William Hui

Retrograde recanalization of chronic total occlusions from the transradial approach; Early canadian experience†

Background: Retrograde approach for chronic total occlusions (CTO) improves recanalization success rates. Eight French (Fr) catheters and the femoral approach are advocated. Objectives: Evaluate whether transradial operators can achieve similar success rates using smaller catheters. Methods: This is a single‐operator series of 42 consecutive cases performed between January and December 2010, including 13 while demonstrating CTO recanalization. Patients were referred because of complexity of the CTO or after failed attempt. Results: Most frequent indications for recanalization were CCS 3–4 angina (52%) and CCS 1–2 in 21%. Eighteen (43%) patients underwent previous failed attempts. CTO was in the right coronary in 74%, left anterior descending in 24%, and a left main in 1. Most lesions (88%) were ≥20 mm long and 52% were calcified. We used septal collateral channels (CC) in 33 (79%), epicardial CC in 8 (20%), and a saphenous vein graft in one case. Radial access was used in all patients and was bilateral in 37 (88%). Five cases required one radial and one femoral access. Six French guides were used in 91% for the retrograde side and 71% for the antegrade side. Otherwise, 7 Fr guides were used. The Corsair® was used in 38 (90%). Procedural success was achieved in 37 (88%), mostly using reverse controlled antegrade–retrograde tracking (60%) or retrograde crossing (29%). The average <24‐h Hb drop was 0.75 ± 0.84 g/dl. No in‐hospital major cardiac events occurred. Conclusion: Transradial retrograde CTO recanalization is feasible, safe, and still associated with high success rates despite the use of smaller guide catheters.

Percutaneous transluminal coronary angioplasty without on-site surgical facilities

Percutaneous transluminal coronary angioplasty (PTCA) is associated with a low risk of serious complications, the most important of which is acute coronary occlusion needing emergency surgery. There is a consensus among many cardiologists and cardiac surgeons that all PTCA procedures need on-site surgical backup. A task force report on PTCA by the American College of Cardiology/American Heart Association mandates the presence of an on-site cardiovascular surgical team. Since 1981, we have performed PTCA without the benefit of on-site surgery but with backup surgery provided at a regional cardiac surgical center located 6 kilometers away. Up to the end of 1991, 762 patients have undergone 847 PTCAs. Most patients had 1-vessel angioplasty (94.6%). The primary success rate since 1981 was 76%, and from January 1990 to December 1991 it was 87% (n = 313). Complications included death in 7 patients (0.9%), myocardial infarction in 16 (2.1%) and emergency surgery in 12 (1.6%). Surgical backup was provided on a next available operating room basis. The average time from decision to transfer to onset of surgery was 164 minutes (range 75 to 320). All patients survived surgery, but 42% developed a new Q-wave myocardial infarction. These patients were followed up until the end of 1991, and are all alive. The results are similar to those reported from centers with and without on-site surgery. With careful selection of patients and a formal, coordinated plan for backup surgery, PTCA can be safely performed without on-site surgery.

Myocardial Infarction as a Rare Consequence of a Snakebite Diagnosis With Novel Echocardiographic Tissue Doppler Techniques

A healthy 28-year-old man with no history of cardiac disease and no cardiac risk factors presented to the hospital 2 hours after being bitten on his right hand by his pet snake. He was in anaphylactic shock and was rapidly resuscitated with fluids, inotropic support, intramuscular antitetanus serum, and intravenous infusion of Viper-FAB, an antidote. His vital signs normalized and he was admitted to intensive care for further observation. One hour after admission, the patient’s systolic blood pressure dropped to 40 mm Hg. Intravenous noradrenaline was started. Thirty minutes later, the patient lost consciousness in association with a rhythm change to torsade de pointes. He was defibrillated with 100 J (biphasic defibrillator) to sinus rhythm. Intravenous magnesium was started, and a repeat 12-lead ECG showed a prolonged corrected QT interval at 490 ms with no ST elevation (Figure 1). An urgent echocardiogram demonstrated normal-sized left ventricle with mild hypokinesis of the anterior wall and a global left ventricular fraction of 60%. Tissue Doppler images acquired by Vivid-7 (GE Medical) …A healthy 28-year-old man with no history of cardiac disease and no cardiac risk factors presented to the hospital 2 hours after being bitten on his right hand by his pet snake. He was in anaphylactic shock and was rapidly resuscitated with fluids, inotropic support, intramuscular antitetanus serum, and intravenous infusion of Viper-FAB, an antidote. His vital signs normalized and he was admitted to intensive care for further observation. One hour after admission, the patient’s systolic blood pressure dropped to 40 mm Hg. Intravenous noradrenaline was started. Thirty minutes later, the patient lost consciousness in association with a rhythm change to torsade de pointes. He was defibrillated with 100 J (biphasic defibrillator) to sinus rhythm. Intravenous magnesium was started, and a repeat 12-lead ECG showed a prolonged corrected QT interval at 490 ms with no ST elevation (Figure 1). An urgent echocardiogram demonstrated normal-sized left ventricle with mild hypokinesis of the anterior wall and a global left ventricular fraction of 60%. Tissue Doppler images acquired by Vivid-7 (GE Medical) …

Images in cardiovascular medicine. Myocardial infarction as a rare consequence of a snakebite: diagnosis with novel echocardiographic tissue Doppler techniques.

A healthy 28-year-old man with no history of cardiac disease and no cardiac risk factors presented to the hospital 2 hours after being bitten on his right hand by his pet snake. He was in anaphylactic shock and was rapidly resuscitated with fluids, inotropic support, intramuscular antitetanus serum, and intravenous infusion of Viper-FAB, an antidote. His vital signs normalized and he was admitted to intensive care for further observation. One hour after admission, the patient’s systolic blood pressure dropped to 40 mm Hg. Intravenous noradrenaline was started. Thirty minutes later, the patient lost consciousness in association with a rhythm change to torsade de pointes. He was defibrillated with 100 J (biphasic defibrillator) to sinus rhythm. Intravenous magnesium was started, and a repeat 12-lead ECG showed a prolonged corrected QT interval at 490 ms with no ST elevation (Figure 1). An urgent echocardiogram demonstrated normal-sized left ventricle with mild hypokinesis of the anterior wall and a global left ventricular fraction of 60%. Tissue Doppler images acquired by Vivid-7 (GE Medical) …A healthy 28-year-old man with no history of cardiac disease and no cardiac risk factors presented to the hospital 2 hours after being bitten on his right hand by his pet snake. He was in anaphylactic shock and was rapidly resuscitated with fluids, inotropic support, intramuscular antitetanus serum, and intravenous infusion of Viper-FAB, an antidote. His vital signs normalized and he was admitted to intensive care for further observation. One hour after admission, the patient’s systolic blood pressure dropped to 40 mm Hg. Intravenous noradrenaline was started. Thirty minutes later, the patient lost consciousness in association with a rhythm change to torsade de pointes. He was defibrillated with 100 J (biphasic defibrillator) to sinus rhythm. Intravenous magnesium was started, and a repeat 12-lead ECG showed a prolonged corrected QT interval at 490 ms with no ST elevation (Figure 1). An urgent echocardiogram demonstrated normal-sized left ventricle with mild hypokinesis of the anterior wall and a global left ventricular fraction of 60%. Tissue Doppler images acquired by Vivid-7 (GE Medical) …

Fistula between right coronary artery vein graft and right atrium as an immediate complication of percutaneous coronary intervention.

Fistula between saphenous vein graft (SVG) and a cardiac chamber or structure is a rare complication after coronary artery bypass grafting (CABG). We report the first case of a fistula between SVG and the right atrium (RA) as an immediate complication after a percutaneous coronary intervention (PCI) in an 86‐year‐old female. She presented with inferior ST‐elevation myocardial infarction (STEMI) and was treated with thrombolytic therapy in a peripheral hospital, which was unsuccessful. PCI to SVG to the right coronary (RCA) was complicated by a fistula to RA. Cardiac magnetic resonance (CMR) confirmed the site of the fistula and also presence of a significant arteriovenous (AV) shunt. Reversal of anticoagulation had no effect on fistula closure. Therefore, a covered stent was deployed for closure of the fistula to avoid long‐term complications of the significant AV shunt. In summary, the diagnosis and appropriate management of this rare complication is challenging, but excellent result can be achieved by the use of appropriate percutaneous techniques.

THE APPLICATION OF THE JAPANESE CHRONIC TOTAL OCCLUSION (J–CTO) SCORE TO TAILOR APPROACHES AND PREDICT SUCCESS IN CHRONIC TOTAL OCCLUSION PERCUTANEOUS CORONARY INTERVENTIONS (CTO PCI)

In the J–CTO model, angiographic variables of blunt entry, calcification, lesion length >20mm, angle>45o and previous PCI attempt are independent predictors of CTO PCI failure. While the use of bilateral injections and retrograde approach during CTO PCI remain operator dependent, these strategies

TCT-341 Unplanned Nontarget Lesion Revascularizations after Percutaneous Coronary Interventions

no differences between DES and BMS groups in terms of TLR [7.8% vs. 6.4%; HR1⁄40.6 (95%CI 0.33-1.28), p1⁄40.207), target vessel revascularization (9.9% vs.12.0%, HR1⁄40.9(95%CI 0.57-1.61), p1⁄40.877), myocardial infarction (13.5% vs. 8.7%; HR1⁄40.8(95%CI 0.51-1.50), p1⁄40.641), death (7.2 vs. 5.5%; HR1⁄41.1(95%CI 0.57-2.47),p1⁄40.642), stroke (1.5% vs. 3.2%, HR1⁄40.9(95%CI 0.25-3.20), p1⁄40.878) and compositeMACCE (27.3% vs. 22.6%,HR1⁄40.9(95% CI 0.66-1.33), p1⁄4 0.746) at 12-monht follow-up.

Thirty years of standalone percutaneous coronary interventions: A 23,261 case experience from a Canadian tertiary referral centre

Background: When percutaneous coronary intervention (PCI) was first performed >35 years ago, on-site cardiac surgery backup for PCI failure was deemed essential. As techniques improved and primary PCI became the preferred reperfusion strategy for acute myocardial infarction, many standalone PCI programs originally established to facilitate access to primary PCI started to perform elective PCI, which remains a Class IIb recommendation in American College of Cardiology Foundation/American Heart Association/Society for Cardiac Angiography and Interventions guidelines. Two recent United States studies showed that outcomes of elective PCI in standalone centres were noninferior to those with on-site cardiac surgery. The Royal Alexandra Hospital in Edmonton (Alberta) performed the first standalone PCI in Canada in 1981. Objectives: The authors describe their first 30 years’ experience with PCI – the largest single-centre standalone experience reported to date. Methods: Patient and procedural data have been collected since the first standalone PCI in 1981, evolving from paper records to a computer database and, in 1995, a provincial database. Quality assurance and peer review in collaboration with the regional cardiac surgery program was established from the outset. Results: The success, emergency coronary bypass and death rates for 23,261 standalone PCIs performed between 1981 and 2011 were 96.0%, 0.2% and 0.5%, respectively. For 9068 PCIs performed between 2007 and 2011 (a period that most reflects contemporary practice), the rates were 96.5%, 0.04% and 0.6%, respectively. These results compare favourably with PCI results reported in literature, irrespective of the presence or absence of on-site cardiac surgery. Conclusions: With high volumes and an experienced team, standalone PCIs can be performed safely with excellent success and low complication rates.

Myocardial Infarction as a Rare Consequence of a Snakebite

A healthy 28-year-old man with no history of cardiac disease and no cardiac risk factors presented to the hospital 2 hours after being bitten on his right hand by his pet snake. He was in anaphylactic shock and was rapidly resuscitated with fluids, inotropic support, intramuscular antitetanus serum, and intravenous infusion of Viper-FAB, an antidote. His vital signs normalized and he was admitted to intensive care for further observation. One hour after admission, the patient’s systolic blood pressure dropped to 40 mm Hg. Intravenous noradrenaline was started. Thirty minutes later, the patient lost consciousness in association with a rhythm change to torsade de pointes. He was defibrillated with 100 J (biphasic defibrillator) to sinus rhythm. Intravenous magnesium was started, and a repeat 12-lead ECG showed a prolonged corrected QT interval at 490 ms with no ST elevation (Figure 1). An urgent echocardiogram demonstrated normal-sized left ventricle with mild hypokinesis of the anterior wall and a global left ventricular fraction of 60%. Tissue Doppler images acquired by Vivid-7 (GE Medical) …A healthy 28-year-old man with no history of cardiac disease and no cardiac risk factors presented to the hospital 2 hours after being bitten on his right hand by his pet snake. He was in anaphylactic shock and was rapidly resuscitated with fluids, inotropic support, intramuscular antitetanus serum, and intravenous infusion of Viper-FAB, an antidote. His vital signs normalized and he was admitted to intensive care for further observation. One hour after admission, the patient’s systolic blood pressure dropped to 40 mm Hg. Intravenous noradrenaline was started. Thirty minutes later, the patient lost consciousness in association with a rhythm change to torsade de pointes. He was defibrillated with 100 J (biphasic defibrillator) to sinus rhythm. Intravenous magnesium was started, and a repeat 12-lead ECG showed a prolonged corrected QT interval at 490 ms with no ST elevation (Figure 1). An urgent echocardiogram demonstrated normal-sized left ventricle with mild hypokinesis of the anterior wall and a global left ventricular fraction of 60%. Tissue Doppler images acquired by Vivid-7 (GE Medical) …