John Conleth Murphy

The Official Journal of EuroPCR and the European Association of Percutaneous Cardiovascular Interventions (EAPCI)

Idiopathic mediastinal fibrosis is a rare, histologically benign condition which often presents with symptoms attributable to compression of vital mediastinal structures. Diagnosis can be difficult and individualized treatments are required for patients, with possible intervention including pharmacotherapy, surgery, and percutaneous stenting. We present a case of idiopathic mediastinal fibrosis present in a 50‐year‐old woman as compression and near obliteration of the pulmonary arteries. A percutaneous approach was utilized with bilateral balloon expandable kissing stents simultaneous deployed from the main pulmonary artery to the right and left pulmonary arteries. There was instantaneous improvement in the pulmonary and systemic hemodynamics. Her immediate postprocedure course was complicated by reperfusion injury to the right lung, requiring intubation and ventilation. The patient made a full recovery and remains well at 6 months. Our case highlights the procedural and postprocedural difficulties that exist in such cases, and reinforces the value of endovascular stenting strategies in the management of patients with this rare condition.

Performing percutaneous coronary intervention (PCI) in arteries with complex anatomy remains a clinical problem. In particular tortuosity within a coronary vessel is frequently encountered and can hamper delivery of balloons or stents to coronary stenoses. This has led to the development of a number of adjuvant devices to assist stent delivery in difficult cases. The safety profile of these novel devices remains to be clearly ascertained. The Guideliner® “child” support catheter is one such device and comprises of a 20‐cm silicon‐coated guide extension that assists delivery of stents in tortuous arteries when conventional techniques have failed. Initial reports suggest it is efficacious and no previous complications relating to the device have been published. We report the first complication involving the Guideliner® catheter which was encountered during primary PCI. We hypothesize regarding the mechanism of the complication and discuss the ways it may be avoided in the future.

A 35-year-old female presented with acute inferior ST-elevation myocardial infarction and underwent emergency cardiac catheterization. Diagnostic images revealed an occlusive filling defect at the first bifurcation of a large dominant circumflex artery (Panel A). The other epicardial coronary arteries were normal. Aspiration thrombectomy removed a significant volume of thrombus and angiography then demonstrated the circumflex to be angiographically normal and no stenting was required (Panel B). Transoesophageal echocardiography (TOE) demonstrated a 0.4 × 0.6 cm mobile echodensity on the atrial aspect of a thickened anterior mitral valve leaflet. No other intracardiac abnormalities were identified. The patient was systemically well with no episodes of pyrexia. Inflammatory markers were not raised (C-reactive protein 7 and erythrocyte sedimentation rate 35) and blood cultures did not identify a bacteraemia. Thrombophilia screen was remarkable for a positive lupus anticoagulant (RVVT norm% correction 48.6%) and a positive anticardiolipin antibody (ACA IgG 44 U/mL). An anti-nuclear antibody was positive for both the nucleolar and homogenous patterns. A diagnosis of Libman–Sacks endocarditis (LSE) was made and the patient was commenced on intravenous heparin. On follow-up TOE, several days later, the mobile echodensity was no longer visible, though the anterior leaflet tip remained thickened (Panels E and F). She was commenced on warfarin and has remained well with no unplanned hospital admissions.

Patients with compelling evidence of cryptogenic stroke due to patent foreamen ovale (PFO) are increasingly likely to be offered percutaneous closure of the defect. With improvements in technique there is now a high procedural success rate with low rates of periprocedural complications. Late complications are also rare, but include late perforation of the aortic root, which is rapidly progressive and potentially fatal. This has lead to the development of lower profile devices, which aim to reduce the risk of both early and late complications. At this stage, it is not clear if lower profile devices have safety profiles which are superior to the more established devices. We report the first case of late perforation of the aortic sinus by the lower profile Atriasept (Cardia) device presenting as life threatening cardiac tamponade in an adult who previously underwent percutaneous PFO closure.