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Once considered a childhood disease, the number of adults living with congenital heart disease (CHD) has now exceeded the number of pediatric patients. The landscape of percutaneous intervention for adult congenital heart disease (ACHD) has evolved over the past decade and has yet to be characterized in Canada. The aim of this study was to begin to understand the current infrastructure underlying ACHD interventions in Canada and to characterize the type and number of interventions being carried out across the country. A cross-sectional national survey was distributed by e-mail to all cardiac catheterization laboratory directors in 2015. All Canadian laboratories involved in ACHD interventions responded, encompassing 19 institutions spanning 69 cardiac catheterization laboratories. A total of 1451 percutaneous interventions were recorded. Nationwide, the most common simple ACHD interventions were for atrial septal defect and patent foramen ovale closures. The most common ACHD interventions of increased complexity were for coarctation stenting and transcatheter pulmonary valve implantation. There was a marked clustering of procedures in Ontario, Québec, British Columbia, and Alberta in keeping with Canada's population-density distribution. A total of 23 ACHD operators were identified, half of whom had ACHD-specific fellowship training. These data can be used as a starting point to inform the present state of affairs in the area and lay the groundwork for further work to assess resource allocation and human resource planning for the care of patients with ACHD in Canada., (Copyright © 2017 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Background: Primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) presents challenges in a large geographic area for achieving treatment time targets and creates demands on the PCI centre resources., Objective: We compare the in-hospital mortality rate of patients presenting with STEMI and referred for PCI from 11 transfer hospitals with those presenting to the cardiac centre in a regional STEMI program with a selective repatriation strategy., Methods: Between June 1, 2003, and June 30, 2007, clinical and procedural data of all STEMI patients who were referred to the catheterization laboratory were prospectively collected. Patients who sustained prolonged cardiac arrest were excluded., Results: A total of 1154 patients from regional hospitals and 325 patients initially presenting to the PCI centre were referred for acute intervention. There was no significant in-hospital mortality difference between the 2 groups (3.7% vs 4.0%, respectively; P = 0.87). Multiple logistic regression analysis showed that advanced age, female gender, multivessel coronary disease, history of hypertension, low ejection fraction, increased left ventricular end-diastolic pressure, and thrombolytic pretreatment, but not transfer status, were independent predictors for mortality. Among the 1154 transfer patients, 937 patients (81.2%) returned immediately post procedure and had a lower mortality rate than the remaining 217 patients (18.2%) who required admission to the PCI centre following cardiac catheterization (1.9% vs 11.5%, P < 0.001)., Conclusion: A regional system of STEMI care based on rapid patient transfer to a PCI centre and repatriation was feasible and safe., (Copyright © 2011 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

The management of vascular disease requires knowledge of clinical assessment, pharmacotherapeutics, endovascular procedures and vascular surgery. In Canada, interventional cardiology, vascular surgery, interventional radiology and neurosurgery specialists may be involved in the care of patients with vascular disease, and they all claim to have expertise and an advantage in treating specific patients. The present article identifies the sources of the potential 'turf war' in vascular medicine, and proposes some possible solutions through reorganization of vascular care, with particular reference to the modern era of Canadian medicine.

Acute limb ischemia due to vascular closure devices is an infrequent complication. However, its incidence is increasing because the use of these devices has become commonplace after cardiac catheterization and coronary angioplasty. It is therefore important for interventional cardiologists to be acquainted with the knowledge and cognitive skills of managing this complication in the catheterization laboratory. The present report describes a strategy to manage this complication in a cardiac catheterization laboratory that is not equipped with standard fluoroscopic equipment for peripheral interventions.

Atherosclerosis manifests as a broad spectrum of clinical pathology involving both coronary and noncoronary circulation. Peripheral artery disease (PAD) and coronary artery disease (CAD) have an important negative impact on each other with respect to treatment options and prognosis. The issue is further compounded by the underdiagnosis and undertreatment of PAD among CAD patients. There are compelling reasons why cardiovascular specialists should take an active role in the care of patients with global atherosclerotic disease. Several areas that impact cardiac patient care and thus are of particular interest to the cardiologists are renal artery disease causing hypertension or renal insufficiency; carotid artery stenosis in precoronary bypass patients; subclavian artery disease causing myocardial ischemia in patients with internal mammary bypass graft; and aortoiliofemoral arterial obstruction causing reduction in exercise tolerence and limitation in arterial access. Risk factor modifications for primary and secondary prevention are similar between CAD and PAD. Moreover, interventional cardiologists possess the necessary skills, which are transferable from coronary intervention to peripheral revascularization. To optimize outcomes, it is important for cardiovascular specialists to have a good foundation of knowledge about the natural history, treatment options and lesion selection. Collaboration with multidisciplinary specialists, including vascular surgeons and neurologists, is advisable for the treatment of PAD.

Background: The appearance of remote ST segment depression (RSTD) on an electrocardiogram (ECG) is associated with more extensive infarction and a worse clinical outcome than when RSTD is absent., Objective: To determine whether RSTD predicts coronary anatomy during acute coronary occlusion. It was hypothesized that RSTD is associated with the occlusion of a proximal lesion, an extensive artery and an artery without distal collateralization., Patients and Methods: In 113 consecutive patients with single vessel disease undergoing percutaneous transluminal coronary angioplasty (PTCA), 12-lead ECGs (recorded at baseline and during balloon inflation) and angiographical data were analyzed independently. Patients with ST segment elevation in the primary territory and RSTD (greater than 1 mm ST depression at 80 ms after the J point) (group A) were compared with patients without RSTD (group B). Proximal lesions were defined as lesions located in the segments proximal to the acute marginal branch, first diagonal artery or first obtuse marginal branch. An extensive right coronary artery (RCA) was one that supplied the posterolateral wall; an extensive left anterior descending (LAD) artery was one that supplied the inferoapical wall; and an extensive circumflex artery was one that supplied the posterior descending artery., Results: Fifty-four patients (48%) had PTCA of the proximal vessels, 43 patients (38%) had extensive target vessels and 11 patients (9.7%) had collaterals. Target vessels included 33% in RCA, 44% in LAD artery and 23% in circumflex artery. Forty-five patients (40%) developed RSTD during balloon inflation (group A). Patients in group A were more likely to have extensive vessels on the angiogram than those in group B (group A 49%, group B 31%; P=0.05). None of the patients in group A had collaterals to the culprit artery, while 16% of patients in group B did (P=0.003). The two groups were not significantly different with respect to the number of proximal lesions (group A 58%, group B 42%; P=0.08). Analysis performed according to the target artery revealed that RSTD was associated with occlusion of an extensive RCA during RCA occlusion (extensive RCA in group A 100%, group B 57%; P=0.006). For the LAD artery, RSTD was associated with proximal lesions (group A 74%, group B 41%; P=0.02) and absence of collaterals (group A 100%, group B 74%; P=0.01)., Conclusions: During acute coronary occlusion, the presence of RSTD on 12-lead ECG was specific for the absence of collaterals. The presence of RSTD during RCA occlusion was strongly associated with an extensive RCA, suggestive of posterolateral wall ischemia. During LAD artery occlusion, the presence of RSTD was associated with proximal occlusion, which resulted in ischemia of the LAD artery and the major diagonal artery territories.

Acute onset dilated cardiomyopathy is a very common presentation encountered by cardiologists in clinical practice, but little is known about the etiology, pathophysiology, definitive diagnosis and management of this syndrome. The vast majority of cases are considered as idiopathic cardiomyopathy, or primary or secondary myocarditis, although rarely definitive diagnoses are obtained after extensive diagnostic procedures. Two scenarios are presented as a basis for a discussion of this challenging syndrome.

Background: Balloon rupture is a potential complication of coronary angioplasty. The literature is inconsistent regarding associated adverse consequences. The experience of St Paul's Hospital, University of British Columbia, Vancouver, British Columbia, with balloon rupture is reviewed., Patients and Methods: All patients who underwent percutaneous coronary intervention complicated by balloon rupture at St Paul's Hospital from April 1992 to March 1996 were identified from the hospital's database (Seattle Systems, Seattle, Washington). Procedural logs, database records, clinical charts and all cineangiograms were reviewed in detail., Results: A total of 2984 patients had percutaneous coronary revascularization and 110 patients experienced balloon rupture. These occurred in 101 (92%) native coronary arteries and 9 (8%) occurred in saphenous vein grafts. Stents were deployed in 44 (40%) patients; 34 of the stents used were half Johnson & Johnson PS153 stents (Johnson & Johnson Interventinal Systems, Peterborough, Ontario). An event-free postangioplasty course during the index hospitalization was observed in 102 patients (93%); eight patients (7%) had one or more important adverse events postprocedure. These included three deaths (one following a dissection and out-of-catheterization laboratory occlusion, a second following an abrupt occlusion of another target artery and emergency bypass surgery, and another with cardiogenic shock postmyocardial infarction and an unaltered course following angioplasty); one urgent bypass surgery after a left main dissection; and two nonfatal myocardial infarctions (one patient had tamponade and one patient experienced congestive heart failure). Four of the eight events were directly related to the procedure. The rate of death and emergency bypass surgery with balloon rupture did not differ from that of patients without balloon rupture in the authors' centre (1.8% versus 1.4%, not significant)., Conclusions: The majority of patients did not experience any adverse clinical outcomes and demonstrated good angiographic results after balloon rupture. The data did not detect an excess of major adverse events beyond that expected in a diverse general angioplasty population.

A 42-year-old man presented with acute anterior myocardial infarction and hemoglobin of 248 g/L. Laboratory studies suggested the diagnosis of polycythemia rubra vera (PRV). Management of this condition with acetylsalisylic acid, heparin, warfarin and phlebotomy constitutes a therapeutic dilemma. This case also brings up the question of the appropriateness of thrombolysis and angioplasty in the treatment of myocardial infarction in the presence of PRV. Due to the rarity of this hematological disease, a call for international collaboration for assessing the efficacy and safety of these treatment modalities is recommended.

Previous cases of diltiazem overdose described patients who presented with hypotension, heart block, bradycardia, or ultimately death. This report concerns an elderly patient presenting to the emergency room with hypotension, an ischemic leg and confusion. He underwent an emergency thrombectomy of the femoral artery. He had severe lactic acidosis, persistent hypotension requiring prolonged inotropic support and difficulty being weaned from the ventilator after the operation. Subsequent investigations confirmed that he attempted suicide by taking an unknown quantity of diltiazem. Because diltiazem has been increasingly prescribed to treat various cardiovascular disorders, overdose may become a more common problem. A high index of suspicion is required to ensure prompt diagnosis and appropriate treatment when patients taking this medication present with sudden circulatory collapse. A guide to the management of diltiazem overdose is provided.