Dual catheter technique for the treatment of severe coronary artery perforations

Objectives : To evaluate the outcome of patients with coronary perforations who were treated with the dual catheter approach. Background : Coronary artery perforation is a grave complication of percutaneous coronary intervention (PCI) with high mortality and morbidity. Treating a coronary artery perforation with two catheters through dual access enables a rapid delivery of covered stent or coils to the vessel, without losing control of the perforation site. Methods : We retrospectively reviewed all patients who had a severe coronary perforation during a PCI in our center, and compared outcomes of patients treated with the dual versus the traditional single guiding catheter approach. Results : Between April 2004 and October 2008, 13,466 PCI's were performed in Columbia University – New York Presbyterian Medical Center. There were 33 documented cases of coronary perforations during that period of time (0.245%), among these, 26 were angiographically severe (Ellis type 2 or 3 perforations). Eleven patients were treated acutely with a dual catheter technique whereas the other fifteen patients were treated using a single guiding catheter. In the dual catheter group one patient expired after emergent CABG (9.1%), and four patients underwent emergent paricardiocentesis (36.4%). In patients treated with single catheter, there were three deaths (20%), two surgical explorations (13.3%), eight emergent pericardiocenthesis (53.3%), and one event of severe anoxic brain damage (6.7%). Conclusion : The dual catheter technique is a relatively safe and reproducible approach to treat a PCI induced severe coronary artery perforation, and may improve outcome compared to historical series. © 2010 Wiley‐Liss, Inc.     

Adverse event rates in congenital cardiac catheterization — A multi‐center experience

Objectives : To describe case mix variation among institutions, and report adverse event rates in congenital cardiac catheterization by case type. Background : Reported adverse event rates for patients with congenital heart disease undergoing cardiac catheterization vary considerably, due to non‐comparable standards of data inclusion, and highly variable case mix. Methods : The Congenital Cardiac Catheterization Outcomes Project (C3PO) has been capturing case characteristics and adverse events (AE) for all cardiac catheterizations performed at six pediatric institutions. Validity and completeness of data were independently audited. Results : Between 2/1/07 and 4/30/08, 3855 cases (670 biopsy, 1037 diagnostic, and 2148 interventional) were recorded, median number of cases per site 480 (308 to 1526). General anesthesia was used in 70% of cases (28 to 99%), and 22% of cases (15 to 26%) were non‐electively or emergently performed. Three institutions performed a higher proportion of interventions during a case, 72 to 77% compared to 56 to 58%. The median rate of AE reported per institution was 16%, ranging from 5 to 18%. For interventional cases the median rate of AE reported per institution was 19% (7 to 25%) compared to 10% for diagnostic cases (6 to 16%). The incidence of AE was significantly higher for interventional compared to diagnostic cases (20% vs 10%, p<0.001), as was the incidence of higher severity AE (9% vs 5%, p<0.001). Adverse events in biopsy cases were uncommon. Conclusions : In this multi‐institutional cohort, the incidence of AE is higher among interventional compared to diagnostic cases, and is very low among biopsy cases. Equitable comparisons among institutions will require the development and application of risk adjustment methods.     

One‐stop shop: Simultaneous direct mitral annuloplasty and percutaneous mitral edge‐to‐edge repair in a patient with severe mitral regurgitation

Percutaneous edge‐to‐edge repair of severe mitral regurgitation has been established as an alternative treatment option for patients at high risk for cardiac surgery. More recently, the introduction of the Cardioband system enabled percutaneous direct annuloplasty. Here, we present a case of simultaneous percutaneous direct annuloplasty with edge‐to‐edge repair. Moreover, annuloplasty did facilitate clip implantation bei approximating the anterior and posterior mitral leaflet. In conclusion, the combination of direct annuloplasty with edge‐to‐edge repair is feasible in a single procedure.     

Myocardial Scar in Sarcoidosis by 12‐lead ECG and Pathology

This case demonstrates the use of QRS scoring to quantify myocardial scar in a patient with cardiac sarcoidosis and left bundle branch block who progressively received an implantable defibrillator, cardiac resynchronization therapy (CRT), left ventricular assist device and cardiac transplantation. QRS scoring has been shown to correlate with magnetic resonance imaging measurements of scar, identify arrhythmogenic substrate and predict response to CRT, but had not previously been compared to pathology‐documented scar in nonischemic cardiomyopathies. Further study is warranted to assess the ability of QRS scoring to guide therapy for individual patients. Ann Noninvasive Electrocardiol 2011;16(2):219–222     

Cooled Ablation

Research on cooled ablation has been evolving for the last 10 years. Findings and current applications are reviewed. A cooled ablation catheter is approved by the FDA for use in idiopathic ventricular tachycardia (VT) patients, based on data originally submitted by Cardiac Pathways, Inc. This technology has subsequently been used by the clinicians in atrial flutter cases, nonischemic VT, epicardial accessory pathways, and atrial fibrillation. The experience at Johns Hopkins suggests that cooled radiofrequency ablation has utility in a variety of situations and in some instances has come to be the ablation system of choice.     

NAFLD is related to Post‐prandial Triglyceride‐enrichment of HDL Particles in Association with Endothelial and HDL Dysfunction

NAFLD is closely related with the metabolic syndrome (MetS) and increased risk of cardiovascular disease. Liver fat associates with post‐prandial hypertriglyceridemia, potentially contributing to triglyceride‐enrichment of high‐density lipoproteins (HDL‐TG), and subsequent HDL dysfunction. We assessed liver fat by MR spectroscopy, and its association with HDL physiochemical properties, and endothelial function, measured as flow‐mediated dilation (FMD), before and following three consecutive meals, in 36 men with type 2 diabetes mellitus (T2DM), with the MetS, and controls. Plasma triglycerides increased significantly following the meals (P < .001). Fasting HDL‐TG was highest in T2DM, relative to MetS and controls (P = .002), and increased post‐prandially in all groups (P < .001). HDL function was negatively associated with HDL‐TG following three meals (r = ?.32, P<.05). Liver fat associated with HDL‐TG after three meals (r = .65, P < .001). HDL‐TG was independently associated with FMD following three consecutive meals (r = ?.477, P = .003). We conclude liver fat is associated with post‐prandial HDL‐TG enrichment which was closely related with endothelial and HDL dysfunction.     

Successful Use of Wearable Cardioverter Defibrillator in a Patient with Dextrocardia and Persistent Left Superior Vena Cava

Congenital disorders, such as dextrocardia and persistent left superior vena cava, are rare. However, their presence is often associated with other cardiac anomalies, and may lead to lethal ventricular tachyarrhythmias, which result in sudden cardiac death. Treating patients with these disorders can present a challenge to clinicians, as it may cause technical difficulties during interventional procedures, and more often, altered defibrillation techniques in a setting of prehospital sudden cardiac arrest. This report describes the first case of successful defibrillation therapy delivered by the wearable cardioverter defibrillator to a patient with dextrocardia and persistent left superior vena cava during a ventricular tachycardia arrest.     

No evidence of transfusion transmission of Adenovirus and Epstein–Barr virus infections in paediatric recipients post–bone marrow transplant

Adenovirus and Epstein–Barr virus can cause significant morbidity and mortality in paediatric patients post–bone marrow transplant. The source of infection is thought to be either reactivation of latent viruses or primary infection. We have investigated whether transfusion of blood components from viraemic donors could provide a route of primary infection in these patients and sought the prevalence of viraemia in the blood donor population from England. In 32 linked donor/recipient samples and 300 unselected blood donors, we found no evidence to suggest that these infections in paediatric bone marrow transplant recipients had been acquired from transfused blood components.     

Catheter Ablation of Atrial Tachycardia Following Atrial Fibrillation Ablation

Atrial tachycardias represent the second front of atrial fibrillation (AF) ablation. They are frequently encountered during the index ablation for patients with persistent AF and are common following ablation of persistent AF, occurring in half of all patients who have had AF successfully terminated. An atrial tachycardia is rightly seen as a failure of AF ablation, as these tachycardias are poorly tolerated by patients. This article describes a simple, practical approach to diagnosis and ablation of these atrial tachycardias.     

Magnetocardiographically-Guided Catheter Ablation

After more than 30 years since the first magnetocardiographic (MCG) recording was carried out with induction coils, MCG is now approaching the threshold of clinical use. During the last 5 years, in fact, there has been a growing interest of clinicians in this new method which provides an unrivalled accuracy for noninvasive, three-dimensional localization of intracardiac source. An increasing number of laboratories are reporting data validating the use of MCG as an effective method for preoperative localization of arrhythmogenic substrates and for planning the best catheter ablation approach for different arrhythmogenic substrates. In this article, available data from literature have been reviewed. We consider the clinical use of MCG to localize arrhythmogenic substrates in patients with Wolff-Parkinson-White syndrome and in patients with ventricular tachycardia in order to assess the state-of-the-art of the method on a large number of patients. This article also addresses some suggestions for industrial development of more compact, medically oriented MCG equipments at reasonable cost.