrimination improvement (IDI) increase of 3.9%. On that basis, the KCQQ further increased IDI of 2.7%. Conclusions. The KCCQ score determined before hospital discharge was significantly associated with 30-day readmission rate in patients with HF, which may provide a clinically useful measure and could significantly improve readmission prediction reliability when combined with other clinical components.

Reduction in Contrast Nephropathy From Coronary Angiography and Percutaneous Coronary Intervention With Ultra-Low Contrast Delivery Using an Automated Contrast Injector System.

OBJECTIVE: To evaluate the incidence of contrast-induced nephropathy (CIN) following coronary angiography and percutaneous coronary intervention (PCI) utilizing a novel ultra-low contrast delivery (ULCD) technique. BACKGROUND: Current techniques for reducing contrast volumes during angiographic and PCI procedures require the use of advanced coronary imaging methods, such as intravascular ultrasound and coronary flow wires. We propose the use of an automated contrast injector system (ACIS) with a novel programming technique that significantly reduces contrast volumes and CIN development. METHODS: From 2013 to 2014, a total of 123 patients with stage III or higher chronic kidney disease (CKD) underwent coronary angiography, PCI, or a combined procedure using the ULCD technique. A retrospective analysis was conducted to evaluate contrast volumes and rate of CIN development. Patients developing CIN were compared using tests of proportions. RESULTS: The median contrast volume was 17.9 mL (n = 123). The study cohorts comprised diagnostic (15.2 mL; n = 72), PCI (17.1 mL; n = 30), and PCI + diagnostic groups (27.9 mL; n = 21). The incidence of CIN observed in the entire cohort through day 7 was 3.3% (4/123). Seventy-five percent of the CIN cases occurred following diagnostic angiography alone. Longitudinal follow-up at 21 days identified an additional 5 cases of CIN. Compared to literature data, the ULCD technique delivers less contrast per case. CONCLUSION: The adaptation of the ULCD technique for coronary procedures significantly reduces contrast volume delivery when compared with conventional practice or previously described low-contrast techniques. The ULCD appears to be an efficacious method of limiting CIN development in a susceptible population with CKD.

Mitral Stenosis Presenting as Asthma.

Although wheezing is one of the most common symptoms and physical findings in asthma, other causes of wheezing should be kept in mind: vocal cord dysfunction, postnasal drip syndrome, chronic obstructive pulmonary disease, bronchiectasis, and non-pulmonary diseases, like heart failure and pulmonary edema. Here, we present a case of severe mitral stenosis with pulmonary edema treated for resistant asthma. If asthma is difficult to control, other etiologies of wheezing, including cardiac disease, should be taken into consideration during diagnosis.

Cardiac Presentation of Multiple Myeloma with Amyloidosis.

Amyloidosis is a rare disease encompassing the accumulation of abnormal and insoluble amyloids systemically or in specific organs. This is a case of a previously healthy 60-year-old male complaining of fatigue and chest pain who proceeded to rapidly decline in functional status within six months from the onset of these symptoms. Cardiac evaluation demonstrated characteristic changes on EKG and echocardiogram was consistent with cardiac amyloidosis. Muscle and gastrointestinal biopsies confirmed multisystem amyloidosis. Monoclonal kappa light chain was identified by serum electrophoresis and the diagnosis of multiple myeloma was confirmed by bone marrow biopsy. The process of amyloid deposition secondary to multiple myeloma was managed with chemotherapy after the patient was referred to a center specialized in amyloidosis treatment. This case highlights the diagnostic challenges, non-specific signs and symptoms, and treatment dilemmas involved in managing amyloid light-chain cardiac amyloidosis.

Implementing the 2013 cholesterol management guidelines into clinical practice.

Although a reduction in atherosclerotic cardiovascular disease (ASCVD) events remains the ultimate goal in cholesterol management, there has been a change in recommended cholesterol management in patients with increased risk. The objective in cholesterol management is no longer reducing low-density lipoprotein (LDL) to a particular target value, but ensuring that patients with the highest ASCVD risk are treated with the most potent statin therapy. The previous practice of statin therapy cessation and routine monitoring for adverse events has also been scrutinized by the recent American Heart Association (AHA)/American College of Cardiology (ACC) guidelines. Identifying patients who are at risk now requires the utilization of a novel tool called the ASCVD pooled cohort calculator. The following article will guide the clinician on implementing the current AHA/ACC guidelines into clinical practice.

Implementing effective hypertensive management--review of the 2014 high blood pressure management guidelines.

The Joint National Committee (JNC 8) hypertension guidelines have modified the blood pressure goals across the spectrum of disease processes and patient characteristics. This article will elucidate these changes and help clinicians improve the clinical care of patients with hypertension. Patients are now conceptually categorized into two different patient populations: those who are at a low- or high-risk of developing atherosclerotic cardiovascular disease (ASCVD) or chronic kidney disease (CKD). A low-risk population comprises patients aged 60 or older who do not have disease processes that enhance ASCVD or CKD disease development. High-risk patients are those with CKD and/or diabetes, and patients less than 60 years of age who remain at risk of future development. The current recommendation for blood-pressure goals in the low- and high-risk population is 150/90 mmHg and 140/90 mmHg, respectively. In all patients considered for antihypertensive therapy, the first line antihypertensive pharmacotherapy should include either a thiazide-type diuretic, calcium channel blocker (CCB), angiotensin-converting enzyme inhibitor (ACEI), or an angiotensin receptor blocker (ARB). Beta blockers no longer have a role as standalone therapy. Thiazide- type diuretics and CCB continue to demonstrate benefit in the African American population and should continue to be considered as first line agents. CKD patients with concomitant hypertension should be treated with an ACE inhibitor or ARB.

Gradual upregulation of OCI-5 expression during occurrence and progression of rat hepatocellular carcinoma.

BACKGROUND: OCI-5, the rat homologene of human glypican 3 (GPC3), is confirmed upregulated in hepatocellular carcinoma (HCC). The present study was undertaken to detect gene expression change of OCI-5 during occurrence and progression of rat HCC. METHODS: Male Sprague-Dawley rats were given diethylnitrosamine (DENA) to induce HCC. Three DENA-induced rats and one control rat were sacrificed every week for 18 weeks during the development of HCC. Tissues specimens were snap-frozen in liquid nitrogen and total RNA was isolated. Sk-Hep1 cells were treated with DENA at different concentrations. The gene expression levels of OCI-5 and GPC3 were detected with the RT-PCR method. RESULTS: OCI-5 was not expressed in normal rat liver tissues. When HCC occurred and aggravated, OCI-5 expression was gradually elevated to a very high level. GPC3 was not expressed in the DENA-treated Sk-Hep1 cells. CONCLUSIONS: OCI-5 was not expressed in normal rat liver tissues but in rat HCC tissues. High-expression of OCI-5 in DENA-induced rat HCC model was the gene expression change of HCC not the DENA-induced gene expression. The expression level of OCI-5 was not only elevated in rat HCC but also gradually along the occurrence and progression of HCC, indicating that GPC3 might serve as a sensitive marker of early stage HCC.