Cardiovascular Revascularization Medicine

Editorial Note

Ron Waksman — 2010-01-01

Thank you for being with us as we bid farewell to 2009 and enter into the journal's 11th year. In the last quarter of 2009, we unfortunately had to say goodbye to two great cardiologists who each made a significant impact on the field. Dr. Donald Baim, interventional cardiologist and chief medical and scientific officer at Boston Scientific, had a stellar academic career. He published nearly 300 scientific papers on interventional technology and edited a leading textbook, Grossman's Cardiac Catheterization, Angiography and Intervention, now in its seventh edition. He served as the principal investigator on dozens of interventional cardiology clinical trials and was a founder of or a key contributor to over 20 startup companies and medical device incubators. We also remember Dr. William Ganz, whose groundbreaking research included the development of the Swan–Ganz catheter and intracoronary thrombolysis. Dr. Ganz came to Cedars–Sinai Medical Center in Los Angeles in 1966, and in 1973, he and Dr. Jeremy (HJC) Swan invented the Swan–Ganz catheter for hemodynamic monitoring. During the 1980s, Ganz and Dr. Prediman K. Shah conducted the first studies of coronary thrombolysis in myocardial infarction patients, and in 1990, his research showed that reperfusion of otherwise-viable myocardium does not expand necrosis. Both Baim and Ganz leave us with a tremendous amount of knowledge that will continue to impact our field.

Predictors of myocardial contractile recovery after coronary revascularization in patients with prior myocardial infarction

Zainab Abdel-Salam, Wail Nammas — 2010-01-01

Abstract: Background: We sought to explore the prognostic power of certain patient characteristics to predict myocardial contractile recovery after coronary revascularization in patients with prior myocardial infarction.Methods and Materials: We enrolled 100 consecutive patients with prior myocardial infarction, significant coronary stenosis/occlusion amenable for revascularization, and regional wall motion abnormality in the distribution of the affected artery. All patients underwent echocardiographic assessment of regional wall motion and left ventricular ejection fraction. Patients underwent coronary revascularization by either percutaneous angioplasty or surgical bypass. Echocardiography was repeated 8 weeks following revascularization. Patients were classified into two groups: Group 1 with evidence of contractile improvement after revascularization at follow-up echocardiography and Group 2 with no such evidence of improvement. The two groups were compared with respect to patients' clinical characteristics and echocardiographic and angiographic data.Results: Predictors of contractile recovery after revascularization included angina pectoris, the shorter age of infarction at the time of revascularization, a higher baseline left ventricular ejection fraction, a lower baseline wall motion score index, the presence of Grade 2–3 collaterals to the infarct-related artery, and the absence of dyspnea or diabetes mellitus. Stepwise regression analysis identified the presence of Grade 2–3 collaterals to the infarct-related artery and the age of infarction at the time of revascularization as independent predictors of contractile recovery after revascularization.Conclusions: In patients with prior myocardial infarction, the presence of Grade 2–3 collaterals to the infarct-related artery and the shorter age of infarction at the time of revascularization independently predicted myocardial contractile recovery after coronary revascularization.

Hyperbaric oxygen preconditioning improves myocardial function, reduces length of intensive care stay, and limits complications post coronary artery bypass graft surgery

2010-01-01

Abstract: Objective: The objective of this study was to determine whether preconditioning coronary artery disease (CAD) patients with HBO2 prior to first-time elective on-pump cardiopulmonary bypass (CPB) coronary artery bypass graft surgery (CABG) leads to improved myocardial left ventricular stroke work (LVSW) post CABG. The primary end point of this study was to demonstrate that preconditioning CAD patients with HBO2 prior to on-pump CPB CABG leads to a statistically significant (P<.05) improvement in myocardial LVSW 24 h post CABG.Methods: This randomised control study consisted of 81 (control group=40; HBO2 group=41) patients who had CABG using CPB. Only the HBO2 group received HBO2 preconditioning for two 30-min intervals separated 5 min apart. HBO2 treatment consisted of 100% oxygen at 2.4 ATA. Pulmonary artery catheters were used to obtain perioperative hemodynamic measurements. All routine perioperative clinical outcomes were recorded. Venous blood was taken pre HBO2, post HBO2 (HBO2 group only), and during the perioperative period for analysis of troponin T.Results: Prior to CPB, the HBO2 group had significantly lower pulmonary vascular resistance (P=.03). Post CPB, the HBO2 group had increased stroke volume (P=.01) and LVSW (P=.005). Following CABG, there was a smaller rise in troponin T in HBO2 group suggesting that HBO2 preconditioning prior to CABG leads to less postoperative myocardial injury. Post CABG, patients in the HBO2 group had an 18% (P=.05) reduction in length of stay in the intensive care unit (ICU). Intraoperatively, the HBO2 group had a 57% reduction in intraoperative blood loss (P=.02). Postoperatively, the HBO2 group had a reduction in blood loss (11.6%), blood transfusion (34%), low cardiac output syndrome (10.4%), inotrope use (8%), atrial fibrillation (11%), pulmonary complications (12.7%), and wound infections (7.6%). Patients in the HBO2 group saved US$116.49 per ICU hour.Conclusion: This study met its primary end point and demonstrated that preconditioning CAD patients with HBO2 prior to on-pump CPB CABG was capable of improving LVSW. Additionally, this study also showed that HBO2 preconditioning prior to CABG reduced myocardial injury, intraoperative blood loss, ICU length of stay, postoperative complications, and saved on cost, post CABG.

An innovative noninvasive respiratory stress test indicates significant coronary artery disease

2010-01-01

Abstract: Background: Respiratory maneuvers can uncover manifestations of myocardial ischemia. Some pulse wave characteristics are strongly associated with significant coronary artery disease (S-CAD). An innovative test using the respiratory stress response (RSR) has been developed for the detection of S-CAD. It is based on spectral analysis of finger pulse wave oscillations measured by photoplethysmography during deep, paced breathing at a rate of six breaths per minute (0.1 Hz) over 70 s.Methods: RSR was assessed, prior to the procedure, in 150 consecutive patients referred for coronary angiography. It was calculated by analyzing the relative spectral power of the respiratory peak area at 0.1 Hz, using proprietary software. The coronary angiograms were analyzed by quantitative coronary angiography by 1 cardiologist who was blinded to the RSR results. S-CAD was defined as luminal stenosis >70% of ≥1 coronary artery with a diameter ≥2 mm, or left main stenosis >50%. A valid RSR was obtained in 150 of 153 patients (98%) with a mean age of 58.7±10.6 years (67% males).Results: S-CAD was found in 36 patients (24%). S-CAD patients had significantly lower RSR compared to patients without S-CAD (6.7%±5.1 vs. 17.4%±10.6; P<.001, respectively). Multivariate logistic regression analysis, adjusted for known CAD risk factors, showed that RSR is a strong independent indicator of S-CAD (odds ratio 41.2, 95% CI 12.2–139.3; P<.001).Conclusion: The innovative RSR test is a simple, noninvasive bedside or office-based tool for the detection of S-CAD.

Transcatheter patent foramen ovale closure is effective in reducing migraine independently from specific interatrial septum anatomy and closure devices design

2010-01-01

Abstract: Background: Relationships between migraine improvement after transcatheter patent foramen ovale (PFO) closure and both specific interatrial septum anatomy and different devices design have not been investigated yet. We sought to assess effectiveness of transcatheter PFO closure in reducing or curing migraine with aura in patients with previous paradoxical embolism in relation with specific interatrial septum anatomy and different closure devices.Methods and Results: We prospectively enrolled 34 patients (22 female and 12 male, mean age 40±3.7 years) who were referred to our centre over a 12-month period for PFO transcatheter closure and migraine with aura and previous paradoxical embolism. All procedures were performed using mechanical intracardiac echocardiographic guidance. Patients were assigned to Amplatzer PFO or ASD Multifenestrated Occluder and Premere Occlusion System implantation dependently from intracardiac echocardiography anatomical findings, which included short-channel with moderate atrial septal aneurysm (ASA) in 6 patients (17.6 %), long-channel with moderate ASA in 3 patients (8.8%), short-channel with huge ASA in 5 patients (14.7%), multifenestrated ASA in 4 patients (11.7%), long-channel PFO without ASA in 10 patients (29.4%), and long-channel PFO with mild ASA in 6 patients (17.6%). Accordingly, 18 patients received an Amplatzer Occluder (9 PFO Occluder and 7 ASD Multifenestrated Occluder), and 16 received a Premere Occlusion System. After a mean follow-up of 9.0±2.8 months, all patients improved their migraine symptoms (mean Migraine Disability Assessment Score 30±1.5 at baseline versus 6.0±2.9 in the follow up, P<.03) independently from specific interatrial septum anatomy and different closure devices.Conclusion: Although our study had several limitations, it suggests that independently from interatrial septum anatomy and device type, PFO closure in patients with migraine with aura resulted in a high rate of migraine improvement.

Percutaneous coronary intervention for chronic total occlusive lesion of a left anterior descending artery using the retrograde approach via a septal–septal channel

Makoto Utsunomiya, Naoki Mukohara, Ryoichi Hirami, Shigeru Nakamura — 2010-01-01

Abstract: The retrograde approach is an effective therapeutic strategy for chronic total occlusion (CTO) intervention. In CTO cases, the retrograde approach from the opposite coronary artery is not always applicable. In certain left anterior descending (LAD) CTO cases, the distal LAD is filled from the septal channel where it is supplied by the proximal septal route. We report two LAD CTO cases of percutaneous coronary intervention (PCI) conducted with a wire from the proximal septal branch to the distal septal channel using the retrograde approach.

Day 1 care in patients with non-ST-segment elevation myocardial infarction

Deepak Thomas, Robert P. Giugliano — 2010-01-01

Abstract: In 2007, the American College of Cardiology/American Heart Association and the European Society of Cardiology updated their guidelines for the management of patients with non-ST-segment elevation myocardial infarction (NSTEMI). Based on evidence from recent clinical studies, both 2007 guidelines recommend early risk stratification, administration of appropriate pharmacologic therapy, and selective use of percutaneous coronary intervention in order to reduce morbidity and mortality in these patients. In this article, we focus on management of patients with NSTEMI during the first 24 h of presentation and present a clinical scenario to illustrate the current guidelines-based management strategy.

Late drug-eluting stent thrombosis: importance of intravascular ultrasound

Andrew McCann, Andrew MacIsaac, Robert J. Whitbourn — 2010-01-01

Abstract: We report two cases of late occurring drug-eluting stent thrombosis (ST) where coronary angiography failed to identify the cause but intravascular ultrasound (IVUS) revealed underlying mechanical problems with the initial stent deployment. Mechanical factors such as stent underexpansion and residual edge stenoses may be more important in the pathogenesis of late drug-eluting ST than previously recognized. Intravascular ultrasound is required to reliably detect these problems and optimize subsequent reintervention.

Origin of a common trunk for the inferior phrenic arteries from the right renal artery: a new anatomic vascular variant with clinical implications

2010-01-01

Abstract: The inferior phrenic arteries constitute a pair of important vessels, supplying multiple organs including the diaphragm, adrenal glands, esophagus, stomach, liver, inferior vena cava, and retroperitoneum. The vast majority (80–90%) of inferior phrenic arteries originate as separate vessels with near equal frequency from either the abdominal aorta or the celiac trunk. Infrequently, the right and left inferior phrenic arteries can arise in the form of a common trunk from the aorta or from the celiac trunk. We herein present three patients with a new anatomic vascular variant: a common trunk of the inferior phrenic arteries arising from the right renal artery. In one case, the left inferior phrenic branch of the common trunk provided collaterals connecting with a supra-diaphragmatic branch of the left internal mammary artery and in another with the lateral wall of the pericardium. Angiographic identification of a common trunk for the inferior phrenic arteries arising from the right renal artery is important for proper diagnosis and clinical management. The presence of this unique vascular variant can impact revascularization of the renal arteries.

Closure of a coexisting ostium secundum atrial septal defect and patent foramen ovale using a single Amplatzer patent foramen ovale occluder device

Michael Luna, Subhash Banerjee, Emmanouil S. Brilakis — 2010-01-01

Abstract: We report the case of a 59-year-old man with cryptogenic stroke who was found to have both an ostium secundum atrial septal defect and a patent foramen ovale (PFO) by intracardiac echocardiography. Both defects were successfully occluded using a single 35-mm Amplatzer PFO occluder device inserted through the atrial septal defect.

Thrombus vaporization by excimer laser angioplasty

Gregory Angelo Sgueglia, Giampaolo Niccoli, Marcello Marino, Filippo Crea — 2010-01-01

A 70-year-old woman, with no traditional cardiovascular risk factor, came to our attention because of a non-ST-segment myocardial infarction. Her cardiac history was uneventful, except the recent onset of episodes of waxing and waning epigastric pain. Of note, 2 weeks earlier, she began therapy with enoxaparin due to the suspicion of deep vein thrombosis. At admission, the patient complained of sharp, persisting pain referred to the epigastrium. Physical examination and routine blood test results were normal. Cardiac enzymes were raised (CK-MB 22.8 ng/ml) and ECG showed diffuse repolarization abnormalities. At echocardiography, mild depression of left ventricle function was found, with hypokinesis of its anterior and lateral walls. Coronary angiography () revealed a critical stenosis of the ramus intermedius with a high thrombus burden downward the lesion (Panel A), thus prompting for percutaneous revascularization in the same session. After wiring of the culprit vessel, excimer laser angioplasty was performed (Panel B). Thrombus vaporization and underlying plaque debulking were concurrently obtained (Panel C). The intervention was eventually completed with bare metal stenting for stabilization of the lesion. Procedure success was achieved with optimal percutaneous coronary flow and myocardial perfusion (Panel D).

Erratum

Hikmet Yorgun — 2010-01-01

Övünç et al. wish to correct an error in their submission, “Multiple coronary artery aneurysm formation one year and four years after sirolimus-eluting coronary stent implantation.” (Cardiovasc Revasc Med 2009;10:252-254) The authors incorrectly stated that the size of the Cypher (Cordis, Johnson & Johnson) stent used was 2.75×10 mm, when in fact, it was 2.75×13 mm in diagonal artery and 3.0×13 mm in left anterior descending artery.