Anterior Descending Artery Research Articles

Aslanger's pattern with acute lesion in the left coronary system: A case report

Acute Coronary Syndrome (ACS) is characterized by the suspicion or confirmation of acute ischemia or acute myocardial infarction (MI). The presence of ST segment elevation (STE) consists in the main criterion for indication of immediate reperfusion therapy due to acute coronary occlusion, although significant part of the acute coronary occlusion cases do not fit the ST-segment elevation myocardial infarction (STEMI) criteria.A case report of a 50 year-old male presenting typical anginal pain, whose electrocardiogram (EKG) presented Aslanger's pattern. The patient had severe lesion of the left anterior descending artery (ADA) and chronic occlusion of the right coronary artery on cardiac catheterization, with important collateral flow from branches of the left coronary artery to the right coronary artery.The dichotomy between STEMI and Non-ST segment elevation myocardial infarction (NSTEMI) must be contested, owing to the evidence that one third of the NSTEMI patients presents a total coronary occlusion. There are other electrocardiographic patterns which must be considered to diagnose ACS. Our case report outlines a different clinical presentation of Aslanger pattern, that shows a ADA acute occlusion, instead of the lesion being in the right coronary system.There is evidence that, in addition to the STEMI vs NSTEMI criteria, the Aslanger pattern and other electrocardiographic patterns characterize occlusive ACS. Recognizing those patterns in clinical practice is essential to improve the diagnosis and early treatment of patients with ACS.

Abstract 12579: Intracoronary Thrombolysis, an Option in Coronary Arteries With Unique Characteristics: A Case Series Report

Cases Description: Case 1: A 47-year-old male with inferior ST-segment Elevation Myocardial Infarction (STEMI). Percutaneous Coronary Intervention (PCI), showed an ectasic Right Coronary Artery (RCA) with an occlusive thrombus in mid-distal segment, TIMI 0. Thromboaspiration was not successful, proceeding to use intracoronary (IC) Alteplase 15mg. 72 hours later, PCI showed a RCA without stenosis, TIMI 2. Intravascular Ultrasound (IVUS) was used, showing no plaques or dissection. Discharged with Rivaroxaban 20mg QD and Acetilsalicylic acid (ASA) 100mg QD. Case 2: A 38-year-old male, with previous PCI and 1 stent in Anterior Descending Artery (ADA); arrives with STEMI. PCI showed a ADA non-occlusive intrastent thrombus, TIMI 2. IC Alteplase 15mg was used. After 72 hours, PCI identified the ADA with TIMI 3 flow. IVUS and Optical Coherence Tomography (OCT) showed a mild intrastent thrombus and proximal infraexpansion of previous stent. Proximal and medial segments were dilated, and 1 stent was placed distal. IVUS showed adequate expansion. Discharged with Apixaban 5mg BID and Clopidogrel 75mg QD. Case 3: A 64-year-old male, with inferior STEMI. PCI shows an ectasic ADA with a proximal and medial segment thrombus, TIMI 2. Tromboaspiration and posterior IC Alteplase 15mg were used, with TIMI 3 result. PCI 24 hours later, shows the ADA with TIMI 3 flow. IVUS identifies that no angioplasty was needed. Discharged with Ticagrelor 90mg BID and ASA QD. Discussion: IC thrombolysis is a useful method in primary PCI, where there is no favorable anatomy or massive IC thrombus. These cases show the utility of using IC imaging to evaluate the anatomy and thrombotic content of angiographic lesions. There is no consensus in the chronic anticoagulation/antithrombotic management after IC thrombolysis.

Takotsubo Syndrome

Abstract Takotsubo syndrome occurs in 1-2% of patients admitted in the emergency department with suspicion of ST-segment elevation myocardial infarction (STEMI), over 90% being postmenopause women. Psycho-emotional or physical stress is the main trigger that causes the release of catecholamines, with an important role in the pathophysiology of Takotsubo cardiomyopathy. In most cases, supportive and symptomatic treatment is sufficient, with a dynamic follow-up of the left ventricular (LV) function. Usually, a complete recovery occurs in 3-4 weeks. We are presenting the case of a 67-year-old patient with a severe angina attack which occuredafter a major psycho-emotional stress, with an electrocardiographic appearance of an anterior STEMI and echocardiographic apical ballooning, both compatible with Takotsubo syndrome. Coronary angiography showed a muscle bridge with a systolic compression of 75% on the anterior descending artery (ADA). The evolution was marked by the occurrence of cardiogenic shock remitted under treatment, with complete recovery of LV systolic function. The particularity of the case resides in an acute coronary syndrome (ACS) after a psycho-emotional stress associated with a muscular bridge, as well as the appearance of the cardiogenic shock.

Perioperative Management of Patient with Coronary Artery Disease 3 Vessels Disease, Chronic Total Occlusion in Left Anterior Descending and Right Coronary Artery, History of Hypertension, Extensive Myocardial Infarction and Low Ejection Fraction: A Case Report

Introduction: Achieving a satisfactory hemodynamic performance is the primary objective in the management of cardiac surgery patient. Optimal cardiac function ensures adequate perfusion and oxygenation of other organ systems (in particular vital organs) and improves the chances for an uneventful recovery from surgery. Case: A 46 year old male diagnosed with Coronary Artery Disease 3 Vessel Disease (CAD 3 VD), CTO in LAD and RCA, history of hypertension, extensive myocard infarction with hypertrophy as well as global function impairment of the left ventricle and low ejection fraction, who underwent Coronary Artery Bypass Graft (CABG). Supportive medications, such as dobutamine and nitroglycerin (NTG) were initiated and maintained intraoperatively, especially after anesthetic induction due to hemodynamic alterations. Patient was able to wean from cardiopulmonary bypass (CPB) machine and transferred to the ICU postoperatively.

Where is the stent? CTA assists angiography: A case of jailed LAD

Stent malpositioning in the septal perforator is a serious procedural complication and especially prominent after main vessel stenting in coronary bifurcation lesions. This case report demonstrates Computed Tomography Angiography’s (CTA) role as a backup imaging tool, in cases where follow-up Coronary Angiogram (CAG) cannot be immediately completed. CTA also functions as a preferred imaging tool to follow up after stenting and assess for stent malpositioning. A 72-year-old female with history of hypertension and hyperlipidemia presented with dyspnea and was found to have STEMI. About a week after her three PCI’s to the Left Anterior Descending (LAD) artery, she returned to the hospital with recurrent dyspnea and V-Tach. Instead of completing a repeat catheterization, a noninvasive CTA was thought to be the next test. CTA imaging indicates that the failed stenting of the side-branch resulted in a jailed main vessel, which may induce ischemia and ventricular tachycardia (V-Tach). After the malpositioned stent finding on CTA, the patient was then referred to the Cath Lab for angiogram. CTA thus provided detailed anatomical information about the stent’s placement, which will greatly assist further management by the interventional cardiologist.

Hypoxia - as a Possible Regulator of the Activity of Epicardial Mesothelial Cells After Myocardial Infarction.

Aim To study the effect of hypoxia on the activity of epithelial-mesenchymal transition (EMT) in epicardial cells, which provides formation of a specialized microenvironment.Material and methods This study used a model of experimental myocardial infarction created by ligation of the anterior descendent coronary artery. The activity of epicardial cells after a hypoxic exposure was studied with the hypoxia marker, pimonidazole, bromodeoxyuridine, immunofluorescent staining of heart cryosections, and in vitro mesothelial cell culture.Results The undamaged heart maintained the quiescent condition of mesothelial cells and low levels of their proliferation, extracellular matrix protein production, and of the EMT activity. Acute ischemic injury induced moderate hypoxia in the epicardial/subepicardial region. This caused a global rearrangement of this region due to the initiation of EMT in cells, changes in the cell composition, and accumulation of extracellular matrix proteins. We found that the initiation of EMT in mesothelial cells may result in the formation of smooth muscle cell precursors, fibroblasts, and a population of Sca-1+ cardiac progenitor cells, which may both participate in construction of new blood vessels and serve as a mesenchymal link for the paracrine support of microenvironmental cells. In in vitro experiments, we showed that 72‑h hypoxia facilitated activation of EMT regulatory genes, induced dissembling of intercellular contacts, cell uncoupling, and increased cell plasticity.Conclusion The epicardium of an adult heart serves as a "reparative reserve" that can be reactivated by a hypoxic exposure. This creates a basis for an approach to influence the epicardium to modulate its activity for regulating reparative processes.

Coronary Intervention in Separate Origin of Left Anterior Descending and Left Circumflex Coronary Artery

Coronary Intervention in Separate Origin of Left Anterior Descending and Left Circumflex Coronary Artery

Clinical Profile and Approach to Osteal LAD Lesion During Primary Angioplasty in Myocardial Infarction (PAMI)

Isolated Coronary Artery Stenoses (CAS) involving the ostium of the Left Anterior Descending (LAD) artery is very challenging, especially in a setting of primary Angioplasty in Myocardial Infarction (PAMI). Intimal atherosclerosis in the Left Main Coronary Artery (LMCA) bifurcation is primarily in area of low shear stress which is the lateral wall, close to the LAD and Left Circumflex (LCx). Thus, carina is usually free of disease, which can explain why single-stent strategy can be successful. However, precise stent placement is often difficult due to unwanted stent movement within vessel or its proximity to side branches. A decision must be made at the outset, to decide on the approach to be employed, to treat osteal LAD lesions. Limited data is available on patients undergoing primary PCI of osteal LAD lesions. Here, we present our experience and problems encountered during the management of osteal LAD lesions in the setting of PAMI.

Abstract 16287: Clinical Characteristics, Treatment and Long-term Mortality of Patients With Congenital Coronary Fistulas

Introduction: Congenital coronary fistulas (CCF) are rare (0.002% in general population) however under-diagnosis is frequent. Patient and fistula characteristics vary among different populations, treatment is controversial and the impact in survival is not well established. Purpose: This study aimed to describe clinical characteristics, treatment received and long-term mortality among different options of treatment for CCF. Methods: We identified all cases of CCF diagnosed from January 2009 to January 2019 in a single center. Clinical data was obtained from medical records and mortality was assessed according to clinical checkups or by phone call. Long-term mortality was defined after at least one-year follow-up. Descriptive statistics were applied to all cases. Results: 22 cases of CCF were diagnosed, medium age was 53.6 years, 65% were male and 31% had smoking history. At presentation 36% had angina and 27% had dyspnea. Only 13.6% had no significant past medical history, 20% had another congenital anomaly associated, 13.6 % had chronic heart failure and 45.4% were associated to coronary artery disease (CAD), usually anterior descending artery (ADA) was affected. Most frequent origin of fistula was from the ADA in 42.3% of the cases and drainage was frequent to the pulmonary artery in 53.4%, 80% had a single fistula and 45% presented small fistulas. Overall mortality was 13.6% (n=3) with median follow-up of 3.6 (1-9.9) years. Among patients treated, 72.8% of the patients received medical treatment with a 12.5% rate of long-term mortality, however only one patient died from cardiovascular cause (worsening heart failure). None of the patients who received interventional treatment (N=3) died at long-term, 13.6% had coronary artery bypass grafting for CAD (none had fistula ligation), only one patient died several years later of neurological cause. Conclusions: The most common origin of CCF was from the ADA and the drainage was common to the pulmonary artery. Long term mortality is low in patients with CCF despite treatment received, only one patient in the entire cohort died of cardiac disease even when 55% had medium to large coronary fistula and 86.4% had previous cardiovascular disease. Further studies are needed to establish treatment guidelines.

Tactics Optimization of Percutaneous Coronary Intervention in the Area of Bifurcation of the Anterior Descending Artery By Means Of Cardiography from the Coronary Sinus

Introduction: The aim of this investigation is to evaluate the possibilities of the method of cardiography from the coronary sinus (ECG-CS) in optimization of stenting bifurcation lesions (BL) of coronary arteries (CA). Materials and Methods: 43 patients with stable CHD with pseudo-BL of the anterior descending artery (ADA) were included in this investigation. We placed a 10-canal electrode into their coronary sinus at the beginning of percutaneous coronary intervention (PCI). Ischemic guidance was done with the WorkMate electrophysiological recording system. Results: In 11 patients (25%) out of 43 with CHD, the diagonal branch (DB) comprometation and ischemia dynamics (p<0.05) in intracardiac lead (CS 3-4) after ADA stenting were discovered according to ECG-CS. Nine patients (20.9%) underwent successful provisional-T-stenting, while a second stent was required for the other 2 patients. Conclusion: ECG-CS provides the possibility to optimize coronary intervention in the area of CA bifurcation.

P1482 Surviving free wall rupture

Abstract Introduction Free wall cardiac rupture (CR) is a rare event accounting for 0.1–0.3% of the patients suffering acute myocardial infarction. Its outcome is very poor and it is the third most common cause of early mortality after hospitalization for ST Elevation Myocardial Infarction (STEMI). Purpose We report a case of a 63 years-old woman surviving a free wall rupture after ST Elevation Myocardial Infarction. Methods The patient was referred to our cath-lab to undergo primary PCI in ST elevation myocardial infarction. Results Coronary angiography showed long thrombotic occlusion of left anterior descendent (LAD) artery and critical stenosis of posterior descending artery. The CULPRIT lesion on the anterior descending artery was treated with angioplasty and implantation of three drug eluting stents (3.0x31 mm; 2.75x15 mm; 2.5x30 mm). Twenty four hours later the patient developed a double cardiac arrest with pulseless electrical activity, which were immediately managed with ALS protocol. The patient recovered both time within a couple of minutes and point-of-care transthoracic echocardiogram (TTE) showed a newly developed circumferential pericardial effusion (maximum diastolic diameter 9 mm), associated to a significant thinning of the anterior interventricular septum. A fibrin clot was tamponating a suspected free wall rupture. Emergent coronary angiography showed an in-stent thrombosis but failed to restore adequate blood flow in the LAD artery. In the following days, the patients developed cardiogenic shock handled with i.v. dobutamine and intra-aortic balloon pump (IABP). Only after day 10 hemodynamic parameters started to improve gradually, allowing IABP removal and finally discharge on day 30. A second TTE, performed on day 7, confirmed massive necrosis of the anterior wall with severely reduced ejection fraction (EF 22%), pericardial thrombus and aneurismatic evolution of the apex and the mid-anterior septum. To support our finding we performed a cardiac magnetic resonance which confirmed missing ventricular wall at the anterior apex. It also showed transmural late gadolinium enhancement (LGE) of the anterior mid-apical septum and of the apex and a huge pericardial thrombus encompassing the whole mid-anterior septum (Figure 1, a-f). Before discharge the patient underwent two cardiac surgery visits which contraindicated surgical treatment in the acute phase. Therefore she was sent to cardiac rehabilitation program. Six months later, the patient finally underwent cardiac surgery and the covered free wall rupture was confirmed in the operating theatre. Conclusion This is a very rare case of covered free wall rupture, treated 6 months after the acute event. Multimodality imaging was essential to confirm the diagnosis and to guide the following management. Abstract P1482 Figure 1

P980 RV longitudinal dysfunction predicts outcomes in anterior ST elevation myocardial infarction treated by primary PCI

Abstract Funding Acknowledgements This work was supported by CREDO Project - ID: 49182, financed through the SOP IEC -A2-0.2.2.1-2013-1 cofinanced by the ERDF Background The prognostic value of LV function in the setting of an acute ST elevation myocardial infarction (STEMI) is well established, but data regarding the association between RV function and adverse events in this population of patients are still scarce, especially for the cases with anterior wall localization of necrosis. Two-dimensional speckle tracking echocardiography (STE) is able to detect subclinical changes in local or regional RV function. AIMS To evaluate the relation between STE parameters of RV global and regional function recorded 24 hours after admission and the occurrence of major non-fatal cardiovascular adverse events (MACE) in anterior STEMI patients treated by primary percutaneous intervention (PCI) Methods We have prospectively analyzed a cohort of 80 consecutive patients (mean age 61.17 years, 68.8% males) presenting with a first STEMI treated successfully by PCI. Patients with history of cardiac or pulmonary disease were excluded. All patients underwent conventional echocardiography and STE, 24 hours after the index event. RV strain was assessed as RV free wall strain (RVFWS) representing the average of peak strain values encountered in three segments of the RV free wall and RV global longitudinal strain (RVGLS) obtained by averaging peak strain values in six segments including RV free wall and interventricular septum . The mean follow-up duration was 8.2 ± 0.69 months.The combined endpoint of non fatal MACE was defined as recurrent myocardial infarction, need for repeat revascularization, hospitalization for heart failure or stroke. Results In the study population 45 patients (56%) had the culprit lesion on the anterior descendent artery. In this group we observed that RVGLS was predictive for non fatal MACE independent of LVEF or extension of necrosis expressed by wall motion score index with OR 0.89 95 % CI 0.7-0.9, p = 0.042, with a ROC curve with a sensitivity 73% and specificity 53%, AUC =0.7. In addition, in anterior STEMI complicated by LVEF <40 % , a RVFWS absolute value lower than -14.3 % has proved to be an additional parameter of negative prognosis with a sensitivity of 91 %, and a specificity of 40% (AUC 0.68, CI 95%: 0.3-0.7) Conclusions In anterior STEMI patients treated by primary PCI, global RV longitudinal dysfunction assessed by STE early after the index event is predictive for non fatal MACE independently of LV function or the infarct size. In addition, RV regional longitudinal dysfunction provides incremental prognostic information in patients with anterior STEMI with moderate or severe LV systolic dysfunction. These data highlight the importance of the assessment of subclinical RV dysfunction in this setting.

ROPIVACAINE-INDUCED CORONARY ARTERY VASOSPASM

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Ropivacaine is a frequently used nerve block for orthopedic procedures. Few cases have been reported in which the amides have caused coronary artery spasm (CAS). We present a case of CAS after ropivacaine administration. CASE PRESENTATION: An 85-year-old male with coronary artery disease, status post 4-vessel coronary artery bypass grafting 11 years prior, peripheral arterial disease, and hypertension, underwent an interscalene nerve block with 0.5% Ropivacaine prior to an orthopedic procedure. Two hours later, the patient developed ventricular fibrillation arrest. He was defibrillated 3 times, received amiodarone, epinephrine, magnesium, and an intralipid emulsion for radical binding of ropivacaine prior to return of spontaneous circulation. Patient had not received any inciting medications and his labs were unremarkable prior to the event. His only prescribed medications included low dose aspirin, clopidogrel, metoprolol, and ramipril. Bedside echocardiogram showed an ejection fraction of 20%; apical anteroseptal and anterolateral akinesis was present; electrocardiogram was remarkable for sinus tachycardia with ST segment elevation in leads V1-V6; his initial troponin T was 3.3 ng/dL. Aspirin, ticagrelor, and heparin infusion were administered, and the patient was rushed to coronary angiography. Angiography demonstrated patent bypass grafts. However, during the investigation of the Left Internal Mammary (LIMA) graft-to-Left Anterior Descending artery (LAD) anastomosis, the LAD had no flow (TIMI 1/0) beyond the LIMA anastomosis. Inframammary nitroglycerin was injected and immediately resolved the diffuse stenosis, suggesting coronary vasospasm. His other coronary arteries demonstrated stable disease related to his chronic CAD. Given the timing of cardiac arrest in relation to the nerve block, coronary vasospasm was presumed secondary to Ropivacaine injection. DISCUSSION: Ropivacaine is a highly potent, lipid soluble amide local anesthetic frequently used as an interscalene nerve block for orthopedic procedures involving the arm or hand. In addition to its arrhythmogenic properties, there have been few cases reported in which the amides have caused coronary artery spasm (CAS), relieved with calcium channel blockers. These cases were reported in individuals with and without underlying coronary artery disease, before, during, and after surgery; these reports are limited as diagnosis of CAS was not directly visualized with coronary angiography. Diagnosis was based upon relief in the setting of calcium channel blockers and nitroglycerin CONCLUSIONS: Our case is unique in that we present a patient who experienced ventricular fibrillation most likely secondary to CAS associated myocardial infarction after the interscalene administration of ropivacaine. This case is even more unique in that CAS reversal with intracoronary nitroglycerin was visualized and documented with cardiac catheterization. Reference #1: Mutlak M1, Nikolsky E. Severe coronary artery spasm induced by epidural injection of bupivacaine hydrochloride: a case report. Acute Card Care. 2011 Sep;13(3):155-8. https://doi.org/10.3109/17482941.2011.567286. Epub 2011 Apr 25. DISCLOSURES: no disclosure on file for Shahyar Gharacholou; No relevant relationships by Alexander Heckman, source=Web Response

Immediate results of three methods of surgical myocardial revascularization in multivessel lesion of the coronary bed

Percutaneous coronary intervention (PTI) and coronary artery bypass grafting (CABG) are currently the most commonly used techniques of myocardial revascularization. However, each of the methods has its own advantages and disadvantages. The creation of hybrid coronary revascularization (HCR) was based on an attempt to combine the benefits of CABG and PTI. The study was aimed at assessing the immediate results of three methods of surgical myocardial revascularization in patients with multivessel lesions of the coronary bed in stable ischaemic heart disease. The study enrolled a total of 155 patients randomized into three groups of myocardial revascularization: HCR, CABG and PTI. In the HCR group, the first stage consisted in minimally invasive myocardial revascularization with the anterior descending artery (ADA) followed by PTI (within 1-3 days) with implantation of drug-eluting second-generation stents Xience to other coronary vessels. In the CABG and PTI groups we performed CABG and PTI, respectively, using the Xience stents. In all three groups we assessed the procedural success, frequency of major adverse cardiovascular events and bleeding. Full myocardial revascularization was achieved in all three groups in more than 90% of cases. No statistically significant differences in either the procedural success rate or frequency of major adverse cardiovascular events between the CABG, PTI and HCR were revealed. The PTI group was characterized by the lowest frequency of bleeding, need for rehabilitation, and length of hospital stay. Hybrid revascularization with the use of minimally invasive direct myocardial revascularization with the ADA followed by PTI with second-generation drug-eluting stents to other coronary arteries is a method of choice in treatment of patients with multivessel lesions of coronary arteries.

Mini OPCAB Coronary Artery Bypass Surgery Plus Medical Treatment: An Option for High Risk Coronary Patients

MINI OPCAB surgery (Xiphoid Approach) is a surgical technique in which the left internal mammary artery is bypassed to the Anterior Descending Artery (ADA) by a medial inferior sternotomy Fourteen high risk patients with multiple coronary disease with a preoperative logistic Euroscore of 10.86 were operated and follow up with medical treatment and strictly control of risks factors MACE at 80 months was 0% and Survival at 7 years 82% (KM) Although is an alternative the combination of Mini OPCAB operation plus medical treatment in high risk.

СЛУЧАЙ УСПЕШНОГО ПРИМЕНЕНИЯ ЧРЕСКОЖНОЙ ВРЕМЕННОЙ ОККЛЮЗИИ ВЕНОЗНОГО СИНУСА СЕРДЦА У БОЛЬНОГО С ОСТРЫМ КОРОНАРНЫМ СИНДРОМОМ С ЭЛЕВАЦИЕЙ СЕГМЕНТА ST ПРИ ОТСУТСТВИИ ГЕМОДИНАМИЧЕСКИ ЗНАЧИМОГО АТЕРОСКЛЕРОТИЧЕСКОГО ПОРАЖЕНИЯ КОРОНАРНЫХ АРТЕРИЙ

The search for new methods of adequate antegrade blood flow restoration in the coronary arteries of patients with acute coronary syndrome with ST-segment elevation (ACSesST) without hemodynamically significant atherosclerotic lesions of the coronary arteries is a poorly studied item. The author gives the clinical example of a patient with ACSesST without hemodynamically significant atherosclerotic lesions of the coronary arteries and deceleration of antegrade blood flow in the area of the anterior descending artery (ADA). Percutaneous temporary occlusion of the coronary sinus was done to the patient during 10 minutes in the balloon catheter «inflation-deflation». The procedure resulted in a positive impact on coronary hemodynamics such as distal coronary spasm cupping, myocardial perfusion improvement and restoration of adequate antegrade blood flow in the pool ADA.

Tamamen Tıkalı Sol İnen ve Sağ Koroner Arterleri Besleyen Süperdominant Bir Konus Dalı

Tamamen Tıkalı Sol İnen ve Sağ Koroner Arterleri Besleyen Süperdominant Bir Konus Dalı

TCTAP C-108 Retrograde Percutaneous Coronary Intervention to Chronic Total Occlusion of Left Anterior Descending and Left Main Arteries Challenging Case

TCTAP C-108 Retrograde Percutaneous Coronary Intervention to Chronic Total Occlusion of Left Anterior Descending and Left Main Arteries Challenging Case

Results of Coronary Artery Bypass Surgery Combined With Endarterectomy and Reconstruction of Anterior Descending Artery in Patients With Diabetes Mellitus

To assess results of coronary artery bypass surgery combined with endarterectomy (EAE) in patients with ischemic heart disease (IHD) and diabetes mellitus (DM), and impact of DM on clinical outcomes. We recruited in this study 152 patients with IHD (43 with and 109 without DM) subjected to coronary artery bypass surgery with EAE from anterior descending artery (ADA) between 2003 and 2010. Forty three patients had concomitant DM (main group) 109 - had not (control group). Mean age was 57+/-18 and 60+/-19 years, portion of patients with class III-IV angina - 71.1 and 73.3%, with history of myocardial infarction - 74.4 and 68.8%, in main and control group, respectively (p>0.05). In hospital mortality was 4.6 and 3.6% in main and control group, respectively. Number of patients examined in remote period was 127 (87.6%). Mean follow-up was 4.5+/-1.2 years. Survival was 90.7 and 100% (p>0.05). Graft angiography was performed in 12 and 43 patients (27.9 and 39.4%) with portions of patent arterial conduits 91.6 and 100%, patent venous conduits 90.0 and 90.3% in main and control group, respectively. Under conditions of strict control of glycemia coronary artery bypass surgery with EAE from ADA in IHD patients with DM is associated with acceptable hospital mortality and survival, moderate risk of remote cardiovascular complications, and satisfactory patency of conduits.

Effects of Intracoronary Collagenase Injection in a Porcine Model: A Safety Dose-Finding Study

Objective: Chronic Total Occlusions (CTO) remains a challenge for Percutaneous Coronary Intervention (PCI). Initial studies of bacterial collagenase injections into experimental arterial CTOs and human coronary CTOs have indicated very promising effects to facilitate guide wire crossing in previously failed cases. The aim of the current study was to assess the vascular and cardiac effects of intracoronary collagenase injections in a porcine model. Methods: Intracoronary injections of collagenase were done in the Left Anterior Descending (LAD) artery of 21 Yorkshire pigs through an over-the-wire balloon catheter. Two groups were studied: 24 hours after injection (n=14) and 30 days after injection (n=6). During balloon inflation, 8 ml of a phosphate buffered solution (PBS) containing either collagenase (range 50-3200 μg) or PBS alone (control) was injected. After sacrifice, hearts were photographed immediately and then fixed in 10% buffered formalin. Myocardial cross-sections were stained with H&E and Movat. Results: One pig died acutely due to arterial dissection during balloon inflation. In collagenase-treated pigs, localized epicardial and myocardial haemorrhages were evident at 24 hr in the LAD distribution at doses more than 800 μg. The extent of haemorrhages was related to the dose and was generally mild at doses less than1600 μg and moderate at doses more than 1600 μg. At 30 d, no evidence of haemorrhages was present. Mild myocardial fibrosis, likely due to ischemia, was present in both placebo and treatment groups. Balloon damaged LAD arteries showed mild intimal hyperplasia but no specific effects related to collagenase. Conclusions: A single intracoronary injection of a bacterial collagenase formulation into normal coronary arteries caused dose-related, localized epicardardial and myocardial haemorrhages, which were well tolerated without later sequelae.