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A 59-year-old woman developed fever and elevated hepatic enzyme levels within days of starting clopidogrel, which had been prescribed in conjunction with a percutaneous coronary intervention. When she discontinued the clopidogrel, her liver enzyme levels returned to baseline and her fever disappeared. These signs and symptoms returned after rechallenge with clopidogrel. Monitoring for fever and elevation of liver enzyme levels in patients taking clopidogrel may be warranted. If a patient has signs of hepatotoxicity with or without fever, discontinuation of clopidogrel should be considered, along with substitution with ticlopidine if clinically warranted.

Approximately 35% of patients hospitalized with heart failure (HF) are diabetic. The prevalence increases further among patients with more severe HF. The most common etiology of HF in diabetics is Coronary Heart Disease (CHD). There is limited and conflicting data regarding the effectiveness of PCI on survival and morbidity in diabetics with CHD and LV dysfunction. Objective: We evaluated our Registry data to determine the impact of PCI on immediate and long-term clinical outcomes in diabetics with advanced HF (LVEF ≤35%). From 1/00 to 2/06, we performed PCI in 382 patients in this subset (mean age 64; 31% female; 36% prior MI; 34% prior CABG). Mean NYHA functional class was 3.2; diastolic dysfunction (DD) was seen in 69%. Mean global LVEF at presentation was 28.3%. Indications for PCI: acute MI (17%), unstable angina (34%), cardiogenic shock (5%), objective evidence of ischemia on stress testing (32%). The culprit lesion was ostial/proximal in 52%; multivessel disease 52%. Adjunctive IABP support was used in 22%; 12% received drug-eluting stents. Results: Procedural success was 96%. Incidence of in-hospital adverse events (acute reclosure 1.5%; CABG 1%; death 0.8%) was low. At 1-year follow up, there was demonstrable improvement in symptoms and signs of HF. Mean NYHA improved to 1.7 (p=0.002), DD persisted in 13% (p Conclusions: In selected diabetic patients with CHD and advanced HF, PCI is a safe and effective means of myocardial salvage, producing significant improvement in multiple functional and clinical parameters. Procedural success was impressive. At 1 year follow-up, there was significant improvement in LV systolic and diastolic performance, which translated into improved functional class, low incidence of hospitalization and acceptable 1-year mortality. Our experience demonstrates that PCI strategies are rewarding in diabetic patients with advanced HF. Effective myocardial salvage appears to be key to improved event-free and absolute survival in these patients.

A complication of balloon mitral valvuloplasty is development of left-to-right interatrial shunt. This report describes right-to-left interatrial shunting following balloon mitral valvuloplasty in a patient with mitral stenosis, tricuspid regurgitation and pulmonary hypertension.