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Objectives We sought to determine the contemporary prevalence and management of coronary chronic total occlusions (CTO) in a veteran population. Background The prevalence and management of CTOs in various populations has received limited study. Methods We collected clinical and angiographic data in consecutive patients that underwent coronary angiography at our institution between January 2011 and December 2012. Coronary artery disease (CAD) was defined as ≥50% diameter stenosis in ≥1 coronary artery. CTO was defined as total coronary artery occlusion of ≥3 month duration. Results Among 1,699 patients who underwent angiography during the study period, 20% did not have CAD, 20% had CAD and prior coronary artery bypass graft surgery (CABG) and 60% had CAD but no prior CABG. The prevalence of CTO among CAD patients with and without prior CABG was 89% and 31%, respectively. Compared to patients without CTO, CTO patients had more comorbidities, more extensive CAD and were more frequently referred for CABG. Percutaneous coronary intervention (PCI) to any vessel was performed with similar frequency in those with and without CTO (50% vs. 53%). CTO PCI was performed in 30% of patients without and 15% of patients with prior CABG with high technical (82% and 75%, respectively) and procedural success rates (80% and 73%, respectively). Conclusions In a contemporary veteran population, coronary CTOs are highly prevalent and are associated with more extensive comorbidities and higher likelihood for CABG referral. PCI was equally likely to be performed in patients with and without CTO.

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Gemella haemolysans is a gram-positive coccoid, facultative anaerobe of the mucous membranes. In rare cases, it has been identified as an opportunistic pathogen in the development of endocarditis. Here, we describe a case of infective endocarditis in a patient with a bicuspid aortic valve. A 38-year-old man presented with the complaint of exertional dyspnea of one month duration. He was found to have leucocytosis and his blood cultures grew Gemella haemolysans. Trans-esophageal echocardiography showed a bicuspid aortic valve with 1.5 x 1.5 cm vegetative mass, severe aortic regurgitation, and an aortic root abscess. The patient was started on intravenous ampicillin and gentamycin. He then underwent mechanical aortic valve replacement and bovine reconstruction of the left ventricular outflow tract. Our case highlights the importance of considering atypical pathogens as causative agents of infective endocarditis.

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