Pathophysiological factors contributing to fractional flow reserve and instantaneous wave-free ratio discordance.

The diagnostic accuracy and clinical benefits of instantaneous wave-free ratio (iFR) compared to fractional flow reserve (FFR) have been well-established in the literature. Despite the advantages of non-hyperemic pressure indices, approximately 20% of iFR and FFR measurements are discordant. Efforts have been made to establish the mechanisms as well as identify causative factors that lead to such a discordance. Recent studies have identified many factors of discordance including sex differences, age differences, bradycardia, coronary artery stenosis location, elevated left ventricular end-diastolic pressure, and diastolic dysfunction. Additionally, discordance secondary to coronary artery microcirculation dysfunction, as seen in diabetics and patients on hemodialysis, has sparked interest amongst experts. As more interventional cardiologists are utilizing iFR independent of FFR to guide percutaneous coronary intervention an emphasis has been placed on identifying factors leading to discordance. The aim of this review is to outline recent studies that have identified factors of FFR and iFR discordance.

Rural versus urban outcomes following transcatheter aortic valve implantation: The importance of the heart team.

BACKGROUND: Rural patients face known healthcare disparities and worse cardiovascular outcomes compared to urban residents due to inequitable access and delayed care. Few studies have assessed rural-urban differences in outcomes following Transcatheter Aortic Valve Implantation (TAVI). We compared short-term post-TAVI outcomes between rural and urban patients. METHODS: We performed a retrospective analysis of n = 413 patients who underwent TAVI at our large academic medical center, between 2011 and 2020 (rural/urban patients = 93/320. Rural/urban males = 53/173). Primary outcomes were all-cause mortality and cardiovascular mortality. Secondary outcomes included stroke/transient ischemic attack, myocardial infarction, atrial fibrillation, acute kidney injury, bleeding, vascular complications, and length of stay. RESULTS: The mean age in years was 77 [IQR 70-82] for rural patients and 78 [IQR 72-84] for urban patients. Baseline characteristics were similar between groups, except for a greater frequency of active smokers and diabetics as well as a greater body mass index in the rural group. There were no statistically significant differences in all-cause or cardiovascular mortality between the groups. There was also no statistically significant difference in secondary outcomes. CONCLUSION: Rural and urban patients had no statistically significant difference in all-cause mortality or cardiovascular mortality following TAVI. Given its minimally invasive nature and quality-centric, multidisciplinary care provided by the TAVI Heart Teams, TAVI may be the preferred modality for the treatment of severe aortic stenosis in rural populations.

Coronary Artery Calcification and Risk of Cardiac Complication in Geriatric Trauma Population.

BACKGROUND: Better means of identifying patients with increased cardiac complication (CC) risk is needed. Coronary artery calcification (CAC) is reported on routine chest CT scans. We assessed the correlation of CAC and CCs in the geriatric trauma population. STUDY DESIGN: A prospective, observational study of patients 55 years and older who had chest CT scan from May to September 2022 at a level 1 trauma center. Radiologists scored CAC as none, mild, moderate, or severe. None-to-mild CAC (NM-CAC) and moderate-to-severe CAC (MS-CAC) were grouped and in-hospital CCs assessed (arrhythmia, ST elevation myocardial infarction [STEMI], non-STEMI, congestive heart failure, pulmonary edema, cardiac arrest, cardiogenic shock, and cardiac mortality). Univariate and bivariate analyses were performed. RESULTS: Five hundred sixty-nine patients had a chest CT, of them 12 were excluded due to missing CAC severity. Of 557 patients, 442 (79.3%) had none-to-mild CAC and 115 (20.7%) has MS-CAC; the MS-CAC group was older (73.3 vs 67.4 years) with fewer male patients (48.7% vs 54.5%), had higher cardiac-related comorbidities, and had higher abbreviated injury scale chest injury scores. The MS-CAC group had an increased rate of CC (odds ratio [OR] 1.81, p = 0.016). Cardiac complications statistically more common in MS-CAC were congestive heart failure (OR 3.41, p = 0.003); cardiogenic shock (OR 3.3, p = 0.006); non-STEMI I or II (OR 2.8, p = 0.017); STEMI (OR 5.9, p = 0.029); and cardiac-caused mortality (OR 5.27, p = 0.036). No statistical significance between pulmonary edema (p = 0.6), new-onset arrhythmia (p = 0.74), or cardiac arrest (p = 0.193). CONCLUSIONS: CAC as reported on chest CT scans demonstrates a significant correlation with CC and should warrant additional cardiac monitoring.

Combined clopidogrel and aspirin therapy in patients undergoing carotid endarterectomy is associated with an increased risk of postoperative bleeding.

This present study investigated the influence of combined preoperative clopidogrel and aspirin (ASA) administration on adverse postoperative outcomes and bleeding risk in patients undergoing carotid endarterectomy (CEA). A retrospective cohort study of all consecutive patients undergoing isolated CEA (n = 1488) between 1998 and 2005 was performed. Patients were classified into three groups: patients receiving combined preoperative clopidogrel/ASA therapy (n = 315), patients receiving preoperative ASA only (n = 639) and patients receiving no preoperative antiplatelet therapy (n = 518). Multivariate logistic regression was performed to determine if combined preoperative clopidogrel and ASA therapy is independently associated with improved perioperative outcomes after CEA in the absence of significant bleeding risk. Clopidogrel/ASA therapy was independently associated with a five-fold increased risk of postoperative bleeding after CEA (odds ratios = 5.1; 95% confidence intervals: 1.8­14.2; P < 0.002). No increase in bleeding risk or reoperation was observed in patients receiving ASA alone. However, the postoperative length of hospital stay (PLOHS) was significantly shorter (P = 0.01) for patients receiving combined clopidogrel/ASA therapy (2.5 ± 2.3 days) versus those receiving no antiplatelet agents (3.2 ± 5.9 days). Preoperative clopidogrel/ASA therapy increases risk of postoperative bleeding after CEA, yet reduces overall PLOHS.

Comparison of Tricuspid Regurgitation Severity Between Cardiac Resynchronization Therapy Versus Right Ventricular Pacing in Patients With Chronic Obstructive Pulmonary Disease.

Background: Right ventricular (RV) lead placement can worsen tricuspid regurgitation (TR). TR is known to be associated with lower survival irrespective of left ventricular ejection fraction (LVEF) or pulmonary hypertension (PH). Patients with chronic obstructive pulmonary disease (COPD) often have PH and pre-existent TR with higher morbidity and mortality from worsening TR. Prior studies are lacking to indicate if cardiac resynchronization therapy (CRT) may be more beneficial in lessening TR in COPD patients. Therefore, we sought to study if patients with COPD will have less TR with CRT versus non-CRT devices. Methods: We performed a retrospective, single-center analysis on 154 COPD patients (mean age = 71.69 ± 10.58, males = 54.14%) that required single-chamber (n = 27), dual-chamber (n = 90), or CRT (n = 37) devices. TR severity, LVEF and right ventricular systolic pressure (RVSP) were evaluated by two cardiologists in a blinded fashion. Analysis of variance (ANOVA) and Chi-square tests were applied for continuous and categorical variables respectively. The primary endpoint was a change in the severity of TR comparing pre-device versus post-device echocardiogram. Secondary endpoints included changes in LVEF and RVSP. Results: COPD patients, who underwent a CRT device had a significantly lower incidence of worsening TR (16%) when compared to single- (37%) (P = 0.001) and dual-chamber devices (30%) (P = 0.02). The increase in RVSP was similar between the groups. There was an expected improvement in LVEF in the CRT group. Conclusions: COPD patients receiving a CRT device were least likely to have worsening TR, compared to single- or dual-chamber devices. Since both COPD and progression in TR may result in poor outcomes, our study may suggest that an upfront strategy of CRT rather than a single- or dual-chamber device may be more beneficial in COPD patients, especially with pre-existent TR.

Inferior Myocardial Infarction Secondary to Coronary Artery Vasospasm Following Regadenoson Stress Imaging.

Coronary artery vasospasm is a rare condition that is caused by hyperactive arterial smooth muscle vasoconstriction leading to reversible coronary artery occlusion. Patients that suffer from coronary artery vasospasm have the potential to develop life-threatening conditions such as myocardial infarction and fatal arrhythmias. ST-elevations are a rare complication that can occur in people with coronary vasospasm, and to the best of our knowledge there are no documented cases of ST-elevation myocardial infarction occurring in patients undergoing regadenoson stress test. We present a unique case of a patient with known coronary artery disease and catheter-induced coronary artery vasospasm who developed ST-segment elevations and typical angina immediately following the administration of regadenoson during an elective myocardial stress test.

Very Late Aortic Endograft Infection With Listeria monocytogenes in an Elderly Man.

Endograft infection with Listeria monocytogenes is a rare, potentially devastating complication of endovascular aortic aneurysm repair. To our knowledge, only 8 cases have been reported. We describe the case of a 72-year-old man who presented with L. monocytogenes endograft infection and a 19-cm degenerative aneurysm 9 years after having undergone endovascular repair of an abdominal aortic aneurysm. The infection was successfully treated with open surgical excision of the infected aortoiliac endograft and its replacement with a rifampin-soaked, bifurcated Dacron graft.

Prevotella bivia cardiac implantable electronic device related endocarditis.

Cases of Gram-negative, anaerobic rod bacteremia and endocarditis have been increasingly recognized in recent years. This increase has been primarily observed in patients at risk for polymicrobial infections, such as those who use injection drugs and patients with diabetes mellitus. Despite a growing incidence, there are few published case reports of cardiac implantable electronic device related endocarditis secondary to Gram negative, anaerobic organisms. We present a unique case of Prevotella bivia cardiac implantable electronic device related endocarditis in a middle-aged woman with no history of injection drug use. This case highlights the increasing incidence of polymicrobial infections and anaerobic endocarditis. Additionally, it demonstrates how Prevotella bivia has the potential to cause native valve infective endocarditis as well as cardiac implantable electronic device related endocarditis.

Use of the CHA2DS2-VASc Score in Assessing Transradial Approach Failure.

BACKGROUND: Radial access is now considered the preferred approach for coronary angiography and percutaneous coronary intervention because of the low risk of vascular complications. However, radial access failure is not uncommon, leading to crossover to a different access site. The CHA2DS2-VASc score is used to estimate stroke risk in patients with atrial fibrillation. Our study aimed to assess the CHA2DS2-VASc score in predicting failure of the transradial approach, resulting in crossover to transfemoral access (TFA) for coronary angiography. METHODS: We performed a single-center, non-randomized, retrospective study. The study included 1775 patients who underwent coronary angiography with or without subsequent percutaneous intervention between July 2018 and October 2019. The study population was divided into three groups based on the CHA2DS2-VASc score: low (≤2), intermediate (3-4), and high score (≥5) groups. The association between the CHA2DS2-VASc score and radial access failure was evaluated and compared between the groups. RESULTS: A total of 197 patients (11.1%) had crossover to the femoral artery. A large percentage of patients (19.2%) had radial access failure in the high CHA2DS2-VASc score group (≥5) compared with 12.5% in the intermediate score group (3-4) and only 6.3% in the low score group (≤2). The highest crossover rate (42.9%) was observed in patients with a CHA2DS2-VASc score of 8. Higher CHA2DS2-VASc scores were also associated with increased fluoroscopy time, contrast administration, and radiation exposure. CONCLUSION: The CHA2DS2-VASc score can predict failure of the transradial approach, with a score of ≥5 having the highest correlation of failure requiring crossover to TFA.

Comparison of Transcatheter Aortic Valve Implantation Outcomes Between Normal-Flow, Low-Gradient Severe Aortic Stenosis and Normal-Flow, High-Gradient Severe Aortic Stenosis.

BACKGROUND: Normal flow low gradient severe aortic stenosis (NFLG-AS) with preserved ejection fraction is the most prevalent form of low gradient severe aortic stenosis. Despite the increased prevalence, the clinical outcomes and management strategy of NFLG-AS remain controversial. Therefore, our study aimed to evaluate transcatheter aortic valve implantation (TAVI) outcomes of patients with NFLG-AS compared with normal flow high gradient severe aortic stenosis (NFHG-AS). METHODS: We performed a retrospective analysis of 394 patients who underwent TAVI between January 2011 to September 2020. Among 394 patients, 232 patients had NFLG-AS, and 162 patients had NFHG-AS. The primary outcomes included all-cause mortality and cardiovascular mortality. In addition, multiple secondary outcomes were evaluated, including stroke, myocardial infarction, duration of hospital stay, new-onset atrial fibrillation, temporary or permanent pacemaker requirement, major bleeding, blood transfusion, vascular complications, acute kidney injury, hemodialysis requirement, symptom improvement, and repeat hospitalizations due to any cardiac disease. RESULTS: The cumulative six months incidence of all-cause mortality and cardiovascular mortality were similar between and NFLG-AS and NFHG-AS (4.32% vs. 5.17%, P = 0.71 and 2.47% vs. 2.59%, P = 0.94 respectively). There was no difference in the rates of stroke, myocardial infarction, duration of hospital stay, new-onset atrial fibrillation, temporary or permanent pacemaker requirement, major bleeding, blood transfusion, vascular complications, acute kidney injury, hemodialysis requirement, and symptom improvement between the two groups. However, patients with NFLG-AS compared to NFHG-AS had more frequent cardiac-related repeat hospitalizations (19.14% vs. 11.64%, P = 0.04%). CONCLUSION: There was no significant difference in all-cause mortality and cardiovascular mortality between NFLG-AS and NGHG-AS six months post-TAVI. However, patients undergoing TAVI with NFLG-AS had significantly higher rates of cardiac-related repeat hospitalizations.

Contemporary relevancy of carotid-subclavian bypass defined by an experience spanning five decades.

BACKGROUND: The contemporary impact of and indications for carotid-subclavian bypass (CSB) are essential considerations in decision making for brachiocephalic reconstruction. METHODS: We analyzed operative outcomes, long-term graft patency, and the extended epidemiological impact of the primary disease process in 287 consecutive patients (mean age, 60.6 years; 43.2% male) who received CSB for symptomatic brachiocephalic disease. RESULTS: Technical success was achieved in each patient. Operative mortality was 1.0% (3/287) and total (ipsilateral [1.4%, 4/287] plus contralateral [0.7%, 2/287]) stroke rate was 2.1% (6/287). Primary patency rates at 5, 10, and 15 years were 94.2 ± 1.9%, 88.6 ± 3.2%, and 86.5 ± 3.8%, respectively. Kaplan-Meier freedom from specific events at 15 years was as follows: restenosis, 86.5 ± 3.8%; death, 67.5 ± 5.2%; coronary revascularization, 59.6 ± 6.3%; myocardial infarction, 82.8 ± 3.9%; stroke, 85.6 ± 4.9%; other vascular procedure, 60.0 ± 5.5%; adverse cardiac outcome (death, myocardial infarction, or coronary revascularization), 44.5 ± 5.5%; and adverse vascular outcome (restenosis, stroke, or other vascular procedure), 48.7 ± 5.3%. CONCLUSIONS: CSB produces excellent long-term patency and extended symptom relief, with acceptably low operative morbidity and mortality. Despite the durability and success of CSB, the primary disease process has an adverse impact on long-term prognosis and significantly influences decision making with regard to management. The proven durability may offer extended symptom relief to the relatively younger patient, a survival advantage associated with preservation of internal mammary artery perfusion in patients at risk for myocardial revascularization, optimal durability in patients requiring a concomitant open procedure, and preservation of limb function in patients who require aortic endovascular graft placement.

Effect of Elevated Left Ventricular End Diastolic Pressure on Instantaneous Wave-Free Ratio and Fractional Flow Reserve Discordance.

BACKGROUND: Instantaneous wave-free ratio (iFR)-guided physiological assessment has been shown to be non-inferior to fractional flow reserve (FFR)-guided assessment for deciding best treatment strategy for angiographically intermediate stenosis. The diagnostic accuracy of iFR compared to FFR reported in various studies is around 80%. Many factors can lead to iFR/FFR discordance, though underlying physiological mechanism of discordance and its associated factors have not been fully evaluated. The effect of left ventricle end diastolic pressure (LVEDP) on iFR/FFR discordance is unknown and needs further evaluation. METHODS: We performed a single center, non-randomized, both retrospective and prospective study. A total of 65 patients with intermediate coronary stenosis undergoing physiological assessment were included in the study. Patients were assigned to two groups (normal LVEDP and high LVEDP group) based on LVEDP cutoff of 15 mm Hg. iFR and FFR were measured for each patient and iFR/FFR results were compared between the two groups. RESULTS: A significantly large number of patients in elevated LVEDP group had iFR/FFR discordance compared to normal LVEDP group (42.8% vs. 6.7%, P = 0.001). More patients with acute coronary syndrome (ACS) had discordance compared to stale coronary artery disease (CAD) patients (53% vs. 15%, P = 0.003). CONCLUSIONS: Elevated LVEDP can affect iFR and FFR measurements and can lead to discordance. Further studies are required to determine effect of elevated LVEDP on iFR/FFR discordance and whether such discordance is clinically relevant. "Normal range" iFR results should be cautiously interpreted in patients with elevated LVEDP, especially those with ACS.

Positional changes leading to transient ischaemia in a patient with neuroendocrine carcinoma of the lung.

Coronary spasm in carcinoid heart disease has an incidence of 10%, but is rare in patients with neuroendocrine tumours without carcinoid heart disease. We present a rare case of right coronary artery spasm and ST elevations secondary to a neuroendocrine carcinoma of the lung, uniquely provoked by positional changes. Our patient is a 55-year-old man with recurrent ST-elevation myocardial infarction secondary to coronary vasospasm that was diagnosed with neuroendocrine carcinoma of the lung. We believe his positional coronary spasm episodes were likely due to intermittent tumour compression from changes in body position. Our case highlights positional coronary spasm as a previously unreported and potentially early manifestation of neuroendocrine carcinoma of the lung.

Successful Low-Dose tPA for Mechanical Mitral Valve Thrombosis in a Patient with Postinfarction Contained Left Ventricular Free Wall Rupture.

Prosthetic valve thrombosis is a potentially life-threatening complication diagnosed by a combination of clinical features and imaging modalities, but the optimal management in high bleeding risk patients remains controversial. Current treatment options for prosthetic valve thrombosis included surgery, thrombolytic therapy, and anticoagulation. We present a very unusual case of a patient with a recent ST-elevation myocardial infarction complicated by contained left ventricle free wall rupture and mechanical mitral valve thrombosis. Deemed a high surgical risk candidate, low-dose tissue plasminogen activator was used despite significant bleeding risk from contained left ventricle free wall rupture, which resulted in resolution of the thrombus. To the best of our knowledge, this is the first report of successful thrombolytic therapy for prosthetic mechanical mitral valve thrombosis in a patient with recent postmyocardial infarction contained left ventricular free wall rupture.

Association of Echocardiographic Diastolic Dysfunction with Discordance of Invasive Intracoronary Pressure Indices.

Instantaneous wave-free ratio (iFR)-guided coronary revascularization has similar clinical outcomes compared to fractional flow reserve (FFR)-guided revascularization strategy. However, some studies have shown a discordance of around 20% between iFR and FFR. Although various factors have been reported in the literature to affect pressure indices and lead to such discordance, there is a paucity of data regarding the effect of diastolic dysfunction on functional assessment of coronary arteries. Our study aimed to investigate whether there was an association between echocardiographic left ventricular diastolic dysfunction and iFR/FFR discordance. This retrospective observational study evaluated 100 patients with angiographically intermediate coronary stenosis (50-70%) who underwent physiological testing with iFR and FFR. Transthoracic echocardiograms were reviewed to assess echocardiographic indices of diastolic function. The study population was divided into two groups based on diastolic function. iFR and FFR discordance was measured in each group and compared to evaluate the statistical difference. The mean age of the study population was 66.22 ± 10.02 years. Discordance between iFR and FFR was seen in 45.16% of patients with diastolic dysfunction compared to 24.64% of patients with normal diastolic function (p = 0.04). Multivariable logistic regression analysis indicated that echocardiographic E/e' was independently associated with iFR/FFR discordance (p = 0.02). Left ventricular diastolic dysfunction is a significant factor that can lead to discordance between iFR and FFR and should be taken into account during coronary physiological testing.

Heme Effects in Lowering Patient Discomfort in Radial Artery Verapamil Injection.

BACKGROUND: The primary objective of this study was to evaluate whether diluting verapamil with heme as compared to normal saline reduces patient discomfort during radial artery injection. Following radial artery access, verapamil is frequently administered to reduce the incidence of radial artery spasm. The injection of verapamil via the radial artery is associated with a temporary "burning" discomfort. It has been hypothesized that the dilution of verapamil with heme rather than saline leads to less patient discomfort during administration. METHODS: This prospective, single-center, randomized study enrolled patients undergoing coronary angiography via radial artery access between August 2017 and April 2018. Patients were randomized 1:1 to receive either verapamil/heme or verapamil/saline administration. Patient discomfort was assessed at the time of injection, and 1-h post procedure. RESULTS: A total of 214 patients were enrolled in the study. Of these, 103 patients were included in the verapamil/heme group and 100 in the verapamil/saline group. For the primary objectives, there were no statistically significant differences in patient discomfort at the time of verapamil injection (P = 0.15), or 1-h post injection (P = 0.48). However, in the verapamil/heme group, there was a trend towards a lower post-injection pain score (M = 2.83, standard deviation (SD) = 3.18) compared to the verapamil/saline group (M = 3.48, SD = 3.01) (P = 0.15). CONCLUSION: There was no significant difference in immediate or 1-h post-procedure patient discomfort with verapamil diluted with heme as compared to dilution with saline. While there was a trend towards lower immediate patient discomfort in the verapamil/heme group, larger studies are needed to further evaluate this trend.

Iatrogenic Arteriovenous Fistula Secondary to Coronary Artery Dissection Caused by Contrast Injection Into a Chronically Occluded Right Coronary Artery.

Coronary arteriovenous fistulas and coronary cameral fistulas are rare anomalies that involve the abnormal communication between a coronary artery and a venous structure, such as a coronary vein or a right-sided cardiac chamber. Iatrogenic coronary arteriovenous fistulas and coronary cameral fistulas can be uncommon complications of coronary artery angiography and intervention. Acquired coronary arteriovenous fistulas that develop during percutaneous coronary intervention of chronic total occlusions have been previously reported in the literature. However, a coronary arteriovenous fistula resulting from contrast injection into a chronically and totally occluded right coronary artery during diagnostic coronary angiography is very rare. We present a unique case of a contrast-induced iatrogenic right coronary dissection leading to a coronary arteriovenous fistula communicating to the right atrium through the middle cardiac vein.

Comparing Echocardiographic Modalities in Native-Valve Infective Endocarditis Due to Methicillin-Resistant Staphylococcus Aureus in People Who Inject Drugs.

BACKGROUND: Methicillin-resistant Staphylococcus aureus (MRSA) infective endocarditis (IE) is associated with high morbidity and mortality. Current IE guidelines recommend transesophageal echocardiogram (TEE) over transthoracic echocardiogram (TTE) to diagnose infective endocarditis. Management of IE in people who inject drugs (PWID) in many medical centers is mainly conservative with prolonged intravenous antibiotics. Cardiac valve replacement in these patients remains controversial, given the high risk of reinfection. This study's purpose is to evaluate whether obtaining sequential TEE after TTE in PWID with MRSA native-valve IE changes the management plan in these patients. METHODS: A retrospective cohort of patients who are 18 years of age or older and inject drugs with definite MRSA IE between 2013 and 2019 were studied. Their echocardiographic reports and overall management plans were reviewed. RESULTS: One hundred and twenty-six patients met the inclusion criteria. TTE was performed in 121 patients and, of these patients, 69 (57%) had detectable valvular vegetations while 52 (43%) did not. Of the 52 patients with a negative TTE, 44 underwent TEE, 28 (53%) of which showed vegetation. A total of 18 (14%) patients underwent surgery. Of these, six (33%) patients had a positive TTE only, with no subsequent TEE. Ten (56%) patients had both a positive TTE and TEE, and two (11%) patients had a negative TTE but positive TEE. CONCLUSION: In this retrospective cohort, obtaining a sequential TEE after a TTE in PWID with proven MRSA native IE by modified Duke's criteria changed the management plan in two patients. The decision to perform a TEE in these patients needs to be individualized. Larger studies are needed to better evaluate the role of TEE in this patient population.

Subaortic stenosis secondary to pannus from a mechanical mitral valve.

A variety of conditions can lead to left ventricle outflow tract obstruction, but cases of subaortic stenosis decades following a mitral valve replacement are exceedingly rare. Any abnormal positioning of a prosthetic valve can result in continuous turbulence leading to permanent deposition of fibrous tissue. We present a case of a 56-year-old female that underwent mechanical mitral valve replacement, due to severe rheumatic mitral valve disease, with recurrent admissions for dyspnea. Ultimately, she underwent a left heart catheterization and during pullback from the left ventricle to the aorta a 100-mmHg pressure gradient was noted below the level of the aortic valve suggestive of subaortic stenosis. The subaortic stenosis was found to be secondary to pannus formation from her mitral valve prosthesis placed over twenty years ago. .

Successful Rescue Intervention of Internal Mammary Artery Anastomotic Site Acute Graft Failure With Direct New Generation Covered Stenting.

Acute, perioperative myocardial infarction (MI) from acute left internal mammary artery (LIMA) to left anterior descending (LAD) graft failure immediately following coronary artery bypass grafting (CABG) surgery is associated with significantly increased in-hospital mortality. The leading etiology of such acute graft failure is acute thrombosis, dissection, spasm, anastomosis failure or no-reflow phenomenon. Repeat bypass surgery carries incremental risk and may not be feasible in hemodynamically unstable patients. Traditional percutaneous coronary intervention (PCI), with or without stent placement is sometimes used in such cases; however, graft anatomy and lesion location increase procedural complexity and challenge technical feasibility. This is particularly true of the LIMA to LAD graft anastomosis, where PCI carries the risk of anastomotic site perforation or avulsion. Therefore, the best revascularization strategy for such a lesion involving the LIMA to LAD graft anastomosis in the immediate perioperative period remains unknown. We present a case of 75-year-old male who suffered an acute MI complicated by cardiogenic shock less than 24 h after two-vessel CABG. Selective angiography revealed acute LIMA to LAD anastomotic site closure, posing a risk for perforation if treated with traditional angioplasty or stenting. We successfully performed rescue PCI, by directly deploying a PK Papyrus covered stent (Biotronik, Berlin, Germany) across the anastomosis. Our case report describes the upfront (rather than a bail out) use of the new covered stent as a novel revascularization strategy to treat "perforation prone" LIMA to LAD anastomotic site acute graft failure.