12th Annual Complex Cardiovascular Catheter Therapeutics: Advanced Endovascular and Coronary Intervention Global Summit (C3)

C3-2016-1: Unusual Case of Coronary Steal – LIMA to PA Fistula

Sinan Alo, DO, Islam Badawy, DO, Srinivas Reddy, MD, Faheem Ahmad, MD 

Midwestern University-Franciscan St. James Hospital

Cardiology Dept, Craigavon Area Hospital, 68 Lurgan Road, Portadown, United Kingdom

SUMMARY: Left internal mammary artery (LIMA) to pulmonary vasculature fistula is a rare complication after coronary artery bypass graft (CABG) surgery. We present a 72-year-old man who presented with anginal symptoms 5 years after bypass surgery. On coronary angiography, selective catheterization of the LIMA showed fistula formation to the pulmonary artery (PA), possibly contributing to his angina due to coronary steal syndrome. 

CASE PRESENTATION: A 72-year-old male patient with a past medical history significant for coronary artery disease (CAD) s/p CABG (LIMA to left anterior descending [LAD], saphenous vein graft [SVG] to posterior descending artery [PDA], SVG to obtuse marginal [OM], SVG to second diagonal [Dx2]) in 2010 presented in 2015 with chest pressure. Electrocardiogram revealed no ischemia. However, troponin was elevated at 0.38. Non-ST elevation myocardial infarction was diagnosed and he was started on medical therapy. He subsequently underwent coronary angiogram. The angiogram revealed severe native vessel CAD. Newly occluded SVG-OM thought to be the culprit lesion, SVG-PDA was patent, SVG-Dx2 was patent, and LIMA-LAD was patent. 

Incidentally, LIMA-LAD arteriogram showed multiple side branches with fistulous tracts to the PA. There was concern for coronary steal syndrome involving the LAD. He was later discharged on appropriate medical therapy. After a long discussion of options, we agreed to attempt medical therapy including nitrates. After 4 months of therapy, anginal symptoms returned. We decided to further rule out coronary steal syndrome. A function stress test to assess for any LAD ischemia with Lexiscan Myoview stress test revealed no reversible ischemia. Furthermore, as an outpatient his symptoms resolved with up-titration of his nitrates. He then remained symptom free and we decided to postpone any surgical intervention, such as ligation of his LIMA side branches.

DISCUSSION: A fistula between the PA and LIMA can occur due to congenital or iatrogenic reasons. In many cases, fistula is possible post CABG but not detected until 2-5 years. It is reported that fistulas extending to the PAs can result in complications such as congestive heart failure, myocardial infarction, and subacute bacterial endocarditis. The fistulas that occur between the PA and LIMA may cause angina and silent myocardial ischemia due to coronary steal syndrome. Fistulas can be prevented during CABG by careful ligation of side branches of the LIMA or pericardial patch. There are multiple imaging modalities to confirm presence of LIMA-PA fistula, including LIMA arteriogram. It is critical to assess functional significance of any steal phenomenon. Surgical repair of the fistula is recommended in those with coronary steal, medication-resistant anginas, congestive heart failure, and aneurysmal dilatation of the fistula. In this case, the patient responded well to medical therapy alone.

C3-2016-2: The Unexpected Route: A Unique Case of Heterotaxy

Ali A. Alsaad and Olufunso W. Odunukan 

Department of Internal Medicine and Cardiovascular Diseases, Mayo Clinic, Florida

INTRODUCTION: Heterotaxy (also known as situs ambiguous) is a disruption of the normal arrangement of the intrathoracic and intraabdominal organs and major vessels. Exploring the vasculature in the presence of heterotaxy can be challenging, especially when encountered on the cardiac catheterization laboratory table for the first time. We present a rare case of situs ambiguous and heterotaxy in a middle-aged female.

CASE PRESENTATION: A 50-year-old female smoker with a history of severe Crohn’s disease was hospitalized for gram-negative severe sepsis requiring aggressive intravenous fluid management resulting in fluid overload. Her hospitalization was complicated by left ventricular dysfunction and congestive heart failure. A total parenteral nutrition via peripherally inserted central venous catheter placement was initiated before an elective bowel surgery.

After stabilization, the patient presented to the cardiac catheterization laboratory for left and right heart catheterizations and hemodynamic measurements. During the catheterization procedure, the right heart catheter coursed up the inferior vena cava (IVC) on the left side of the vertebral column, raising concern for perforation of the IVC into the aorta. However, blood return from the IVC looked clearly venous and was confirmed by the oxygen saturation levels. 

A quick review of a computed tomography (CT) angiogram demonstrated a diagnosis of abdominal situs inversus. The course of the right heart catheter ultimately extended through the left IVC into the azygous vein, which drained into the right atrium through a persistent left sided superior vena cava (PLSVC). The PLSVC emptied into an extremely enlarged coronary sinus. The coronary angiography demonstrated just an insignificant coronary artery disease. The other findings demonstrated on CT and magnetic resonance imaging (MRI) in this patient include polysplenia in mirror-image position, a left-sided stomach, intestinal malrotation, and a central liver with left-sided IVC. The procedure was well tolerated without any complications.

CONCLUSION: This case illustrates the potential for confusion when cases of situs ambiguous and heterotaxy are encountered. As they are usually associated with significant congenital heart disease, actual cases of situs ambiguous in middle age are quite rare. Hence, providers must be aware of the challenges involved when patients with lateralizing defects present. Imaging with CT scan and MRI has become the gold standard in the diagnosis of these patients.

C3-2016-3: Focal Myocarditis Presenting as Acute ST-Elevation MI

Islam Badawy, DO, Manan Naik, DO, Michael Nicolas, DO, Faheem Ahmad, MD 

Midwestern University-Franciscan St. James Hospital

SUMMARY: Myocarditis typically presents in younger patients with chest pain, elevated cardiac enzymes, and diffuse ST elevation. Less commonly, ST elevations are localized to contiguous leads correlating to a specific coronary territory raising the suspicion of coronary disease. This is a case of a young adult with focal myocarditis presenting as an acute coronary syndrome.

CASE PRESENTATION: An 18-year-old male with no significant past medical history presents with acute onset of severe substernal chest pain radiating to his back with associated shortness of breath.  He reports fevers, malaise, cough, and night sweats during the past 1 week. He denies any recent weight loss, orthopnea, paroxysmal nocturnal dyspnea, lower-extremity edema, or diarrhea. He denies cocaine or stimulant use.  This patient emigrated from Nigeria 1 year ago, but denies any recent sick contacts. He is up to date with his immunizations. His physical exam is significant for an age-appropriate male in acute distress, afebrile, with stable vital signs, lungs clear to auscultation, no JVD, heart regular rate and rhythm without gallops or murmurs and no lower-extremity edema. ECG showed NSR with ST elevation in the inferolateral leads with reciprocal changes. Computed tomography chest was negative for aortic dissection and pulmonary embolism. Troponin T and CK were elevated at 1.340 ng/mL and 1124 IU/L, respectively. 

Echocardiogram reveals distal inferolateral, mid-inferior, and apical-inferior wall hypokinesis. An emergent angiogram demonstrates normal coronaries. A left ventricular angiogram notes an EF of 30-35% with inferior hypokinesis. In light of the decreased ejection fraction (EF), negative angiogram, positive troponins and ST-elevation in contiguous leads, the patient is diagnosed with focal myocarditis. Cardiac magnetic resonance imaging (MRI) demonstrated hypokinesis of the basal septum and a corresponding large area of mid-inferior myocardial delayed enhancement with sparing of the sub-endocardial tissue. Repeat echocardiogram on hospital day 4 demonstrated improvement in wall motion and EF to 45%-50%. A subsequent outpatient echo performed after 1 month revealed normal wall motion and EF of 55%-60%. 

DISCUSSION: Myocarditis is suspected in patients with appropriate clinical presentation and elevated cardiac enzymes once ACS has been excluded. This patient’s age and history of viral illness supports the suspicion for myocarditis. The clinical presentation of crushing chest pain with ST elevation in contiguous leads can create difficulty in distinguishing between ACS and focal myocarditis. The gold standard in diagnosis is an endomyocardial biopsy, but is not frequently performed due to limited sensitivity (43%-64%) and relatively high incidence of complications of ~6%. The use of antimyosin antibody has been evaluated to diagnose myocarditis; however,  it only identifies myocardial necrosis, which can be non-specific. Myocarditis has a characteristic pattern on cardiac MRI, revealing contrast enhancement in the location of damage with subendocardial sparing. On the contrary, a myocardial infarction would typically show subendocardial enhancement. The MRI in our patient was classic for focal myocarditis, and also corresponded to the electrocardiographic changes and echocardiographic wall-motion abnormality. Thus, further investigation toward protocols for rapid cardiac MRI in patients with suspicion for focal myocarditis may prevent unnecessary invasive procedures such as an angiogram.

C3-2016-4: The Fate of Patients With Massive Myocardial Infarction

Supreeti Behuria, Madeeha Saeed, John Fox, and Yumiko Kanei 

Department of Cardiology, Mount Sinai Beth Israel, New York, New York

BACKGROUND: Studies have shown that the extent of myocardial necrosis that occurs during a myocardial infarction (MI) can be assessed by the measurement of cardiac biomarkers, which has prognostic implications. Large MI can be a potential indication for early hemodynamic support, but little is known regarding the prognosis of massive MI. The aim of this study is to review the clinical presentation and outcomes of patients who had a massive MI.

METHODS: This is a retrospective review of our ST-segment elevation MI database from 2007-2014. “Massive” MI was defined as peak creatine kinase (CK) more than 10,000 IU/L. Among 650 patients, there were 21 patients who had a massive MI and their clinical characteristics, angiographic characteristics, and in-hospital outcomes were recorded.

RESULTS: The mean age of the patients was 61 ± 13 years, and 18 (86%) were men. Four patients (19%) had a prior history of coronary artery disease; 3 patients had a prior stent and presented with stent thrombosis and 1 patient had known multivessel CAD. Five patients (25%) presented with cardiac arrest. Nineteen patients (90%) underwent percutaneous coronary intervention. The median CK was 10,866 IU/L, CK-MB was 678 IU/L, and Troponin I was 424 µg/L. In the majority of patients, the culprit artery was the LAD (81%), and the mean left ventricular ejection fraction was 29 ± 9%. Six patients (29%) died during the hospital stay. Among those patients who died, 5 patients (83%) presented with cardiac arrest or shock, compared to 1 patient (4%) among the patients who survived (P=.01). Although the median CK was similar in both groups, the median troponin was higher among patients who died than patients who survived (540 µg/L vs 345 µg/L).

CONCLUSION: In this retrospective review of patients who presented with massive MI, the in-hospital survival was 71%. Although patients with massive MI suffered significant myocardial necrosis, those who did not present with cardiac arrest or shock were discharged home in stable condition. Long-term follow-up of these patients will give us further insight into this condition.

C3-2016-5: Postdilatation After Implantation of Bioresorbable Everolimus- and Novolimus-Eluting Scaffolds: An Observational Optical Coherence Tomography Study of Acute Mechanical Effects 

F. Blachutzik, N. Boeder, J. Wiebe, A. Mattesini, O. Dörr, A. Most, T. Bauer, M. Tröbs, J. Röther, C. Schlundt, S. Achenbach, 

C. Hamm, H. Nef

OBJECTIVES: The objective was to investigate the acute mechanical effects of postdilatation on bioresorbable scaffolds (BRS) as determined by optical coherence tomography (OCT).

BACKGROUND: Non-compliant balloon postdilatation is regarded as a key component of BRS implantation for treatment of coronary artery stenoses. However, the impact of postdilatation on BRS in vivo has not been thoroughly investigated.

METHODS: OCT was performed after implantation procedure of 51 everolimus-eluting or novolimus-eluting polylactic acid-based BRS with (n = 27) or without postdilatation (n = 24). OCT analysis regarding the number of malapposed struts, strut fractures, edge dissections, residual in-scaffold area stenosis, and incomplete scaffold apposition area was performed over the complete length of each BRS with a spacing of 1 mm.  

RESULTS: OCT revealed a significantly lower incomplete scaffold apposition area if postdilatation was performed (0.16 ± 0.49 mm² with postdilatation vs 2.65 ± 2.78 mm² without postdilatation; P<.001), as well as a significantly lower absolute number of malapposed struts (1 ± 2 with postdilatation vs 13 ± 13 without postdilatation; P<.001). No significant differences regarding residual in-scaffold area stenosis, strut fracture, edge dissection, symmetry index, or eccentricity index were observed in patients with vs without postdilatation.

CONCLUSION: Non-compliant balloon postdilatation of BRS significantly reduces the number of malapposed struts and incomplete scaffold apposition area without inducing higher rates of edge dissection or strut fracture. Based on these findings, postdilatation should be performed routinely after implantation of BRS.

C3-2016-6: Overlapping Implantation of Bioresorbable Novolimus-Eluting Scaffolds: An Observational 

Optical Coherence Tomography Study

Florian Blachutzik, Niklas Boeder, Jens Wiebe, Alessio Mattesini, Oliver Doerr, Astrid Most, Timm Bauer, Monique Troebs, 

Jens Roether, Christian Schlundt, Stephan Achenbach, Christian Hamm, Holger Nef

OBJECTIVES: The aim of this study was to analyze the acute effects of overlapping implantation on bioresorbable scaffolds (BRS) as determined by optical coherence tomography (OCT).

BACKGROUND: Overlapping implantation of bioresorbable vascular scaffolds is frequently necessary, but its influence on vessel and scaffold structure has not been thoroughly analyzed previously. 

METHODS: A total of 38 patients with de novo coronary artery stenoses who underwent OCT in the context of implantation of novolimus-eluting BRS (DESolve, Elixir Medical Corporation, Sunnyvale, California) were investigated. In 15 patients, overlapping implantation of 2 BRS devices was performed, while 23 patients with implantation of 1 BRS served as the control group. OCT data were retrospectively analyzed regarding acute scaffold implantation results. 

RESULTS: There were no significant differences between the overlap and control group in terms of residual in-scaffold area stenosis, scaffold area, mean or minimal lumen area, eccentricity index, incomplete scaffold apposition area, or malapposition. While strut fracture was slightly more frequent in BRS with overlap, its incidence was low overall. In patients with overlapping BRS, overlap segments did not display smaller lumen areas than segments without overlap (mean lumen area overlap: 8.16 ± 2.97 mm² vs no overlap: 7.70 ± 2.55 mm²; P=.71; minimal lumen area overlap: 6.83 ± 2.71 mm² vs no overlap: 6.17 ± 2.58 mm²; P=.37). 

CONCLUSION: Acute mechanical performance of novolimus-eluting BRS is not impaired by overlapping implantation. Vessel expansion compensates for the double scaffold layer in the overlap area, resulting in a similar lumen area in overlap areas and in those with a single strut layer.

C3-2016-7: Angiographic Findings and Revascularization Success in Patients With Acute Myocardial 

Infarction and Previous Coronary Bypass Surgery 

Florian Blachutzik, Christian Schlundt, Monique Troebs, Jens Roether, Holger Nef, Christian Hamm, Stephan Achenbach

BACKGROUND: Current guidelines recommend invasive coronary angiography and interventional revascularization in acute myocardial infarction (STEMI and NSTEMI). The aim of this study was to learn more about culprit lesion and revascularization success in patients with previous bypass surgery. 

METHODS: We analyzed the data of 121 consecutive patients in whom coronary angiography was performed in the setting of STEMI or NSTEMI and who had previous coronary bypass surgery. Coronary angiograms were reviewed and clinical data were evaluated. The culprit vessel was identified by means of ECG, echocardiography, and coronary angiography.

RESULTS: A bypass graft was the culprit vessel in 86% of patients with STEMI and 68% of patients with NSTEMI. Venous grafts were culprit vessels significantly more frequently than arterial grafts (81 of 260 venous grafts vs 4 of 65 arterial grafts; P<.001). Attempted acute percutaneous revascularization was successful in 97% of native arteries (31 of 32 patients), but only in 81% of bypass grafts (68 of 84 patients;  P=.03). Overall in-hospital mortality was 13% (STEMI, 25%; NSTEMI, 10%; P<.001) and was significantly higher after failed acute percutaneous coronary intervention (PCI) (6/11 patients; 55%) as compared to successful acute PCI (7/110 patients; 6%; P=.01).

CONCLUSION: In conclusion, the culprit lesion in patients with previous bypass surgery who present with STEMI or NSTEMI is more often located in bypass grafts than in native arteries. Acute percutaneous revascularization of a native artery is more promising as compared to bypass grafts. 

C3-2016-8: Patent Foramen Ovale Closure: A Single-Center Experience

L. Candilio, MD (Res), A. Sinha, MRCP, F. Keshavarzi, MD, N. Melikian, MD

BACKGROUND: Patent foramen ovale (PFO) is present in up to 20% of the adult population and has been associated with stroke, migraine, myocardial infarction with normal coronary arteries, decompression syndrome, high-altitude pulmonary edema, and obstructive sleep apnea exacerbation. PFO closure presents a 0.2%-1.5% rate of major complication (death, major hemorrhage, cardiac tamponade, or fatal pulmonary emboli) and 7.9%-11.5% rate of minor complication (periprocedural atrial arrhythmias, device arm fractures, device embolization, thrombosis, and catheter insertion-site hematomas). The European Stroke Organization and American Association of Neurology recommend PFO closure for patients with recurrent ischemic stroke or for high-risk patients in whom paradoxical embolism is suspected. The American Heart Association recommend medical therapy post recurrent cerebral ischemic event. The NICE guidelines give the option for clinicians to use this management option in patients who are not suitable for antiplatelet or anticoagulation therapy and can be used as an adjunct to other open-heart surgery.

METHODS: We conducted a retrospective data analysis on patients discussed at the Neurocardiac multidisciplinary meeting at King’s College Hospital (London, United Kingdom) between February and September 2015. Data collected included patient demographics, presenting complaint, comorbidities, relevant investigations (brain imaging, computed tomography angiography, carotid Doppler, echocardiography, cardiac magnetic resonance imaging, 24-hour Holter monitoring, and thrombophilia screen), decision made at the MDM, complications during or post procedure, anticoagulation or antiplatelets recommended post procedure, and outcome at follow-up appointment. Paper notes and Electronic Patient Recording system notes were used for data collection. Data were analyzed using Microsoft Excel and SPSS systems.

RESULTS: Fifty-one patients’ notes were included in this study. The mean (± standard deviation) age of patients when they were discussed at the neurocardiac MDM was 49 ± 15 years old; 53% of the patients were female. The most common presentation was a cerebrovascular accident (45% of the patients), 10% of the patients were found to have no detectable pathology. Hypertension and hyperlipidemia were the most common comorbidities (combined prevalence of 30%). The most common neurological and cardiac investigations were computerized tomography of brain (84%) and transthoracic echocardiogram (84%), respectively. Of patients who had a cerebrovascular accident, middle cerebral artery territories were most commonly affected (38%). The most common form of interatrial septal (IAS) defect was PFO (82%); 21(47%) of the patients with PFO were managed with attempted percutaneous closure, and of these 19 were successful and 2 unsuccessful (1 due to size of PFO and 1 due to the anatomy of the PFO). Two of the patients with ASD had attempted percutaneous closure and both of them were successful. Of the 21 patients whose outcomes were not for closure, the most common reason was an absence of thromboembolic event (38%). An Amplatzer device was used in 48% of the closures followed by a Figulla Flex occlude device (42%). None of the patients had any periprocedure or postprocedure complications. Thirteen of the patients who had successful IAS defect closure had dual-antiplatelet therapy for 3 months with mono-antiplatelet therapy for life, while 5 of the patients had dual-antiplatelet therapy for 3 months followed by mono-antiplatelet therapy for 12 months. Eleven of the patients with successful IAS closure had an echocardiogram in the first 6 months post procedure. Four of these patients had no residual flow between the atria, 3 did have residual interatrial flow of no significant relevance, and 4 patients’ echocardiographic findings were not reported on the system. 

CONCLUSION: We found a 91% success rate of percutaneous closure of IAS defects in our cohort of patients. Clinical follow-up was achieved in 76% within 6 months of their procedure, with no reported periprocedure or postprocedure complications. This study confirms the value of IAS defect closure in patients who have suffered from a cerebrovascular event, due to the procedure’s safety profile and efficacy in preventing further cerebrovascular events.

C3-2016-9: STEMI and Multivessel Coronary Artery Disease: Do We Treat the Culprit Lesion Only?

L. Candilio, MD (Res), I. Webb, PhD

BACKGROUND: Significant multivessel (MV) coronary artery disease (CAD) is present in up to 40% of patients presenting with ST-segment elevation myocardial infarction (STEMI) and has been associated with increased mortality in these subjects. Current guidelines recommend treatment of the infarct-related artery (IRA) only in the absence of cardiogenic shock, thereby either leaving bystander disease untreated (culprit-only revascularization) or addressing these lesions during a later elective procedure (staged revascularization) if ischemia is documented. However, these recommendations derive from a series of retrospective observational registries and subgroup analyses of randomized clinical trials (RCTs) suggesting worse clinical outcomes with in-hospital complete revascularization. Recent RCTs have demonstrated that index admission preventive PCI in non-IRA coronary arteries improves clinical outcomes at 12 or 23 months in subjects presenting with STEMI and significant MV disease.

CASE PRESENTATION: We present the case of a 57-year-old gentleman with no significant cardiovascular risk factors who was admitted following an acute onset of chest pain and evidence of anterolateral ST-segment elevation on ECG. He was hemodynamically stable and bedside transthoracic echocardiogram demonstrated moderate left ventricular dysfunction with severe anterolateral hypokinesis. Urgent coronary angiography via the right radial approach showed minor atheroma of the left main stem (LMS); severe proximal left anterior descending (LAD) artery disease with a focal stenosis in the mid vessel and a further significant lesion in a tortuous distal segment; proximal occlusion of left circumflex (LCX) artery, which was the culprit lesion; chronic total occlusion (CTO) of the dominant right coronary artery (RCA) in the mid vessel with reasonable collaterals from the LAD septal system. We therefore proceeded to intervene on the occluded LCX artery: this was predilated with 2.5 and 3 mm balloons, with restoration of TIMI 3 flow.  At this stage, it became clear that the LCX was severely diseased from the mid-course to the ostium with notable size-mismatch and involvement of the LMS.

Different treatment strategies could have been adopted at this point, including: (1) discontinuation of primary PCI (PPCI) and referral to the cardiothoracic team for consideration of emergency coronary artery bypass (CABG) surgery; (2) PPCI to mid-LCX segment only; (3) PPCI of LCX from mid-segment to the ostium with or without LMS-PCI; or (4) PPCI from mid-LCX to the LMS and bystander LAD revascularization.

We decided to proceed to complete revascularization of the left coronary system: after exchanging for an Extra-Support wire and with microcatheter support, we delivered a 3.5 x 26 mm drug eluting stent (DES) to the stenosed segment. We then prepared the proximal LAD with a BMW wire and 2.5 and 3 mm balloons.  The proximal circumflex was then stented back into the left main with a 3 x 30 mm DES, which was optimized with a 4.5 mm non-compliant (NC) balloon. The LAD was rewired with a Pilot 50, predilated with 1.5 and 2 mm balloons and stented with a 3 x 26 mm DES in the mid-segment and a 4 x 26 mm DES proximally. Following re-wiring of the LCX with a Pilot 50, we performed kissing inflations to the left main bifurcation with 4 mm NC balloons in both limbs and finally optimized the LMS with a 5 mm short NC balloon: this led to excellent angiographic results with TIMI 3 flow in both the LCX and LAD. The patient tolerated the procedure without complications and following standard post-STEMI care on coronary care unit, was successfully discharged on long-term dual antiplatelets. His bystander RCA-CTO disease will be addressed at a later stage with non-invasive functional tests. 

CONCLUSION: We have presented a challenging case of STEMI with severe bystander CAD disease, in which IRA-only revascularization was considered not appropriate and where complete revascularization of the left coronary system led to excellent angiographic and clinical results. Large RCTs are required in order to definitely establish whether index admission preventive PCI improves clinical outcomes in patients presenting with STEMI.

C3-2016-10: Double Right Coronary Artery in Primary PCI: Finding the Hidden Treasure…

Luciano Candilio, MD (Res), Roberto Nerla, MD, Jonathan Byrne, PhD

BACKGROUND: Congenital anomalies of the coronary arteries are present in 0.2%-1.4% of the general population and double right coronary artery (RCA) is one of the rarest conditions (0.01%-0.07%). It can originate from a single ostium and split into two branches after a variable distance or from different ostia in the right sinus of Valsalva. Recent observational studies found a high prevalence of atherosclerotic lesions in these subjects, particularly in those with a single ostium double RCA, in accordance with the concept of atherosclerosis occurring predominantly at sites of low or oscillatory shear stress. We present the case of an inferoposterior ST-segment elevation myocardial infarction (STEMI) in the context of a double RCA with one the two RCA branches as culprit lesion. 

CASE PRESENTATION: A 63-year-old lady with a smoking history but no other significant cardiovascular risk factor presented with acute-onset chest pain and evidence of inferoposterior STEMI on ECG. Coronary angiogram showed severe stenosis in mid left anterior descending coronary artery and moderate-to-severe “hazy” disease in the distal RCA, which was felt to be the culprit lesion. A Balance Middleweight (BMW) wire was therefore inserted into the RCA in order to proceed to percutaneous coronary intervention; however, the BMW wire “unexpectedly” jumped into a side branch, revealing a “potentially” large-size vessel. The latter was then predilated at the ostial level and three drug-eluting stents were deployed, with a further drug-eluting stent positioned in the mid-segment of the “main” vessel as originally planned. Final angiogram demonstrated double RCA anatomy with excellent angiographic results in both vessels. 

CONCLUSION: In the context of double RCA, atherosclerotic lesions may affect the ostium of each single branch, thus raising diagnostic issues in identifying the culprit vessel. Therefore, double RCA may also represent a diagnostic and therapeutic challenge that coronary interventionists should be aware of in order to avoid misinterpretation of coronary angiograms potentially leading to inappropriate treatment. To the best of our knowledge, only a few cases of STEMI secondary to acute occlusion of one of the two constituting vessels of a double RCA have been reported.

C3-2016-11: Systolic Compression of the Right Coronary Artery and Coronary Sinus From Left Ventricular Pseudoaneurysm After Bioprosthetic Mitral Valve Annular Dehiscence

Santosh Desai, DO, Clinton Jokerst, MD, Kelley Kennedy, MD, John Sweeney, MD, Richard Lee, MD

INTRODUCTION: Left ventricular pseudoaneurysm is a rare, but well documented complication of mitral valve surgery. Heavy mitral annular calcification and intraprocedural trauma are two of the many potential factors that may increase the risk of developing a pseudoaneurysm. Compression of surrounding cardiac structures via mass effect from the pseudoaneurysm is one potential complication. Specifically, coronary artery compression by the pseudoaneurysm has been described as an early and late complication following mitral valve surgery. We describe a case of intermittent right coronary artery and coronary sinus compression from a pseudoaneurysm as a subacute complication of mitral valve annular dehiscence.

CASE PRESENTATION: A 74-year-old female with history of severe mitral stenosis 2 months status post bioprosthetic mitral valve replacement was evaluated in outpatient cardiology clinic for severely limiting and progressive shortness of breath. Given the clinical presentation and cardiac history, the patient was admitted to the hospital for further evaluation. Prior to mitral valve surgery, the patient was noted to have a preserved left ventricular ejection fraction and coronary angiogram demonstrated no significant obstructive coronary artery disease. Repeat echocardiography in the hospital revealed significantly reduced ejection fraction along with new inferior-wall akinesis and question of basal inferior and inferoseptal aneurysm. Coronary angiography was performed to investigate the new abnormalities and again revealed no significant obstructive coronary artery disease. However, we did observe systolic compression of the distal right coronary artery. Computed tomography (CT) of the chest was performed to better characterize the local anatomy, particularly given recent cardiac surgery. CT imaging revealed dehiscence at the inferior portion of the sewing ring of the bioprosthetic mitral valve resulting in a large left ventricular pseudoaneurysm and subsequent mass effect on the distal right coronary artery and coronary sinus. Cardiac surgery consultation was obtained to explore the possibility of surgical correction. Given the pseudoaneurysm was well contained and operative mortality for redo surgery was deemed high, a medical treatment strategy with close observation was selected.

DISCUSSION: Left ventricular pseudoaneurysm is an unfortunate complication of valvular surgery. Unfavorable anatomy and heavy calcification necessitating extensive debridement can make the operation technically challenging and predispose patients to pseudoaneurysm formation. Another well-described etiology of left ventricular pseudoaneurysm and subsequent coronary compression is valvular abscess extension from infection. Our unique case involves a structural defect caused by mitral annular dehiscence with subsequent pseudoaneurysm formation and compression of surrounding cardiac structures. This patient also had deterioration of left ventricular systolic function in a relatively short period of time. Our patient did not undergo surgical correction; however, her medical therapy has been optimized with the goal of left ventricular recovery to be determined by serial follow-up echocardiography.

C3-2016-12: Analyzing ST Elevation in a New Light

Jerald Insel, MD, FACC, FSCAI, Rachel Moshman

BACKGROUND: A 34-year-old gentleman presents to the emergency room, complaining of worsening chest pain for the last 12 to 14 hours. His troponin level is 5.0. He has a strong family history of coronary artery disease. He also smoked 1-1.5 packs of cigarettes per day leading up to this incident. Blood pressure is 140/80 mm Hg. Electrocardiogram shows sinus rhythm, rate of 55-60, poor R-wave progression. There are 1-1.5 mm ST elevations in leads II, III, and AVF indicating acute inferior myocardial infarction. There are small QS and non-specific ST-T wave changes in the anterior leads. No JVD, S1, S2, no edema, lungs clear.

METHODS: Based on the exam, the patient was taken to the cath lab on STEMI protocol. The cath showed that the left main coronary artery had a 20%-30% distal stenosis. Left anterior descending coronary artery had a mild diffuse lumpy-bumpy disease in the mid-distal vessel, all <20%. It gave off a diagonal that bifurcated into two small vessels with no significant stenosis. Left circumflex coronary artery gave off a small-caliber vessel with 20%-30% proximal stenosis. It bifurcated into two small vessels free of significant stenosis. The main circumflex had up to 20%-30% distal eccentric stenosis before giving off small-caliber second obtuse marginal. Right coronary artery gave off a moderate-caliber RB branch in the mid-segment with a 20% stenosis at its ostium. It then gave off a PDA and posterolateral branch with mild diffuse non-obstructive atherosclerosis with no critical stenosis. Ventriculography was performed in the right and left anterior oblique projections. Frequent PVCs were detected. There was no focal regional wall-motion abnormality noted, but frequent PVCs decrease accuracy of the test. There was no evidence of critical coronary artery disease, thrombus, myocardial bridging, or obvious spasm during the test. Left ventricular end-diastolic pressure was normal at 13.0. Ejection fraction was 50%-55%, with frequent premature ventricular contractions during ventriculography. 

Echocardiogram showed an ejection fraction of approximately 60%-65%. No regional wall-motion abnormalities or pericardial effusion were noted. The pericardium was not thickened. There were no murmurs. No valvular disease was noted.Differential diagnoses include coronary spasm, variant angina, early repolarization, myocarditis, or hyperkalemia. Treatment included antiplatelet therapy, calcium-channel blockers, nitrates, and statins. The patient was also counseled to quit smoking.

Post hospital course, the patient still had recurrent left-sided chest pain. He had occasional shortness of breath that worsened with exertion despite having stopped smoking. He complained of non-specific muscle aches and pains. Thirty-day event monitor was negative for ST elevation and SVT. Occasional sinus tachycardia was noted. The new differential diagnosis included pericarditis, coronary spasm, early repolarization, new myocardial injury, catecholamine-induced chest pain, or non-coronary disease (ie, tumor or myocarditis).

RESULTS: Magnetic resonance imaging was ordered to test for chronic myocarditis. Thirty-day event monitor was placed to check for coronary spasm. Statin therapy was decreased due to complaints of joint pain. CK and CPK labs were drawn. The patient was instructed to start CoQ10. Cardiac MRI revealed inflammatory process involving the mid-myocardial and subepicardial portions of the left ventricle along the inferior and inferolateral segments of the mid cavity, edema, and delayed enhancement. Myocarditis was a likely differential consideration.

CONCLUSION: Myocarditis can mimic acute myocardial infarctions. Inflammation of blood vessels can cause chest pain that mimics myocardial infarction. Influx of inflammatory cells can lead to coronary artery spasm. This causes narrowing of one of the coronary arteries. MRI reveals inflammation with edema and delayed enhancement indicating myocarditis.This case represents an unusual case of myocarditis mimicking acute inferior myocardial infarction in a patient with risk factors for coronary artery disease and spasm. This teaches us to look for the unusual when what seems common is not the case.

C3-2016-13: Spontaneous Coronary Artery Dissection and Takotsubo’s Cardiomyopathy – A Lethal Combination

Jerald Insel, MD, FACC, FSCAI, Basha Behrman, Avraham Shugarman

BACKGROUND: Spontaneous coronary artery dissection (SCAD) is a rare, life-threatening event where the layers of the coronary arterial wall become separated by hemorrhage. Clinical presentation of SCAD includes STEMI-like symptoms. This is usually seen in younger women including peri partum women. Takotsubo, or stress cardiomyopathy, is an atypical state of myocardial stunning that mimics the symptoms of an acute STEMI. Most patients with this condition are postmenopausal women who have undergone severe emotional stress. 

METHODS: A 58-year-old, overweight, hypertensive white female came into the hospital with sudden chest pain and ventricular tachycardia with marked ST elevation in the anterolateral leads. When the event occurred, the patient had been bringing home her grandchild from the hospital. She was cardioverted to normal sinus rhythm and due to the persistent chest pain and ST elevations in the anterolateral leads, she was brought to the cath lab. 

RESULTS: Upon cardiac catheterization, the patient was noted to have a spontaneous non-atherosclerotic dissection of a large ramus intermedius vessel that extended nearly to the left main coronary artery. The patient’s right coronary artery was large and normal, her circumflex was normal, and her left anterior descending artery was small and diffusely diseased. Ventriculography revealed severe left ventricular dysfunction in the anterior, anterolateral, and apical distribution consistent with Takotsubo’s cardiomyopathy, with preserved contractility of the left inferior and posterior basal segments. These findings were not consistent with infarct in the ramus intermedius distribution. The patient had an ejection fraction of 25% and an elevated troponin.

Due to the fact that there was a double density line with a dissection almost reaching the left main, the patient underwent successful stenting with multiple stents. Over the next several days, the patient had significant recovery of anterior function with minimal residual hypokinesis of the apex. Approximately 2 weeks post procedure, the patient’s ejection fraction was back to normal. These symptoms are in line with the parameters of Takotsubo as outlined by the Mayo Clinic.

CONCLUSION: This case represents an unusual case of the combination of two less common etiologies of acute coronary syndrome: Takotsubo and SCAD. This combination has rarely been seen. It may be the cause of catecholamine-induced causing a Takotsubo cardiomyopathy, as well as a spontaneous non-atherosclerotic tear in the coronary artery (SCAD). This case serves as an important lesson, although very rare, of the need to look carefully at the coronary artery for SCAD, which can present in a very subtle way whenever Takotsubo’s cardiomyopathy is seen as the cause of ACS. Because SCAD can be subtle, if missed it can have life-threatening consequences. This case represents a rare combination of ACS causes with an excellent outcome and valuable teaching points.

C3-2016-14: A Vexing Case of Cardiac Tamponade – It’s More Than Skin Deep

Jerald Insel, MD, FACC, FSCAI, Sossie Ansbacher, Avraham Shugarman, Max Rossberg, Basha Berhman

BACKGROUND: Pericarditis, especially in a young, healthy, immune-competent individual, is usually of viral origin and if treated appropriately, resolves without any serious side effects or complications. We are reporting a case where Propionibacterium acnes, which is a skin commensal, largely seen as part of normal skin flora, appear to be the etiology. Propionibacterium acnes has at times been shown to be an opportunistic pathogen. This can be seen in patients who have had surgical procedures and certain infections. Propionibacterium acnes, however, can stimulate formation of inflammatory mediators, ie, tumor necrotic factors and metalloproteinases which in rare cases may cause development of inflammation and infection in otherwise healthy individuals. We are presenting such a case with potential life-threatening consequences.

METHODS: A 24-year-old Caucasian male with a history of anxiety disorder on Cymbalta presented with complaints of shortness of breath for 1 week with intermittent left sided chest pain. The patient developed fever and chills, and followed up with his primary care physician the next morning. Physical exam showed a fever of 102°F, decreased bruit sounds at base, and heart rate of 120 bpm. No edema or JVD. Chest x-ray showed cardiomegaly with mild left pleural effusion. Cardiology consult called in late Friday afternoon.

Patient appeared ill with a fever of 101°F. Blood pressure was 110/70 mm Hg, heart rate was 120-130 bpm, no JVD. Cardiac exam showed decreased heart sounds in S1, S2, and early systolic rub. Positive pulses alternans noted. Decreased lung sounds at the bases with left pleural rub respiratory rate of 20-22. Electrocardiogram showed electrical alternans with heart rate 124 bpm in sinus tachycardia. Echo showed a large circumferential pericardial effusion with right atrial and right ventricular diastolic collapse with a normal ejection fraction. Diagnosis was cardiac tamponade.

Emergency pericardiocentesis was performed. Using a parasternal approach, 300 mL of serosanguinous fluid was removed from the pericardium with significant improvement in the pericardial effusion by echocardiogram. Pericardial drain was placed with orders for a repeat echo in the morning showing mild residual pericardial effusion with no evidence of tamponade. At that point, the drain was removed. 

RESULTS: A bac gram stain showed very light polymorphonuclear leukocytes. No organism was seen. Lyme studies were negative. Rheumatologic studies were negative. Cell block showed acute and chronic inflammation. No malignant organism was seen. Pericardial culture in enriched broth at 8 days showed Propionibacterium acnes growth present. Propionibacterium acnes was also grown in aerobic blood culture bottle.

Questions remained. Was the cause of the pericardial effusion viral or bacterial? Is the Propionibacterium acnes a contaminant or the pathologic cause of the pericarditis? Should the patient be treated with antibiotics or undergo careful clinical monitoring with appropriate antiinflammatory agents? 

The patient was treated with broad spectrum antibiotics. Once the organism was identified 7 days later, the patient was switched to high-dose intravenous penicillin for 6 weeks. He also continued on antiinflammatories consisting of ibuprofen and colchicine. Five days post discharge, the patient complained of increased chest pain and shortness of breath. Echocardiogram showed persistent circumferential pericardial effusion of 0.6-1.4 cm. No cardiac tamponade was present. Indomethacin was added to the colchicine with resolution of pericardial effusion 1 week later.

CONCLUSION: This case is important for several factors. The importance of diagnosing this rapidly on physical exam helped save this individual’s life. This case presented in an immune competent, healthy young man that appeared to be a routine case of viral pericarditis complicated by cardiac tamponade. The patient, however, grew out Propionibacterium acnes bacteria, a component of normal skin flora that rarely causes infection in a healthy individual. Its presence in the pericardium suggests a bacterial etiology. 

There have only been several cases in the literature where this organism has caused pericarditis leading to cardiac tamponade and ultimately constrictive pericarditis. The patient’s symptoms resolved with the decision to treat this bacterium with high-dose intravenous penicillin preventing the progression to constrictive pericarditis. The awareness of the potential virulence of a routine organism causing life-threatening illness is the key teaching point that should be considered despite the rarity of this presentation.

C3-2016-15: Massive Coronary Collateralization Saving a Life: Anomalous Origin of the Left Coronary Artery From the Main Pulmonary Artery Presenting in An Adult

Sabeeda Kadavath, MD¹, Jenne Manchery, RPA-C¹, Robert Donnino, MD², Lekshmi Dharmarajan, MD, FACP, FACC, FAHA¹¹Division of Cardiology, Lincoln Medical And Mental Health Center, Bronx; ²Division of Cardiology, NYU School of Medicine

INTRODUCTION: Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) occurs in 1/300,000 live births. Up to 9 of 10 children with ALCAPA die within a year without surgery. Asymptomatic presentation in adulthood is rare, and patients must have a well-developed coronary collateral circulation with retrograde perfusion.

CASE PRESENTATION: A 44-year-old woman undergoing preoperative assessment for ovarian cyst was noted to have an electrocardiogram, with T-wave abnormality in anterior leads.The patient had non-specific cardiac complaints including chronic dyspnea and chest discomfort at rest for 1 year. She reported atypical chest pain reproducible on palpation. Family history was negative for cardiac disease. Examination was significant for a systolic murmur in the aortic area and along the left sternal border. Hemoglobin was 11.4 g/dL. Echocardiogram showed a normal left ventricle size and ejection fraction, normal right ventricle function, moderate left atrial enlargement, possible sinus of Valsalva aneurysm/coronary artery aneurysm, no valvular abnormalities, and multiple areas of turbulence along the interventricular septum. 

 Due to flow abnormalities in the echocardiogram, the patient was referred for cardiac magnetic resonance imaging, which confirmed an anomalous left coronary artery arising from the pulmonary artery. Coronary computed tomography angiography revealed extensive collateralization from the right coronary to the left coronaries. An exercise stress test with nuclear imaging showed reversible perfusion defect in the basal lateral wall at a submaximal heart rate. The patient underwent open-heart surgery to correct the anomalous left coronary artery with reimplantation of left coronary artery into the aorta. Metoprolol, aspirin, and atorvastatin were prescribed at discharge.

DISCUSSION: ALCAPA is a rare congenital defect seen in adults. Collateral circulation between right and left coronary system can lead to reversal of the left coronary artery flow, leading to an underperfused LV myocardium, which can cause LV dysfunction and heart failure. Subendocardial ischemia can occur even in the presence of well-established coronary collateral vessels because of preferential coronary blood flow into the low-pressure pulmonary circulation. Prognosis has improved greatly with early diagnosis using echocardiography color-flow mapping and improved surgical techniques. If left untreated, the mortality rate is 90% in the first year of life. Even if asymptomatic, uncorrected adult ALCAPA patients are at risk for sudden death. 

CONCLUSION: Anomalous origin of the left coronary artery from the pulmonary artery is a rare presentation in adults.

Reference

1.    Schwerzmann M, Salehian O, Elliot T, Merchant N, Siu SC, Webb GD. Anormalous origin of the left coronary artery from the main pulmonary artery in adults. Circulation. 2004;110:e511-e513.

C3-2016-16: Mortality Rates Unchanged: Use of Intraaortic Balloon Pump in Cardiogenic Shock

Asif H. Khan, MBBS, BSc, MRCP (UK), MRCPS, Cardiology Specialist Registrar

Ganesh Manoharan, MBBCh, MD, FRCP (I), FRCP (Edin), FESC, Consultant Cardiologist 

Royal Victoria Hospital, Belfast HSC Trust, Northern Ireland

INTRODUCTION: Cardiogenic shock remains the most common cause of death for the patients hospitalized with acute myocardial infarction.¹ The use of intraaortic balloon pump (IABP) for hemodynamic support and early revascularization remain vital modalities for favorable outcomes. IABP support was strongly considered a class I indication in cardiogenic shock until 2012 in international guidelines.^2,3 Further multicenter trials showed no significant survival benefit due to IABP treatment in patients undergoing early revascularization in cardiogenic shock,^1,4 and therefore the current guidelines downgraded the recommendations to IIA.⁵

METHODS: A retrospective analysis was performed on IABP use within our tertiary center for the year 2012, along with 12-month follow-up mortality data, which were collected utilizing the British Cardiovascular Intervention Society (BCIS) database. Patient and procedural data were obtained with corroboration of outcome using the Northern Ireland Electronic Care Record (NIECR) system.

RESULTS: From January 2012 to December 2012, a total of 92 IABP procedures were performed. Outcome data were available for 90 patients. Sixty-three patients (68.5%) were male with mean age of 68 years. Sixty-two percent of procedures were performed during out of hours. Significant co-morbidities include hypertension (60%), hypercholesterolemia (52%), smoking (37%), IHD (31%), diabetes mellitus (22%), peripheral vascular disease (19%), chronic kidney disease (13%), and cerebrovascular accident/transient ischemic attack (13%). Left ventricular assessment was performed in 85% of patients pre-procedure; 31.5% of patients showed good ejection fraction (>50%), 20% showed moderate ejection fraction (30%-50%), 33.6% showed poor function (ejection fraction <30%), and 13% presented with cardiac arrest. The reasons for insertion of IABP were mainly acute coronary syndrome (STEMI/NSTEMI; 92%). Intraaortic balloon pump insertion in 34 patients (37%) awaited inpatient cardiac surgeries mainly (65% CABG and 17% valve replacement/repair). Forty-seven patients (51%) required IABP for cardiogenic shock, of which 19 (40%) presented with cardiac arrest and 18 (38.2%) had LMS or equivalent lesion. 

There were 34 total deaths (36.0%), with 26 (28.0%) hospitalized up to 30 days. The mortality in the group of patients with cardiogenic shock was 40.0% at 30 days and 49.0% at 12-month follow-up. Significant mortality noted in patient with poor EF (55.8%), cardiac arrest (47%) either out of hospital or intra-hospital and patients with severe LMS or equivalent disease (41%) during the first month (Table). The better outcome was noted in the preoperative group with 6 deaths (17.6%) and 3 deaths (8.8%) with good ejection fraction in the first 30 days of presentation.

CONCLUSION: IABP treatment has not shown any significant reduction in 30-day mortality in patients with cardiogenic shock complicating acute myocardial infarction with an early revascularization strategy. This analysis has the same mortality trends and neutral outcomes as seen in the IABP-SHOCK II trial.⁴ The presentation of patients with cardiac arrest, presence of poor left ventricular systolic function, and significant LMS or equivalent disease were the predictors of adverse outcome and mortality. The use of IABP in the preoperative group has shown better overall outcomes.

KEY WORDS: intraaortic balloon pump (IABP), cardiogenic shock (CS).

References

1.    Berger PB, Holmes DR Jr, Stebbins AL, Bates ER, Califf RM, Topol EJ. Impact of an aggressive invasive catheterization and revascularization strategy on mortality in patients with cardiogenic shock in the Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO-I) trial. An observational study. Circulation. 1997;96:122-127.

2.    Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction-executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction). Circulation. 2004;110:588-636.

3.    Van de Werf F, Bax J, Betriu A, et al. Management of acute myocardial infarction in patients presenting with persistent ST-segment elevation: the Task Force on the Management of ST-Segment Elevation Acute Myocardial Infarction of the European Society of Cardiology. Eur Heart J. 2008;29:2909-2945.

4.    Thiele H, Zeymer U, Neumann FJ, et al; for the IABP-SHOCK II Trial Investigators. Intraaortic balloon support for myocardial infarction with cardiogenic shock. N Engl J Med. 2012;367:1287-1296.

5.    Windecker S, Kolh P, Alfonso F, et al. 2014 ESC/EACTS guidelines on myocardial revascularization: the task force on myocardial revascularization of the ESC and the EACTS. Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J. 2014;35:2541-2619. Epub 2014 Aug 29.

C3-2016-17: PCI to Native LAD via LIMA Using a Guide-Catheter Extension

Sudheer Koganti, Elliot Smith, Christos Bourantas

BACKGROUND: Mother-in-child catheter technique using a guide-catheter extension is used to deliver stents in complex and tortuous coronary anatomies. Herein, we present a case where we had to use this technique to deliver a stent to native left anterior descending (LAD) artery via a tortuous calcified left internal mammary artery (LIMA) using a guide-catheter extension.

CASE REPORT: A 66-year-old male was admitted with non-ST elevation myocardial infarction. Twelve-lead electrocardiogram showed left bundle-branch block. His medical history included type 2 diabetes mellitus ischemic heart disease and previous coronary artery bypass grafting with a LIMA to LAD and saphenous venous graft (SVG) to left circumflex (LCX) artery, severe left ventricular systolic dysfunction, and previous ablation for ventricular tachycardia (VT) and implantation of a cardioverter defibrillator following an admission with VT storm. Coronary angiography and graft study revealed critical ostial and calcific distal left main stem disease, occluded LAD in the proximal segment, significant disease in the ostium of the LCX, chronic total occlusion of the right coronary artery, and patent LIMA to LAD, with significant disease in the mid LAD beyond LIMA insertion. The LIMA had a tortuous course and was calcified, but it did not have a significant obstruction. The SVG to LCX was also patent. The decision was made to carry out percutaneous coronary intervention to the culprit lesion in the mid-LAD via LIMA as the native LAD had a chronic occlusion in the proximal segment.

PCI PROCEDURE: Right femoral access was gained and a 6 Fr internal mammary artery catheter was used to engage the LIMA. The LAD was wired using a Sion blue wire (Asahi Intecc) and the LAD lesion was predilated with a 2.0/12 semicompliant balloon. Our attempts to study the tortuous LIMA and LAD with intravascular ultrasound (IVUS) were futile as we were unable to advance the IVUS catheter. It was also not possible to advance the stent to the LAD though the tortuous LIMA. On retrieving the stent, we noticed significant stent distortion. A buddy-wire strategy was adopted using a Grand Slam wire (Asahi Intecc), but we still were unable to deliver the stent. Next, we adopted the mother-and-child technique and advanced a 6 Fr Guideliner (Vascular Solutions) to the distal LIMA with the help of an anchor balloon inflated in the culprit lesion. Through the Guideliner, we were able to successfully deliver and deploy a 2.25 x 16 mm Xience stent (Abbott Vascular). Angiographic results were excellent; the patient was discharged a few days later with standard-of-care pharmacological treatment; he remains symptom free and event free at 6 months.

CONCLUSION: Through this case, we demonstrated how to successfully perform PCI to native LAD via LIMA using a guide-catheter extension as an escalating strategy.

C3-2016-18: Association of Abdominal Aortic Plaque With Coronary Artery Disease

Wei Li, Songyuan Luo, Jianfang Luo, Yuan Liu, Wenhui Huang, Jiyan Chen

BACKGROUND: As atherosclerotic disease is a major cause of severe cardiovascular events, identifying atherosclerotic plaques will be of utmost importance for early diagnosis and intervention. Evidence is available indicating that atherosclerotic plaques in carotid artery are associated with the presence and severity of coronary artery disease (CAD). However, the association between abdominal aortic plaques and CAD has not yet been clarified. The purpose of this study was to determine the prevalence of abdominal aortic plaques by ultrasound imaging and to explore its association with CAD in patients undergoing coronary angiography.

METHODS: Between October 2014 and June 2015, a prospective study was conducted in the department of cardiology at Guangdong General Hospital, Guangzhou, People’s Republic of China. Ultrasound scanning of the abdominal aorta was performed in 1667 consecutive patients undergoing coronary angiography. Excluded were patients with aortic diseases, congenital heart disease, infectious diseases, autoimmune diseases, or neoplasma. Clinical characteristics and coronary profile were collected from the patients.

RESULTS: Of the 1667 study patients (male, 68.9%; mean age, 63 ± 11 years) undergoing coronary angiography, a total of 1268 had CAD. Compared with 399 patients without CAD, 1268 patients with CAD had higher prevalence of abdominal aortic plaques (37.3% vs 17%; P<.001). In multivariate analysis, abdominal aortic plaques were an independent factor associated with the presence of CAD (odds ratio, 2.08; 95% confidence interval, 1.50-2.90; P<.001). Of the 1268 patients with CAD, the prevalence of abdominal aortic plaques was 27.0% (98/363) in patients with 1-vessel disease, 35.0% (107/306) in patients with 2-vessel disease, and 44.7% (268/599) in patients with 3-vessel disease. Stepwise increases in the prevalence of abdominal aortic plaques were found depending on the number of stenotic coronary vessels (P<.001; P for trend <.001). In an ordinal logistic regression model, abdominal aortic plaques were an independent factor associated with the severity of CAD according to the number of stenotic coronary vessels (P<.001).

CONCLUSION: The prevalence of abdominal aortic plaques was higher in patients with CAD than without CAD. Abdominal aortic plaques were an independent factor associated with the presence and severity of CAD.

C3-2016-19: Migration of CoreValve Immediately After Prosthesis Implantation and Second Valve Implanted

Rodrigo Martin,  Antonio Scuteri

INTRODUCTION: Nowadays, transcatheter aortic valve implantation (TAVR) is an accepted technique for patients with severe aortic stenosis and high surgical risk. However, there are still some technical issues to be solved. The incidence of CoreValve dislocation is reported to be 3%-12%, and an unfavorable anatomy, such as a curving of the ascending aorta, is considered one of the anatomic risk factors for dislocation. Here, we show a case of in-procedure migration of a CoreValve in a patient with unfavorable anatomy who was successfully treated using a second valve with elective valve-in-valve (VIV) strategy.

CASE PRESENTATION: We report the case of an 81-year-old man with severe aortic stenosis (indexed aortic valve area, 0.84 cm²; mean pressure gradient, 82 mm Hg) symptomatic for dyspnea class III and syncope. His medical history was lung and thyroid cancer, both with surgical treatment. Before TAVR, we performed left circumflex PCI. Logistic EuroScore was 16.74. The angiogram showed calcifications and curving of the ascending aorta. Through right femoral approach, we began to implant a 29 mm CoreValve prosthesis; immediately after the placement and release, the prosthesis migrated up to the ascending aorta. We decided to catch the migrated prosthesis with a bow and hold it strongly in the ascending aorta to avoid occlusion of the coronary artery. Subsequently, we went on to implant a second 29 mm CoreValve, which was successfully released (VIV). During the procedure, we saw a new left bundle-branch block that spontaneously resolved. No aortic regurgitation or other complication was noted. The patient was transferred to intensive care unit, and with significant improvement he was discharged 5 days after the procedure. Three months later, the patient underwent a multi-slice computed tomography (MSCT) for evaluation and it showed good fixation of both prostheses at the appropriate positions. The patient was in good condition, without symptoms or cardiovascular events.

CONCLUSION: Elderly patients can have unfavorable anatomy and these conditions can lead to complications. We achieved technical success with the second valve, and the risk and long-term outcome of this procedure are not well established.

C3-2016-20: Percutaneous Repair of Abdominal Aortic Aneurysm With Renal Artery Arising Within Body of the Aneurysm Treated Using the Snorkel Technique

Syed Yaseen Naqvi, MD, MSc, Tisa Saha, MD, Muhammad Raza, MD, Daniel McCormick, DO, Sheldon Goldberg, MD

Department of Cardiology, Pennsylvania Hospital, University of Pennsylvania Health System, Philadelphia, Pennsylvania

BACKGROUND: Endovascular aneurysm repair (EVAR) has predominantly replaced open surgical repair for the treatment of abdominal aortic aneurysms (AAAs). We describe a patient with an enlarging aneurysm with right renal artery involvement that was successfully repaired percutaneously using the snorkel technique.

CASE DESCRIPTION: A 78-year-old female with a past medical history of AAA, hypertension, hyperlipidemia, prior stroke, and prior myocardial infarction presented for routine follow-up. Her vital signs were normal, but her physical exam revealed a non-tender pulsatile expansile abdominal mass. A computed tomography (CT) angiogram of the abdomen 6 months prior revealed a 4.8 cm AAA with associated mural thrombus and right renal artery involvement. A follow-up ultrasound and repeat CT angiogram confirmed progressively enlarging aneurysm of 5.8 cm with associated mural thrombus. The right renal artery originated at the neck of the aneurysm, making an endovascular repair challenging. The patient was urgently referred to vascular surgery for an operative opinion. She was deemed high risk for open repair and was denied due to her advanced age and medical comorbidities. She underwent successful endovascular aortic aneurysm repair using the snorkel technique. Bilateral femoral artery in addition to left brachial artery access was obtained. A Gore Excluder AAA endoprosthesis was deployed at the level of the left renal artery. This was followed by deployment of an 8 x 100 mm self-expanding covered stent in the right renal artery. Balloon inflation was performed in a kissing fashion in the right renal artery and aortic stent. The final angiogram of the aorta showed exclusion of the AAA with patent right renal stent, without any evidence of endoleak. The patient had a follow-up abdominal ultrasound 6 months after, which revealed shrinkage of the AAA to 4.8 cm without any endoleak. The patient was asymptomatic at an 18-month follow-up visit.

CONCLUSION: Endovascular AAA repair using the snorkel technique can be performed successfully in patients with juxta-renal AAA who are at high risk for open surgical repair.

C3-2016-21: Intracardiac Tuberculoma in the Immunocompromised Population – A Review

Cornelius C. Nwora, MD, RCIS, RDMS, RT, MASCP

PURPOSE: To understand the peculiar factors that guide the diagnosis of intracardiac tuberculoma, especially in sick children with altered immunity.

METHODS: Literature review of scientific papers in Medline/PubMed and other popular search engines.

RESULTS: Tuberculosis (TB) is a contagious and airborne disease. The WHO ranks TB alongside HIV/AIDS as a leading cause of death worldwide.¹ At least one-third of people living with HIV worldwide in 2014 were infected with TB bacteria. People living with HIV are 20 to 30 times more likely to develop active TB disease than people without HIV. It is estimated that pediatric cases account for 10%-15% of the global TB. The majority of them occur in infants and children under 5 years of age.²

The diagnosis of TB in children is more difficult than in adults, because few signs are associated with primary infection, interferon-gamma release assays (IGRA) and tuberculin skin test (TST) are less reliable in younger children.³ In the pediatric age, the prodromal stage is often very short, and the risk of progression to active disease is higher in infants (30%-40% in those younger than 1 year of age) and children (24% in 1-5 years of age) as compared with the subsequent ages if treatment is inadequate. 

Following the inhalation of mycobacteria, innate immunity controls infection in immune-competent patients.³ Children are in fact prone to develop extrapulmonary TB; about 4% of children infected under the age of 5 develop tubercular meningitis or miliary TB.⁴ 

Cardiac TB is usually found at post mortem examination. Endocardial tuberculoma is extremely rare, found in only 0.14% of autopsy cases. Studies carried out before the introduction of specific anti-tuberculous therapy assert that the myocardium is involved in less than 0.30% of patients dying of TB.⁵ The myocardium might be affected by direct spread from the mediastinal gland, by the lymphatic routes, or the bloodstream. Organ involvement with M. tuberculosis infection was classified as being miliary (numerous small tubercules each less than 3 mm in diameter and resulting from blood-spread infection) or nodular (large rounded tuberculous lesions formed by confluent foci of tuberculous infection). Nodular myocardial TB might develop into a ventricular aneurysm.⁶

A tuberculoma is a clinical manifestation of tuberculosis that conglomerates tubercles into a firm lump, and so can mimic cancer tumors of many types in medical imaging studies.⁷ Since these are evolutions of primary complex, the tuberculomas may contain within caseum or calcification. They can affect any organ such as the brain, intestines, ovaries, breast, lungs, esophagus, liver, pancreas, bones, heart, and many others. As the histological and clinical indications, as well as tumor markers such as CA-125, are similar, it is often difficult to differentiate tuberculoma from cancer. For these reasons, tuberculosis should always be considered in differential diagnosis of cancer.⁸

Intracardiac tuberculomas may be localized at any part of the heart. They were found at the proximal superior vena cava and the right atrium in a 17-year-old male patient initially diagnosed as angiosarcoma or rhabdomyosarcoma.⁹ In one case presentation of an 8-year-old boy, two-dimensional echocardiography revealed a large mass in the right atrium, left atrium and left ventricle, with normal valves.¹⁰ “Clinically, tuberculomas may be asymptomatic or may present with arrhythmias, complete heart block, congestive heart failure, superior vena caval obstruction, right ventricular outflow obstruction, aortic insufficiency, and sudden cardiac death.”¹¹

CONCLUSION: Intracardiac tuberculoma is a rare finding, often diagnosed in patients with miliary TB. They were initially thought to be a disease of infants and children. However, the increased prevalence of HIV/AIDS and other immunosuppressive conditions led to their emergence among young adults and adults with TB. Intracardiac tuberculomas have been diagnosed in patients with negative tuberculin skin test. They are sometimes insidious and final diagnosis made following the positive effect with anti-tuberculosis treatment. The major presenting symptom is arrhythmia in the milieu of miliary TB.

References

1.    WHO: Global Tuberculosis Report; 2015, 20th Edition. Accessed May 4, 2016.

2.    WHO: Global Tuberculosis Report 2012. Geneva: World Health Organization; 2012.

3.    Piccini P, Chiappini E, Tortoli E, de Martino M, Galli L. Clinical peculiarities of tuberculosis. BMC Infect Dis. 2014;14(Suppl 1):S4. 

4.    Carrol ED, Clark JE, Cant AJ. Non-pulmonary tuberculosis. Pediatr Respir Rev. 2001;2:113-119.

5.    Horn H, Saphir O. The involvement of the myocardium in tuberculosis: a review of the literature and report of three cases. Am Rev Tuberc. 1935;32:492-506.

6.    Rose AG. Cardiac tuberculosis: a study of 19 patients. Arch Pathol Lab Med. 1987;111:422-426.

7.    Pitlik SD, Fainstein V, Bodey GP. Tuberculosis mimicking cancer – a reminder. Am J Med. 1984;76:822-825.

8.    Tuberculoma. Wikipedia, the free encyclopedia. Accessed May 10, 2016.

9.    Chang BC, Ha JW, Kim JT, Chung N, Cho SH. Intracardiac tuberculoma. Ann Thorac Surg. 1999;67:226-228.

10.    Rajeshwari K, Gupta S, Dubey A, Gera R. Asymptomatic multiple intracardiac tuberculomas in a child. Cardiol J. 2012;19:518-520. 

11.    Monga A, Arora A, Makkar RPS, Gupta AK. A rare site for tuberculosis. CMAJ. 2002;167:1149-1150.

C3-2016-22: Not All Thrombotic Appearing Lesions are Really Thrombotic

Hemang B. Panchal, MD, MPH, Samit Bhatheja, MD, MPH, Timir K. Paul, MD, PhD

BACKGROUND: Thrombotic coronary artery occlusion is believed to be the most common etiology for acute coronary syndrome (ACS). We present a case with ACS who did not have any acute thrombotic coronary occlusion on coronary angiogram. 

CASE PRESENTATION: A 57-year-old female presented at outside hospital with substernal chest pain radiating down to left shoulder for about 2 hours. She denied any other relevant symptoms. Past medical history included coronary artery disease with 3-vessel coronary artery bypass graft (CABG) 20 years ago, diabetes mellitus, hypertension, hyperlipidemia, obesity, and smoker.  Vitals and physical examination were unremarkable. Electrocardiogram revealed inferior STEMI. Troponin was 0.45 at presentation. The remaining laboratory values were unremarkable. Emergent coronary angiogram was done by an interventional cardiologist that showed non-thrombotic lesion in right coronary artery (RCA) with TIMI-3 flow, which suggested probable clot lysis in the culprit vessel. The left main artery had 40% stenosis, mid left anterior descending (LAD) artery had 90% stenosis. Ostial left circumflex artery had chronic total occlusion. RCA showed 95%, 70%, and 60% stenoses in proximal, mid, and distal arteries. Left internal mammary artery to mid LAD was known to be chronically occluded. Saphenous venous graft (SVG) to ramus intermedius was atretic. The mid SVG to first obtuse marginal (OM) had a 99%  hazy lesion that appeared a large thrombus and was thought to be the culprit lesion for concurrent NSTEMI since patient continued to have chest pain, with next troponin of >80 ng/mL. There was no other thrombotic lesion. 

DISCUSSION: The patient was placed on an intraaortic balloon pump (IABP), heparin drip, and was sent to our tertiary-care hospital for an evaluation for redo-CABG. She was a very high-risk surgical candidate for redo-CABG evaluated by cardiothoracic surgery. Echocardiogram showed ejection fraction at 40%-45%. Her chest pain was significantly improved with conservative management. The patient was continued on IABP over the weekend for 2 days. On day 4, the patient underwent a high-risk PCI to LAD and RCA using drug-eluting stents. On day 5, during PCI of SVG to OM1 graft, it was revealed that the lesion was not thrombotic; rather, a severely calcified complex lesion, which was stented with a bare-metal stent. The filter wire would not cross the lesion and aggressive balloon dilation, buddy wire, and wiggle wires were needed to deploy the stent. The patient tolerated the procedure very well and was sent home on day 6. She was doing well on further follow-up in our clinic.

C3-2016-23: Acute Vessel Closure Following Atherectomy: A Lesson to Assess Plaque Stability Before the Use of Pantheris Device

Ahmed Seliem, MD, Nishant Sethi, MD, Yassir Nawaz, MD, Peter Farrugia, MD, FACC 

Newark Beth Israel Medical Center, Newark, New Jersey

PATIENT HISTORY: The patient is a 49-year-old male with a history of diabetes mellitus, hyperlipidemia, active smoking (two packs per day), anxiety, and peripheral vascular disease with ulceration on the lateral aspect of the left foot. Non-invasive imaging showed severe diffuse left superficial femoral artery (SFA) disease along with multilevel below-the-knee disease.

PROCEDURE DETAILS: Right femoral arterial access was obtained with a 6 Fr arterial sheath.  Distal aortic-iliac arteriography was then performed using the Contra catheter. The initial angiogram showed that the left SFA in its mid portion had moderate disease, the TP trunk was 100% chronically occluded, the posterior tibial artery was 100% occluded down the left leg, the origin and proximal portion of the peroneal artery was also chronically occluded, and the anterior tibial artery was patent with some moderate disease noted at its ostium. 

Using a 0.035˝ Quick-Cross, the Terumo Advantage wire was exchanged for a 0.014˝ Command wire.  The wire was then successfully navigated through the chronic total occlusion of the origin of the TP trunk and placed into the distal peroneal artery.  A 2.0 x 200 mm balloon was advanced over the wire and inflated twice for 2 minutes, extending from the distal peroneal back to the origin across the AT into the P3 segment of the popliteal artery.  A 3.0 x 200 mm balloon was then advanced over the Command wire and inflated twice through the peroneal artery from distal to proximal portions. Following this, angiography revealed improvement. A 7 Fr Pantheris optical coherence tomography (OCT)-guided directional atherectomy device was then advanced over the wire and placed into the distal SFA. Six successful runs of directional atherectomy were completed. The patient had significant thrombosis of the mid-to-distal SFA and was occlusive at the Emboshield. The Emboshield was then removed using an extraction catheter. Suction thrombectomy was performed using a Pronto catheter. Repeat angiography revealed acute thrombosis of the entire distal popliteal artery into P3 and the origin of the anterior tibial and the peroneal arteries. Mechanical thrombectomy of the anterior tibial artery and popliteal artery into the P2 segment was performed successfully for removal a total of 98 mL of blood with thrombus. Repeat angiography revealed significant improvement in TIMI-3 flow compared with the beginning of the study down the SFA, popliteal, and into the anterior tibial artery.  There was maintenance of flow down the peroneal artery through the PT trunk, into the mid and distal calves.

FINDINGS: Mechanical thrombectomy is a safe and useful bail-out method when faced with acute vessel closure secondary to mechanical atherectomy device.

C3-2016-24: Knowing the Tools of the Trade: Percutaneous Balloon Angioplasty of a Surgically Ligated 

Common Femoral Artery After Transcatheter Valve Implantation

Ahmed Seliem, MD, Nishant Sethi, MD, Yassir Nawaz, MD, Najam Wasty, MD, FACC, Marc Cohen, MD, FACC, 

Mark Russo, MD, MS 

Newark Beth Israel Medical Center, Newark, New Jersey

PATIENT PRESENTATION: The patient is an 84-year-old Caucasian female with complaints of dyspnea on exertion, generalized fatigue, and lower-extremity edema. She has a reported past medical history of severe aortic stenosis, NYHA class III chronic diastolic congestive heart failure (ejection fraction, 48.5%), coronary artery disease status post percutaneous coronary intervention to the right coronary artery, hypertension, dyslipidemia, and chronic obstructive pulmonary disease. Society of Thoracic Surgeons score was calculated to be 21% (high risk) and thus the patient was scheduled for transcatheter aortic valve replacement.

PROCEDURE DETAILS: A left femoral approach was chosen due to a more favorable anatomy. The right common femoral artery and vein were accessed, using a  micropuncture technique, and a 6 Fr sheath was placed in each of the vessels. Using the roadmapping technique, the left common femoral artery was accessed using micropuncture needle and a 6 Fr sheath was then inserted. The Preclose technique was attempted on the left side using two Perclose devices.  We were unable to advance the E-sheath of the Edwards Sapien 3 system due to severe tortuosity and calcification. An elective cutdown was performed at that time. The vessel was dilated using a 14 Fr dilator without any difficulty and the E-sheath was placed. A 23 mm Sapien 3 valve was then deployed with no significant paravalvular leak.

Postprocedure angiogram was performed after surgical closure. The left femoral artery was noticed to be completely ligated by the surgical sutures. After discussion with the primary surgeon, endovascular repair was attempted due to the risk of heavy bleeding and poor visualization of the surgical field. The Rim catheter was used to negotiate the aortic bifurcation and cross over to the left common iliac artery. Multiple wires were used but we were unable to cross the ligated segment. An angled Quick Cross was parked at the ligation point, a 0.014˝ Confianza Pro-12 wire was used to cross the occluded segment. The wire traversed the occlusion in the subintimal plane and crossed into the true lumen of the common femoral artery distally, with the guidance of  the angled Quick Cross catheter.  The profunda femoris artery was cannulated with a Confianza wire, which was then exchanged for a Prowater 0.014˝ wire using a Quick Cross catheter. Balloon dilation of the common femoral artery was then performed using a 4.0 mm balloon.  The superficial femoral artery was cannulated using a Twin Pass catheter with a Runthrough wire. The Twin Pass allowed us to cannulate and maintain access in both arteries. Kissing-balloon dilation of the superficial femoral artery and profunda femoris was performed using two 4.0 mm balloons. Adequate flow was obtained, with 40%-50% residual lesion. Suboptimal results were accepted as there was good flow and palpable distal pulses. Doppler flow velocity showed moderate stenosis of the common femoral artery.

FINDINGS: The Preclose technique utilizing two Perclose devices has been widely described in the literature and accepted as a safe technique for the closure of large-bore arteriotomies. Use of the Perclose device carries with it a wide range of complications ranging from bleeding and vessel compromise to frank device failure. The above case is a description of how endovascular repair of a surgically ligated artery is possible utilizing the unique and safe subintimal reentry technique.

C3-2016-25: Matching the Zeros Improves Hemodynamics Deployment of Evolut R System by Aligning the Node Zero to the Bioprosthetic Annular Plane During Valve-in-Valve Implantation

Ahmed Seliem, MD, Nishant Sethi, MD, Yassir Nawaz, MD, Najam Wasty, MD, FACC, Marc Cohen, MD, FACC, 

Mark Russo, MD, MS 

Newark Beth Israel Medical Center, Newark, New Jersey

PATIENT HISTORY: An 88-year-old male with a history of NYHA class III chronic diastolic congestive heart failure (ejection fraction, 50%), coronary artery disease, 3-vessel coronary artery bypass grafting in 1996, and surgical aortic valve replacement using a #23 Epic bioprosthetic valve on May 11, 2010  presented with complaints of exertional dyspnea and fatigue. His STS score was calculated to be 9.67% (high risk).

ECHOCARDIOGRAPHIC FINDINGS: Aortic valve area index was 0.58 cm² with a mean gradient of 35 mm Hg. The aortic valve inner diameter of the prosthetic ring was 19-20 mm and the estimated ejection fraction was 50.3%. The aortic valve bioprosthesis was described as having thickened leaflets with severe stenosis and mild valvular aortic insufficiency.

CHOICE OF EVOLUT R SYSTEM (23 MM VALVE): The Evolut R system was chosen in this patient because he  had a previous surgical bioprosthetic aortic valve replacement. The Evolut R system is the only FDA-approved valve for percutaneous valve-in-valve indication and he had a severely calcified left ventricular outflow tract.

DEPLOYMENT TECHNIQUE: The valve was advanced beyond the bioprosthetic annulus and three-quarters of the valve was unsheathed. The aortic pressure tracing had a peak systolic pressure of 60-65 mm Hg in the setting of no rapid pacing. The valve was recaptured. The second attempt had similar results. Due to the more favorable hemodynamic measurements, the final deployment of the entire valve stent was done keeping the node zero at the bioprosthetic annular plane. The aortic pressure was 120 mm Hg systolic, with a mean of 90 mm Hg.

CONCLUSION: During valve-in-valve implantation of the Evolut R system, the default deployment (4-6 mm below the bioprosthetic annulus) failed to yield optimal hemodynamics. This can likely be explained by the restricted expansion of the Evolut R system, due to the presence of a surgical valve ring and long bioprosthetic leaflets, in the first two attempts. Keeping node zero at the level of the bioprosthetic valve ring yielded more favorable hemodynamics.

C3-2016-26: The Relation Between Interleukin-2 and Acute Coronary Syndrome

Abdel Mohsen Moustafa Abdou Aboualia¹, Mohamed Osama Kayed¹, Mohsen Ali Salama¹, Kamal Ahmed Merghany¹, 

Ahmed Badr¹, Mohamed Yousri Shahin² 

¹Al-Azhar University, Cardiology Department, Cairo, Egypt; ²Al-Azhar University, Clinical Pathology, Cairo, Egypt

BACKGROUND: Interleukin-2 (IL-2) has multiple, sometimes opposing, functions during an inflammatory response. Some studies showed that IL-2 may act as a predictor in vascular disease and stroke, but no studies have been performed on its effect in acute coronary syndrome (ACS) patients. The aim of this study is to investigate the role of IL-2 in ACS patients and compare them with control.

METHODS: The study group comprised 90 patients with the diagnosis of ACS (30 patients diagnosed as unstable angina [UA], 30 patients diagnosed as ST-elevation myocardial infarction [STEMI] with successful thrombolytic therapy, and 30 patients diagnosed as STEMI with failed thrombolytic therapy) who were treated at the Coronary Care Unit in the Cardiology Department at Al Hussein University Hospital between March to June 2013, and 30 apparently healthy subjects as a control.

RESULTS: Mean age was 32.4 ± 5.19 years in the UA group, 44.7 ± 9.41 years in the STEMI success group, 58.3 ± 7.93 years in the STEMI failed group, and 27 ± 7.07 years in the control group. In the current study, diabetes mellitus and age <50 years were more prevalent in the UA group than the other groups and hypertension was more prevalent in the STEMI success group. Interleukin-2 was 171.53 ± 39.48 pg/mL in the control group, 217.15 ± 73.17 pg/mL in the UA group, 274.3 ± 104.20 pg/mL in the STEMI success group, and 215.1 ± 49.43 pg/mL in the STEMI failed group. 

CONCLUSION: Serum IL-2 concentrations were significantly higher in patients with ACS vs control, in patients with STEMI vs the UA group, and in the STEMI success group vs the STEMI failed group.

C3-2016-27: Temporary Balloon Occlusion of the Hypogastric Arteries Before Cesarean Hysterectomy for the Management of Abnormal Placentation

Aldo Rodriguez Saavedra, Alejandra Vega, Nicolas Urday, Javier Lukestik, Gustavo Samaja 

Hospital de Alta Complejidad de Formosa, Argentina

BACKGROUND: The abnormal adherence of the placenta to the uterine wall is due to the absence of the decidua basalis and the fibrinoid layer of Nitabuch, so the chorionic villi directly attach to the myometrium. The abnormal placental implantation is subdivided according to the depth of penetration by the villi: accreta when it adheres to the myometrium without invading it, increta when it invades the myometrium, and placenta percreta when it grows through the myometrium and penetrates the serosa even adhering to the bladder or other structures adjacent. Abnormal placentation unexpectedly encountered at the time of delivery can lead to catastrophic consequences for the mother and the child, and has become a challenging problem of rising incidence in obstetric practice, related to the higher maternal age and the increasing rate of cesarean deliveries, significant risk factors. The traditional approach was surgical removal of the placenta with subsequent partial or total hysterectomy, procedure with high risk of bleeding. The surgical approach to obstetric hemorrhage is ligation of hypogastric or uterine arteries, usually initiated after significant bleeding has occurred and often complicated because visualization can be impaired and distorted vessel anatomy can complicate the ligation. Endovascular prevention of hemorrhage is an interesting alternative: preoperative uterine embolization or placement of occlusion catheters in aorta, iliac, and uterine arteries.

OBJECTIVE: To present our experience in endovascular prevention of obstetrical hemorrhage in 5 cases of abnormal placentation using temporary occlusion of the hypogastric arteries, describing our technique and analyzing feasibility and outcomes.

METHODS: Bilateral femoral access, and contralateral position of a tailored peripheral balloon catheter in the anterior branch of the internal iliac artery. The catheters were secured and the patient taken to the operating room for the surgery. After the infant was delivered by Cesarean section and the cord was clamped, both balloons were simultaneously inflated before performing partial or total hysterectomy: 10 minutes of inflation and 15 seconds of deflation for avoiding ischemic complications. Catheter removal was performed at the postoperative recovery room if the patient’s hemodynamic status and coagulation profile were unremarkable. 

RESULTS: We used our technique in 5 cases of abnormal placentation (Table). Surgical removal of the placenta and hysterectomy were performed with minimal blood loss, and only 1 patient required blood transfusion (1 red blood cell unit). In 1 patient, the diagnosis of placenta accreta was not confirmed, so an abdominal Cesarean and tubal ligation were performed. There were no thrombotic or vascular complications related to the intravascular procedure. The procedures were practiced with success, for both the mothers and the neonates. Only 1 neonate required intensive care for 2 weeks, due to complications not related to the endovascular procedure but to her low gestational age. 

CONCLUSION: Temporary occlusion of hypogastric arteries is a useful resource for preventing severe hemorrhage in patients with abnormal placentation and could reduce the high rate of maternal and neonatal morbidity and mortality associated with this entity. 

TAKE-HOME MESSAGES: (1) Abnormal placentation is a grave and potentially lethal entity, with increasing frequency.  (2) Correct antenatal diagnosis for planning appropriate strategy can be the difference between life and death because infiltrating placental tissues invade a highly vascularized uterus and the bladder, with serious risk of life-threatening hemorrhage. (3) Temporary occlusion of hypogastric arteries is an elegant resource for preventing severe hemorrhage in these high-risk delivering mothers. The key for success: multidisciplinary approach focused on predelivery diagnosis and careful preparation of the endovascular and surgical procedures.

C3-2016-28: Atrial Fibrillation and Acute Coronary Syndrome: Data From the Swiss National Registry on Myocardial Infarction (AMIS Plus)

L. Biasco, D. Radovanovic, H. Rickli, M. Roffi, F. Eberli, R. Jaeger, T. Moccetti, M. Moccetti, P. Erne, G. Pedrazzini

BACKGROUND: Patients (pts) with acute coronary syndromes (ACS) may present with concomitant atrial fibrillation (AF), a complex clinical condition with challenging therapeutic implications. In the present analysis, we aim to describe clinical characteristics and outcome of pts presenting with AF enrolled in AMIS Plus.

METHODS: A total of 1644 out of 35958 patients who enrolled in AMIS Plus between 2004 and 2015 showed AF at admission. AF pts were compared to non-AF pts with regard to clinical characteristics and outcome (in-hospital and 12-month mortality).

RESULTS: Overall incidence of AF in ACS was 4.5%. Pts with AF were more frequently males (34.0% vs 26.3%; P<.001), elderly (76.8 ± 10.7 years vs 65.6 ± 13.2 years; P<.001), showed a higher incidence of previous coronary artery disease, heart failure, cerebrovascular disease, or renal impairment and presented more frequently with dyspnea (relative risk [RR], 1.48; 95% CI, 1.29-1.69; P<.001) and cardiac arrest (RR, 1.62; 95% CI, 1.26-1.93; P<.001). Rates of revascularization (RR, 0.67; 95% CI, 0.64-0.70; P<.001) and dual-antiplatelet therapy (RR, 0.73; 95% CI, 0.7-0.75; P<.001) were significantly lower in the AF cohort. In-hospital mortality (13.1% vs 5.1%; P<.001) as well as rate of cardiogenic shock (6.8% vs 3.4%; P<.001) and bleedings (3.2% vs 2.6%; P<.001) were significantly higher among AF pts. One-year mortality was also higher (13.7% vs 3.2%; P<.001) in a subgroup of long-term follow-up pts. 

CONCLUSION: ACS pts with AF at admission showed a greater complexity, lower access to therapies, and increased incidence of in-hospital and 1-year events, deserving higher intensity of care in order to optimize outcome. 

C3-2016-29: Impact of New-Onset Atrial Fibrillation in ACS Patients. Insights From the Swiss AMIS Plus Registry

L. Biasco, D. Radovanovic, H. Rickli, M. Roffi, F. Eberli, R. Jaeger, T. Moccetti, M. Moccetti, P. Erne, G. Pedrazzini

BACKGROUND: Atrial fibrillation (AF) may be present either at admission or appear during hospitalization in patients with acute coronary syndromes (ACS). In the present analysis, we aim to evaluate the impact of new-onset of AF in pts enrolled in the AMIS Plus registry. 

METHODS: A total of 1953 out of 35958 patients enrolled in the nationwide Acute Myocardial Infarction in Switzerland (AMIS) Plus registry between 2004 and 2015 showed AF. Out of them, 1644 showed AF at admission while 309 had new-onset AF during hospital stay. Groups were compared with regard to clinical characteristics and outcome (in-hospital and 12-month mortality).

RESULTS: Patients with new-onset AF were younger (74.6 ± 10.9 years vs 76.8 ± 10.7 years; P<.001), less frequently hypertensive (relative risk [RR], 0.86; 95% CI, 0.79-0.93; P=.003) or with history of coronary disease (RR, 0.77; 95% CI, 0.65-0.91; P=.002), heart failure (RR, 0.51; 95% CI, 0.31-0-85; P=.009), or renal impairment (RR, 0.72; 95% CI, 0.58-0.99; P=.04), presented more frequently with STEMI (RR, 1.29; 95% CI, 1.16-1.43; P<.001), and more frequently needed hemodynamic support with vasopressors (RR, 1.56; 95% CI, 1.18-2.07; P=.002) and balloon counterpulsation (RR, 2.42; 95%CI, 1.67-3.51; P<.0001). In-hospital bleedings (6.5% vs 3.2%; RR, 2.04; 95% CI, 1.23-3-38; P=.005) and cerebrovascular events (4.2% vs 1.3%; RR, 3.13; 95% CI, 1.59-6.15; P<.001) were more common in new-onset AF pts. In-hospital (13.1% vs 10.7%; RR, 0.88; 95% CI, 0.57-1.14; P=.22) and 1-year (landmark) mortality (13.7% vs 12.1%; RR, 1.1; 95% CI, 0.53-2.38; P=.73) were comparable among groups. 

CONCLUSION: ACS patients with new-onset of AF showed a lower baseline risk profile but a greater need for hemodynamic support and higher incidence of serious in-hospital complications, leading to a mortality rate comparable to pts with preexisting AF. 

C3-2016-30: Culprit in a Cardiac Arrest: Right Coronary Artery or Left Anterior Descending Artery

Obiora Egbuche, MD, Pradyumna Agasthi, MD, Kalaivani Sivakumar, MD, Rajesh Sachdeva, MD 

Division of Cardiology, Department of Internal Medicine, Morehouse School of Medicine, Atlanta, Georgia

BACKGROUND: Cardiac arrest may occur during cardiac ischemia. Ischemia results from coronary occlusion caused by atherosclerotic plaque rupture, thrombo-emboli, or vasospasm. These may occur in any segment of the coronary tree resulting in ischemia in the territory supplied by the artery. The right coronary artery (RCA) supplies the posterior wall of the left ventricle; the left anterior descending artery (LAD) supplies the anterior wall; the circumflex artery supplies the lateral wall; and the posterior descending artery (PDA) supplies the inferior wall. Coronary dominance is determined by the origination of the PDA. The RCA is referred to as a dominant RCA when it gives origin to the PDA. Otherwise, it is called a non-dominant RCA. In an electrocardiogram, ischemia/injury to each wall may be seen as ST-segment elevation on the leads corresponding to those walls. We present a case of chronic RCA stenosis masking a culprit LAD stenosis as a cause of acute inferior wall myocardial ischemia leading to cardiac arrest. 

CASE PRESENTATION: A 45-year-old man with a medical history of hyperlipidemia was brought to the emergency department (ED) after ventricular fibrillation cardiac arrest. He exercised regularly and usually biked to work. On the day of the event, the patient lost consciousness after running a mile and a bystander initiated cardiopulmonary resuscitation. On arrival of the emergency medical personnel, he was found to be pulseless. After being connected to an automated external defibrillator, an initial shock was advised. He returned to sinus rhythm with return of spontaneous circulation after a single shock. Initial electrocardiogram en route to the hospital revealed subtle ST-elevation in inferior leads (Figure 1) that returned to baseline on repeat electrocardiogram in the ED (Figure 2). Coronary angiography revealed a long-segment 99% stenosis of the RCA with TIMI-1 flow (Figure 3A) and tandem 50% stenosis in the proximal and mid LAD (Figures 3B and 3C). Percutaneous coronary intervention (PCI) was performed with placement of 4 drug-eluting stents in the RCA (Figure 3D). The RCA stenosis behaved like a chronic occlusion instead of acute thrombotic occlusion. Subsequent echocardiography showed inferior-wall hypokinesis. A staged PCI was performed on the LAD during indexed hospitalization. 

The tandem LAD stenosis was assessed for ischemia by fractional flow reserve (FFR). Initial FFR across tandem stenosis was 0.77 (Figure 4A) and on pullback above the mid stenosis, FFR remained the same. 

After stenting the proximal LAD stenosis (Figure 4B), FFR was repeated. FFR was 0.78 (Figure 4C) as a result of mid LAD stenosis. Bifurcation LAD, diagonal stenting was performed (Figure 4D) and FFR was repeated to be 0.93.

DISCUSSION: Our patient had cardiac arrest with transient electrocardiographic changes suggesting inferior-wall ischemia. It was expected that the dominant RCA was the culprit artery. Angiographically and after revascularization was attempted, RCA stenosis technically was a chronic occlusion. It was presumed that the inferior wall was supplied by the LAD through septal collaterals. In the setting of chronic stenosis of a dominant RCA and tandem ischemic stenosis in LAD, acute inferior-wall ischemia in this patient was likely as a result of decreased flow to the watershed inferior wall from the LAD stenosis. However, the main limitation regarding this case is that there was no left coronary angiography to demonstrate the collaterals prior to the RCA-PCI.

CONCLUSION: In patients who have chronic stenosis of a dominant RCA, the inferior wall may be collateralized by the LAD through the septal collaterals. This area becomes most prone to ischemia for being a watershed area. Acute inferior wall ischemia in these patients may be as a result of blood flow reduction from stenosis in the artery providing the collaterals.

C3-2016-31: ECMO in the Cath Lab: Peripheral VA-ECMO in Primary PCI

R. Francis¹, A. Ladwiniec¹, Jo-anne Fowles², Will Davies¹, S. Hoole¹, Alain Vuylsteke²

¹Department of Cardiology, Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom

²Critical Care Unit, Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom

INTRODUCTION/AIM: Peripheral veno-arterial extracorporeal membrane oxygenation (VA-ECMO) increases afterload and may not be ideal for an acutely ischemic heart. We retrospectively reviewed consecutive patients undergoing primary percutaneous coronary intervention (PPCI) who required emergency peripheral VA-ECMO for acute cardiogenic shock. 

METHODS: All patients placed onto VA-ECMO in the context of PPCI in a high-volume tertiary referral center between 2011-2015 were identified. Data were gathered regarding case complexity, patient demographics, and outcome.

RESULTS: In the study period, approximately 2800 patients were admitted through the PPCI service and 14 were placed on VA-ECMO. 

•  Average age: 56.8 years old

•  12 (86%) were male

•  Most had no significant comorbidity

•  Average of 15 minutes of cardiopulmonary resuscitation prior to angioplasty

•  11 (79%) had multivessel coronary disease

•  Mean SYNTAX score was 32, representing intermediate to high-risk coronary disease

•  5 (36%) of patients presented with an occluded left main stem

•  4 (29%) went on to have coronary artery bypass graft surgery

•  Complications were frequent, severe and related both to cardiac failure and ECMO

•  Only 3/14 (21%) of patients survived to 30 days.

CONCLUSION: Patients presenting with cardiogenic shock and an acute coronary syndrome are exceptionally high risk and the poor outcome is not surprising. This cohort was considerably younger and fitter, on average, than most patients presenting with STEMI, suggesting a selection bias toward patients more likely to benefit from ECMO.

C3-2016-32: Coronary Artery Perforation During Percutaneous Coronary Intervention: Incidence and 

Outcomes

O.P. Guttmann, D.A. Jones, T. Crake, M. Ozkor, A. Wragg, E. Smith, R. Weerackody, C.J. Knight, A. Mathur, C. O’Mahony

Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust

BACKGROUND: Coronary artery perforation during percutaneous coronary intervention (PCI) is a rare but severe complication, with a high morbidity and mortality. The incidence of this complication is reported to range from 0.1%-1%. 

OBJECTIVE: To examine the clinical outcome following PCI complicated by vessel perforation. 

METHODS: The procedural records of 28,537 patients undergoing coronary intervention were reviewed. Mortality data were obtained from the United Kingdom Office of National Statistics.

RESULTS: Vessel perforation affected 103 patients (0.36%), ranging from wire exit to free flow into the pericardial space. Fifty-three perforations (51.9%) occurred during elective procedures, 22 (21.6%) in chronic occlusions.

In 26 of 103 (25.2%), a significant pericardial effusion ensued requiring surgical or percutaneous drainage. Six of the 26 patients were referred for emergency bypass surgery (23.1%), 2 of whom subsequently died. Three patients died despite pericardial drains being inserted.

In all, 24 patients had covered stents inserted and 5 did not survive to discharge. Ten of the 24 (41.7%) who had covered stents had drains compared to 16/79 (20.3%) who did not. Of the 19 patients with a covered stent that survived to hospital discharge, 6 (30.0%) had definite stent thrombosis and 2 (10.0%) had possible/probable stent thrombosis.

CONCLUSION: Coronary artery perforation during intervention is rare. The development of pericardial tamponade carries a high mortality. While the use of covered stents may provide a valuable rescue option acutely, high rates of stent thrombosis suggest more potent antiplatelet agents may be needed.

C3-2016-33: Introduction of the Punctual Guidewire for Arterial and Venous Access

Richard R. Heuser

BACKGROUND: Vascular access, whether arterial or venous, was utilized in over 13.2 million procedures in the United States alone in 2013. Transradial approach (TRA) for cardiac catheterization and percutaneous coronary intervention is increasingly being used worldwide in procedures because it is associated with fewer vascular applications compared to the transfemoral approach and allows immediate ambulation. Techniques gleaned from the TRA are also translatable to other access techniques including the pedal approach being used more frequently in peripheral vascular disease treatment.  In order to simplify the radial and pedal technique, we have developed a basic needle approach to arterial access with a 24 gauge needle and a unique hollow nitinol .035˝ wire. Accessing with the small-gauge needle results in immediate .035˝ wire passage, eliminating the need for a microsheath placement before placement of a 5 Fr or 6 Fr sheath. 

METHODS: We have utilized the Punctual guidewire in a porcine model to obtain brisk and reliable blood flashback and .035˝ access. This simple access device may not only be useful with experienced operators, but may also be easier to use for training new operators for radial and pedal access. It may also have a much wider application in venous access. Just in the United States, there are 13 million plus vascular access procedures performed per year.

CONCLUSION: The Punctual guidewire, while originally conceived for use in the TRA market, can also replace a standard micropuncture kit in all vascular applications.  The Punctual guidewire may offer less trauma and faster access, with potentially fewer complications.

C3-2016-34: Anomalous Left Main Coronary Artery: Not Always a Simple Surgical Reimplantation

Asif H. Khan, MBBS, BSc, MRCP¹, Cardiology Specialist Registrar, I.B.A. Menown², MD, FRCP, Consultant 

Cardiologist, A. Graham¹, MD, FRCS, Consultant Cardiothoracic Surgeon, J.A. Purvis³, MD, FRCP, FRCPI, FESC, Consultant Cardiologist

¹Royal Victoria Hospital, Belfast Trust, N. Ireland, ²Craigavon Cardiac Centre, Southern Trust, N. Ireland, ³Altnagelvin 

Hospital, Western Trust, N. Ireland

KEY WORDS: anomalous left main stem, right coronary cusp, coronary artery bypass grafting cardiac computer tomography, cardiac catheterization, pressure wire assessment.

ABSTRACT: We present the case of a 56-year-old woman who required complex coronary artery bypass grafting (CABG) for high-risk anomalous left main coronary artery (LMCA) originating from right coronary cusp including conventional reimplantation of the LMCA plus left internal mammary artery (LIMA) graft to the left anterior descending (LAD) and saphenous vein graft (SVG) to the circumflex. On subsequent cardiac computer tomography (CT) screening and cardiac catheterization, the LIMA graft was occluded after just a few centimeters, but the SVG graft was patent with good run-off into the native circumflex and also filled the LAD retrogradely. The reimplanted left main stem demonstrated at least moderate ostial stenosis although pressure wire assessment of this was not significant (fractional flow reserve, 0.89), probably due to good retrograde filling of the LAD from the SVG to circumflex; therefore, we did not proceed the LMCA ostial stenting. She remains on yearly review with a low threshold for considering stenting of the LMCA ostium should the SVG to left circumflex develop even moderate stenosis. This case illustrates how patients with anomalous LMCA may sometimes benefit from grafting in addition to conventional reimplantation.

INTRODUCTION: The majority of coronary artery anomalies (80%) are benign and asymptomatic.¹ The incidence of an anomalous LMCA originating from the ostium of the right coronary artery (RCA) is low (0.05%).² But if the artery takes an interarterial course between the aorta and the pulmonary artery, sudden death may take place by compression during vigorous exercise.³ Standard management includes surgical reimplantation of the left main ostium. We report a case of LMCA with an anomalous origin from right coronary cusp, surgical management strategy, and invasive follow-up.

SUMMARY OF CASE: A 56-year-old Caucasian lady presented to our Rapid Access Chest Pain clinic following 3 episodes of non-specific sharp central chest discomfort over the previous 6 weeks. She had occasional palpations but no history of presyncope or collapse. 

Cardiac catheterization was undertaken and showed no obstructive coronary artery disease (CAD) at rest, but the LMCA had an anomalous origin arising from right coronary cusp (Figures 1a and 1b). Subsequent cardiac CT angiography (Figure 2) showed this anomalous course was a high-risk type, running between the aortic root and pulmonary artery. The heart team decided that surgery should be performed and that reimplantation of the anomalous LMCA was the best option.

However, due to the surgeon’s concerns that there remained the possibility for compression of the distal vessel, a LIMA was grafted to the LAD as a back-up. The patient made a full recovery.

Follow-up cardiac CT was arranged, and showed the surgically reimplanted LMCA to have ostial stenosis (Figure 3c). The LIMA graft was occluded after just a few centimeters (Figure 3a), but the SVG graft was patent with good run-off into the native left circumflex (LCX) with retrograde filling of the LAD (Figure 3b). 

Computed tomography findings were confirmed with invasive angiography (Figure 4a-4c). Pressure-wire assessment of reimplanted LMCA ostium yielded no significant stenosis (fractional flow reserve, 0.89), probably due to the good retrograde filling of the LAD from the SVG to LCX. She remains under yearly review with a low threshold to consider stenting of the LMCA ostium should the SVG to LCX develop even moderate stenosis.

DISCUSSION: Anomalous LMCA with high-risk course is a rare but important diagnosis. Accurate diagnosis can prevent the risk of sudden death and aid surgical planning. Most cases are unfortunately diagnosed post mortem.^4,5

This case demonstrates the difficulties in choosing the most appropriate surgical strategy. The initial operation was complicated by VF on closure of the chest despite the addition of a LIMA graft to the LAD. The surgeon remained concerned about the effect of competitive flow between reimplanted LMCA and the LIMA causing later occlusion of the graft.  Potentially, the heart would be dependent on LIMA graft flow during occasions of LMCA compression such as vigorous exercise but not at rest.⁶ A vein graft was added to the first obtuse marginal as it was the surgeon’s belief that vein grafts are more resistant to the effects of competitive flow than internal mammary artery grafts due to a reduction in flow-related contractility, although it is acknowledged that firm evidence for this is lacking.

CONCLUSION: Anomalous origin coronary arteries should be worked up comprehensively and an aggressive treatment strategy adopted, especially if there is an interarterial course. Non-invasive and invasive modalities can assess the success of a complex surgical reimplantation strategy.

References

1.    Yamanaka O, Hobbs RE. Coronary artery anomalies in 126,595 patients undergoing coronary arteriography. Cathet Cardiovasc Diagn. 1990;21:28-40.

2.    Desmet W, Vanhaecke J, Vrolix M, et al. Isolated single coronary artery: a review of 50,000 consecutive coronary angiographies. Eur Heart J. 1992;13:1637-1640.

3.    Basso C, Corrado D, Thiene G. Congenital coronary artery anomalies as an important cause of sudden death in the young. Cardiol Rev. 2001;9:312-317.

4.    Frescura C, Basso C, Thiene G, et al. Anomalous origin of coronary arteries and risk of sudden death: a study based on an autopsy population of congenital heart disease. Hum Pathol. 1998;29:689-695.

5.    De Rosa G, Piastra M, Pardeo M, Caresta E, Capelli A. Exercise-unrelated sudden death as the first event of anomalous origin of the left coronary artery from the right aortic sinus. J Emerg Med. 2005;29:437-441.

6.    Kawamura M, Nakajima H, Kobayashi J, Funatsu T, Otsuka Y, Yagihara T, Kitamura S. Patency rate of the internal thoracic artery to the left anterior descending artery bypass is reduced by competitive flow from the concomitant saphenous vein graft in the left coronary artery. Eur J Cardiothorac Surg. 2008;34:833-838. Epub 2008 Aug 23.

C3-2016-35: PCI to Distal Left Main Trifurcation Disease With Final Kissing Using Three-Balloons Technique

Mohamed Mandour, MD, MsC, PhD, Khaled Mandour, MD, MsC, National Heart Institute, Cairo, Egypt 

CASE HISTORY: A 68-year-old man with multiple risk factors for coronary artery disease (CAD) (hypertension, diabetes mellitus, smoker), and a history of previous anterior myocardial infarction in 2010 presented on June 8, 2015 with new-onset CCS class III angina and a positive ETT (Duke treadmill score -12). Cardiac catheterization revealed 3-vessel and left main CAD and normal left ventricular function; Syntax score was +33. Coronary artery bypass grafting was recommended, but the patient declined the procedure and underwent PCI and total revascularization.

INDEX CORONARY ANGIOGRAM: Left main (LM): short atherosclerotic vessel that shows distal shelf like calcified lesion. Left anterior descending (LAD): atherosclerotic vessel showing proximal subtotal in-stent restenosis followed by mid-segment 80% lesion, gives very early diagonal that shows ostial to proximal 90% lesion. Left circumflex (LCX): atherosclerotic vessel showing proximal 90% lesion. Right coronary artery (RCA): atherosclerotic small non-dominant vessel showing a tight mid-segment lesion.

ON PHYSICAL EXAMINATION: ABP 135/85 mm Hg, pulse 80 bpm, regular equal on both arms, chest x-ray: harsh vesicular breathing, normal S1 & S2, RBS 150 mg/dL, Hg 12.8 g/dL, INR: 1.0, creatinine level, 0.8 mg/dL.

PROCEDURE STEPS: A radial approach using a left 3.5, 7 Fr guiding catheter was used to cannulate the left coronary artery. Predilation to LM, LAD lesions, diagonal lesion. Predilation of LAD lesion resulted in dissection with slow flow at mid LAD so stenting the mid LAD occurred first. Then, mini-crush technique to LM-LAD and diagonal, followed by final kissing with excellent results. Then, stenting the LCX using TAP techniques followed by final kissing in LAD and LCX, which resulted in compromised diagonal ostium. Then, final kissing using three-balloon technique LM/LAD-diagonal and LCX, simultaneously inflated, with excellent final results.

QUESTIONS: Regarding this case scenario, double bifurcation stenting or triple kissing stents? Do you agree that LM intervention in the setting of multivessel disease and high SYNTAX score is feasible? Is SYNTAX score still reliable? After seeing the end result of PCI and total revascularization in this case, is CABG really a better option? Is re-POT mandatory after bifurcation technique?

CONCLUSIONS: PCI to LM trifurcation disease is feasible, and should be considered given its low invasiveness in patients at high surgical risk or multiple co-morbidities. The guiding catheter should be disengaged from the ostium of the ULMCA to permit full visualization and expansion of the stent. Postdilation with the balloon protruding into the ascending aorta must be performed to flare the proximal portion of the stent. No two bifurcations are identical, and no single strategy exists that can be applied to every bifurcation. Thus, the more important issue in bifurcation PCI is selecting the most appropriate strategy for an individual bifurcation and optimizing the performance of this technique.

C3-2016-36: Implanting BVS in CTO

Dr Bilal S. Mohydin

Punjab Institute of Cardiology, Lahore, Pakistan

BACKGROUND: A bioresorbable vascular scaffold (BVS) system is a bulky “stent” with less strength than the metallic stents (bare-metal or drug-eluting stents). This case is a demonstration that BVS can be safely implanted in chronic total occlusion (CTO). As the lesion length was more than 28 mm, two BVSs were implanted side-to-side; this technique is also well demonstrated. We also wanted to see whether vascular hemodynamics would be regained after absorption in a calcified vessel. This case was done on September 22, 2014; presently, the patient is doing well. I will attempt to perform coronary angiography in 2017 to get this answer.

SHORT CASE HISTORY: A 70-year-old woman complained of gradual worsening chest pain with worsening shortness of breath. She was hypertensive for the last 20 years, but was presently well controlled. No other significant major risk factor was present. CTO of the LAD filled faintly from left collaterals (Figure 1). Proximal cap penetrated with a 0.014˝ Progress 140, it got directed toward a septal branch. By parallel technique, the lesion was crossed with 0.014 Progress 120, and Progress 140 removed. The entire length of the lesion was dilated with a 1.0 x 10 mm Sapphire up to 18 atm. A 0.014˝ BMW wire was placed in distal LAD and the Progress 120 was removed. The entire length of the lesion was dilated with a 2.5 x 15 mm Trek NC balloon at 18 atm and then viewed. The entire length of the lesion was then dilated with a 3.0 x 12 mm Trek NC at 14 to 18 atm. The distal half of the lesion was then stented with a 2.5 x 28 mm Absorb as per Absorb deployment protocol (started inflation 30 second after stent introduction, and the inflation is gradually increased after every 5 seconds by 2 mm Hg and then at 10 atm we waited for 30 seconds). Total deployment time was about 60 seconds. BVS was postdilated with a 3.0 x 12 mm Trek NC at 14-16 atm, and the proximal segment of lesion was also dilated with it. The BVS was placed side to side with platinum dot of first stent overlapped by stent balloon dot (Figure 2). Note the two platinum dots are placed side to side (Figure 3). A focal area of the proximal half of the second stent is slightly underdeployed; this along with the stent overlap was postdilated with 3.25 x 15 Trek NC at 14-18 atm. The final check injection revealed no residual stenosis with TIMI III flow into the distal LAD (Figure 4).

CONCLUSION: The BVS system can be implanted in a CTO lesion; however, it requires a 1:1 predilation. More than one BVS can also be placed in one long lesion and this requires precise second stent placement. If any part of the stent appears underdeployed, a BVS can be postdilated like a metallic stent.

C3-2016-37: Left Main Ostial Stenting by BiRD Technique. (Bilal (2 wires, 2 senior operators) Rapid Delivery)

Dr Bilal S. Mohydin, Dr Tahir Naveed, Dr Masood Ali Akbar, Dr Abdul Wajid Faisal

Punjab Institute of Cardiology, Lahore, Pakistan

BACKGROUND: Isolated left main ostial and/or mid-vessel disease sparing the ostia of branch vessels is relatively an infrequent entity. In unprotected left main ostial intervention it is essential to be precise and quick, more so in a left dominant system. The Syntax score of an isolated left main ostial disease in both right and left dominant systems is less than 22 and as per 2010 ESC guidelines, its indication is IIa B. Coronary artery bypass graft (CABG) indication remains IA. The left main ostium is anatomically different with a lot of elastic tissue; thus, for PCI it is not just successful stent placement but it has to be optimal stent placement. For this vessel sizing, matched stent availability and post analysis with intravascular ultrasound (IVUS) or optical coherence tomography (OCT) may be essential. As such, no specific technique is recommended for left main stem (LMS)ostial stenting. The “BiRD” technique is one by which LMS ostial stenting can be done safely, rapidly, and precisely.

METHOD: The BiRD technique does not require any high tech tools. It can be done safely in experienced hands, taught and duplicated. The preferred guider is one that can be well controlled; I prefer JL. One workhorse wire (BMW) is placed in distal LAD and the second wire is hanged in the aorta (bi = two wires) – this way, the ostium of the LMS is not engaged and is well marked. IVUS may be done to confirm diameter, length, and size of the LMS ostium, followed by predilation if needed. For ostial stenting we usually need a 4 x 8 mm or at times a 3.5 x 8 mm drug-eluting stent with good radial strength. If needed, only the LMS ostium is dilated, sparing the ostium of branch vessels. The distal stent marker is well inside the main vessel sparing the ostiums of the LAD artery and left circumflex artery. The proximal marker is placed just distal to the catheter tip, as the catheter cannot be engaged due to the second wire - which hangs in the aorta – thus, this way optimum ostial coverage with minimum overhang into aorta is established/ensured. After placement, the two operators give the go ahead for stent deployment. If needed, IVUS or OCT may be done post stenting followed by postdilation if needed and then again IVUS or OCT until a satisfactory result. An example case is shown in Figures 1-6.

RESULTS: So far, I have done 12 cases by this technique, with all showing excellent immediate satisfactory result and a follow-up of 3 to 24 months showing no in-stent restenosis.

CONCLUSION: The BiRD technique is a safe and reproducible way of stenting the ostium of the LMS, and has excellent immediate and follow-up results.

C3-2016-38: Very Rare Case of Ostial LIMA Stenosis

Arun K. Nagabandi, MBBS, Augusta University/Medical College of Georgia, Division of Cardiology; Amudhan 

Jyothidasan, MD, Augusta University/Medical College of Georgia, Division of Cardiology; Mahendra K. Mandawat, MBBS, MD, MRCP, FACC, Charlie Norwood VA Medical Center - Augusta University/Medical College of Georgia, Division of Cardiology, Joe B. Calkins, Jr, MD, FACC, FACP, FASE, Charlie Norwood VA Medical Center - Augusta University/

Medical College of Georgia, Division of Cardiology

BACKGROUND: Stenosis involving the left internal mammary arterial (LIMA) bypass graft is most commonly located at the distal anastomotic site followed by the graft body. Ostial stenosis of the LIMA is very rare and is thought to be due to extension of subclavian atheroma into the graft and/or trauma to the ostium during surgery or catheterization. We present a patient with symptoms due to this rare condition.

CASE PRESENTATION: A 61-year-old man with diabetes mellitus and severe peripheral arterial disease underwent 4-vessel coronary artery bypass graft (CABG). Postoperative course was complicated by left lower-extremity ischemia that required femoro-popliteal bypass surgery, multiple fasciotomies, and skin grafting. He presented with a non-STEMI 6 months postoperatively. Coronary angiogram showed stenoses of 80% and 90% involving the proximal left anterior descending artery (LAD) and 1st obtuse marginal (OM) branch, respectively, complete occlusion of the right coronary artery (RCA) and the saphenous vein grafts to the diagonal, OM, and distal RCA, and an 85% ostial stenosis of the LIMA graft.

A vasospastic etiology of the ostial stenosis of the LIMA was excluded with intraarterial administration of nitroglycerin. Atherosclerotic involvement of the graft was then confirmed with intravascular ultrasound. The patient was at high risk for an adverse outcome with a repeat CABG and so percutaneous intervention was pursued. Drug-eluting stents (Xience V) were placed in the ostial LIMA and OM1 with good angiographic results and relief of symptoms. Thirteen days later, the patient presented with chest pain and shortness of breath of a few hours duration and rapidly deteriorated with hypotension, renal failure, and hyperkalemia with terminal ventricular fibrillation. He did not have any electrocardiographic evidence of ischemia. Autopsy revealed a recent lateral wall infarct without extension to the anterior wall or septum.

DISCUSSION: Ostial LIMA stenosis is a relatively rare entity with just a handful of cases being reported in the literature. In most reported cases the patients had severe peripheral vascular disease and prior CABG. Subclavian atheroma with extension into LIMA ostium is a proposed mechanism given the extensive vasculopathic profile in these patients. Other mechanisms suggested include trauma to the ostial LIMA during surgery or during prior catheterizations. Use of intravascular ultrasound (IVUS) helps in determining the nature and potentially the etiology of stenosis and also for preintervention assessment. In our patient, redo-CABG was not an option and so we proceeded with PCI with a drug-eluting stent with good angiographic results. There is limited literature on the outcomes of ostial LIMA interventions with the largest case series reporting on 5 patients. There was angiographic success in all patients, with 3 undergoing PTCA and the other 2 stenting. One patient who had PTCA suffered sudden cardiac death within 2 months of the procedure and another died from shock 3 years from the procedure. The third patient had unstable angina from in-stent restenosis 4 months after the procedure needing repeat revascularization with PTCA. The other 2 who underwent stenting in addition to PTCA did well on reported follow-up to 35 months. Our patient suffered cardiogenic shock from a myocardial infarction not involving the left anterior territory but possibly from thrombosis of the stent to the obtuse marginal artery.

CONCLUSION: Ostial LIMA stenosis is a rare entity. Optimal treatment strategy is uncertain due to the rarity of the condition. Good initial angiographic and clinical outcomes have been reported with percutaneous techniques; however, these patients appear to remain at high risk for adverse outcomes due to a high atherosclerotic burden.

References

1.    Berger A, MacCarthy PA, Siebert U, et al. Long-term patency of internal mammary artery bypass grafts: relationship with preoperative severity of the native coronary artery stenosis. Circulation. 2004;110[Suppl II]:II-36–II-40.

2.    Hearne SE, Davidson CJ, Zidar JP, Phillips HR, Stack RS, Sketch MH Jr. Internal mammary artery graft angioplasty: acute and long-term outcome. Cathet Cardiovasc Diagn. 1998;44:153-156; discussion 157-158.

3.    Jacq L, Lancelin B, Brenot P, Caussin C. Percutaneous transluminal angioplasty of ostial lesions of internal mammary artery grafts. Catheter Cardiovasc Interv. 2001;52:368-372.

C3-2016-39: Primary Angioplasty – Beware of Coronary Arteries

Dr Panneerselvam Arunkumar MD, DM, PSG Institute of Medical Sciences & Research, Coimbatore, India

ABSTRACT: A 50-year-old diabetic male presented with AWMI and was taken for PAMI. The diagnostic angiogram showed small-caliber diffusely diseased LMCA with occluded LAD and LCX (Figure 1). This resulted in a dilemma regarding how to revascularize this vessel. While attempting to cannulate with guiding catheter, another large-caliber left coronary (Figure 2) was engaged and it showed a proximal LAD lesion, which was stented. The initial coronary artery that was engaged during diagnostic study was an anomalous, hypoplastic left system that was arising from the left sinus close to the larger left system. It is mandatory for interventionalists to be aware of such congenital hypoplastic rudimentary coronary arteries, as attempting angioplasty in such vessels can be dangerous.

C3-2016-40: Current Trends In Bifurcation Lesions

Manish Patwardhan, Aman Gupta, Ramesh Daggubati

East Carolina University, Vidant Medical Center, Greenville, North Carolina

BACKGROUND: Bifurcation coronaries form up to 15%-20% of percutaneous coronary interventions.¹ Provisional side-branch stenting is the recommended approach for small side branches with mild to moderate focal disease. Elective side-branch stenting may be undertaken when the risk of side-branch occlusion is high.² However, there are limited data about the current trends of periprocedural pharmacology and device use. We present a retrospective review of a single-center bifurcation registry.

METHODS: We retrospectively reviewed charts and angiograms with bifurcation lesions at our institution from July 2014 to December 2014. Bifurcation lesions were classified using the Medina classification. True bifurcation lesions were identified as (1,0,1), (1,1,1), and (0,1,1) lesions. Demographics, vascular risk factors, prior cardiac interventions, and treatment were collected.

RESULTS: A total of 100 bifurcation lesions were identified. Of these, 45 were true bifurcation lesions, and were predominantly arising from the left anterior descending (LAD) artery. Antiplatelet use was comparably distributed between clopidogrel and newer P2Y12 inhibitors. Unfractionated heparin and bivalirudin formed the cornerstone for anticoagulation. Everolimus-eluting stent was used in the majority of cases. Glycoprotein IIb/IIIa inhibitor use was uncommon. All but 3 bifurcation lesions were treated using the provisional side-branch stenting approach. Crush technique was used in cases with elective double stenting.

DISCUSSION: While one size does not fit all, we found provisional side-branch stenting to be the favored strategy. Newer P2Y12 inhibitors were used liberally. Intravascular imaging was used only in selected cases. Bifurcation registries in “real-world” settings could be used in a prospective manner to monitor the current trends, follow outcomes, and identify areas for improvement.

LIMITATIONS: Retrospective, single-center study, and lack of long-term longitudinal data are some of the limitations.

References

1.    Tsuchida K, Colombo A, Lefevre T, et al. The clinical outcome of percutaneous treatment of bifurcation lesions in multivessel coronary artery disease with the sirolimus-eluting stent: insights from the Arterial Revascularization Therapies Study part II (ARTS II). Eur Heart J. 2007;28:433–442.

2.    Levine GN, Bates ER, Blankenship JC, et al. 2011 ACC/AHA/SCAI guideline for percutaneous coronary intervention. Circulation. 2011;124:e574-e651.

C3-2016-41: Drug-Eluting Stents Appear Superior to Bare-Metal Stents for Vein Graft PCI in a 

Propensity-Matched Cohort

K. Safwan, O. Guttmann, D.A. Jones, S. Gallagher, K.S. Rathod, S. Hamshere, E. Smith, A. Jain, A. Mathur, A. Wragg, 

C. Knight, R. Weerackody

BACKGROUND: Research trials have shown improved short-term outcome with drug-eluting stents (DES) over bare-metal stents (BMS) in saphenous vein graft (SVG) percutaneous coronary intervention (PCI), primarily by reducing target-vessel revascularization (TVR) for in-stent restenosis. We compared the outcomes in patients undergoing SVG stent implantation treated with DES or BMS. In exploratory analyses, we investigated the influence of stent generation and diameter.

METHODS: Data were obtained from a prospective database of 657 patients who underwent PCI for SVG lesions between 2003 and 2011. A total of 344 patients had PCI with BMS and 313 with DES. Propensity scores were developed based on 15 observed baseline covariates in a logistic regression model with stent type as the dependent variable. The nearest-neighbor-matching algorithm with Greedy 5-1 Digit Matching was used to produce two patient cohorts of 313 patients each. We assessed major adverse cardiac event (MACE) rate out to a median of 3.3 years (interquartile range, 2.1-4.1 years). MACE was defined as all-cause mortality, myocardial infarction (MI), TVR, and stroke.

RESULTS: There was a significant difference in MACE between the two groups in favor of DES (17.9% DES group vs 31.2% BMS group; P=.0017) over the 5-year follow-up. However, for stent diameters over 4 mm, no difference in MACE rate was seen (Figure 1A).  MACE was driven by in-stent restenosis in both groups and the difference between groups was due to increased TVR in the BMS group. There was no difference in death, MI, or stroke between the stent types. 

Adjusted Cox analysis confirmed a decreased risk of MACE (in stents with diameter less than 4 mm) for DES compared with BMS of 0.75 (95% confidence interval, 0.52-0.94) with no difference in the hazard of all-cause mortality (hazard ratio, 1.08; 95% confidence interval, 0.77-1.68) (Figure 1B).

CONCLUSION: In our cohort of patients who had PCI for treatment of SVG disease, the use of DES resulted in lower MACE rate compared to BMS over a 5-year follow-up; however, no difference in MACE rates was seen for stent diameters over 4 mm.

C3-2016-42: Assessment of Aortic Intervention Related Thrombocytopenia: Systematic Review and 

Meta-Analyses 

Marwah Zahaf, Thelma Dangana, Yousef Bader, Sanjib Basu, Sefer Gezer, Igor Palacios

INTRODUCTION: Thrombocytopenia has been reported after aortic interventions, including transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) for patients with aortic valve disease, especially after Freedom Solo (FS) valves (SAVR-FS). However, the degree of postoperative thrombocytopenia needs to be systematically quantified.

METHODOLOGY: Data source. PubMed, Cochrane library, and references of selected articles. Study eligibility criteria and participants. Comparative clinical studies with pre- and post-platelet count in patients undergoing aortic intervention. Studies were published before May 2015 in English and involved only adults. The lowest reported postoperative platelet count (PoOPC) was chosen. Assessment of endpoints. Thrombocytopenia (x10³ mL) was defined as mild 150-101 x10³, moderate 100-50 x10³, severe <50 x10³ post TAVR, SAVR, SAVR-FS, SAVR non-FS, and overall aortic interventions. The cut-off preoperative platelet count (PrOPC) and PoOPC mean difference (MD) was not significant <50, mild 50-100, moderate 101-149, severe >150; percentage reduction from baseline was mild <33%, moderate 33%-66%, severe >66%; correlation was none <25, mild 25-49, moderate 50-75, and strong >75. Statistical analyses. Random effect model of the continuous variables was used to estimate the study endpoints. Heterogeneity and publication bias were done.

RESULTS: A total 2710 subjects from 16 studies were quantitatively assessed. Thrombocytopenia was mild post SAVR non-FS, and moderate after other all aortic interventions. Post SAVR-FS, the correlation between PrOPC and PoOPC was strongest (r=0.85%), and both MD and percent reduction were severe (157.5 ± 12.9; 69%). Overall, there was significant heterogeneity and publication bias.

CONCLUSION: Aortic intervention resulted in a moderate drop in platelet count especially post SAVR-FS, and to estimate its severity, we recommend using the mean difference and percent reduction beside the absolute PoOPC value. 

DISCLOSURE: The study has no funding or conflict of interest to disclose. Special thanks to John Somberg, program director of master of science in clinical research, Graduate College, Rush University, Chicago, Illinois, USA.

C3-2016-43: Meta-Analyses for Redo Post Failed MitraClip Therapy: A Repeat MitraClip Versus Mitral Valve Surgery 

Marwah Zahaf, Najah Aldreak, Naveed Mallick, Igor Palacios

BACKGROUND AND OBJECTIVES: The trend for mitral valve intervention (MVI) after failed percutaneous MitraClip (MC) therapy for patients with moderate to severe mitral valve regurgitation is currently unknown, yet depends on surgical risk assessment. We sought to determine the rate of  repeat MC versus mitral valve surgery (MVS) after failed MC, and post-MC overall mortality rate due to any cause.

METHODOLOGY: Data source. PubMed, EMBASE, Cochrane library, and references of selected articles. Study eligibility. Clinical studies concerning MVI post failed MC were assessed quantitatively and included in meta analyses. Those were in English and involved only humans, and were published before May 2016. Statistical analyses. Random effect model to summarize independent event rates used to assess the study endpoints. In case of zero event, a correction of 0.5 was added. Heterogeneity (I² and Q) was assessed.

RESULTS: A total of 1499 patients belonging to 6 multinational multicenter studies were included. The majority were elderly females having functional mitral valve regurgitation. The rate of repeat MVI post failed MC was low, and both MC and MVS were equivalently chosen with no significant heterogeneity (MC: ER=2.1% [P<.001]; MVS: ER=2.4% [P<.001]). Post-MC overall mortality rate due to any cause was ER=8.6%; P<.001. 

CONCLUSION: MC was a safe and effective method to treat high-risk patients with limited therapeutic options. The risk of repeat MVI is proven negligible, with repeat MC being a viable option. 

DISCLOSURE: Special thanks to Ted E. Feldman and Anitha Gadam. All authors have approved the final draft and they have no conflicts of interest. 

C3-2016-44: Comparative Assessment of IV Acetaminophen and Moderate Sedation for Pain Relief During Invasive Cardiac Procedures 

Zainab Alam, BS¹, Diana Lacy, RN¹, Tina Terry, RN¹, Atif Mohammad, MD^1,2, Erum Whyne, MS¹, Subhash Banerjee, MD^1,2

¹Veteran Affairs North Texas Health Care System and ²University of Texas Southwestern Medical Center, Dallas, Texas

BACKGROUND: Current consensus allows pain medications to be administered at the discretion of operators during cardiac catheterization, which can lead to delayed ambulation and discharge times. This study evaluates effects of intravenous (IV) acetaminophen during catheterization in place of standard moderate sedation.

METHODS: Retrospective data analysis of 120 patients between October, 2014-September, 2015 was conducted from the VA North Texas Cardiac Catheterization database. Patients were matched in a 1:1 ratio for treatment with IV acetaminophen (Tylenol arm) vs moderate sedation (control arm). Perception of pain was recorded using Visual Analogue Scale (VAS). Continuous variables were expressed as means ± standard deviations or percentages. Univariate analysis was performed using an independent two-sample t-test and the Wilcoxon-Rank sum test. Multiple logistic regressions using ANOVA analyzed confounding factors.

RESULTS: There was no significant difference in demographic and cardiac risk factors between the two study arms. Likewise, there were no significant differences in procedural characteristics like number of vessels treated, stents, and previous history of PCI. However, mean pain score was significantly lower in the Tylenol arm compared with control (52.3 vs 68.6; P<.05), indicating better pain control with IV acetaminophen. Multivariate analysis indicated that use of IV acetaminophen and presence of diabetes mellitus were independent predictors of lower pain perception. Patients in the treated arm (P=.02) and with diabetes had reduced pain perception (P=.05). 

CONCLUSION: Perception of pain during cardiac catheterization is reduced using IV acetaminophen compared with moderate sedation medications. 

C3-2016-45: Carotid Intervention in a Symptomatic Patient at High Risk for Both Surgery and Stent Placement 

Denise Auberson, MD, Daniel McCormick, DO, Sheldon Goldberg, MD

Pennsylvania Hospital of the University of Pennsylvania Health System, Philadelphia, Pennsylvania

INTRODUCTION: Carotid artery stenting (CAS) is a preferred revascularization method for patients with symptomatic severe (>70%) carotid stenosis and high-risk features for surgery.¹ We present the case of a patient with both high surgical and stenting risk factors who underwent successful carotid stenting.

CASE PRESENTATION: A 74-year-old male is referred for evaluation of increasing falls, intermittent visual disturbances, and increasing somnolence. His medical history is significant for deafness, left partial pneumonectomy, peripheral vascular disease and two cerebellar infarcts with residual left spastic hemiplegia.

Carotid ultrasound revealed complete right common carotid occlusion and severe left internal carotid stenosis (70%-99%). Left proximal carotid velocities were 615/276 cm/s and LICA/LCCA ratio was 9.32. Cardiac pharmacological nuclear stress test showed normal perfusion and left ventricular ejection fraction of 58%. 

A diagnostic carotid angiogram revealed a type II aortic arch and a total occlusion at the ostium the right common carotid (Figure 1). There was complete occlusion at the ostium of the left external carotid artery and a severe 90% calcified proximal left internal carotid artery stenosis (Figure 2, left). There was collateralization of the right anterior and middle cerebral arteries by crossover from the left-sided circulation via the polygon of Willis (Figure 2, right).

With the presence of contralateral carotid artery disease, the patient was deemed to be a high surgical risk and CAS was performed. The right femoral artery was accessed and a 5 Fr angled glide catheter was advanced to the left common carotid artery. A 7 Fr sheath was inserted and a 7.2 mm distal filter was placed. The lesion was predilated with a 4.00 x 30 mm balloon at 10 atm, followed by deployment of a 9-7 x 40 mm closed-cell self-expanding nitinol stent. Postdilation was performed with a 5.00 x 20 mm balloon at 15 atm, with marked improvement of the residual waist. The procedure achieved 30% residual stenosis (Figure 3, left) and significant improvement of flow to both hemispheres was noted (Figure 3, right).  

The patient’s somnolence significantly improved after the procedure. The carotid ultrasound performed 3 weeks later showed left proximal carotid artery of velocities of 160/69 cm/sec, LICA/LCCA ratio of 1.80.

DISCUSSION: The SAPPHIRE trial proposed a number of risk factors for CEA.^2,3 Our patient had severe bilateral disease, a known surgical risk factor, as well as complete occlusion of the contralateral artery (CCO). Patients with CCO may have a higher risk of perioperative stroke and death.^4-6 CAS offers a less invasive therapeutic option to patients with high surgical risk factors, including contralateral carotid occlusion.^2,6 Our patient was deemed at high risk for carotid stenting, with an estimated CAS periprocedural risk of 6%-10% (risk factors: age, history of stroke and TIA, type II aortic arch, lesion length).^7-9 Risk prediction scores based on patient co-morbidities and anatomical and procedural factors may help providers in their decision process.^7,10,11 There are currently insufficient data to determine the best approach for symptomatic patients with both high surgical and stenting risk. Nonetheless, clinical judgment and operator experience remain essential in deciding on the optimal revascularization strategy.  

References

1.    Brott TG, Halperin JL, Abbara S, et al. 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease. A report of the American College of Cardiology Foundation/American Heart Association Task Force. J Am Coll Cardiol. 2011;57:e16-e94. 

2.     Gurm HS, Yadav JS, Fayad P, et al. Long-term results of carotid stenting versus endarterectomy in high-risk patients. N Engl J Med. 2008;358:1572-1579. 

3.     Mozes G, Sullivan TM, Torres-Russotto DR, et al. Carotid endarterectomy in sapphire-eligible high-risk patients: implications for selecting patients for carotid angioplasty and stenting. J Vasc Surg. 2004;39:958-965. 

4.     Antoniou GA, Kuhan G, Sfyroeras GS, et al. Contralateral occlusion of the internal carotid artery increases the risk of patients undergoing carotid endarterectomy. J Vasc Surg. 2013;57:1134-1145. 

5.     Faggioli G, Pini R, Mauro R, et al. Contralateral carotid occlusion in endovascular and surgical carotid revascularization: a single centre experience with literature review and meta-analysis. Eur J Vasc Endovasc Surg. 2013;46:10-20. 

6.     Ricotta II JJ, Upchurch GR Jr, Landis GS, et al. The influence of contralateral occlusion on results of carotid interventions from the Society for Vascular Surgery Vascular Registry. J Vasc Surg. 2014;60:958-65.e2. 

7.     Wimmer NJ, Yeh RW, Cutlip DE, Mauri L. Risk prediction for adverse events after carotid artery stenting in higher surgical risk patients. Stroke. 2012;43:3218-3224. Epub 2012 Nov 5.

8.     Ricotta JJ, AbuRahma A, Ascher E, et al. Updated Society for Vascular Surgery guidelines for management of extracranial carotid disease. J Vasc Surg. 2011;54:e1-e31. 

9.     White CJ. Carotid artery stenting. J Am Coll Cardiol. 2014;64:722-731. 

10.     Macdonald S, Lee R, Williams R, Stansby G, Panel  on behalf of the DCSC. Towards safer carotid artery stenting: a scoring system for anatomic suitability. Stroke. 2009;40:1698-1703. 

11.     Setacci C, Chisci E, Setacci F, et al. Siena carotid artery stenting score: a risk modelling study for individual patients. Stroke. 2010;41:1259-1265.

C3-2016-46: Recurrent Subclavian Artery In-stent Restenosis Presenting With Acute Coronary Syndrome 

Successfully Treated With Balloon-Expandable Covered Stent

O.A. Ayah, S.Y. Naqvi, Z. Mahmoud, T. Saha, B. Bravette, D.J. McCormick, S. Goldberg

INTRODUCTION: Subclavian artery stenosis can be associated with arm claudication, vertebral basilar insufficiency, and myocardial ischemia if a prior LIMA was used and lower-extremity claudication if a prior axillo-femoral bypass was used.¹History. A 75-year-old woman presented with non-ST elevation myocardial infarction (NSTEMI). Her past medical history was significant for the following: hypertension, hyperlipidemia, congestive heart failure. Nineteen years prior to presentation, she underwent coronary artery bypass graft (CABG) surgery with a LIMA to the left anterior descending (LAD) artery, and saphenous vein grafts (SVG) to the left circumflex (LCX) and right coronary artery (RCA). Five years prior, she developed angina and had placement of a bare-metal stent in the left subclavian artery due to subclavian artery stenosis. Seventeen months prior, a right axillo-femoral bypass was performed due to severe bilateral iliac artery stenosis. Ten months prior, she developed exertional angina and subsequent angiography revealed severe in-stent restenosis with a 30 mm Hg gradient across the subclavian stenosis, with a patent LIMA to the LAD as the only remaining vessel, with chronic total occlusions of the SVGs to the RCA and LCX. The patient underwent placement of another bare-metal stent in the proximal L subclavian artery with resolution of her symptoms.

CASE PRESENTATION: She again presented with recurrent severe myocardial ischemia with troponin elevation and severe repolarization abnormalities on electrocardiogram. Her physical exam was significant for a barely palpable left radial artery pulse and a bounding right radial pulse. She was started on a heparin drip for NSTEMI and underwent angiography.

PROCEDURE: A 7 Fr sheath was inserted via the left brachial artery. Angiography showed severe in-stent stenosis in the left subclavian artery with a 50 mm pressure gradient (Figure A). A 7 x 22 mm balloon-expandable covered stent was inserted and expanded at 17 atm. This led to a marked reduction in stenosis severity and pull-back showed 0 mm Hg pressure gradient with excellent antegrade flow in the LIMA and left vertebral artery (Figure B). 

CLINICAL FOLLOW-UP: Placement of the covered stent led to complete resolution of anginal symptoms at 23 months follow-up. On physical exam, she was once again found to have equal blood pressures in both arms, the most recent being 140/70 mm Hg. 

CONCLUSION: Differences in blood pressures between both arms, absent or significantly diminished pulses in one arm compared to the other or the presence of a bruit should raise concern for subclavian artery stenosis.¹ Coronary-subclavian steal syndrome should be considered in the differential diagnosis for patients who present with anginal symptoms in whom coronary artery bypass graft surgery was performed using the internal mammary artery as a conduit. Covered stents can be used to seal degenerated vein grafts, cover arterial perforations including coronary and extra cranial perforation, aneurysms or fistulas.² This case demonstrates the utility of a covered balloon-expandable stent for the treatment of incessant in-stent restenosis of the subclavian artery with resultant sustained relief of severe myocardial ischemia. 

References

1.    Ochoa VM, Yeghiazarians Y. Subclavian artery stenosis: a review for the vascular practitioner. Vasc Med. 2011;16:29-34. Epub 2010 Nov 15. 

2.    Jamshidi P, Mahmoody K, Erne P. Covered stents: a review. Int J Cardiol. 2008;130:310-318. Epub 2008 Jul 30.

C3-2016-47: No Coil or Plug, No Foam or Clot, Then How Should I Clog: A Technique of Taking Down a Native Vessel When Conventional Therapy is Unavailable 

Isheeka Edwards, MD, Ahmed Seliem, MD, Nishant Sethi, MD, Yassir Nawaz, MD, Marc Cohen, MD, FACC

Division of Cardiology, Newark Beth Israel Medical Center, Newark, New Jersey

INTRODUCTION: We describe a patient in which a rare vascular complication during cardiac catheterization from radial approach occurred.

PATIENT PRESENTATION: A 70-year-old man with a past medical history of dyslipidemia, Tetralogy of Fallot repaired in the 1960s, coronary artery disease s/p prior 4-vessel CABG in the 1980s, ischemic cardiomyopathy managed with cardiac transplant in 2008 and known non-obstructive cardiac allograft vasculopathy presented with history of exertional shortness of breath worsened over the 3 days prior to presentation. Evaluation with echocardiogram, chest radiography, and laboratory studies were unremarkable.

PROCEDURAL DETAILS: Heart failure attending performed diagnostic coronary angiogram via right femoral artery, which demonstrated 80% proximal LAD lesion at junction of the first septal branch. 

Intervention was planned for the following day. Right radial artery was accessed and a 6 Fr sheath was placed. Heparin 3000 IU was given. XB 4.0 guiding catheter was advanced over guidewire toward the aortic arch. When resistance was met, angiography was obtained which demonstrated perforation of the right internal mammary artery (RIMA). 

An immediate CT surgery consult was called and the decision was made to attempt percutaneous closure considering his 4 prior thoracic surgeries with likely extensive adhesions.

Ten mg intraarterial protamine was given. A 4.0 x 25 mm compliant balloon was used to obstruct RIMA flow for 30 minutes. GraftMaster Abbott 4.0 x 16 mm and 3.5 x 16 mm stents were deployed at nominal pressure over the origin of extravasation and then postdilated with a non-compliant balloon. Angiograms taken via over-the-wire balloon demonstrated resolution of RIMA extravasation and suggested thrombosis of the vessel.

Review of previous computed tomography chest demonstrated occlusion of the right subclavian artery consistent with previous Blalock-Taussig shunt palliative surgery not previously documented in medical record.  Patient had successful LAD intervention performed at a later date.

FINDINGS: Intraarterial protamine with deployment of covered stents and distal balloon inflation can be useful as a bail-out technique to manage perforation of native vessels when conventional therapy is unavailable. 

C3-2016-48: Dual vs Triple Antiplatelet Therapy in Patients With Acute Coronary Syndromes Undergoing Coronary Artery Stenting 

Hitesh Gurjar, Yash Paul Sharma, Shiv Bagga, Jasmina Ahluwalia, Ramalingam Vadivelu 

BACKGROUND: Triple-antiplatelet therapy (TAT) has been found to be superior to dual-antiplatelet therapy (DAT) in patients with acute coronary syndromes (ACS) undergoing percutaneous coronary intervention (PCI) with drug-eluting stents (DES). The objective of the study was to see the effect of adding cilostazol to aspirin and clopidogrel on platelet function in patients with ACS undergoing PCI.

METHODS: A prospective, double-blinded, randomized study was conducted in ACS patients undergoing PCI with DES and control population without any coronary artery disease (CAD). ACS patients were randomized into DAT group (DAT, aspirin + clopidogrel) and TAT group (TAT, aspirin + clopidogrel + cilostazol). Patients in the TAT group were given loading doses of 200 mg of cilostazol periprocedurally (within 6 to 12 hours prior to the procedure to 1 to 2 hours post procedure) followed by 100 mg/day for at least 6 months. Patients were evaluated at baseline, at 7 days, and at 6-month intervals for clinical outcomes. ADP, collagen, and epinephrine-induced platelet aggregation was measured at baseline and at 7-day intervals.

RESULTS: There were no significant differences in the baseline characteristics in both groups. Comparison between DAT and TAT groups showed significantly greater inhibition of ADP-induced platelet aggregation in the TAT group at 7- day interval (19.05 ± 14.06%  vs 36.20 ± 25.0%; P=.02) and trend toward greater platelet inhibition at baseline between the two groups (19.2 ± 27.32% vs 33.0 ± 22.01%;  P=.077), respectively. The TAT group had fewer patients who had hyporesponsiveness to antiplatelet therapy (defined as inhibition of less than 50% of ADP, collagen, or epinephrine-induced platelet aggregation). The study was underpowered for assessing major adverse cardiovascular event outcomes.

CONCLUSIONS: Cilostazol is a significant add-on therapy to standard DAT with aspirin and high maintenance dose clopidogrel. Its loading dose of 200 mg, followed by 100 mg BD provides greater inhibition of ADP-induced platelet aggregation without increase in bleeding complications or tolerance issues.

C3-2016-49: An Unusual Case of Chest Pain: Early Post-Infarction Pericarditis Mimicking Acute Coronary Syndrome 

Hisham Hakeem, MD¹, Lokesh Dayal MD¹, Dennis Katechis DO, FACC, FASE²

¹Department of Internal Medicine, Englewood Hospital and Medical Center, New Jersey

²Department of Internal Medicine, Division of Cardiology, Englewood Hospital and Medical Center, New Jersey 

INTRODUCTION: Pericarditis is the most common cause of chest pain after acute myocardial infarction (AMI). The incidence of early post-infarction pericarditis has decreased due to early reperfusion strategies. There is a need to differentiate myopericarditis from early post-infarction pericarditis.

CASE DISCUSSION: An 83-year-old male presents to the ER with substernal-epigastric discomfort of 4 days duration. His medical history comprised hypertension, hyperlipidemia, and localized bladder cancer. The pain was initially described as a pressure-like sensation and 9 out of 10 in severity with no radiation. It occurred at rest and would spontaneously resolve. Two days later, the pain became “less severe,” radiated to the left shoulder, worsened on taking a deep breath, and was relieved when bending forward. His cardiovascular risk factors included an active 70 pack-year smoking history, remote carotid endarterectomy, and early coronary artery disease in his brother. 

His Initial electrocardiogram revealed normal sinus rhythm with 1 mm concave ST-segment elevation in the inferior leads and V2 to V4 with PR segment elevation in lead aVR. Initial Troponin I was 16.1 with CK-MB was 6.9. Myopericarditis was a possibility, but evolving myocardial ischemia with post-infarction pericarditis had to be ruled out. An urgent echocardiogram revealed an ejection fraction of 55%-60% with inferolateral hypokinesia without pericardial effusion. Patient was diagnosed as having an NSTEMI with a TIMI score of 4 and managed medically. Overnight, the patient developed new-onset atrial fibrillation with rapid ventricular response. Ten hours after presentation, the electrocardiogram revealed convex 1-2 mm ST-segment elevation in inferior leads, V6, and I with ST-segment flattening in lead aVL. The patient underwent emergent cardiac catheterization which uncovered a right dominant circulation with complete occlusion of the distal left circumflex artery. The vessel was successfully dilated with restoration of TIMI 2 flow and was not stented due to its small size. The patient had complete resolution of chest pain post procedure.

CONCLUSIONS: Pericarditis is multifactorial in nature, with 80%-90% of cases deemed idiopathic. Differentiating the various entities is essential as non-steroidal anti-inflammatory drugs and glucocorticoids used in pericarditis is potentially harmful in post-infarction pericarditis.

Our patient presented with pericarditis-like chest pain, greatly elevated cardiac troponins, leukocytosis, and an elevated C reactive protein. The electrocardiogram was atypical for pericarditis with localized ST and PR-segment changes suggestive of concurrent myocardial involvement. We postulate the patient had an acute coronary syndrome at the onset of chest pain and subsequently developed early post-infarction pericarditis as indicated by change in character of chest pain. This explains the disparity between the persistently elevated troponins and negative CK-MB, which had returned to baseline. A recent study showed that ST-segment depression of at least 0.25 mm in lead aVL to be 100% sensitive and specific for inferior STEMI compared with pericarditis. Our patient’s electrocardiogram was consistent with this study with left circumflex artery as the culprit lesion.

One must maintain a high index of suspicion for acute coronary syndromes in pericarditis like chest pain. Important clues like character of chest pain, risk factors for CAD, localized convex ST-segment elevations and reciprocal ST-segment changes may warrant repeat electrocardiograms, serial cardiac biomarkers, and in some cases activation of the cardiac catheterization laboratory to rule out underlying myocardial infarction.

C3-2016-50: Holosystolic Murmur from VSD Posing Challenges During Primary PCI 

Swarnalatha Kanneganti, MD; Samuel Roberto, MD; George Broderick, MD

BACKGROUND: New murmurs, preexisting valvular regurgitations or intracardiac shunts pose challenges to interventionists in the setting of acute myocardial infarction (MI).

CASE REPORT: A 55-year-old Caucasian man with history of hypertension and no previous heart problems, presented with chest pain. Physical Exam revealed 3/6 intensity holosystolic murmur at the left sternal border. 12-lead electrocardiogram showed acute ST-segment elevations in leads II, III, and aVF. Serum troponin was elevated at 3.41.

Emergent cardiac catheterization revealed 100% proximal occlusion of right coronary artery which was successfully opened by PCI and drug-eluting stent placement. While attempting to do the left ventriculogram, the pigtail catheter appeared to extend beyond the left ventricular contour transiently and then flipped back into normal position in the left ventricle. During left ventriculogram in the right anterior oblique view, the contrast was seen outside the left ventricular contour in the inferior aspect, filling the enlarged right ventricle (Figure 1). No mitral regurgitation was noted. It was realized that the pigtail catheter actually entered the right ventricle through a possible ventricular septal defect (VSD) transiently and then flipped back into the left ventricle before. This raised concerns of possible perforation or VSD.

Emergent bedside echocardiogram showed a large membranous VSD (Figure 2) with bidirectional shunt. Initially there was a thought whether it could be congenital VSD due to its location in membranous septum rather than in muscular portion where infarction-related VSDs are common. But it is not congenital, as this large defect usually causes symptoms and manifests in childhood itself. Also, it was very unlikely due to procedure as the ventriculogram was performed easily without any resistance or difficulty with the catheter. Subsequently, the patient developed hemoptysis, cardiogenic shock, and biventricular failure. Right heart catheterization revealed significant left-to-right shunting at the ventricular level with Qp/Qs of 2.17. Subsequently, he was transferred to a tertiary-care center for VSD repair.

DISCUSSION: Acute rupture of the interventricular septum is a life-threatening complication that occurs in 0.5%-1% of patients with acute MI.^1,2 Age, female gender, hypertension, development of cardiogenic shock, right ventricular dysfunction, and inferior wall location of infarction are risk factors associated with interventricular septal rupture.^3,4 Prompt recognition and hemodynamic stabilization followed by surgical repair are recommended.

CONCLUSIONS: Certain complications of acute MI like VSD need to be distinguished from preexisting cardiac conditions and procedure-related complications. This case underscores the importance of their prompt recognition and management.

References

1.    Koh AS, Loh YJ, Lim YP, Le Tan J. Ventricular septal rupture following acute myocardial infarction. Acta Cardiol. 2011;66:225-230.

2.    Moreyra AE, Huang MS, Wilson AC, Deng Y, Cosgrove NM, Kostis JB. Trends in incidence and mortality rates of ventricular septal rupture during acute myocardial infarction. Am J Cardiol. 2010;106:1095-1100.

3.    Serpytis P, Karvelyte N, Serpytis R, et al. Post-infarction ventricular septal defect: risk factors and early outcomes. Hellenic J Cardiol. 2015;56:66-71.

4.    Vargas-Barron J, Molina-Carrion M, Romero-Cardenas A, et al. Risk factors, echocardiographic patterns, and outcomes in patients with acute ventricular septal rupture during myocardial infarction. Am J Cardiol. 2005;95:1153-1158.

C3-2016-51: Paradoxical Embolism: an Important Cause of Acute Limb Ischemia 

Swarnalatha Kanneganti, MD, Gary Fishbein, MD 

INTRODUCTION: Paradoxical embolism of deep venous thrombosis through a right-to-left shunt is a rare but possible cause of acute limb ischemia.¹ Presence of atrial septal aneurysm and patent foramen ovale greatly enhance this risk.

CASE REPORT: An 83-year-old African-American woman presented with sudden onset of left leg pain with paresthesia and weakness leading to fall. Physical exam revealed tachycardia, hypoxemia with saturation of 80%, cold, pulseless, and paretic left leg. Emergent arterial Doppler revealed an embolic occlusion of left leg. Echocardiogram showed acute right ventricular strain concerning for pulmonary embolism. Computed tomographic angiogram of chest and aortogram confirmed acute bilateral pulmonary embolism (Figure 1) and embolic occlusion of left common femoral artery (Figure 2). Patient was treated with systemic thrombolysis with rapid clinical improvement and a subsequent peripheral arteriogram showed residual partial occlusive thrombus in her left profunda femoris artery, distal popliteal artery, and tibioperoneal trunk. She was treated with intraarterial thrombolysis. A repeat angiography the next day demonstrated complete resolution of the residual thrombus. An echocardiogram with agitated saline contrast confirmed an interatrial shunt. An IVC filter was placed and she was discharged on systemic anticoagulation.

DISCUSSION: Patients with acute ischemic stroke or a peripheral thromboembolic occlusion should be evaluated for embolic sources. In the absence of common causes of embolic events, the possibility of paradoxical embolism from occult venous thrombosis and a right-left-shunt should be considered (Figure 3).² These patients should have transesophageal echocardiogram, which has higher sensitivity than transthoracic echocardiogram. This patient presented with bilateral submassive pulmonary embolism, prompting the possibility of paradoxical embolism. Many a times, clinical signs of DVT can be masked by more prominent features of acute arterial ischemia, making the clinician miss the paradoxical embolism as a diagnostic consideration.

CONCLUSION: Paradoxical embolism should be considered with high index of suspicion in patients with pulmonary embolism and acute limb ischemia or other systemic embolization, especially in the absence of obvious embolic source. Early diagnosis and treatment makes remarkable impact on clinical outcome.

References

1.    Chaikof EL, Campbell BE, Smith RB 3rd. Paradoxical embolism and acute arterial occlusion: rare or unexpected? J Vasc Surg. 1994;20:377-384.

2.    Mas JL. Diagnosis and management of paradoxical embolism and patent foramen ovale. Curr Opin Cardiol. 1996;11:519-524.

C3-2016-52: Safety and Feasibility of Rotational Atherectomy in Elderly Patients with Calcific Left Main Coronary Artery (LMCA) Disease undergoing PCI: A Retrospective Observational Analysis 

Falak Shah, Amani Erra, Mahmoud Khreis, Mohamad Hani Lababidi, Amir Darki, Bruce E. Lewis, Ferdinand Leya, 

John J. Lopez, Lowell H. Steen

Loyola University Medical Center, Presence Saint Joseph Hospital 

BACKGROUND: Severe left main coronary artery (LMCA) stenosis represents a high-risk subset of patients. Surgical revascularization is typically considered the preferred management for LMCA disease; but, when the patient is unsuitable for surgery, the interventional cardiologist faces a complex percutaneous coronary intervention (PCI). Complex, calcific LMCA disease can be technically challenging to treat with increased risks and may require the use of rotational atherectomy (RA) to allow stent implantation. The research on using RA in such patients is limited.

METHODS: Patients with calcific coronary artery disease (CAD) who underwent PCI with RA between February 2010 and May 2015 at Loyola University Medical Center were reviewed. Among these patients, only those who underwent PCI of the LMCA with RA were included. A retrospective analysis was conducted. Demographics, procedure parameters, and complications were analyzed.

RESULTS: A total of 108 patients (26% female, mean age, 71.3 years) were studied. The mean ejection fraction was 49%. All procedures were performed transfemorally, and scheduled electively, except for 21 patients (16 of whom had acute coronary syndromes). None of the patients were candidates for surgical revascularization: 20% had no history of coronary artery bypass graft surgery, and the others had at least one left coronary system graft deemed to be significantly diseased. Burr sizes ranged from 1.25 to 2.15 mm, with a mean of 1.86 mm, and a mean of 1.80 different burrs were used. In each case, RA was performed on a mean of 2.30 different arteries. A drug-eluting stent was placed in the LMCA in 87% of the patients. Average length of hospital stay for the elective cases was 1.1 days. Mean contrast volume used was 222 mL with a mean fluoroscopy time of 30.7 minutes. None of the elective patients required a blood product transfusion. Procedural complications were rare: 1 patient had a small perforation of the ramus intermedius artery that was successfully treated with balloon tamponade; 1 patient required a permanent pacemaker and 5 patients suffered from a small groin hematoma.

CONCLUSIONS: RA is a safe and feasible technique for treating calcific left main coronary artery disease in elderly patients. Procedural complications are rare, with a postprocedure hospital stay of approximately 1 day for elective procedures. Additional study of PCI in calcific left main CAD with or without RA, along with major adverse cardiovascular events and mortality, is warranted.

C3-2016-53: Rare Etiology of Ischemic Heart Disease in a Young Adult 

Guruprasad Sharma, Ravindranath Reddy, Deepesh Venkatraman, Umesh Nareppa, Bhaskar Venkatakrishnaiah, 

Maruthi Haranal, Shivaprakash Shivanna, Srinivas Hittalmani

Department of Cardiology & Cardiovascularthoracic Surgery, BGS Global Hospital, Bengaluru, Karnataka, India 

BACKGROUND: Ischemic heart disease is being diagnosed in young adults more often these days. It is usually due to coronary atherothrombotic and atherosclerotic disease in people with any of the conventional risk factors. Congenital coronary anomalies are quite a rare cause. We would like to report one such rare anomaly in a young adult male.

CASE PROFILE: A 34-year-old male presented with atypical chest pain of 2 years duration that was crescendo in intensity from 2 months prior to consultation. He had no coronary risk factors except for a strong  family history of coronary artery disease, with his mother undergoing coronary artery bypass graft surgery at the age of 55 years. His clinical examination was unremarkable. Electrocardiogram showed sinus rhythm with left-axis deviation, poor ‘R’ wave progression in precordial leads, and T-wave inversion in I, aVL. TMT was negative for inducible ischemia at 10 mets. Two-dimensional echo revealed akinetic and thinned out anterolateral segments of left ventricle with ejection fraction of 40% and ectatic right coronary artery. Conventional coronary angiography done through right radial artery using 5 Fr Tig catheter showed ectatic right coronary artery arising from right coronary cusp and filling the left coronary artery through collaterals. This was confirmed on computed tomography coronary angiography which revealed the left coronary artery arising from the posterolateral aspect of main pulmonary artery. Cardiac MRI demonstrated subendocardial delayed gadolinium enhancement caused by subendocardial infarction resulting from chronic subendocardial ischemia.

DIAGNOSIS AND TREATMENT: Based on the above investigation modalities, a diagnosis of anomalous origin of left coronary artery from pulmonary artery (ALCAPA) was made. Also, the patient had mild left ventricular systolic dysfunction, mild left ventricular anterolateral wall scarring with areas of viable myocardium, and mild mitral regurgitation. Hence, the patient was referred for surgical correction. In view of the technical difficulties in establishing normal anatomical relation of the coronary arteries, the patient underwent closure of the pulmonary opening of left coronary artery with a pericardial patch followed by on-pump bypass grafting of LIMA to LAD and SVG to OM.

DISCUSSION: ALCAPA syndrome, also known as Bland-White-Garland syndrome, is a rare but serious congenital cardiac anomaly that affects 1 of every 300,000 live births and accounts for 0.25%-0.5% of all congenital heart defects with no sex or racial predilection and multifactorial inheritance. Approximately 85% of patients present with clinical symptoms of congestive heart failure (CHF) within the first 1-2 months of life, with mortality rate in the first year of life being 90% secondary to myocardial ischemia or infarction and mitral valve insufficiency leading to CHF. Rarely, ALCAPA syndrome manifests in adults. Adult patients may be asymptomatic, or they may present with mitral insufficiency, ischemic cardiomyopathy, or malignant dysrhythmias, which lead to sudden death. Factors in infants that enable survival to adulthood include abundant interarterial collateral vessels between the RCA and the LCA, RCA dominance, minimal coronary steal from the pulmonary artery, and development of systemic blood supply to the LCA. Direct visualization of the LCA arising from the main pulmonary artery is the diagnostic hallmark of ALCAPA syndrome, which is demonstrated best on computed tomographic angiography and magnetic resonance imaging. The treatment of choice for ALCAPA syndrome is surgical repair. Early diagnosis and prompt surgical intervention lead to excellent results. Postoperative complications necessitate long-term follow-up imaging, with computed tomographic angiography being a valuable tool.