James J. Glazier

Percutaneous balloon mitral valvuloplasty

Percutaneous balloon mitral valvuloplasty, first performed by Inoue in 1982, was a rational progression from 4 decades of experience with the blunt surgical dilatation technique of closed mitral commissurotomy. As with surgical commissurotomy, balloon valvuloplasty relieves mitral stenosis by the splitting of fused commissures. A series of studies have shown that balloon valvuloplasty achieves excellent acute hemodynamic results in close to 90% of patients, with a typical 100% increase in mitral valve area. Over the past 15 years since Inoues first patient, a number of other techniques have been introduced and largely discarded in favor of the original approach. Advances have occurred along the lines of improved noninvasive assessment of mitral valve disease, which have allowed better case selection and prediction of outcome. Follow-up series have shown sustained improvement, with modest rates of complications and restenosis. Comparative studies have shown that balloon valvuloplasty is as effective and safe as surgical commissurotomy, and is a cost-effective procedure of first choice in ideal patients.

Retrospective comparative study of primary intracoronary stenting versus balloon angioplasty for acute myocardial infarction

Balloon angioplasty has been shown to be an effective therapy for the treatment of acute myocardial infarction but is associated with a high restenosis rate, substantial early recoil, persistent thrombus and need for intracoronary thrombolysis, and a high rate of reclosure. Because many of the limitations of balloon angioplasty in the noninfarction setting are addressed by intracoronary stenting, we examined the results of primary stenting of 18 consecutive patients treated for acute myocardial infarction, and compared the results to those achieved with primary balloon angioplasty in 18 prior cases. Despite the presence of thrombus prior to angioplasty in 13 of the stented patients, no intracoronary thrombolytic therapy was required. Mean percent stenosis using quantitative coronary angiography was 17.7 +/- 10.2% after primary stenting compared with 43.7 +/- 20.3% after primary balloon angioplasty (P < .001). One stent patient who had all anticoagulant and antiplatelet therapy withdrawn early suffered subacute thrombosis. Patients were followed up to 3 yr. Complications were similar in two groups. We conclude that primary stenting for acute myocardial infarction results in superior angiographic appearance as well as resolution of thrombus without the need for routine thrombolysis, and is associated with a low complication rate and excellent short-term clinical patency.

Successful redeployment of an unexpanded coronary stent

We report on treatment of a patient in whom failure to deploy the distal portion of a Palmaz-Schatz stent occurred but was not recognized. After an unstable course, the patient underwent repeat coronary angiography, at which time the stent was rewired and redilated. Full deployment of the stent with restoration of TIMI grade 3 flow was achieved. The putative cause of the problem, incomplete deployment of the stent because of inadvertent advancement of the stent delivery sheath, should be avoided, and needs to be recognized if it occurs. Crossing and redilating the stent is possible, although technically difficult.

Laser balloon angioplasty combined with local intracoronary heparin therapy: Immediate and short-term follow-up results☆☆☆★

Laser balloon angioplasty (LBA) has been shown to acutely increase angiographic luminal dimensions after conventional balloon angioplasty (PTCA) without a favorable impact on chronic restenosis. Experimentally, laser and thermal energy enhance binding of heparin to the injured arterial wall and to the thrombus. In view of the anticoagulant, antiproliferative, and antifibrotic activities of the drug, a pilot study was performed to evaluate the potential safety and efficacy of LBA combined with local heparin therapy. Ten patients scheduled for elective PTCA were entered in the study. In each patient, a single lesion was treated with a laser balloon and coated with a heparin film (3000 I.U. at a concentration > 100,000 I.U./gm) immediately after optimal PTCA. The mean minimum luminal diameter and mean percent stenosis of the 10 treated lesions after PTCA were 1.62 +/- 0.39 mm and 37% +/- 9%, respectively. After LBA and local heparin therapy, the mean minimal lumen diameter increased to 2.01 +/- 0.34 mm (p < 0.01) and the mean percent stenosis decreased to 20% +/- 10% (p < 0.01). Systemic heparin was discontinued immediately after the procedure in all patients. Acute or inhospital complications, either major or minor, occurred in none (0%) of the 10 patients (95% confidence interval 0% to 31%); all were discharged home on the day after the procedure. All patients remained well and free of cardiac symptoms for at least 2 months after the procedure. However, restenosis developed in six (60%) of the 10 patients (95% confidence interval 26% to 88%) 2 to 6 months after the procedure. The results suggest that LBA and local heparin therapy, with discontinuation of systemic heparin immediately after angioplasty, is a safe treatment modality that yields favorable acute angiographic results.

Atresia of internal thoracic artery grafts following placement to noncritically obstructed vessels.

Four patients postcoronary bypass surgery, utilizing the left internal thoracic artery as a jump graft, were found to have atresia of either the proximal segment (2 patients) or the distal interposition segment (2 patients) of this graft. In all 4 cases the atretic portion of the graft was the segment that had been anastomosed to a noncritically obstructed vessel. The segment anastomosed to the severely narrowed portion of the vessel functioned normally and approximated the target vessel size.

In Reference to Trends, Etiologies, and Predictors of 90-Day Readmission After Percutaneous Ventricular Assist Device Implantation: A National Population-Based Cohort Study

We read with interest Virk et als recent informative study regarding trends, etiologies and predictors of 90-day readmission after percutaneous ventricular assist device (pVAD) implantation. 1 We have a number of comments and concerns regarding this article. This article is protected by copyright. All rights reserved.

Left ventricular perforation after Impella placement

We read with interest Peritz et al.’s recent report of fatal left ventricular perforation occurring after placement of an Impella 2.5 catheter [1]. The device had been implanted at another center and there had been an extended delay in transfer. The authors postulate that, during transportation of the patient, the Impella catheter had migrated deep into the left ventricle and subsequently eroded through the wall. The authors do not, however, provide any information regarding the implantation procedure or postprocedural monitoring at the referring center. Without such information, it is not possible to determine when and how the perforation occurred. Indeed, it is possible that the perforation occurred soon after implantation and that the mechanism of perforation was one other than gradual erosion through the myocardium. In considering such alternative mechanisms, analysis of procedural details is key. At our center, and other centers that we are familiar with, prior to placement of the rather bulky (9 Fr) Impella catheter in the left ventricle, the aortic valve is first crossed with a 6 Fr end-hole catheter, such as a Multipurpose or Judkins right catheter. Next, an 0.1800 deployment wire is advanced through the end-hole catheter which is then changed out for the pigtail shaped Impella catheter [2]. Of these two catheter types, it is the end-hole catheter that historically has been associated with cardiac perforation [3]. Accordingly, a possible alternative explanation for the perforation occurring in the reported patient is that the perforation was actually caused by an end-hole catheter used for initial crossing of the aortic valve. Then as the deployment wire was advanced through this catheter, the wire became embedded in the area of perforation, possibly enlarging it, and, subsequently serving as a rail to the perforation site for the Impella catheter. Alternatively, the deployment wire itself may have initiated the perforation. A clearer understanding of mechanisms responsible for this newly described complication associated with implantation of the Impella device may lead to earlier detection and effective management. Accordingly, we invite the authors of this important report to provide more technical details regarding the initial implantation of the Impella device in their patient.

Successful Treatment of Occlusive Left Main Coronary Artery Dissection by Impella-Supported Stenting

We report successful treatment of a patient, who, during diagnostic angiography, developed an ostial left main coronary artery dissection with stump occlusion of the vessel. First, mechanical circulatory support with an Impella CP device was established. Then, patency of the left coronary system was achieved by placement of stents in the left anterior descending, left circumflex, and left main coronary arteries. On completion of the procedure, left ventricular systolic function, as assessed by echocardiography, was normal. At 24-month clinical follow-up, the patient remains angina-free and well. This is the first reported case of the use of an Impella device to support treatment of iatrogenic left main coronary artery dissection.