Successful Percutaneous Intervention Research Articles

Abstract 17995: NT-proBNP Predicts Myocardial Damage and Correlates With Stem Cell Mobilization in Patients With ST-Eelevation Myocardial Infarction

Introduction: N-Terminal prohormone of brain natriuretic peptide (NT-proBNP) is released from cardiomyocytes during injury. However, the relationship between plasma levels, extent of myocardial damage and its correlation with bone marrow stem cell (BMSC) mobilization are poorly understood. Methods: Plasma levels of NT-proBNP (pg/ml), troponin I (ng/ml) and CK (IU/L) were assessed in 76 patients with ST-elevation myocardial infarction (STEMI) at baseline (time of successful primary percutaneous intervention) then at 6, 12, 24, and 48-hour intervals. Levels of circulating Lin-/CD45- cells that are positive for CXCR4, CD34 and CD133 (BMSCs) were examined at the same time points using flow cytometry. Echocardiography and cardiac MRI (CMR) were performed prior to hospital discharge for assessment of cardiac function and scar size. Extent of myocardial damage was quantified using peak biomarker levels and gadolinium enhancement on CMR. Results: Patients characteristics were consistent with the typical demographics for STEMI population (Panel A). Plasma levels of NT-proBNP increased steadily following STEMI to peak at 24 hours (Panel B). Peak NT-proBNP levels correlated positively with indices of myocardial damage such as peak troponin I (r=0.6, P<0.001), peak CK (r=0.3, P=0.04) and late gadolinium enhancement on CMR examination (r=0.54, P=0.02) (Panels C-E). NT-proBNP levels correlated negatively with left ventricular ejection fraction and volume on echocardiography and CMR. There was strong correlation between peak NT-proBNP levels and peak numbers of circulating BMSCs such as Lin-/CD45-/CXCR4+ BMSCs (r=0.6, P<0.001) (Panel F). Conclusion: Peak levels of NT-proBNP following STEMI are predictive of the extent of myocardial damage quantified by cardiac biomarkers or CMR. NT-proBNP levels are also associated with the extent of BMSC release, raising the possibility that it has a role in initiating the myocardial reparative process following STEMI.

Calculation of Coronary Angiographic Total Blush in Patients with Coronary Artery Disease and its Prognostic Implication.

Background:Myocardial perfusion grade (MPG) is an accepted method of evaluating myocardial perfusion. However, it does not take into the account, the extent of the perfusion. We hypothesized that myocardial blush area times MPG (total blush) would be more accurate than simple MPG, and yield better prognostic information.Methods:About 34 patients were recruited after they had consented to both coronary angiography (CAG) and single photon emission computed tomography (SPECT), and divided into two groups. A special dedicated computer was employed to calculate the total blush. The CAG was performed as a conventional way. Scintigraphic technetium 99m methoxyisobutyl-isonitrile rest and stress images were evaluated quantitatively. The comparison was made between stenosis versus chronic total occlusion (CTO), MPG 1, 2 versus MPG 3, percutaneous intervention (PCI) successful versus failure. A correlation was made between ejection fraction (EF) and myocardial perfusion by MPG, total blush, SPECT, and syntax score.Results:The perfusion indices of total blush, summed difference score (SDS) and syntax score were insignificant between the two groups (P > 0.05). However, the left ventricular end diastolic volume was significantly larger in CTO (P < 0.05). The patients with stenosis had better MPG than with CTO (P < 0.05). The increased MPG was associated with increased total blush, higher syntax score, and EF (P < 0.05). Successful PCI resulted in better perfusion indicated by increased total blush, and MPG (P < 0.05) but successful PCI did not change syntax score, EF and SDS significantly. Multivariate linear analysis with EF as the dependent factor and syntax score, SDS, total blush, blush area, and MPG as the independent factors showed a significantly higher degree of correlation (R = 0.87, P < 0.05).Conclusion:After PCI the total blush and EF improved significantly indicating its potential application in the future.

Manual Aspiration Thrombectomy in Acute Myocardial Infarction: A Clinical Experience

Multiple clinical studies have failed to establish the role of routine use of thrombectomy in ST-elevation myocardial infarction (STEMI) patients. There is a paucity of data on the impact of thrombectomy in unselected STEMI patients outside clinical trials. We sought to evaluate the clinical variables and outcomes associated with the performance of thrombectomy in STEMI patients. We retrospectively examined the clinical outcomes in all STEMI patients who underwent successful percutaneous intervention (PCI) at our center. Patients were divided into two groups, one with patients who underwent conventional PCI and another with patients who had thrombus aspiration in addition to conventional PCI. We compared the baseline clinical characteristics, laboratory investigations, re-infarction rates, and all-cause mortality. Total 477 consecutive STEMI patients were identified. Overall, 29% (139) of the patients underwent conventional PCI and 71% (338) of the patients were treated with aspiration thrombectomy and PCI. In addition to the presence of thrombus, patients with nonanterior infarction, and patients with hemodynamic instability requiring intra-aortic balloon pump support were more likely to undergo thrombectomy. Thrombectomy was associated with higher enzymatic infarction (creatine kinase: 2,796 [2,575] vs. 1,716 [1,662]; p < 0.0001; CK-MB: 210.6 [156.0] vs. 142.0 [121.9], p < 0.0001). However, thrombectomy was not associated with any difference in 30 day reinfarction rate (3.3 vs. 2.9%, p = 0.83), mortality (5.0 vs. 7.2%, p = 0.35), or composite of death and 30 day reinfarction (7.7 vs. 9.4%, p = 0.55). We observed that STEMI patients with anterior infarction and hemodynamic instability were more likely to undergo thrombectomy during primary PCI.

PREDICTORS OF DEPRESSED LEFT VENTRICULAR FUNCTION IN PATIENTS PRESENTING WITH ST-ELEVATION MYOCARDIAL INFARCTION

Background: Left ventricular dysfunction after ST segment elevation myocardial infarction (STEMI) is the most important factor affecting morbidity and mortality. The primary objective of reperfusion therapy is to restore epicardial flow and to reperfuse the myocardial tissue. However, in some cases lack of microvascular reperfusion and, consequently, significant left ventricular (LV) dysfunction persist despite the rapid and sustained restoration of blood flow. Early in the course of STEMI, therapies that may harm patients who develop LV dysfunction, such as beta-blockers, are often administered. Aim of the work: construct a predictive score of the risk of developing left ventricular dysfunction in patients with STEMI. Patient and methods: This study was done in Cardiology department, Zagazig University on 100 patients; 78 males (78%) & 22 females (22%) with first acute STEMI underwent successful primary percutaneous intervention (pPCI). Within 72 hours of admission, all of the following parameters were reported: risk factors, blood pressure, heart rate, KILLIP class, need for mechanical ventilation (MV), cardiac enzymes, admission blood sugar, kidney function, lipid profile, electrocardiographic data (ST elevation in millimeters (mm), location of infarction, ST resolution, QRS width in milliseconds (ms), Selvester score), echocardiography (ejection fraction by Simpson's method, wall motion score index) and angiographic data (culprit artery, Total number of diseased vessels, severity of coronary artery disease, Gensini score and door to balloon time). Results: LV dysfunction was associated with decreased renal function (creatinine >1.1 mg/dl, p= 0.029), number of diseased vessels >2 (p=0.034), absence of complete ST segment resolution (p 2.05 (p=0.008), sum of ST segment elevation >13.5 mm (p 98.5 ms (p 3.5 (p 95 (p 1 (p=0.003). A prediction score using these variables stratified patients into low, intermediate and high-risk groups for LV dysfunction; positive likelihood ratios for LV dysfunction in these groups were 2.9, 2.1, and 2.4, respectively. Conclusions: 10 key predictors of in-hospital LV dysfunction after STEMI were identified; a risk score based on these predictors helps to quickly identify patients presenting with STEMI who are at the highest risk for developing significant LV dysfunction and could guide optimal therapeutic choices. Key words: ST-elevation myocardial infarction, left ventricular dysfunction, predictors, score, primary angioplasty.

Successful Primary Percutaneous Intervention to the Circumflex Artery Originating From Right Coronary Artery

The incidence of coronary artery anomalies are reported in to of the population Although their freuency is rare, these congenital anomalies are important due to their relation ith myocardial infarction and sudden cardiac death In this case, e presented a years old male patient ho has been admitted to our emergency service ith acute posterior myocardial infarction and transferred to the catheterisation laboratory for the purpose of primary percutaneous coronary intervention Coronary angiography revealed culprit lesion in anomalous circumfle artery originating from the proimal part of the right coronary artery and the patient as treated ith successful primary angioplasty and stent implantation ( Sakarya Med J 2015, 5(4):236-239 ) Keywords: Coronary artery anomalies Acute myocardial infarction ercutaneous coronary intervention

OCT during left main bifurcation PCI

80 years old male was admitted with recent history of acute coronary syndrome. Coronary angiogram showed minimal distal left main disease with significant ostial left anterior descending artery (LAD) lesion (Fig. 1A & Video 1). Optical coherence tomogram (OCT) guided percutaneous intervention (PCI) to Left main and LAD was planned using Provisional T stenting strategy. OCT evaluation showed minimal disease in distal left main (E). Ostial LAD showed thin cap fibro-atheroma with multiple calcified plaques (Fig. 1B, C & D). There was no significant calcium requiring de-bulking. Left circumflex artery (LCX) ostium showed minimal disease. After pre-dilatation and stenting of LAD lesion, there was significant plaque shift into the LCX (Fig. 1F & Video 2). Hence it was converted to two stent strategy and bifurcation stenting of LAD/LCX was done using T and protrusion technique (Fig. 1G, H & Video 3). Post stenting, left main bifurcation was assessed by OCT which showed good apposition of the stents in both LAD and LCX (Fig. 1I). Compared to IVUS OCT with lower penetration has limitations in large vessels like the left main, but its higher resolution helped in identifying a clear landing zone in the left main and a TCFA involving ostial LAD which predicted the plaque shift. Fig. 1 A: CAG in AP cranial view showing tight Ostial LAD lesion without any significant Ostial LCX disease. B: Longitudinal OCT image run from LAD to Left main (orientation-from left to right its distal to proximal) C: Cross-sectional OCT image from mid LAD ... Supplementary data related to this article can be found at http://dx.doi.org/10.1016/j.ihj.2014.08.009. The following are the supplementary data related to this article: Video 1: Initial CAG showing critical Ostial LAD disease without any significant left main or LCX disease. Click here to view.(1.1M, mp4) Video 2: After pre-dilation there was significant plaque shift into the LCX ostium. Click here to view.(1.0M, mp4) Video 3: Final angiogram after successful bifurcation PCI to LAD/LCX with two stents using TAP technique. Click here to view.(1.2M, mp4)

Outcomes of a Pharmacoinvasive Strategy for Successful Versus Failed Fibrinolysis and Primary Percutaneous Intervention in Acute Myocardial Infarction (from the Strategic Reperfusion Early After Myocardial Infarction [STREAM] Study)

Although a fibrinolytic pharmacoinvasive strategy is recommended for patients with ST elevation myocardial infarction (STEMI) unable to undergo timely primary percutaneous coronary intervention (PCI), there are limited data addressing outcomes specific to those with successful or unsuccessful pharmacologic reperfusions. Accordingly, we evaluated a contemporary pharmacoinvasive strategy for failed and successful reperfusions within the STrategic Reperfusion Early After Myocardial infarction study. Of 1,823 per-protocol-treated patients with STEMI, we examined clinical outcomes and angiographic and electrocardiographic metrics in 3 groups as follows: fibrinolysis requiring rescue (rescue, n = 348), fibrinolysis with scheduled angiography (scheduled, n = 516), and primary PCI (n = 927). Compared with pharmacoinvasive patients undergoing scheduled angiography, rescue patients were more likely to have anterior wall myocardial infarction, more baseline ST-segment elevation and deviation, as well as Q waves in the distribution of their ST elevation. Residual ST elevation ≥ 2 mm 30 minutes after angiography occurred in 27.9%, 7.9%, and 24.8% of patients who underwent rescue, scheduled, and primary PCI, respectively. Thirty-day composite event rates (all-cause death, cardiogenic shock, heart failure, and reinfarction) were 18.7%, 5.5%, and 13.9%; all-cause death: 6.1%, 2.1%, and 3.9%; cardiogenic shock: 7.5%, 2.0%, and 5.4%; heart failure: 11.8%, 2.3%, and 7.6%; and reinfarction: 1.5%, 1.4%, and 2.2%, for rescue, scheduled, and primary PCI, respectively. Compared with successfully reperfused patients undergoing scheduled angiography, the adjusted relative risk of the primary outcome was 2.92 (95% confidence interval 1.92 to 4.45) in rescue patients. In conclusion, pharmacoinvasive-treated patients requiring rescue angiography had greater baseline risk with more co-morbidities and worse 30-day outcomes compared with successful fibrinolytic-treated patients. Residual ST elevation after reperfusion assists in defining prognosis.

The clinical significance and management of patients with incomplete coronary angiography and the value of additional computed tomography coronary angiography

To assess the anatomical background and significance of incomplete invasive coronary angiography (ICA) and to evaluate the value of coronary computed tomography angiography (CTA) in this scenario. The current study is an analysis of high volume center experience with prospective registry of coronary CTA and ICA. The target population was identified through a review of the electronic database. We included consecutive patients referred for coronary CTA after ICA, which did not visualize at least one native coronary artery or by-pass graft. Between January 2009 and April 2013, 13,603 diagnostic ICA were performed. There were 45 (0.3%) patients referred for coronary CTA after incomplete ICA. Patients were divided into 3 groups: angina symptoms without previous coronary artery by-pass grafting (CABG) (n=11,212), angina symptoms with previous CABG (n=986), and patients prior to valvular surgery (n=925). ICA did not identify by-pass grafts in 21 (2.2%) patients and in 24 (0.2%) cases of native arteries. The explanations for an incomplete ICA included: 11 ostium anomalies, 2 left main spasms, 5 access site problems, 5 ascending aorta aneurysms, and 2 tortuous take-off of a subclavian artery. However, in 20 (44%) patients no specific reason for the incomplete ICA was identified. After coronary CTA revascularization was performed in 11 (24%) patients: 6 successful repeat ICA and percutaneous intervention and 5 CABG. Incomplete ICA constitutes rare, but a significant clinical problem. Coronary CTA provides adequate clinical information in these patients.

Optical coherence tomogram of spontaneous coronary artery dissection managed with drug eluting stent

A 42-year-old male patient with no known risk factors for coronary artery disease was admitted after an episode of break through seizures. Incidentally his electrocardiogram showed evidence of antero-septal myocardial infarction and the echocardiogram showed regional wall motion abnormality involving the inter-ventricular septum. Cardiac bio-markers including highly sensitive troponins were negative, thus excluding an acute event. Coronary angiogram (Fig. 1A & Video 1) showed dominant left system with intra luminal filling defects (arrow) in the proximal and mid left anterior descending artery (LAD). To further define the nature of the filling defects an optical coherence tomogram (OCT) was done, which showed dissection flaps (Fig. 1B) with multiple false lumens involving the proximal and mid LAD. Successful percutaneous intervention with drug eluting stent was done to the LAD. Good angiographic results (Fig. 1C & Video 2) were confirmed on OCT (Fig. 1D). OCT helped in confirming the filling defects to be dissection flaps and also in deciding the length of the stent to cover the entire diseased segment. Fig. 1 Supplementary video related to this article can be found online at http://dx.doi.org/10.1016/j.ihj.2014.02.005. The following are the Supplementary video related to this article: Video 1: Click here to view.(779K, mp4) Video 2: Click here to view.(1.5M, mp4)

Percutaneous Angioplasty of Upstream Right Pulmonary artery stenosis post Tetralogy of Fallot (TOF) repair with use of 3D Multi slice-CT imaging

Pulmonary artery stenosis [PAS] is not an uncommonly missed diagnosis in associated with congenital heart diseases including Tetralogy of Fallot's. We report similar case of a preadolescent girl who presented with symptoms of exertional shortness of breath after surgical repair of Tetralogy of Fallot. 2 D echocardiography revealed the right pulmonary artery stenosis, which was upstream to the surgical trans-annular patch across main pulmonary artery. It was better delineated using 64 slice CT angiography and by cropping with the help of software. The Successful percutaneous intervention in the form of right pulmonary angioplasty could alleviate her symptoms.

Prognostic Value of 2D Speckle Tracking Echocardiography in Patients with ST Segment Elevation Myocardial Infarction

OP-002 We aimed to investigate the prognostic value and reveal the role of a novel method speckle tracking echocardiography for predicting adverse cardiovascular events in STEMI patients undergoing successful primary percutaneous intervention (PCI). We included 117 patients who admitted to Kocaeli

Percutaneous Treatment of Congenital Heart Defects in the Rubinstein-Taybi Syndrome

The Rubinstein-Taybi syndrome is a genetic disorder characterized by distinctivefacial features, abnormalities in hands and feet, microcephaly and mentalretardation. Approximately 30% of subjects with this syndrome have associatedcongenital heart defects.This presentation describes two cases of patients with Rubinstein-Taybi syndromeassociated with congenital heart defects: a 25-year-old patient with juxtaductalnative aortic coarctation and an 11-month old infant with a large patent ductusarteriosus. Both patients underwent successful percutaneous intervention, withfavorable long-term outcome.

Non-Fibroatheroma Lesion Phenotype and Long-Term Clinical Outcomes: A Substudy Analysis From the PROSPECT Study

The purpose of this study was to determine the clinical impact of non-fibroatheroma lesion phenotype in patients presenting with an acute coronary syndrome (ACS). Although fibroatheromas (FAs) are known to be clinically unstable, the impact of non-FA lesion phenotype on clinical outcomes has not been studied. In the PROSPECT (Providing Regional Observations to Study Predictors of Events in the Coronary Tree) study, patients presenting with an ACS underwent 3-vessel grayscale and virtual histology intravascular ultrasound (VH-IVUS) after successful percutaneous intervention for all culprit lesions and were followed for 3 years. Patients were divided into those who had only the non-FA phenotype (pathological intimal thickening or fibrotic and/or fibrocalcific lesions) versus those who had at least 1 nonculprit FA. Among 2,880 nonculprit lesions identified by VH-IVUS, 39.8% were non-FAs (1,042 pathological intimal thickening, 72 fibrotic, and 33 fibrocalcific). Nonculprit major adverse cardiac events (MACE) (death, myocardial infarction, or urgent rehospitalization for progressive or unstable angina) were attributed to only 7 non-FA lesions (0.7%) versus 43 FA lesions (2.7%, p < 0.001) during 3 years follow-up. Of 609 patients, 67 (11.0%) patients had only non-FA lesion phenotypes. Patients with only non-FAs tended to be younger and more often female, have fewer nonculprit lesions and less overall plaque burden and necrotic core, and fewer nonculprit lesion MACE compared with patients with at least 1 FA. In the adjusted Cox proportional hazards model, absence of a FA was a significant predictive of a lower 3-year nonculprit MACE rate (hazard ratio: 0.23; 95% confidence interval: 0.06 to 0.95). Non-FA lesions were clinically stable and were rarely associated with clinical events during 3 years of follow-up. The intermediate-term prognosis in patients presenting with ACS in whom all nonculprit lesions are non-FAs is favorable. ( An Imaging Study in Patients With Unstable Atherosclerotic Lesions; NCT00180466).

Transcatheter Management of Neonates With Pulmonary Atresia With Intact Ventricular Septum: A Single Center Experience From Turkey

Pulmonary atresia with intact ventricular septum (PAIVS) is characterized by a broad spectrum of heterogeneous morphologies. Perforation of the atretic valve, balloon dilatation, and stenting of the patent ductus arteriosus are the percutaneous techniques that are used with increasing frequency in our clinic as well. They have some advantages over surgery, including short hospital stay and short intensive care unit stay. The main goal of the primary interventional approach is to avoid surgery. However, a group of patients with PAIVS still need surgery due to poor right ventricular growth. Therefore, the final achievement of the initial percutaneous treatment strategies is still debatable. In this article, we present the early- and mid-term results of the percutaneous approach utilized at our clinic in order to investigate the final effects of interventional therapy according to initial morphology. Between May 2010 and May 2012, 15 neonates diagnosed with PAIVS underwent transcatheter intervention. Detailed echocardiographic examination focused on right ventricle size, and tricuspid valve morphology and coronary sinusoids were performed in all the patients before the intervention. Nine of the patients were boys and six were girls. The mean age was 11.40 ± 12.87 days and mean weight was 3.34 ± 0.46 kg. Only one procedure-related mortality occurred. The mean follow-up period was 10.05 ± 3.42 months (1-26 months). The mean duration of intensive care was 7.19 ± 5.14 days. The mean follow-up time was 10.05 ± 3.42 months. After this period, survival rate was 66% (10/15). Two of the patients achieved biventricular physiology after pulmonary valve perforation. Two patients still have univentricular physiology. Six patients have been followed as a one and half ventricle repair candidate. Five out of 15 patients had stent patency during 6 months of follow-up, while restenosis developed in one patient (1/5, 20%), who had undergone the Glenn operation at 5 months of age. Transcatheter management for PAIVS is a feasible, safe, and effective primary palliative treatment in newborns. Shunt surgery may be considered in cases where cyanosis occurs despite transcatheter intervention. Right ventricular size determines the type of intervention. The early outcomes can be comparable with surgical palliation. However, a group of PAIVS, particularly with severe right ventricular hypoplasia, needs surgery even after a successful primary percutaneous intervention.

Directable needle guide: efficacy for image-guided percutaneous interventions.

Diagnostic and therapeutic image-guided percutaneous interventions have become increasingly important in the clinical management of various conditions. Though precise needle placement via a safe route is essential for successful percutaneous interventions, it is often difficult in cases of deeply situated, small lesions. The present paper describes the efficacy of the directable needle guide (DNG), which allows manipulation of the direction of a fine needle within organs. The DNG was used in patients for needle biopsy of hepatic (n = 26) and splenic (n = 1) lesions and for percutaneous ethanol injection therapy for liver tumors (n = 33) under sonographic or computed tomography guidance. The DNG enabled the direction of a 21- or 22-gauge needle to be successfully changed during needle advancement in all cases, allowing adjustment of the location of the needle tip or needle access root to avoid vessels, the gallbladder, and the lungs. We conclude that DNG increases the safety and ease of percutaneous interventions.

Renal denervation in a patient with prior renal artery stenting

This is a case report of a 69-year-old female with treatment-resistant severe arterial hypertension despite prior successful percutaneous intervention to both renal arteries for significant renal artery stenoses (stenting of the right and balloon angioplasty of the left renal artery). The office blood pressure was 221/108 mm Hg at baseline. Secondary hypertension was ruled out and catheter-based renal denervation performed (distal to the stent in the right renal artery and in the usual fashion in the left renal artery) without complications. The office blood pressure decreased at 1- and 3-month follow-up to 185/93 mm Hg and 182/95 mm Hg, respectively. This case illustrates the feasibility and potential efficacy of catheter-based renal denervation in patients with a renal artery stent, an important finding as persistent hypertension is common in patients despite successful renal artery stenting and currently available trials examining renal denervation have excluded patients with prior renal artery stents.

Percutaneous treatment of a free-floating thrombus in the right atrium of a patient with pulmonary embolism and acute myocarditis

Free-floating thrombi in the right atrium (RA) are extremely hazardous to patients with pulmonary thromboembolism, and optimal treatment methods remain unclear. We report a case of successful percutaneous intervention of a critical right atrial thrombus. The patient was a 50-year-old woman who had been under medication for acute myocarditis when she complained of sudden severe dyspnea. Echocardiography showed a mobile snake-like thrombus in the RA. The thrombus was pulled back to the distal inferior vena cava (IVC) using a catheter and an IVC filter was placed. Percutaneous treatment is useful for treating free-floating RA thrombi.

Percutaneous intervention on anomalous circumflex coronary arteries — a single centre experience

Anomalies of the origin and course of the circumflex artery are amongst the most common seen at coronary angiography. There is limited information regarding patient and procedural characteristics, technical feasibility and outcomes associated with percutaneous intervention (PCI) to these vessels. The aim of this study is to examine our experience with PCI to anomalous circumflex vessels and compare this to some aspects of percutaneous intervention on non-anomalous circumflex vessels. Over a 41 month period, 20 PCI procedures on anomalous circumflex vessels were identified and 1550 PCI procedures on non-anomalous circumflex arteries. In 9 anomalous cases, the circumflex arose from the left coronary cusp, in 7 cases from the right coronary cusp, and in the remaining 4 cases from the proximal right coronary artery. There were no differences in demographics or pattern or severity of coronary disease between the 2 groups. A higher proportion of patients with anomalous vessels presented acutely. Screening times were longer in the anomalous group. All 20 procedures were associated with immediate procedural success. There was one peri-procedural myocardial infarction unrelated to anomalous circumflex intervention. After a median follow-up period of 7.3 months, the only major adverse cardiac event recorded in the anomalous group was an ischaemia-driven revascularisation to a non-target vessel branch. We describe techniques which can be used to improve support and facilitate successful PCI to anomalous circumflex vessels. PCI to anomalous circumflex vessels may be technically challenging, but is feasible and carries favourable short and long-term clinical outcomes. This single centre observational study demonstrates that percutaneous coronary intervention to anomalous circumflex coronary arteries although technically challenging can be performed with satisfactory procedural success rates and favourable short and longer-term clinical outcomes. It describes various techniques that can be employed to optimise successful intervention.

Percutaneous intervention in peripheral artery disease improves calf muscle phosphocreatine recovery kinetics: A pilot study

We hypothesized that percutaneous intervention in the affected lower extremity artery would improve calf muscle perfusion and cellular metabolism in patients with claudication and peripheral artery disease (PAD) as measured by magnetic resonance imaging (MRI) and spectroscopy (MRS). Ten patients with symptomatic PAD (mean ± SD: age 57 ± 9 years; ankle-brachial index (ABI) 0.62 ± 0.17; seven males) were studied 2 months before and 10 months after lower extremity percutaneous intervention. Calf muscle phosphocreatine recovery time constant (PCr) in the revascularized leg was measured by (31)P MRS immediately after symptom-limited exercise on a 1.5-T scanner. Calf muscle perfusion was measured using first-pass gadolinium-enhanced MRI at peak exercise. A 6-minute walk and treadmill test were performed. The PCr recovery time constant improved significantly following intervention (91 ± 33 s to 52 ± 34 s, p < 0.003). Rest ABI also improved (0.62 ± 0.17 to 0.93 ± 0.25, p < 0.003). There was no difference in MRI-measured tissue perfusion or exercise parameters, although the study was underpowered for these endpoints. In conclusion, in this pilot study, successful large vessel percutaneous intervention in patients with symptomatic claudication, results in improved ABI and calf muscle phosphocreatine recovery kinetics.

Quality Measurement and Improvement in the Cardiac Catheterization Laboratory

Case Presentation: A 46-year-old man with a past medical history significant for morbid obesity (body mass index of 66), hypertension, tobacco use, and dyslipidemia presented to an outside hospital with a non–ST-segment elevation myocardial infarction and was transferred for coronary angiography. Femoral arterial access was obtained for an uncomplicated percutaneous intervention (PCI) with the use of unfractionated heparin and a glycoprotein IIB/IIIA inhibitor. After successful PCI of the right coronary artery with drug-eluting stent implantation, the femoral arteriotomy was closed without complication. Two hours after the completion of the procedure, the patient experienced ventricular fibrillation and respiratory arrest requiring prolonged resuscitation with a subsequent hematocrit level noted to be 12.5%. The patient was resuscitated with fluid and blood products. Emergent angiography showed no active iliofemoral contrast extravasation and a widely patent coronary stent. An abdominal CT scan without contrast confirmed the diagnosis of a retroperitoneal hemorrhage. Unfortunately, the patient experienced recurrent ventricular fibrillation, and he died despite additional resuscitative efforts. Cardiac catheterization is one of the most common invasive procedures performed in the United States.1 Although the benefits of cardiac catheterization remain great, the large number of procedures performed coupled with infrequent but potentially significant complications make the cardiac catheterization laboratory an important environment in which to constantly strive to improve quality. Although optimal patient outcomes remain paramount, state and national regulatory requirements, public reporting, and payers' interests in both outcomes and cost raise the importance of quality measurement and improvement in the cardiac catheterization laboratory.2 Minimal requirements for quality monitoring in the cardiac catheterization laboratory vary with individual state regulatory practices. As an example, in Massachusetts, data elements are collected and reported as mandated by the Massachusetts Department of Public Health, The Joint Commission, Centers for Medicare & Medicaid Services, and mandated participation in the American College …