Hypereosinophilic vasculitis, a variant of eosinophilic granulomatosis with polyangiitis, affects small- and medium-sized arteries. Cardiac involvement may manifest as heart failure, pericarditis, or valvular insufficiency (1, 2). Eosinophilia affects the endothelium and microvasculature, leading to thrombosis and fibrosis involving the endocardium and valves (3). Coronary artery aneurysms due to hypereosinophilia are extremely rare and have been reported sparsely in the literature (4, 5). Here, we describe a patient with hypereosinophilic vasculitis and widespread coronary artery aneurysms.

Case: A 50-year-old woman with a prior right carotid aneurysm repair presented for chest pain. An evaluation 13 years ago showed a normal echo and cardiac catheterization. Four years prior, an echo showed an enlarged left ventricle with ejection fraction 57% and mid-anterolateral and inferolateral wall hypokinesis. Coronary angiography showed diffuse aneurysms of all coronary arteries with a proximal stenosis of the LAD, followed by a giant coronary aneurysm (Figure 1). CT angiography revealed bilateral intercostal artery aneurysms and a mildly ectatic aorta. She underwent bypass of the LAD with the LIMA. Aortic biopsy revealed no aortitis and prior carotid aneurysm pathology showed plasmalymphocytic inflammation; labs showed hypereosinophilia and elevated inflammatory markers with other negative immunologic work-up. She was diagnosed with hypereosinophilic vasculitis without evidence of granulomatosis and started on immunosuppressants.Due to symptoms, she underwent coronary angiography. Her LAD was occluded ostially with distal flow via a patent LIMA (Figure 2). There was progression of her aneurysmal disease at her proximal right coronary artery. No intervention was recommended. Instead, to improve control of her vasculitis, a Janus kinase inhibitor will be started. Discussion: Hypereosinophilic vasculitis, a variant of eosinophilic granulomatosis with polyangiitis, affects small- and medium-sized arteries and is challenging to diagnose. This case highlights a rare cardiac complication that can occur with this condition. Cardiac involvement often manifests as heart failure, pericarditis, valvular insufficiency, or rarely, coronary aneurysms.

•Single radial artery access for direct transmitral gradient measurement is feasible•A radial TIG coronary catheter can be advanced retrograde into the left atrium•A coronary pressure wire is delivered to the left atrium and left in place•The catheter is subsequently withdrawn into the left ventricle•This permits simultaneous left atrial and left ventricular hemodynamic assessment

The coronavirus disease-2019 (COVID-19) is a viral illness with heterogenous clinical manifestations, ranging from mild symptoms to severe acute respiratory distress syndrome and shock caused by the severe acute respiratory syndrome coronavirus-2. The global healthcare community is rapidly learning more about the effects of COVID-19 on the cardiovascular system, as well as the strategies for management of infected patients with cardiovascular disease. There is minimal literature available surrounding the relationship between COVID-19 infection and acute coronary syndrome. We describe the case of a woman who presented with an acute anterior ST-elevation myocardial infarction managed by primary percutaneous coronary intervention, who subsequently developed severe COVID-19 infection and ultimately succumbed to multisystem organ failure.

Introduction and Background: The incidence of coronary artery disease in patients undergoing transcatheter aortic valve replacement (TAVR) averages nearly 70%. According to current guidelines, coro...

Hypothesis: Distance to a PCI hospital will impact the treatment and outcome of patients presenting with ST elevation myocardial infarction (STEMI). Methods: We studied all STEMI patients treated w...

Introduction: Cardiac catheterization followed by a delayed percutaneous coronary intervention (PCI) for patients with multivessel coronary artery disease (CAD) allows time for shared decision making and procedural planning. However ad-hoc PCI performed in the same procedure as the diagnostic catheterization, occurs frequently. Whether repeat revascularization is comparable for ad-hoc and delayed PCI patients with multivessel CAD is not well studied. Methods: We identified 8,306 non-emergent PCI patients with multivessel CAD from 2004-2014 from a regional registry of consecutive procedures excluding patients with a recent STEMI and censoring staged procedures. We compared repeat PCI or coronary artery bypass grafting from the registry over 11 years for ad-hoc versus delayed PCI patients. We used Cox’s proportional hazards modeling adjusting for differences in patient characteristics using inverse probability weighting. Results: There were 6,938 (83.5%) ad-hoc and 1,368 (16.5%) delayed PCI patients with a median follow up of 4.8 years. Delayed PCI patients were older, had more comorbidities and more 3 vessel disease (3VD). After adjustment for patient characteristics, ad-hoc PCI patients were not more likely than delayed PCI to undergo repeat revascularization (HR: 1.13, 95%CI: 0.98, 1.30); However, among 1,898 (22.9%) patients with 3VD, ad-hoc PCI was significantly associated with more repeat revascularization than delayed PCI (HR: 1.41, 95%CI: 1.07, 1.85; see figure). There was no difference in adjusted 3VD completeness of revascularization between ad-hoc and delayed PCI (OR: 1.05, 95%CI: 0.92, 1.19). There was no difference in survival between ad-hoc or delayed PCI. Conclusions: While ad-hoc PCI is favored by physicians for efficiency and patients for comfort, it is associated with a higher risk of repeat revascularization than delayed PCI for 3VD patients. These tradeoffs should be carefully considered before proceeding with ad-hoc PCI.

Objectives To compare the variability in the assessment of coronary stents among interventional cardiologists (readers) using optical coherence tomography (OCT) and intravascular ultrasound (IVUS). Background IVUS is established and validated in the evaluation of coronary stent. For cardiologists without core lab expertise, the utility of IVUS is limited by image quality. OCT yields higher image resolution; however, the consistency with which these readers interpret OCT images has not been fully evaluated or compared with IVUS. Methods OCT and IVUS image sets (five pairs) obtained after stent placement were reviewed by readers with clinical experience in both modalities. Parameters assessed included stent expansion and symmetry, reference vessel and in‐stent cross‐sectional area (CSA) and diameter, and stent strut apposition as well as Multicenter Ultrasound Stenting in Coronaries criteria. These interpretations were compared with core lab readings and examined for interobserver variability. Results The interobserver variability for measurement of in‐stent CSA was 1.34 mm 2 using IVUS compared with 0.85 mm 2 using OCT ( P = 0.024). Variation in the deviation from core lab measurement of in‐stent CSA for IVUS was 1.48 mm 2 compared with 0.87 mm 2 for OCT ( P = 0.042). The interobserver agreement for obtaining the Multicenter Ultrasound Stenting in Coronaries criteria using IVUS was 80.4% compared with 81.1% using OCT ( P = 0.78). Compared with the corelab measurement, the readers obtained an agreement of 72.7% using IVUS vs. 67.3% using OCT ( P = 0.43). Conclusion In the assessment of deployed coronary stents by practicing cardiologists, OCT images are interpreted more consistently compared with IVUS and can be used to assess stent deployment using IVUS‐validated metrics. © 2015 Wiley Periodicals, Inc.

Intravascular ultrasound (IVUS) is well established and validated in the evaluation of coronary stents. However, for the practicing interventionalist (PI) without core lab expertise, the utility of IVUS is often limited by difficulty interpreting images. Frequency Domain-Optical Coherence Tomography

Introduction: Cardiovascular imaging and interventions account for 40% of total medical radiation exposure (excluding radiation therapy). Exposure to ionizing radiation may cause skin injuries or increased risk of cancer and genetic defects. Hypothesis: Changing fluoroscopy defaults to low dose and low frame rate, while maintaining the option to use higher settings when needed, would decrease average patient radiation dose during cardiac catheterization without compromising procedural success. Methods: In 5/2013 we changed fluoroscopy defaults in 1 of 4 cardiac catheterization laboratories to lower dose (600 nGy/sec from 660 nGy/sec to the detector), lower frame rate (7.5 frames/sec from 15 frames/sec) and lower maximum patient exposure (5 Rad/min from 10 Rad/min). We recorded the air kerma (AK) in mGy/case for 719 coronary angiograms (448 pre, 271 post intervention) and 730 coronary interventions (451 pre, 279 post intervention) performed in this laboratory from 6/12-12/13. We used statistical process control analysis to evaluate changes in average monthly AK and to assess for statistical significance. Results: Following fluoroscopy default changes, average AK/case decreased by 21.2% for coronary angiograms (1282.1 ± 857.7 pre vs 1010.9 ± 846.4 post) and by 17.7% for coronary interventions (2858.6 ± 1802.9 pre vs 2353.6 ± 1210 post). After 5/13 there was a significant reduction in average monthly AK with a value below the 3 sigma line in 10/13 for coronary angiograms, and 2 consecutive values below the 2 sigma line in 11/13 and 12/13 for coronary interventions. There were no temporal changes in the incidence of adverse outcomes for interventions. Conclusions: Utilizing low fluoroscopy dose and frame rate defaults can significantly decrease exposure to ionizing radiation for patients undergoing cardiac catheterizations without affecting procedural success.

IVUS guided stent deployment using validated criteria (MUSIC) has been shown to improve outcomes. However, for the practicing interventionalist (PI) without core lab support, the utility of IVUS is often limited by difficulty interpreting images. Optical Coherence Tomography (OCT) is a new intra-

The benefit of drug-eluding stents (DES) in reducing target vessel revascularization (TVR) is greatest in patients at high risk of restenosis with bare metal stents (BMS). Lowering the risk of TVR with DES must be weighed against the potential increased risks of stent thrombosis and of bleeding from

BACKGROUND:A 68-year-old man was referred for stable angina pectoris and a large apical perfusion defect on stress myocardial scintigraphy. Medical history included chronic oral anticoagulation with warfarin due to longstanding atrial fibrillation, type 2 diabetes mellitus, hypertension, and dyslipidaemia.INVESTIGATION:Coronary angiography.DIAGNOSIS:Severe stenosis of the mid left anterior descending coronary artery.TREATMENT:Percutaneous coronary intervention with implantation of drug-eluting stent.

Chronic kidney disease is now widely accepted as an independent risk factor for coronary disease and the dialysis population may represent the highest risk subgroup. Among all dialysis patients, a cardiac cause of mortality has been estimated at 40%. In addition, prior studies have demonstrated that when cardiac catheterization is obtained in a consecutive series of asymptomatic diabetic patients on dialysis the rates of coronary disease can approach 50%. However, the ability to define the problem continues to be greater than the ability to treat or prevent it. Coronary revascularization strategies have limitations in the general population which are amplified in the dialysis population. The ability to accurately diagnose an acute coronary syndrome is more difficult, clinical outcomes have a smaller margin of benefit, and technical challenges result in higher complication rates. Recent data demonstrate an inverse relationship between glomerular filtration rate and the risk of presenting with an acute myocardial infarction rather than unstable angina suggesting that patients with CKD may have a unique pathophysiologic profile that is more prone to plaque rupture. However, these vulnerable plaques typically are associated with stenoses <50% prior to rupture and are thus poor targets for revascularization and perhaps best treated with medical therapy. Although the benefits of revascularization may continue to outweigh the risks in the context of acute coronary syndromes, preventive strategies would have to overcome the lower margin of benefit and higher complication rates.

Background The aim of this study was to summarize our single-center real-world experience with percutaneous coronary intervention (PCI) stenting of unprotected left main coronary artery (ULMCA). PCI-stenting of the ULMCA, while controversial, is emerging as an alternative to coronary artery bypass graft (CABG) surgery in select patients and clinical situations. Methods Between January 2005 and December 2008, PCI-stenting was performed on 125 patients with ULMCA lesions at our institution. Clinical and procedural data were recorded at the time of procedure, and patients were followed prospectively (mean 1.7 years; range 1 day-4.1 years) for outcomes, including death, myocardial infarction (MI), and target vessel revascularization (TVR). Results The majority of cases were urgent or emergent (82.5%), 50.4% of patients were non-surgical candidates, and 63.2% had 3 vessel disease. Many emergent patients presented in shock (62.1%), were not surgical candidates (89.7%), and had high mortality (20.7% in-hospital, 44.8% long-term). Mortality in the elective group was 6.3%. Cumulative death and TVR rates were 28.8% and 13.6%, respectively. Independent predictors of mortality were ejection fraction (EF) ≤ 35% (HR 2.4, CI 1.1 - 5.4) and left main bifurcation (HR 2.7, CI 1.2 - 5.7). Conclusions PCI-stenting is a viable option in patients with LMCA disease and extends options to patients who are poor candidates for CABG. Elective PCI in low-risk CABG patients results in good long-term survival. Cumulative TVR is 13.6%. EF ≤ 35% and left main bifurcation are independently associated with increased mortality.

Several high profile cases have called into question whether interventionalists are performing percutaneous coronary interventions (PCI) on lesions that are not flow limiting. We hypothesized that in northern New England there is agreement among interventionalists on what vessel segments have flow

Background: The prevalence of pulmonary hypertension (pulmonary HTN) in patients with end stage renal disease has been estimated to be 40-50% using noninvasive techniques, and this finding has been demonstrated to be a risk factor for increased morbidity and mortality in the renal transplant (RT) population. We sought to further classify these patients based on invasive hemodynamics. Methods: We retrospectively identified twelve RT candidates over a five year period (2006-2011) who were found to have a pulmonary artery systolic pressure ≥ 40 mmHg on noninvasive testing with echocardiography and underwent a subsequent right heart catheterization prior to transplant. Patient categories were created based on hemodynamic profiles (see below). The electronic medical record was reviewed to obtain demographic, echocardiographic, and hemodynamic data. Results: All patients were on dialysis and had an arteriovenous fistula (AV fistula). Eleven of the twelve RT candidates were found to have a mean pulmonary artery ...

We compare real-world, extended target vessel revascularization (TVR)-free survival following percutaneous coronary intervention (PCI) for patients receiving either sirolimus-eluting stents (SES) or paclitaxel-eluting stents (PES) following an index drug-eluting stent (DES) supported procedure. We analyzed 2,363 consecutive patients having first DES-supported PCI at receiving PES (n = 1,012) or SES (n = 1,332) from April 2004 to July 2006. Baseline clinical and procedural characteristics and in-hospital outcomes were recorded during the time of the index procedure and extended clinical outcomes data were obtained thereafter. TVR and all cause mortality were identified during the study period. Adjusted Kaplan-Meier and Cox's proportional hazard survival methods were performed. TVR-free survival at 2.3 years was 91.3% for SES compared with 88.9% for PES (P = 0.06). Kaplan-Meier survival curves did not significantly differ (adjusted hazard ratio -1.39 [95% CI 0.99-1.97]) between the SES and PES patient cohorts. TVR was similar between the stent platforms at one (96.6% for SES [95% CI 95.3-97.6] vs. 95.7% for PES [95% CI 94.1-96.9]) and two (95.0%[95% CI 93.0-96.4] for SES vs. 93.7% for PES [95% CI 91.6-95.3]) years. Overall survival at 2 years was 96.2% for SES (95% CI 94.7-97.3) and 95.3% for PES (95% CI 93.7-96.5). SES and PES drug-eluting stent platforms have good and similar extended outcomes in this real world registry of unselected patients having PCI.