James A. Goldstein

Percutaneous Mechanical Support for the Failing Right Heart

Right ventricular (RV) failure is an increasingly common clinical problem that may require mechanical support. In contrast to severe left ventricular failure, RV failure is typically more reversible. Therefore, application of shorter-term percutaneous support devices is potentially attractive. Current innovations promise greater availability of such percutaneous RV support devices. This article considers the available mechanical approaches to provide hemodynamic support to treat profound RV failure in the common clinical scenarios in which percutaneous mechanical RV support may be most beneficial.

A novel complete radiation protection system eliminates physician radiation exposure and leaded aprons.

Occupational health hazards associated with fluoroscopic‐based procedures are well known, including a high prevalence of orthopedic problems, and those related to radiation exposure, particularly cancer and cataracts. This article reports the “first‐in‐man” clinical experience with a novel radiation protection system designed to eliminate radiation exposure to operators and thereby obviate the need for orthopedically burdensome leaded aprons. The Trinity Radiation Protection System consists of a combination of fixed shields, radiation drapes, and interconnecting flexible radiation resistant materials creating a complete radiation protection environment for the operators, yet maintaining full and unimpeded contact with the patient and total control of all operational elements of the catheterization equipment.

Orthopedic afflictions in the interventional laboratory: tales from the working wounded.

The breadth and pace of interventional innovations have been astonishing, yielding gratifying benefits to our patients and society. Ironically, while taming diseases once intractable, the medical professionals working in the interventional fluoroscopic laboratory are subjected to distinct

Plaque disruption by coronary computed tomographic angiography in stable patients vs. acute coronary syndrome: a feasibility study

AIMSnThis study was designed to determine whether coronary CT angiography (CTA) can detect features of plaque disruption in clinically stable patients and to compare lesion prevalence and features between stable patients and those with acute coronary syndrome (ACS).nnnMETHODSnWe retrospectively identified patients undergoing CTA, followed by invasive coronary angiography (ICA) within 60 days. Quantitative 3-vessel CTA lesion analysis was performed on all plaques ≥25% stenosis to assess total plaque volume, low attenuation plaque (LAP, <50 HU) volume, and remodelling index. Plaques were qualitatively assessed for CTA features of disruption, including ulceration and intra-plaque dye penetration (IDP). ICA was employed as a reference standard for disruption. A total of 145 (94 ACS and 51 stable) patients were identified. By CTA, plaque disruption was evident in 77.7% of ACS cases. Although more common among those with ACS, CTA also detected plaque disruption in 37.3% of clinically stable patients (P < 0.0001).nnnCONCLUSIONSnClinically stable patients commonly manifest plaques with features of disruption as determined by CTA. Though the prevalence of plaque disruption is less than patients with ACS, these findings support the concept that some clinically stable patients may harbour silent disrupted plaques. These findings may have implications for detection of at risk plaques and patients.

Invasive evaluation of plaque morphology of symptomatic superficial femoral artery stenoses using combined near-infrared spectroscopy and intravascular ultrasound

The purpose of this study is to characterize the plaque morphology of severe stenoses in the superficial femoral artery (SFA) employing combined near-infrared spectroscopy and intravascular ultrasound (NIRS-IVUS). Atherosclerosis is the most common cause of symptomatic peripheral arterial disease. Plaque composition of SFA stenoses has been characterized as primarily fibrous or fibrocalcific by non-invasive and autopsy studies. NIRS has been validated to detect lipid-core plaque (LCP) in the coronary circulation. We imaged severe SFA stenoses with NIRS-IVUS prior to revascularization in 31 patients (46 stenoses) with Rutherford claudication ⩾ class 3. Angiographic parameters included lesion location and stenosis severity. IVUS parameters included plaque burden and presence of calcium. NIRS images were analyzed for LCP and maximum lipid-core burden index in a 4-mm length of artery (maxLCBI4mm). By angiography, 38 (82.6%) lesions were calcified and 9 (19.6%) were chronic total occlusions. Baseline stenosis severity and lesion length were 86.0 ± 11.0% and 36.5 ± 46.5 mm, respectively. NIRS-IVUS identified calcium in 45 (97.8%) lesions and LCP in 17 (37.0%) lesions. MaxLCBI4mm was 433 ± 244. All lesions with LCP also contained calcium; there were no non-calcified lesions with LCP. In conclusion, this is the first study of combined NIRS-IVUS in patients with PAD. NIRS-IVUS demonstrates that nearly all patients with symptomatic severe SFA disease have fibrocalcific plaque, and one-third of such lesions contain LCP. These findings contrast with those in patients with acute coronary syndromes, and may have implications regarding the pathophysiology of atherosclerosis in different vascular beds.

Acute right ventricular infarction.

This article reviews the pathophysiology, hemodynamics, natural history, and management of patients with inferior myocardial infarction complicated by right ventricular infarction. Five key areas are highlighted in which advances may impact catheterization and laboratory management of these acutely ill patients.

Severe mitral regurgitation and biventricular heart failure successfully treated with biventricular percutaneous axial flow pumps as a bridge to mitral valve surgery.

Prompt recognition of acute right ventricular failure is essential in order to provide timely hemodynamic support. We report a case of a patient with severe mitral regurgitation complicated by cardiogenic shock that failed to improve with left ventricular support alone. The recognition of concomitant right ventricular failure led to the addition of a right ventricular support device, resulting in dramatic hemodynamic improvement.

Periprocedural myocardial infarction: It's the plaque, not the stent†

Although percutaneous coronary intervention (PCI) routinely achieves excellent angiographic success, 3– 15% of cases (depending on the definition) are complicated by periprocedural myocardial infarction (PMI), associated with adverse long-term outcomes and in some cases immediate adverse events due to profound no-reflow [1,2]. PMI has been attributed to distal embolization of lipid-core plaque (LCP) contents and/ or intraluminal thrombus [1–7]. The present report by Tandjunga et al. [8] addresses whether stent type influences the incidence of PMI. This retrospective analysis compared the incidence of PMI in patients undergoing treatment with first versus second generation drug eluting stents (DES). Routine peri-interventional assessment of cardiac biomarkers defined PMI according to an ‘‘ updated definition’’ as 23 upper reference limit (URL) of creatine kinase (CK); these enzymatic results were then compared to PMI calculated by ‘‘traditional’’ criteria (>33URL CK MB). In these 800 patients, a total of 1522 DES (363 Taxus; 385 Endeavor; 382 Xience V; 392 Resolute) were implanted to treat 1232 lesions. Overall, there was a low incidence of PMI (4.75%), with no difference between first and second generation DES (5.5% vs. 4.0%; P 5 0.29). The only independent predictors of PMI were presentation with acute coronary syndrome (ACS) and the total number of stents implanted.

Cardio-Oncology: Implications for interventionists.

CV complications in cancer patients predominantly result from collateral damage from chemotherapy and radiation Complex interplay of manifold pathophysiologic processes poses evaluation challenges and management conundrums. Pre‐cath planning essential, employing advanced non‐invasive imaging of myocardium, PC, and great vessels.

Decompressing the left atrium to relieve the right ventricle.

The benefits of ventricular assist devices (VAD) for hemodynamic stabilization of cardiogenic shock due to left ventricular (LV) and/or right ventricular (RV) pump failure are well established [1]. VAD’s, both surgically implanted and percutaneous, have been predominantly used in patients with ventricular “contractile failure” resulting from acute myocardial infarction, refractory decompensated congestive heart failure, and in various post-surgical settings. The present case report [2] describes the use of the percutaneous Tandem Heart LVAD in a patient with “acute-on-chronic” severe mitral regurgitation (MR), causing pulmonary edema, pulmonary arterial hypertension (PAHTN), RV failure (RVF), and ultimately cardiogenic shock. The magnitude of RVF gave caution to mitral valve surgery, accordingly the LVAD was placed both to reduce left atrial pressure (LAP) and unload the pulmonary circulation (thereby relieving the RV) and concomitantly mechanically enhancing forward cardiac output (CO) and aortic pressure (AOP). The benefits were immediate and impressive: Reduction in LA, PA, and right heart pressures, with simultaneous increments in systemic CO and AOP. The hemodynamic relief provided allowed surgery to subsequently proceed with a recovered RV and excellent clinical outcome. This innovative deployment of an LVAD stabilized this patient suffering from an incompetent mitral valve. Although the primary mechanism of hemodynamic collapse differed from the usual “pump failure” indication for VAD, the ultimate hemodynamic goals were similar: Unload the lungs and RV, while restoring systemic perfusion.