Heavy lone coronary artery thrombosis treated by stent retriever, in the setting of COVID-19 infection.

We present a case of heavy lone coronary thrombosis in the setting of COVID-19 infection. We highlight the special angiographic, ultrasonographic, and histological features of this thrombus, and we describe the application of carotid stent retriever for its removal.

Combined radial-tibial access strategy and radial-tibial reverse CART in a patient with aortobifemoral graft and complex superficial femoral artery occlusion.

We present the case of a patient with a history of aortobifemoral grafting who presented with left lower extremity ischemic rest pain. Aortofemoral angiography was performed through a left radial access and showed a long, calcified total occlusion of the left superficial femoral artery (SFA) and a subtotal popliteal occlusion. The popliteal artery and SFA were crossed retrogradely through a 4-Fr anterior tibial access; the retrograde devices went subintimally and did not reenter at the common femoral level. Subsequently, the radial access was used for antegrade subintimal crossing and dilatation of the SFA, which allowed reentry of the retrograde devices (radial-tibial reverse controlled antegrade-retrograde tracking [CART]). The SFA was then successfully treated retrogradely with orbital atherectomy and drug-coated balloon angioplasty, through a 4-Fr equivalent tibial sheath. © 2017 Wiley Periodicals, Inc.

Combined Radial-Pedal Access Strategy and Radial-Pedal Rendezvous in the Revascularization of Complex Total Occlusions of the Superficial Femoral Artery (the "No Femoral Access" Strategy).

PURPOSE: To describe the combined use of radial-pedal access for recanalization of complex superficial femoral artery (SFA) occlusions unsuitable for transfemoral recanalization. TECHNIQUE: Patients are selected for this strategy if they have a long (≥ 10 cm) SFA occlusion with unfavorable aortoiliac anatomy, an absent ostial stump, or severely diseased and calcified distal reconstitution. Left radial artery and distal anterior or posterior tibial artery are accessed with 6-F and 4-F sheaths, respectively. The SFA lesion is crossed retrogradely with a 0.035-inch wire system. If retrograde crossing is not immediately successful, transradial subintimal tracking and radial-pedal subintimal rendezvous are used to allow retrograde reentry. Fifteen patients (mean age 62 ± 5 years; 11 men) have been treated in this fashion, and frequently stented, through the tibiopedal access. Seven patients required radial-pedal rendezvous to facilitate retrograde reentry. Two patients underwent transradial iliac stenting during the same session, and 1 patient underwent transradial kissing angioplasty of the profunda. No major complication occurred in any patient. After the procedure, the pulse across the accessed tibial artery was palpable in all patients. CONCLUSION: In patients with long and complex SFA occlusion unsuitable for transfemoral recanalization, a radial-pedal strategy can overcome revascularization obstacles.

Atrioventricular Accessory Pathways: Mechanisms, Electrocardiograms, and Associated Arrhythmias.

An atrioventricular accessory pathway (AP) may be manifest or concealed. When manifest, it leads to preexcitation on the baseline electrocardiogram, which is called the Wolff-Parkinson-White pattern. The degree of preexcitation varies according to the relative conduction speed of the atrioventricular node versus the AP, the AP location, and the AP refractory period. This explains that even a manifest AP may lead to only intermittent preexcitation. The AP conducts faster than the atrioventricular node but has a longer refractory period, which allows the initiation of a reentrant arrhythmia called atrioventricular reciprocating tachycardia. In addition to re-entry, a manifest AP may allow the fast antegrade conduction of an atrial tachyarrhythmia, leading to a small risk of sudden death; the latter depends on the AP refractory period (ie, the number of atrial waves it can conduct back to back) rather than the AP conduction speed. This can be assessed invasively and noninvasively and allows risk stratification of asymptomatic individuals.

New or presumably new left bundle branch block in patients with suspected acute coronary syndrome: Clinical, echocardiographic, and electrocardiographic features from a single-center registry.

BACKGROUND: In patients with suspected acute coronary syndrome, a new or presumably new left bundle branch block (LBBB) does not always imply ST-segment elevation myocardial infarction (STEMI). We aimed to show the low frequency of STEMI-equivalent in this population and determine the diagnostic value of electrocardiographic and echocardiographic features. METHODS: From the 387 patients captured by the Louisiana State University code STEMI registry between 2009 and 2012, we examined data on 26 patients with LBBB. These patients were divided into 3 groups according to the final diagnosis: (1) STEMI-equivalent, defined as an acute coronary occlusion on angiography (2 patients), (2) non-ST-segment elevation myocardial infarction (4 patients), and (3) diagnoses other than myocardial infarction (non-MI) (20 patients). RESULTS: Troponin elevation and left ventricular systolic dysfunction were common in all 3 groups (non-significant p-values). Compared with non-MI patients, patients with STEMI-equivalent had a larger degree of ST-segment discordance and T-wave discordance, as assessed by ST/QRS and T/QRS ratios (p<0.001). ST/QRS ratio ≥ 0.2 and T/QRS ratio ≥ 0.5 were sensitive and specific for the diagnosis of STEMI-equivalent in the setting of LBBB. Conversely, absolute values of ST-segment and T-wave discordance were not significantly different between groups. ST-segment concordance was highly specific for the diagnosis of STEMI-equivalent, but had a limited sensitivity. CONCLUSION: Only a minority of patients with suspected acute coronary syndrome and LBBB have a STEMI-equivalent. Excessive relative discordance of the ST segment or the T wave appears predictive of STEMI-equivalent, but this is only hypothesis-generating considering the small population size.

Intravenous iron therapy for patients with iron deficiency and heart failure: a systematic review and meta-analysis of randomized controlled trials.

Introduction: Heart failure (HF) presents a significant health challenge, with intravenous (IV) iron therapy considered a potential treatment avenue. Method: We assessed IV iron therapy's efficacy in HF patients with concurrent iron deficiency versus standard of care. Primary outcomes included the composite of HF hospitalizations or cardiovascular-related mortality, HF hospitalizations, and all-cause, HF, and cardiovascular mortality rates. Secondary measures encompassed improvements in New York Heart Association functional classification, quality of life, 6-minute walk test, left ventricular ejection fraction, and adverse events. We used a random-effects model to compute relative risk (RR) or mean difference (MD) with 95% confidence intervals (CIs). Results: Based on an analysis of 14 randomized controlled trials involving 6614 patients, IV iron therapy significantly reduced composite outcome (RR: 0.84, 95% CI: 0.73, 0.96; P = 0.01) and HF hospitalizations (RR: 0.74, 95% CI: 0.61, 0.89; P = 0.002) compared to standard of care. Mortality rates showed no significant difference. IV iron therapy improved New York Heart Association functional classification, quality of life, and 6-minute walk test, with no major impact on left ventricular ejection fraction. Adverse events remained stable. Conclusions: IV iron therapy holds promise for diminishing HF hospitalizations and enhancing quality of life and 6-minute walk test in HF patients. Yet, its effect on all-cause or cardiovascular mortalities appears limited.

Hypothermia as an Adjunctive Therapy to Percutaneous Intervention in ST-Elevation Myocardial Infarction: A Systematic Review and Meta-Analysis of Randomized Control Trials.

INTRODUCTION: In the setting of acute ST-elevation myocardial infarction (STEMI), several randomized control trials (RCTs) suggested a potential benefit with the use of therapeutic hypothermia (TH). However, results from previous studies are contradictory. METHOD: We performed a comprehensive literature search for studies that evaluated the efficacy and safety of adjunctive TH compared to the standard percutaneous coronary intervention (PCI) in awake patients with STEMI. The primary outcomes were the infarct size (IS) and microvascular obstruction (MVO) assessed by cardiac imaging at the end of follow-up. The secondary outcomes were major adverse cardiovascular events (MACE), procedure-related complications, and door-to-balloon time. Relative risk (RR) or the mean difference (MD) and corresponding 95 % confidence intervals (CIs) were calculated using the random-effects model. RESULTS: A total of 10 RCTs, including 706 patients were included. As compared to standard PCI, TH was not associated with a statistically significant improvement in the IS (MD: -0.87 %, 95%CI: -2.97, 1.23; P = 0.42) or in the MVO (MD: 0.11 %, 95%CI: -0.06, 0.27; P = 0.21). MACE and its components were comparable between the two groups. However, the TH approach was associated with an increased risk of infection and prolonged door-to-balloon time. Furthermore, there was a trend in the TH group toward an increased incidence of stent thrombosis and paroxysmal atrial fibrillation. CONCLUSIONS: According to our meta-analysis of published RCTs, TH is not beneficial in awake patients with STEMI and has a marginal safety profile with potential for care delays. Larger-scale RCTs are needed to further clarify our results.

Characteristics and in-hospital outcomes of patients presenting with non-ST-segment elevation myocardial infarction found to have significant coronary artery disease on coronary angiography and managed medically: stratification according to renal function.

BACKGROUND: The characteristics, therapies, and outcomes of patients presenting with non-ST-segment elevation myocardial infarction, found to have significant coronary artery disease on coronary angiography, and managed without revascularization ("nonrevascularized patients") have not been evaluated previously in a large-scale registry. METHODS: We examined data on 13,872 non-ST-segment elevation myocardial infarction nonrevascularized patients who were captured by the Acute Coronary Treatment and Intervention Outcomes Network registry. Patients were divided according to baseline renal function in 4 groups: no chronic kidney disease (CKD) and CKD stages 3, 4, and 5. RESULTS: The in-hospital mortality of nonrevascularized patients was 3.7%, whereas their in-hospital major bleeding rate was 10.8%. Overall, 44.2% (n = 6,132) of nonrevascularized patients had CKD. Compared with patients with normal renal function, nonrevascularized patients with CKD had significantly more history of myocardial infarction, heart failure, more 3-vessel coronary artery disease, and received fewer antithrombotic therapies. In addition, they had significantly higher rates of in-hospital mortality and major bleeding; CKD stage 4 was associated with the highest risk of adverse events. The multivariable-adjusted odds ratios of in-hospital mortality for CKD stages 3, 4, and 5 relative to no CKD were 1.5, 2.5, and 2.2, respectively (global P < .0001), and the analogous adjusted odds ratios of major bleeding were 1.5, 2.5, and 1.8 (global P < .0001). CONCLUSION: Nonrevascularized patients have a high in-hospital mortality. Nonrevascularized patients with CKD have more comorbidities than patients without CKD and less frequently receive guideline-recommended therapies. Chronic kidney disease is strongly associated with in-hospital mortality and bleeding.

Drug eluting versus bare metal stents in cardiac allograft vasculopathy: a systematic review of literature.

BACKGROUND: Cardiac allograft vasculopathy (CAV) is a distinct pathological condition characterized by diffuse and progressive arteriopathy and it is an important determinant of long-term graft survival. Definitive CAV treatment is retransplantation but palliation with stenting might temporarily alleviate it. The benefit of drug eluting stents (DES) over bare metal stents (BMS) in the treatment of such lesions is debatable. We therefore sought to do a literature search to review the available evidence comparing DES to BMS. METHODS: We conducted Pub Med, EMBASE, Cochrane database review, Web of Science search of studies comparing DES with BMS in CAV. Available studies were retrospective in nature with either direct comparison groups (n = 5) or historical controls (n = 1). The main outcomes analyzed were in stent restenosis (ISR) during follow-up and clinical outcomes. RESULTS: A total of 312 patients from six studies were included in the review (1995-2007). Most commonly used DES were sirolimus eluting stent. DES appeared to reduce the long-term risk of ISR compared with BMS. Three of the five studies showed a statistically significant reduction in ISR at 12 months while the one study assessing ISR at 6 months showed no significant difference. Clinical endpoints such as death and major adverse cardiac events were not statistically different. CONCLUSION: DES appear to reduce the incidence of ISR in CAV as compared with BMS. Prospective randomized clinical trials are needed to determine the clinical benefit of DES beyond a reduction in ISR.

Isolated pharmacomechanical thrombectomy for the management of chronic DVT.

Thrombo-reduction in the setting of deep vein thrombosis (DVT) to prevent the postthrombotic syndrome has not been traditionally managed by interventional cardiologists. We report a case series of successful chronic DVT management with pharmacomechanical thrombectomy utilizing the Trellis device.

A novel hemodynamic observation: worsening of tricuspid regurgitation with dobutamine infusion during a hemodynamic study.

Dobutamine has been shown to improve right ventricular contractility and cardiac output in right ventricular failure. However, the effect of dobutamine in the select group of patients with severe tricuspid regurgitation (TR) has not been described previously. We report the case of a patient with severe TR and right heart failure who developed ventricularization of right atrial pressure after dobutamine infusion. This highlights the potential worsening of TR and right heart failure in patients with TR receiving dobutamine.

Bifurcated aortic endograft limb occlusion managed with a novel method of isolated pharmacomechanical thrombectomy.

Limb occlusion of an aortic endograft is uncommon, however, it can result in permanent sequelae if management is delayed. We report the first case utilizing the Trellis device to achieve localized and prompt isolated pharmacomechanical thrombectomy (PMT) for the treatment of acute limb thrombosis of a bifurcated aortic endograft.

Use of Trellis thrombectomy system in acute aortofemoral graft occlusion.

Acute aortofemoral graft occlusion is often effectively treated with endovascular therapy but a substantial proportion of patients experience failure or complications of this therapy, and most of them require definitive surgery for the underlying inflow, outflow, or graft disease. We describe a case of an aortofemoral graft occlusion that was successfully treated with the Trellis thrombectomy-thrombolysis system (Covidien, Dublin, Ireland). Subsequent stenting of the graft obviated the need for a definitive graft revision surgery. The Trellis system combines mechanical and local pharmacologic lysis of the thrombus, with more rapid and more effective thrombus dissolution and theoretically less risk of systemic dispersion of the thrombolytic agent and less bleeding.

Antiplatelet and anticoagulant therapies in acute coronary syndromes.

The combination of aspirin and clopidogrel is the mainstay antiplatelet therapy for acute coronary syndromes (ACS). However, the dosing of aspirin, the dosing of clopidogrel, the timing of clopidogrel initiation as well as the duration of clopidogrel therapy remain controversial matters. Clopidogrel resistance is an emerging concept with potential clinical implications. In the era of clopidogrel and bivalirudin, the role of glycoprotein IIb/IIIa antagonists is being challenged, yet they are still indicated in a select high-risk population. Concerning anticoagulant use in ACS, newer agents, bivalirudin and fondaparinux, have improved outcomes in comparison to heparin in patients managed with an invasive or conservative strategy, respectively. Combining multiple antiplatelet agents and an anticoagulant is the standard of care for ACS.

Left ventricular diastolic size in patients with normal ejection fraction and elevated left filling pressures.

OBJECTIVE: To evaluate the left-ventricular diastolic chamber size in patients with a normal ejection fraction and elevated left-sided filling pressures. BACKGROUND: The consensus view that patients with normal left ventricular ejection fraction (LVEF) and elevated left-sided filling pressures have a normal left ventricular diastolic size is a point of controversy. METHODS: We reviewed the coded database of echocardiographic studies performed at one institution between July 2007 and July 2008. We performed a retrospective descriptive study of 35 patients with normal ejection fraction (> or = 55%) and elevated left-sided filling pressures. We looked at their left ventricular internal diastolic diameter (LVIDD). RESULTS: Our population had a high prevalence of hypertension (100%), obesity (63%), diabetes (40%), chronic kidney disease (51%), coronary artery disease (25%), anemia (43%), and left ventricular hypertrophy (65%). Clinical diagnosis of heart failure was documented in 63% of the patients. LVIDD was mildly increased in comparison to a normal historical population: 4.85 + or - 0.5 cm for females, 5.3 + or - 0.5 cm for males, as compared to 4.6 + or - 0.3 cm for normal females (P = 0.045) and 5 + or - 0.4 cm for normal males (P < 0.001). However, the distribution of the indexed LVIDDs in these patients was comparable to the normal population (2.6 + or - 0.4 cm/m(2) for the study population, as compared to 2.7 + or - 0.2 cm/m(2) for the normal population, P = 0.16). CONCLUSION: In a population of patients with a normal LVEF and high left ventricular filling pressures, the indexed LV diastolic size is not increased in comparison to a normal population. (Echocardiography 2010;27:501-504).

Ventricular Septal Defect in a 66-Year-Old Man.

A 66-year-old man presented with a moderate-sized ventricular septal defect and severe pulmonary hypertension that was responsive to vasodilator therapy. His electrocardiogram demonstrated biatrial enlargement and biventricular hypertrophy. Presentation at this age is unusual for this type of shunt.

Dynamic ST-Segment Abnormality.

A 37-year-old man came to the emergency department because of several days of intermittent chest pain. An electrocardiogram (ECG) showed sinus rhythm, left atrial and left ventricular enlargement, and an early repolarization pattern. A second ECG recorded 10 minutes later was strikingly different, with ST-segment elevation and large upright T waves in the anterior precordial leads, interpreted as evidence of an ST-segment elevation myocardial infarction, and the cardiac catheterization team was activated. Closer inspection of the ECG, however, disclosed that the changes were because of intermittent ventricular pre-excitation of the Wolff-Parkinson-White type, and no electrocardiographic, echocardiographic, or serum markers of myocardial infarction were found.

Combined Radial-Tibial Access Strategy With Radial-Tibial Reverse CART, Radial-Tibial Kiss, and Tibial-Tibial Kiss.

A 45-year-old male smoker presented with extensive non-healing ulcerations and an occluded right common femoral artery. His left forearm had contractures from a prior stroke. We describe a combined radial-tibial access revascularization strategy.