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Journal: Catheterization and cardiovascular interventions : official journal of the Society for Cardiac Angiography & Interventions


Background: The polygon of confluence (POC) represents the zone of confluence of the distal left main (LM), ostial left anterior descending (LAD), and ostial left circumflex (LCX) arteries. Methods: We used intravascular ultrasound (IVUS) to assess the POC pre and post-drug-eluting stent implantation for unprotected distal LM disease. Four segments within 82 LM bifurcation lesions were defined by longitudinal IVUS reconstruction: (1) ostial LAD, (2) POC, and (3) distal LM (DLM)-from LAD-pullback, and (4) ostial LCX from LCX-pullback. Results: Preprocedural minimum lumen area (MLA) and poststenting minimum stent area (MSA) within the LM were mainly located within the POC (51 and 71%). On ROC analysis, a cut-off of the MLA within the POC of 6.1 mm(2) predicted significant LCX carinal stenosis (85% sensitivity, 52% specificity, AUC = 0.7, 95% CI = 0.57-0.78, P < 0.01). Poststenting MSA within the distal LM proximal to the carina (to include DLM and POC) positively correlated with the preprocedural MLA within the POC (r = 0.283, P = 0.02); it was significantly smaller in 48 lesions with a pre-PCI MLA within the POC < 6.1 mm(2) versus 25 lesions with a pre-PCI MLA ≥6.1 mm(2) (7.5 ± 2.1 mm(2) vs. 8.6 ± 2.0 mm(2) , P = 0.04). Independent predictors for poststenting LCX carinal MLA also included preprocedural MLA within the POC (β = 0.240, 95% CI = 0.004-0.353, P = 0.04). Conclusion: The MLA within the POC was a good surrogate reflecting the overall severity of LM bifurcation disease including ostial LCX stenosis pre-PCI and the ability to expand a stent within the distal LM as well as final ostial LCX lumen area post-PCI. © 2011 Wiley Periodicals, Inc.

Concepts: Prediction, Left coronary artery, Blood, Myocardial infarction, Vein, Artery, Intravascular ultrasound, Atherosclerosis



TAPVR associated with HLHS is a rare condition, and from the therapeutical point of view associated with a high Aristotle score and thus increased mortality. We report two newborns with HLHS, one with a supracardiac type of TAPVR and mildly obstructed left vertical vein, and one with a supracardiac type of TAPVR in association with cor triatriatum and serverely obstructed left-sided vertical vein. In both patients, radio frequency perforation from the pulmonary venous confluence to the systemic venous atrium was performed with consecutive gradual balloon dilatation, followed by stent placement in one. Hybrid stage I, and comprehensive stage II were successfully performed thereafter. Currently, both are awaiting their Fontan completion. Transcatheter intracardiac connecting of supracardiac type of TAPVR in newborns with HLHS is feasible and might render these children suitable candidates for further hybrid approach. © 2012 Wiley Periodicals, Inc.

Concepts: Blood, Systemic circulation, Fontan procedure, Lung, Total anomalous pulmonary venous connection, Vein, Cardiovascular system, Heart


Percutaneous implantation of valved stents is now routinely performed to treat pulmonary valve regurgitation and stenosis. In addition, there are isolated reports of implantation of valved stents in the tricuspid position to treat prosthetic tricuspid stenosis or regurgitation when a prosthetic valve ring exists. We present a case in which a patient with combined severe tricuspid valve and pulmonary valve disease was successfully treated with sequential implantation of percutaneous valved stents in a single procedure. The procedure was straightforward, of short duration, and dramatically improved the patient’s functional status. © 2012 Wiley Periodicals, Inc.

Concepts: Tricuspid valve


Objective oTo evaluate whether administration of nitroglycerin through the sheath at the end of a trans-radial procedure might preserve the patency of the radial artery. Background Despite the increasing acceptance of trans-radial approach, radial artery occlusion (RAO) continues to be a vexing problem of trans-radial access and limits utility of the radial artery as an access site in the future. Methods We conducted a multi-center, prospective, randomized, placebo-controlled, operator-blinded trial and enrolled 1706 patients who underwent trans-radial catheterization in three experienced radial centers. Patients were randomized to receive either 500 µg nitroglycerin (n=853) or placebo (n=853), given intra-arterially through the sheath at the end of the radial procedure. The primary outcome was the incidence of RAO as confirmed by absence of antegrade flow at one day after the trans-radial procedure evaluated by duplex ultrasound of the radial artery. Results The use of nitroglycerin, as compared with placebo, reduced the risk of the primary outcome (8.3% vs. 11.7%; odds ratio, 0.62; 95% confidence interval [CI], 0.44 to 0.87; P=0.006). From a multivariable analysis, duration of hemostasis was a predictor of RAO (odds ratio, 3.21; 95% CI, 1.73 to 5.96; P<0.001). There were no significant differences between the groups with respect to the sheath size (P=0.311), number of puncture attempts (P=0.941), duration of hemostasis (P=0.379) and procedural time (P=0.095). Conclusion The administration of nitroglycerin at the end of a trans-radial catheterization, reduced the incidence of RAO, examined one day after the radial procedure by ultrasound. Post procedural/pre-hemostasis pharmacologic regimens may represent a novel target for further investigation to reduce RAO. © 2014 Wiley Periodicals, Inc.

Concepts: Odds, Multivariate statistics, Placebo, Medical ultrasonography, Nitroglycerin, Order theory, Radial artery


Objectives: To evaluate early outcomes of left atrial appendage (LAA) closure via a percutaneous LAA ligation approach with the SentreHeart LARIAT™ snare device. Background: Atrial fibrillation increases the risk of stroke 4-5 fold, which can have devastating outcomes. Exclusion of the LAA is believed to decrease the risk of embolic stroke. Methods: Twenty-seven patients with atrial fibrillation, a high risk of stroke, and contraindication or intolerance for anticoagulation therapy underwent percutaneous ligation of the LAA with the LARIAT device. Initial LAA closure was confirmed with TEE and contrast fluoroscopy. Results: The acute procedural success was 92.6%. One patient sustained a perforation of the LAA and was treated conservatively. The patient underwent LAA closure surgically the next day. In one patient the attempt to advance the LARIAT over the LAA was unsuccessful. Patients were followed for a mean of 4 months. Preserved LAA closure was confirmed with a 45 day follow-up TEE in 22 of 25 patients completing the procedure. Peri-operative complications included three cases of pericarditis and one case of a periprocedural CVA due to thrombus formation on the transseptal sheath. During follow-up, there was one stroke thought to be non-cardioembolic and one pleural effusion. There were no deaths. Conclusions: These results show that percutaneous LAA exclusion can be achieved successfully with an acceptable rate of periprocedural and short-term complications. Further studies and longer follow-up are needed to determine whether LAA exclusion lowers the long-term risk of thromboembolic events in patients with AF and contraindications to anticoagulation. © 2013 Wiley Periodicals, Inc.

Concepts: Pleural effusion, Left atrial appendage occlusion, Patient, Thrombosis, Left atrial appendage, Thrombus, Stroke, Atrial fibrillation


Objective: We compare clinical outcomes among unselected patients undergoing PCI with drug-eluting stents (DES) stratified in categories of treating hospital PCI volume. Background: Previous observational evidence suggests an inverse relation between hospital percutaneous coronary intervention (PCI) volume and patients' outcomes. However, there are no mid-term outcomes data with the use of drug-eluting stents (DES). Methods: We used data from DES.DE (German Drug-Eluting Stent) registry to compare in-hospital and 1-year outcomes among unselected patients. Primary endpoints at one year follow-up were the rate of major adverse cardiac and cerebrovascular events (MACCE) and target vessel revascularization (TVR). Results: Between 2005 and 2006, 2,075 patients were treated in group I hospitals (<1,000 PCIs/year), 1,624 in group II hospitals (1,000-1,500 PCIs/year) and 1,790 in group III hospitals (>1,500 PCIs/year). Compared with group II and group III, group I allocation was associated with higher rates of overall hospital mortality (1.1% versus 0.2% versus 0.2%; p<0.0001) and severe bleeding (1.0% versus 0.4% versus 0.5%; p<0.05); similarly, poorer outcomes with respect to MACCE (7.2% versus 6.5% versus 4.7%; p<0.01), stent thrombosis (5.2% versus 5.0% versus 3.0%; p<0.01) and non-fatal stroke (1.5% versus 0.9% versus 0.7%; p<0.05) were documented in group I. Conversely, TVR rates were highest in group II (10.2% versus 14.2% versus 11.7%; p<0.01); these differences persisted after risk adjustment for heterogeneous baseline characteristics. Conclusions: In the era of modern coronary intervention technological advances such as DES have not offset the inverse relation between procedural volume and both in-hospital and 1-year outcomes after PCI. © 2013 Wiley Periodicals, Inc.

Concepts: Inverse relation, Restenosis, Drug-eluting stent, Hospital, Coronary stent, Stent, Cardiology, Percutaneous coronary intervention


Pseudoaneurysm of the right ventricular outflow tract (RVOT) is a rare complication following surgical repair of congenital heart disease involving a homograft or conduit. Traditionally surgical intervention is indicated due to risk for rupture, thrombosis, compression of adjacent structures and infection. We describe a case of a RVOT pseudoaneurysm in a 5 kg patient that was palliated with interventional catheterization utilizing an Amplatzer Ductal Occluder (ADO) with four years follow-up. Interventional catheterization can successfully manage this complication in small patients for the long term and thus avoids additional surgery and delays conduit replacement. © 2013 Wiley Periodicals, Inc.

Concepts: Vein, Surgery, Left ventricle, Ventricle, Blood, Right ventricle, Pulmonary artery, Heart


Background. Device closure of atrial septal defect (ASD) and patent foramen ovale (PFO) are both associated with short- and long-term complications. Our knowledge of the complication rates of ASD and PFO closure is limited. Our objective was to review the peri-procedural and long-term complications of ASD and PFO closure. Methods. Medline, EMBASE, and Scopus databases were searched between 1973 and 2012. A total of 28142 patients from 203 case series were included. Of these 203 articles, 111 were reporting ASD closure, 61 were reporting PFO closure, and 31 were reporting both. Pooled incidence rates of cardiac complications were calculated separately for peri-procedural and at follow-up. Results. Peri-procedural major complications were reported from 0% to 9.4%, with a pooled estimate rate of 1.4% (95% CI: 1.3% to 1.6%). It was 1.6% (95% CI, 1.4-1.8) in ASD group, 1.1% (95% CI, 0.9-1.3) in PFO group, and 1.3% (95% CI, 0.9-1.9) in ASD/PFO group. The most common major complication was the device embolization requiring surgery. Peri-procedural minor complications were reported with a pooled estimate rate of 1.4% (95% CI, 1.2-1.7). It was 1.6% (95% CI, 1.2-2.1) in ASD group, 1.3% (95% CI, 1.0-1.7) in PFO group, and 1.5% (95% CI, 1.1-1.2.1) in ASD/PFO group. The most frequent major complications at follow-up were cerebrovascular events (1.3% (95% CI: 1.1% to 1.6%)) and device thrombosis (1.2% (95% CI: 1.0% to 1.4%)). Both were more frequent in PFO group. Conclusion. Device closure of ASD and PFO are associated with non-negligible serious complications, both in early and long-term. © 2013 Wiley Periodicals, Inc.

Concepts: Ostium primum, Ventricular septal defect, Foramen ovale, Atrial septal defect


OBJECTIVES: to assess the endothelial dysfunction (ED) after bare metal stents (BMS) and sirolimus eluting stents (SES) implantation in the same patient, overcoming the confounding role of individual variables. BACKGROUND: SES reduce restenosis rate compared to BMS but cause more ED. ED is a potentially unsafe phenomenon, since it is the first step in the cascade of atherosclerosis. Studies showing more pronounced ED with drug eluting stents than BMS involved different series of patients, making the comparison difficult because endothelial function (EF) is responsive to many risk factors. METHODS: we designed a prospective comparison of 6 months post-deployment EF of SES vs. BMS implanted in the same patient, but in different coronary segments. Forty-eight lesions were randomly assigned on a 1:1 allocation using block sizing of 4 according to a computer-generated sequence (SAS System, Version 9.1) basis to treatment with SES or BMS. The EF was evaluated by measuring vessel diameter variation in the stented segment, before and after selective intracoronary infusion of acetylcholine (iiAch). RESULTS: In eligible patients, the relative magnitudes of major vasoconstriction were 2.6, 2.9, 4.6, and 3.1 at 5 mm proximal and 5, 10 and 20 distal to the stent edge. Overall, a 3.5 fold major distal vasoconstriction after iiAch of SES vs. BMS was calculated. CONCLUSIONS: in the same patients, but treating different coronary segments, SES implantation induces a higher rate of vasoconstriction compared to BMS. The increased vasoconstriction after iiAch is an indicator of ED. © 2013 Wiley Periodicals, Inc.

Concepts: Artery, Restenosis, Endothelial dysfunction, Cardiology, Endothelium, Atherosclerosis, Bare-metal stent, Drug-eluting stent