Conventional Coronary Angiogram Research Articles

Frequency of Reversibility of Complete Heart Block in Acute Myocardial Infarction

Objective The aim of current study was to evaluate the frequency of reversibility of complete heart block in patients of acute myocardial infarction. Methods Total one hundred and thirty eight patients with complaint of syncope and atypical chest pain presented at emergency ward of Punjab Institute of Cardiology, Lahore. All patients underwent conventional coronary angiogram to roll out the ischemic etiology of underlying bradyarrhythmias. Among them more than 90% patients have mild coronary artery disease and they were kept on medical management. But all patients remained TPM dependant for two weeks which were then treated with permanent pacemakers. Results Results of the current study revealed that the mean age of patients was 51.48 ± 15.46 with minimum age 18 and maximum was 65 years. Out of 138 patients, 84(61%) were male while 54(39%) were female., 52(37.7%) patients diagnosed of diabetes mellitus, 75(54.3%) patients of hypertension and 58(42.03%) patients were smoker, 41(29.7%) have family history, 47(34.1%) patients have dyslipidemia and only 50(36.2%) obese patients. Patients divided into two groups; patients with complete heart block in the age grouped between 16-35 years, only 6(4.3%) as compare with age grouped 36-65 years only 10(7.2%) have complete heart block, male 8(5.8%), only 5(3.6%) hypertensive patients and 4(2.9%) diabetic patients suffering complete heart block, 2(1.4%) patients presented during 1-12 hours compare with 7(5.1%) presented between 13-24 hours, results showed statistically insignificant as p-value > 0.05. 2nd Degree AV Block and complete heart block showed significant difference between troponin level as p-value <0.05 in patients diagnosed with ACS. Conclusion Atrioventricular block is frequently reversible in people with AMI. As a result, in situations with AMI permanent pacemaker installation should be postponed.

Role of MDCT in Assessment of Long-term Graft Patency in Female Patients

Objectives: The aim of the study was to analyze the utility of CT-coronary angiogram (CT-CAG) in assessment of long-term graft patency compared to conventional invasive coronary angiography (ICA) and highlight any gender-specific issues in female post-coronary artery bypass surgery (CABG) patients. Materials and Methods: The medical records and images of 30 patients including four female patients who had CABG in the past and underwent both conventional and CT-CAGs were analyzed retrospectively. Results: We studied 30 patients who had CABG in whom both CT-CAG and conventional coronary angiograms were performed. CT-CAG was able to evaluate the grafts better than ICA and was useful even in those which could not be assessed due to technical failure by ICA. There were only four female patients in this series. In first patient, the arterial graft (left internal mammary artery [LIMA]) was patent but distal run off was absent in LAD in CT-CAG images and was reported as poor in conventional coronary angiogram. The second patient had CABG 10 years back. The arterial graft (LIMA) to LAD was patent and there was total block in SVG graft to RCA at proximal anastomotic site. The third patient with hypertension and diabetes also had CABG 10 years back. Both LIMA to LAD and SVG to PDA were patent in her. In last case who had CABG 7 years, two of the three SVG grafts were blocked which were well-demonstrated on CT CAG, including one SVG missed on conventional CAG. Conclusion: CT-CAG is a non-invasive and less cumbersome alternative to conventional CAG for the assessment of grafts long after CABG even in women. The data generated by CT-CAG in post-CABG are as good as the invasive CAG and it has distinct advantage of greater acceptability.

Right Coronary Artery Originating From Mid Left Anterior Descending Artery: A Rare Variant of Anomalous Right Coronary Artery Detected on CT Coronary Angiography.

Background: A single coronary artery (SCA) is a rare anomaly encountered using conventional coronary angiography. A right coronary artery (RCA) originating from a left anterior descending artery (LAD) is a rare subtype of SCA. Only a few cases are described in published literature. Case presentation: We described this anomaly in a 55-year-old male who presented with angina pectoris. The anomalous RCA was suspected by conventional coronary angiogram and was confirmed by computed tomography (CT) coronary angiography. Using CT, we demonstrated the course of the abnormal vessel and its relation to the main vessel. We also detected the presence of plaque, which caused luminal stenosis of the proximal LAD, which may cause global ischaemia. Conclusion: We concluded that although conventional coronary angiography is an important diagnostic method, new non-invasive methods such as CT coronary angiography can be a better screening tool to detect and characterise coronary anomalies. Electronic Supplementary Materials Supplementary Material 1: Coronary angiogram demonstrates anomalous RCA originating from LAD. Supplementary Material 2: CTA coronary shows anomalous RCA originates from the mid-portion of LAD.

Predictive role of novel echocardiographic parameter aortic velocity propagation, QRISK3 and Framingham risk score for presence and severity of CAD in Asian patients.

Introduction: Despite having clinical relevance, arterial stiffness is neglected and not routinely used parameter for evaluation of atherosclerosis. This study aimed to investigate the predictive role of simple non-invasive echocardiographic index of aortic stiffness aortic velocity propagation (AVP), Framingham risk score (FHS) and QRISK3 score for presence and severity of CAD. Methods: This cross-sectional comparative study included 250 patients who required conventional coronary angiogram for stable CAD. The relationship of AVP, FHS and QRISK3 score with CAD were evaluated using spearman's correlation, logistic regression analysis and ROC curve. Results: On logistic regression analysis, AVP, FHS and QRISK3 were found significant predictors for the presence and severity of CAD. Inverse correlation between AVP and presence of CAD, number of coronary vessels involved and severity of CAD was observed with P=0.001. AVP value≤78 cm/s predicted presence of CAD with 86.4% sensitivity and 84.6% specificity (P≤0.0001, AUC=0.948) and≤39 cm/s predicted severe CAD (Syntax score>22) with 66.7% sensitivity and 97.9% specificity (P≤0.0001, AUC=0.868). FHS value>10 predicted the presence of CAD with a sensitivity of 33.9% and specificity of 91 % (P=0.01, AUC=0.644). QRISK3value>13.4 predicted presence of CAD with 57.1% sensitivity and 87% specificity (P≤0.0001, AUC=0.788). Conclusion: Arterial stiffness parameter AVP is inversely associated with the presence and severity of CAD. AVP and QRISK3 score may be used as a simple bedside tool for risk stratification of patients suspected of having atherosclerotic CAD.

Clinical and Paraclinical Characteristics of Patients With Coronary Artery Anomalies

Abstract Introduction Coronary artery anomalies are rare congenital abnormalities often found incidentally on conventional coronary angio-gram or coronary computed tomography angiography. They may result in various clinical outcomes. The objective of this study was to investigate the prevalence of coronary artery anomalies, the clinical and laboratory characteristics of patients with coronary artery anomalies, and the outcomes at five-year follow-up of these patients in a high-volume coronary interventional center in Romania. Materials and Methods To define the study population we reviewed all coronary angiograms performed between 01.01.2014 and 31.12.2014. A total number of 5832 coronary angiograms were analyzed, and we identified 31 patients with coronary artery anomalies. Results The prevalence of coronary artery anomalies was 0.53%. Eighty-seven point four percent of the patients had origin and distribution anomalies, and twelve point nine percent of the patients had a coronary artery fistula. The most common coronary artery anomalies were the anomalous origin of the right coronary artery and the anomalous origin of the left circumflex artery from the initial segment of the right coronary artery. Sixty-one point three percent of the patients underwent coronary angiogram due to atypical chest pain. Twenty-nine percent of the patients had significant coronary artery disease. No death or significant complication were recorded in the 31 patients during the 5 years follow-up. Conclusions The prevalence of coronary artery anomalies in this study was slightly lower but still like that of previous studies. The majority of patients presented with atypical symptoms, and only a minority had coronary artery disease. In the context of no death or significant complication at 5-year follow-up highlights the benign prognosis of most coronary artery anomalies.

Association between higher serum uric acid levels and plasma N-terminal pro-B-type natriuretic peptide concentrations in patients with coronary artery disease and without overt heart failure

BackgroundThe association between serum uric acid (SUA) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) concentrations in patients with coronary artery disease (CAD) is unclear. MethodsWe retrospectively studied 171 patients with suspected or established CAD and without overt heart failure who were consecutively admitted to our Division of Cardiology from February to August 2016. Plasma NT-proBNP concentrations were measured using a chemiluminescent immunoassay method. A conventional echocardiography and coronary angiogram were also performed in all patients. ResultsPatients in the 3rd SUA tertile had higher median plasma NT-proBNP concentrations compared with those belonging to 2nd or 1st SUA tertile, respectively (443 [IQR: 222–1381] vs. 224 [99–487] vs. 162 [68–307] pg/mL; p < 0.001). After adjustment for age, sex, body mass index, hypertension, diabetes, chronic kidney disease, prior ischemic heart disease, prior heart failure, medication use, and left ventricular ejection fraction (LVEF), patients belonging to the 3rd SUA tertile had an increased risk of higher plasma NT-proBNP concentrations (adjusted-standardized beta coefficient: 0.310, p < 0.001). Almost identical results were found when patients treated with allopurinol (n = 14), or those with prior HF (n = 8) were excluded from the analyses. ConclusionsThese results show that increased SUA levels are strongly associated with higher plasma NT-proBNP concentrations in patients with suspected or established CAD and without overt heart failure, independent of established cardiovascular risk factors, LVEF, medication use and other potential confounders.

Rare Cause of Secondary Pulmonary Arterial Hypertension

Abstract Unilateral absent pulmonary artery (UAPA) is a rare congenital disorder. Most of the patients will be diagnosed in the early childhood because of recurrent respiratory tract infections and hemoptysis, but adult presentation is not uncommon. We report a 47-year-old female who was earlier diagnosed as bronchiectasis with pulmonary artery hypertension but now presented with complaints of typical angina and dyspnea on exertion. During right heart catheterization we failed to enter right pulmonary artery (RPA), and conventional coronary angiogram showed a large left atrial branch of left circumflex giving collateral blood supply to the right lung. Computed tomography angiogram showed absent RPA. We report this case not only because the patient was misdiagnosed but also because of rarity of coronary collaterals in UAPA patients and unusual bilateral bronchiectasis. According to reported literature, ours is the 28th case of this nature.

Prognostic value of a novel index: computational pressure-flow dynamics derived fractional flow reserve in patients with stable coronary artery disease treated with optimal medical therapy alone

Abstract Background The use of fractional flow reserve (FFR) is limited due to the need of invasive pressure wire and hyperaemic stimulus. Computational pressure-flow dynamics derived fractional flow reserve (caFFR) is a novel non-invasive index to determine the FFR in patients with stable coronary artery disease (CAD). Purpose The clinical value of caFFR remains uncertain. The aim of the study is to evaluate the prognostic role of caFFR in patients with stable CAD who were treated by optimal medical therapy alone. Methods A total of 558 stable CAD patients (mean age=64.5±11.2, 59.0% male) with ≥1 coronary lesion detected during conventional coronary angiogram were included. All of them did not undergo percutaneous coronary intervention and were treated with optimal medical therapy alone. Patients were then classified into 4 groups according to their caFFR value; caFFR ≤0.70 (n=40), caFFR = 0.71–0.80 (n=28), caFFR = 0.81–0.90 (n=292), caFFR = 0.91–1.00 (n=198), with a lower caFFR indicating a greater magnitude of myocardial ischemia. The primary endpoint was 3-year major adverse cardiac events (MACE), defined as a composite of all-cause mortality, myocardial infarction or any unplanned revascularization. Results During a median follow-up of 36 months, a total of 49 composite events occurred, including 27 all-cause mortality, 4 myocardial infarction and 18 unplanned revascularization. After multivariate adjustment, caFFR was an independent predictor of MACE (adjusted hazard ratio [HR] = 0.97 per 0.01 increase in caFFR; 95% confidence interval [Cl], 0.95–0.99; P&amp;lt;0.01), all-cause mortality (adjusted HR = 0.96 per 0.01 increase in caFFR; 95% Cl, 0.94–0.99; P&amp;lt;0.01), and stroke (adjusted HR = 0.95 per 0.01 increase in caFFR; 95% Cl, 0.90–0.99; P=0.03). The area under the curve (AUC) by receiver-operating characteristic curve analysis (ROC) is 0.70 (95% Cl, 0.62–0.78; P&amp;lt;0.01). The optimal cut-off of caFFR defined by ROC analysis for predicting MACE is 0.80, concluding that patients with caFFR ≤0.80 have significantly higher adverse event rate, which is consistent with the cut-off from wire-based FFR. Using caFFR = 0.91–1.00 as reference, the risk of MACE was highest in patients with caFFR ≤0.70 (adjusted HR = 4.65; 95% Cl, 1.81–11.94; P&amp;lt;0.01), followed by caFFR = 0.71–0.80 (adjusted HR = 3.67; 95% Cl, 1.12–11.33; P=0.02). The risk of MACE was nonetheless similar among patients with caFFR &amp;gt;0.8 (adjusted HR = 1.39; 95% Cl, 0.61–3.19, P=0.44). Conclusion In patients with stable CAD who were treated with optimal medical therapy alone, those with more significant myocardial ischemia, indicated by lower caFFR, had higher risks of adverse outcomes. The finding thus supports the use of this non invasive index to quantify the severity of myocardial ischemia, improve risk-stratification, and predict adverse outcomes in patients with stable CAD. Funding Acknowledgement Type of funding sources: Public hospital(s). Main funding source(s): The University of Hong Kong, Queen Mary Hospital

Usefulness of Pre-Procedural Imaging of the Coronary Venous System With Coronary Angiography Before Cardiac Resynchronization Therapy.

Cardiac resynchronization therapy (CRT) is a treatment modality for selected patients with refractory heart failure. We intended to examine the usefulness of coronary venous system imagining with conventional coronary angiogram before the CRT implantation procedure. A total of 180 patients were scheduled for CRT and were prospectively randomized 1:2 into 2 groups. Group 1 (n = 60) received standard CRT procedure without the guidance of selective left coronary angiography. In group 2 (n = 120), CRT implantation was accomplished with the guidance of the preprocedural coronary angiography. We compared the 2 groups in terms of the total implantation time, total fluoroscopy time, the amount of contrast medium used, and cumulative radiation exposure. The total implantation and fluoroscopy times, the amount of contrast medium used, and cumulative radiation exposure were significantly less in group 2 compared with group 1 (53 ± 7 vs 66 ± 9 minutes, 11 ± 3 vs 20 ± 5 minutes, 24 ± 8 vs 42 ± 14 mL, 26 192 ± 6658 vs 37 388± 9064 mGy cm2, and 253 ± 49 vs 392 ± 79 mGy, P < .0001, respectively). We concluded that coronary angiography prior to CRT implantation is useful in simplifying the procedure, saving time, reducing radiation exposure, and reducing contrast use.

Post renal transplant acute myocardial infarction

Background: Renal transplant recipients (RTR) have a comparatively lower risk of acute myocardial infarction (AMI) than wait-list patients. Cardiovascular diseases especially AMI are the leading cause of morbidity and mortality in post-renal transplant patients.1,4 They account for up to 50% of the deaths in RTR. The incidence of AMI in RTR is about 0.2% but it is on the rise. Meticulous pre-operative assessment of cardiac status, appropriate pre-operative cardiac management, and post-operative cardiac monitoring will prevent mortality.2 Recently it has been emphasized and there is ample evidence to use cardiac troponins from day zero in the post-operative period to diagnose peri-operative cardiac events like AMI.3 We report a case of post-operative myocardial infarction in a live renal donor transplant patient. This case report will serve to increase the awareness of the cardiovascular event in RTR. Case Report: A 62-year-old obese male patient known to have Type II diabetes mellitus, dyslipidemia, hypertension, end-stage renal disease (ESRD) on peritoneal dialysis, presented for live non-related donor renal transplant. In the pre-operative evaluation, his comorbidities were well controlled. His electrocardiogram (ECG) was normal and an echocardiogram revealed left ventricular enlargement and grade 1 diastolic dysfunction. Induction of anesthesia and intra-operative periods were smooth and he remained hemodynamically stable. The patient did not consent for epidural catheter insertion. Intra-operatively his iliac arteries showed multiple plaques, and his renal vessels were anastomosed with difficulty. After a 6-hour surgery, he was admitted to the surgical intensive care unit (SICU) sedated, intubated, and ventilated.In SICU initially, his hemodynamics were stable, passing 20 to 30 ml of urine per hour, and started on 100% renal replacement with IV Ringer's Lactate. The central venous pressure was between 12 to 14 mmHg. He was rapidly weaned from the ventilator and extubated after 8 hours. Post-extubation, he was awake, stable, and resumed his oral medications.On day 2, during physiotherapy, he complained of shortness of breath and developed severe bradycardia (24 beats/minute). Twelve-lead ECG showed ST-segment depression in the anterior-lateral leads. Within a few minutes, he went into cardiac arrest requiring CPR (cardio-pulmonary resuscitation) for 1 minute. Cardiac biomarkers were elevated (Figure 1) and chest x-ray showed pulmonary congestion (Figure 2). An echocardiogram revealed left ventricular ejection fraction of 58% and mild hypokinesia of the anterior wall. CT coronary angioram or conventional coronary angiogram was not done to avoid constrast induced injury to the transplanted kidney.He was started on aspirin and heparin infusion. His newly grafted kidney was functioning well and he was passing 50-100 ml of urine per hour. He was hemodynamically stable and transferred to the ward on day three. From there, he was discharged home and followed in the transplant and cardiac outpatient clinics. After three months of follow-up, his kidney was functioning well and his echocardiogram became normal. Conclusion: RTR are at greater risk of cardiovascular events, particularly AMI though significantly less than the wait-list patients. Cardiac troponins should be monitored in the post-operative period as early detection of acute coronary syndrome improves their outcome.3

Stress Diastolic Function for Assessment of Coronary Artery Disease

Abstract Introduction Prevalence of coronary artery disease (CAD) has increased to alarming levels globally. There is a significant improvement in the noninvasive modalities for the early CAD detection by costly investigations such as computed tomographic (CT) coronary angiogram. The authors want to see the efficacy of adding pulse and tissue Doppler parameters, which is a cheaper modality, to the TMT (treadmill test) stress testing, for the detection of CAD. Materials and Methods The authors have recruited 51 patients, who were referred for TMT for detection of inducible ischemia. Mean age of the patients was 51.9 years. Patients with renal failure, rhythm disturbances, and hypertension more than stage 1 were excluded. Along with the TMT, basal and exercise pulse wave and tissue Doppler parameters were recorded. These echocardiogram parameters were compared with presence and absence of CAD, along with the severity of CAD (SVD [single-vessel disease], DVD [double-vessel disease], and TVD [triple-vessel disease]) on a conventional coronary angiogram (CAG).There was no statistical difference between basal and after TMT in pulse wave diastolic parameters (basal E-wave velocities: 0.76 ± 0.18 vs. 0.88 ± 0.22, p = 0.29: after TMT: 1.03 ± 0.22 vs. 1.12 ± 0.21, p = 0.29) for detection of CAD on CAG. However, most tissue Doppler velocities were significantly different both in basal and after TMT in CAD group when compared with no-CAD group (S′ septal, basal, and after TMT, p = 0.002, E′ septal, basal, and after TMT, p = 0.0015, A′ septal, basal, and after TMT, p = 0.0195, S′ lateral, basal, and after TMT, p = 0.0018, E′ lateral, basal, and after TMT, p = 0.0016, S′ Inferior, basal, and after TMT, p = 0.0036, A′ inferior, basal, and after TMT, p = 0.023). Average E/E′ after TMT for DVD was 12.29 ± 2.09 (vs. no-CAD 10.70 ± 2.00) and for TVD it was 12.2 ± 2.19 (vs. no-CAD 10.69 ± 2.1), which were statistically significantly higher than no-CAD (p = 0.02, p = 0.02). Conclusion Tissue Doppler velocities of different left ventricular (LV) walls (S′, E′, A′ of septal; S′, E′, of lateral; S′, A′ of inferior) in CAD at basal and after TMT were different from the no-CAD group, which were statistically different. Ratios such as E/E′, E/A′ of septal, lateral, and inferior, after TMT were useful for the detection of not only the presence of CAD but also for the severity of the CAD (for DVD: 12.29 ± 2.09 vs. 10.70 ± 2.00, p = 0.023; TVD: 12.2 ± 2.19 vs. 10.69 ± 2.1, p = 0.023). In conclusion, diastolic stress evaluation is useful to predict the occurrence of CAD and its severity.

Comparison between Myocardial Perfusion Scintigraphy Using Technetium 99m Tetrofosmin and Conventional Coronary Angiogram in Assessing Coronary Artery Disease at Royal Hospital, Oman

Comparison between Myocardial Perfusion Scintigraphy Using Technetium 99m Tetrofosmin and Conventional Coronary Angiogram in Assessing Coronary Artery Disease at Royal Hospital, Oman

SYNTAX Score in Patients with High Computed Tomography Coronary Calcium Score.

Objectives:To study the conventional coronary angiogram ( CA) findings in patients with high coronary calcium on multidetector computed tomogram.Materials and Methods:Fifty patients with coronary calcium high enough in its extent and location to interfere with the interpretation of a contrast-filled coronary artery for a significant lesion were studied with conventional CA. Framingham risk score (FRS), computed tomography (CT) coronary calcium score (CCS), and SYNTAX score (SS) from the CA were calculated by separate investigators who were blinded to other scores. Effectively, 250 coronary arteries (left main, left anterior descending, left circumflex, and right coronary artery and posterior descending artery in each subject) with calcium scores were studied for lesions on CA.Results:Thirty-five subjects had high FRS, 10 had intermediate FRS, and 5 had low FRS. Eight subjects of 25 (32%) with CCS between 350 and 1000 had no significant coronary artery disease (CAD). Overall, the CCS and the SS had a strong agreement with each other (r = 0.68, P < 0.01) that persisted in those with very high scores >1000 (r = 0.55, P < 0.01, n = 30), but only a nonsignificant weak correlation with scores between 350 and 1000 (r = 0.1, P = 0.62, n = 20). Individual vessel calcium scores correlated strongly for the presence of any lesion (r = 0.52, P < 0.01) in the same artery but only weakly for a significant lesion (r = 0.29, P = 0.05).Conclusion:High CT CCS in this cohort of intermediate to high (Framingham score) risk patients correlated strongly with the subject's global burden of the CAD as derived by the SS, more so for subjects with very high scores. Similarly, CCS correlated strongly with the presence of any lesion but only weakly for a significant stenosis; also, about one-third of patients with CCS between 350 and 1000 may not have significant disease on conventional CA.

Aortic velocity propagation: A novel echocardiographic method in predicting atherosclerotic coronary artery disease burden

BackgroundThe major burden of cardiovascular disease mortality around the globe is due to atherosclerosis and its complications. Hence its early detection and management with easily accessible and noninvasive methods are valuable. Aortic velocity propagation (AVP) through color M-mode of the proximal descending aorta determines aortic stiffness, reflecting atherosclerosis. The aim of this study was to find the utility of AVP in predicting coronary artery disease (CAD) burden assessed through SYNTAX (SYNergy between percutaneous coronary intervention with TAXus and cardiac surgery) score and compared with carotid intima-media thickness (CIMT), which is an established surrogate marker of atherosclerosis. MethodsIn this cross-sectional comparative study, we measured AVP by color M-mode and CIMT by using Philips QLAB-IMT software in 100 patients, who underwent conventional coronary angiogram (CAG) between May 2013 and November 2014. Coronary artery disease is considered significant if >50% diameter stenosis is present in any epicardial coronary artery and insignificant if otherwise. ResultsInitially, to know the normal range we measured AVP and CIMT in 50 patients without any major risk factors for CAD but CAG was not done. Aortic velocity propagation ranged from 46cm/s to 76cm/s (mean=58.62±6.46cm/s), CIMT ranged from 0.50mm to 0.64mm (mean=0.55±0.03mm). Among 100 patients who underwent CAG we found 69% had significant CAD, 13% had insignificant CAD, and 18% had normal coronaries. Those with significant CAD had significantly lower AVP (41.65±4.94cm/s) [F (2,97)=44.05, p<0.0001] and significantly higher CIMT (0.86±0.11mm) [F (2,97) =35.78, p<0.0001]. AVP had significant strong negative correlation with CIMT (r=−0.836, p<0.0001, n=100) and SYNTAX score (r=–0.803, p<0.0001, n=69), while CIMT was positively correlated with SYNTAX score significantly (r=0.828, p<0.0001, n=69). ConclusionsAVP and CIMT can predict CAD burden in a robust way. AVP may emerge as an exquisite bedside tool to predict atherosclerotic burden and guide in implementing preventive therapy for cardiovascular disease.

Percutaneous Coronary Intervention in Spontaneous Coronary Artery Dissection: Role of Intravascular Ultrasound.

Spontaneous coronary artery dissection (SCAD) is a rare, life-threatening condition that usually manifests as an acute myocardial infarction. Diagnosing SCAD with conventional coronary angiogram can be challenging, particularly if the true lumen is severely narrowed. Our case highlights the challenges in performing successful percutaneous coronary intervention (PCI) in patients with SCAD. Intravascular ultrasound can prove to be a pivotal tool in the diagnosis and successful management of such cases by establishing the anatomic site of dissection, and confirming stent placement in the true lumen following PCI.Electronic supplementary materialThe online version of this article (doi:10.1007/s40119-014-0029-4) contains supplementary material, which is available to authorized users.

Diagnostic value of cardiac multi-detector computed tomography for detection of subclinical atherosclerosis in asymptomatic diabetic patients

Purpose: Silent myocardial ischemia in asymptomatic subjects with no history of ischemic heart disease is a frequent condition in diabetic patients. Therefore the detection of subclinical atherosclerosis in asymptomatic diabetic patients is important. The aim of the present study was to investigate the prevalence, characteristics, and prognostic value of coronary 64-slice multi-detector computed tomography (MDCT) in asymptomatic diabetic patients. Methods: We retrospectively enrolled self-referred 444 diabetic patients (age = 58.2±8.3 years, 326 males) who underwent both coronary MDCT angiography and coronary calcium scoring from January 2008 to June 2011. For all subjects, we evaluated clinical risk factors and investigated cardiac events. Subclinical atherosclerosis was defined as the any detectable plaques on MDCT and significant stenosis was defined as more than 75% narrowing of coronary artery diameter in this study. Results: Subclinical atherosclerosis was found in 214 subjects (48.2%). The subclinical atherosclerosis group was older, more patients with male, smokers, high level of fasting serum glucose. Independent predictors of subclinical atherosclerosis were old age (≥ 65years) [odds ratio (OR): 1.099, 95% confidence interval (CI): 1.01-1.19, p=0.022], and high level of HbA1C (≥ 7.0%) (HR: 1.64, 95% CI: 1.02-2.66, p=0.042) in multivariate logistic regression analysis. And significant coronary stenosis in MDCT was found in 83 patients (18.7%). The significant stenosis group was older, more patients with hypertension, smokers, high level of high sensitivity C-reactive protein (hs-CRP). High level of hs-CRP high (≥ 2mg/L) was an independent predictor of significant stenosis (OR: 2.66, 95% CI: 1.67-4.02, p=0.012). 71 patients who showed significant stenosis underwent stress test, such as treadmill exercise test or myocardial SPECT. Among them, 48 patients underwent conventional coronary angiogram and 20 patients underwent percutaneous coronary intervention. During clinical follow-up (mean follow-up period=21.5±11.3 months), of all subjects myocardial infarction was developed in 3, unstable angina in 17, target lesion revascularization in 4 patients. Conclusions: In this study, the prevalence of subclinical coronary atherosclerosis in asymptomatic diabetic patients was nearly fifty percent. Cardiac MDCT will be an useful method for detection of subclinical atherosclerosis in diabetic patients.

Coronary Artery Ectasia in an Adult Noonan Syndrome Detected on Coronary CT Angiography

Coronary ectasia is rare in patients with Noonan syndrome. When suspected during echocardiography more common causes including Kawasaki disease in children and atherosclerosis coronary artery disease in adults should be ruled out. Coronary CT angiogram, a non-invasive imaging tool may be preferred over conventional coronary angiogram in the initial diagnosis and monitoring the progression of coronary ectasia in such patients. Aspirin may be considered to prevent coronary thrombosis.

Absent Left Main with Anomalous Origin of All Three Coronary Arteries From Left Aortic Sinus: A Previously Undescribed Combination of Coronary Anomalies

Coronary artery anomalies resulting in all three coronary arteries arising separately from single sinus of Valsalva is very rare. We report a patient with two coincidental coronary anomalies: absent left main with left anterior descending, and left circumflex arteries arising separately from left sinus of Valsalva along with anomalous origin of right coronary artery from left sinus of Valsalva. Computed tomography angiogram and conventional coronary angiogram showed anomalous right coronary artery from left sinus with an interarterial course, but with no significant lesions. However, there was significant stenosis of left anterior descending and circumflex arteries that was treated with angioplasty and stenting. To the best of our knowledge, absent left main with all three major coronary arteries arising separately from left aortic sinus has never been reported previously.

AS-281: A Prospective Multi-Center Study Exploring Method of Clopidogrel Pre-Rreatment Undergoing Conventional Coronary Angiogram in Angina Patients

Periprocedural myonecrosis is a frequent occurrence in percutaneous coronary intervention(PCI). Several studies have corroborated the relationship between periprocedural MI and intermediate- and long-term clinical outcomes. Clopidogrel pre-treatment was understood to decrease periprocedural ischemic events. We evaluated method of clopidogrel pre-treatment undergoing conventional coronary angiogram to reduce periprocedural myonecrosis in angina patients.

Congenital anomalies of coronary arteries: Diagnosis with 64 slice multidetector CT

ObjectiveCongenital coronary artery anomalies are generally incidental, uncommon and asymptomatic. Some can cause severe potentially life threatening symptoms. The common mode of studying the coronary arteries is Conventional Coronary Angiogram. ECG-gated-multidetector CT is a non invasive modality. The objective of our study was to identify rare congenital coronary artery anomalies and discuss their clinical significance. Material and methodsA total number of 900 MDCT coronary angiograms were carried out at our institution between the period of April 2006 and October 2010. Patients with coronary artery anomaly constituted the subject of study. ResultsThe incidence of anomalous anatomical origin and course of the coronary arteries in our study was 1.55%. Hemodynamical significance was seen in five patients. 3 cases of single coronary artery originating from right coronary sinus were seen. 1 case of anomalous left coronary artery arising from main pulmonary artery was seen. 4 cases of anomalous RCA arising from left aortic cusp, 6 cases of absent LMCA with separate origin of LAD and LCX were seen. ConclusionMultidetector row CT is a noninvasive modality in cardiac imaging. It provides superior resolution of coronary tree and its variant. No projectional vascular overlap is seen. Various postprocessing techniques outclass catheter angiography imaging. Definition of ostia and proximal course of the coronary arteries by Multidetector CT is better than catheter angiography.