An 84-year-old female patient suffered from dyspnea due to severe aortic stenosis. Several comorbidities and her advanced age made her acceptable for transcatheter aortic valve implantation (TAVI). The TAVI procedure was performed via a femoral access and a 26-mm CoreValve prosthesis (Medtronic, Minneapolis, MN, USA) was implanted. The prosthesis was deployed at a high position because of short distance between the annulus base and coronary arteries. Aortic angiography indicated normal contrast flow into both coronary arteries. Six months later she was readmitted to our hospital because of acute coronary syndrome. Although selective intubation of coronary arteries could not be achieved because of high valve position, both coronary arteries seemed to be well contrasted. As a consequence, the second coronary angiography was undertaken because of recurring chest pains. The aortic root angiogram showed a decreased contrast flow into both coronary arteries. During the examination she deteriorated rapidly, developed cardiopulmonary arrest, and a percutaneous cardiopulmonary support and an intra-aortic balloon pump needed to be inserted. She was then transferred to the operating room for aortic valve replacement. This is the first case of delayed coronary ischemia after TAVI, necessitating the removal of an implanted CoreValve and its replacement with a new prosthetic valve.
Sirolimus-eluting stents (SES), especially those deployed at distal sites, cause more coronary vasospasm and endothelial dysfunction in the chronic phase compared to bare-metal stents (BMS). In comparison, endothelial dysfunction is less frequently induced by the Biolimus-A9 eluting stent (BES). A 75-year-old man with effort-induced angina pectoris previously underwent a total of three SES implantations in the left anterior descending coronary artery (LAD) and right coronary artery (RCA) in 2010 and 2011. He was referred to our hospital for the management of chest discomfort at rest in August 2014. We diagnosed this patient with coronary spastic angina (CSA) and coronary endothelial dysfunction (CED) induced by the SES, together with an atherosclerotic lesion in the left main coronary artery (LMCA). Adequate medication for CSA and CED and intervention for the atherosclerotic lesion contributed to improvement of vascular function and disappearance of his symptoms.
Introduction: Acute myocardial infarction (AMI) has been a major cause of death worldwide. Recently, living alone as a proxy for social isolation has been considered to increase the risk of cardiovascular disease. We thus investigated the impact of living alone on mortality in AMI patients. Methods: Subjects comprised 277 AMI patients who underwent percutaneous coronary intervention (PCI). Associations between all-cause death after PCI and baseline characteristics including living alone and Global Registry of Acute Coronary Events (GRACE) risk score, which is widely used for estimating mortality in AMI patients, were assessed. Results: Eighty-three patients (30%) were living alone and 194 patients (70%) were not. Median duration of follow-up was 1153 days (interquartile range, 560-1566 days). Thirty patients died after PCI including 20 cardiac deaths. Patients living alone showed higher incidences of both all-cause and cardiac deaths compared with patients not living alone (18% vs. 8%, p = 0.019 and 14% vs. 4%, p = 0.004, respectively). Multivariate Cox proportional hazards regression analysis modeling using relevant factors from univariate analysis showed living alone [hazard ratio (HR), 2.60; 95% confidence interval (CI), 1.20-5.62; p = 0.016] and GRACE risk score (HR, 1.02; 95%CI, 1.01-1.03; p = 0.003) correlated significantly with all-cause death. The interaction of GRACE risk score and living alone showed a value of p = 0.25. The optimal cut-off on the receiver-operating characteristic curve of GRACE risk score for predicting all-cause death was 162. Cox proportional hazards modeling using GRACE risk score and living alone revealed that patients living alone with GRACE risk score ≥162 showed a significantly greater risk of all-cause death than patients not living alone with GRACE risk score <162 (HR 11.50; 95%CI 5.59-23.67; p < 0.001). Conclusions: Among AMI patients, living alone represents an independent risk factor for all-cause death after PCI, separate from GRACE risk score. In addition, AMI patients living alone with high GRACE risk scores may experience an additively increased risk of mortality after PCI.
Elevation of the ST segment after percutaneous coronary intervention (PCI) using rotational atherectomy (RA) for severely calcified lesions often persists after disappearance of the slow-flow phenomenon on angiography. We investigated clinical factors relevant to prolonged ST-segment elevation following RA among 152 patients with stable angina undergoing elective PCI. PCI procedures were divided into two strategies, RA without (primary RA strategy) or with (secondary RA strategy) balloon dilatation before RA. Incidence of prolonged ST-segment elevation after disappearance of slow-flow phenomenon was higher in the 56 patients with primary RA strategy (13%) than in the 96 patients with secondary RA strategy (3%, p = 0.039). Univariate logistic regression analysis showed levels of low-density lipoprotein cholesterol (LDL-C) (odds ratio [OR] 0.95, 95% confidence interval [CI] 0.93–0.99; p = 0.013), levels of triglycerides (OR 0.97, 95%CI 0.94–0.99; p = 0.040), and secondary RA strategy (OR 0.23, 95% CI 0.05–0.85; p = 0.028) were inversely associated with occurrence of prolonged ST-segment elevation following ablation. However, hemodialysis, diabetes mellitus, left-ventricular ejection fraction, lesion length ≥ 20 mm, and burr size did not show significant associations. Multivariate logistic regression analysis modeling revealed that secondary RA strategy was significantly associated with the occurrence of prolonged ST-segment elevation (Model 1: OR 0.24, 95% CI 0.05–0.95, p = 0.042; Model 2: OR 0.17, 95% CI 0.03–0.68, p = 0.018; Model 3: OR 0.21, 95% CI 0.03–0.87, p = 0.041) even after adjusting for levels of LDL-C and triglycerides. Secondary RA strategy may be useful to reduce the occurrence of prolonged ST-segment elevation following RA.
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