Concentrated ethanol has been used to induce controlled myocardial infarct in patients with hypertrophic obstructive cardiomyopathy. We report the acute and early follow-up results of an alternative agent, n-butyl cyanoacrylate (n-BCA) glue, in a dog model. In 11 mongrel dogs, we injected n-BCA into different branches of the left anterior descending artery. Biplane left ventriculogram and coronary angiogram were performed before and after injection. In the surviving animals, we performed programmed stimulation (PS) to test for inducible ventricular tachycardia (VT) 48 days later. Following euthanasia, the removed hearts were studied with computer tomography (CT) and gross and histologic examination. Three dogs were lost before injection. Four dogs died within 2 hr to 4 days, and four animals survived 48 days. Accidental embolization of n-BCA into nontarget vessels was documented in four subjects. In the n-BCA-injected animals, homogeneous circumscribed scar was demonstrated by CT and histology. The glue was confined strictly to the tributary of the injected vessel, infiltrating arterioles of 14 mum. There was intense granulomatous reaction (GR) in the vessel wall and in the surrounding myocardium. Remote areas were unaffected. Monomorphic VT was not inducible with PS. We report a feasibility study of n-BCA injection to selected coronary arteries of dogs to cause controlled myocardial infarction. We demonstrated that the glue does not escape from the target artery through capillaries or small collateral vessels and thus produces a sharply demarcated and homogeneous scar, which is confined strictly to the supply zone of the injected vessel. Improvement of the delivery system is necessary to eliminate inadvertent embolization. Long-term follow-up is needed to study the GR induced by n-BCA.

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In patients referred for evaluation of Cushing's syndrome or hyperprolactinaemia (due to microadenomas) or after surgery, magnetic resonance is clearly preferable to computerized tomography. In macroadenomas both scans are equally diagnostic but magnetic resonance offers more information on pituitary morphology and neighbouring structures. Nevertheless, there are cases in which the results of computerized tomography and magnetic resonance will complement each other, since different parameters are analysed with each examination and discordant results are encountered.

High risk angioplasty with drug eluting stent placement into an unprotected left main coronary artery in a heart transplant recipient with allograft vasculopathy is reported. Ten month angiographic follow up is reported. The literature is reviewed and current methods of revascularisation are described in detail. This is the first report of drug eluting stent use in this clinical situation.A llograft vasculopathy is the main cause of death in heart transplant recipients surviving the first year of transplantation.1 Medical treatment has very limited efficacy in preventing allograft vasculopathy.2 3 Coronary artery bypass grafting (CABG) is seldom possible because of the diffuse nature of the disease and is often a high risk procedure, carrying a 40-80% perioperative mortality. Retransplantation has worse prognosis than the first transplant procedure and is limited by a severe shortage of donor organs. Therefore, percutaneous coronary intervention (PCI) has been attempted and good immediate success and a varying rate of restenosis have been reported.Unprotected left main coronary artery balloon angioplasty is technically feasible but procedural and three year mortality rates are high: 9% and 64% for elective cases, and 50% and 70% for acute myocardial infarction. [7][8][9] Stenting improved procedural success rates (. 95%) in highly selected patients and improved restenosis in 14-23%. 10 For elective stenting in patients with left ventricular ejection fraction . 40%, 86% event-free survival was reported at six months. 7 We report the first case of the treatment of unprotected left main coronary artery stenosis in a heart transplant recipient with drug eluting stent placement. CASE REPORTSignificant allograft vasculopathy of the left main coronary artery was diagnosed in a 58 year old man. Subjective symptoms were worsening fatigue and decreasing exercise capacity. A dobutamine echocardiogram showed normal baseline systolic function and no wall motion abnormalities with stress. Coronary angiogram showed significant focal coronary artery disease in the proximal segments of the left anterior descending, circumflex, and right coronary arteries, as well as a shelf-like plaque in the proximal to mid-left main stem ( fig 1A, B). The focal nature of obstructive lesions in the proximal coronary tree made angioplasty a technically feasible alternative. The patient had had three previous sternotomies for open heart surgery. Because of the high risk of CABG in this clinical presentation, the patient requested a staged series of angioplasties instead of another operation.The patient's medical history was significant for orthotopic heart transplantation in 1989 for valvar cardiomyopathy, hypertension, and hypercholesterolaemia. The patient had had a single episode of documented grade 1A, focal, mild, acute cellular rejection in 2001. Home medications were aspirin, clopidogrel, atenolol, pravastatin, amiodarone, prednisone, and cyclosporine. Complete blood count and a metabolic panel, including normal serial creatinine concentra...

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