We describe a clinical entity of recurrent episodes of microembolisation followed by fatal VLST occurring 2.5 years after implantation of overlapping long Taxus and Cypher stents. Uncovered stent struts and malapposition was observed as underlying pathogenesis of thrombosis. On histological examination the two distal stents had neointimal coverage while the proximal stent showed areas of inflammation and patches with absent to minimal neointima around stent struts. In the area of absent neointimal coverage, there was also identified a non-occlusive luminal platelet rich thrombus. The post-mortem examination of the heart revealed multiple areas of fibrosis with focal areas with acute inflammatory cells infiltration and myocyte necrosis, consistent with an acute myocardial infarction superimposed on a healed myocardial infarction. Recurrent episodes of chest and abdominal pain were likely to be caused by repeated embolisation of thrombotic material originating from the proximal part of the stented segment even though angiographic examination showed open coronary arteries.
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A 48 year old man admitted with exertional chest pain had a negative stress test at an optimal workload. Despite this, coronary angiography revealed a significant ostial left anterior descending artery stenosis. The patient subsequently underwent coronary artery bypass grafting. Three months later, the patient developed recurrent exertional chest pain and repeat angiography revealed a new critical stenosis of the distal left main involving the ostium of the left circumflex artery. This case illustrates the limitations of non-invasive functional testing and invasive angiography and the stochastic nature of coronary artery disease.
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Transfemoral Aortic Valve Replacement (TAVI) was first performed in 2002 and is increasingly being used to treat elderly or high-risk patients with aortic stenosis. The two technologies currently used in medical practice worldwide consist of the CoreValve Revalving System™ (CRS™) and the EDWARDS Sapien™ prosthesis. Balloon inflation of the stainless steel frame of the EDWARDS prosthesis is performed using sudden onset rapid right ventricular pacing to minimise cardiac output and, thereby, preventing valve migration or even embolisation. Rapid pacing is not needed when using the CRS™. The frame and valve are expanded by the gradual release of a protective sheath that covers the frame. Adjustments of the position of the CRS™ is possible during expansion. We have reported the embolisation of an EDWARDS bioprosthesis as a result of a premature stopping of the rapid pacing. In this paper, we report the embolisation and cause of the CRS™.
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Coronary anomalies can cause technical problems during coronary angiography as well as during intervention and we should be prepared for 'primary' angioplasty (PAMI) in difficult settings. This case involves a patient who presented with acute inferior wall chest pain, having an anomalous origin of the right coronary artery (ARCA) from the left sinus of valsalva (LSOV) in which the guiding catheter could not be aligned coaxially. We used the hydrophilic WHISPER wire to cross and subsequently complete the procedure. We also review the various techniques used in the setting of "PAMI in ARCA".
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