Reza Arsanjani

Successful removal of an entrapped and kinked catheter during right transradial cardiac catheterization by snaring and unwinding the catheter via femoral access

Since its introduction by Campeau in 1989, the transradial approach for coronary angiography has gained significant popularity among interventional cardiologists due to its lower access site complication rates, cost-effectiveness, and shorter hospital course. Although the transradial approach is much safer than the transfemoral approach, it has its own inherent rare complications including radial artery occlusion, thrombosis, nonocclusive radial artery injury, vasospasm, and compartment syndrome. Herein, we present an unusual case of entrapment and kinking of a catheter in the radial artery, which was successfully removed by using a gooseneck snare via the transfemoral route. The distal and proximal tips were then simultaneously rotated in opposite directions, allowing for the unkinking and removal of the catheter. To our knowledge, this is the first report of this rare complication.

Antibody to granulocyte macrophage colony-stimulating factor reduces the number of activated tissue macrophages and improves left ventricular function after myocardial infarction in a rat coronary artery ligation model.

Granulocyte macrophage colony-stimulating factor (GM-CSF) promotes infarct expansion and inappropriate collagen synthesis in a myocardial infarction (MI). This study was designed to determine if treatment with anti-GM-CSF will inhibit macrophage migration, preserve function, and limit left ventricular (LV) remodeling in the rat coronary artery ligation model. Treatment with a monoclonal antibody to GM-CSF (5 mg/kg) was initiated 24 hours before coronary artery ligation and continued every 3 days for 3 weeks. Left coronary arteries of rats were ligated, animals were recovered, and cardiac function was evaluated 3 weeks postligation. Tissue samples were processed for histochemistry. Anti-GM-CSF treatment increased LV ejection fraction (37 ± 3% vs 47 ± 5%) and decreased LV end systolic diameter (0.75 ± 0.12 vs 0.59 ± 0.05 cm) with no changes in LV systolic pressure (109 ± 4 vs 104 ± 5 mm Hg), LV end diastolic pressure (22 ± 4 vs 21 ± 2 mm Hg), LV end diastolic diameter (0.96 ± 0.04 vs 0.92 ± 0.05 cm), or the time constant of LV relaxation tau (25.4 ± +2.4 vs 22.7 ± 1.4 milliseconds) (P < 0.05). Significantly lower numbers of tissue macrophages and significant reductions in infarct size were found in the myocardium of antibody-treated animals (81 ± 21.24 vs 195 ± 31.7 positive cells per 0.105 mm2, compared with controls. These findings suggest that inhibition of macrophage migration may be beneficial in the treatment of heart failure after MI.

Modified Thrombolytic Therapy for Massive Pulmonary Emboli

Cardiac arrest in the setting of massive pulmonary embolism requiring cardiopulmonary resuscitation (CPR) is often fatal and requires immediate thrombolytic therapy. The recommended tissue plasminogen activator (tPA) dose used for pulmonary embolism is a fixed dose of 100 mg of tPA given over 2 hours, which is inadequately slow. troke protocol uses a much faster tPA infusion time (inravenous tPA 0.9 mg/kg, maximum 90 mg; with 10% of the ose given as a bolus followed by an infusion lasting 60 inutes) without the use of heparin. In this report, we resent a case of a patient with a thrombus in transit through he right ventricle detected on transthoracic echocardioram, subsequently causing a massive pulmonary embolism nd cardiac arrest. The tPA stroke protocol along with 0,000 units of heparin was successfully implemented with ull recovery.

Unusual Combination of Holt-Oram Syndrome and Persistent Left Superior Vena Cava

UNLABELLED Holt-Oram (HO) is a syndrome characterized by congenital cardiovascular malformations, specifically atrial and ventricular septal defects, and skeletal abnormalities of the upper limbs bones. Associations of HO cardiac disorders with other congenital cardiac malformations, specifically persistent left superior vena cava (PLSVC) are rarely reported and its real incidence is unknown. We present a case of this unusual combination in a patient undergoing cardiac resynchronization therapy (CRT) device implant. METHODS AND RESULTS A 63-year-old male with HO and a history of repaired atrial septal defect was presented for implantable cardioverter defibrillator (ICD) upgrade to CRT. The old implant was located in the right prepectoral area. The old device pocket in the right was accessed and a venous access to the right subclavian vein was obtained. The coronary sinus (CS) was easily cannulated and a long sheath advanced into the CS. A contrast injection revealed an unusually big-sized CS, with a diameter 2.5 times the fully deployed balloon. A 0.035 wire was advanced retrograde reaching the confluence of the innominate and left subclavian veins. The outer sheath was advanced to this location and contrast venography through the sheath allowed visualization of the left jugular and subclavian veins and visualization of the PLSVC draining into the CS. No target veins for lead implant were identified. The patient was referred for surgical implant of an epicardial lead. Transesophageal echocardiogram showed a CS identified as an unusually big vascular structure located between the left atrium and the left atrial appendage. CONCLUSION We report an uncommon association of HO and PLSVC. This association was only reported twice in the past and this is the first one that constitutes a casual finding during the attempt of CRT device implant. This is a combination that may complicate a device implant and recognition of it in advance may avoid performing potentially unsuccessful procedures.

Optimal visualization of five different stent layers during and after percutaneous coronary intervention for recurrent in-stent restenosis using optical coherence tomography (OCT)

Optical coherence tomography (OCT) has gained increasing popularity in the recent years. In this case, we documented optimal visualization of four stent layers that were seen during percutaneous coronary intervention for recurrent in-stent restenosis. OCT was clearly able to penetrate all of the neointimal tissue layers extending through to the last stent, which was near the adventitia. Our case demonstrates the excellent utility of OCT for detail assessment of a lesion with multiple stents. To our knowledge, this case is the first case report that could demonstrate excellent visualization of 5 different stent layers using OCT, extending through the deepest stent layer near the adventitia.