Mitral valve repair with the MitraClip device after prior surgical mitral annuloplasty.

While mitral valve repair using the MitraClip device is currently being evaluated in the EVEREST trials, surgical approaches to mitral regurgitation remain the standard of care, at least for operative candidates. Two patients in whom previous surgical annuloplasty failed to maintain MR reduction and who were treated with the MitraClip device after mitral valve repair surgery are described. Imaging and hemodynamic considerations associated with this approach are discussed.

Prevalence of renal artery stenosis requiring revascularization in patients initially referred for coronary angiography.

To evaluate the prevalence of clinically significant renal artery stenosis (RAS) in patients referred for coronary angiography, we analyzed data on 2,439 consecutive patients. Patients underwent selective renal angiography in conjunction with coronary angiography if refractory hypertension (blood pressure > 140/90 on two drugs) or flash pulmonary edema was present. A total of 1,089 renal arteries of 534 patients were evaluated. Twelve percent (137/1,089) of the renal arteries in 19% (101/534) of patients had > 70% diameter stenosis in at least one vessel. Bilateral renal artery stenosis was present in 26% (26/101) of patients. One hundred and thirty-two of the 137 vessels underwent stent revascularization due to clinical renovascular hypertension. Acute clinical success (< 20% diameter stenosis without death or urgent surgery) was 98% (99/101). Due to high prevalence and effective available treatment, we recommend routine screening for RAS in all patients with refractory hypertension referred for coronary angiography.

Acute and long-term results after intra-arterial thrombolysis of occluded lower extremity bypass grafts using recombinant tissue plasminogen activator for acute limb-threatening ischemia.

Occlusion of lower extremity vascular bypass grafts results in acute limb-threatening ischemia. The underlying cause of graft failure generally is distal anastomosis stenosis, and relief of culprit stenosis is a required to maintain long-term patency. Of the three thrombolytic agents used for prolonged infusion to accomplish fibrinolysis, streptokinase was the first to be used and is limited owing to the antigenicity that precludes repeated use. Urokinase had been the mainstay of thrombolytic therapy until it was withdrawn by the U.S. Food and Drug Administration in 1999 because of the potential of transmission of infectious agents during its manufacturing process. Recombinant tissue plasminogen activator (rt-PA) has not been studied adequately to assess safety and efficacy, and there are no standardized dosing guidelines. We report our experience with six patients presenting with acute limb-threatening ischemia attributable to thrombosis of synthetic lower extremity bypass grafts. After thrombolysis using rt-PA (mean bolus dose, 12.2 +/- 3.6 mg; range, 6-15 mg administered over 5 minutes followed by infusion at 2 mg/h for 15.6 +/- 6.4 hours; total dose, 51 +/- 16 mg), successful thrombolysis was achieved in 84% of the patients. The primary patency rate was 75% and the secondary patency rate 100% at 16 weeks. One patient underwent amputation owing to unsuccessful thrombolysis. No major bleeding or vascular complications occurred. We conclude that intra-arterial thrombolysis using rt-PA is a safe and effective therapy for patients with thrombotic occlusion of synthetic lower extremity bypass grafts presenting with acute limb-threatening ischemia and allows a high rate of secondary patency, avoiding amputation.

Safety of therapeutic beta-blockade in patients with coexisting bronchospastic airway disease and coronary artery disease.

Atherosclerotic coronary artery disease and bronchospastic airway disease frequently coexist in older patients. There are substantial data suggesting reduced mortality with the use of beta-adrenergic blocking drugs in patients with symptomatic coronary artery disease, especially patients who have postmyocardial infarction and/or severe coronary artery disease associated with left ventricular dysfunction. Conversely, the use of beta-adrenergic blocking drugs (even selective beta(1)-adrenergic blocking drugs) has the potential of exacerbating bronchospasm. This prospective registry evaluates the safety of use of selective beta(1)-adrenergic blocking drugs in patients with symptomatic coronary artery disease and bronchospastic airway disease. A total of 835 consecutive patients with symptomatic coronary artery disease were prospectively evaluated for coexisting coronary and bronchospastic airway disease. Of these, 30 patients (mean age: 61 +/- 14 years) met the qualifying inclusion criteria. All these study patients except 1 (29/30 [96%]) reached therapeutic beta-blockade (resting heart rate <70 beats per minute). The 1 patient who discontinued use of beta-adrenergic blocking drugs as a result of lifestyle-limiting bronchospasm had no serious adverse outcome. No hospitalizations were required because of worsening bronchospasm. Ten percent of patients reported increased requirement of inhaled beta(2)-agonist use. The patients were followed for 15 +/- 9 months. One patient died of stroke at 22 weeks of follow-up. In conclusion, use of selective beta(1)-adrenergic blocking drugs at a therapeutic dose is safe (as long as careful clinical follow-up is available) and should be considered in all patients with coexisting symptomatic coronary artery disease and bronchospastic airway disease.

Suture-mediated closure of antegrade femoral arteriotomy following infrainguinal intervention.

Antegrade femoral arterial access has been less commonly adopted for infrainguinal intervention due to increased risk of retroperitoneal hemorrhage secondary to noncompressibility of arteriotomy site. We evaluated the efficacy and safety of suture-mediated closure of antegrade femoral arteriotomy using the Closer device. Twelve consecutive patients undergoing infrainguinal intervention (females, 5; mean body weight, 69 +/- 16 kg; limb threatening ischemia, 50%) underwent repair of the antegrade femoral arteriotomy immediately postprocedure using the Closer. Indications for antegrade access were excessive iliac tortuosity (6/12), long femoral artery occlusion (5/12), and bilateral aortoiliac bifurcation stents (1/12). The acute procedural success (immediate hemostasis without need for manual compression) was 100%. The mean time to ambulation was 3.9 +/- 1.5 hr and the procedure-related length of stay was 18 +/- 5.5 hr. In conclusion, repair of antegrade arterial puncture is safe and effective following infrainguinal intervention.

Safety and efficacy of combined use of low molecular weight heparin (enoxaparin, lovenox) and glycoprotein IIb/IIIa receptor antagonist (eptifibatide, integrelin) during nonemergent coronary and peripheral vascular intervention.

Coronary and peripheral intervention requires intraprocedural anticoagulation to prevent intraluminal thrombosis. Traditionally, unfractionated heparin (UFH) is administered during the procedure to achieve activated clotting time (ACT) of 300 to 400 seconds. When the intravenous IIb/IIIa antagonists are also used, the recommended ACT is 250 to 300 seconds because higher anticoagulation (ACT, 300-400 seconds) is accompanied by an unacceptable bleeding complication rate without added benefits. Because low molecular weight heparin has a more predictable anticoagulant effect and a higher anti-factor Xa/anti-factor IIa ratio, allows better bioavailability, is resistant to inhibition by activated platelets, and does not require routine monitoring using ACT, its use for intraprocedural anticoagulation (instead of UFH) has been an area of increasing interest. The safety and efficacy of coadministration of low molecular weight heparin with IIb/IIIa antagonists have not been adequately evaluated. We report a study of prospective evaluation of the safety and efficacy of combined use of intravenous enoxaparin and intravenous eptifibatide during nonemergent coronary and peripheral vascular intervention in 93 consecutive procedures performed on 56 patients. The procedural success rate was 99% (92/93 procedures), the acute clinical success rate was 98% (54/55 patients), the major bleeding complication rate was 2% (1/56 patients), and the vascular complication rate was 0.0%. In conclusion, the use of intravenous enoxaparin in conjunction with intravenous eptifibatide during nonemergent coronary and peripheral vascular intervention is safe and effective and eliminates the need for routine measurement of ACT during the procedure.