Faculty Bibliography

OBJECTIVES: Our purpose was to describe the contemporary utilization, clinical outcomes and complication rates of intra-aortic balloon pump (IABP) therapy in this current age. BACKGROUND: IABP use and outcomes, in the setting of modern antiplatelet therapy and primary percutaneous coronary intervention and the use of drug-eluting stents as we know them today, have not been clearly established. METHODS: We performed a retrospective cohort study by collecting detailed clinical and device data from all 150 consecutive patients who received IABP therapy in our institution between 2004 and 2009. RESULTS: Thrombocytopenia occurred in 50%, fever in 36%, bleeding in 27%, and vascular embolic events in 1%. Thrombocytopenia was the most common adverse event and was not significantly associated with the use of antiplatelet agents. The presence of diabetes mellitus, elevated white blood cells at presentation, and longer duration of IABP were significantly associated with the development of fever. Furthermore, those who developed fever had higher in-hospital mortality (31% versus 16%; p = 0.0487). CONCLUSIONS: In this contemporary cohort of IABP patients, complication rates of thrombocytopenia, fever and bleeding were relatively high but similar to prior studies, even in this current era of revascularization and antiplatelet medications.

Previous studies have shown that the right radial approach encounters more tortuosity than the left radial approach during transradial coronary angiography. The objective of this study was to compare the procedural difficulty of the right and left radial approaches in the modern era with dedicated transradial catheters. One hundred ninety-three patients scheduled for transradial coronary angiography with normal Allen test results and without histories of coronary artery bypass grafting were randomized to the right or left radial approach. The choice of catheter was left to the discretion of the operator, with the preferred catheter being a dedicated transradial Optitorque catheter. The primary end point was procedural difficulty, defined as (1) hydrophilic or coronary wire use for tortuosity, (2) stiff wire use for the coronary engagement, (3) multiple catheters used, or (4) nonselective injection. The clinical characteristics were similar between the 2 groups. Procedural success was achieved in 98 of 101 (98%) in the right radial group and 91 of 92 (99%) in the left radial group. Procedural difficulty, fluoroscopy time, and contrast use were similar between the 2 groups. The use of a single catheter was more common in the right radial group (73% vs 18%, p <0.001). In conclusion, procedural success and difficulty were similar in the comparison groups. The right and left radial approaches are feasible and effective to perform coronary angiography and intervention

BACKGROUND: In acute inferior ST-segment elevation myocardial infarction (STEMI), multiple electrocardiographic algorithms have been proposed to predict the culprit artery. Our purpose is to review these and compare them to ST depression in lead aVR to predict culprit artery in inferior STEMI. METHODS: In 106 patients with acute inferior STEMI who underwent emergent coronary angiography, we correlated electrocardiographic and angiographic findings pertaining to the culprit artery. We then reviewed the algorithms proposed by Fiol et al and Tierala et al, and applied them and our own from Kanei et al using ST depression in aVR for predicting the left circumflex artery (LCx) as the culprit, to the population. Finally, we compared the sensitivities and specificities of the respective algorithms for predicting the culprit artery. RESULTS: The sensitivity and specificity of ST depression in lead aVR to predict LCx as the culprit were 53% and 86%, respectively, and 86% and 55%, respectively for predicting the right coronary artery (RCA) as the culprit. When their algorithms were applied to our population, the sensitivities and specificities of Fiol et al and Tierala et al were slightly higher. CONCLUSION: Compared to other proposed algorithms, ST depression in aVR is a simple method with satisfactory sensitivity and specificity to predict the culprit artery in inferior STEMI.

Although the provisional stenting technique to treat coronary bifurcation lesions is the preferred method, many bifurcation lesions still require a two-stent technique to optimize the result and clinical outcome. This manuscript summarizes the tips and tricks of bifurcation stenting with cases illustrations. As interventionists are encountering more complex and difficult cases, one may find the tips and tricks in this manuscript helpful in daily practice

Myocardial bridging is a common congenital coronary anomaly that is clinically silent in the majority of cases. Case reports suggest myocardial ischemia and infarction can be caused by myocardial bridging. The proposed mechanisms by which myocardial bridging causes myocardial ischemia include compromised coronary blood flow, endothelial dysfunction, thrombus formation and a strong association with coronary vasospasm. We reported a case of myocardial infarction caused by both myocardial bridging and coronary vasospasm. We reviewed the literature and suggest that coronary stenting may have a role in treating myocardial ischemia due to myocardial bridging and coronary spasm that is refractory to medical management.

BACKGROUND: ST-segment depression in lead aVR in acute inferior wall ST-segment elevation myocardial infarction (STEMI) has recently been suggested as a predictor of left circumflex (LCx) artery involvement. The purpose of this study is to evaluate the clinical significance of aVR depression during inferior wall STEMI. METHODS: This study included 106 consecutive patients who presented with inferior wall STEMI and underwent urgent coronary angiogram. Clinical and angiographic findings were compared between patients with and without aVR depression > or = 0.1 mV. RESULTS: The sensitivity and specificity of aVR depression as a predictor of LCx infarction were 53% and 86%, respectively. In patients with right coronary artery infarction, aVR depression was associated with increased cardiac enzymes and the involvement of a large posterolateral branch, which may explain the larger infarction. CONCLUSIONS: ST-segment depression in lead aVR in inferior wall STEMI predicts LCx infarction or larger RCA infarction involving a large posterolateral branch.