Consecutive Coronary Angiograms Research Articles

Angiographic SYNTAX score reduction in de novo left main coronary stenosis patients over the last decade: implications for revascularization approach

Abstract Introduction Percutaneous management of left main (LM) coronary artery stenosis is an acceptable alternative to surgery in selected group of patients. Purpose To investigate potential angiographic trends in de novo LM coronary artery stenosis patients. Those may impact revascularization mode but remain undetermined. Methods Clinical records and all consecutive coronary angiograms in our Institution from 1st January 2010 to 31stDecember 2019 were evaluated to identify those with newly diagnosed angiography-significant (≥50% lumen diameter reduction) LM stenosis. Angiographic SYNTAX score (SS) assessment was performed by agreement of two experienced analysts (an angiographic core lab analyst and a Heart Team interventional cardiologist) on anonymized angiograms. Values of the overall SS, SS of the LM lesion and SS beyond LM were determined according to SS assessment methodology. Pearson's correlation and Fisher transformation were used to evaluate parametric variables. Spearman's rho was used to determine trends. Results Overall, out of 12315 coronary angiographies performed in de novo referrals in the last decade, 357 (2.90%) showed significant left main stenosis; the proportion varied from 2.30% to 3.48% annually. Patient mean age was 68.8 years (23.3% women). No temporal trends in patient age or gender occurred over the last decade while the overall SS deceased from a mean value of 35 to 28 (SC=−0.16, p=0.003). Further analysis showed a particular negative trend in the non-LM-SS (SC=−0.17, p=0.001) but not in the LM-SS (SC=0.04, p=0.47). No temporal trend was present is the prevalence of isolated LM stenosis (p=0.48) and no temporal trend in the LM stenosis angiographic severity (<70% vs. ≥70%; p=0.61), LM stenosis location (ostial/mid/bifurcation/entire left main; p=0.30) nor in the number of LM segments affected (SC=0.05, p=0.30). Reduction in the non-LM-SS was associated with a decrease in the number of coronary arteries with a significant angiographic atherosclerotic involvement (SC=−0.12, p=0.03) and in the number of coexisting total occlusions (SC=−0.25, p<0.001). Conclusion(s) (1) In patients with newly diagnosed LM critical stenosis overall angiographic SS showed a statistically significant negative trend over last decade, with a reduction from mean 35 (2010) to 28 points (2019); a finding that may be related to a change in the angiographic presentation of the disease or an earlier identification of LM stenosis patients over time. (2) The overall SS reduction was driven by a decrease in non-LM-SS. This, taken together with the overall SS reduction from above 32 to below 32, favours (as per current guidelines) the endovascular approach to left main revascularization. Our findings suggest an increase in the proportion of LM stenosis patients with angiography feasible to percutaneous intervention. SYNTAX score trends over the last decade Funding Acknowledgement Type of funding source: None

Incidence of acute bronchospasm during systemic adenosine administration for coronary angiography.

Adenosine is frequently used during coronary angiography to induce hyperaemia and allow operators to perform quantitative measurements of lesion severity. Acute bronchospasm is a recognised side effect relating to the activation of 'off target' A2B receptors. The true incidence of severe bronchospasm relating to adenosine administration is not known. Using an electronic patient database, we analysed 100,253 consecutive coronary angiograms over almost 19 years. Fractional flow reserve (FFR) was measured under systemic adenosine in 9,440 cases. Adenosine-related bronchospasm was reported in only five cases (0.05%). One case resulted in a life-threatening respiratory arrest. This study reveals the incidence of acute bronchospasm during FFR testing to be extremely low. Although rare, these reactions can be severe and are not simply limited to patients with brittle airways disease. Physicians should be aware of the utility of bolus intravenous aminophylline providing targeted therapy to reverse and treat adenosine-related bronchospasm.

Prevalence and clinical characteristics of patients with myocardial bridging in a population from North Kerala

BackgroundMyocardial bridging refers to a condition in which a band of myocardial tissue overlies a segment of an epicardial coronary artery. The exact prevalence of this entity is not known and varies considerably in different studies. In this study, we aimed to estimate the prevalence of myocardial bridging from consecutive coronary angiograms done over a period of last seven years at our institute and also assess the clinical and angiographic profile of these patients. Method and resultsA total of 3146 coronary angiograms were reviewed and 153 patients were found to be having myocardial bridging. The prevalence of myocardial bridging was 4.86%, which was highest among the previously reported Indian studies. 89 (58.16%) patients had isolated myocardial bridging without significant coronary artery involvement where as the rest 64 (41.83%) had coronary artery disease (CAD). The incidence of diabetes mellitus and family history of CAD was significantly higher in patients with myocardial bridges and CAD compared to those with myocardial bridges without significant CAD. 49 patients with hypertrophic cardiomyopathy underwent coronary angiogram out of which myocardial bridging was seen in 8 (16.32%) patients. Among patients with rheumatic heart disease (RHD), the incidence of myocardial bridging was 3.44%. ConclusionThe study showed a higher incidence of myocardial bridging then that of previous Indian studies. A significant proportion of patients presented with angina and acute coronary syndrome despite having no coronary artery disease. The incidence was higher in patients with hypertrophic cardiomyopathy whereas it was similar to that of general population in patients with rheumatic heart disease.

Coronary aneurysms in the acute patient: Incidence, characterization and long-term management results.

Coronary aneurysms (1.5 times dilation the reference-vessel) are uncommon and have been diagnosed with increasing frequency with coronary angiography. The incidence varies from 1.5% to 5%. Reported complications are multiple: thrombosis, distal embolization, rupture and vasospasm, causing ischemia, heart failure or arrhythmias. However, the natural history and prognosis remains obscure. We aimed to describe the characteristics of acute patients with coronary aneurysms. Prospective coronariography registry of patients with the diagnosis of coronary aneurysm between 2002 and 2013. Among 51,555 consecutive coronary angiograms, 414 patients with aneurysms were reported, of which 256 were considered acute (82% NSTE-ACS). Predominantly male (80%, mean age 65.5years), cardiovascular risk factors were common (hypertension 65%, dyslipidemia 65%, obesity 25%, diabetes mellitus 28.5%, and smokers 67%). With frequent coronary stenoses (94%), mostly with one aneurysm (80%), it was observed more frequently in the anterior descending artery. After a median follow-up of 52months, 53 died (14 cardiac causes) and 42% presented a cardiovascular event. Complications from the aneurysm were found in 4. The duration of dual antiplatelet therapy, LVEF, age and peripheral vascular disease highlighted in the multivariate analysis of death. The presence of coronary aneurysms in patients undergoing coronary angiography with an acute event is low. Patients who present them also have a large burden of atherosclerotic risk factors. In the long-term, the probability of cardiovascular complications is high, but only a small proportion are due to the aneurysm itself. A more intense and prolonged antithrombotic treatment may result in lower mortality rates.

Reducing Radiation Dose in Coronary Angiography and Angioplasty Using Image Noise Reduction Technology

This study sought to quantitatively evaluate the reduction of radiation dose in coronary angiography and angioplasty with the use of image noise reduction technology in a routine clinical setting. Radiation dose data from consecutive 605 coronary procedures (397 consecutive coronary angiograms and 208 consecutive coronary interventions) performed from October 2014 to April 2015 on a coronary angiography system with noise reduction technology (Allura Clarity IQ) were collected. For comparison, radiation dose data from consecutive 695 coronary procedures (435 coronary angiograms and 260 coronary interventions) performed on a conventional coronary angiography system from October 2013 to April 2014 were evaluated. Patient radiation dosage was evaluated based on the cumulative dose area product. Operators and operator practice did not change between the 2 evaluated periods. Patient characteristics were collected to evaluate similarity of patient groups. Image quality was evaluated on a 5-grade scale in 30 patients of each group. There were no significant differences between the 2 evaluated groups in gender, age, weight, and fluoroscopy time (6.8 ± 6.1 vs 6.9 ± 6.3minutes, not significant). The dose area product was reduced from 3195 ± 2359 to 983 ± 972 cGycm(2) (65%, p <0.001) in coronary angiograms and from 7123 ± 4551 to 2431 ± 1788 cGycm(2) (69%, p <0.001) in coronary interventions using the new noise reduction technology. Image quality was graded as similar between the evaluated systems (4.0 ± 0.7 vs 4.2 ± 0.6, not significant). In conclusion, a new x-ray technology with image noise reduction algorithm provides a substantial reduction in radiation exposure without the need to prolong the procedure or fluoroscopy time.

Removing the Antiscatter Grid: A simple way to lower radiation during both Angiography and PCI

Aim: Radiation reduction is essential. In cardiac electrophysiology imaging without the anti-scatter grid has been proven as a means of achieving further radiation reduction. We evaluate the application of this gridless imaging technique to deliver further reductions in radiation risk to both patients and personnel during coronary angiography(C/C) and percutaneous coronary interventions (PCI). Methods and Results: We compared 6 consecutive coronary angiograms and 4 consecutive PCIs with and without the antiscatter grid in our new Toshiba Infinix-I angiography suite (Toshiba Medical Systems, Japan) in patients with a Body Mass Index (BMI) under 30. We chose this number as we felt it was a threshold BMI above which image quality may be compromised. For all cases all radiation and clinical data were recorded. All procedures were performed without complication. An appreciable difference in image quality without the grid was noted only during fluoroscopy with movement. However during still fluoroscopy and cine acquisition there was no notable difference. One possible future approach may also be selected use of the gridless technique with re-introduction of the grid in larger patients or during aspects of the procedure where image quality is important. The most marked difference in radiation reduction was seen during PCI.

Comparing stress testing and fractional flow reserve to evaluate presence, location and extent of ischemia in coronary artery disease

BackgroundFFR provides an accurate and reproducible assessment of the functional severity of coronary stenosis. Whereas stress testing remains the preferred initial modality for assessment of ischemia, there is limited data comparing it with FFR. We sought to determine the correlation between cardiac stress testing and coronary fractional flow reserve (FFR) measurement for assessing the presence, location, and burden of myocardial ischemia in patients referred for evaluation of coronary artery disease (CAD). MethodsOver 5-year study period, of the 5420 consecutive coronary angiograms that were screened, 326 patients had FFR measurements. Of these, 96 patients with FFR measurements who had a preceding stress test (stress echocardiography [SE] or myocardial perfusion imaging [MPI]) within a year were included. ResultsOf the 96 patients, there were 46 (48%) men and 50 (52%) women with a mean age of 61 ± 10 years. SE was performed in 57 (59.3%) and MPI in 32 (40.7%) of patients. FFR was ≤0.79 in 54 (56%) patients. Stress testing had low sensitivity (55%) and specificity (47%) compared to FFR. The concordance between FFR and stress testing was low for both presence (k=0.03) and location (k=0.05) of the ischemic territory. The number of ischemic vascular territories was correctly estimated in only 39% of the stress tests. SE was more likely to overestimate and MPI more likely to underestimate extent of ischemia. ConclusionsIn patients referred for evaluation of CAD, there was poor correlation between stress testing and FFR. A prospective study comparing these two modalities with FFR is needed.

Long-Term Prognostic Factors in Patients with Significant Left Main Coronary Artery Disease

Introduction and Objectives: The natural history of patients with left main coronary artery disease (LMCAD) is largely unknown. Our objective was to analyse the predictors of long-term mortality in these patients, both those that have had surgery and those that have not undergone surgery for various reasons, in a cohort treated at a university hospital. Methods: The study included patients with significant LMCAD diagnosed through consecutive coronary angiograms from 2001 to 2009. Clinical variables, the reasons for cardiac catheterisation, therapeutic decisions and clinical evolution in long-term follow-up were analysed. Results: Of the 163 patients included in the analysis, a total of 109 (66.9%) underwent revascularisation, while the remaining 54 (33.1%) received other medical treatment. We analysed the clinical events that took place with a mean follow-up period of 54 months (IQR: 25-95). The non-revascularised group had a lower survival rate than the revascularised group in unadjusted analysis (logrank test 0.005). Age (OR 1.04, CI 1.02-1.07, p = 0.001), ventricular dysfunction (OR 2.87, CI95% 1.71-4.81, p 0.0001), clinical instability (OR 2.11, CI95% 1.08 to 4.13, p = 0.028) and above 70% severity of LMCAD (OR 1.78, CI 1.09 to 2.91, p = 0.021) were independent predictors of mortality for the entire cohort, but revascularisation was not. Conclusions: Revascularisation is associated with improved survival in patients with LMCAD, but only age, ventricular dysfunction, clinical instability and the severity of the lesion are independent predictors of long-term mortality in the unselected population.

Coronary Artery Fistulae after Orthotopic Heart Transplantation Are Associated with Decreased Prevalence of Transplant Coronary Artery Disease

Purpose Coronary artery fistulae (CAF) occur with a high frequency in orthotopic heart transplantation (OHT) patients. It is unknown whether CAF formation has any relationship with development of transplant coronary artery disease (TCAD). Methods and Materials We evaluated 432 consecutive coronary angiograms of recipients transplanted from 1994-2011. Presence of CAF and TCAD were recorded. TCAD was defined as angiographic epicardial stenosis ≥ 30%. Unpaired t test and Fisher’s exact test were used for statistical analysis. Results A total of 212 CAF were identified in 163 patients (37.7% of all patients) within one year post OHT. The most common termination structures were the pulmonary artery (55.7%), right atrium (23.1%), thoracic vessel (7.5%), and right ventricle (6.6%). During angiographic follow-up of 5.2±4.3 years, TCAD occurred in 9.8% of patients with CAF compared to 20% of patients without CAF (p=0.005). Immunosuppression with tacrolimus and mycophenolate mofetil was more frequent in patients with CAF (72%) compared to patients without CAF (58%) (p=0.005). Other transplant characteristics were not statistically different. Conclusions CAF formation after OHT is associated with a 50% decrease in downstream development of TCAD. The implications of this finding and the mechanism of CAF formation in OHT will require further investigation. Transplant Characteristics in Patients With and Without Coronary Artery Fistulae (n=432) Coronary Artery Fistulae (n=163) No Coronary Artery Fistulae (n=269) p value Female 36 (22.1%) 50 (18.6%) 0.39 Transplant Age (years) 55 ± 14 56 ± 13 0.55 Donor Age (years) 31 ± 12 30 ± 11 0.18 Ischemic Time (minutes) 193 ± 78 178 ± 68 0.070 Previous Sternotomy 76 (46.6%) 107 (39.8%) 0.19 Cytomegalovirus Mismatch 30 (18.4%) 67 (24.9%) 0.12 Ischemic Reason for Transplant 74 (45.4%) 123 (45.7%) 1.0 Induction Therapy 55 (33.7%) 96 (35.7%) 0.75 Rejection within Year 1 of Transplant 11 (6.7%) 24 (8.9%) 0.47 Transplant Coronary Artery Disease 16 (9.8%) 54 (20.1%) 0.005

Cardiac Allograft Vasculopathy Is Less Frequent in Contemporary Heart Transplant Population

Purpose Coronary allograft vasculopathy (CAV) remains an important contributor of mortality following orthotopic heart transplantation (OHT). Prevalence of epicardial coronary stenosis ≥30% at 5 years post OHT is reported to be 30%. The purpose of this study was to define the prevalence of CAV in a contemporary cohort. Methods and Materials We studied 432 consecutive coronary angiograms of patients transplanted from 1994-2011 (87.3% transplanted after January 2000). Baseline characteristics were obtained from medical records. CAV status was classified according to the International Society for Heart and Lung Transplantation grading report: mild (CAV1), moderate (CAV2), or severe (CAV3). Unpaired t test and Fisher’s exact test were used for statistical analysis. Results During a mean angiographic follow-up period of 5.2±4.3 years (all follow-up ≥1 year), angiographic stenosis ≥30% was identified in 70 (16%) patients. Mean time to development of epicardial coronary stenosis ≥30% was 5.8±3.9 years. Prevalence of coronary stenosis ≥30% at 1 year was 1.6%, at 3 years 6.3%, at 5 years 8.3%, and at 10 years 14.1%. CAV1 severity was identified in 33 (7.6%) patients, CAV2 in 25 (5.8%) patients and CAV3 in 12 (2.8%) patients. Percutaneous coronary intervention was necessary in 5.8% of all patients. Mean transplant age (55±12 years), donor age (32±12 years), gender (22% female), ischemic time (185±70 minutes) and choice of calcineurin inhibitor (tacrolimus vs cyclosporine) were not significantly different between patients with and without CAV. Patients with CAV were more likely to have had cellular or humoral rejection within the first year of transplant than patients without CAV [13/70 (19%) vs 25/362 (6.9%), p=0.0043]. Conclusions The prevalence of allograft vasculopathy appears to have decreased in a large contemporary cohort compared to prior reports. Rejection continues to play a role in CAV formation but may not be the only contributing factor. Further investigation is warranted to ascertain which aspect(s) of clinical care has contributed to this positive outcome.

Clinical and angiographic characteristics of patients with coronary artery ectasia

BackgroundThe relationship of the extent of coronary artery ectasia (CAE) with coronary blood flow in the major epicardial arteries has not been adequately assessed.This study aimed at investigating the association of the topographical extent of CAE with coronary flow velocity and clinical characteristics in patients with isolated CAE and in patients with coexisting obstructive coronary artery disease (CAD). MethodsWe reviewed 3764 consecutive coronary angiograms performed at Athens Euroclinic and identified patients with CAE according to standard criteria. The topographical extent of ectasia was considered, and coronary flow velocity was determined using the TIMI frame count (TFC). The severity of CAD was assessed using the modified Gensini index and the number of diseased vessels. Clinical data were correlated with TFC and CAD severity analysis. ResultsEctatic lesions were identified in 119 patients. The mean TFC correlated positively with the topographical extent of CAE (rs=0.733, p<0.001). Stepwise multiple linear regression revealed that the topographical extent of CAE and the maximum diameter of the ectatic segment in the corresponding artery are independent predictors of TFC in LAD and RCA. Using multivariate analysis, a history of myocardial infarction was independently associated with CAE extent, and CAD severity. ConclusionsThe extent of ectasia in the coronary vasculature is correlated with coronary flow velocity and associated with clinical presentation independent of coexisting significant coronary stenoses.

Pure coronary ectasia differs from atherosclerosis: Morphological and risk factors analysis

Coronary artery ectasia (CAE) is defined as localized coronary dilatation that exceeds the diameter of the normal adjacent segments or the diameter of the patients' largest coronary artery by 1.5 times [ [1] Syed M. Lesch M. Coronary artery aneurysm: a review. Prog Cardiovasc Dis. 1997; 40: 77-84 Google Scholar ]. The prevalence of the disease varies between 1.5 and 5% with an occurrence rate of 10% among Indians, and with male predominance [ 2 Giannoglou G.D. Antoniadis A.P. Chatzizisis Y.S. Damvopoulou E. Parcharidis G.E. Louridas G.E. Prevalence of ectasia in human coronary arteries in patients in northern Greece referred for coronary angiography. Am J Cardiol. 2006; 98: 314-318 Google Scholar , 3 Sharma S.N. Kaul U. Sharma S. et al. Coronary arteriographic profile in young and old Indian patients with ischaemic heart disease: a comparative study. Indian Heart J. 1990; 42: 365-369 Google Scholar ]. Such variation in disease prevalence is related to other associated conditions e.g. Kawasaki disease [ [4] Newburger J.W. Burns J.C. Kawasaki disease. Vasc Med. 1999; 4: 187-202 Google Scholar ] and connective tissue disorders, e.g. particularly polyarteritis nodosa [ [5] Pick R.A. Glover M.U. Vieweg W.V. Myocardial infarction in a young woman with isolated coronary arteritis. Chest. 1982; 82: 378-380 Google Scholar ] and Takayasu arteritis [ [6] Suzuki H. Daida H. Tanaka M. et al. Giant aneurysm of the left main coronary artery in Takayasu aortitis. Heart. 1999; 81: 214-217 Google Scholar ]. Despite the documented etiological role of atherosclerois [ [7] Antoniadis A.P. Chatzizisis Y.S. Giannoglou G.D. Pathogenetic mechanisms of coronary ectasia. Int J Cardiol. 2008; 130: 335-343 Google Scholar ], it fails to explain the paradoxically low prevalence of CAE among diabetics [ [8] Androulakis A.E. Andrikopoulos G.K. Kartalis A.N. et al. Relation of coronary artery ectasia to diabetes mellitus. Am J Cardiol. 2004; 93: 1165-1167 Google Scholar ], the anatomical predominance of the right coronary artery (RCA) [ [9] Farto e Abreu P. Mesquita A. Silva J.A. Seabra-Gomes R. Coronary artery ectasia: clinical and angiographic characteristics and prognosis. Rev Port Cardiol. 1993; 12: 305-310 Google Scholar ], the histological loss of the musculo-elastic component of the arterial wall [ [10] Markis J.E. Joffe C.D. Cohn P.F. Feen D.J. Herman M.V. Gorlin R. Clinical significance of coronary arterial ectasia. Am J Cardiol. 1976; 37: 217-222 Google Scholar ] and the potential genetic polymorphisms found in the promoter regions of MMP-2, MMP-3, MMP-9 and MMP-12 [ [11] Lamblin N. Bauters C. Hermant X. Lablanche J.M. Helbecque N. Amouyel P. Polymorphisms in the promoter regions of MMP-2, MMP-3, MMP-9 and MMP-12 genes as determinants of aneurysmal coronary artery disease. J Am Coll Cardiol. 2002; 40: 43-48 Google Scholar ]. We hypothesized that CAE has different nature from that of atherosclerotic coronary artery disease (CAD). We therefore examined consecutive coronary angiograms performed at the Umeå Heart Centre, Sweden and Letterkenny General Hospital, Ireland, between 2003 and 2009, with the objective of identifying all patients diagnosed as having CAE (Fig. 1), described the exact angiographic findings and analyzed the cardiovascular risk factors. Patients were classified as having pure or mixed lesions according to the following criteria. Pure CAE (Fig. 2A and C) when there was no evidence for atherosclerosis and mixed CAE (Fig. 2B and D) when, in addition to the dilated segments, there was classical evidence for atherosclerotic changes (plaque formation or minor atheromata ≤10% of lumen narrowing). We also recorded the anatomical sites of ectatic arteries and any ectatic lesion exceeding 20 mm in length. Patients with evidence for prior coronary intervention or other cardiac conditions were excluded. Clinical and angiographic variables of patients with CAE were later compared with 37 age-matched controls (65±8 years, 13 male) who were found to have normal angiograms. Conventional statistics including unpaired Student t test, chi-square test, univariate and multiple logistic regression analyses were used with p<0.05 as significance. Fig. 2Image showing the quantitative angiographic diferences between Pure (A, C) and mixed CAE (B, D). View Large Image Figure Viewer Download Hi-res image

Three‐Dimensional Vessel Analyses Provide More Accurate Length Estimations than the Gold Standard QCA

The aim of this study was to compare lesion dimensions as determined by a three-dimensional quantitative coronary angiographic (QCA) system to that of a validated two-dimensional QCA system. In an era of drug-eluting stents, device sizing has become an important clinical application of online QCA. The CardiOp-B system integrates two standard angiographic projections to provide a three-dimensional reconstruction of the arterial segment of interest. Phase 1 - 47 stenoses from consecutive coronary angiograms were assessed in two projections with both systems providing two data sets for the CMS-Medis system and a single data set for CardiOp-B. Phase 2--a perspex phantom with a known lesion length, was analyzed at increasing degrees of foreshortening with acceptance criteria set at 5% from the absolute value. Phase 1 demonstrated an adequate correlation between the CardiOp-B and Medis systems when minimal luminal diameter was measured in the optimal view (1.32 +/- 0.47 mm vs 1.42 +/- 0.49 mm respectively; r = 0.82). A stronger correlation was noted when length was measured (25.27 +/- 10.76 mm and 21.32 +/- 8.08 mm, respectively; r = 0.95); however CardiOp-B provided a consistently longer length (P < 0.0001). On phantom length measurements the mean accuracy result for the CardiOp-B system was -1.3%. This compared favorably with the two-dimensional system where all measures performed at greater than 20 degrees of for shortening were beyond the 5% criteria from the known length. Three-dimensional QCA provides accurate and precise vessel diameter assessments. Length assessments are consistently longer than two-dimensional measures and are significantly less affected by foreshortened projections.

Abolition of Respiratory-Motion Artifact in Computed Tomography Coronary Angiography with Ultrafast Examinations: A Comparison Between 64-row and 320-row Multidetector Scanners

Purpose To compare the incidence of respiratory artifact in computed tomography (CT) coronary angiography performed with 64-row and 320-row multidetector scanners and to assess its effect on coronary evaluability. Methods A retrospective review of consecutive coronary angiograms performed on a 64-row multidetector CT from March to April 2007 (group 1: 115 patients, 63 men; mean age [standard deviation] 59.6 ± 12.8 years) and on a 320-row multidetector CT from March to April 2008 (group 2: 169 patients, 89 men; mean [SD] age 57.9 ± 11.6 years). Two cardiac radiologists assessed the occurrence of respiratory artifact and coronary evaluability in studies with respiratory artifacts. Unevaluable coronary segments because of motion at the same anatomical level of the respiratory artifact were considered unevaluable because of this artifact. The association between the occurrence of respiratory artifact and patient biometrics, medication, and scan parameters was examined. Results Respiratory artifacts were detected in 9 of the 115 patients from group 1 (7.8%) and in none of the 169 patients from group 2 ( P < .001). Group 1 had longer scan times (median, 9.3 seconds; range, 7.5−14.4 seconds) compared with group 2 (median, 1.5 seconds; range, 1.1−3.5 seconds; P < .001). In group 1, 4 patients (3.5%) showed unevaluable coronary segments because of respiratory artifacts, and the CT coronary angiography was repeated in 1 patient (0.9%). Conclusions Respiratory artifacts are important in CT coronary angiography performed with 64-row multidetector scanners and impair the diagnostic utility of the examination in up to 3.5% of the studies. These artifacts can be virtually eliminated with a faster scan time provided by 320-row multidetector CT.

Coronary angiography and dual-source computed tomography are complementary methods in diagnosis of significant stenosis of the right coronary artery originating from the left aortic sinus

Abstract Anomalous origin of the right coronary artery from the contralateral aortic sinus is a rare but potentially fatal congenital abnormality. We analyzed 8.066 consecutive coronary angiograms and found 4 cases demonstrating this anomaly. In 2 cases the right coronary artery was without significant atherosclerotic lesions and coursed between the aorta and pulmonary trunk. In the 2 other cases the right coronary artery was significantly stenosed. In the last case, diagnosis was based on angiographic and dual-source computed tomographic examinations. Dual-source computed tomography showed precisely the origin and course of the right coronary artery between the ascending aorta and pulmonary artery. Moreover, stenoses of the anomalous coronary artery were depicted. Subsequent coronary interventions required modification of the Amplatz left guiding catheter, which enabled a sufficient support even for coronary artery stenting. Both methods seem to be complementary in the diagnostic and therapeutic process of this coronary anomaly.

Comparison of operator radiation exposure with optimized radiation protection devices during coronary angiograms and ad hoc percutaneous coronary interventions by radial and femoral routes

Although underestimated by interventional cardiologists for a long time, radiation exposure of operators and patients is currently a major concern. The objective of the present operator-blinded registry was to compare related-peripheral arterial route radiation exposure of operators. During 420 consecutive coronary angiograms (CAs) and percutaneous coronary interventions (PCIs), four interventional cardiologists were blindly screened. Radiation exposures were assessed using electronic personal dosimeters. Protection of operator was ensured using a lead apron, low leaded flaps, and leaded glass. Radiation exposure of operators was significantly higher using the radial route when compared with the femoral route for both CAs and CAs followed by ad hoc PCIs: 29.0 [1.0-195.0] microSv vs. 13.0 [1.0-164.0] microSv; P < 0.0001 and 69.5 [4.0-531.0] microSv vs. 41.0 [2.0-360.0] microSv; P = 0.018, respectively. Similarly, radiation exposure of patients was significantly higher using the radial route when compared with the femoral route for both CAs and CAs followed by ad hoc PCIs. Moreover, procedural durations and fluoroscopy times were significantly higher throughout the radial route. Although the radial route decreases peripheral arterial complication rates, increased radiation exposure of operators despite extensive use of specific protection devices is currently a growing problem for the interventional cardiologist health. Radial route indication should be promptly reconsidered in the light of the present findings.

Evaluation of Myocardial Bridging of the Left Anterior Descending Coronary Artery by 64-Slice Multidetector Computed Tomographic Angiography

The purpose of this study was to use the unique characteristics of multidetector computed tomographic coronary angiography to evaluate the prevalence and characteristics of myocardial bridging (MB) in a large series of patients and to assess the relation between atherosclerosis and MB. Three hundred consecutive coronary angiograms obtained by 64-slice multidetector computed tomography were evaluated retrospectively. For comparison of symptoms and concomitant atherosclerosis, 245 patients were included in the study and categorized into group 1 (n = 108) with MB and group 2 (n = 137) with no MB in the left anterior descending coronary artery (LAD). Axial and multiplanar reformatted images of all arteries were analyzed for the presence of measurable obstructive coronary disease (>25% stenosis) and minor luminal (<25% stenosis) calcified and noncalcified plaque and for MB in the LAD. Longitudinal and cross-sectional views were used for MB measurements. MB was found in 44% of patients (108 of 245) and was present equally in men and women (45% and 41%, p = NS). The mid LAD was the most common location (66%, p <0.001). There were no atherosclerotic lesions within the MB segments. The presence of MB did not influence the presence or severity of atherosclerotic lesions in the nonbridged segments of the LAD. In conclusion, MB as demonstrated by 64-slice multidetector computed tomographic coronary angiography is more common than previously reported by coronary angiography. The bridged segment appears to be free of atherosclerosis.

Near‐normal coronary angiography in a patient, who is entirely asymptomatic 24 years after successful intracoronary thrombolysis for ST elevation myocardial infarction. Follow‐up of the historically first Czech intracoronary thrombolysis patient

Extremely long-term follow-up (24 years) of the historically first Czech myocardial infarction patient, treated by intracoronary thrombolysis, is presented. His current coronary angiography confirmed the finding 24 years ago, that this was a case of smoking-induced thrombosis in otherwise healthy coronary arteries. Experience with 76 similar cases among 4093 consecutive coronary angiograms (including 778 done acutely for STEMI) is briefly described.

Second reading of coronary angiograms by radiologists

In many hospitals in the provinces of Quebec and Nova Scotia, as well as in some hospitals in the rest of Canada, coronary angiograms are performed and interpreted by invasive cardiologists, and are later reinterpreted and reported by radiologists. To evaluate the value of second readings of coronary angiograms by radiologists. Cardiology and radiology reports of a total of 160 consecutive coronary angiograms were compared from patients at three hospitals. Ten segments of the coronary tree were considered and 1582 segments were included. Agreement between cardiology and radiology interpretations was evaluated using per cent agreement, Pearson correlation and Bland-Altman limits of agreement. Agreement was calculated for each arterial segment and for each hospital. Excellent agreement was found between cardiology and radiology interpretations of coronary angiograms. Per cent agreement ranged from 94.9% to 100%, Pearson correlation ranged from 0.83 to 0.97 and Bland-Altman limits of agreement ranged from -18.1 to 19.4. Agreement was similar for each segment and for each hospital. Agreement remained excellent after exclusion of normal angiograms (n=348 segments), with a per cent agreement of 96.3%. Secondary analyses demonstrated a mean time delay of 13 days between angiograms and the subsequent radiology reports. There are minimal differences between the cardiology and radiology interpretations of coronary angiograms. Routine second reading by a radiologist may be redundant.

Prevalence of unfavorable angiographic characteristics for percutaneous intervention in patients with unprotected left main coronary artery disease

The goal of this study was to determine the proportion of patients with left main coronary disease (LMCD) with unfavorable characteristics for percutaneous coronary intervention (PCI). Published series suggest that LMCD can be treated percutaneously, however, the proportion of patients in whom PCI is an option based on angiographic criteria is unknown. In 13,228 consecutive coronary angiograms, 476 (3.6%) patients had < or =60% stenosis of the left main. In 232 patients with unprotected LMCD, the clinical characteristics and angiograms were reviewed with six features chosen as "unfavorable" for PCI: (1) Bifurcation LMCD, (2) occlusion of a major coronary, (3) ejection fraction <30%, (4) occlusion of a dominant RCA, (5) left dominant circulation, and (6) coexisting three-vessel disease. Treatment modality and 1 year mortality were determined. The mean age was 69 years and 68% were male. Unfavorable characteristics were common with at least one unfavorable characteristic seen in 80%. Bifurcation disease was the most common unfavorable characteristic observed (53%) and coexisting three-vessel disease was seen in 38%. Treatment consisted of CABG in 205 (88%), medical therapy in 24 (10%) and PCI in 3 (1%). Among patients referred for CABG, 1 year survival was 88% with similar rates of survival for those with favorable characteristics (86%) compared to those with at least one unfavorable characteristic (88%). Most patients with LMCD have at least one unfavorable characteristic for PCI suggesting that PCI may be a technically difficult option for most patients with LMCD.