Percutaneous intervention for unprotected left main disease prior to explantation of a left ventricular assist device.

Percutaneous coronary intervention of unprotected left main coronary arterial disease is an alternative to surgical revascularization in selected patients. In this report, a patient with an implanted left ventricular assist device (LVAD) underwent successful coronary intervention prior to its planned removal. The implanted LVAD clearly assisted the technical performance of the intervention.     

Percutaneous left atrial to femoral arterial bypass pumping for circulatory support in high-risk coronary angioplasty

Left atrial to femoral arterial bypass was evaluated as a means of supporting patients who were considered to be at high risk for the performance of percutaneous transluminal coronary angioplasty. A 20 French drainage catheter was inserted percutaneously into the left atrium via a modified transseptal technique. Blood was withdrawn from the left atrium and returned through a femoral arterial cannula using a roller pump. Thirteen patients were treated in this fashion with excellent circulatory support. Pump flows varied from 1.5 to 3 liters per minute and bypass time ranged from 27 to 106 min (mean 43±17). Aortic mean pressure was well supported during balloon inflation. No significant complications were encountered. Neither an oxygenator nor a perfusionist is required. The ability to obtain direct left ventricular decompression offers a major potential advantage. Further evaluation of this technique for the support of such patients is indicated. © 1993 Wiley-Liss, Inc.     

Percutaneous coronary intervention of unprotected left main coronary artery disease

Data have emerged demonstrating the safety and efficacy of percutaneous coronary intervention (PCI) of the unprotected left main (ULM) artery. The 2009 American College of Cardiology/American Heart Association/Society for Cardiovascular Angiography and Interventions focused guidelines for PCI no longer state that ULM PCI is contraindicated in patients with anatomic conditions that are associated with a low risk of procedural complications and clinical conditions that predict an increased risk of adverse surgical outcomes. ULM PCI should be performed by operators with experience in the management of the anatomic complexities of left main and multivessel disease, specifically in issues relating to bifurcation disease, calcification, and hemodynamic support. Patients with ostial or shaft disease have lower risk of restenosis compared with distal bifurcation disease. Drug‐eluting stents (DES) should be used whenever possible as they reduce clinical restenosis. Intravascular ultrasound is an integral component of the procedure as it provides accurate assessment of lesion severity and can confirm optimal stent expansion and apposition. Compliance with dual antiplatelet therapy for at least 12 months is essential if DES are used. A collaborative, multidisciplinary approach with a “Heart Team” represented by a cardiac surgeon, interventional cardiologist, and non‐invasive cardiologist may optimize patient education and objective decision making when obtaining informed consent. Application of clinical and angiographic variables into risk models facilitates appropriate patient selection. Randomized clinical trials will address unanswered issues and help build consensus between cardiology and surgical societies to inform clinical decision making and optimize the outcomes for patients with ULM coronary artery disease. © 2011 Wiley Periodicals, Inc.     

Early and long‐term results of percutaneous coronary intervention for unprotected left main trifurcation disease

Objectives: We aimed to conduct a retrospective cohort study focusing on our 5‐year experience in the percutaneous treatment of unprotected left main (ULM) trifurcation disease. Background: Percutaneous treatment of ULM trifurcation remains a challenging and rare procedure for most interventional cardiologists. Moreover, data on long‐term outcomes are lacking. Methods: We retrieved all patients with ULM trifurcation disease treated percutaneously at our Institution since 2002, and adjudicated baseline, procedural, and outcome data. The primary end point was the long‐term rate of major adverse cardiovascular events (MACE, i.e., cardiac death, myocardial infarction, bypass surgery, or target vessel revascularization). Results: A total of 27 patients underwent percutaneous coronary intervention with stent implantation for ULM trifurcation disease, with 14 (52%) cases of true trifurcations, i.e., with concomitant significant stenoses of the distal ULM/ostial left anterior descending plus ostial ramus intermedius and ostial circumflex. Bare‐metal stents were implanted in 8 (29%) patients and drug‐eluting stents (DES) in 26 (96%), with a main branch stent only strategy in 11 (40%), T stenting in 9 (33%), and V stenting in 6 (27%). Procedural and clinical success occurred in 26 (96%), with one postprocedural death. Angiographic follow‐up was obtained in 22 patients (81%), and clinical follow‐up was completed in all subjects after a median of 28 ± 17 months, showing overall MACE in 9 (33%), with cardiac death in 4 (15%), myocardial infarction in 1 (4%), coronary artery bypass grafting (CABG) in 4 (15%), and percutaneous target vessel revascularization in 5 (19%). Definite stent thrombosis was adjudicated in 1 (3%) patient. Treatment of a true trifurcation lesion and recurrence of angina during follow‐up were significantly associated with an increased risk of MACE (P = 0.029 and P = 0.050, respectively). Conclusions: Percutaneous treatment of ULM trifurcation disease is feasible, associated with favorable mid‐term results, and may be considered given its low invasiveness in patients at high surgical risk or with multiple comorbidities. © 2008 Wiley‐Liss, Inc.     

Percutaneous left ventricular assist device, TandemHeart, for high-risk percutaneous coronary revascularization. A single centre experience

Patients with severe depression of left ventricular ejection fraction and high-risk coronary lesions are at risk of developing complications during percutaneous coronary interventions (PCI). Intra-aortic balloon pump (IABP) is a support that helps the interventionalist in such hemodynamic complications during high-risk PCI, but it does not offer complete circulatory support. Instead, TandemHeart (Cardiac Assist, Pittsburg, PA, USA) is a percutaneous left ventricular assist device (pLVAD) that gives total left circulatory support and can be used for patients in cardiogenic shock or for elective PCI at high-risk. TandemHeart is a percutaneous transseptal ventricular assist device that allows a rapid percutaneous left ventricular support without the need for surgical implantation. Between November 2003 and April 2005, 6 patients admitted to our coronary care unit (CCU) underwent either emergency (n = 3) or elective (n = 3) placement of the TandemHeart device before a high-risk procedure. From our initial experience we conclude that the percutaneous transseptal ventricular assist device, TandemHeart, can be easily and rapidly deployed either in emergency or in elective high-risk PCI to achieve complete cardiac assistance.     

左心室收缩功能正常的老年冠心病患者无保护左主干病变PCI治疗预后的影响因素

目的 探讨左心室收缩功能正常（左心室射血分数≥40％）的老年冠状动脉粥样硬化性心脏病（冠心病）患者无保护左主干（unprotected left main,ULM）病变经皮冠状动脉介入（percutaneous coronary intervention,PCI）治疗预后的影响因素.方法 回顾性分析2009年1月至2011年12月在广西壮族自治区人民医院因ULM接受PCI治疗的左心室收缩功能正常的患者112例的临床资料和冠状动脉造影结果.根据患者的情况分为非老年组（年龄＜60岁）和老年组（≥60岁）,比较两组间的基线资料和冠状动脉造影结果.应用多因素回归分析法观察年龄对ULM介入治疗结果的预测价值.结果 总计入选符合条件的患者112例,其中非老年组42例和老年组70例.老年组糖尿病、高脂血症、吸烟史、既往PCI治疗、主要心脑血管不良事件（MACCE）、术后心肌梗死发生率明显高于非老年组,差异有统计学意义（分别为42.9％ vs.21.1％,P=0.021;40％ vs.11.9％,P=0.040; 28.6％ vs.9.5％,P=0.017;18.6％ vs.4.8％,P=0.038;48.6％ vs.23.8％,P=0.009;22.9％ vs.0％,P=0.001）.Logistics回归分析得出女性、年龄、吸烟史、合并多支血管病变、远端或分叉病变均为主要心脑血管不良事件的独立预测因素.结论 左心室收缩功能正常的患者,其年龄因素是ULM介入治疗预后不良的强力预测因素.     

Percutaneous coronary intervention for stable coronary artery disease

Patients with significant coronary artery stenoses are at increased risk of future cardiac events. However, in the absence of acute coronary syndrome or recent myocardial infarction and residual ischemia, elective percutaneous coronary intervention has not been shown to improve prognosis. Possible explanations for this might be the limited follow-up time adopted by most randomized trials comparing percutaneous coronary intervention with medical therapy, limited number of patients with proven ischemia enrolled in these trials, and adoption of complex, elaborate techniques that have not proved their usefulness. Published evidence identifies certain indications for percutaneous coronary intervention in patients with stable coronary lesions: demonstration of significant inducible ischemia, particularly in the context of a recent myocardial infarction; detection of unequivocally reduced fractional flow reserve; and specific angiographic features of coronary stenoses. Operators should take into account long-term consequences of adopted techniques rather than immediate angiographic results. We review existing evidence and provide our recommendations in this setting.     

Percutaneous coronary intervention with rotational atherectomy for severely calcified unprotected left main: immediate and two-years follow-up results

Introduction : According to current practice guidelines, coronary bypass surgery is the standard care option for unprotected left main (ULM) stenosis. However, a group of high surgical risk patients who are not eligible for coronary bypass surgery could benefit from percutaneous coronary intervention (PCI). Severe calcification hampers PCI in this setting, and rotational atherectomy (RA) could be of great help. Methods : We retrospectively analyzed a cohort of 40 patients with severely calcified ULM stenosis, not eligible for coronary artery bypass grafting, who underwent RA in our center. Results : Forty patients (mean age, 73 ± 8 years; 26 males) with ULM stenosis were treated with RA. Twenty‐seven (67%) had distal stenosis. The mean number of treated vessels was 2.38 ± 0.74, with a mean lesion length of 30 ± 18 mm. Abciximab was used in 12 (30%) cases and an intra‐aortic balloon pump in three cases. One patient died during the procedure and another two patients died in the first 24 hr after the procedure. The major events registered after the procedure included one significant branch loss, and two minor and one major case of bleeding (the latter requiring transfusion) at the puncture point. After a median of 24.7 (IQR 19.6–34.3) months of follow‐up, 12 cardiac deaths were recorded. Survival free of cardiac death was 71 ± 7% and clinical guided target vessel revascularization 19.3 ± 7% at 2 years. Conclusion : In a group of high surgical risk patients, RA on severely calcified left main stenosis is feasible and, in spite of high mortality rates, could pose the only possible effective treatment. © 2012 Wiley Periodicals, Inc.     

Percutaneous transluminal coronary angioplasty of the left internal thoracic artery graft: a case report in a child

A 9-year-old girl who had undergone previous coronary artery bypass surgery at the age of 3.5 years for stenoses of the left anterior descending and right coronary arteries resulting from Kawasaki disease presented with recurrent exertional angina. Stenosis was found at the anastomosis of the left internal thoracic artery to the left anterior descending artery. Percutaneous transluminal coronary angioplasty was successfully performed. This is the first reported case of percutaneous transluminal coronary angioplasty of an internal thoracic artery graft in a child. © 1994 Wiley-Liss,Inc..     

Percutaneous treatment of left ventricular assist device outflow graft obstruction

Owing to the growing population with end stage heart failure, the use of left ventricular assist devices (LVADs) have become more widely accepted. Although survival has improved with newer generation LVADs, multiple complications including pump failure due to outflow graft obstruction have become more clinically relevant. Patients with this complication will present with heart failure symptoms due to inadequate unloading of the left ventricle by LVAD. This rare complication often requires open surgical repair in an already high-risk patient population. Alternative means to relieve the obstruction via percutaneous intervention has been described in rare cases. We present two unique cases of LVAD outflow graft obstruction which were percutaneously treated successfully. This article illustrates a potential treatment strategy for outflow graft obstruction with stenting as an alternative to open-heart surgery.     

Single-center experience with the TandemHeart percutaneous ventricular assist device to support patients undergoing high-risk percutaneous coronary intervention

We describe our experience of patients, from December 2005 through May 2007 who underwent percutaneous coronary intervention (PCI) with severely depressed left ventricle systolic function and complex coronary lesions. The complex coronary lesions included multiple vessel coronary artery disease, left main (LM) coronary artery disease, calcified coronary lesions and bypass graft disease. All patients were clinically assessed to be at too high of a risk for circulatory collapse without maximal hemodynamic support while they underwent high-risk PCI. The TandemHeart percutaneous ventricular assist device (THpVAD) may be able to provide the necessary circulatory support required to enhance procedural success and patient safety during high-risk PCI. METHODS AND RESULTS: We implanted the THpVAD in 6 patients who underwent high-risk PCI. There was unanimity among several physicians in our institution that each patient was an exceptionally high risk for circulatory collapse due to the anticipated procedural complexity. The average ejection fraction was 33% (range 15-65%). Five of the patients were considered to be at an unacceptably high risk for coronary artery bypass surgery. All 6 patients underwent multivessel PCI. Five of the 6 underwent unprotected LM PCI. One patient of the 5 underwent vein-graft PCI as well as a debulking procedure with rotational atherectomy and PCI of the LM. We had a 100% success rate with implantation of the THpVAD. Five of the 6 patients were alive at 30 days post procedure. One patient died 3 days after the procedure due to multiorgan failure. A vascular surgeon performed the removal of the devices with no associated complications. CONCLUSIONS: Our clinical experiences with the TandemHeart pVAD demonstrated that hemodynamic support could be achieved safely, efficiently and effectively by way of a percutaneous route in anticipation of high-risk PCI.     

Results of percutaneous drug‐eluting stent implantation for unprotected left main coronary disease according to left ventricular systolic function

Objectives: We aimed to appraise the early and long‐term outcome after percutaneous coronary intervention (PCI) with drug‐eluting stents (DES) in patients with unprotected left main disease (ULM) and left ventricular systolic dysfunction (LVD). Background: PCI with DES has being performed with increasing frequency in subjects with ULM and LVD, but few specific data are available. Setting and Patients: We identified patients undergoing PCI with DES for ULM at our Center and distinguished those with ejection fraction (EF) >50% from those with 40% <EF ≤50% and those with EF ≤40%. The primary end‐point was the rate of major adverse cerebro‐cardiovascular events (MACCE, ie death, myocardial infarction [MI], stroke, repeat PCI or bypass surgery). Results: A total of 197 patients were included, 57.4% with EF >50%, 32.0% with 40% <EF ≤50%, and 10.6% with EF ≤40%. In‐hospital mortality was significantly higher in those with EF ≤40% (9.5% vs. 0 and 3.2%, P < 0.001). A total of 96% patients were followed for 23 ± 14 months, yielding a MACCE rate of 44.2% (41.6% in those with EF >50%, 41.6% in those with 40% <EF ≤50%, and 61.9% in those with EF ≤40%, P = 0.4). Specifically, death occurred in 2.7%, 7.9%, and 28.6% (P < 0.001), cardiac death in 1.8%, 4.8%, and 23.8% (P = 0.001), MI in 8.0%, 7.9% and 0 (P = 0.4), and TVR in 15.9%, 11.1% and 33.3% (P = 0.6). Conclusion: Systolic ventricular dysfunction is highly correlated with in‐hospital and long term death rates in patients undergoing PCI with DES for ULM disease. However it does not confer an increased risk of nonfatal adverse events or stent thrombosis. © 2009 Wiley‐Liss, Inc.     

Percutaneous (nonsurgical) supported angioplasty in unprotected left main disease and severe left ventricular dysfunction

A 69-year-old patient with the equivalent of severe, unprotected left main coronary artery disease associated with marked left ventricular dysfunction with ventricular aneurysm who had Class IV angina, underwent supported angioplasty utilizing a total percutaneous approach. The patient tolerated occlusion of his main left coronary artery for a total of 7 minutes without difficulty, during dilatation of left anterior descending and two circumflex lesions. He was discharged the following day, symptom free.     

Double loop guiding catheter: A primary catheter for angioplasty of the right coronary artery

Double loop guiding catheters have been used for percutaneous transluminal coronary angioplasty (PTCA) of the right coronary artery (RCA) in 42 consecutive cases. A catheter with a 90- degree primary curve was used when the proximal RCA had horizontal or inferior orientation. When the proximal segment of the RCA was oriented superiorly (shepherd's crook), the catheter with a 75-degree primary curve was used. Catheters were fabricated with short (1.5 cm) or long (2.3 cm) (USCI, C.R. Bard, Inc., Billerica, MA) distal tips. Short-tip catheters were satisfactory in the majority of cases. When the RCA had a complex course and more backup was necessary or when the ascending aorta was wide, long-tip catheters were found to be the best choice. Angioplasty of 49 lesions was attempted in 42 consecutive patients. In 39 patients successful dilatation was achieved (93%). In three patients the procedure was unsuccessful. In one patient, the lesion could not be crossed with the guidewire despite an excellent backup. In another patient, two of three stenoses were dilated successfully; the distal lesion was crossed with a guidewire but could not be crossed with the balloon catheter in spite of a good backup. The lack of a satisfactory engagement and inadequate backup were responsible for the failure in only one patient. There were no complications related to these guiding catheters. We conclude that double loop guiding catheters are safe and can be the primary choice in all right coronary angioplasties. These catheters provide an excellent backup with consequent high success rate.     

Percutaneous transluminal coronary angioplasty in left main stem coronary stenosis: a five-year appraisal

Left main stem coronary stenosis is now uniformly treated with coronary artery bypass grafting. The advent of percutaneous transluminal coronary angioplasty has permitted a non-operative improvement in myocardial blood flow in many cases of single- and multi-vessel coronary atherosclerosis. The use of percutaneous transluminal coronary angioplasty in left main stem coronary stenosis has been sporadic and controversial. Twenty percutaneous transluminal coronary angioplasties were attempted in 19 patients as the treatment of choice for left main stem coronary stenosis in the past 66 months. The primary success rate was 95% (19/20 patients). The emergency surgery was performed only once (5%), and no death occurred secondary to percutaneous transluminal coronary angioplasty itself. In the follow-up (mean 41 months) period, 12 patients (63%) remained in satisfactory condition with no further need for surgical intervention. Seven patients (37%) ultimately required coronary artery bypass grafting. Although coronary artery bypass grafting will remain the fundamental treatment for left main stem coronary stenosis, this series delineates those anatomic and clinical exceptions wherein percutaneous transluminal coronary angioplasty may be utilized as the primary therapy for left main stem coronary stenosis.