Coronary Artery Segments Research Articles

Optical coherence tomography as a method for assessing the conduit-anastomosis-artery system in patients after coronary artery bypass grafting

Background. Coronary artery bypass grafting (CABG) remains the most common cardiac surgery in the world. In the long-term follow-up period after surgery, graft failure occurs in a substantial proportion of CABG conduits and is a complex pathomorphological process. Optical coherence tomography (OCT) is a high-resolution intravascular imaging modality that allows to assess in-vivo endothelial integrity.Aim. To substantiate the efficacy and safety of OCT assessment of the conduitanastomosis-artery system in CABG patients.Methods. The prospective observational cohort study included 21 patients with chronic coronary artery disease who underwent CABG. 3–5 days after CABG, patients underwent OCT and angiography of arterial and vein grafts, including distal anastomosis and nearby segment of the target coronary artery. At 12-month follow-up, all patients underwent repeated OCT and angiography of the conduitanastomosis-artery system to assess the changes. The primary endpoint of the study was graft failure; secondary endpoints of the study included unplanned repeat myocardial revascularization, cardiac death, and myocardial infarction due to graft failure.Results. At 12-month follow-up, 14.3% of graft failure and 9.5% of cases of unplanned repeated myocardial revascularization were registered. In most cases of graft failure, primary OCT revealed pronounced changes in the conduit and the native coronary artery (conduit/artery diameter ratio was more than 2 mm), whereas the diameter of the coronary artery anastomosis was less than 2.5 mm. Myocardial infarctions and death within 12 months were not registered.Conclusion. Thus, OCT is an effective and safe intravascular imaging technique for assessing coronary arteries and the conduit-anastomosis-artery system. OCT makes it possible to identify morphological changes in coronary bypass grafts, which can predict their early failure. The conduit/artery diameter ratio greater than 2 and target coronary artery diameter less than 2.5 mm was associated with graft failure within 12 months after CABG.

The association of coronary artery disease with age, gender and affected coronary segments

The study aims to determine the age-gender distribution of individuals with and without coronary artery disease (CAD) and to analyze the percentage size of CAD detected in different coronary artery segments by gender, including the right coronary artery (RCA), left main coronary artery (LMCA), circumflex artery (Cx), and left anterior descending artery (LAD). The research was conducted in Batman Training and Research Hospital's digital subtraction angiography (DSA) unit using angiography data obtained between April 2019 and July 2020. Coronary arteries were divided into proximal, middle, and distal segments, and the stenosis size was measured as a percentage for each segment. Among patients with CAD, in the gender distribution, males showed a significantly higher prevalence than females at a rate of 85.62% (p<0.05). The group with the highest incidence of disease lesions in the age-related distribution was 51-60, accounting for 32.45% of cases. The most common parts of the narrowing in the distribution according to the coronary artery parts were LAD-middle (64.36%) and RCA-proximal (49.47%). Additionally, in the distribution of the lesioned coronary arteries detected in each heart, the involvement of Cx, LAD, and RCA collectively was the most frequent form of lesioned coronary artery distribution (p<0.05). Our study presents detailed data revealing the localization, occlusion size, age, and gender distribution of coronary artery disease, a condition associated with high mortality risk and is therefore of paramount importance. We believe that the presented data are particularly significant in the fields of anatomy, epidemiology, and cardiology.

Еволюція тактик лікування пацієнтів зі стовбуровими ураженнями коронарних артерій

Damage to the trunk of the left coronary artery is the most dangerous manifestation of coronary atherosclerosis. Mortality with this type of lesions occurs by 3–4 times more often compared to lesions of other segments of coronary arteries. On the basis of previous clinical studies demonstrating advantages of coronary artery bypass grafting over drug therapy in terms of patient survival, coronary artery bypass grafting has long been considered the gold standard for the treatment of these lesions. The purpose of the work was to study the literature data on the evolution and peculiarities of the choice of methods of surgical treatment of coronary heart disease in patients with severe lesions of the trunk of the left coronary artery. Results and discussion. Along with the improvement of endovascular instrumentation, stenting procedures, antithrombotic agents, as well as concomitant drug therapy, percutaneous coronary interventions for lesions of the left trunk are becoming more and more widespread and show favorable clinical results in these patients. This is evidenced by the data of many randomized multicenter studies (SYNTAX, EXCEL). Based on the results of these studies, ESC/EACTS approved the following guidelines for myocardial revascularization in 2018. Percutaneous coronary interventions are indicated in the case of damage to the left trunk with scores on the SYNTAX scale less than 22 – class I, scores on the SYNTAX scale 23–32 – class IIa, and scores on the SYNTAX scale greater than 32 – class III. However, it is worth noting that both the American and the European guidelines recommend a discussion by a team of endovascular surgeons, cardiologists and cardiac surgeons (Heart Team) when choosing a treatment strategy for coronary artery disease patients with lesions of the trunk of the left coronary artery. Since the data of many studies on the treatment of patients with lesions of the trunk of the left coronary artery remain quite contradictory and ambiguous. Conclusion. Current literature data have shown that left coronary artery stenting is a fairly safe procedure, with a high rate of immediate success, low mortality, and few complications, especially in low-risk surgical patients. The use of stents with medical coating made it possible to reduce the frequency of repeated interventions to 10–12%. A number of issues remain, the solution of which would allow optimizing the application of this technique. These include: development of indications for surgical or endovascular treatment of lesions of the left coronary artery trunk, optimization of stenting techniques, assessment of the significance of concomitant pathology in the effectiveness of treatment of patients with lesions of the left coronary artery trunk

Wellens Syndrome on the basis of critical occlusion of the medial segment of the anterior ventricultural branch of the left coronary artery (clinical type)

The aim of the work is to determine the peculiarities of the clinical course of Wellens syndrome due to the presence of critical occlusion of the medial segment of the anterior interventricular coronary artery bifurcation.Material and Methods. Clinical manifestations of the disease, including dynamics of ECG changes; coronary angiography data; results of echocardiographic and laboratory tests.Results. This article presents the peculiarities of the clinical course of Wellens syndrome in patient L., 70, who met the currently recognized diagnostic criteria of the syndrome, but the critical occlusion of the anterior interventricular branch of the left coronary artery was localized in its medial segment. Along with this, there was hemodynamically irrelevant stenosis of the proximal coronary artery section (60%). Electrocardiographic changes were consistent with pattern B (deeply inverted T waves in V2-V6). Сonditional normalization of the T waves, indicating the absence of repeated coronary artery occlusion after spontaneous reperfusion. Stenting of the anterior interventricular coronary artery vein of the left coronary artery prevented the possible occurrence of “stuttering” pattern and the occurrence of myocardial infarction.Conclusions. Acute coronary syndrome with complete coronary artery occlusion is often accompanied by spontaneous reperfusion, which contributes to the relief of chest pain and the appearance of characteristic T waves on ECG and is the basis of the so-called Wellens syndrome. The most frequent localization of coronary artery occlusion is the proximal segment of the anterior interventricular branch of the left coronary artery, but we witnessed the occlusion in the medial segment of these coronary arteries. Immediate coronary angiography with stenting of the occluded artery will prevent the occurrence of myocardial infarction in the patient.

279 LAYERED PLAQUES: NOT ALL ARE HEALED

Abstract Layered plaques are the effect of a previous plaque event. They are associated with coronary spasm and found in more than 50% of patients with stable angina and a quarter of those with an acute coronary syndrome. Nevertheless, it is not clear whether their presence is indicative of a healing process or rather is predictive of an increased risk of future events. A 71-year-old male, heavy smoker and hypertensive, presented with episodes of angina at rest that resolved spontaneously in less than 5 minutes, with evidence of ST-segment elevation (STE) in the lower leads during one of these episodes. Coronary angiography showed an intermediate stenosis at the end of the mid segment of the dominant right coronary artery (RCA) (Figure A). Optical coherence tomography (OCT) revealed a layered plaque, consisting of high backscattering layers alternated with low reflection layers (Figures A1-3). Given the minimum luminal area of 3.65 mm2 and the absence of other criteria for plaque instability (erosion, thin-cap, etc.), we treated the patient conservatively with medical therapy alone, consisting of a single antiplatelet agent and a high-dose statin with ezetimibe. A non-dihydropyridine calcium antagonist and a long-acting nitrate were started given the suspicion of coronary spasm. Four months later the patient returned to the emergency department for persistent oppressive chest pain unresponsive to sublingual nitrates with evidence of STE in the lower leads. Emergency coronary angiography showed an acute occlusion of RCA with TIMI 0 flow in correspondence to the layered plaque highlighted 4 months earlier on OCT (Figure B). Antegrade flow was restored with manual thrombus aspiration (Figure C) and OCT showed lesion progression with many new layers, together with a cavity suggestive of plaque rupture (Figures C1-3). A 3.5×38 mm everolimus eluting stent was deployed – based on OCT sizing – and post-dilated with a 4.0×8 mm non-compliant balloon, obtaining an excellent angiographic result with TIMI 3 flow (Figure D). Low-reflecting layers within layered plaques are generally considered to be lipid deposits, but they could also represent intraplaque haemorrhages, generated by coronary spasm. The haematoma can be reorganised within the plaque to create a new layer, leading to lesion progression without necessarily requiring a loss of endothelial integrity. The progressive increase of the haematoma may lead to plaque rupture when the pressure exceeds the resistance of superficial layers. This case reveals a new possible mechanism of plaque progression in patients with coronary spasm and explains how layered plaques can be ambivalently considered to be either stable or vulnerable. Their treatment should be meticulously tailored not only based on classical criteria of plaque instability but also according to the underlying trigger mechanism.

273 CORONARY ARTERIES ANEURYSMS: CASE-BASED DISCUSSION

Abstract Coronary artery aneurysm (CAA) is an abnormal dilatation of a coronary artery segment; when its diameter is bigger than 20 mm or it is more than four times bigger as compared to the normal vessel size, the coronary artery aneurysm is defined as Giant. However, there are multiple definition of Giant CAA and miss a standardized classification. The reported prevalence of coronary aneurysms in the population underwent coronary angiography, ranges from 0.3% to 5% and often CAA are found in patient with aneurysms in other sites as ascending or abdominal aorta. In half of the cases an atherosclerotic etiology could be recognized; often CAA is found in the context of acute coronary syndrome. Seldom CAA is found at the autopsy of patient died for sudden cardiac death. Up today very few data exist about CAA management and their prognostic relevance; moreover, CAA treatment is not still clearly codified but rather case-based. Indeed, up today there are not published dedicated studies on which is the best medical therapy in example with antiplatelets or anticoagulant agents rather than an interventional approach, by endovascular or surgical technique. In this review, through two clinical cases, it will be described the current evidence about diagnostic tools and treatment options of CAAs.

Coronary Artery Aneurysm and Ectasia: Spectrum of Aetio-Pathology, Clinical Presentation and Outcome

The terms coronary artery ectasia and coronary artery aneurysm are used to describe aneurysmal dilation of coronary arteries. Coronary artery aneurysms and ectasia are uncommon and frequently incidental finding in patients advised Coronary Angiography for coronary artery disease evaluation. Aneurysmal dilation of coronary arteries is observed in up to 5% of patients undergoing coronary angiography and are usually describe a localised dilatation of a coronary artery segment more than 1.5-fold compared with adjacent normal segments. Aneurysms and ectasia are associated with a vast group of disorders, and the evaluation and characterization of coronary aneurysms and ectasia represent a great diagnostic task with clinical and therapeutic implications. The underlying etiology is variable and includes degenerative, congenital, inflammatory, infectious, toxic, and traumatic causes. Causative factors include atherosclerosis, Takayasu arteritis, congenital disorders, Kawasaki disease (KD), and percutaneous coronary intervention. Due to their poorly elucidated underlying mechanisms, their variable presentations, and the lack of large scale outcome data on their various treatment modalities, coronary artery aneurysms and coronary ectasia pose a challenge to the managing clinician. Unlike aneurysms, ectasia is more frequently seen in association with atherosclerosis or as a compensatory mechanism in those cases in which a proximal stenosis is noted in the opposite coronary artery; ectasia is also seen in some coronary artery anomalies, such as anomalous origin from the pulmonary artery, or as a result of a high-flow state, as seen in coronary artery fistulas. The natural history of CAAs remains unclear; however, several recent studies have postulated the underlying molecular mechanisms of CAAs, and genome-wide association studies have revealed several genetic predispositions to CAA. Controversies persist regarding the. The diagnostic approach depends on the clinical scenario, and nowadays, noninvasive evaluation with multidetector computed tomography is possible. The purpose of this review is to summarize the present knowledge of CAAs and collate the recent advances regarding the epidemiology, etiology, pathophysiology, diagnosis, and to provide a succinct review of aneurysmal coronary disease, with a special emphasis on the challenges associated with its interventional treatment.

Phenomapping approach to interpreting coronary dimensions in febrile children.

Coronary artery dilation may occur in febrile children with and without Kawasaki disease (KD). We explored the application of unsupervised learning algorithms in the detection of novel patterns of coronary artery phenotypes in febrile children with and without KD. A total of 239 febrile children (59 non-KD and 180 KD patients), were recruited. Unsupervised hierarchical clustering analysis of phenotypic data including age, hemoglobin, white cell count, platelet count, C-reactive protein, erythrocyte sedimentation rate, albumin, alanine aminotransferase, aspartate aminotransferase, and coronary artery z scores were performed. Using a cutoff z score of 2.5, the specificity was 98.3% and the sensitivity was 22.1% for differentiating non-KD from KD patients. Clustering analysis identified three phenogroups that differed in a clinical, laboratory, and echocardiographic parameters. Compared with phenogroup I, phenogroup III had the highest prevalence of KD (91%), worse inflammatory markers, more deranged liver function, higher coronary artery z scores, and lower hematocrit and albumin levels. Abnormal blood parameters in febrile children with z scores of coronary artery segments <0.5 and 0.5-1.5 was associated with increased risks of having KD to 8.7 (P = 0.003) and 4.4 (P = 0.002), respectively. Phenomapping of febrile children with and without KD identified useful laboratory parameters that aid the diagnosis of KD in febrile children with relatively normal-sized coronary arteries.

Unsupervised machine learning based on clinical factors for the detection of coronary artery atherosclerosis in type 2 diabetes mellitus

BackgroundCoronary atherosclerosis can lead to serious cardiovascular events. In type 2 diabetes (T2DM) patients, the effects of clinical factors on coronary atherosclerosis have not been fully elucidated. We used a clustering method to distinguish the population heterogeneity of T2DM and the differences in coronary atherosclerosis evaluated on coronary computed tomography angiography (CCTA) among groups and to facilitate clinical management.MethodsClinical data from 1157 T2DM patients with coronary atherosclerosis who underwent CCTA in our hospital from January 2018 to September 2021 were retrospectively collected. The coronary artery segment plaque type and stenosis, the number of involved vessels, the segment involvement score (SIS) and the segment stenosis score (SSS) were evaluated and calculated. Unsupervised clustering analysis based on clinical information was used (cluster 1: n = 463; cluster 2: n = 341; cluster 3: n = 353). The association of coronary plaque characteristics with cluster groups was evaluated.ResultsThe clinical data among the three groups were different in several aspects: (1) Cluster 1 had the least male patients (41.7%), the lowest proportion of patients with smoking (0%) or alcohol history (0.9%), and the lowest level of serum creatinine (74.46 ± 22.18 µmol/L); (2) Cluster 2 had the shortest duration of diabetes (7.90 ± 8.20 years) and was less likely to be treated with diabetes (42.2%) or statins (17.6%) and (3) Cluster 3 was the youngest (65.89 ± 10.15 years old) and had the highest proportion of male patients (96.6%), the highest proportion of patients with smoking (91.2%) and alcohol (59.8%) history, the highest level of eGFR (83.81 ± 19.06 ml/min/1.73m2), and the lowest level of HDL-C (1.07 ± 0.28 mmol/L).The CCTA characteristics varied with different clusters: (1) Cluster 1 had the largest number of segments with calcified plaques (2.43 ± 2.46) and the least number of segments with mixed plaques (2.24 ± 2.59) and obstructive stenosis (0.98 ± 2.00); (2) Cluster 1 had the lowest proportion of patients with mixed plaques (68%) and obstructive stenosis (32.2%); (3) Cluster 3 had more segments with noncalcified plaques than cluster 1 (0.63 ± 1.02 vs 0.40 ± 0.78, P < 0.05) and the highest proportion of patients with noncalcified plaques (39.9%) and (4) There was no significant difference in the extent of coronary plaques among the three clusters.ConclusionsThe unsupervised clustering method could address T2DM patients with heterogeneous clinical indicators and identify groups with different types of coronary plaque and degrees of coronary stenosis. This method has the potential for patient stratification, which is essential for the clinical management of T2DM patients with coronary atherosclerosis.

Feasibility analysis on reducing iodine delivery rate of coronary CT angiography with 100 kVp to 60% of 120 kVp standard

Objective: To investigate the feasibility of reducing the iodine delivery rate (IDR) of coronary CT angiography(CCTA)with 100 kVp to 60% of 120 kVp standard. Methods: A total of 205 patients (105 males and 100 females, aged from 23 to 87 years) underwent CCTA due to suspected coronary artery disease in Department of Radiology of Peking University Third Hospital from February to July 2022 were enrolled. Those patients were divided into five subgroups according to their body weight: <50 kg, 50 to 59 kg, 60 to 69 kg, 70 to 79 kg and ≥ 80 kg, respectively. All the cases were scanned with 100 kVp tube voltage and combined with mixed iterative reconstruction technology KARL 3D. The IDR injection protocol was set to 60% of the 120 kVp IDR standard (10% lower than the guideline), and the IDR of each group was 0.9, 1.0, 1.1, 1.3 and 1.4 gI/s, respectively. The CT attenuations (CT value) and noise (SD value) of the aortic root, proximal left anterior descending branch and the distal segments of the right coronary artery, the signal-to-noise ratio (SNR) and contrast noise ratio (CNR) of proximal left anterior descending branch and the distal segments of the right coronary artery, the whole subjective image quality scores of the coronary artery, and effective dose (ED) of CCTA in the five groups were compared. The One-way ANOVA or Kruskal-walls test was used for statistical analysis. Results: There was no significant difference in CT attenuations and noise of aortic root, proximal left anterior descending and the distal segments of the right coronary artery, SNR and CNR of proximal left anterior descending branch and the distal segments of the right coronary artery, and subjective image quality scores among the five groups (all P>0.05). The difference of the dosage of contrast medium and ED among the five groups were statistically significant (all P<0.05). The dosage of contrast medium in the five groups were 30, 34, 38, 43 and 48 ml, and the ED in the five groups was 2.24 (1.88, 2.56), 2.62 (2.24, 3.17), 2.70 (2.48, 3.20), 4.13 (3.85, 4.40) and 4.44 (4.01, 5.02) mSv, respectively. Conclusion: It is feasible to reduce the IDR injection protocol of coronary CT angiography with 100 kVp to 60% of the standard injection protocol with 120 kVp, which is worthy of promotion.

Myocardial bridge evaluation towards personalized medicine: study design and preliminary results of the RIALTO registry.

Myocardial bridge (MB) is the most frequent inborn coronary artery variant in which a portion of the myocardium overlies an epicardial coronary artery segment. Although MB has long been considered a benign entity, a growing body of evidence has suggested its association with angina and adverse cardiac events. However, to date, no data on long-term prognosis are available, nor on therapies improving cardiovascular outcomes. We are currently conducting an ambispective, observational, multicentre, study in which we enrol patients with a clinical indication to undergo coronary angiography (CA) and evidence of MB, aiming to describe the incidence of symptoms and cardiovascular events at baseline and at long-term follow-up (FUP). The role of invasive full-physiology assessment in modifying the discharge therapy and eventually the perceived quality of life and the incidence of major cardiovascular events will be analysed. Basal clinical-instrumental data of eligible and consenting patients have been acquired after CA; FUP was performed 6, 12, and 24 months after the angiographic diagnosis of MB. The primary endpoint of the study is the incidence of major adverse cardiovascular events (MACE), defined as the composite of cardiac death, myocardial infarction, cardiac hospitalization, and target vessel revascularization; the secondary endpoints are the rate of patients with Seattle Angina Questionnaire (SAQ) summary score <70 and the incidence of MACE in patients undergoing invasive intracoronary assessment. Among patients undergone FUP visits, we recorded 31 MACE at 6 months (11.6%), 16 MACE at 12 months (6.5%), and 26 MACE at 24 months (13.5%). The rate of patients with SAQ <70 is 18.8% at 6 months, 20.6% at 12 months, and 21.8% at 24 months. To evaluate the prognostic role of invasive intracoronary assessment, we compared MB patients who underwent only angiographic evaluation (Angio group) to those who underwent acetylcholine (ACH) provocative test with indication to calcium-channel blockers (CCBs) at discharge (Angio + ACH + CCBs group) and those who underwent functional assessment with fractional flow reserve (FFR) with indication to beta-blockers (BBs) at discharge (Angio + FFR + BBs group). After 2 years of FUP, the rate of MACE was significantly reduced in both Angio + ACH + CCBs group (6 vs. 25%, P = 0.029) and Angio + FFR + BBs group (3 vs. 25%, P = 0.005) compared with Angio group. The preliminary results of our study showed that MB may be a cause of angina and adverse cardiac events in patients referred to CA for suspected coronary artery disease (CAD). Full-physiology assessment unmasking MB-related ischaemia mechanisms, allowed to guide the treatment, personalizing the clinical management, improving the quality of life, and cardiovascular outcomes in patients with MB.

Comprehensive functional and anatomic assessment of myocardial bridging: Unlocking the Gordian Knot.

Myocardial bridging (MB) is the most frequent congenital coronary anomaly in which a segment of an epicardial coronary artery takes a tunneled course under a bridge of the myocardium. This segment is compressed during systole, resulting in the so-called "milking effect" at coronary angiography. As coronary blood flow occurs primarily during diastole, the clinical relevance of MB is heterogeneous, being usually considered an asymptomatic bystander. However, many studies have suggested its association with myocardial ischemia, anginal symptoms, and adverse cardiac events. The advent of contemporary non-invasive and invasive imaging modalities and the standardization of intracoronary functional assessment tools have remarkably improved our understanding of MB-related ischemia, suggesting the role of atherosclerotic lesions proximal to MB, vasomotor disorders and microvascular dysfunction as possible pathophysiological substrates. The aim of this review is to provide a contemporary overview of the pathophysiology and of the non-invasive and invasive assessment of MB, in the attempt to implement a case-by-case therapeutic approach according to the specific endotype of MB-related ischemia.

On the Natural History of Coronary Artery Disease: A Longitudinal Nationwide Serial Angiography Study.

Background The long-term course of coronary atherosclerosis has not been studied in large nationwide cohorts. Understanding the natural history of coronary atherosclerosis could help identify patients at risk for future coronary events. Methods and Results All coronary artery segments with <50% luminal stenosis in patients with a first-time coronary angiogram between 1989 and 2017 were identified (n=2 661 245 coronary artery segments in 248 736 patients) and followed until a clinically indicated angiography within 15 years was performed or until death or end of follow-up (April 2018) using SCAAR (Swedish Coronary Angiography and Angioplasty Registry). The stenosis progression and incidence rates were 2.6% and 1.45 (95% CI, 1.43-1.46) per 1000 segment-years, respectively. The greatest progression rate occurred in the proximal and middle segments of the left anterior descending artery. Male sex and diabetes were associated with a 2-fold increase in risk, and nearly 70% of new stenoses occurred in patients with baseline single-vessel disease (hazard ratio, 3.86 [95% CI, 3.69-4.04]). Coronary artery segments in patients with no baseline risk factors had a progression rate of 0.6% and incidence rate of 0.36 (95% CI, 0.34-0.39), increasing to 8.1% and 4.01 (95% CI, 3.89-4.14) per 1000 segment-years, respectively, in patients with ≥4 risk factors. The prognostic impact of risk factors on stenosis progression was greatest in younger patients and women. Conclusions Coronary atherosclerosis progressed slowly but more frequently in the left coronary artery in men and in the presence of traditional risk factors. Coronary artery segments in patients without risk factors had little or no risk of stenosis progression, and the relative impact of risk factors appears to be of greater importance in younger patients and women. These findings help in the understanding the long-term course of coronary atherosclerosis.

Coronary Arteries Aneurysms: A Case-Based Literature Review.

Coronary artery aneurysm (CAA) is an abnormal dilatation of a coronary artery segment; those coronary artery aneurysms that are very large in size are defined as giant. However, a standardized dimension cut-off to define giant CAAs is still missing. The reported prevalence of coronary aneurysms in the population who underwent coronary angiography ranges from 0.3% to 5%, and often CAAs are found in patient with aneurysms in other sites, such as the ascending or abdominal aorta. In half of the cases an atherosclerotic etiology could be recognized; often, CAA is found in the context of acute coronary syndrome. Seldomly, CAA is found at the autopsy of patients who died due to sudden cardiac death. Currently, very few data exist about CAA management and their prognostic relevance; moreover, CAA treatment is still not clearly codified, but rather case-based. Indeed, currently there are no published dedicated studies exploring the best medical therapy, i.e., with antiplatelets or anticoagulant agents rather than an interventional approach such as an endovascular or surgical technique. In this review, through two clinical cases, the current evidence regarding diagnostic tools and treatment options of CAAs will be described.

Gender Specific Coronary Artery Diameters in CT Coronary Angiogram: A Comparative Study in Female and Male Population

Objectives: Women show significant in-hospital morbidity and mortality with greater extent of symptoms, poorer post-revascularization outcome with increased restenosis and repeat revascularization after angioplasty, than men. Smaller sized coronary arteries in females can be attributable for this differential outcome, which is also similar in case of Indians, compared to Caucasians. Our aim is to assess the gender-specific difference in coronary arteries using noninvasive Multidetector Computed-Tomography Coronary-Angiogram(CT-CAG) and comparing the same with other racial database. Materials and Methods: With Ethics committee approval, present retrospective comparative study conducted in 128CT-CAG scans in 18-45years aged 100 women and 89 men with no atherosclerotic burden excluding pathological coronaries and high calcium score&gt;100. Diameter measurements of proximal (≤10mm) segments of right coronary artery(RCA), left main coronary artery(LMCA), left anterior descending(LAD) and circumflex(LCx) arteries were taken, averaged and compared using 2-sample z-test. Considering the obtained mean diameters of total sample as South-Indian dataset which is then compared with Caucasians dataset taken from previous study. Results: Women showed smaller coronary artery diameters compared to men in all the arteries, with greater gender-specific age-adjusted difference in LMCA, followed by LAD, RCA and least in LCX. South-Indians showed statistically significant smaller diameters of all the coronary arteries compared to Caucasians. Conclusion: Gender-specific difference among the coronary arteries does exist, with females having smaller dimensions; South-Indians also show smaller diameters. This warrants a clinician for gender-specific approaches during the interventions because of technical difficulties.

Prevalence of coronary atherosclerosis in individuals with pre-diabetes and diabetes compared to normoglycemic individuals

Abstract Background Patients with type 2 diabetes have a two- to four-fold higher risk of death and cardiovascular events than the general population. Understanding the characteristics of atherosclerosis in people with different stages of dysglycaemia compared to normoglycaemic individuals may be useful for tailored prevention strategies in the future. Purpose To characterise the prevalence of coronary artery atherosclerosis in individuals with prediabetes, previously undetected diabetes and previously known diabetes compared with normoglycaemic individuals in a large population-based cohort. Methods Data were obtained from the Swedish CArdiopulumonary bioImage Study (SCAPIS), a population-based cohort of participants aged 50–64 years. The 25,553 study participants were categorised according to their glycaemic status: normoglycaemic (glucose: &amp;lt;6.1 mmol/L and HbA1c &amp;lt;6.0% (&amp;lt;42 mmol/mol)), pre-diabetes (6.1–6.9 mmol/L and/or elevated HbA1c 6.0–6.5% (42–47mmol/mol)), previously undetected diabetes (glucose ≥7.0 mmol/L and/or HbA1c &amp;gt;6.5% (≥48 mmol/mol)) or known diabetes. Plaque burden (number of diseased coronary segments) was determined by coronary computed tomography angiography (CCTA) in all 18 coronary artery segments. Total coronary artery atherosclerotic burden was assessed by segment involvement score (SIS) ≥4 and any coronary atherosclerosis. Imaging and analyses were performed using a calcium scoring protocol. The calcium content in each coronary artery was measured and summed to obtain an overall coronary artery calcification score (CACS). Results Study participants with dysclycaemia were defined as pre-diabetes (n=3,989, 16%), undetected diabetes (n=648, 2.5%) or known diabetes (n=1,033, 6.5%). The prevalence of CCTA-detected atherosclerosis among study participants, stratified by glycaemic status into four groups, is shown in Figure 1. The distribution of CACS categories by glycaemic status is shown in Figure 2. The association between CACS and glycaemic status, with normoglycemia as reference, was further explored in an adjusted (age, sex and site) ordinal regression: pre-diabetes 1.33 (95% CI 1.25–1.42), undetected diabetes 1.82 (95% CI 1.59–2.09), known diabetes 2.88 (95% CI 2.59–3.20). In a sensitivity analysis excluding people with previous myocardial infarction, coronary artery bypass grafting, percutaneous coronary intervention or with stent (n=693), the results were virtually unchanged, pre-diabetes 1.31 (95% CI 1.23–1.40), undetected diabetes 1.80 (95% CI 1.57–2.07), known diabetes 2.73 (95% CI 2.45–3.05). Conclusions The prevalence of coronary atherosclerosis increased substantially with increasing dysglycaemia. Our data suggest that more aggressive screening and/or treatment of individuals with prediabetes and diabetes to prevent cardiovascular disease should be discussed in the future. Funding Acknowledgement Type of funding sources: Foundation. Main funding source(s): The main funding body of The Swedish CArdioPulmonary bioImage Study (SCAPIS) is the Swedish Heart- and Lung Foundation.

Molecular imaging of alphaVbeta3 integrin for evaluation of myocardial injury after acute myocardial infarction

Abstract Background 68Ga-NODAGA-RGD is a positron emission tomography (PET) tracer targeting αvβ3 integrin that is upregulated during angiogenesis. αvβ3 integrin expression increases early after acute myocardial infarction (AMI), and has been proposed as a marker of myocardial repair. Purpose We prospectively evaluated the uptake of 68Ga-NODAGA-RGD and its association to left ventricular function after human AMI. Methods Thirty patients underwent PET at 7.7±3.8 days after primary percutaneous coronary intervention for ST-elevation AMI. Resting myocardial perfusion was evaluated using 15O-water PET followed by evaluation of 68Ga-NODAGA-RGD uptake 60–75 minutes after injection of 179 MBq of tracer. Left ventricular function was evaluated by transthoracic echocardiography on the day of PET, and at 6-month follow-up. The definition of the ischemic area at risk and remote myocardial segments was based on the culprit coronary arterial segments in invasive angiography. 68Ga-NODAGA-RGD images were co-registered with perfusion images and uptake was measured as the standardized uptake value in the segment with the highest uptake (SUVmax) in ischemic area at risk, and the mean standardized uptake value (SUVmean) in remote segments. In addition, we calculated 68Ga-NODAGA-RGD uptake corrected to the mean myocardial blood flow (MBF) in the area at risk (SUVmax/MBFmean) to account for reduced distribution of tracer in non-viable tissue. Results Mean age of patients was 64±9 years, and 90% were males. Uptake of 68Ga-NODAGA-RGD was low in the remote myocardium, but focally increased in the ischemic area at risk (Figure 1). SUVmax in the ischemic area at risk was higher than SUVmean of the remote myocardium (0.73±0.16 vs. 0.51±0.11, p&amp;lt;0.001). 68Ga-NODAGA-RGD SUVmax did not correlate with MBF in the area at risk. Univariable predictors of 68Ga-NODAGA-RGD SUVmax in the area at risk included peak Troponin T (p&amp;lt;0.001), peak pro-BNP (p&amp;lt;0.001), low global longitudinal strain (p=0.01), and low regional longitudinal strain in the area at risk (p=0.02). In multivariable analysis, peak pro-BNP independently predicted SUVmax in the area at risk (p&amp;lt;0.001). At follow-up, left ventricular ejection fraction increased by 1.6±6.9% and global longitudinal strain by 0.5±3.2%. In univariable analysis, SUVmax and SUVmax/MBFmean in the area at risk predicted improvement of global longitudinal strain at 6 months after AMI (p=0.04 and p&amp;lt;0.001, respectively). Conclusion 68Ga-NODAGA-RGD uptake shows increased αvβ3 integrin expression in the ischemic area at risk early after reperfused AMI that is associated with the extent of myocardial injury, both regional and global systolic dysfunction, and increased left ventricular filling pressure. Increased 68Ga-NODAGA-RGD uptake in ischemic myocardium at risk predicts left ventricular function improvement at 6 months after AMI. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Academy of Finland, Finnish Foundation for Cardiovascular Research

Neutrophil proteinase 3 — An LDL- and HDL-proteolyzing enzyme with a potential to contribute to cholesterol accumulation in human atherosclerotic lesions

Neutrophil proteinase 3 (PR3) is a multifunctional neutral serine protease involved in the regulation of pro-inflammatory processes, but its potential causal roles in the lipid-driven responses in atherosclerosis have remained unexplored. This study aimed to investigate the presence of PR3 in human atherosclerotic lesions and the ability of this protease to modify the structure and functions of LDL and HDL particles in vitro. Coronary artery segments were collected from autopsied subjects and immunostained for PR3. Atherosclerotic lesions but not normal intima contained PR3. Incubation of LDL particles with the PR3 led to extensive degradation of their apoB-100 component and strongly increased their binding strength to isolated human aortic proteoglycans in vitro. Moreover, cultured human monocyte-derived macrophages avidly ingested the PR3-modified LDL particles and were converted into foam cells. Incubation of HDL particles with PR3 led to proteolysis of their major apolipoproteins (apoA-I, apoA-II, and apoE) and impaired their ability to promote cholesterol efflux from the macrophage foam cells. We conclude that PR3 is present in human atherosclerotic lesions and that this neutral serine protease has proatherogenic properties. Thus, by proteolytically modifying LDL and HDL particles, PR3 may promote cholesterol accumulation both extra- and intracellularly in atherosclerotic lesions, and so contribute to the lipid-driven component of atherogenesis.

TCT-314 The Additive Effect of Multiple High Risk Coronary Artery Segments on Patient Outcomes: A Sub-analysis of the Lipid Rich Plaque Study

TCT-314 The Additive Effect of Multiple High Risk Coronary Artery Segments on Patient Outcomes: A Sub-analysis of the Lipid Rich Plaque Study

Additive Effect of Multiple High-Risk Coronary Artery Segments on Patient Outcomes: LRP Study Sub-Analysis

BackgroundThe Lipid Rich Plaque (LRP) Study established the association between high volume of lipidic content (maximum Lipid Core Burden Index [maxLCBI4mm] >400) in the coronary arteries and subsequent non-culprit major adverse cardiac events (NC-MACE). This analysis sought to assess the clinical impact of more than one lipid-rich plaque in the coronary tree. MethodsThe LRP patient population was divided into four cohorts: 1) patients with all segments with maxLCBI4mm = 0; 2) patients with all coronary segments maxLCBI4mm < 400, but >0; 3) patients with 1 segment maxLCBI4mm > 400; and 4) patients with 2+ coronary segments with maxLCBI4mm > 400. Baseline characteristics, plaque-level characteristics, and follow-up outcomes were described. ResultsAmong 1550 patients, only 3.2 % had all segments with maxLCBI4mm = 0; 65.1 % had segments with maxLCBI4mm > 0 but <400; 22.5 % had one segment with maxLCBI4mm > 400; and 9.5 % had 2+ coronary segments with maxLCBI4mm > 400. Distribution within the coronary tree (one versus multiple arteries) did not differ. Overall, 1269 patients were allocated to follow-up (per study design). The composite of all-cause death, cardiac death, any revascularization, and NC-MACE was statistically higher in patients with 1 segment maxLCBI4mm > 400 and numerically even higher in patients with 2+ segments with maxLCBI4mm > 400. Patients with maxLCBI4mm = 0 had no events within two years. ConclusionThere is a stepwise increased risk of all-cause death, cardiac death, any revascularization, and NC-MACE according to the number of coronary segments with maxLCBI4mm > 400. In contrast, maxLCBI4mm = 0 results in a low event rate. Clinical Trial RegistrationThe Lipid-Rich Plaque Study (LRP), https://clinicaltrials.gov/ct2/show/NCT02033694, NCT02033694.