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There is much debate on the pathogenesis of ischemic mitral regurgitation (MR), usually related to global or regional left ventricular dysfunction or remodeling secondary to chronic ischemic changes, altering the tethering and closing forces on the mitral apparatus. There is a paucity of literature describing MR in the setting of acute ischemia. We describe a case in which the MR was dynamic and directly related to changes in coronary collateral flow.

Background: Primary percutaneous coronary intervention (PPCI) for ST-elevation myocardial infarction (STEMI) is associated with increased bleeding complications, impacting clinical outcome. Transradial PPCI could decrease the risk of bleeding, but concerns about technical difficulties and longer reperfusion times limit its adoption., Aim and Methods: This was a retrospective comparison of reperfusion times and bleeding complications in a large cohort of STEMI patients treated by PPCI through the transradial (TR; n = 244) or transfemoral approach (TF; n = 364) from January 2005 to December 2009. Endpoints were door-to-balloon time, access-site and non-access site bleeding, as well 1-month and 1-year mortality rates., Results: Patients treated with TR-PPCI were younger than those having TF-PPCI, (57 ± 13 years vs 62 ± 13 years, respectively; P<.01), more frequently males (84% vs 73%, respectively; P<.01), and had less renal failure (9% vs 16%, respectively; P<.01) or hemodynamic compromise, ie, pulmonary edema or cardiogenic shock (1% vs 4%, respectively; P=.01). Angiographic and angioplasty characteristics, including the angiographic success rate, were similar, with the exception of a higher use of aspiration devices in the TR-PPCI group (31% vs 15%, respectively; P<.01). The door-to-balloon time was similar in both groups (76 ± 40 minutes vs 74 ± 41 minutes; P=NS). Significant lower rates of overall bleeding (6% vs 31%; P<.01), access-site bleeding (4% vs 27%; P<.01), non-access site bleeding (1% vs 3%; P=.01) and need for blood transfusion (0% vs 3%; P=.01) were observed in the TR-PPCI group. One-month (3% vs 7%; P<.05) and 1-year mortality rates (4% vs 11%; P<.05) were lower in the TR-PPCI group. Radial PCI was an independent predictor of 1-year mortality., Conclusion: TR-PPCI is feasible in STEMI patients and can be performed efficiently within the time limits recommended. This approach provides advantages in terms of reduction of bleeding that could translate into an improved clinical outcome.

Objectives: Angioplasty of a stenosis at the ostium of a diagonal branch of the left anterior descending artery as an isolated lesion often poses a dilemma due to the risk involved in treating the lesion in comparison to the potential benefit. Therefore, we sought to investigate our experience with this issue., Methods: Between 1995 and 2010, we retrospectively analyzed 39,300 patients who underwent invasive coronary angiography in our institution. Of these, a total of 22 had an isolated diagonal stenosis. The patients were either treated conservatively or underwent angioplasty and were followed for several years. Clinical and angiographic data were compared between the two groups., Results: Thirteen of the patients were treated conservatively and 9 underwent successful PCI. Baseline characteristics did not differ between the groups. The severity of the stenosis was also similar in the two groups, but in the angioplasty group, the diameter of the vessel was significantly larger (P<.01). More patients were recatheterized during the follow-up period in the conservative arm, although this did not reach statistical difference. There was no difference in mortality between the two groups., Conclusions: Initial conservative medical approach is a reasonable approach in treating isolated diagonal ostial stenosis.

Objectives: The infarct-related artery (IRA) in inferior wall myocardial infarction (IMI) may be problematic to identify due to occasional instances in which the right coronary (RCA) and left circumflex (CX) arteries are both occluded. We sought to investigate if impaired collateral myocardial blush (CMBG) identifies the correct IRA., Methods: Between 2002 and 2010, we retrospectively analyzed 1907 patients who underwent primary angioplasty at our institution. Of these, 44 had an IMI together with total occlusion of both the RCA and CX., Results: Thirty of these had good collaterals to both distal vessels. Ten of this group had impaired CMBG, indicating the IRA. In 2 patients, angioplasty was attempted in the wrong artery in retrospect., Conclusions: The correct IRA may be difficult to identify in patients with IMI and occlusion of both RCA and CX arteries. Impaired CMBG is a new tool to aid in this challenge.

We present the first case reported of fracture of a coronary guidewire during thrombectomy of a massive thrombus in a recently occluded coronary bypass graft with the recently developed atherectomy catheter X-Sizer. The thrombus was successfully aspirated without distal embolisation and the guidewire fragment was trapped in the graft after covering with a coronary stent. Possible reasons for this unusual complication of X-Sizer are discussed.

Heart catheterization is frequently applied in patients with coronary artery disease for diagnostic and therapeutic implications. Using the femoral approach, post-procedure bed rest of 4 to 6 hours is recommended to prevent groin complications. This extended strict bed rest is associated with patient discomfort and increased medical costs, and interferes with more efficient catheterization laboratory management of referred outpatients. Accordingly, we tested a simple clinical approach to identify low-risk patients who may benefit from ambulation within two hours after sheath removal. Ninety-eight outpatients were stratified to early (time=1.5 to 2.0 hours; n=74) or conventional ambulation (time=4 to 5 hours; n=24) based on difficulties in obtaining arterial access, presence of oozing or hematoma after completing manual compression. Ecchymosis was the most frequent complication, noted in one early ambulated and three conventionally ambulated patients at hospital discharge and in eleven early ambulated and six conventionally ambulated patients at one-week follow-up. No large hematomas, retroperitoneal bleeding or need for blood transfusion occurred in any patients. Using simple clinical parameters, most outpatients who undergo elective diagnostic catheterization may benefit from safe early ambulation.

We investigated the efficacy of percutaneous coronary intervention (PCI) in coronary thrombotic lesions according to the timing of the procedure. Eighty-two patients who underwent immediate PCI (IPCI) were compared to 24 patients who underwent PCI 4.9 3 days after the diagnostic catheterization [delayed PCI (DPCI)]. DPCI was associated with a lower rate of thrombus-related angiographic events (4% versus 27%; p < 0.03), including coronary embolism (0% versus 7%; p = NS), no-reflow phenomenon (0% versus 8%; p = NS), acute closure (0% versus 10%; p = NS), stent thrombosis (4% versus 1%; p = NS) and residual thrombus (0% versus 17%; p = 0.03). No differences were seen in the hospital clinical outcome, including non-fatal myocardial infarction (4% versus 9%; p = NS), death (4% versus 0%; p = NS) or major bleeding (4% versus 3%). Delayed PCI after pharmacological treatment is a safe and efficient strategy of treatment for coronary thrombus.

Acute vessel closure complicates 0.5 9.3% of percutaneous coronary interventional procedures. This case series demonstrates the potential value of distal vessel angiographic visualization during abrupt vessel closure, which allows rapid determination of the underlying mechanism and the subsequent appropriate therapy.

Coronary dissection during angioplasty can evolve into pseudoaneurysm. Stenting should prevent this complication. We present a case of coronary pseudoaneurysm after dissection that developed despite stent implantation. Intravascular ultrasound demonstrated no sealing of the false lumen due to undersizing and non-apposition to the wall by the stent.