Objectives This study sought to compare interrupted and uninterrupted oral anticoagulant therapy (I-OAC vs. U-OAC) in patients on OAC undergoing percutaneous coronary intervention.
Objectives The aim of this study was to explore the early versus late benefits and risks of dabigatran dual therapy versus warfarin triple therapy in the RE-DUAL PCI (Randomized Evaluation of Dual Antithrombotic Therapy With Dabigatran Versus Triple Therapy With Warfarin in Patients With Nonvalvular Atrial Fibrillation Undergoing Percutaneous Coronary Intervention) trial.
Objectives This study analyzed the learning curve effect when a new stroke thrombectomy program was initiated in a cardiac cath lab in close cooperation with neurologists and radiologists.
Evidence for antithrombotic treatment following lower extremity revascularization (LER) for peripheral artery disease (PAD) is limited, leading to weak and conflicting guideline recommendations and heterogeneous practice patterns. This variability in post-LER antithrombotic treatment raises quality-of-care issues that have long been under-studied. This Viewpoint reviews the most updated guidelines, currently-available evidence, and contemporary data about practice patterns and practitioner opinions in this area. Particular attention is paid to distinctions between antiplatelet therapy, anticoagulant therapy, and combination therapy in light of the recent VOYAGER-PAD (Vascular Outcomes Study of ASA [acetylsalicylic acid] Along with Rivaroxaban in Endovascular or Surgical Limb Revascularization for PAD) trial. The implications of VOYAGER-PAD pertaining to various subgroups of patients undergoing LER are explored. Overall, this Viewpoint argues for consideration of post-LER therapy targeted at both platelet function and the coagulation cascade, though further LER-specific analyses, including expected VOYAGER-PAD sub-analyses, are needed.
A group of Japanese experts developed a complex technique for antegrade chronic total occlusion (CTO) crossing using 3-dimensional (3D) angiographic guidance based on the detection of the tip and the shaft of the guidewire in 2 orthogonal views (1,2). Successful implementation of this technique requires identifying the location of the wire shaft within the artery, and the accurate approximation of the guidewire tip direction in relation to the target. Based on these 2 factors, a mental 3D image of the guidewire tip to target path can be constructed. We present a modified version of 3D wiring, while applying the same principal of 3D wiring, with the intent to make it easier to understand and implement by the interventional community.
Morbidly obese patients presenting with ST-segment elevation myocardial infarction (STEMI) present with unique challenges, especially when their weight limit exceeds that of the angiography table. Although thrombolytic therapy is an option, dosing guidelines do not exist for such extreme body weights.
A 47-year-old man with 10-year history of untreated syphilis was referred to our hospital for chest tightness, pain, and shortness of breath after activity for about 1 month. Findings from biomarker assays showed an increased cardiac troponin T level (968.4 ng/l, reference 0 to 14 ng/l). The electrocardiogram on admission showed ST-segment depression in leads V2 to V4, I, and aVL with T-wave inversion, which indicated non–ST-segment elevation myocardial infarction. An emergency coronary angiography revealed critical bilateral coronary ostial stenosis with a normal coronary bed distally (Figure 1, Videos 1 and 2). After balloon pre-expansion, intravenous ultrasound showed a severe fibrous plaque from the left coronary proximal segment (Figure 2A) to ostium with a minimal luminal area of 2.8 mm2 (Figure 2B, Video 3). In the right coronary artery, no fibrous plaque was found, but the luminal area was shrinking sharply from proximal segment (Figure 2C) (luminal area 29.6 mm2) to ostium (Figure 2D) (luminal area 6.1 mm2) (Video 4). Two drug-eluting stents were implanted for complete revascularization. Additional serological assays revealed positive nontreponemal (toluidine red unheated serum 1:32) and treponemal (Treponema pallidum particle agglutination) tests. Echocardiography (Figure 3A) revealed mild aortic regurgitation with left ventricular dilatation and global left ventricular dysfunction. On aortic computed tomography angiogram, circumferential thickening of the thoracic aorta involving the bilateral coronary ostium (Figures 3B and 3C) and the ostia of its other major branches was found (Figure 3D). The patient was diagnosed with syphilitic coronary ostial stenosis, which is a rare condition resulting from aorta wall thickening caused by endarteritis obliterans of the aortic vasa vasorum. He was discharged with dual antiplatelet and intramuscular penicillin therapy regimens for 4 weeks. The stents were patent on coronary angiography at 6-month follow-up, and no symptoms were reported at 2-year follow-up.
A 62-year-old man presented with chest pain. He had a negative stress echocardiogram, but was referred to coronary computed tomography angiography (CTA), given his persistent pain with anginal characteristics. CTA suggested significant left anterior descending and right coronary artery (RCA) disease, and an anomalous RCA origin with dual ostia (Figures 1A and 1B). He underwent coronary angiography showing nonobstructive disease (30% proximal left anterior descending coronary artery, 50% distal RCA) and confirming the dual ostia of the RCA (Figures 1C and 1D, Video 1). He was started on aspirin, atorvastatin, and metoprolol, with symptomatic improvement.
A 32-year-old man presented to our hospital with generalized weakness and backache. Electrocardiographic results aroused concern that he had an ST-segment elevation myocardial infarction, and emergent coronary angiography was considered to confirm the diagnosis. The electrocardiogram showed ST-segment elevation in leads I, aVL, and V7 to V9, and concomitant depression in leads III, aVF, aVR, V3R, V4R, V5R, and V1 to V4 (Figure 1A). He had no chest pain or any risk factors of coronary heart disease, and his cardiac biomarkers were in the normal range. On further discussion with the patient and review of the records, it was discovered that he had been diagnosed as having hepatic angiosarcoma for 10 months, which was treated with regular chemotherapy and transarterial chemoembolization. Echocardiogram (Figures 1B to 1D, Videos 1 and 2) showed a huge mass in the right atrium, which was considered to be metastatic tumor. The electrocardiographic pattern was thought to be due to tumor invasion of the myocardium. Unfortunately, the patient died because of massive hemoptysis and asphyxia.
A 78-year-old woman, who underwent hemodialysis and magnetic resonance imaging (MRI) nonconditional pacemaker implantation for sick sinus syndrome, presented with non–ST-segment elevation myocardial infarction. A coronary angiogram and subsequent intravascular ultrasound from the right brachial artery revealed severe circumferential calcified stenosis of the middle right coronary artery, which required atheroablation (Figure 1A). Previous computed tomography (CT) showed a heavily calcified tortuous descending aorta, which made it difficult to use any supporting devices via the femoral artery (Figure 2). Therefore, adequate blood pressure (BP) was maintained to avoid coronary slow-flow phenomenon during the procedure. However, she complained of severe chest oppression during orbital atherectomy, and her BP suddenly increased to >200 mm Hg, resulting in large BP fluctuations. She gradually became restless and had difficulty following commands. After the successful procedure, her confusion and disturbed consciousness persisted (Figure 1B). Thereafter, head CT showed cerebral edema and focal contrast pooling in the posterior lobe, which suggested a blood–brain barrier dysfunction (Figure 3). Because her cerebrospinal fluid test was normal, she was diagnosed with posterior reversible encephalopathy syndrome (PRES), and her BP was controlled under 140 mm Hg. Serial head CT evaluation showed a gradual improvement of cerebral edema, which was accompanied by ameliorating neurological findings. Six days later, her neurological abnormalities fully recovered.
Transcatheter mitral valve interventions (TMVI) have established as an alternative to surgery in selected cases. Transesophageal echocardiography is crucial to perform detailed imaging during procedures. Different photo-realistic rendering views (Philips, Andover, Massachusetts) have developed: transillumination, tissue-transparency (TT), and both with 3-dimensional (3D) color (1).
Two years after coronary angioplasty for ST-segment elevation myocardial infarction, a 58-year-old man complained of a painless lump in his right wrist at the puncture site. He did not report any particular symptoms. Physical examination revealed a palpable, pulsatile lump with a continuous murmur on the volar aspect of the patient’s right wrist. The lump was not focally tender, and there were no signs of infection or erythema (Figure 1). There were no neurological abnormalities. Doppler and angiography confirmed the presence of a large aneurysmal arteriovenous (AV) fistula with a flow of 550 ml/min (Figures 2 and 3). Considering the persistent discomfort and the constant increase in size, curative treatment with endovascular sealing or surgery was discussed. Finally, due to the very distal location of the fistula, which was not optimal for covered stent deployment, surgery was scheduled (Figure 4). Resection of the aneurysm was performed with radial arterioplasty as an out-patient procedure. The outcome was uneventful, and radial pulse was recovered.
Percutaneous mitral edge-to-edge repair is an alternative for patients with primary severe mitral regurgitation (MR) (1). New-generation devices may improve the effectiveness in complex patients (2). A 64-year-old man was monitored in an outpatient clinic due to moderate-to-severe MR. His last transesophageal echocardiogram showed massive MR, huge prolapse of the posterior leaflet (P2, partially involving P1), ruptured chordae tendineae, severe pulmonary hypertension, and right ventricle severe dysfunction (Figure 1, Videos 1 and 2). The heart team considered the high risk of surgery and decided on edge-to-edge percutaneous repair, despite a wide flail with a 16-mm gap, clearly above the 10-mm limit of the EVEREST II (Pivotal Study of a Percutaneous Mitral Valve Repair System) trial (1). New-generation MitraClip G4 (Abbot Vascular, Santa Clara, California) offers the possibility of a wider clip and independent grasping, allowing leaflet grasp to be optimized individually.
A 75-year-old man with a history of hypertension, dyslipidemia, and coronary artery disease with previous percutaneous coronary intervention in the left anterior descending, first obtuse marginal, and right coronary artery presented with non–ST-segment elevation myocardial infarction, ongoing chest pain, and ST-segment changes in the anterior leads. He was referred for an emergent coronary angiography. Right radial access was difficult. The patient had a weak radial pulse and he complained of arm pain during the first attempt.
A 75-year-old woman with a medical history of hypertension presented with palpitations and elevated cardiac troponin. Coronary angiography was carried out from the right radial artery with a 6-F sheath (Glidesheath, Terumo, Tokyo, Japan), and a Judkins right 4 catheter was advanced to the elbow, where a brachial loop had to be navigated with a 0.025-inch hydrophilic coated wire (Glidewire, Terumo). This then advanced easily into the subclavian artery, where resistance prompted reorientation of the wire, subsequently allowing progress into the ascending aorta. A standard dose of 5,000 IU of heparin was administered. The diagnostic angiogram demonstrated unobstructed coronary arteries. Shortly after, the patient developed a large, painful hematoma over the right breast (Figure 1).
Cookies Sociales
Son esos botones que permiten compartir el contenido del sitio web en sus redes sociales (Facebook, Twitter y Linkedin, previo tu consentimiento y login) a través de sistemas totalmente gestionados por dichas redes sociales, así como los recursos (pej. videos) y material que se encuentra en nuestra web, y que de igual manera se presta y gestiona completamente por un tercero.
Si no acepta estas cookies, no podrá compartir nuestro contenido a través de los botones, y en su caso, no podrás visualizar el contenido de terceros que hayamos incrustado en el sitio.
No las utilizamos