Deepak Kapoor

Coarctation of the aorta: a secondary cause of hypertension.

Coarctation of the aorta is a constriction of the aorta located near the ligamentum arteriosum and the origins of the left subclavian artery. This condition may be associated with other congenital disease. The mean age of death for persons with this condition is 34 years if untreated, and is usually due to heart failure, aortic dissection or rupture, endocarditis, endarteritis, cerebral hemorrhage, ischemic heart disease, or concomitant aortic valve disease in uncomplicated cases. Symptoms may not be present in adults. Diminished and delayed pulses in the right femoral artery compared with the right radial or brachial artery are an important clue to the presence of a coarctation of the aorta, as are the presence of a systolic murmur over the anterior chest, bruits over the back, and visible notching of the posterior ribs on a chest x‐ray. In many cases a diagnosis can be made with these findings. Two‐dimensional echocardiography with Doppler interrogation is used to confirm the diagnosis. Surgical repair and percutaneous intervention are used to repair the coarctation; however, hypertension may not abate. Because late complications including recoarctation, hypertension, aortic aneurysm formation and rupture, sudden death, ischemic heart disease, heart failure, and cerebrovascular accidents may occur, careful follow‐up is required.

Angina, an Unusual and Late Complication of the Cabrol Procedure: A Case Report and Review of the Literature

Several techniques exist for surgical reimplantation of the coronary arteries to a composite aortic graft for repair of the ascending aorta. The Cabrol graft is an attachment of a Dacron tube between the coronary arteries and the composite aortic graft in aortic root replacement. Very late presentation of myocardial ischemia related to the Cabrol conduit graft is exceedingly rare. We report a rare and late development of angina due to a dysfunctional Cabrol conduit, which was successfully cured with coronary bypass grafting. Knowledge of this technique is vital for the accurate interpretation of coronary angiograms and CT scan findings and crucial for the treatment planning in patients who have had previous implantation of the Cabrol graft.

Utility of the HAS-BLED Score in Risk Stratifying Patients on Dual Antiplatelet Therapy Post 12 Months After Drug-Eluting Stent Placement

Current guidelines recommend continuation of dual anti‐platelet therapy (DAPT) for 12 months after percutaneous coronary intervention (PCI). Recent studies have shown benefit in continuing DAPT beyond 12 months but at the risk of increase bleeding. To date, there has been little data on risk stratifying patients to determine who can continue DAPT beyond 12 months at minimal bleeding risk. Methods: All patients who underwent drug‐eluting stent (DES) placement from January 1, 2013 to September 30, 2014 were reviewed. Patients who had follow‐up for at least 12 months, placement of 2nd generation everolimus‐coated DES, and were on DAPT for at least 12 months were included. Patients with a history of atrial fibrillation, follow‐up time less than 12 months, or were on concurrent oral anticoagulation therapy were excluded. Results: Five hundred thirty‐one patients were analyzed as described above. Two hundred two patients included in our study with 7 patients in the bleeding cohort and 195 patients in no‐bleed cohort. The HAS‐BLED score in patients who had a bleeding episode vs. those who did not was 3.29 vs. 2.24 (P value of 0.0009). Although not statistically significant, patients who had a bleeding episode were more likely to have renal dysfunction, alcohol use, be on prasugrel, and be on 325mg of aspirin. Conclusion: The study shows that the HAS‐BLED score can be of utility in risk stratifying patients in determining who can continue DAPT beyond 12 months. Furthermore, a HAS‐BLED score of less than 2 may help guide extended DAPT beyond 12 months at minimal bleeding risk.

How to prevent and manage radiation-induced coronary artery disease

Radiation-induced coronary heart disease (RICHD) is the second most common cause of morbidity and mortality in patients treated with radiotherapy for breast cancer, Hodgkin’s lymphoma and other prevalent mediastinal malignancies. The risk of RICHD increases with radiation dose. Exposed patients may present decades after treatment with manifestations ranging from asymptomatic myocardial perfusion defects to ostial, triple-vessel disease and sudden cardiac death. RICHD is insidious, with a long latency and a tendency to remain silent late into the disease course. Vessel involvement is often diffuse and is preferentially proximal. The pathophysiology is similar to that of accelerated atherosclerosis, characterised by the formation of inflammatory plaque with high collagen and fibrin content. The presence of conventional risk factors potentiates RICHD, and aggressive risk factor management should ideally be initiated prior to radiation therapy. Stress echocardiography is more sensitive and specific than myocardial perfusion imaging in the detection of RICHD, and CT coronary angiography shows promise in risk stratification. Coronary artery bypass grafting is associated with higher risks of graft failure, perioperative complications and all-cause mortality in patients with RICHD. In most cases, the use of drug-eluting stents is preferable to surgical intervention, bare metal stenting or balloon-angioplasty alone.

Alarming ST-segment elevation in a young male with left anterior descending coronary artery myocardial bridging.

Chest pain continues to be one of the leading emergency department presentations. Acute coronary syndrome is the most dreaded chest pain scenario, as “time is myocardium” in this situation. Numerous benign and less life-threatening diseases like early repolarization, acute pericarditis, and vasospastic angina can present with a similar clinical picture. ST-segment elevation on an electrocardiogram can occur in all these situations and in many others, creating diagnostic dilemma. A young male with chest pain and concurrent ST-segment elevation was reported. He was ultimately discovered to have myocardial bridging of a coronary arterial segment.

Outcomes of rotational atherectomy in patients with severe left ventricular dysfunction without hemodynamic support

INTRODUCTION Elective insertion of a percutaneous circulatory assist device (PCAD) in high-risk patients is considered a reasonable adjunct to percutaneous coronary intervention (PCI). There is limited data examining the safety and efficacy of rotational atherectomy (RA) without hemodynamic support in patients with reduced left ventricular ejection fraction (LVEF). METHODS We retrospectively identified 131 consecutive patients undergoing RA without elective PCAD over a three-year period. Patients were categorized into three groups: LVEF ≤30%, LVEF 31-50%, and LVEF >50%. The incidence of procedural hypotension, major adverse cardiac events (MACE), and mortality were recorded. RESULTS Statistical analysis included 18, 42, and 71 patients with LVEF ≤30%, 31-50%, and >50%, respectively. Bailout hemodynamic support was required in four cases. Analysis revealed a significant trend as bailout hemodynamic support was required in 11.1% vs 2.4% (P = 0.1551) in the ≤30% vs 31-50% and 11.1% vs 1.4% (P = 0.0416) in the ≤30% vs >50% subgroups. Combined subgroup analysis also demonstrated statistical significance 11.1% vs 1.8% (P = 0.0324) in the ≤30% vs >30% subgroups. No-reflow phenomenon was more prevalent in patients with reduced LVEF (LVEF ≤30%: 11.1%, LVEF 31-50%: 2.4%, LVEF >50%: 0%; P = 0.0190). Otherwise, no significant differences in in-hospital MACE, or mortality were observed. CONCLUSION RA can be effectively utilized in patients with severely reduced LVEF; however, these patients are at increased risk of prolonged procedural hypotension requiring bailout hemodynamic support. If indicated, prompt implementation of hemodynamic support mitigated any impact of procedural hypotension on in-hospital MACE and mortality.

Efficacy of a heparin based rota-flush solution in patients undergoing rotational atherectomy

INTRODUCTION The efficacy of heparin based flush solutions in rotational atherectomy (RA) has not been validated. Recently, a single center study demonstrated the feasibility of an alternative flush solution with 10,000U of unfractionated heparin (UFH) in 1L of normal saline. We aimed to evaluate the safety and efficacy of an alternative flush solution intermittently utilized at our institution. METHODS We retrospectively identified 150 patients undergoing RA over a three year period. One hundred cases utilized an alternative flush solution containing 10,000U UFH, 400mcg nitroglycerin, and 10mg verapamil in 1L normal saline and fifty cases utilized RotaGlide Lubricant (Boston Scientific) in addition to heparin and vasodilators in the same dose. The primary end point was to compare rates of procedural success. Secondary endpoints were to report procedural characteristics including the incidence of major adverse cardiac events (MACE) and minor periprocedural complications. RESULTS Procedural success was achieved in 98% (98/100) of cases utilizing the alternative Rota-Flush solution compared to 100% (50/50) in the Rota-Glide group (P=0.553). A total of 292 lesions (200 Rota-Flush vs 92 Rota-Glide) were targeted for intervention. MACE occurred in 13 (13%) and 4 (8%) cases in the Rota-Flush and Rota-Glide groups, respectively (P=0.425). CONCLUSION Rotational atherectomy performed with the previously defined Rota-Flush or Rota-Glide solutions resulted in similar rates of procedural success. There were no significant disparities in incidence of MACE and minor periprocedural complications between the two groups. Heparin based rota-flush solutions can be effective alternatives to traditional solutions containing RotaGlide Lubricant.