SAS for what was until a recently a fatally progressive disease without surgery. But these patien... more SAS for what was until a recently a fatally progressive disease without surgery. But these patients often have a poor functional reserve and are prone to significant morbidity if any complication arises. This case illustrates the multiple cardiac and vascular complications that can result from TAVI. It emphasises the importance of a multidisciplinary approach to appropriately select patients in whom possible morbidity may be avoided.
Post-infarction ventricular septal defects (VSD) are rare (1-2%) but often fatal complications of... more Post-infarction ventricular septal defects (VSD) are rare (1-2%) but often fatal complications of acute myocardial infarction. These post infarction defects require urgent surgical treatment. We report a case unique in being a late presentation of post MI multiple VSDs. The patient survived surgery and a stormy post repair course with an excellent final outcome.
Background: Contemporary percutaneous coronary intervention (PCI) with current generation drug-el... more Background: Contemporary percutaneous coronary intervention (PCI) with current generation drug-eluting stents reduces instent restenosis. Stents have potential disadvantages such as late and very late stent thrombosis (ST), and long-term antiplatelet requirements. Bioresorbable vascular scaffold (BVS) represents a novel approach to provide shortterm vessel support and maintain drug-delivery capability. Objective: To retrospectively assess the in-hospital MACE, ST and target lesion revascularisation (TLR) in the first 101 patients undergoing PCI using 2nd generation BVS at our institution. Method: The PCI procedural data on all patients undergoing BVS implantation from August 2012 to October 2014 was reviewed. In-hospital MACE, ST, TLR events were identified from review of case notes and our PCI database. Clinical follow-up was conducted by telephone at an average of 18 months post procedure. Results: A total of 122 BVS (122 lesions) were implanted in 101patients (72% male; mean age 56 years; median number BVS 1.2/pt). Clinical presentation was with Angina in 34/101, ACS-NSTEMI 45/101 and STEMI 22/101. Deployment was successful in 100/101 patients (121/122 BVS; 99%). The majority of lesions were ACC/AHA type B lesion classification 76(62%). Minimum 12-month follow-up was available for 78% (79/101) of the patients. 18-month cumulative target vessel failure (composite of all-cause mortality, any myocardial infarction [MI] and TLR]) rate was 4.9%, including 1% definite ST and 3% TLR. Conclusion: Our experience suggests that unrestricted 'real-world' use of the BVS is associated with successful deployment and favourable short-to mid-term follow-up in a selected population with low stent thrombosis and MACE at 18 months.
Introduction: Stent malapposition is a known risk for stent restenosis and thrombosis. Although c... more Introduction: Stent malapposition is a known risk for stent restenosis and thrombosis. Although coronary angiography is the gold standard modality for imaging the coronary arteries, its 2D-nature and limited resolution make it difficult to accurately assess stent expansion. Optical coherence tomography (OCT) is being increasingly used in the cardiac-cath lab and offers a high resolution making it ideally suited to examine apposition. Aim: We describe our approach using the latest 3D angiographic and OCT techniques to better assess stent apposition. Method: OCT pullbacks were obtained using the iLumien system (St Jude's Medical). Multiplane angiography was performed using Xper-Swing view (Philips systems). This incorporates continuous cine imaging while a rotating C-arm follows a curved trajectory. Using the X-ray angiograms, 3D skeletal curves were created using a stereoscopic projection technique implemented in an inhouse Matlab code. Contours defining the inner wall from the OCT scans were then mapped onto the skeleton before creating a triangulated surface representing the inner lumen. We present 3D OCT/angiographic reconstruction of a complex bifurcation stent. Results: Combination 3D OCT with 3D angiography is feasible and may improve visualisation of coronary vessels in relation to stented segment. Conclusions: 3D angiography helps improve visualisation of optimal viewing angles and thus reducing foreshortening and is particularly suited to assessing complex lesions. Combining cutting edge imaging techniques with 3D reconstructive systems and OCT may offer an improved visualisation of coronary anatomy, lesion complexity and stent apposition and offers a promising ongoing area of research into the future.
artery in patients with resistant hypertension. The effect on central BP is less clear. Aim: To c... more artery in patients with resistant hypertension. The effect on central BP is less clear. Aim: To compare the effects of RDN on central and peripheral BP. Method: Thirty patients referred to Princess Alexandra Hospital RDN service were screened. Inclusion criteria: (1) peripheral BP >160/90 or (2) 24 ambulatory BP mean >150/90 or (3) home BP diary >150/90 on ≥3 drugs or (4) (i) ≥4 drugs to maintain normotension and (ii) evidence of end organ damage or (5) in the consensus opinion of the RDN Team, unique patient factors are such that the patient could potentially benefit from RDN therapy (e.g. severe intolerance to multiple medications). Patients were required to undergo a reasonable search for secondary causes and a period of appropriate medical therapy up titration. Central BP was measured non invasively using a SyphgmoCor Device. Results: Thirteen procedures on 12 patients. Eleven males. Mean age 54. Median 6 antihypertensives. Results at six months: peripheral systolic BP reduction from 171 ± 29 mmHg to 160 ± 31 mmHg (mean −11 mmHg, 95% CI (−36.4 to 14.4)). Peripheral diastolic BP reduction from 101 ± 21 mmHg to 96 ± 21 mmHg (mean −5 mmHg, 95% CI (−27.4 to 17.4)). Central systolic BP reduction from 149 ± 30 mmHg to 143 ± 36 (mean −6 mmHg, 95% CI (−34.3 to 21.8)). Conclusion: In our experience RDN shows a trend to decreasing peripheral brachial BP by a larger amount than central BP. This may have implications for long term morbidity and mortality benefits. Larger patient numbers will be required to achieve adequate statistical power and the trial is ongoing.
W e report a case of severe pulmonary vein stenosis in multiple vessels despite obtaining a satis... more W e report a case of severe pulmonary vein stenosis in multiple vessels despite obtaining a satisfactory electro anatomical merge during the ablation (Fig. 1). He was treated with stenting in 3 veins with a good recovery both clinical and radiological. A 52-year-old man was treated with pulmonary vein isolation for paroxysmal atrial fibrillation in April 2008. The ablation was performed using the CARTO system with CARTOMEGRE TM (Biosense Webster, Johnson and Johnson, Diamond Bar, CA) and a Navi-star D TM 3.5 mm thermo-cool irrigated (17 ml/h) ablation catheter (Biosense Webster, Johnson and Johnson, Diamond Bar, CA) with an energy of 30 W throughout and a maximum temperature of 50 • C. A Lasso TM 20 mm pulmonary vein mapping catheter (Biosense Webster, Johnson and Johnson, Diamond Bar, CA) was used. The right upper pulmonary vein (RUPV), right lower pulmonary vein (RLPV) and right middle pulmonary vein (RMPV) were isolated as one ring. The left upper pulmonary vein (LUPV) and left lower pulmonary vein (LLPV) were isolated individually and additionally a roof line was placed. A merge was made with tubes of RUPV, RLPV, LUPV, LLPV, left atrial appendage points, roof points, mitral annular points and posterior wall (52 applications). No contrast angiography was used. All veins were isolated and block confirmed by the Lasso TM catheter at the completion of the procedure. He had initial improvement in symptoms, however 1 month later he developed shortness of breath, persistent cough and reduced effort tolerance. A Magnetic Resonance Imaging (MRI) and a CT scan (Fig. 2) of his pulmonary veins showed significant stenosis in the right
A pseudoaneurysm with compression of the left main coronary artery causing significant ischaemia ... more A pseudoaneurysm with compression of the left main coronary artery causing significant ischaemia was successfully treated with a covered stent. We report this rare complication of cardiac surgery for infective endocarditis with a large root abscess. The patient developed a pseudoaneurysm arising from the body of the left main and causing compression of this vessel following his fourth redo aortic valve replacement for staphylococcal endocarditis. The endocarditis had been successfully managed and ongoing infection was excluded. The patient was then treated percutaneously with a covered stent that excluded the aneurysm and relieved the stenosis in the vessel.
A 41-year-old woman was admitted to the general medical department of a district general hospital... more A 41-year-old woman was admitted to the general medical department of a district general hospital with intermittent history of left sided chest pains for the past several weeks. She described the chest pain as a heaviness which was constricting in nature but without radiation or diaphoresis. The pain did not seem to be related to exertion and occurred at rest on occasion. The pains were also self limiting but on the day of admission they lasted longer and required sub-lingual nitrates to relieve the pain. She was an ex-smoker but otherwise denied all other risk factors for coronary artery disease. She did however admit to intravenous drug abuse and had previously abused heroin till about a year ago. She had a medical history of a previous donor nephrectomy and chronic back pain. Physical examination was unremarkable and
Coronary artery disease (CAD) is a complex disease with environmental and genetic determinants. M... more Coronary artery disease (CAD) is a complex disease with environmental and genetic determinants. Many other cardiovascular (CV) conditions also have a genetic basis. A positive family history of CV disease in first-degree relatives is a strong independent risk factor for CAD as well as several other cardiac disorders. This genetic susceptibility to CV diseases will be understood more clearly when combined with genomics, proteomics and genotyping.The Department of Cardiology at Gold Coast Hospital (Queensland, Australia) with the Faculty of Health, Science and Medicine at Bond University (Queensland, Australia) established the Gold Coast Cardiovascular DNA bank in 2006. The dataset on each individual volunteer includes coronary angiograms, clinical information (including a coronary risk factor profile), biochemical (including cardiac biomarkers) and hematological parameters, and electrocardiograms and echocardiograms. The establishment of the DNA biobank was associated with several ke...
SAS for what was until a recently a fatally progressive disease without surgery. But these patien... more SAS for what was until a recently a fatally progressive disease without surgery. But these patients often have a poor functional reserve and are prone to significant morbidity if any complication arises. This case illustrates the multiple cardiac and vascular complications that can result from TAVI. It emphasises the importance of a multidisciplinary approach to appropriately select patients in whom possible morbidity may be avoided.
Post-infarction ventricular septal defects (VSD) are rare (1-2%) but often fatal complications of... more Post-infarction ventricular septal defects (VSD) are rare (1-2%) but often fatal complications of acute myocardial infarction. These post infarction defects require urgent surgical treatment. We report a case unique in being a late presentation of post MI multiple VSDs. The patient survived surgery and a stormy post repair course with an excellent final outcome.
Background: Contemporary percutaneous coronary intervention (PCI) with current generation drug-el... more Background: Contemporary percutaneous coronary intervention (PCI) with current generation drug-eluting stents reduces instent restenosis. Stents have potential disadvantages such as late and very late stent thrombosis (ST), and long-term antiplatelet requirements. Bioresorbable vascular scaffold (BVS) represents a novel approach to provide shortterm vessel support and maintain drug-delivery capability. Objective: To retrospectively assess the in-hospital MACE, ST and target lesion revascularisation (TLR) in the first 101 patients undergoing PCI using 2nd generation BVS at our institution. Method: The PCI procedural data on all patients undergoing BVS implantation from August 2012 to October 2014 was reviewed. In-hospital MACE, ST, TLR events were identified from review of case notes and our PCI database. Clinical follow-up was conducted by telephone at an average of 18 months post procedure. Results: A total of 122 BVS (122 lesions) were implanted in 101patients (72% male; mean age 56 years; median number BVS 1.2/pt). Clinical presentation was with Angina in 34/101, ACS-NSTEMI 45/101 and STEMI 22/101. Deployment was successful in 100/101 patients (121/122 BVS; 99%). The majority of lesions were ACC/AHA type B lesion classification 76(62%). Minimum 12-month follow-up was available for 78% (79/101) of the patients. 18-month cumulative target vessel failure (composite of all-cause mortality, any myocardial infarction [MI] and TLR]) rate was 4.9%, including 1% definite ST and 3% TLR. Conclusion: Our experience suggests that unrestricted 'real-world' use of the BVS is associated with successful deployment and favourable short-to mid-term follow-up in a selected population with low stent thrombosis and MACE at 18 months.
Introduction: Stent malapposition is a known risk for stent restenosis and thrombosis. Although c... more Introduction: Stent malapposition is a known risk for stent restenosis and thrombosis. Although coronary angiography is the gold standard modality for imaging the coronary arteries, its 2D-nature and limited resolution make it difficult to accurately assess stent expansion. Optical coherence tomography (OCT) is being increasingly used in the cardiac-cath lab and offers a high resolution making it ideally suited to examine apposition. Aim: We describe our approach using the latest 3D angiographic and OCT techniques to better assess stent apposition. Method: OCT pullbacks were obtained using the iLumien system (St Jude's Medical). Multiplane angiography was performed using Xper-Swing view (Philips systems). This incorporates continuous cine imaging while a rotating C-arm follows a curved trajectory. Using the X-ray angiograms, 3D skeletal curves were created using a stereoscopic projection technique implemented in an inhouse Matlab code. Contours defining the inner wall from the OCT scans were then mapped onto the skeleton before creating a triangulated surface representing the inner lumen. We present 3D OCT/angiographic reconstruction of a complex bifurcation stent. Results: Combination 3D OCT with 3D angiography is feasible and may improve visualisation of coronary vessels in relation to stented segment. Conclusions: 3D angiography helps improve visualisation of optimal viewing angles and thus reducing foreshortening and is particularly suited to assessing complex lesions. Combining cutting edge imaging techniques with 3D reconstructive systems and OCT may offer an improved visualisation of coronary anatomy, lesion complexity and stent apposition and offers a promising ongoing area of research into the future.
artery in patients with resistant hypertension. The effect on central BP is less clear. Aim: To c... more artery in patients with resistant hypertension. The effect on central BP is less clear. Aim: To compare the effects of RDN on central and peripheral BP. Method: Thirty patients referred to Princess Alexandra Hospital RDN service were screened. Inclusion criteria: (1) peripheral BP >160/90 or (2) 24 ambulatory BP mean >150/90 or (3) home BP diary >150/90 on ≥3 drugs or (4) (i) ≥4 drugs to maintain normotension and (ii) evidence of end organ damage or (5) in the consensus opinion of the RDN Team, unique patient factors are such that the patient could potentially benefit from RDN therapy (e.g. severe intolerance to multiple medications). Patients were required to undergo a reasonable search for secondary causes and a period of appropriate medical therapy up titration. Central BP was measured non invasively using a SyphgmoCor Device. Results: Thirteen procedures on 12 patients. Eleven males. Mean age 54. Median 6 antihypertensives. Results at six months: peripheral systolic BP reduction from 171 ± 29 mmHg to 160 ± 31 mmHg (mean −11 mmHg, 95% CI (−36.4 to 14.4)). Peripheral diastolic BP reduction from 101 ± 21 mmHg to 96 ± 21 mmHg (mean −5 mmHg, 95% CI (−27.4 to 17.4)). Central systolic BP reduction from 149 ± 30 mmHg to 143 ± 36 (mean −6 mmHg, 95% CI (−34.3 to 21.8)). Conclusion: In our experience RDN shows a trend to decreasing peripheral brachial BP by a larger amount than central BP. This may have implications for long term morbidity and mortality benefits. Larger patient numbers will be required to achieve adequate statistical power and the trial is ongoing.
W e report a case of severe pulmonary vein stenosis in multiple vessels despite obtaining a satis... more W e report a case of severe pulmonary vein stenosis in multiple vessels despite obtaining a satisfactory electro anatomical merge during the ablation (Fig. 1). He was treated with stenting in 3 veins with a good recovery both clinical and radiological. A 52-year-old man was treated with pulmonary vein isolation for paroxysmal atrial fibrillation in April 2008. The ablation was performed using the CARTO system with CARTOMEGRE TM (Biosense Webster, Johnson and Johnson, Diamond Bar, CA) and a Navi-star D TM 3.5 mm thermo-cool irrigated (17 ml/h) ablation catheter (Biosense Webster, Johnson and Johnson, Diamond Bar, CA) with an energy of 30 W throughout and a maximum temperature of 50 • C. A Lasso TM 20 mm pulmonary vein mapping catheter (Biosense Webster, Johnson and Johnson, Diamond Bar, CA) was used. The right upper pulmonary vein (RUPV), right lower pulmonary vein (RLPV) and right middle pulmonary vein (RMPV) were isolated as one ring. The left upper pulmonary vein (LUPV) and left lower pulmonary vein (LLPV) were isolated individually and additionally a roof line was placed. A merge was made with tubes of RUPV, RLPV, LUPV, LLPV, left atrial appendage points, roof points, mitral annular points and posterior wall (52 applications). No contrast angiography was used. All veins were isolated and block confirmed by the Lasso TM catheter at the completion of the procedure. He had initial improvement in symptoms, however 1 month later he developed shortness of breath, persistent cough and reduced effort tolerance. A Magnetic Resonance Imaging (MRI) and a CT scan (Fig. 2) of his pulmonary veins showed significant stenosis in the right
A pseudoaneurysm with compression of the left main coronary artery causing significant ischaemia ... more A pseudoaneurysm with compression of the left main coronary artery causing significant ischaemia was successfully treated with a covered stent. We report this rare complication of cardiac surgery for infective endocarditis with a large root abscess. The patient developed a pseudoaneurysm arising from the body of the left main and causing compression of this vessel following his fourth redo aortic valve replacement for staphylococcal endocarditis. The endocarditis had been successfully managed and ongoing infection was excluded. The patient was then treated percutaneously with a covered stent that excluded the aneurysm and relieved the stenosis in the vessel.
A 41-year-old woman was admitted to the general medical department of a district general hospital... more A 41-year-old woman was admitted to the general medical department of a district general hospital with intermittent history of left sided chest pains for the past several weeks. She described the chest pain as a heaviness which was constricting in nature but without radiation or diaphoresis. The pain did not seem to be related to exertion and occurred at rest on occasion. The pains were also self limiting but on the day of admission they lasted longer and required sub-lingual nitrates to relieve the pain. She was an ex-smoker but otherwise denied all other risk factors for coronary artery disease. She did however admit to intravenous drug abuse and had previously abused heroin till about a year ago. She had a medical history of a previous donor nephrectomy and chronic back pain. Physical examination was unremarkable and
Coronary artery disease (CAD) is a complex disease with environmental and genetic determinants. M... more Coronary artery disease (CAD) is a complex disease with environmental and genetic determinants. Many other cardiovascular (CV) conditions also have a genetic basis. A positive family history of CV disease in first-degree relatives is a strong independent risk factor for CAD as well as several other cardiac disorders. This genetic susceptibility to CV diseases will be understood more clearly when combined with genomics, proteomics and genotyping.The Department of Cardiology at Gold Coast Hospital (Queensland, Australia) with the Faculty of Health, Science and Medicine at Bond University (Queensland, Australia) established the Gold Coast Cardiovascular DNA bank in 2006. The dataset on each individual volunteer includes coronary angiograms, clinical information (including a coronary risk factor profile), biochemical (including cardiac biomarkers) and hematological parameters, and electrocardiograms and echocardiograms. The establishment of the DNA biobank was associated with several ke...
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