During the past 50 years, there have been remarkable advances in the fields of electrophysiology, interventional cardiology, peripheral vascular disease, and structural heart disease. In 1967, Drs Duerer and Coumel independently demonstrated the successful use of electrical stimulation and intracardiac activation mapping to analyze the site and mechanisms of cardiac arrhythmias. The strategy of localizing the origin and the pathway of the arrhythmia ushered in an era of new therapies to treat tachycardias. With the combined help of pathologists and electrophysiologists, surgeons were able to make incisions in the heart to disrupt the circuitry responsible for arrhythmias; these can now be done percutaneously by electrophysiologists. Concurrently, programmed stimulation was used to incite and, when needed, terminate cardiac arrhythmias, leading to the development of the implantable automatic defibrillator to detect and terminate lethal arrhythmias.The history of percutaneous treatment of vascular disease dates back to 1964, when Charles Dotter performed the first percutaneous transluminal angioplasty of a stenotic femoral artery. This ushered in the field of interventional radiology, the development of embolization techniques, and vascular stents. In 1977, Andreas Gruentzig introduced the concept of coronary balloon angioplasty to the world as a means to treat coronary artery stenoses. Despite initial skepticism and frequent early complications, technological advances led to the wide acceptance of this procedure, with the subsequent development of coronary stents, the use of which has become the most common method to achieve coronary revascularization. Following the pathway of coronary stenting, percutaneous treatment of aortic stenosis with both balloon-expandable and self-expanding valvular stents initiated the era of percutaneous treatment of structural heart disease.In the April issues of JACC: Case Reports, we can see how these fields have evolved. The development of new technologies has not been without complications, and it is with addressing these complications that further advancement in invasive technologies has occurred.In the case reported by Guber et al, ventricular tachycardia occurred after the rare occurrence of glue and coil portosystemic embolization used in the treatment of esophageal varices. Intracardiac mapping was useful in determining the nidus of the newly developed arrhythmia, presumed to be the result of focal mechanical irritation of the right ventricular outflow tract, resulting in the wide-complex tachycardia. This was successfully treated with amiodarone and a beta-blocker. In the report by Sudo et al, cryoballoon ablation was used to successfully treat a patient with persistent atrial fibrillation. This percutaneous procedure was complicated by a life-threatening pulmonary vein perforation requiring lobectomy. Lee et al report the early recognition of arteriovenous fistula after the placement of a permanent pacemaker. Sharing from the developments of the endovascular world, the fistula were successfully treated nonsurgically. After the implantation of a dual-chamber implantable cardioverter-defibrillator for the management of long-QT syndrome, a young woman experienced an arrhythmic storm. The device used to treat the potentially lethal arrhythmia resulted in recurrent lethal arrhythmia, determined to be due to an atrial lead fracture as reported by Fabbricatore et al. Simple decommissioning of the lead without removal led to resolution of the issue. Percutaneous removal of leads has been fraught with serious vascular complications. Hayashi et al report on the rare development of pseudoaneurysm formation of the superior vena cava after lead extraction. In both cases, the patients were treated conservatively without any further untoward events.Bouaouina et al demonstrate again how thoughtful our field has become. They applied refined physiology to help in their decision process to treat a coronary pulmonary fistula. It is enlightening to see how physiology has become an obligatory part of our repertoire. O’Sullivan et al show us that not only does one have to possess excellent technical skills to perform chronic total occlusion percutaneous coronary intervention in coronary artery bypass grafting patients, but also how nuanced clinical judgement is priceless. They managed a hematoma compressing the left atrium by careful observation and achieved success by being thoughtful and calm during a potentially catastrophic complication.Vijayachandra et al report a rare femoral complication: arteriolymphatic fistula. Not only is this report educational, it demonstrates good percutaneous technique to address this rare complication. Guide extension devices have introduced a small revolution in the percutaneous coronary intervention world. Righetti et al share with us a very clever and remarkably useful technique to remove a dislodged stent with a guide extension catheter. We hope everybody gets this nifty technique in their toolbox. It could save the day! Costa et al show us how one must stay calm and rise to the occasion during a left main antegrade and retrograde aortic dissection. No one wants to be in this situation, but this case report shows how good manual skills, calm demeanor, and great judgement make a good interventionalist.We are pleased to share with our readers these cases and more as JACC: Case Reports presents a selection of extraordinary case reports covering thoughtful recognition and management of complications in cutting-edge advanced contemporary care. From these reports we hope to learn how to better treat complications, but more importantly how to prevent complications.
Funding Support and Author Disclosures
Dr Vidovich has received royalty payments from Merit; and grant funding from Boston Scientific. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.