Hybrid coronary revascularization for the treatment of left main coronary stenosis: a feasibility study

Objective : To determine the feasibility of a hybrid coronary revascularization (HCR) approach for the treatment of left main (LM) coronary artery stenosis. Background : The recommended therapy for significant LM stenosis is coronary artery bypass grafting (CABG). Percutaneous coronary intervention (PCI) of unprotected LM lesions is reserved for patients at high risk for complications with CABG. HCR in LM disease has not been studied. Methods : Twenty‐two consecutive patients with LM stenosis >70% underwent staged HCR. Following a robotic or thoracoscopic‐assisted minimally invasive left internal mammary artery (LIMA) to left anterior descending artery (LAD) coronary bypass, PCI of the LM, and non‐LAD targets was performed after angiographic confirmation of LIMA patency. Intravascular ultrasound confirmed optimal stent deployment. Thirty‐day adverse outcomes and long term follow up was obtained. Results : In the 22 patients with LM lesions, 6 were ostial, 5 mid, and 11 distal. LIMA patency was FitzGibbon A in all cases. LM stenting was successful in all patients with drug‐eluting stents (DES) placed in 21 of 22 cases. Three patients underwent stent implantation in the right coronary artery. There were no 30‐day major adverse cardiac or cerebrovascular events. At a mean of 38.8 ± 22 months postprocedure, 21 patients were alive without reintervention; one death occurred at 454 days. Conclusions : HCR for LM coronary disease is a feasible alternative to CABG and unprotected LM PCI. This approach combines the long‐term durability of a LIMA‐LAD bypass with the less invasive option of PCI in non‐LAD targets with DES. © 2011 Wiley Periodicals, Inc.     

Long‐term complication after LM bifurcation treatment

Two months after left anterior descending (LAD) artery and left circumflex (LCx) artery bare metal stent implantation, a proliferative subocclusive in‐stent restenosis in LCx coronary with severe LM coronary (LM) involvement developed. The present clinical case describes a simplified strategy for unprotected LM percutaneous coronary intervention using two bioabsorbable biolimus‐eluting stents without involvement of the LAD coronary using an “L” technique. © 2010 Wiley‐Liss, Inc.     

Early recognition of catheter‐induced left main coronary artery vasospasm: Implications for revascularization

Catheter‐induced left main coronary artery (LMCA) vasospasm is a rare complication of coronary angiography that confounds the decision for coronary artery bypass graft (CABG) surgery. We report two cases of catheter‐induced LMCA vasospasm. The first case was a 68‐year‐old woman who presented 6 years after CABG for presumed severe LMCA atherosclerotic disease. Coronary angiography demonstrated totally occluded CABGs and normal native coronary arteries, including a normal LMCA. The second case was a 56‐year‐old man with severe LMCA stenosis, who was scheduled for unprotected LM percutaneous coronary intervention (PCI). Repeat angiography 2 days later showed no stenosis. These cases emphasize the need for meticulous technique and a high index of suspicion of LMCA vasospasm. Intravascular ultrasound (IVUS) at the time of angiography may help to identify minimal atherosclerotic disease suggesting vasospasm. Alternatively, noninvasive testing, such as Computed Tomography (CT) angiography, may diagnose LM spasm in these patients prior to CABG surgery. © 2010 Wiley‐Liss, Inc.     

Primary percutaneous coronary intervention of an unprotected left main using mini‐crush drug‐eluting stents facilitated by intracoronary reteplase

Patients suffering from acute myocardial infarction with involvement of unprotected left main (LM) coronary artery disease represent a very high‐risk subgroup. A 37‐year‐old male patient was admitted with posterolateral acute myocardial infarction and in borderline hemodynamic condition. His left ventricular ejection fraction was 30% with posterior, lateral wall, and apical akinesis along with mild mitral regurgitation. Emergency coronary angiography demonstrated ostial occlusion of the left circumflex artery (without stump, flow Thrombolysis in Myocardial Infarction 0/Rentrop 0) and severe distal LM disease with superimposed thrombus. The primary percutaneous coronary intervention procedure combined intracoronary reteplase plus thrombus aspiration to restore flow in the left circumflex and deployment of two everolimus‐eluting stents with mini‐crush technique to successfully reconstruct the LM bifurcation. The patient recovered without complications and had a favorable outcome at mid‐term.© 2011 Wiley‐Liss, Inc.     

Novel shunt modification with an adjustable stent‐embedded “fenestrated” septal occluder in a patient with pulmonary hypertension

A 60‐year‐old woman with progressive dyspnea and cyanosis, O2‐dependent pulmonary hypertension despite optimal medical therapy and remote atrial septostomy presented with worsening cyanosis and right‐to‐left shunting. The creation of a “fenestrated” ASD closure device with the insertion of a peripheral stent through an AMPLATZER? ASD closure device was deployed to minimize right to left shunting and allow for enlargement of the shunt if needed. This case demonstrates the benefit of diminishing a right to left shunt with a self‐fabricated fenestrated AMPLATZER device to improve symptoms in pulmonary hypertension patients with a pre‐existing ASD.     

Unprotected left main coronary artery stenting with zotarolimus (Endeavor) drug‐eluting stents

Objectives: To report the safety and efficacy of zotarolimus eluting stents for treatment of unprotected left main coronary artery disease. Background: Percutaneous stent insertion is an increasingly popular alternative to bypass surgery for the management of left main (LM) coronary artery disease. While data support the use of sirolimus‐ and paclitaxel‐coated stents in the LM coronary artery, there are no published series reporting results with Endeavor (zotarolimus) stents, particularly in the context of unprotected left main (ULM) lesions. Methods: We retrospectively identified 40 consecutive patients who had ULM disease treated with Endeavor stents (ZES) and who had follow‐up angiography. The primary endpoint was the prevalence of major adverse cardiac events (MACE), including cardiac/unexplained death, nonfatal myocardial infarction (MI), and in‐stent restenosis (ISR)/target lesion revascularization (TLR). Results: Angiographic and procedural success was achieved in all cases. Follow‐up angiography occurred on average 5.6 ± 0.9 months after the index procedure. There were three incidences of ISR requiring TLR and another patient who had a NSTEMI in the follow‐up period. At late follow‐up (12.4 ± 1.8 months) three patients underwent CABG (one for RCA stenosis) and four patients died without knowledge of the status of the ULM stent (two cardiovascular and two deaths related to cancer progression). Conclusions: In conclusion, our experience with Endeavor stents for the treatment of ULM disease demonstrates excellent angiographic and clinical outcomes, with a 7.5% ISR/TLR rate and a 15% MACE rate, respectively, at an average clinical follow‐up of 12.4 months. © 2011 Wiley Periodicals, Inc.     

Anatomical Factors Triggering Platypnea‐Orthodeoxia in Adults

Right to left shunting through a patent foramen ovale (PFO) or atrial septal defect (ASD) can cause platypnea‐orthodeoxia even in a setting of normal pulmonary artery pressures. However, the late onset of symptoms despite the congenital origin of the anatomical defects is not well understood. We report a case series of patients presenting with dyspnea and orthodeoxia who developed right to left shunting as a result of associated anatomical changes that occur with aging such as tortuosity and elongation of the aorta. We propose that these acquired anatomical changes can favor right to left shunting in the setting of congenital abnormalities, therefore explaining the late onset of symptoms. Copyright © 2009 Wiley Periodicals, Inc.     

Immediate and short‐term effects of transcatheter device closure of large atrial septal defect in senior people

Objectives: We sought to evaluate the safety and efficacy in improving cardiac function and functional capacity with device closure of large atrial septal defects (ASD) in senior adults.
Background: Atrial septal defect accounts for about 10% of all congenital heart dis‐ ease. It still remains unclear whether large ASD closure in senior people should be performed or not. Hence we aim to prospectively assess the safety and clinical status of senior patients after transcatheter closure in large ASD.
Patients and interventions: This was a prospective study of all patients aged over 50 years who underwent device closure of a secundum large ASD between January 2013 and January 2018. Investigations including brain natriuretic peptide level, electrocardiography, chest X‐ray, transthoracic echocardiogram, transesophageal echocardiogram, and 6‐minute walk test were performed before and at 2 days and 4 weeks and 6 months after the procedure.
Results: Twenty patients (median age 68 years, 10 women) had transcatheter device closure of large ASD successfully. Median ASD size was 32 mm (range 30‐39 mm). Median pulmonary artery pressure was 58 mm Hg (range 47‐67 mm Hg). At 6 months, there was a significant change in right atrium size (P < .001) and right ventricle size (P < .01) and left ventricle size (P < .001) and also pulmonary artery pressure (P < .0001), New York Heart Association functional class improved (P = .03) in 19 patients and also significant improvement in 6‐minute walk test distance (P < .001). There were no major complications.
Conclusions: Our data showed that large ASD closure at senior people results in sat‐ isfactory cardiac remodeling and cardiac function improvement.     

Anomalous and Diseased Left Main Coronary Artery Arising fromthe RightCoronarySinus in an Elderly Lady

We report a case of 66-year-old female patient who presented with unstable angina and New York Heart Association Class III symptoms. Echocardiogram demonstrated wall motion abnormalities in the anterior and inferior walls. Coronary angiography demonstrated a severely diseased right coronary artery (RCA) and anomalous left main (LM) coronary artery arising from the right coronary sinus and courses posterior to the aorta and runs between the aorta and the main pulmonary artery with severe multiple atherosclerotic disease. Patient underwent successful coronary artery bypass grafting and was dismissed in good general status.     

Catheter‐guided Open Ligation of a Pulmonary Artery to Left Atrium Connection

Congenital malformations causing mild cyanosis can be overlooked. A large intrapulmonary right pulmonary artery to left atrium connection was the unusual etiology of arterial oxygen desaturation and erythrocytosis in an asymptomatic 30‐year‐old patient. The shunt was not possible to detect at echocardiography. It was closed via a median sternotomy without the aid of cardiopulmonary bypass. A novel technique was to use an angiographic catheter inserted through the wide shunt into the left atrium before the operation to securely identify it at the surgical dissection.     

How to deal with atrial septal defect closure from right internal jugular vein: Role of venous‐arterial circuit for sizing and over‐the‐wire device implantation

Secundum atrial septum defect (ASD) is the most common congenital heart disease. It is usually treated by a transcatheter approach using a femoral venous access. In case of bilateral femoral vein occlusion, the internal jugular venous approach for ASD closure is an option, in particular in cases where ASD balloon occlusion test and sizing is needed. Here, we report on a new technique for ASD closure using a venous‐arterial circuit from the right internal jugular vein to the femoral artery. Two patients (females, 4 and 10 years of age) had occlusion of both femoral veins because of a previous history of pulmonary atresia and intact ventricular septum, for which they underwent percutaneous radiofrequency perforation and balloon angioplasty. These subjects needed balloon occlusion test of a residual ASD to size the hole and to check for hemodynamic suitability to ASD closure. After performing a venous‐arterial circuit, a 24 mm St Jude ASD sizing balloon catheter was advanced over the circuit and the defect closed for 15 min to check hemodynamics and size the defect. ASD was closed is hemodinamically suitable. This technique was safe and reliable. © 2016 Wiley Periodicals, Inc.     

Myocardial ischemia induced by anomalous aortic origin of the right coronary artery in a patient with atrial septal defect

A 27-year-old woman with atrial septal defect (ASD) and a sensation of squeezing in the anterior chest by effort was admitted to our hospital. In addition to the ASD, the coronary angiogram showed an abnormal anomalous position of the right coronary artery. Exercise thallium (Tl)-201 cardiac scintigram with an electrocardiogram clearly detected myocardial ischemia in the inferior area. In the operative findings, the orifice of the right coronary artery was positioned high above the commissure between the right and left sinuses of Valsalva, and it ran between the aorta and pulmonary trunk. Considering myocardial ischemia possibly caused by the anomalous origin of the right coronary artery, a coronary artery bypass graft (CABG) was simultaneously performed to the right coronary artery with direct closure of ASD. The myocardial ischemic finding in the inferior area disappeared after the operation, and she was also relieved from the chest pain. In view of these findings, we suggest that an active combination treatment such as CABG and ASD closure is highly successful in a patient with a threatening coronary anomaly and congenital heart disease.     

Coronary‐pulmonary arterial fistula in a neonate with pulmonary atresia—ventricular septal defect and single coronary artery

In cases of pulmonary atresia with ventricular septal defect (PA‐VSD), coronary‐pulmonary arterial fistula (CPAF) as the main source of pulmonary blood supply is extremely rare. These fistulae may arise from the left coronary artery, right coronary artery, or a single coronary artery. Fistulae from a single coronary artery are unusual. We are reporting a case of PA‐VSD with single coronary artery and CPAF as the main source of pulmonary supply in addition to two major aortopulmonary collateral arteries (MAPCAS). Successful surgical correction with VSD closure and right ventricle (RV) to the pulmonary artery (PA) conduit was made.     

Adult‐type ALCAPA syndrome: A rare coronary artery anomaly

Anomalous origin of the left coronary artery arising from the pulmonary artery (ALCAPA or Bland–White–Garland syndrome) is a rare but serious congenital coronary artery anomaly, with a poor prognosis without surgical repair. There are two types of ALCAPA syndrome: infant type and adult type. We present a rare case of a 63‐year‐old female patient, with isolated left anterior descending artery origin from the pulmonary artery. Coronary computed tomography angiography revealed giant and tortuous coronary arteries with many collaterals between the left and right coronary system. The patient refused any surgical treatment.     

Right‐sided aortic arch and Kommerell diverticulum with aberrant left subclavian artery: Preliminarily diagnosed by echocardiography

Kommerell diverticulum (KD) with aberrant left subclavian artery (ALSA) is a rare congenital variation of vascular structure. We reported a case of 3‐year‐old boy with KD and ALSA, which was preliminarily diagnosed by transthoracic echocardiography and verified by computed tomography angiography (CTA). The patient was treated successfully with KD resection and anastomosed the left subclavian artery directly to the left carotid artery under cardiopulmonary bypass. Our case illustrates that echocardiography and CTA should be used to comprehensively assess all the internal and external cardiac structures in order to determine the appropriate surgical plan.     

Adult‐Type Anomalous Origin of the Left Coronary Artery from the Main Pulmonary Artery: One Case Report

Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital defect that presents even less frequently in adults. Here we described a 40‐year‐old patient presenting with palpitations. Electrocardiography revealed frequent ventricular ectopy. Echocardiography revealed a dilated left ventricle and an abnormal flow pattern in the pulmonary artery and at the right side of the interventricular septum. Coronary angiography demonstrated an enlarged right coronary artery (RCA) with collateralization to the left coronary artery (LCA) and reflux of contrast into the pulmonary artery. Computed tomography confirmed ALCAPA syndrome. Surgical corrections were planned. (ECHOCARDIOGRAPHY, Volume **, ***********)     

Left main coronary angioplasty: early and late results of 127 acute and elective procedures

The results of 127 left main (LM) coronary angioplasties were reviewed to assess short- and long-term effectiveness. Three major subgroups were considered: (1) elective "protected" (defined as the presence of a patent bypass graft to the left coronary circulation) patients (n = 84); (2) elective "unprotected" patients (n = 33); and (3) acute patients, in whom LM coronary angioplasty was performed in the setting of an acute myocardial infarction (n = 10). Successful LM dilation was achieved in 94% of elective patients and 90% of acute patients. Procedural mortality was 4.3% in elective patients (2.4 and 9.1% in protected and unprotected patients, respectively, p = 0.14) and 50% in the acute subgroup. Long-term follow-up data, available for 98% of patients, revealed actuarial 3-year survival rates of 90 and 36% in elective protected and unprotected subgroups, respectively (p less than 0.0005). In the acute subgroup, 3 patients (30%) were alive at the time of follow-up; all had undergone coronary artery bypass surgery. Thus, although elective angioplasty of an unprotected LM coronary artery is technically feasible, the long-term prognosis of such patients is very poor. LM angioplasty in this subgroup should be reserved for patients in whom surgical revascularization is not an option. In contrast, elective angioplasty of a protected LM coronary artery can be accomplished safely with good long-term results. LM coronary angioplasty for acute myocardial infarction can be effective as a salvage procedure; however, adjunctive coronary bypass surgery is important for long-term survival.     

Endovascular stenting for treatment of a left internal mammary artery pseudoaneurysm following redo‐sternotomy: A case report

An 85‐year‐old gentlemen with a history of previous triple vessel coronary bypass grafting presented with severe aortic stenosis and occlusion of the previous saphenous vein grafts but with patent left internal mammary artery (LIMA)–left anterior descending. The patient underwent uncomplicated repeat sternotomy and aortic valve replacement with repeated coronary bypass. On post‐operative day 21 the patient was successfully resuscitated from a pulseless electrical activity (PEA) arrest, and was found to have a 1‐cm pseudoaneurysm of the left internal mammary artery at the level of sternomanubrial junction with associated hemothorax. The LIMA remained patent and a pinhole source of extravasation was discovered by angiography at the aneurysmal site. The defect was successfully repaired by endovascular implant of a 3.5 mm × 12 mm Graft Master covered stent (Abbott Vascular). The patient recovered well from the procedure without further complications and was discharged after a total of 48 days of hospital stay. Our experience confirms the feasibility of repairing post‐operative pseudoaneurysm in the internal mammary artery by endovascular stent grafting, thereby avoiding the risks and complications of a repeat open chest procedure. © 2013 Wiley Periodicals, Inc.     

Perioperative rupture of the LIMA graft leading to cardiogenic shock,emergency angiography,and stenting with a polytetrafluoroethylene‐covered stent

A 58‐year‐old man underwent an elective coronary bypass graft for severe four‐vessel stenosis. Cardiogenic shock developed just after coronary bypass grafting with a left internal mammary artery (LIMA) to left anterior descending (LAD) artery and superficial venous graft to 1^st and 2^nd obtuse marginal (OM1/OM2) arteries the posterior descending artery (PDA) was too small to graft. Despite significant inotropes and an intra‐aortic balloon pump, the patient deteriorated in intensive care unit with cardiogenic shock and ventricular arrhythmia. Urgent coronary angiography revealed a rupture or torn LIMA graft with extravasation of contrast into the left pleural cavity. There was no distal LIMA to LAD flow probably due to graft thrombosis. Revascularisation was performed on the severe ostial native LAD stenosis with a drug eluting stent. The rupture graft was then stented with a polytetrafluoroethylene‐covered stent, which stopped the bleeding, and latter, led to total graft thrombosis. The patient improved significantly and supportive inotropes could be weaned down. At 11 month follow‐up, the patient had mild left ventricular dysfunction, widely patent ostial LAD stent and thrombosed LIMA graft. © 2011 Wiley Periodicals, Inc.     

Contrast‐Enhanced Echocardiographic Evaluation of a Giant Saphenous Vein Graft Aneurysm

A 61‐year‐old man presented with unstable angina 16 years after undergoing coronary artery bypass grafting with a left internal mammary artery graft to the left anterior descending coronary artery and a sequential saphenous vein graft (SVG) to the right coronary artery and an obtuse marginal branch. Transthoracic echocardiography (TTE) with a Philips iE33 machine and an S5 transducer revealed a 5.3 cm × 4.6 cm mass with a central echolucent area, surrounded by a peripheral zone of increased echodensity adjacent to, and partially compressing, the right atrium. Contrast echocardiography following an intravenous bolus injection of Definity revealed late appearance of contrast within the mass consistent with a giant SVG aneurysm. Coronary artery bypass graft angiography revealed a giant aneurysm in the SVG proximal to the RCA anastomosis; the distal limb of the graft to the obtuse marginal branch was occluded. Under intravascular ultrasound guidance, a 7‐mm spider filter was placed in the distal graft; then, a 6 mm × 10 cm Viabahn self‐expanding nitinol polyethylene terephthalate‐covered stent was deployed in the SVG with good seal zones proximally and distally. A follow‐up contrast‐enhanced transthoracic echocardiogram 1 day postprocedure revealed partial thrombosis of the aneurysm cavity. Ultrasound contrast did not appear in the aneurysm following intravenous injection, consistent with complete exclusion from the systemic circulation. This is the first report demonstrating feasibility of contrast‐enhanced transthoracic echocardiography for the diagnosis of SVG aneurysm and confirming procedural success by documenting exclusion from the systemic circulation following intervention.