Cardiovascular Revascularization Medicine: Interesting Cases最新文献

Percutaneous coronary intervention for true bifurcation lesions is challenging because they have a poor prognosis due to side branch (SB) complications. The modified jailed balloon technique (MJBT) is useful for significant SB protection. However, even with the MJBT, provisional stenting in true bifurcation lesions does not dispel the risk of SB occlusion because re-crossing the guidewire through the stent struts into the SB remains a challenge, particularly when SB dissection occurs after stent implantation. Recently, the rewiring of dissected branches along the jailed balloon (real JAB) technique has been reported as a bailout method for this issue. We present the first series of successful provisional stenting cases in five patients with true bifurcation lesions using the real JAB technique in combination with the MJBT.

Transradial arterial access for cardiac catheterization is an overall safe procedure but is associated with infrequent complications. Although very rare, the potential disability resulting from transradial access site complications can be profound, especially in cases involving the dominant hand. In this case report, we present a right-handed patient who underwent cardiac catheterization via right transradial access complicated by chronic neuropathic pain and weakness of the right forearm and hand. The degree of pain and weakness prevented him from returning to work, demonstrating the potential for rare but significant morbidity associated with radial access.

Background

Left main coronary artery vasospasm is rare with a limited number of cases previously reported. Coronary artery vasospasm manifests as chest pain, which can result in acute coronary syndrome, ventricular arrhythmias, and death. While cannabis remains the most abused psychoactive substance, its association with coronary artery vasospasm remains unclear.

Case summary

A 46-year-old-female, with a history of recurrent angina and cannabis use, presented with severe chest pain. She suddenly entered ventricular fibrillation and was emergently cardioverted. Electrocardiogram showed ST segment elevations in leads aVR, V1, and V2 with reciprocal changes. Emergent coronary angiography revealed severe spasms of both the left main coronary artery and the left anterior descending artery. Intravenous nitroglycerin was initiated and her coronary artery vasospasms improved.

Discussion

Coronary artery vasospasm, due to cannabis, can be attributed to amplified catecholamine release causing vasoconstriction, presenting as decreased blood flow in coronary vessels, and increased myocardial oxygen demand due to a dose-dependent increase in cardiac output. Decreased anginal threshold combined with stimulation of pro-atherogenic CB1 receptors and hyper-sympathetic activity further propagates the risk of acute coronary syndrome.

Conclusion

Young patients presenting with coronary artery vasospasm should prompt the exclusion of cannabis as a contributing cause. Further studies are indicated to assess cannabis's impact on coronary vasculature.

The field of endovascular procedures has seen notable recent advancements. However, despite being considered an uncommon complication, stent migration is emerging as a growing concern. This case report describes a 56-year-old man who was diagnosed with a new onset of atrial fibrillation in the setting of a migrated iliac vein stent into the right atrium.

Percutaneous coronary intervention (PCI) for chronic total occlusions (CTOs) is challenging. The complexity of the lesions increases the risk of procedure-related complications. Here, we report a case of a patient who presented with simultaneous donor-vessel stent thrombosis and contained coronary perforation of the septal collateral artery during total occlusion PCI.

We report a case of 61-year-old man with an intriguing differential diagnosis between two often interchangeably ambiguous coronary conditions, successfully resolved through the application of OCT and physiological assessments. This clinical scenario highlights the importance of a multidisciplinary approach for achieving a thorough understanding of complex coronary pathologies.

A 32-year-old male with severe aortic stenosis (AS) and severe aortic regurgitation (AR) due to a partial-fusion bicuspid aortic valve with an aortic annulus area of 917mm² was admitted with cardiogenic shock. Transthoracic echocardiography (TTE) demonstrated aortic valve mean gradient (MG) of 73mmHg, peak gradient (PG) 108mmHg, aortic valve area (AVA) 0.4cm² and severe eccentric AR. Left ventricular ejection fraction (LVEF) was 16%.

Following Heart Team review, the patient was deemed unsuitable for surgical aortic valve replacement (SAVR), upfront left-ventricular assist device (LVAD) or extracorporeal membrane oxygenation (ECMO). He therefore underwent transcatheter aortic valve implantation (TAVI).

A 29mm Edward SAPIEN-3 valve was deployed with balloon dilatation at nominal volume plus 6mL. Anticipated inferior valve shortening did not occur and the implantation was relatively deep as the valve was gripped within the leaflets, resulting in moderate AR through the struts. There was restriction of the superior aspect of valve; thus, post-dilatation was performed at nominal volume plus 8mL, resulting in balloon rupture. Valve migration was noted due to the lemon seeding effect from the restricted superior aspect of the stent frame; thus, a second 29mm S3 valve was implanted and dilated to nominal volume plus 7mL. This resulted in a stable valve position with improvement in AR. The final LVEDP was 16mmHg with an aortic diastolic pressure of 95mmHg. ECMO was not required. TTE at two-months demonstrated mild paravalvular leak (PVL) with LVEF of 56%.

We demonstrate a successful off-label TAVI in a critically unwell patient with aortic annulus area >900mm².

An 80-year-old patient with refractory angina and prior coronary artery bypass graft surgery, was referred for percutaneous coronary intervention (PCI) of a chronically occluded obtuse marginal (OM) artery. PCI of the OM chronic total occlusion (CTO) was attempted using an occluded saphenous vein graft (SVG) as the retrograde conduit. The strategy was aborted due to branch vessel perforation which was rescued by placement of a covered stent across the OM ostium. CTO PCI of the SVG to OM graft was then successfully performed using a novel technique with laser atherectomy, mechanical thrombectomy, and distal occlusion for in-situ embolic protection. The vessel remained patent on repeat angiography at six months.

Objectives

This is a case report describing technical challenges due to the presence of a right atrial filamentous structure during implantation of septal occluder in a patient with cryptogenic stroke and patent foramen ovale (PFO).

Background

The association of patent Foramen ovale (PFO) and cryptogenic ischemic stroke in young patients has been well described. Eustachian valve remnants (also variably and rather interchangeably referred to as Chiari network in the literature) are vestigial remnants of the sinus venosus and it is often associated with PFO and atrial septal aneurysm. Such filamentous structures can interfere during right heart procedures. Careful peri-procedural evaluation with transesophageal echocardiography (T.E.E) or Intracardiac echocardiography (I.C.E) can help identify and prevent inadvertent complications.

Conclusion

Peri-procedural intracardiac imaging is the cornerstone in identifying right atrial filamentous structures during right heart structural procedures, electrophysiology procedures etc. Such guidance and previously described “Pull-Push” technique can avoid undue complications.