Fractional flow reserve-guided PCI versus medical therapy in stable coronary disease

The preferred initial treatment for patients with stable coronary artery disease is the best available medical therapy. We hypothesized that in patients with functionally significant stenoses, as determined by measurement of fractional flow reserve (FFR), percutaneous coronary intervention (PCI) plus the best available medical therapy would be superior to the best available medical therapy alone.

Effect of biolimus-eluting stents with biodegradable polymer vs bare-metal stents on cardiovascular events among patients with acute myocardial infarction: the COMFORTABLE AMI randomized trial

The efficacy and safety of drug-eluting stents compared with bare-metal stents remains controversial in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI).

Left atrial appendage closure with the Amplatzer cardiac plug in patients with atrial fibrillation

Percutaneous left atrial appendage closure (LAAC) has emerged as an alternative to oral anticoagulation (OA) for prevention of thromboembolic stroke in patients with non-valvular atrial fibrillation (NVAF).

Accidental closure of the left upper pulmonary vein with an Amplatzer atrial septal defect occluder

We report the clinical outcome of a 46-year-old man referred for percutaneous closure of an atrial septal defect under transthoracic echocardiographic and fluoroscopic guidance, whose upper left pulmonary vein was erroneously obliterated using an Amplatzer atrial septal defect occluder. Various medical conditions have been associated with pulmonary vein stenosis including dyspnea on exertion or at rest, cough, and hemoptysis. However, there were no short- or long-term symptoms in this patient.

Amplatzer Septal Occluder to treat iatrogenic cardiac perforations

Iatrogenic free wall cardiac perforation is a rare but serious complication encountered during percutaneous cardiac procedures, which usually leads to tamponade and death. Septal occluder devices have been developed for sealing intracardiac shunts but may be also used in this emergency setting.

Closure of apical access site after transapical, transcatheter paravalvular leak closure

The safety of percutaneous transapical mitral paravalvular leak (PVL) closure could potentially be enhanced by device closure of the ventricular access site. Percutaneous transapical PVL closure was performed. The 9F delivery sheath was pulled back, and a 6-mm Amplatzer muscular ventricular septal defect occluder was deployed at the apical puncture site. Immediate hemostasis was achieved. Total hospitalization was 9 days. New York Heart Association functional class was improved, hemoglobin and haptoglobin rose, while lactate dehydrogenase fell. Follow-up fluoroscopy and transthoracic echocardiography revealed a good functional result. Closure of the apical access site by means of an Amplatzer muscular ventricular septal defect occluder is feasible.

Coronary stent choice in patients with acute myocardial infarction

A prompt reperfusion with primary percutaneous coronary intervention represents the current gold standard treatment for patients with acute myocardial infarction. In this setting, coronary stents have been shown to improve outcomes compared to plain angioplasty and are routinely used. However, the stent selection among patients with acute myocardial infarction is still a matter of some debate. An increased risk of very late (>1-year) stent thrombosis has been associated with the use of early-generation drug-eluting stents (DES), leading to concerns regarding the long-term safety of these devices. Newer-generation DES were developed with the aim of addressing this safety issue, and were recently investigated in a few randomized studies in patients with acute myocardial infarction. The objective of the present review is to summarize the accumulated evidence, to guide the stent selection in patients with acute myocardial infarction.

Impact of atrial fibrillation on clinical outcomes among patients with coronary artery disease undergoing revascularisation with drug-eluting stents

Coronary artery disease (CAD) and atrial fibrillation (AF) are major determinants of morbidity and mortality. A combined treatment with antiplatelet agents and vitamin K antagonists limits the risk of stent thrombosis and stroke while increasing the rate of bleeding. The objective of this study was to investigate the impact of atrial fibrillation (AF) on long-term clinical outcomes in patients with CAD undergoing percutaneous coronary intervention (PCI) with drug-eluting stents (DES).

Intravascular ultrasound-guided creation of re-entry sites to improve intermittent claudication in patients with aortic dissection

PURPOSE: To report percutaneous fenestration of aortic dissection flaps to relieve distal ischemia using a novel intravascular ultrasound (IVUS)-guided fenestration device. CASE REPORTS: Two men (47 and 62 years of age) with aortic dissection and intermittent claudication had percutaneous ultrasound-guided fenestration performed under local anesthesia. Using an ipsilateral transfemoral approach, the intimal flap was punctured under real-time IVUS guidance using a needle-catheter combination through which a guidewire was placed across the dissection flap into the false lumen. The fenestration was achieved using balloon catheters of increasing diameter introduced over the guidewire. Stenting of the re-entry was performed in 1 patient to equalize pressure across the dissection membrane in both lumens. The procedures were performed successfully and without complications. In both patients, ankle-brachial indexes improved from 0.76 to 1.07 and from 0.8 to 1.1, respectively. Both patients were without claudication at the 3- and 6-month follow-up examination. CONCLUSION: Percutaneous intravascular ultrasound-guided fenestration and stenting at the level of the iliac artery in aortic dissection patients with claudication is a technically feasible and safe procedure and relieves symptoms.

Superselective embolization of deep femoral artery branch pseudoaneurysm with a coaxial microcatheter system

This report describes the use of transluminal coil embolization to treat pseudoaneurysm of deep femoral artery branch in two patients. The pseudoaneurysms had developed after coronary angiographv in one patient and after hip replacement in the other. Immediate control angiography after embolization procedures demonstrated complete closure of the pseudoaneurysms. During follow-up of 19 and 3 months, respectively, there was no recurrent bleeding. The aim of this case report is to show the advances in endovascular microcatheter technology, and embolic materials, that made percutaneous transluminal embolization of arterial pseudoaneurysms safe and efficient. In addition, it keeps the medical personnel aware of vascular injuries at the access site related to endovascular procedures as well as vascular complications of total hip arthroplasty. It calls their attention to the possibility of endovascular treatment as an alternative to surgery.

Intracardiac devices for stroke prevention

Stroke is a significant cause of serious disability and death worldwide. A substantial proportion of strokes are related to an underlying cardiac embolic source, most commonly in association with atrial arrhythmias (fibrillation/flutter). Atrial fibrillation is considered a major risk factor for stroke. Although long-term prophylactic oral anticoagulation has been shown to be very effective in reducing stroke in patients with atrial fibrillation, it has a number of major limitations and is not feasible in all patients. In such cases, the use of percutaneously (transvenous) implanted left atrial appendage occlusive devices or surgical appendage obliteration is being explored. Similarly, the presence of a patent foramen ovale, especially in the presence of an atrial septal aneurysm, is now recognized as an important potential mediator of paradoxical cardiogenic embolism. Percutaneous patent foramen ovale closure is becoming increasingly established as a safe and effective means of preventing recurrent strokes in the presence of a patent foramen ovale. In this account, the authors discuss the intracardiac devices and techniques available and the relative merits of their use for stroke prevention.

Safety and exercise tolerance of acute high altitude exposure (3454 m) among patients with coronary artery disease

OBJECTIVES: To assess the safety and cardiopulmonary adaptation to high altitude exposure among patients with coronary artery disease. METHODS: 22 patients (20 men and 2 women), mean age 57 (SD 7) years, underwent a maximal, symptom limited exercise stress test in Bern, Switzerland (540 m) and after a rapid ascent to the Jungfraujoch (3454 m). The study population comprised 15 patients after ST elevation myocardial infarction and 7 after a non-ST elevation myocardial infarction 12 (SD 4) months after the acute event. All patients were revascularised either by percutaneous coronary angioplasty (n = 15) or by coronary artery bypass surgery (n = 7). Ejection fraction was 60 (SD 8)%. beta blocking agents were withheld for five days before exercise testing. RESULTS: At 3454 m, peak oxygen uptake decreased by 19% (p < 0.001), maximum work capacity by 15% (p < 0.001) and exercise time by 16% (p < 0.001); heart rate, ventilation and lactate were significantly higher at every level of exercise, except at maximum exertion. No ECG signs of myocardial ischaemia or significant arrhythmias were noted. CONCLUSIONS: Although oxygen demand and lactate concentrations are higher during exercise at high altitude, a rapid ascent and submaximal exercise can be considered safe at an altitude of 3454 m for low risk patients six months after revascularisation for an acute coronary event and a normal exercise stress test at low altitude.