Sridevi R. Pitta

Clinical Features, Management, and Prognosis of Spontaneous Coronary Artery Dissection

Background— Spontaneous coronary artery dissection (SCAD) is an acute coronary event of uncertain origin. Clinical features and prognosis remain insufficiently characterized. Methods and Results— A retrospective single-center cohort study identified 87 patients with angiographically confirmed SCAD. Incidence, clinical characteristics, treatment modalities, in-hospital outcomes, and long-term risk of SCAD recurrence or major adverse cardiac events were evaluated. Mean age was 42.6 years; 82% were female. Extreme exertion at SCAD onset was more frequent in men (7 of 16 versus 2 of 71; P<0.001), and postpartum status was observed in 13 of 71 women (18%). Presentation was ST-elevation myocardial infarction in 49%. Multivessel SCAD was found in 23%. Initial conservative management (31 of 87) and coronary artery bypass grafting (7 of 87) were associated with an uncomplicated in-hospital course, whereas percutaneous coronary intervention was complicated by technical failure in 15 of 43 patients (35%) and 1 death. During a median follow-up of 47 months (interquartile range, 18–106 months), SCAD recurred in 15 patients, all female. Estimated 10-year rate of major adverse cardiac events (death, heart failure, myocardial infarction, and SCAD recurrence) was 47%. Fibromuscular dysplasia of the iliac artery was identified incidentally in 8 of 16 femoral angiograms (50%) undertaken before closure device placement and in the carotid arteries of 2 others with carotid dissection. Conclusions— SCAD affects a young, predominantly female population, frequently presenting as ST-elevation myocardial infarction. Although in-hospital mortality is low regardless of initial treatment, percutaneous coronary intervention is associated with high rates of complication. Risks of SCAD recurrence and major adverse cardiac events in the long term emphasize the need for close follow-up. Fibromuscular dysplasia is a novel association and potentially causative factor.

Complications associated with left ventricular puncture

Objective: To report complications in a consecutive series of patients undergoing percutaneous left ventricular apical puncture (LVAP) and sheath placement for diagnostic or interventional procedures. Background: Percutaneous LVAP is only rarely used to provide hemodynamic data in the presence of mechanical prosthetic valves. Recently, LVAP has been used to facilitate complex interventional procedures such as paravalvular leak closures. These frequently necessitate placement of 4–6 F sheaths, rather than smaller needles. Optimal technique and outcomes are largely unknown for this uncommon procedure. Methods: We retrospectively analyzed 32 patients undergoing LVAP with echocardiographic and fluoroscopic guidance at our institution between 2002 and 2009. These patients were referred to the cardiac catheterization laboratory for hemodynamic assessment to rule out prosthetic dysfunction and or to facilitate paravalvular leak closure. Sheaths ranged from 4 to 6 F were removed at the end of the procedure after reversing any anticoagulation. No specific closure devices were used for hemostasis. Frequency of access site complications associated with LVAP recorded. Results: Apical access site related complications were higher in patients requiring LVAP for intervention than for diagnostic purposes (25% vs. 12.5%). Hemothorax was the most frequent serious complication occurring in 6 (19%) patients and frequently required intervention 5(16%). Three patients had local bleeding with no drop in hemoglobin or need for intervention. Conclusions: LVAP is associated with a significant incidence of access‐related complications. There is a need for safe and reliable methods of closing percutaneous LVAP access sites.

Bedside Assessment of Cardiac Hemodynamics: The Impact of Noninvasive Testing and Examiner Experience

BACKGROUNDnKnowledge of cardiac filling pressures is critical in the diagnosis and management of patients with dyspnea or heart failure. Echocardiography and B-natriuretic peptide (BNP) testing are commonly used to estimate these pressures, but their incremental value beyond physical examination remains unknown.nnnMETHODSnRight and left heart filling pressures were prospectively estimated as normal or abnormal by staff cardiologists and cardiovascular trainees based upon physical examination findings alone, or examination coupled with echocardiographic and BNP data in patients referred for cardiac catheterization. Net reclassification improvement was calculated to determine whether echocardiographic/BNP data had incremental value in the determination of right and left heart pressures.nnnRESULTSnTwo hundred fifteen observations were made by 9 examiners in 116 consecutive patients. Right and left heart pressures were accurately predicted from examination alone in 71% and 60% of observations, respectively. Examination-based accuracy was greater for staff cardiologists compared with trainees for right heart (82 vs 67%, P=.03) and left heart pressures (71% vs 55%, P=.03). Exposure to echocardiographic and BNP data did not enhance accuracy beyond bedside examination alone, both for left heart pressures (net reclassification improvement=-0.004; 95% confidence interval, -0.12-0.12) and right heart pressures (net reclassification improvement=0.02, 95% confidence interval, -0.09-0.13).nnnCONCLUSIONSnCardiac filling pressures can be estimated from physical examination with modest accuracy, which is enhanced with experience. While echocardiographic and BNP data predict cardiac filling pressures, they may not provide information of incremental value beyond examination alone. Rigorous teaching and practice of cardiac examination skills should continue to be emphasized during medical training.

Location of femoral artery access and correlation with vascular complications

Objectives: The aim of the study was to document the frequency of optimal femoral artery access location and its correlation with vascular complications in contemporary practice. Background: Vascular access bleeding during coronary interventions is associated with adverse outcomes. A potential strategy for reducing access‐site bleeding is to achieve optimal location for the femoral access. However, there is a paucity of data on how well this goal is achieved in clinical practice using anatomical landmarks. Methods: We retrospectively evaluated femoral angiograms of 300 patients undergoing percutaneous coronary intervention to identify the location of the access that had been performed using anatomical landmarks. Patients were divided into two groups based on the location of the arterial access: above the femoral bifurcation but below the inferior border of the inferior epigastric artery (optimal location) and those that were either above or below these landmarks (suboptimal location). Frequency of access site complications was recorded. Results: The femoral artery access site was located outside the optimal location in 38 (13.0%) patients. There was no significant difference regards to baseline characteristics. Overall, access‐related complications occurred in 17 (5.7%) patients. Vascular complications were significantly more frequent in patients who had a femoral artery access outside the optimal location (18% vs. 4%, P < 0.001). Conclusions: The femoral artery access site is not at the optimal location in a significant proportion of patients, and this is associated with an increased risk of vascular complications. Improving the rates of optimal arterial access by routine use of fluoroscopy or ultrasound guidance has the potential of reducing vascular complications and improving outcomes.

Using prehospital electrocardiograms to improve door-to-balloon time for transferred patients with ST-elevation myocardial infarction: a case of extreme performance.

A 45-year-old man was walking his dog at 5:30 am in June 2009 and developed crushing 10/10 substernal chest pain. He called 911 at 6:05 am after his symptoms persisted for 35 minutes. Emergency medical services (EMS) paramedics arrived at the scene at 6:09 am and obtained a brief history and examination showing a diaphoretic man, pulse of 92 bpm, blood pressure of 170/140 mm Hg, normal respiratory rate, and no rales or murmurs. Treatment was initiated including supplemental oxygen, sublingual nitroglycerin, and aspirin. A 12-lead prehospital (PH) ECG was acquired at the scene at 6:16 am and interpreted by paramedics as showing acute ST-elevation myocardial infarction (STEMI) (Figure 1). On the basis of the PH ECG, paramedics made a single phone call to the closest community hospital emergency department and activated the PH ECG STEMI protocol at 6:17 am. The closest community hospital was located within 5 miles and did not have capability for percutaneous coronary intervention (PCI). The STEMI protocol activation consisted of autolaunching helicopter transport to intercept the patient at the community hospital and alerting the cardiac catheterization team at the tertiary PCI center located 50 miles away with the estimated patient arrival time. The patient arrived at the community hospital emergency department (door 1) by ground ambulance at 6:26 am. Helicopter transport picked up the patient and departed the community hospital at 6:37 am with a door 1 in–to–door 1 out time of 11 minutes. The patient arrived at the tertiary PCI center (door 2) at 7:10 am and was transported directly to the cardiac catheterization laboratory. During transport from the helipad to the cardiac catheterization laboratory, the patient had ventricular fibrillation in the elevator, and a shock was delivered with 120 J of selected energy. Coronary angiography showed a thrombotic occlusion of the …

Using Prehospital Electrocardiograms to Improve Door-to-Balloon Time for Transferred Patients With ST-Elevation Myocardial Infarction

A 45-year-old man was walking his dog at 5:30 am in June 2009 and developed crushing 10/10 substernal chest pain. He called 911 at 6:05 am after his symptoms persisted for 35 minutes. Emergency medical services (EMS) paramedics arrived at the scene at 6:09 am and obtained a brief history and examination showing a diaphoretic man, pulse of 92 bpm, blood pressure of 170/140 mm Hg, normal respiratory rate, and no rales or murmurs. Treatment was initiated including supplemental oxygen, sublingual nitroglycerin, and aspirin. A 12-lead prehospital (PH) ECG was acquired at the scene at 6:16 am and interpreted by paramedics as showing acute ST-elevation myocardial infarction (STEMI) (Figure 1). On the basis of the PH ECG, paramedics made a single phone call to the closest community hospital emergency department and activated the PH ECG STEMI protocol at 6:17 am. The closest community hospital was located within 5 miles and did not have capability for percutaneous coronary intervention (PCI). The STEMI protocol activation consisted of autolaunching helicopter transport to intercept the patient at the community hospital and alerting the cardiac catheterization team at the tertiary PCI center located 50 miles away with the estimated patient arrival time. The patient arrived at the community hospital emergency department (door 1) by ground ambulance at 6:26 am. Helicopter transport picked up the patient and departed the community hospital at 6:37 am with a door 1 in–to–door 1 out time of 11 minutes. The patient arrived at the tertiary PCI center (door 2) at 7:10 am and was transported directly to the cardiac catheterization laboratory. During transport from the helipad to the cardiac catheterization laboratory, the patient had ventricular fibrillation in the elevator, and a shock was delivered with 120 J of selected energy. Coronary angiography showed a thrombotic occlusion of the …

Saphenous Vein Graft Pseudoaneurysm

![Figure][1] nn[![Graphic][3] ][3][![Graphic][4] ][4]nnnnA 71-year-old man with a history of coronary artery bypass grafting 10 years earlier presented with recurrent angina. A repeat coronary angiogram revealed a large pseudoaneurysm in the saphenous vein graft supplying the right

Transradial iliac artery intervention with dual downstream embolic protection

We report a case of a thrombotic common iliac lesion with concern for elevated risk of downstream embolization during intervention. In this case, a transradial approach enabled the novel, simultaneous deployment of two embolic protection devices, one in the internal iliac artery and the other in the common femoral artery, for complete downstream protection during intervention. An endovascular stent, which accommodates a 0.035-inch wire lumen, was able to be delivered over both 0.014-inch protection device wires simultaneously and was successfully deployed with evidence of captured embolic material.

Using prehospital electrocardiograms to improve door-to-balloon time for transferred patients with st-elevation myocardial infarction a case of extreme perf

A 45-year-old man was walking his dog at 5:30 am in June 2009 and developed crushing 10/10 substernal chest pain. He called 911 at 6:05 am after his symptoms persisted for 35 minutes. Emergency medical services (EMS) paramedics arrived at the scene at 6:09 am and obtained a brief history and examination showing a diaphoretic man, pulse of 92 bpm, blood pressure of 170/140 mm Hg, normal respiratory rate, and no rales or murmurs. Treatment was initiated including supplemental oxygen, sublingual nitroglycerin, and aspirin. A 12-lead prehospital (PH) ECG was acquired at the scene at 6:16 am and interpreted by paramedics as showing acute ST-elevation myocardial infarction (STEMI) (Figure 1). On the basis of the PH ECG, paramedics made a single phone call to the closest community hospital emergency department and activated the PH ECG STEMI protocol at 6:17 am. The closest community hospital was located within 5 miles and did not have capability for percutaneous coronary intervention (PCI). The STEMI protocol activation consisted of autolaunching helicopter transport to intercept the patient at the community hospital and alerting the cardiac catheterization team at the tertiary PCI center located 50 miles away with the estimated patient arrival time. The patient arrived at the community hospital emergency department (door 1) by ground ambulance at 6:26 am. Helicopter transport picked up the patient and departed the community hospital at 6:37 am with a door 1 in–to–door 1 out time of 11 minutes. The patient arrived at the tertiary PCI center (door 2) at 7:10 am and was transported directly to the cardiac catheterization laboratory. During transport from the helipad to the cardiac catheterization laboratory, the patient had ventricular fibrillation in the elevator, and a shock was delivered with 120 J of selected energy. Coronary angiography showed a thrombotic occlusion of the …

Percutaneous Subclavian Artery Bypass for Myocardial Perfusion During Endovascular Intervention

A 75-year-old woman with familial hypercholesterolemia was admitted with unstable angina. Thirteen years earlier, she had undergone coronary artery bypass grafting with a left internal mammary artery (LIMA) to the left anterior descending artery (LAD) and subsequently bilateral common carotid bypass surgery through a second sternotomy 3 years later. Physical examination revealed left brachial hypotension, a left subclavian bruit, and features of severe aortic stenosis. Transthoracic echocardiography demonstrated severe valvular and supravalvular aortic obstruction with an area of 0.50 cm2. Noncontrast computed tomography showed complete calcification of the ascending aorta (porcelain aorta) and confirmed supravalvular obstruction with calcific plaque (Figure 1). She was subsequently offered placement of a left ventricular apex-descending aorta conduit through a left thoracotomy.nnPreoperative diagnostic angiography revealed a critical ostial left subclavian artery stenosis, with flow reversal in the vertebral artery and preferential entering of contrast into the LIMA (steal phenomenon, Figure 2, Movie 1). The LIMA graft was widely …