Atypical Angina Research Articles

Chronic mesenteric ischemia: a case report and review of the literature

Chronic mesenteric ischemia (CMI) is a rare vascular disease. Unlike acute ischemia with a sudden onset, CMI is characterized by permanent or episodic intestinal hypoperfusion, usually due to atherosclerotic vascular lesion. Despite the high prevalence of atherosclerosis of mesenteric arteries in the general population, clinical manifestations of CMI may be absent up to the end-stage disease, which is due to the formation of extensive collateral circulation and the presence of residual fetal circulation. CMI not only worsens the quality of life, but also increases the risk of acute ischemia against the background of chronic. This problem is relevant, since the incidence and related mortality do not tend to decrease. The article presents the case report of CMI in a patient with an atypical abdominal angina. The etiopathogenesis, clinical picture, diagnosis and treatment methods are described in relation not only to the presented report, but also to literature data. This improves understanding and management strategy of this rare life-threatening pathology.

1100 When multimodality imaging is needed to understand the etiology of diffuse negative t waves

Abstract Introduction We present the case of a 50 year old woman, active smoker, hypercholesterolemic, nondiabetic, with normal body mass index, referred to our cardiology department for atypical chest pain and ECG changes (diffuse negative T waves in V1-V6, DII, DIII) (Panel A), also present on a resting ECG recorded 4 years previously. Purpose To highlight the fact that even though the most frequent cause of negative T waves remains coronary artery disease (CAD), the cause could be related to other more rare medical conditions. Methods After clinical examination and ECG, 2D echocardiography was performed. It revealed a normal sized left ventricle (LV) with perserved global and regional function, normal global longitudinal strain, nondilated atria and no significant valvular disease. The subcostal view suggested a hypertrophied right ventricle (RV) free wall (10 mm thickness, with apparent homogeneous echogenicity) (Panel B, arrow), with normal longitudinal function and no regional wall motion abnormalities. Cardiac magnetic resonance (CMR) was performed for a better tissue characterization. The CMR examination found normal cardiac cavities, normal wall thickness of both ventricles (RV free wall of 3 mm), no late gadolinium enhancement, but described a large amount of fat with concentric disposition, maximum thickness of 9 mm anterior of RV, 3 mm posterior of LV (Panel C). Since this was not fully explaining the ECG changes and the patient presented with a low-intermediate pretest probability for CAD, an angio-CT coronary scan was performed and showed a calcium score of 7 AU, no significant coronary atherosclerosis, and a hypoplastic circumflex artery (Panel D, arrow). A total volume of 149 ml. of pericardial fat was measured (Panel E). Stress echocardiography was performed with maximal workload achieved (145 bpm, 85% predicted, 100 W); no chest pain was reported, no regional wall motion abnormalities were seen and there was normal contractile reserve. Results Using multimodality imaging a differential diagnosis was followed, which included: arrhythmogenic cardiomyopathy (negative T waves, apparent changes of RV free wall on echo, but no family history of sudden cardiac death), CAD (atypical angina, cardiovascular risk factors, negative T waves), and pericarditis (but negative inflammatory markers, no pericardial fluid). The final hypothesis is that the ECG changes are related to the abnormal pericardial adipose tissue deposit, which acts similar to pericarditis. Conclusions The present case report is, to our knowledge, the first to describe an association between large pericardial fat deposit and ECG changes, when other causes were excluded. Even if the current findings are benign, the patient should be followed closely, and risk factors should be thoroughly controlled, as several studies have shown that pericardial fat is associated with poorer cardiovascular prognosis Abstract 1100 Figure. Multimodality imaging in our patient

Does Coronary Microvascular Spasm Exist? Objective Evidence from Intracoronary Doppler Flow Measurements During Acetylcholine Testing

A 43-year-old woman with recurrent atypical angina underwent invasive coronary angiography including intracoronary Doppler blood flow assessment and coronary spasm provocation testing. While obstructive epicardial disease could be ruled-out angiographically, the patient experienced reproduction of her angina symptoms after intracoronary administration of acetylcholine (100 µg) during spasm provocation testing. Simultaneously, the ECG showed new-onset ST-segment depression in the absence of epicardial spasm. In addition, coronary flow velocity was significantly reduced after acetylcholine compared to the baseline condition. Following intracoronary administration of nitroglycerine (200 µg), the patient’s symptoms as well as the ECG changes and coronary flow reduction were reversed. Considering the ongoing challenges in appropriate evaluation of the pathophysiological mechanisms of coronary microvascular dysfunction, simultaneous intracoronary Doppler flow measurement during spasm testing – as shown in this case – may provide objective evidence for microvascular spasm in addition to the standardized diagnostic criteria, especially if they are ambiguous.

The Diagnostic Accuracy of Сoronary Сomputed Tomography Angiography in the Diagnosis of Stable Coronary Artery Disease in Patients Aged 70 Years and Older

The purpose of this study was to evaluate the diagnostic accuracy of сoronary сomputed tomography angiography (CCTA) in the diagnosis of stable coronary artery disease (CAD) in patients aged ≥70 years. The study included 390 patients aged ≥70 years with symptoms suggested stable CAD which underwent elective coronary artery angiography (CAG). Initially the prevalence of angiographically significant CAD was estimated according to the gender and chest pain character, and identifications of patients in whom CCTA was appropriate. After that diagnostic accuracy and сost-efficiency of CCTA in the diagnosis of stable CAD in 82 patients with atypical angina and non-anginal chest pain were evaluated. The prevalence of obstructive CAD in patients with typical angina was very high and they were excluded from the final analysis. Among 82 patients with atypical angina and non-anginal pain which underwent CCTA 48 (59%) patients had obstructive CAD. CСTA data matched with results of CAG in all cases. Among 34 patients that had non-obstructive CAD the results of CCTA and CAG matched in 88% cases. CCTA has sensitivity, specificity, positive predictive value, negative predictive value of 100%, 88%, 92% and 100% respectively. The likelihood ratio for positive result was 8.3, likelihood ratio for negative result was 0.3. Positive result increased post-test probabilityof obstructive CAD from 42% to 86%, negative result reduced post-test probabilityof obstructive CAD to 0%. negative CCTA result in patients aged 70 years and older with atypical angina and non-anginal pain allows to exclude the presence of obstructive CAD. The likelihood ratio for positive result indicates a moderately difference between the pre-test and post-test probability of the presence of obstructive CAD. In patients aged ≥70 years with atypical angina or non-anginal chest pain which have inconclusive results of functional testing or unable undergo functional testing CCTA allows to increase diagnostic yield of CAG and reduce the frequency of minor complications and diagnostic evaluation costs.

Coronary Computed Tomography Angiography-Derived Fractional Flow Reserve in Patients with Anomalous Origin of the Right Coronary Artery from the Left Coronary Sinus.

ObjectiveTo examine the fractional flow reserve derived from computed tomographic angiography (CT-FFR) in patients with anomalous origin of the right coronary artery from the left coronary sinus (R-ACAOS) with an interarterial course, assess the relationship of CT-FFR with the anatomical features of interarterial R-ACAOS on coronary computed tomographic angiography (CCTA), and determine its clinical relevance.Materials and MethodsNinety-four patients with interarterial R-ACAOS undergoing CCTA were retrospectively included. Anatomic features (proximal vessel morphology [oval or slit-like], take-off angle, take-off level [below or above the pulmonary valve], take-off type, intramural course, % proximal narrowing area, length of narrowing, minimum luminal area [MLA] at systole and diastole, and vessel compression index) on CCTA associated with CT-FFR ≤ 0.80 were analyzed. Receiver operating characteristic analysis was performed to describe the diagnostic performance of CT-FFR ≤ 0.80 in detecting interarterial R-ACAOS.ResultsSignificant differences were found in proximal vessel morphology, take-off level, intramural course, % proximal narrowing area, and MLA at diastole (all p < 0.05) between the normal and abnormal CT-FFR groups. Take-off level, intramural course, and slit-like ostium (all p < 0.05) predicted hemodynamic abnormality (CT-FFR ≤ 0.80) with accuracies of 0.69, 0.71, and 0.81, respectively. Patients with CT-FFR ≤ 0.80 had a higher prevalence of typical angina (29.4% vs. 7.8%, p = 0.025) and atypical angina (29.4% vs. 6.5%, p = 0.016).ConclusionTake-off level, intramural course, and slit-like ostium were the main predictors of abnormal CT-FFR values. Importantly, patients with abnormal CT-FFR values showed a higher prevalence of typical angina and atypical angina, indicating that CT-FFR is a potential tool to gauge the clinical relevance in patients with interarterial R-ACAOS.

Correlation of Coronary Artery Calcium and Invasive Coronary Angiographically in Patients with Atypical Angina Pectoris (CACICA - Trial)

OBJECTIVES This study correlated the multi - detector computed tomography (MDCT) calcium scores with the results of coronary angiography in diabatic and/or hypertensive patients with atypical angina pectoris in order to assess its value to predict or exclude significant coronary artery disease (CAD). BACKGROUND Muti-detector computed tomography is a sensitive method to detect coronary calcium. However, it is unclear whether it may play a role as a filter before invasive procedures in patients with atypical angina pectoris. METHODS A total of 150 patients (116 men and 34 women) with diabetic and/or hypertension for at least 5 years and atypical angina pectoris from a single center were included in our study. patients underwent calcium screening with MDCT and have calcium score more than 100 , then all patient underwent invasive coronary angiography. RESULTS The Mean age was 62±5.7 and 77.3% were male, 78% of men and 88.2 % of women revealed significant coronary stenoses (&gt; 50% lumen narrowing of left main trunk stenosis and &gt; 70% stenosis of any epicardial coronary artery). Significant correlation between calcium scoring and significant coronary artery stenosis was seen (P: 0001). A 70% were DM, 90% were hypertensive and 61.3% were HTN and DM. The LAD artery was the most stenotic artery by 53.3% followed by RCA (37.3%) and finally LCX (30.7%). one significant coronary artery was 42% followed by two significant CAD (26.7%), while 9.3% included three-vessel disease. The significant coronary artery diseases was increased with age ( P: 0003). CONCLUSIONS Coronary calcium proved to have good diagnostic performance for significant coronary artery stenosis in patient with atypical angina pectoris.

The Diagnostic Accuracy of Exercise Treadmill Testing and Stress Echocardiography for the Detection of Obstructive Coronary Artery Disease in Patients Aged ≥ 70 Years

to compare diagnostic accuracy of exercise treadmill testing and stress echocardiography in the diagnosis of stable coronary artery disease (CAD) in patients aged &gt;70 years. The study included 390 patients aged &gt;70 years with suspected stable ischemic heart disease, who underwent elective coronary artery angiography (CAG). Exercise treadmill testing (ETT) according to the modified Bruce protocol was carried out in 189 patients (48 %), bicycle stress echocardiography - in 179 patients (46 %). Initially we determined the prevalence of angiographically significant CAD according to the gender and chest pain character, and identified persons in whom stress testing was appropriate. After that diagnostic accuracy of both tests was evaluated in patients with atypical angina and non-anginal chest pain. Among 72 patients with atypical angina and non-anginal pain who underwent ETT and had unequivocal results, 38 (53 %) had obstructive CAD. ETT for detection of obstructive CAD had sensitivity 79 %, specificity 82 %, positive likelihood ratio (LR+) 4.4, and negative likelihood ratio (LR-) 0.3. Positive result increased probability of obstructive CAD from 53 % to 83 %, negative result reduced probability of obstructive CAD to 25 %. Among 111 patients with atypical angina and non-anginal pain who underwent stress echocardiography and had unequivocal results, 69 (62 %) had obstructive CAD. Sensitivity, specificity, LR+, and LR- of stress echocardiography were equal to 89 %, 95 %, 17.8, and 0.1, respectively. Positive result increased probability of obstructive CAD from 62 % to 95 %, negative result reduced probability of obstructive CAD to 16 %. bicycle stress echocardiography was found to be more accurate than ETT to rule in or rule out obstructive CAD in patients aged ≥ 70 years with atypical angina and non-anginal pain.

Atorvastatin in patients with coronary artery disease and left ventricular systolic dysfunction

Coronary artery disease (CAD) can manifest as a classic chest pain, or atypical angina. At the same time, the prevalence of CAD in a group of male patients with atypical angina over the age of 60 can reach 59--78%. It should be noted that the clinic manifestation of the chronic heart failure (CHF), which will be the main limiting factor, may take centre stage in diffuse coronary artery atherosclerosis. In patients with coronary artery disease and heart failure, who take atorvastatin, one should expect a decrease in the risk of adverse outcomes and hospitalizations due to heart failure. However, this does not negate the need for treatment and optimization of heart failure, if necessary. The therapy of these patients is based on the administration of high doses of angiotensin converting enzyme inhibitors (ACE inhibitors), beta-blockers (BB) and statins. The routine use of statins in heart failure with low ejection fraction (EF) is not recommended for the management of patients with heart failure from clinical guidelines point of view. This conclusion is based on two multicenter randomized clinical trials that have purposefully studied the use of statins in heart failure (CORONA and GISSI-HF). However, this document recommends the use of statins to prevent heart failure in patients with coronary artery disease. Continuing statin therapy in patients, who are already receiving these drugs for coronary artery disease or hyperlipidemia, should also be discussed. Thus, the use of atorvastatin in patients with coronary artery disease and systolic left ventricular myocardial dysfunction can reduce the risk of adverse outcomes and hospitalizations due to heart failure. In patients with non-ischemic heart failure, taking statins is not associated with improved survival. Thus, the decision to prescribe this group of drugs in patients with chronic heart failure should take into account the specific clinical situation and be strictly individualized.

P6164High level of EPA is associated with lower perivascular coronary attenuation as measured by coronary CTA

Abstract Introduction Pericoronary adipose tissue (PCAT) composition has been recently shown to be a potential novel marker of coronary inflammation with higher PCAT attenuation shown to indicate increased cardiac mortality. Polyunsaturated fatty acids (PUFAs), especially Omega-3 fatty acids (n3), are thought to alter inflammatory response and intake of high dose Eicosapentaenoic acid (EPA, C20_5 n3) was shown to decrease mortality, however exact pathophysiological mechanisms are unclear. Therefore, we sought to determine whether blood levels of PUFAs are associated with differences in pericoronary fat attenuation. Methods In 64 symptomatic patients with intermediate pretest-likelihood for coronary artery disease presenting with atypical angina, coronary CTA was performed. PCAT attenuation was measured in Hounsfield Units (HU) around the proximal 40mm of the right coronary artery (RCA) using semi-automated software. Erythrocyte membrane fatty acid composition (in percentage) was analyzed with a standardized analytical methodology, displaying a variety of fatty acids including n-3 fatty acids using gas chromatography. Results Patients were divided into two groups (each n=32) using the median PCAT attenuation of −78.1 Hounsfield units (HU), resulting in one group with low (−95.58 to −78.17 HU) and one with high (−78.06 to −62.92 HU) PCAT attenuation. Among both groups, no differences were seen in age, sex, BMI, traditional cardiovascular risk factors or the number of cardiovascular risk factors (all p&gt;0.05). In univariate analysis, significantly higher values of EPA (1.00% [0.78; 1.26] vs. 0.78% [0.63; 0.99]; p=0.02) were seen in patients with lower PCAT attenuation. All other fatty acids showed no significant differences (all p&gt;0.05). Moreover, a significant negative correlation was seen between PCAT attenuation and EPA (Pearson correlation coefficient −0.38; p=0.002), but not for age, sex, BMI or number of cardiovascular risk factors (all p&gt;0.1). Multivariable linear regression analysis confirmed this association and showed a significant inverse association of EPA to PCAT attenuation (β=−0.31, p=0.017), independent of age, gender, BMI and number of CV risk factors (all p&gt;0.1). Conclusion High levels of EPA are associated with lower PCAT attenuation on coronary CTA indicating different composition of pericoronary adipose tissue potentially caused by a lesser degree of coronary inflammation.

Diagnosis of obstructive coronary artery disease using computed tomography angiography in patients with stable chest pain depending on clinical probability and in clinically important subgroups: meta-analysis of individual patient data

ObjectiveTo determine whether coronary computed tomography angiography (CTA) should be performed in patients with any clinical probability of coronary artery disease (CAD), and whether the diagnostic performance differs between subgroups...

Stress echocardiography in coronary artery disease: a practical guideline from the British Society of Echocardiography

Stress echocardiography is an established technique for assessing coronary artery disease. It has primarily been used for the diagnosis and assessment of patients presenting with chest pain in whom there is an intermediate probability of coronary artery disease. In addition, it is used for risk stratification and to guide revascularisation in patients with known ischaemic heart disease. Although cardiac computed tomography has recently been recommended in the United Kingdom as the first-line investigation in patients presenting for the first time with atypical or typical angina, stress echocardiography continues to have an important role in the assessment of patients with lesions of uncertain functional significance and patients with known ischaemic heart disease who represent with chest pain. In this guideline from the British Society of Echocardiography, the indications and recommended protocols are outlined for the assessment of ischaemic heart disease by stress echocardiography.

Obstructive coronary artery disease in women presenting with ischemic chest pain: Prevalence and risk determinants

Background: Women present more commonly with atypical angina, false-positive exercise test, and normal/nonobstructive coronary angiogram. It thus becomes essential to identify the predictors of obstructive coronary artery disease (CAD) in women to avoid unnecessary invasive angiograms. Methods: We prospectively recorded the data of consecutive 578 women who underwent coronary angiography in our institute for typical/atypical chest pain suspected to be secondary to CAD. Results: Normal coronaries/nonobstructive CAD were seen in 273 (47.2%) patients, whereas 305 (52.8%) patients were found to have obstructive CAD (P 55 years, smoking, diabetes mellitus, hypertension, low-density lipoprotein cholesterol >150 mg/dl, and high-density lipoprotein cholesterol

Diagnostic Utility of CT Coronary Angiography for the Detection of Coronary Heart Disease in Patients with Dyspnoea

Introduction: Current UK guidelines recommend CT coronary angiography (CTCA) first line for the detection of coronary heart disease (CHD) in patients who present with typical or atypical stable angina. However, CTCA is not infrequently requested to investigate for CHD as a cause of breathless without chest discomfort or 'angina equivalent'. A PubMed search using the terms 'coronary angiography' and 'dyspn(o)ea' revealed limited information regarding CTCA in this population. The aim of this study was to assess the prevalence of obstructive CHD in patients with dyspnoea but no chest discomfort undergoing CTCA

Pretest probability for patients with suspected obstructive coronary artery disease: re-evaluating Diamond-Forrester for the contemporary era and clinical implications: insights from the PROMISE trial.

To update pretest probabilities (PTP) for obstructive coronary artery disease (CAD ≥ 50%) across age, sex, and clinical symptom strata, using coronary computed tomography angiography (CTA) in a large contemporary population of patients with stable chest pain referred to non-invasive testing. We included patients enrolled in the Prospective Multicenter Imaging Study for Evaluation of Chest Pain (PROMISE) trial and randomized to CTA. Exclusively level III-certified readers, blinded to demographic and clinical data, assessed the prevalence of CAD ≥ 50% in a central core lab. After comparing the recent European Society of Cardiology-Diamond and Forrester PTP (ESC-DF) with the actual observed prevalence of CAD ≥ 50%, we created a new PTP set by replacing the ESC-DF PTP with the observed prevalence of CAD ≥ 50% across strata of age, sex, and type of angina. In 4415 patients (48.3% men; 60.5 ± 8.2 years; 78% atypical angina; 11% typical angina; 11% non-anginal chest pain), the observed prevalence of CAD ≥ 50% was 13.9%, only one-third of the average ESC-DF PTP (40.6; P < 0.001 for difference). The PTP in the new set ranged 2-48% and were consistently lower than the ESC-DF PTP across all age, sex, and angina type categories. Initially, 4284/4415 (97%) patients were classified as intermediate-probability by the ESC-DF (PTP 15-85%); using the PROMISE-PTP, 50.2% of these patients were reclassified to the low PTP category (PTP < 15%). The ESC-DF PTP overestimate vastly the actual prevalence of CAD ≥ 50%. A new set of PTP, derived from results of non-invasive testing, may substantially reduce the need for non-invasive tests in stable chest pain.

Acute Coronary Syndrome Following Long-Term Erlotinib Treatment

Abstract Introduction. The treatment of neoplasia has advanced due to targeted molecular therapies. Erlotinib, a tyrosine kinase inhibitor that acts by blocking epidermal growth factor receptor (EGFR), is used to treat advanced or metastatic chemotherapy-resistant non-small cell lung cancers (NSCLC). Erlotinib is a safe and well tolerated medication. Although the most common adverse effects are cutaneous or gastrointestinal, its cardiotoxicity is an important topic in the treatment and follow-up of neoplastic patients. Clinical case. A 76-year-old male patient with 40 Pack Year history of smoking that has quitted 20 years ago, was admitted in 2009 for night sweats, dry cough and weight loss. He is diagnosed with lung cancer in the right upper lobe (T4N2M1), with the histopathological diagnosis of clear cell adenocarcinoma. The patient performs radiotherapy and chemotherapy with 6 series of Gemcitabine and Cisplatin with partial response, followed by Erlotinib treatment with favorable progression with regression of tumor size. In December 2017, he presents recurrent episodes of atypical angina lasting about 2 weeks. The electrocardiographic examination reveals ST segment elevation, with tall T waves and Q waves are present in the lower branches, associated with the increase of myocardial necrosis enzymes. Echocardiography highlights inferior hypokinesia with left ventricle ejection rate estimated at 45%. The patient has a favorable evolution during admission without recurrence of pain. Coronary angiography is performed at distance with evidence of vascular atherosclerotic lesions and the installation of active pharmacodynamic stents. Discussions. Tyrosine kinase inhibitors may be the cause of acute coronary events both by affecting myocardiocytes following EGFR inhibition, but also by increasing atheromatic plaque instability and by prolonging theQT segment. In conclusion a systemic cardiologic assessment of Erlotinib-treated patients may be recommended throughout the course of therapy.

The importance of characteristics of angina symptoms for the prediction of coronary artery disease in a cohort of stable patients in the modern era

ObjectiveAngina is an important clinical symptom indicating underlying coronary artery disease (CAD). Its characteristics are important for the diagnosis and risk stratification of patients with CAD. Currently, we aimed to investigate the association of chest pain characteristics with the presence of obstructive CAD in a contemporary cohort of patients undergoing coronary angiography for suspected stable CAD. MethodsConsecutive patients undergoing coronary angiography for suspected stable CAD (n = 686) in a single university hospital cardiology department were enrolled. Chest pain was classified as typical angina, atypical angina, nonangina chest pain, and lack of symptoms. The presence of significant angiographic CAD was diagnosed by standard coronary angiography. ResultsTypical angina symptoms were associated with a higher prevalence of CAD (odds ratio [OR], 3.47, p < 0.001), whereas atypical angina symptoms were associated with a lower prevalence of CAD (OR, 0.49, p = 0.003) than the nonangina symptoms/or asymptomatic status. In multivariate analysis, typical angina symptoms remained an independent predictor of CAD (OR, 2.54, p < 0.001), with a greater predictive accuracy than other clinical risk factors (area under the curve [AUC], 0.715, p < 0.001) and similar to the accuracy of the high-sensitivity C-reactive protein (AUC, 0.712, p < 0.001). In a multivariate model, the combination of all studied factors further improved the predictive accuracy (AUC, 0.81, p < 0.001). ConclusionIn a contemporary cohort of patients referred for coronary angiography for stable CAD, the presence of typical angina symptoms was the most important independent predictor of obstructive CAD. The association of atypical angina symptoms with low CAD prevalence compared to nonangina chest pain or absence of significant symptoms probably reflects different management and referral strategies in these groups of patients.

ANGINA AS A SEQUELA OF A CONGENITAL HEART DEFECT

In 2000, an estimated 800,000 adults with congenital heart disease lived in the United States. Medical care for this growing population of individuals often requires a coordinated multidisciplinary healthcare team. We present a case of atypical angina in a young female from suspected subclavian

Coronary magnetic resonance imaging after routine implantation of bioresorbable vascular scaffolds allows non-invasive evaluation of vascular patency.

BackgroundEvaluation of recurrent angina after percutaneous coronary interventions is challenging. Since bioresorbable vascular scaffolds (BVS) cause no artefacts in magnetic resonance imaging (MRI) due to their polylactate-based backbone, evaluation of vascular patency by MRI might allow for non-invasive assessment and triage of patients with suspected BVS failure.MethodsPatients with polylactate-based ABSORB-BVS in proximal coronary segments were examined with 3 Tesla MRI directly (baseline) and one year after implantation. For assessment of coronary patency, a high-resolution 3D spoiled gradient echo pulse sequence with fat-saturation, T2-preparation (TE: 40 ms), respiratory and end-diastolic cardiac gating, and a spatial resolution of (1.08 mm)3 was positioned parallel to the course of the vessel for bright blood imaging. In addition, a 3D navigator-gated T2-weighted variable flip angle turbo spin echo (TSE) sequence with dual-inversion recovery black-blood preparation and elliptical k-space coverage was applied with a voxel size of (1.14 mm)3. For quantitative evaluation lumen diameters of the scaffolded areas were measured in reformatted bright and black blood MR angiography data.Results11 patients with implantation of 16 BVS in the proximal coronary segments were included, of which none suffered from major adverse cardiac events during the one year follow up. Vascular patency in all segments implanted with BVS could be reliably assessed by MRI at baseline and after one year, whereas segments with metal stents could not be evaluated due to artefacts. Luminal diameter within the BVS remained constant during the one year period. One patient with atypical angina after BVS implantation was noninvasively evaluated showing a patent vessel, also confirmed by coronary angiography.ConclusionsCoronary MRI allows contrast-agent free and non-invasive assessment of vascular patency after ABSORB-BVS implantation. This approach might be supportive in the triage and improvement of diagnostic workflows in patients with postinterventional angina and scaffold implantation.Trial registrationGerman Register of Clinical Studies DRKS00007456

Ebstein Anomaly in a 60 Years Patient: A Lucky Finding

Ebstein anomaly is a rare congenital disease of the tricuspid valve (<1%) diagnosed at all ages. A single case of an 85 y old patient was reported in 1979 as the longest survival with ebstein anomaly who had no cardiac symptoms until 79 years old. The aim of this case report is to highlight the need for an early echocardiographic diagnosis of this disease to prevent sudden death from arrhythmias or other complications because as we see patients with ebstein anomaly can live a healthy long life asymptomatic. The patient described in this case is a 60 years old male diabetic and heavy smoker, who presented to the cardiology department with fatigue and atypical angina with dyspnea on moderate effort. Cardiac ultrasound was in favor of an isolated Ebstein anomaly type A, with partial atrialization of the right ventricle (RV) with an adequate volume of the right ventricle (17cm2) and no specific other associated anomalies. Symptoms described by the patient were purely pulmonary due to a mild obstructive disease. Patient was diagnosed with chronic obstructive lung disease due to his smoking habits. Reaching this age and being asymptomatic with conserved RV and LV function is a sign of good outcome. This case was an interesting lucky finding. It was astonishing to see a patient surviving this anomaly at 60 years old asymptomatically.

Frequency and angiographic characteristics of coronary microvascular dysfunction in stable angina: a hybrid imaging study.

Coronary microvascular dysfunction (CMD) can cause angina in the absence of obstructive coronary artery disease (CAD). We studied the frequency and angiographic characteristics of CMD in symptomatic patients with suspected stable CAD and identified CMD as diffusely abnormal coronary vasodilator capacity by positron emission tomography (PET) perfusion imaging. We recruited prospectively 189 patients with intermediate pre-test probability of CAD who underwent coronary computed tomography angiography and quantitative 15O-water PET perfusion imaging followed by invasive coronary angiography, and assessment of fractional flow reserve when feasible. Prevalence of obstructive epicardial CAD was 37%. Absolute myocardial blood flow was diffusely reduced (<2.4 mL/g/min) within the left ventricle during adenosine stress in 32 (17%) patients. In 15 (8%) patients, this was explained by three-vessel obstructive CAD, whereas the remaining 17 (9%) were diagnosed with CMD. Of these, 2 (1% of all patients) had no coronary atherosclerosis, 5 (3% of all patients) had non-obstructive atherosclerosis, and in 10 (5% of all patients) CMD co-existed with obstructive CAD. Atypical angina or non-anginal chest pain (53%) was the most common presentation. Older age and male sex were associated with CMD, but other risk factors of CAD were equally common in patients with or without CMD. Coronary microvascular dysfunction exists in 9% of symptomatic stable patients with suspected CAD. However, the prevalence of microvascular dysfunction without any coronary atherosclerosis is low (1%) in this population.