Duplex ultrasonography of vertebral and subclavian arteries.

Duplex ultrasonography of the vertebral artery is an integral part of extracranial cerebrovascular screening and provides noninvasive diagnostic clues for subclavian or vertebral artery stenosis. This review describes technique for the ultrasound examination of the vertebral and subclavian arteries. Duplex images from various patients are used to illustrate a spectrum of hemodynamic changes that occur in the vertebral artery Doppler signal caused by subclavian artery stenosis and subclavian-vertebral steal.

Cardiac tamponade.

Cardiac tamponade is a common cardiac emergency requiring prompt diagnosis and intervention. A thorough understanding of the spectrum of clinical and hemodynamic changes in patients with pericardial effusion is vital for interventional cardiologists. This review discusses pathophysiology of cardiac tamponade with emphasis on hemodynamic aberrations.

Atypical hemodynamic manifestations of cardiac tamponade.

Clinical examination and transthoracic echocardiography play a vital role in the management of patients with pericardial effusion and cardiac tamponade physiology. We report patients in advanced phase 3 cardiac tamponade with variant clinical and hemodynamic presentations. These atypical cardiac tamponade cases include: A patient with severe aortic valve regurgitation who lacked pulsus paradoxus; a patient with systemic sclerosis without hypotension; and a patient with pulmonary hypertension lacking right heart collapse on echocardiography.

Early ostial saphenous vein graft stenosis associated with the use of Symmetry sutureless aortic proximal anastomosis device: successful percutaneous revascularization.

A recent advance in technology permits the creation of sutureless proximal aortic anastomosis during coronary artery bypass graft surgery. This new tool has significant potential benefit by minimizing aortic manipulation with subsequent reduction in neuroembolization. Implantation of a nitinol-based proximal aortic connector (Symmetry) has a potential to elicit intimal hyperplastic reaction analogous to restenosis after coronary stent placement.

Combined distal embolization protection and rheolytic thrombectomy to facilitate percutaneous revascularization of totally occluded saphenous vein grafts.

Totally occluded saphenous vein grafts are difficult to treat percutaneously with a higher likelihood of distal embolization and slow-flow or no-reflow during percutaneous interventions. The PercuSurge system, which utilizes a distal balloon occlusive device, has been shown to improve clinical outcomes during saphenous vein graft (SVG) interventions. This device may not be optimal in the setting of heavy thrombus or debris burden, a situation frequently encountered in totally occluded SVGs.

Prediction of significant left main coronary artery stenosis by the 12-lead electrocardiogram in patients with rest angina pectoris and the withholding of clopidogrel therapy.

We report the prospective use of an electrocardiographic sign--lead aVR ST-segment elevation greater than that seen in lead V(1)--in patients with an acute coronary syndrome as a method to prompt early angiography, to withhold clopidogrel therapy, and to perform urgent coronary bypass surgery leading to successful clinical outcomes.

Prospective serial evaluation of myocardial perfusion and lipids during the first six months of pravastatin therapy: coronary artery disease regression single photon emission computed tomography monitoring trial.

Objectives: This study was designed to assess prospectively changes in serum lipid profile and myocardial perfusion with serial radionuclide single photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) during the first six months of pravastatin therapy.

Background: Morbid coronary events occur despite statin therapy and lipid-lowering in patients with coronary artery disease (CAD). A reliable strategy to identify responders with effective treatment from nonresponders on statin therapy before clinical events is needed.

Inadvertent dilation of a saphenous vein graft stenosis by the PercuSurge GuardWire distal protection balloon.

Distal embolization protection devices are fast becoming an integral part of percutaneous vein graft interventions. The distal elastomeric balloon of the PercuSurge GuardWire system is supposed to be atraumatic to the vessel wall. We report the inadvertent dilation of a moderate distal stenosis at the site of GuardWire balloon inflation while intervening on a critical proximal saphenous vein graft stenosis.

Complete situs inversus and bicuspid aortic valve stenosis.

Patients with congenital heart disease are increasingly surviving to adulthood and present interesting challenges during cardiac catheterization. Situs inversus with dextrocardia is a type of cardiac malposition most likely to exist with a structurally normal heart. We present the case of a patient with complete situs inversus and bicuspid aortic valve stenosis, a hitherto unreported association.

Myocardial Bridge: a clinical review.

Human coronary arteries occasionally course intramyocardially--a condition termed Myocardial Bridge. We review the anatomic and pathophysiological basis of the Myocardial Bridge and discuss clinical presentations, prognoses and the current treatment options for this interesting coronary angiographic variant.

Intrapulmonary arteriovenous shunt: diagnosis by saline contrast bubbles in the pulmonary veins.

A 54-year-old man with end-stage cirrhosis of the liver presented for evaluation of dyspnea. Intrapulmonary arteriovenous shunting was suspected. Transthoracic echocardiography with agitated saline contrast injection from the right antecubital vein was performed.

Distal emboli protection in patients undergoing percutaneous coronary intervention after a recent myocardial infarction.

Devices to prevent distal atheroembolization are an important addition to the armamentarium of an interventional cardiologist. We report the use of PercuSurge, a distal balloon occlusion device, in two patients with recent myocardial infarction of differing etiologies. The first case is a patient with an old degenerated vein graft with thrombotic occlusion of greater than 48-hr duration and the second case is a patient with an embolic myocardial infarction in a native coronary artery.