Javier León Jiménez

Trapping as retrieval technique to resolve a ruptured and entrapped coronary balloon catheter

A 69 year old male, with a previous percutaneous revascularization of the mid‐circumflex with a bare metal stent in 2007 was admitted to our centre for unstable angina. The angiography showed a severely calcified coronary tree with a functionally severe plaque on the proximal left anterior descending artery (LAD) and a critical focal lesion on the proximal right coronary artery. After a high pressure predilation on the proximal LAD, the balloon ruptured causing a retrograde LAD‐left main (LM) dissection that was rapidly sealed with three overlapping zotarolimus‐eluting stents from medial LAD to LM. We then used a new non‐compliant balloon for successive aggressive postdilation. After a difficult handling, when the balloon catheter was pulled out of the body and we realized that the tip and membranous part of the balloon‐catheter was separated from the rest, and entangled at the LM. After a first approach to retrieve the dislodged balloon with a snare, the ruptured balloon was successfully removed by trapping and withdrawing the whole system, including the guiding catheter and the wire.

Detection of spontaneous coronary artery spasm with optical coherence tomography in a patient with acute coronary syndrome

We present 2 illustrative cases of acute coronary syndrome and spontaneous coronary artery spasm evaluated by optical coherence tomography. Different spasm patterns were showed by optical coherence tomography (OCT), according to whether there were underlying atherosclerotic plaques or not.

Radial/Ulnar angioplasty in selected patients undergoing elective angiography or PCI using complex forearm approach

BACKGROUND Angioplasty on the radial artery have been performed with good success rates in patients with critical hand ischemia. We sought to assess the feasibility and safety of radial angioplasty on complex radial access in patients undergoing coronary angiography. METHODS/MATERIAL A prospective series of procedures with complex radial/ulnar access to which radial-ulnar angioplasty (RU-A) was performed. We set goals of efficacy and safety that included the success rate of the procedure (need for ¨Crossover femoral¨) and the existence of radial pulse at one month. RESULTS 18 cases of RU-A out of 11,500 procedures from March 2010 to July 2016 (0.15%) were included. The majority of the patients were men with a variety of cardiovascular risk factors (age 71±9; 94% Hypertensive, 56% Diabetic, 18% chronic kidney disease). The most common indication for radial/ulnar angioplasty was severe arteriosclerotic stenosis. Angioplasty was performed with different types of over the wire peripheral balloons (Mean diameter 4,3±1 and mean length 42±15mm), in one case a stent implantation was needed. The success rate was 100% without vascular complications at 1-month clinical and vascular doppler follow-up. CONCLUSIONS Radial/ulnar artery angioplasty is feasible and safe in selected patients undergoing elective angiography or percutaneous coronary intervention using complex forearm approach.

Spontaneous Coronary Artery Dissection and Hypothyroidism

INTRODUCTION AND OBJECTIVES Thyroid hormone affects the metabolism of all tissues in the body. The aim of this study was to analyze the prevalence and implications of thyroid disorders in a cohort of consecutive patients with spontaneous coronary artery dissection (SCAD). METHODS A total of 73 patients with SCAD were analyzed. Baseline characteristics and clinical outcomes were compared between euthyroid and hypothyroid patients. Subsequently, the prevalence of thyroid function abnormalities and the clinical characteristics of SCAD patients were compared with those in 73 patients with acute coronary syndrome but without SCAD, matched by age, sex, and presentation. RESULTS Mean age was 55 ± 12 years and 26% had hypothyroidism. Compared with patients with normal thyroid function, patients with SCAD and hypothyroidism were all women (100% vs 69%, P = .01), more frequently had dissection in distal (74% vs 41%, P = .03) and tortuous coronary segments (68% vs 41%, p = .03), and more frequently received conservative medical management (79% vs 41%, P = .007). During a mean clinical follow-up of 4.1 ± 3.8 years, 23% of the patients had adverse cardiac events irrespective of thyroid function status. The prevalence of hypothyroidism was higher in patients with SCAD than in matched patients with acute coronary syndrome without SCAD (26% vs 8%, P = .004). CONCLUSIONS There is a high prevalence of hypothyroidism in patients with SCAD. Patients with SCAD and hypothyroidism are more frequently women, more frequently have distal dissections in tortuous vessels, and are more frequently managed with a conservative medical strategy.

Bioresorbable Scaffolds in Spontaneous Coronary Artery Dissection: Long-Term Follow-Up in 4 Patients

Spontaneous coronary artery dissection is a rare condition, and diagnosis and treatment are challenging among patients who present with acute coronary syndrome. Typically, the condition affects young females who have no underlying atherosclerotic disease. To date, few cases of bioresorbable scaffold implantation for the treatment of spontaneous coronary artery dissection have been reported. Therefore, we describe the cases of 4 patients whom we treated with scaffolds. We evaluated the long-term results by using intravascular ultrasound and optical coherence tomographic scanning.Spontaneous coronary artery dissection is a rare condition, and diagnosis and treatment are challenging among patients who present with acute coronary syndrome. Typically, the condition affects young females who have no underlying atherosclerotic disease. To date, few cases of bioresorbable scaffold implantation for the treatment of spontaneous coronary artery dissection have been reported. Therefore, we describe the cases of 4 patients whom we treated with scaffolds. We evaluated the long-term results by using intravascular ultrasound and optical coherence tomographic scanning.

Metallic Stent Optimization in Dedicated Bifurcation Stent Assessment

The patient was a 67-year-old man, with a history that included hypertension, diabetes, and dyslipidemia. He presented with a non–STsegment elevation lateral myocardial infarction. The Figure 1A shows a severe bifurcation lesion (1,0,0) (arrow) in the circumflex artery, which was resolved by implantation of a specific stent for bifurcations (3.5 14 mm Axxess) (Figure 1B, box), with a good angiographic result (Figure 1B). Optical coherence tomography using 3-dimensional reconstruction confirmed the correct apposition of the stent in distal terms and the proper covering of the ostium of both branches, leaving the carina free of struts (Figure 2). Using the OPTIS Metallic Stent Optimization software package, we processed the images (Figure 2, Figure 3A, Figure 3B, and Video of the supplementary material), in which it is possible to see a discernible poor apposition at the middle level and very poor apposition at the proximal level. The struts colored in yellow represent slightly poor apposition, whereas those in red reflect considerably poor apposition (> 300 mm). Given these findings, we performed postdilatation with an unadaptable balloon, and the angiographic results were excellent, as shown by optical coherence tomography. The results after implantation were evaluated using intracoronary imaging techniques, especially when the lesions involved the bifurcation. They were very useful despite the good angiographic results. Reconstruction using the Metallic Stent Optimization system shows, in a novel, rapid and highly illustrative way, the results after the implantation.

Left ventricle rupture during percutaneous coronary intervention

Rupture of the free wall of the left ventricle (LV) after acute myocardial infarction (AMI) is a rare complication, with an incidence in the era of interventional cardiology of less than 1–2%. It accounts for 2–5% of hospital deaths in the context of AMI. Occurs in 50% of patients during the first five days after AMI, reaching 90% in the first two weeks. Older women, especially those with recurrent postinfarction angina, and patients with systemic hypertension more commonly experience myocardial rupture after AMI. Although transthoracic echocardiography is the urgent diagnostic technique of choice, there is rarely enough time to perform it given the rapid haemodynamic deterioration. Although only a few patients exceed the acute phase to reach the operating room, survival after surgery is over 70%. We report the case of a 79-year-old female patient with a history of hypertension and dyslipidaemia who was transferred to our unit with an evolved inferior ST segment elevation myocardial infarction (Fig. 1). Elective coronary angiography was performed 72 h later and showed a left dominant coronary tree, with a thrombotic occlusion of the mid circumflex artery (Suppl. Video 1 — see journal website). After wiring the thrombotic occlusion (white arrow in Fig. 2A, Suppl. Video 2 — see journal website) the patient suffered a sudden haemodynamic deterioration followed by electromechanical dissociation and cardiac arrest. Whereas the aortography ruled out acute aortic syndrome, (Suppl. Video 3 — see journal website) the ventriculography showed a significant pericardial effusion (white arrow in Fig. 2B, Suppl. Video 4 — see journal website) secondary to in-situ LV free wall rupture at inferoapical level (blue arrow in Fig. 2C, Suppl. Video 5 — see journal website). Despite advanced cardiopulmonary resuscitation and emergency pericardiocentesis, the patient eventually died. Diagnosis of free wall rupture is strongly suspected when a patient with a high-risk profile — age > 55 years, first transmural acute myocardial infarct, absence of overt heart failure, persistent ST segment elevation, prolonged pain during the acute phase — presents with sudden hypotension or electromechanical dissociation, often preceded by recurrence of chest pain, together with raised jugular venous pressure and a moderate-to-severe pericardial effusion on echocardiography/angiography. To avoid semantic confusion, it is proposed that the term “acute free wall rupture” be reserved for patients with cardiac arrest caused by electromechanical dissociation or severe hypotension. When cardiac arrest has occurred, management includes cardiac massage, ventilatory support, administration of inotropic agents and colloids, and pericardiocentesis. If improvement occurs, conservative management is then continued in close consultation with the surgical team. If initial management does not result in improvement, emergency thoracotomy is performed, preferably without cardiopulmonary bypass, and the rupture site is repaired with a Teflon patch glued to the epicardium. To the best of our knowledge, this is the first reported case, angiographically recorded, of LV rupture during percutaneous coronary intervention. Unfortunately, the patient eventually died.

Pęknięcie wolnej ściany lewej komory podczas przezskórnej interwencji wieńcowej

Rupture of the free wall of the left ventricle (LV) after acute myocardial infarction (AMI) is a rare complication, with an incidence in the era of interventional cardiology of less than 1–2%. It accounts for 2–5% of hospital deaths in the context of AMI. Occurs in 50% of patients during the first five days after AMI, reaching 90% in the first two weeks. Older women, especially those with recurrent postinfarction angina, and patients with systemic hypertension more commonly experience myocardial rupture after AMI. Although transthoracic echocardiography is the urgent diagnostic technique of choice, there is rarely enough time to perform it given the rapid haemodynamic deterioration. Although only a few patients exceed the acute phase to reach the operating room, survival after surgery is over 70%. We report the case of a 79-year-old female patient with a history of hypertension and dyslipidaemia who was transferred to our unit with an evolved inferior ST segment elevation myocardial infarction (Fig. 1). Elective coronary angiography was performed 72 h later and showed a left dominant coronary tree, with a thrombotic occlusion of the mid circumflex artery (Suppl. Video 1 — see journal website). After wiring the thrombotic occlusion (white arrow in Fig. 2A, Suppl. Video 2 — see journal website) the patient suffered a sudden haemodynamic deterioration followed by electromechanical dissociation and cardiac arrest. Whereas the aortography ruled out acute aortic syndrome, (Suppl. Video 3 — see journal website) the ventriculography showed a significant pericardial effusion (white arrow in Fig. 2B, Suppl. Video 4 — see journal website) secondary to in-situ LV free wall rupture at inferoapical level (blue arrow in Fig. 2C, Suppl. Video 5 — see journal website). Despite advanced cardiopulmonary resuscitation and emergency pericardiocentesis, the patient eventually died. Diagnosis of free wall rupture is strongly suspected when a patient with a high-risk profile — age > 55 years, first transmural acute myocardial infarct, absence of overt heart failure, persistent ST segment elevation, prolonged pain during the acute phase — presents with sudden hypotension or electromechanical dissociation, often preceded by recurrence of chest pain, together with raised jugular venous pressure and a moderate-to-severe pericardial effusion on echocardiography/angiography. To avoid semantic confusion, it is proposed that the term “acute free wall rupture” be reserved for patients with cardiac arrest caused by electromechanical dissociation or severe hypotension. When cardiac arrest has occurred, management includes cardiac massage, ventilatory support, administration of inotropic agents and colloids, and pericardiocentesis. If improvement occurs, conservative management is then continued in close consultation with the surgical team. If initial management does not result in improvement, emergency thoracotomy is performed, preferably without cardiopulmonary bypass, and the rupture site is repaired with a Teflon patch glued to the epicardium. To the best of our knowledge, this is the first reported case, angiographically recorded, of LV rupture during percutaneous coronary intervention. Unfortunately, the patient eventually died.

TCT-586 Utility of intracoronary imaging techniques in the characterisation of substrates causing acute coronary syndrome in normal o near normal coronary angiography (NONCA)

angle ( ) 70.5 14.4 58.5 22.2 0.007 Santiago Jesús Camacho Freire, Antonio Gomez Menchero, Javier Leon Jimenez, Rosamariacardenal Piris, Jessica Roa-Garrido, jose morgado, Prudenciagomez Fernandez, Francisco Javier Landero Garcia, J.F. Diaz Fernandez University Hospital Juan Ramón Jiménez, Ecija, Spain; Juan Ramon Jiminez, Huelva, Spain; Hospital Juan Ramon Jimenez, Seville, Spain; SAS, Huelva, Spain; Servicio Andaluz de Salud, HUELVA, Spain; SAS, sevilla, Spain; Hospital Juan Ramon Jimenez, Huelva, Spain; National Taiwan University Hospital, Huelva, Spain; University Hospital Juan Ramon Jimenez, Huelva, Spain

TCT-46 Coronary artery aneurysms: incididence, etiology, management and outcomes in a long-term follow up.

Coronary artery aneurysm (CAA) is defined as coronary dilatation which exceeds the normal adjacent segments or the diameter of the patients largest coronary vessel by 1.5 times. The aim of this study was to evaluate the incidence, etiology, clinical features, management and long term outcomes of