Michael Liang

Transradial simultaneous kissing stenting (SKS) with SheathLess access

Transradial coronary intervention is usually performed via a 5 or 6 Fr sheath due to the small calibre of radial arteries. Simultaneous kissing stenting (SKS) technique requires a guiding catheter 7 Fr or larger and is therefore difficult to perform via transradial approach. Conversion to femoral approach or additional arterial access is usually required to achieve this goal. To overcome this limitation, a hydrophilic 7.5 Fr SheathLess guiding catheter can be exploited. This catheter possesses approximately the same size outer diameter as a 6 Fr sheath and an internal diameter of a 7.5 Fr catheter. A smooth and successful performance of SKS through transradial approach is described using this catheter.

Heart Rate and Cardiovascular Disease: An Alternative to Beta Blockers

Ivabradine, an I f inhibitor, acts primarily on the sinoatrial node and is used to reduce the heart rate with minimal effect on myocardial contractility, blood pressure, and intracardiac conduction. Heart rate reduction is an important aspect of care in patients with chronic stable angina and heart failure. Many patients with coronary artery disease have coexisting asthma or chronic obstructive airway disease, and most of them are unable to tolerate beta blockers. Ivabradine may thus be a useful medicine in therapeutic heart rate management especially in patients who are intolerant of beta-blockers.

Congenital Left Main Coronary Artery to Main Pulmonary Artery Fistula with Bicuspid Aortic Valve: A Case Report and Review of Literature

Abstract  Congenital coronary artery fistulas (CAFs) are uncommon abnormalities. A connection between the left main stem and main pulmonary artery is extremely rare. Congenital CAFs are frequently associated with another congenital heart disease. Associated anomalies include atrial septal defect, tetralogy of Fallot, patent ductus arteriosus, ventricular septal defect, and pulmonary atresia. Association of bicuspid aortic valve with CAF has not been reported in literature to date. We report on a 68‐year‐old man with congenital left main to pulmonary artery fistula associated with bicuspid aortic valve and moderate aortic stenoses, who underwent successful aortic valve replacement with ligation of CAF and also review the natural history, pathophysiology, and management of CAF. (J Card Surg 2010;25:295‐299)

Enterococcus gallinarum causing native valve endocarditis and aorto-atrial fistula: a case report and literature review.

Case Report: A 16-year-old female from Samoa with no known prior illness presented with a fever. She had a 4-week history of lethargy, malaise, poor appetite, and pyrexia, and had received two intramuscular injections of ceftriaxone in Samoa 2 weeks previously. She failed to improve and presented to our institution on arrival to New Zealand. She was febrile, tachycardic with mild hypotension, visible carotid neck pulsations, and had a long early diastolic murmur, with no signs of left ventricular failure. A chest x-ray showed pulmonary venous congestion and marked cardiomegaly. Her electrocardiogram (Vivid 7, GE Healthcare, Chalfont St Giles, United Kingdom) showed persistent sinus tachycardia with a normal PR interval, and no conduction abnormalities. White cell count and inflammatory markers were elevated. A transthoracic echocardiogram (TTE) showed a severely dilated left ventricle, severe aortic regurgitation, and two oscillating masses on the noncoronary and left coronary aortic valve cusps (Fig. 1; Movie clip 1). Serial blood cultures were positive for Enterococcus gallinarum and antibiotics (gentamycin and amoxicillin) were commenced. Transesophageal echocardiography (TEE) (Vivid 7) confirmed TTE findings and also demonstrated vegetations on the interventricular septum and the mitral-aortic intervalvular fibrosa, and a possible paravalvular abscess (Fig. 2; Movie clips 2a, 2b, 2c). A communication between the aorta and the right atrium was also noted, with color flow demonstrated between the two (Fig. 2; Movie clip 2d). Aortic

Mitral stenosis as a risk factor for embolic myocardial infarction--anticoagulation for some patients, individual treatment for all.

A 28 year-old lady with severe rheumatic mitral stenosis presented with non-ST-elevation myocardial infarction secondary to angiographically confirmed right coronary artery embolus with a likely source of mitral valve stenosis origin. This patient was successfully treated medically with dual anti-platelet and 72 hours of intravenous heparin, glycoprotein IIb/IIIa inhibitor and eptifibitide (Integrilin) with a repeated coronary angiogram showing complete resolution of embolus. The management of embolic myocardial infarction is discussed along with the risks of embolism in patients with mitral stenosis who remain in sinus rhythm.