Percutaneous Catheter Intervention Research Articles

A case of pulmonary visceral subpleural hematoma treated by hematoma evacuation during care of post-cardiopulmonary resuscitation

BackgroundThe occurrence of pulmonary visceral subpleural hematoma during care of post-cardiopulmonary resuscitation including chest compressions and anticoagulant and antiplatelet therapies is extremely rare. Also, there are few reports of treatment of visceral subpleural hematoma, most of which are treated by lung resection. Here we describe a rare case that pulmonary visceral subpleural hematoma arose during post-cardiopulmonary resuscitation care and was treated by hematoma evacuation.Case presentationA 58-year-old male with no smoking history and, past medical histories of rheumatoid arthritis, chronic atrial fibrillation, hypertension, diabetes, and dyslipidemia developed ventricular fibrillation due to myocardial infarction and fainted. He received bystander cardiopulmonary resuscitation and defibrillation by the ambulance crew and had return of spontaneous circulation. After transfer to our hospital, the patient underwent percutaneous catheter intervention and stenting with a diagnosis of myocardial infarction, followed by anticoagulant and antiplatelet therapies. On the 8th hospital day, chest radiography suggested right lower lobe pneumonia, and subsequent chest computed tomography revealed pulmonary hematoma in the visceral subpleural area from S6 to S10. Since no improvement was observed in hypoxemia, treatment was considered necessary. First, an attempt at computed tomography-guided drainage of hematoma was made, but insertion of the Pig-tail catheter was difficult due to hardness of the hematoma. Next, evacuation of hematoma was performed on the 13th hospital day. The hematoma was located in the visceral subpleural area and was removed by incising the pleura. TachoSil Tissue Sealing sheet and Polyglycoal acid sheet were applied to the sites of air leakage and oozing after hematoma evacuation. No re-bleeding or air leakage was observed after the treatment, and the patient was discharged on the 26th hospital day after an uneventful course.ConclusionsPulmonary visceral subpleural hematoma may occur during post-cardiopulmonary resuscitation care, including chest compressions and anticoagulant and antiplatelet therapies. In our case, CT-guided puncture and drainage was difficult and surgical treatment by incision of the visceral pleura and hematoma evacuation alone was done successfully.

Predictors and prognostic implications of left ventricular ejection fraction trajectory improvement in the spectrum of heart failure with reduced and mildly reduced ejection fraction

BackgroundThe latest guidelines emphasize the significance of evaluating the left ventricular ejection fraction (LVEF) trajectory in patients with heart failure (HF). Because patients with HF with reduced ejection fraction (HFrEF) and HF with mildly reduced ejection fraction (HFmrEF) have reduction in systolic function, they might be in a trajectory of LVEF improvement after medical and device-based therapies. While previous studies have primarily focused on LVEF improvement in HFrEF, there is limited research on LVEF trajectory improvement across the spectrum of HFrEF and HFmrEF. This study aimed to assess the determinants and prognostic implications of LVEF trajectory improvement in HFrEF and HFmrEF patients. MethodsThe cohort was classified into the improved group (HFrEF-to-HF with improved ejection fraction (HFimpEF) and HFmrEF-to-HF with preserved ejection fraction (HFpEF)) and the unimproved group (lack of improved group criteria). The primary endpoints were the composite of all-cause mortality or HF hospitalization, all-cause mortality, and HF hospitalization. Predictors of LVEF trajectory improvement were also evaluated. ResultsA total 1303 patients were included in the study (improved/unimproved group: n = 497/806). Cox regression analysis showed that the improved group experienced lower risks of prespecified end points than the unimproved group. Multivariate logistic regression analysis showed that atrial flutter, use of spironolactone, and treatment with catheter ablation were associated with LVEF trajectory improvement, while myocardial infarction, prior percutaneous catheter intervention or coronary artery bypass graft, E/e′, and left ventricular end-diastolic diameter were identified as negative predictors of LVEF trajectory improvement. In the improved subgroup, the prognosis for the HFrEF-to-HFimpEF and HFmrEF-to-HFpEF was comparable. ConclusionsLVEF trajectory improvement patients had improved clinical outcomes and it was associated with important clinical, baseline cardiac structure and function, and treatment factors. Outcomes were similar in both HFrEF-to-HFimpEF and HFmrEF-to-HFpEF subgroups. These results suggest that emphasis should be placed on LVEF trajectory improvement to improve the outcomes of this population.

Cinematic Rendering of Acute Myocardial Infarction.

HomeRadiologyRecently Published PreviousNext Reviews and CommentaryFree AccessImages in RadiologyCinematic Rendering of Acute Myocardial InfarctionXiaoqing Ding , Zhigang GongXiaoqing Ding , Zhigang GongAuthor AffiliationsFrom the Department of Radiology, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, No 528, Zhangheng R. Pudong New Area, Shanghai, 201203, China.Address correspondence to X.D. (email: [email protected]).Xiaoqing Ding Zhigang GongPublished Online:Jan 31 2023https://doi.org/10.1148/radiol.221828MoreSectionsPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In Supplemental material is available for this article.A 43-year-old male patient presented to the emergency department with acute chest pain. The patient condition was stable, and an electrocardiography scan was obtained and showed ST segment changes with troponin I levels of 106.251 ng/mL; however, the patient refused percutaneous catheter intervention. To exclude aortic and pulmonary artery disease, dual-source CT angiography (CTA) of the chest was performed. No aortic or pulmonary artery abnormalities were identified; however, CTA demonstrated suspicious occlusion of left anterior descending coronary artery, focal hypodensity of the anterior wall, and interventricular septum, which is further highlighted with use of cinematic rendering reconstruction technique (Figure, Movie).CT angiography of the chest in a 43-year-old man with acute chest pain. Cinematic rendering of (A) four-chamber heart view and (B) anteroposterior view shows a focal area of decreased attenuation in the myocardium (anterior wall and interventricular septum).Download as PowerPointOpen in Image Viewer Get the Flash Player to see this video.Movie: Cinematic rendering of the heart, show a focal area of decreased attenuation in the myocardium.Download Original Video (20.9 MB)With increasing temporal resolution, it becomes possible to observe changes in myocardial density in the setting of acute myocardial infarction with use of conventional CTA of the chest (1). Cinematic rendering reconstruction technique (2) allows CTA to achieve highly realistic, photograph-level, postprocessed images that show the areas of acute myocardial ischemia more intuitively in three dimensions.Disclosures of conflicts of interest: X.D. No relevant relationships. Z.G. No relevant relationships.

Intracardiac echocardiography Chinese expert consensus.

In recent years, percutaneous catheter interventions have continuously evolved, becoming an essential strategy for interventional diagnosis and treatment of many structural heart diseases and arrhythmias. Along with the increasing complexity of cardiac interventions comes ever more complex demands for intraoperative imaging. Intracardiac echocardiography (ICE) is well-suited for these requirements with real-time imaging, real-time monitoring for intraoperative complications, and a well-tolerated procedure. As a result, ICE is increasingly used many types of cardiac interventions. Given the lack of relevant guidelines at home and abroad and to promote and standardize the clinical applications of ICE, the members of this panel extensively evaluated relevant research findings, and they developed this consensus document after discussions and correlation with front-line clinical work experience, aiming to provide guidance for clinicians and to further improve interventional cardiovascular diagnosis and treatment procedures.

Hybrid Approach for Correction of Recurrent Aortic Arch Obstruction After Repair of Interrupted Aortic Arch—A Case Report

Recurrent aortic arch obstruction (RAAO) following repair of interrupted aortic arch (IAA) occurs in up to 50% of patients. Treatment options are surgical correction or percutaneous catheter intervention. Balloon angioplasty has become more popular over the last 3 ​decades, but current studies suggest that it may be less effective than surgical treatment.1,2

Successful percutaneous closure of a recurrent aorto-left ventricular tunnel with an Amplatzer Vascular Plug II.

Aorto-left ventricular tunnel is an extremely rare CHD clinically impressing as aortic regurgitation. This is usually corrected surgically, sometimes by percutaneous catheter intervention. Recurrent aorto-left ventricular tunnel has been reported occasionally. Reports of percutaneous closure of such recurrent aorto-left ventricular tunnels are rare. We hereby describe successful closure of a recurrent aorto-left ventricular tunnel with an Amplatzer Vascular Plug II.

Long-term outcome of primary percutaneous stent angioplasty for pediatric posttransplantation portal vein stenosis.

This study aims to evaluate the long-term efficacy and reintervention rate after primary percutaneous portal vein stent angioplasty for portal vein stenosis (PVS) in pediatric liver transplantation (LT) recipients. From 2004 to 2020, a total of 470 pediatric LTs were performed in our center. All cases were screened for interventional PVS treatment and analyzed retrospectively. We identified 44 patients with 46 percutaneous angioplasties for posttransplantation PVS. The median interval from LT to percutaneous catheter intervention was 5 months (16 days-104 months) with a median follow-up (f/u) period after catheter intervention of 5.7 years (2-156 months). In 40 patients, an endovascular stent was placed as primary (n=38) or secondary (n=2) intervention. The median age at stent placement was 23 (6-179) months with a median weight of 10 kg (6-46 kg). Technical success and relief of PVS were achieved in all patients irrespective of age or weight. Adverse events occurred peri-interventionally in two patients and were resolved with standard care. All primary portal vein (PV) stents remained patent until the end of f/u. Reinterventions have been successfully performed in 10 patients for suspected or proven restenosis, resulting in a primary patency rate of 75% and an assisted patency rate of 25%. The median time to reintervention was 6.2 years (range 1-10 years). The need for reintervention was independent of age or weight at both transplantation and initial angioplasty as well as of additional risk factors due to portal hypertension. Percutaneous transhepatic PV stent angioplasty in children is safe and effective in all age groups, with excellent long-term patency. Primary stent angioplasty should be considered as first-line treatment for PVS after pediatric LT.

Influence of percutaneous catheter intervention for congenital perimembranous ventricular septal defects in children on the cardiac conduction system and associated risk factors: a meta-analysis

BackgroundThe aim of this study was to investigate adverse outcomes and risk factors for the cardiac conduction system in children with perimembranous ventricular septal defects (pmVSDs) who had been treated by catheter intervention.MethodPubMed, EMBASE, Web of Science, and the Cochrane Library were searched for studies in English on interventional treatment of pmVSDs in pediatric patients published up to the end of October 15, 2020. We used random- or fixed-effect models to obtain pooled estimates of the success rate and postoperative complications.ResultsA total of 1650 pediatric patients from 8 publications were included, with a mean age ranging from 3.44 to 8.67 years old. The pooled estimate of successful implantation was 98.2% (95% CI 97.1–99.4%, I2 = 69.4%; P < 0.001), and the incidence of cardiac conduction system complications was 17.4% (95% CI 8.4–26.4%, I2 = 96.1%; P < 0.001), among which the incidence of heart block was 14.8% (95% CI 6.4–23.3%, I2 = 96.9%; P = 0.001). The incidence of impulse formation disorders was 4.1% (95% CI 0.7–7.6%, I2 = 91.7%; P = 0.019), and the incidence of complete atrioventricular block was 0.8% (95% CI 0.3–13%, I2 = 0.0%; P = 0.001). Risk factors for newly emerging arrhythmias included the VSD size MD = 0.89 (95% CI 0.46–1.32, I2 = 0%; P < 0.0001) and device size MD = 1.26 (95% CI 0.78–1.73, I2 = 0%; P < 0.00001).ConclusionsPercutaneous catheter intervention is safe and effective in treating pediatric patients with pmVSD, and the risk factors leading to arrhythmias include the sizes of the pmVSD and device.

The impact of advances in percutaneous catheter interventions on redo cardiac surgery.

Toward the end of the twentieth century, redo cardiac surgery accounted for approximately 15-20% of total cardiac surgical volume. Major risk factors for redo cardiac surgery include young age at time of the first operation, progression of native coronary artery disease (CAD), vein graft atherosclerosis, bioprosthetic valve failure and endocarditis, and transplantation for end stage heart failure. Historically, redo coronary artery bypass grafting (CABG) alone carried a mortality risk of around 4%. Factors such as older age, female sex, comorbidities, combined procedures, hemodynamic instability, and emergency procedures contributed to even higher mortality and morbidity. These poor outcomes made it necessary to look for less invasive alternate methods of treatment. Advances in catheter-based interventions have made a major impact on redo cardiac surgeries, making it no longer the first option in a majority of cases. Percutaneous interventions for recurrence following CABG, transcutaneous aortic valve replacement (TAVR) for calcific aortic stenosis, valve in valve (VIV) implantations, device closure of paravalvular leaks (PVL), and thoracic endovascular aortic repair (TEVAR) for residual and recurrent aneurysms and mitral clip to correct mitral regurgitation (MR) in heart failure are rapidly developing or developed, obviating the need for redo cardiac surgery. Our intent is to review these advances and their impact on redo cardiac surgery.

Effects of salvianolate on myocardial perfusion after primary percutaneous catheter intervention in patients with ST-segment elevation myocardial infarction: a multicenter, randomized, double-blind, placebo-controlled study.

BackgroundDespite prompt revascularization following acute myocardial infarction, poor myocardial perfusion commonly occurs due to impaired microvascular circulation and is an independent predictor of adverse outcomes. The current trial sought to examine the effects of salvianolate on myocardial perfusion in patients with ST-segment-elevation myocardial infarction (STEMI) who were undergoing primary percutaneous coronary intervention (PCI).MethodsThis randomized, double-blind, placebo-controlled, multicenter study evaluated the effects of intravenous salvianolate on the achievement of complete epicardial and myocardial reperfusion after PCI, defined as thrombolysis in myocardial infarction flow grade 3 and thrombolysis in myocardial infarction myocardial perfusion grade 3. We also measured plasma total creatine kinase-mass band fraction (CK-MB)-estimated infarct size and echocardiography-derived left ventricular ejection fraction and recorded the 30-day clinical and safety outcomes. A total of 536 patients presenting with acute STEMI were randomized to receive either an i.v. infusion of salvianolate (n=265) or placebo (n=271).ResultsSalvianolate administration exerted beneficial effects on coronary microcirculation. There was a trend of reduced myocardial infarct size in the salvianolate group compared to the placebo group (P=0.070), although no significant difference in left ventricular ejection fraction was found between the two groups.ConclusionsSalvianolate administration is associated with improved myocardial perfusion in patients with STEMI undergoing PCI. A larger study is required to assess the impact of this therapy on clinical cardiac outcomes.

Percutaneous catheter interventions via Glidesheath Slender in small children.

Catheterization in small children should be performed with the lowest diameter introducer sheaths to prevent permanent vessel damage. The objective of this study is to evaluate the clinical safety and efficacy of the Glidesheath Slender in small children. We present a group of 52 patients (male: n = 36) with median age 118.5 days (min. 3; max. 1302), median weight: 5.3 kg (min. 1.4; max. 14.0), median height: 60.5 cm (min. 39; max. 102), and median body surface area 0.28 m2 (min. 0.12; max. 0.63) in whom percutaneous catheter interventions (n = 55) were performed via a Glidesheath Slender. In 49 children, the intervention was performed from femoral access (artery n = 35; vein n = 14) in 2 from the axillary arterial access and in 1 from the jugular venous access. In all patients, the vessel access was obtained under ultrasound guidance. After the catheterization, the pulse on the peripheral arteries (posterior tibial artery or radial artery) was palpable in all patients, and no signs for vessel dysfunction were present. The Glidesheath Slender effectively reduces the outer sheath diameter for various types of interventions in small children by one French, reducing the risk of vessel complications (stenosis, occlusion). Interventions via Glidesheath Slender in small patients are safe and feasible and extend the transcatheter possibilities in small children with congenital heart diseases.

Assessment of Knowledge and Practices of myocardial Infarction, Patients After Primary Percutaneous Coronary Intervention at Outpatient Clinic in Heart Hospital Assiut University

Primary percutaneous coronary intervention (PPCI) is an emergent percutaneous catheter intervention in the setting of ST elevation myocardial infarction, it is the preferred reperfusion strategy. Aim of the study: Assessment of knowledge and practices of myocardial infarction patients after (PPCI). Study design: A descriptive cross- sectional study research design has been utilized. Setting: the study was conducted at outpatient clinic Cardiovascular, Heart Hospital Assiut University. Subjects: A convenience sample of 150 patients was included in the study. Tools: A structured interview questionnaire including three parts included personal data, patients' knowledge about myocardial infarction, (PPCI)and reported practices Results: It was found that 43,3% of patients their age were younger than 50 year and 77.0% of them were males also it was found that 58.0% of patients had poor knowledge about myocardial infarction and (PPCI). More than three quarters of patients always take food rich in fat. 60.7 % of them never practice any kind of exercise, 83.3% of them were smokers. Conclusion: There was a great lacking of the necessary basic knowledge and practice of studied patients about myocardial infarction after (PPCI). Recommendations: Health education program is needed for patients with myocardial infarction to improve their knowledge and practice regarding their disease

A case report: stent implantation to treat coarctation of persistent 5th aortic arch associated with interrupted 4th aortic arch.

BackgroundPersistent 5th aortic arch is a rare cardiac anomaly that is usually surgically corrected during infancy or early childhood if it is associated with coarctation of the aorta. Here, we report an adult with coarctation of the 5th aortic arch who was successfully treated by stent implantation.Case summaryAn asymptomatic 32-year-old woman presented with hypertension and a significant arm–leg difference in pressure. On suspicion of coarctation of the aorta, a chest computed tomography was performed, leading to a diagnosis of an interrupted 4th aortic arch with coarctation of a persistent 5th aortic arch. Percutaneous catheter intervention using a PALMAZ large stent dilated to 12 mm resulted in a minimal peak-to-peak pressure gradient. The patient was discharged home after a 2-day monitoring without hypertension and arm–leg blood pressure difference. She remained normotensive with a patent aortic arch on echocardiography performed 10 months after treatment.DiscussionAs for simple coarctation of the aorta, stent implantation was feasible and effective in an adult patient with coarctation of the 5th aortic arch.

Rupture of the Anterolateral Papillary Muscle Caused by a High Lateral Branch Occlusion

Although necrosis of the left ventricular papillary muscles during acute myocardial infarction is common, rupture of the anterolateral papillary muscle due to occlusion of high lateral branch is rare. We present a rare case of anterolateral papillary muscle rupture caused by occlusion of a high lateral branch of the left coronary artery. Although the patient was in cardiogenic shock on admission, she was successfully treated by emergency mitral valve replacement after percutaneous catheter intervention and intra-aortic balloon pumping support. This case implies that the anterolateral papillary muscle can have a single blood supply and that it can be ruptured by an occlusion of a high lateral branch. Prompt diagnosis, immediate mechanical stabilization and aggressive surgical treatment are essential to save this group of patients.

Clinical Outcomes of Patients Undergoing Rotational Atherectomy Followed by Drug-eluting Stent Implantation: A Single-center Real-world Experience.

Background:Rotational atherectomy (RA) is used to improve procedural success of percutaneous catheter interventions (PCIs) of complex and heavily calcified coronary lesions. We report the clinical experience and outcomes in our institution with the use of RA, followed by drug-eluting stent implantation.Materials and Methods:Data of 81 patients treated with PCI and adjunctive RA were analyzed. Clinical follow-up for the occurrence of major adverse events (MAEs) was obtained in all patients and correlated with significant variables using multivariate Cox proportional hazards analysis.Results:Mean age was 67.9 ± 9.2 years, 61.7% had diabetes, 20.9% had chronic kidney disease, and 48.1% had previous acute coronary syndrome (ACS). Mean SYNTAX score was 29.8 ± 12.2, with a 92.5% angiographic success rate achieved. In-hospital MAEs rate was 7.4% while mortality rate was 8.6%. On median follow-up of 12.2 months, incidence of MAEs of 13.5% with a 75% free incidence from MAEs at 34 months. Multivariate analysis revealed that a history of previous ACS, ejection fraction, neutrophil to lymphocyte ratio, platelet to lymphocyte ratio, SYNTAX score, burr to artery ratio, and attainment of angiographic success were significant predictors of MAEs.Conclusion:RA followed by drug-eluting stent implantation is a safe and effective method in improving procedural success as well as short- and long-term outcomes of PCI in our center. A combination of clinical and procedural factors is predictive for the occurrence of MAEs and should be taken into account in the application of this technique.

Global Risk Score and Clinical SYNTAX Score as Predictors of Clinical Outcomes of Patients Undergoing Unprotected Left Main Percutaneous Catheter Intervention.

BackgroundRisk stratification is an important component of left main percutaneous catheter intervention (PCI) which has emerged as a feasible alternative to cardiac surgery. We sought to compare the clinical SYNTAX score and the global risk score in predicting outcomes of patients undergoing unprotected left main PCI in our institution.MethodsClinical, angiographic and procedural characteristics of 92 patients who underwent unprotected left main PCI (mean age 62 ± 12.1 years) were analyzed. Patients were risk stratified into tertiles of high, intermediate and low risk using the global risk score (GRS) and the clinical SYNTAX score (CSS) and were prospectively followed up at 1 year for the occurrence of major adverse cardiovascular events (MACEs), defined as a composite of all cause mortality, cardiac mortality, non-fatal myocardial infarction, stroke, coronary artery bypass, and target vessel revascularization.ResultsThere were 26 (28.2%) who experienced MACEs, of which 10 (10.8%) patients died. Multivariable hazards analysis showed that the GRS (hazard ratio (HR) = 5.5, P = 0.001) and CSS (HR = 4.3, P = 0.001) were both independent predictors of MACEs. Kaplan-Meier analysis showed higher incidence of MACEs with the intermediate and higher risk categories compared to those classified as low risk. Receiver-operator characteristic analysis showed that the GRS has better discriminatory ability than the CSS in the prediction of 1 year MACEs (0.891 vs. 0.743, P = 0.007).ConclusionThe GRS and CSS are predictive of outcomes after left main PCI. The GRS appears to have superior predictive and prognostic utility compared to the CSS. This study emphasizes the importance of combining both anatomic and clinical variables for optimum prognostication and management decisions in left main PCI.

Insulin Postconditioning Reduces Infarct Size in the Porcine Heart in a Dose-Dependent Manner.

Insulin and glucose may have opposite effects when used to reduce ischemia-reperfusion injury. When insulin is administered alone, feeding state determines tolerance and further induces metabolic and hormonal changes. Higher insulin doses are needed for similar activation of cardioprotective Akt signaling in the fed compared to the fasted pig heart. Thus, the aim of the study was to investigate the effects of 2 prespecified insulin doses on infarct size, apoptosis, metabolism, and cardiac function in a clinically relevant, randomized large animal model using conventional percutaneous catheter intervention techniques and including different fasting states. Twenty-seven female pigs were subjected to 40-minute ischemia and 120-minute reperfusion. Pharmacological postconditioning with intracoronary infusions administered over 3 × 30 seconds was performed at immediate reperfusion. Animals were randomly assigned to 3 groups-preexperimental fasting and intracoronary saline ( controls), preexperimental fasting and 0.1U of insulin ( fasted Ins0.1U), and preexperimental feeding and 1.0U of insulin ( fed Ins1.0U). A significant reduction in infarct size was demonstrated in the fed Ins1.0U group ( P = .047) but not in the fasted Ins0.1U group ( P = .531) compared to controls (infarct size normalized to area at risk ± standard deviation: controls 70.2% ± 12.9%, fasted Ins0.1U 65.0% ± 9.4%, and fed Ins1.0U 54.4% ± 7.3%). Infarct limitation was associated with more uncleaved caspase-3 in the area of risk and the infarcted area, lower circulating free fatty acids, and less increase in heart rate during reperfusion. Fed animals had higher levels of glucose, carnitine, potassium, and normetanephrine and higher heart rate at baseline compared to controls. Insulin postconditioning reduced infarct size in the in vivo pig heart, but the beneficial effects were restricted to the highest dose, which is limited by side effects and can only be given to nonfasted animals. The finding challenges successful general use of insulin in the treatment of reperfusion injury in clinical acute myocardial infarction.

Role of CT Coronary Angiography in Recanalization of Chronic Total Occlusion

Chronic total occlusion (CTO) is considered as the most challenging frontier in interventional cardiology and the last one to be conquered. With availability of state of the art hardware, wires and catheters in particular and increased skills of the operators, the success rate for recanalization of CTO by percutaneous catheter intervention (PCI) has improved. Yet the complications rate and longterm adverse events are high, mostly due to failure in tracking or navigation of hardware through the occluded CTO segment, prolonged exposure to radiation and high doses of contrast used. Therefore, proper selection of patient is of utmost importance. One of the major challenges for successful CTO recanalization is satisfactory visualization of the occluded CTO segment. Conventional invasive catheterization fails to fill the gap and the shortcomings and handicaps of such invasive imaging can be resolved with the use of non-invasive CT coronary angiography (CTCA). CTCA helps to better define the morphological features of the occluded CTO segment, which are established predictors of success, like the actual length of the occluded segment and any calcification or tortuosity in its course. Integration of reconstructed three-dimensional CT coronary images with twodimensional fluoroscopic images, offers directional guide to select the best angiographic plane for visualization of angiographically “missing segment”. With advances in CT technology, CTCA has now become an established technology for pre-procedure evaluation of CTO segment, thereby help in planning and execution of successful PCI.

Composite Outcomes in Coronary Bypass Surgery Versus Percutaneous Intervention

Recent observational studies show that patients with multivessel coronary disease have a long-term survival advantage with coronary artery bypass grafting (CABG) compared with percutaneous coronary intervention (PCI). Important nonfatal outcomes may also affect optimal treatment recommendation. CABG was compared with percutaneous catheter intervention by using a composite of death, myocardial infarction (MI), or stroke. Medicare patients undergoing revascularization for stable multivessel coronary disease from 2004 through 2008 were identified in national registries. Short-term clinical information from the registries was linked to Medicare data to obtain long-term follow-up out to 4 years from the time of the procedure. Propensity scoring with inverse probability weighting was used to adjust for baseline risk factors. There were 86,244 CABG and 103,549 PCI patients. The mean age was 74 years, with a median 2.67 years of follow-up. At 4 years, the propensity-adjusted adjusted cumulative incidence of MI was 3.2% in CABG compared with 6.6% in PCI (risk ratio, 0.49; 95% confidence interval, 0.45 to 0.53). At 4 years, the cumulative incidence of stroke was 4.5% in CABG compared with 3.1% in PCI patients (risk ratio, 1.43; 95% confidence interval, 1.31 to 1.54). This difference was primarily due to the higher 30-day stroke rate for CABG (1.55% vs 0.37%). For the composite of death, MI, or stroke, the 4-year adjusted cumulative incidence was 21.6% for CABG and 26.7% for PCI (risk ratio, 0.81; 95% confidence interval, 0.78 to 0.83). The 4-year composite event rate of death, MI, and stroke favored CABG, whereas the risk of stroke alone favored PCI.

A Rare Cause of Pulmonary Hypertension: Congenital Bilateral Atresia of the Superior Pulmonary Arteries and Bilateral Stenosis of the Inferior Pulmonary Arteries

Bilateral absence (atresia) of the superior pulmonary arteries, combined with bilateral stenosis of the inferior pulmonary arteries, has not to our knowledge been reported before now. We report such a case in a 48-year-old woman, together with the medical and percutaneous catheter interventions used to treat her condition.