BACKGROUND:Coronary vasomotion disorders, although prevalent among patients with ischemia, remain poorly understood given limited use of invasive functional testing. CASE SUMMARY:Presented here is a case of isolated severe right-coronary-artery vasospasm with acetylcholine reactivity testing resulting in ventricular arrhythmias. DISCUSSION:Determining the type of coronary vasomotion disorder is important for providing the appropriate treatment; therefore, performing invasive functional testing is critical. Although isolated right-coronary-artery vasospasm is rare, if vasospastic angina is of high suspicion, evaluating the right coronary artery is necessary. TAKE-HOME MESSAGES:Vasospastic angina can occur in any phase of coronary atherosclerotic disease and result in myocardial infarction or sudden cardiac death. Vasomotor disorders can involve variable regions and combinations of microvascular and epicardial coronary arteries. A comprehensive diagnosis of vasomotor disorders is only possible with reactivity testing, with isolation of both right and left coronary arteries when indicated.

Introduction: Metastatic tumors to the heart can have varied clinical presentations depending on location. We present a case of right atrial (RA) metastatic melanoma with near obstruction of the tricuspid valve resulting in significant hypoxia. Case Presentation: A 34-year-old man with a history of retinoblastoma and astrocytoma presented to the emergency department with 2 weeks of progressively worsening shortness of breath. On examination he was hypoxic and in respiratory distress. Computed tomography of the chest with contrast showed a large hypoattenuating homogeneous mass in the RA that protruded into the right ventricle and extended to the superior and inferior vena cavae. Transthoracic echocardiography (TTE) showed a large (9.1 x 4.6 cm) echodensity filling the RA and almost completely obstructing the tricuspid valve. Due to worsening hypoxia, the patient underwent palliative surgical resection of the mass. Intraoperatively, the mass was densely adherent to all walls of the RA. Surgical pathology identified the mass as metastatic malignant melanoma. The patient was started on pembrolizumab and discharged home in stable condition. At his 1-month follow-up, his symptoms had improved and he had returned to work. Discussion: Metastases to the heart are more common than primary cardiac tumors. Left-sided cardiac masses are commonly benign, whereas right-sided masses raise suspicion for metastatic disease. Melanoma, lymphoma, leukemia, and breast and lung cancers commonly metastasize to the heart. The size of the RA mass in this patient was significant enough to cause hypoxia and near occlusion of the tricuspid valve. Successful palliative resection of the mass resulted in a large improvement in symptoms. Conclusion: As the incidence of malignant melanoma increases, clinicians need to have a high index of suspicion for cardiac metastasis. Early identification of cardiac metastasis is critical as these cases can often be associated with poor prognosis.

Purpose: Dual antiplatelet therapy is standard for patients undergoing percutaneous coronary intervention (PCI) with stents. Traditionally, patients swallow the loading dose of a P2Y12 inhibitor before or during PCI. Time to achieve adequate platelet inhibition after swallowing the loading dose varies significantly. Chewed tablets may allow more rapid inhibition of platelet aggregation. However, data for this strategy in patients with stable ischemic heart disease or non-ST-elevation acute coronary syndrome (NSTE-ACS) are less robust. Methods: In this single-center prospective trial, 112 P2Y12-naïve patients with stable ischemic heart disease or NSTE-ACS on aspirin therapy and who received ticagrelor after coronary angiography but before PCI were randomized to chewing (n = 55) or swallowing (n = 57) the ticagrelor loading dose (180 mg). Baseline variables were compared using 2-sample t-test and chi-squared/Fisher’s exact tests as appropriate, with alpha set at 0.05. P2Y12 reaction units (PRU) were compared at baseline, 1 hour, and 4 hours using Wilcoxon rank-sum test. Patients then received standard ticagrelor dosing. Results: After exclusions, P2Y12 PRU in the chewed and swallowed groups at baseline, 1 hour, and 4 hours after ticagrelor loading dose were 243 vs 256 (P = 0.75), 143 vs 210 (P = 0.09), and 28 vs 25 (P = 0.89), respectively. No differences were found in major adverse cardiac events (MACE) or major bleeding at 30 days and 1 year. Conclusions: In patients with stable ischemic heart disease or NSTE-ACS, chewing rather than swallowing ticagrelor may lead to slightly faster inhibition of platelet aggregation at 1 hour with no increase in MACE or major bleeding.

Acromegaly—a rare endocrine disorder—results when a growth hormone–secreting somatotroph pituitary adenoma leads to increased insulin-like growth factor 1 production. Acromegaly is known to cause left ventricular hypertrophy. We present a case of acromegaly with massive left ventricular hypertrophy that was determined to be coexistent with gene-positive hypertrophic obstructive cardiomyopathy. (Level of Difficulty: Intermediate.)

Purpose: Coronary artery bypass graft is the standard treatment for unprotected left main disease; however, some patients are poor surgical candidates due to comorbidities. We assessed the safety and clinical outcome of elective, unprotected left main coronary artery stenting in nonsurgical patients. Methods: Between October 2004 and June 2006, 50 consecutive patients underwent elective, unprotected left main coronary artery stenting at our institution. Patients were followed for a median of 16 and 96 months and clinical outcomes monitored. Results: Median logistic euroSCORE was 28.6 (interquartile range: 14.6-43.4). Median baseline left ventricular ejection fraction (LVEF) was 50%. Procedural success rate was 100%. The rates of cerebrovascular accident, myocardial infarction, target vessel revascularization and cardiovascular death were 2%, 4%, 4% and 2%, respectively, at 30 days, 2%, 6%, 6% and 2% at 16 months, and 2%, 6%, 12% and 4% at 96 months. Major adverse cardiac and cerebrovascular event rate was 12% at 30 days, 16% at 16 months and 24% at 96 months. Median LVEF at 16 months was 55%, significantly improved from baseline (P<0.001). Conclusion: In nonsurgical patients with left main disease, stenting of the unprotected left main coronary artery is safe, with acceptable rates of major adverse cardiac and cerebrovascular event up to 96 months poststenting.

In patients with STEMI and multivessel disease (MVD), ACC/AHA guidelines classify PCI of a noninfarct vessel as Class III unless there is hemodynamic instability. We hypothesized that, with rapid door-to-balloon time and favorable anatomy, outcomes for multivessel PCI during STEMI would be

BACKGROUND:The predictors and clinical significance for stent fracture (SF) in drug-eluting stents (DES) remain unknown. We identified procedural factors leading to SF and its clinical consequences in DES. METHODS:Percutaneous coronary interventions were performed on 3,920 patients with DES over 12 months. In-stent restenosis (ISR) of DES was observed in 188 cases with 121 cases (64.4%) receiving a sirolimus-eluting stent (SES) and 67 (35.6%) a paclitaxol-eluting stent (PES). RESULTS:SF was identified in 35 (18.6%) of the 188 cases. The 35 cases were then compared with 153 cases of ISR without angiographic evidence of SF. SF was identified in 29 (23.9%) SES compared with 6 (9.0%) in PES (P < 0.05). With univariate analysis, additional factors associated with SF included longer mean stented segment length, male gender, overlapping stents, vessel segment angulation >75 degrees , and more stents (all P < 0.05). With multivariate adjustment, three factors, i.e., stenting on a bend >75 degrees (OR = 13.8, 95%CI 3.7 to 51; P < 0.001), SES (OR = 4.1, 95%CI 1.3 to 13.4; P < 0.018) and overlapping stented segments (OR = 3.9, 95%CI 1.1 to 14.1; P < 0.041) were statistically significant independent predictors of SF while larger stent diameter was protective (OR = 0.14, 95%CI 0.04 to 0.70; P < 0.017). CONCLUSION:SF proved to be associated with angiographically-documented clinical ISR. Although the exact mechanism is unknown, factors that appear to play a negative role in SF include vessel tortuosity, use of SES and overlapping stents. Larger stent diameter was protective. Further studies are needed to better define the factors important in the mechanism of SF.

CONTEXT The American College of Cardiology guidelines consider elective percutaneous coronary intervention (PCI) without on-site surgical backup (OSB) a Class-III indication. OBJECTIVE Our objective was to determine the safety of elective PCI without OSB. DESIGN The study is a prospective analysis of a cohort of patients who underwent elective PCI without OSB at our institution. All patients were at our community satellite institution in Beloit, Wis. Three hundred twenty-one elective interventions were performed (mean age 64 +/-12, 68% male). The prevalence of diabetes and hypertension was 28% and 82.5% respectively. INTERVENTION A predefined protocol was designed to transfer patients to a cardiac surgical facility if necessary. An experienced interventional cardiologist reviewed the diagnostic angiograms. Patients with complex lesions were excluded from the study. MAIN OUTCOME MEASURE Any procedure-related death or emergency coronary artery bypass graft surgery. RESULTS Three hundred eighty-two vessels were stented. Multi-vessel intervention was performed in 61 patients (19%). Only 5% of lesions were type C. Four hundred thirty-seven stents were deployed. IIb-IIIa inhibitors were used in 77 (24%) cases. Procedural success was 99.7%. There were no deaths, myocardial infarctions nor need for urgent target vessel revascularization at 6 months. CONCLUSION With careful patient/lesion selection, an experienced interventional cardiologist and a predefined transfer protocol, elective PCI without OSB can be performed safely.

Hepatic artery stenosis is a recognized vascular complication of orthotropic liver transplant that carries significant morbidity and mortality. The authors present a case of hepatic artery stenosis in a 50-year-old female successfully treated with balloon angioplasty and stent. This case report highlights the importance of percutaneous intervention as a preferred treatment option in patients with hepatic artery stenosis postorthotropic liver transplant. (C) 2007 Wiley-Liss, Inc.

Introduction: The purpose of this study was to examine BiV pacing‐dependent changes in QT interval and the related potential for proarrhythmia. Biventricular (BiV) pacing has emerged as a promising therapy for patients with advanced congestive heart failure (CHF) and bundle branch block (BBB). Methods and Results: One hundred and seventy‐six consecutive patients (123 men and 53 women; mean age 67 ± 16 years) with ischemic (n = 128) or nonischemic (n = 48) cardiomyopathy in New York Heart Association Class II (8%) or III (92%) CHF (ejection fraction 24 ± 9%) underwent atrial synchronous BiV pacing. The QRS, QT, and JT intervals were measured at 30 minutes after initiation of BiV pacing, at 24 hours, and at 1 month postimplant. QT interval was defined as the time interval between the initial deflection of the QRS complex and the point at which the T wave crossed the isoelectric line. At baseline, the average QRS duration was 178 ± 10 ms, attributable to left BBB (n = 158) or intraventricular conduction delay (n = 18). BiV pacing resulted in a small but statistically significant reduction in QRS duration (148 ± 9 ms during BiV pacing vs 178 ± 10 ms at baseline [P < 0.0001]), yet the QT increased to 470 ± 34 ms with BiV pacing versus 445 ± 32 ms at baseline [P < 0.0001]). The JTc interval during BiV pacing was significantly shorter than during LV pacing (290 ± 9 ms vs 320 ± 20 ms, P < 0.0001). During a mean follow‐up of 24 ± 6 months, one patient developed recurrent torsade de pointes. That was eliminated once left ventricular pacing was discontinued. Conclusion: Biventricular pacing prolongs QT interval. However, the occurrence of torsade de pointes is uncommon.

We describe a case of angiographically documented stent fracture and pseudoaneurysm formation in a patient with femoropopliteal disease, which was successfully treated with deployment of an endovascular stent graft. Technical aspects of the procedure are discussed and the experience with stent fractures previously reported in the literature is reviewed. © 2006 Wiley‐Liss, Inc.