Coronary Collaterals Research Articles

The Correlation of Collateral Circulation and Age during Acute Ischemic Heart Disease

Backgroundː Coronary collaterals (CC) are alternative sources of blood supply to myocardium jeopardized by Ischemia. Aim: To investigate the dependence and influence of collateral circulation on age during acute ischemic heart disease. Methods: Analysis shows that 673 patients were studied from the SamgoriMedi Clinic (Tbilisi, Georgia) aged 27– 94 years (64.7+11.48) with acute coronary syndromes. Basic medical data such as sex, age, cardiovascular risk factors, angina pectoris, revascularization history, echocardiography, and laboratory data were obtained from the patient’s medical records. CC vessels were graded according to the Rentrop grading system of 0 to 3. Resultsː The development index of collateral circulations visibly increases with age. Average age increases accordingly as follows: rentrop 0 - 62.85+12.01, rentrop 1 - 64.90+10.79, rentrop 2 - 66.84+10.49, and rentrop 3 - 69.04+9.68 (p<0.0001). There is positive significant correlation between the development of collateral circulation and age groups r=0.170**, p<0.001. The cases of female sex, hypertension, acute MI without ST elevation, CABG frequency (also EF% - 35-45%, <35%), and multiple vessel coronary lesion are noticed to increase with age, while the male sex and EF (ejection fraction) >45% cases decreases with age. Conclusion Collateral circulation shows significantly positive correlation with age and female sex. However, it should be mentioned that in elderly patients with a high ejection fraction and normal diastolic function, the development of collateral vessels is low.

Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) diagnosed in children and adolescents

BackgroundAnomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) is a rare but potentially fatal congenital coronary anomaly associated with early infant mortality and sudden adult death. By the development or lack of coronary collateral, it can be classified as infantile or adult type. However, even with the compensatory mechanism in adult patients, there is an estimated 80 to 90% incidence of sudden death at the mean age of 35 years.MethodsWe enrolled 9 patients with ALCAPA within the age group 5 to 16 years.ResultsOnly one patient developed symptoms (apsychia), whereas other patients were asymptomatic, and there was no evident left ventricular dysfunction found in any of the cases.ConclusionWith the development of imaging techniques, asymptomatic adult-type ALCAPA patients could be identified and diagnosed in childhood or adolescence. As a potential cause of sudden death, ALCAPA should be surgically repaired soon after the diagnosis.

Impact of coronary collateralization on long-term clinical outcomes in type 2 diabetic patients after successful recanalization of chronic total occlusion

BackgroundTo assess the prognostic role of coronary collaterals in patients with type 2 diabetes mellitus (T2DM) after successful percutaneous coronary intervention (PCI) for chronic total occlusion (CTO).MethodsCoronary collateralization was graded according to Rentrop scoring system in 198 type 2 diabetic patients and 335 non-diabetics with stable angina undergoing PCI for at least one CTO lesion. Left ventricular ejection fraction (LVEF) was determined and major adverse cardio-cerebral events (MACCE) were recorded during follow-up.ResultsPoor collateralization was more common in patients with T2DM than in non-diabetics (40% vs 29%, p = 0.008). At 13.5 ± 4.1 months, the rate of composite MACCE (17.3% vs 27.6%, p = 0.034) and repeat revascularization (15.2% vs 25.5%, p = 0.026) was lower and the increase in LVEF (3.10% vs 1.80%, p = 0.024) was greater in patients with good collaterals than in those with poor collaterals for non-diabetic group. The associations were in the same direction for T2DM group (35% vs 44%; 30% vs 36%; 2.14% vs 1.65%, respectively) with a higher all-cause mortality in diabetic patients with poor collaterals (p = 0.034). Multivariable Cox proportional hazards analysis showed that coronary collateralization was an independent factor for time to MACCE (HR 2.155,95% CI 1.290–3.599, p = 0.003) and repeat revascularization (HR 2.326, 95% CI 1.357–3.986, p = 0.002) in non-diabetic patients, but did not enter the model in those with T2DM.ConclusionsT2DM is associated with reduced coronary collateralization. The effects of the status of coronary collateralization on long-term clinical outcomes and left ventricular function appear to be similar in size in type 2 diabetic patients and non-diabetics after successful recanalization of CTO.

Sprouting Angiogenesis Contributes to Coronary Collateral Growth Induced by Repetitive Ischemia in Adult Mice

In the United States, coronary heart diseases (CHD) are the leading cause of mortality and morbidity. A well‐developed coronary collateral circulation ameliorates the consequences of CHD, reducing the incidence of sudden death and infarct sizes following coronary occlusion. Stimulation of coronary collateral growth (CCG) is also an alternative therapeutic approach to patients with intractable angina pectoris. The importance of CCG is undisputable, but the process and mechanism underlying CCG is unclear. We developed a mouse model of CCG induced by repetitive ischemia (RI) and validated CCG by contrast echocardiography to measure the coronary blood flow in the normal zone (NZ) and the collateral dependent zone (CZ). We also used Micro‐CT scans to reconstruct the coronary vasculature in 3D and quantify CCG. In this study, we crossed ROSA mT/mG double fluorescent reporter mice with cell type‐specific cre mice to investigate the roles that different cell‐types play at various stages of CCG. Mice were subjected to the RI protocol and their cardiac function and coronary blood flow was measured by echocardiography. Following sacrifice, hearts were fixed for immunostaining or imaging under confocal and multiphoton microscopy. In ROSA mT/mG floxed, Apln cre mouse hearts, large vessels (diameter of 20–50 μm) expressing GFP were identified in the collateral dependent zone in the early stage of RI, indicating that they originated from sprouting endothelial cells. At the end of RI, a complete network of these vessels was observed anastomosing with existing vasculature from the NZ. Immunostaining revealed an outer layer of smooth muscle cells in these vessels, suggesting the arteriogenesis or arterialization. Interestingly, in ROSA mT/mG floxed, Lyz2 cre mouse hearts, GFP expressing myeloid cells were observed in high numbers around newly formed large vessels, suggesting that immune cell recruitment occurs in the early stages of CCG. Our preliminary data show that coronary collaterals form in response to RI, are of microvascular origin and are associated with early recruitment of immune cells to the CZ. Our further study will focus on the process of CCG in greater detail at the molecular and cellular level, potentially leading toward a therapeutic application of induced CCG in patients of ischemic heart diseases.Support or Funding InformationThe research is funded by National Institutes of Health grant 2R01HL103227‐05 (YZ, LY), 1R01HL135110‐01 (WMC, LY), 1R01 HL137008‐01A1 (LY) from American Heart Association (LY).

Regulation of Coronary Collateral Growth by MicroRNA‐21 in Metabolic Syndrome

Well‐developed coronary collaterals prove to be highly beneficial in salvaging ischemic myocardium, preserving cardiac function, and improving patient outcome post‐occlusion. However, this process of coronary collateral growth (CCG) is impaired in patients with metabolic syndrome. A complete understanding of the underlying mechanism, cell types, and genes contributing towards this impairment have yet to be elucidated. Therefore, uncovering more about the process may lead to potential therapeutics to induce CCG in metabolic syndrome. MicroRNA‐21 (miR‐21) is abundantly expressed in vascular and immune cells with numerous implications in cardiovascular disease including atherosclerosis, heart failure, and myocardial infarction. Furthermore, miR‐21 has been shown to regulate processes such as apoptosis, immune cell polarization, and endothelial progenitor proliferation. Additionally, miR‐21 dysregulation has been rooted in the diabetic population where lies a systemic inflammatory state. In this study, we investigated the role of miR‐21 in a mouse model of CCG.Our preliminary data suggested that down‐regulating miR‐21 rescues impaired CCG in a diet‐induced model of metabolic syndrome. Thus, we investigated the underlying mechanism and focused on the roles of miR‐21 in the maintenance of vascular homeostasis, function and inflammatory responses in metabolic syndrome. First, we studied whether miR‐21 regulates endothelial homeostasis by modulating the function and homing of bone marrow stem cells in metabolic syndrome. We analyzed endothelial progenitor cells (CD34+) in bone marrow and peripheral blood, along with endothelial proliferation in WT, miR‐21 knockout, and metabolic syndrome mice. Second, we studied whether miR‐21 regulates the inflammatory response in metabolic syndrome by characterizing bone marrow derived macrophages from WT and miR‐21 knockout animals along with mapping their influence on vascular cells. Third, we utilized a myeloid specific miR‐21 knockout to study its role during CCG in vivo. We found CCG to be blunted in these animals which suggests the importance of myeloid derived miR‐21 in healthy mice. Further studies will give us more insight on miR‐21 and its regulation of CCG in metabolic syndrome.Support or Funding InformationThe research is funded by National Institutes of Health grant 2R01HL103227‐05 (YZ, LY), 1R01HL135110‐01 (WMC, LY), 1R01 HL137008‐01A1 (LY)from American Heart Association (LY).

The relationship between serum homocysteine levels and development of coronary collateral circulation in patients with acute coronary syndrome

Aim: Homocysteine is an amino acid that plays a role in folate metabolism and inhibits endothelial cell proliferation which is important for angiogenesis. In this study, we aimed to investigate the relationship between serum homocysteine levels and coronary collateral development. Material and Method: 176 consecutive patients, with acute coronary syndrome and chronic total occlusion, were divided into two groups according to coronary collateral development. Rentrop 0 and 1 were regarded as group I and Rentrop 2 and 3 as group II. Results: Plasma homocysteine levels were 18,2 ± 7,0 μmol/L in the group I and 15,7 ± 5,1 μmol/L in the group II. Univariate logistic regression analysis showed that mean platelet volume and homocysteine were associated with poor coronary collateral. Multivariate logistic regression analysis showed that homocysteine level was independently associated with poor coronary collateral circulation (OR 1,069 [95% CI 1,012-1,130]; P=0,018). Conclusion: In this study clearly demonstrates that high serum homocysteine level is associated with poor collateral development in patients with acute coronary syndrome.

Coronary collaterals in patients with ST-elevation myocardial infarction presenting late after symptom onset

The role of coronary collaterals in ST-elevation myocardial infarction (STEMI) remains controversial. So far, studies examining the effect of collaterals on outcome mainly focused on patients presenting early after symptom onset. We sought to investigate the prognostic influence of coronary collateralization in patients presenting with prolonged ischemia late after symptom onset. The study is a subanalysis of a randomized trial addressing thrombus aspiration in STEMI patients presenting between 12 and 48h after symptom onset with a follow-up period of a minimum of 4years. A total of 95 patients with a Thrombolysis In Myocardial Infarction (TIMI) flow grade 0 or 1 prior to percutaneous coronary intervention (PCI) were included in the analysis. Of these, 62 patients (65%) had none or poor coronary collateralization according to the Rentrop classification (Rentrop grade 0 or 1) compared to 33 (35%) with well-developed collateralization (Rentrop grade 2 or 3). In comparison, patients with well-developed collateralization had a smaller area of microvascular obstruction (2.1 ± 3.8 vs. 4.5 ± 4.9% of left ventriclular mass (%LV), p = 0.03) and infarct size (27.9 ± 11.7 vs. 34.8 ± 17.2% LV, p = 0.047) on magnetic resonance imaging. Further, mortality at 4-years follow-up was lower (6% Rentrop grade 2 or 3 vs. 25% Rentrop grade 0 or 1, p = 0.02). Poor collateralization was an independent predictor of long-term mortality on multivariate Cox regression analyses in addition to cardiogenic shock and unsuccessful PCI during the index procedure. Sufficient coronary collateralization has a positive impact on microvascular obstruction, infarct size and long-term mortality in STEMI patients presenting between 12 and 48h after symptom onset.

Androgens Stimulate EPC-Mediated Neovascularization and Are Associated with Increased Coronary Collateralization.

Endothelial progenitor cells (EPCs) play a key role in neovascularization and have been linked to improved cardiovascular outcomes. Although there is a well-established inverse relationship between androgen levels and cardiovascular mortality in men, the role of androgens in EPC function is not fully understood. In this study, we investigated the effects of androgens on 2 subpopulations of EPCs, early EPCs (EEPCs) and late outgrowth EPCs (OECs), and their relationships with coronary collateralization. Early EPCs and OECs were isolated from the peripheral blood of young healthy men and treated with dihydrotestosterone (DHT) with or without androgen receptor (AR) antagonist, hydroxyflutamide, in vitro. Dihydrotestosterone treatment enhanced AR-mediated proliferation, migration, and tubulogenesis of EEPCs and OECs in a dose-dependent manner. Furthermore, DHT augmented EPC sensitivity to extracellular stimulation by vascular endothelial growth factor (VEGF) via increased surface VEGF receptor expression and AKT activation. In vivo, xenotransplantation of DHT pretreated human EPCs augmented blood flow recovery and angiogenesis in BALB/c nude male mice, compared to mice receiving untreated EPCs, following hindlimb ischemia. In particular, DHT pretreated human OECs exhibited higher reparative potential than EEPCs in augmenting postischemic blood flow recovery in mice. Furthermore, whole blood was collected from the coronary sinus of men with single vessel coronary artery disease (CAD) who underwent elective percutaneous intervention (n = 23). Coronary collateralization was assessed using the collateral flow index. Serum testosterone and EPC levels were measured. In men with CAD, circulating testosterone was positively associated with the extent of coronary collateralization and the levels of OECs. In conclusion, androgens enhance EPC function and promote neovascularization after ischemia in mice and are associated with coronary collateralization in men.

Effect of Recruitment of Acute Coronary Collaterals on In-Hospital Mortality and on Left Ventricular Function in Patients Presenting With ST Elevation Myocardial Infarction

Recruitment of the coronary collateral circulation is frequently observed during ST elevation myocardial infarction (STEMI) and is of uncertain significance. The aim of this study was to identify and determine the predictors and prognostic implications of the presence of robust collaterals during STEMI. All patients presenting to a large tertiary centre with a STEMI undergoing percutaneous coronary intervention from 2010 to 2018 were reviewed. Patients with poor collateral recruitment were defined as those with Rentrop grade 0 or 1 collaterals, whilst patients with robust collateral recruitment were defined as Rentrop grade 2 or 3. A total of 1,625 patients were included in the study, with 1,280 (78.8%) patients having poor collateral recruitment and 345 patients (21.2%) having robust collateral recruitment. Patients with robust collaterals were younger (63.1 vs 65.1 years, p < 0.05), had a longer ischemic time (628.5 minutes vs 433.1 minutes, p < 0.0001), and more likely to have a chronic total occlusion of a noninfarct related artery (10.4% vs 5.3%, p < 0.001). The presence of robust collaterals was associated with higher rates of normal or mildly impaired left ventricular function (83.5% vs 63.2%, p < 0.0001) and lower in-hospital mortality (2.1% vs 7.6%, p < 0.0001). After correcting for left ventricular function, collateral recruitment was not an independent predictor of mortality. In conclusion, in patients presenting with STEMI, the presence of robust coronary collaterals appears to be associated with improved left ventricular function. Further research is required to identify mechanisms of collateral maturation and recruitment.

Neutrophil-To-Lymphocyte Ratio Predicts Coronary Collateral Circulation in Multivessel Coronary Artery Disease

Background: Coronary collateral circulation (CCC) is an adaptive response to chronic myocardial ischemia. Patients with coronary stenosis develop varying degrees of collateral. Levels of inflammatory cells were suggested as potential determinants of collateral development. Neutrophil to lymphocyte (N/L) ratio has been proposed as a prognostic marker to determine systemic inflammatory response and the development of CCC. Our aim was to determine the relationship between N/L ratio and development of CCC in patients with coronary artery disease (CAD) with multivessel disease.Method:A total of 151 patients with multivessel disease were included in this study. Coronary collateral grades were classified according to Rentrop collateral grades as either poorly developed CCC (Rentrop grade 0-1) or well developed CCC (Rentrop grades 2-3). Factors significant at the p≤0.25 in the bivariate models were put into multiple logistic regressions. The receiver–operating characteristic (ROC) analysis were performed to determine the cutoff value of NLR in predicting poor CCC.Result: Of the 151 CAD patients in this study, 76 patients had poorly developed CCC and 75 patients had well developed CCC. Poorly developed CCC had significantly higher N/L ratio than well developed CCC (2.25±1.189 vs. 3.03±1.527, p &lt;0.001). Logistic regression analysis showed that N/L ratio (OR0.756; CI 95% 0.587 – 0.974, p 0.031) was independent predictor of poorly developed CCC. The ROC analysis provided a cut-off value of 1.99 (AUC 0.72, sensitivity 78.9%, specificity 52%) for N/L ratio to predict poorly developed CCC.Conclusion: Higher neutrophil to lymphocyte ratio was useful in predicting poor coronary collateral circulation in stable coronary heart disease with multivessel disease. Neutrophil to lymphocyte ratio &gt;1.99 was independently associated with impairment in coronary collateralization. This value had a sensitivity of 78.9% and specificity of 52%.

ASSOCIATION BETWEEN CORONARY COLLATERALS AND MYOCARDIAL VIABILITY IN PATIENTS WITH A CHRONIC TOTAL OCCLUSION

Current guidelines advocate viability assessment before revascularization of chronic coronary total occlusions (CTO). The present study evaluated associations between coronary collaterals and myocardial viability assessed by cardiac magnetic resonance (CMR) imaging in patients with a CTO. Patients

CRT-100.27 Impact of Acute Coronary Artery Collaterals on Left Ventricular Ejection Fraction (LVEF) and 24-Month Mortality in Patients With STEMI

In patients with acute ST-elevation myocardial infarction (STEMI), collaterals to the infarct-related arteries are angiographically noticed in around 40% of cases. Some controversies have arisen regarding the long-term beneficial impact of coronary collaterals in patients with STEMI in the

LncRNA-LUNAR1 Levels Are Closely Related to Coronary Collaterals in Patients with Chronic Total Coronary Occlusion.

Coronary collaterals can effectively improve myocardial blood supply to the area of CTO (chronic total coronary occlusion) and can, thus, reduce infarct size. LUNAR1(leukemia-induced noncoding activator RNA-1) is a specific LncRNA regulated by Notch signaling that not only can enhance the expression of IGFR-1 but also can promote angiogenesis and cell survival. Here, we investigated the relationship between LncRNA-LUNAR1 levels in peripheral plasma and the formation of coronary collaterals. In total, 172 patients with CTO were enrolled and followed up for 12months. Coronary collaterals were scored according to the Rentrop scoring system. Preclinical tests of tube formation were used to address the mechanisms behind the association between LncRNA-LUNAR1 and development of collaterals. Clinical data and inflammatory factors, including comorbidity, CD14++CD16- monocytes, and CCL2 (chemokine motif ligand 2), were compared and analyzed. Real-time PCR was used to detect the expression of LncRNA-LUNAR1 in peripheral blood plasma. The Rentrop score was positively correlated with LncRNA-LUNAR1 levels in patients with CTO (R = 0.47, p < 0.001). Tube formation assay proved the direct association between LncRNA-LUNAR1 and development of collaterals (p = 0.011). The univariate Kaplan-Meier analysis revealed that patients with low LncRNA-LUNAR1 expression exhibited worse clinical outcomes than those with high LncRNA-LUNAR1 levels (p = 0.008). Receiver operating characteristic (ROC) curve and correlation analysis further confirmed that LncRNA-LUNAR1 expression was closely related to chronic inflammatory diseases, especially diabetes (area = 0.644, p = 0.001; 95% CI, 0.562-0.726). Furthermore, both CD14++CD16- monocytes (r = - 0.37; p < 0.001) and CCL2 levels (r = - 0.35; p < 0.001) negatively affected the expression of LncRNA-LUNAR1. LncRNA-LUNAR1 expression was positively correlated with coronary collaterals in patients with CTO. Inflammatory factors, including CD14++CD16- monocytes and CCL2, may be risk factors affecting LncRNA-LUNAR1 expression.

P1338 Anomalous left coronary artery from pulmonary artery syndrome diagnosed in adulthood: case of a mother of five

Abstract Funding Acknowledgements Project no. NVKP_16-1-2016-0017 has been implemented with the support provided from the National Research, Development and Innovation Fund of Hungary Introduction Bland-White-Garland syndrome or ALCAPA (anomalous left coronary artery from pulmonary artery) syndrome is a rare congenital disorder with a prevalence of 1: 300,000. This condition is one the most common causes of infant myocardial infarction. It can ultimately lead to heart failure before the age of one, however when pronounced left and right coronary artery collateralization is present, patients may remain asymptomatic until older age. Due to the development and availability of non-invasive imaging techniques, these patients diagnosed more frequently in recent years. Case description: We present a 53-year-old patient with treated hypertension and five uncomplicated pregnancies. At the age of 40, the patient was referred to coronary angiography due to her dyspnea on exertion. The examination showed that the left main coronary artery (LMCA) originates from the pulmonary artery 7 mm above the pulmonary valve and the right coronary artery is significantly dilated. Based on the mild complaints and good left ventricle systolic function, conservative therapy was recommended by the cardiac surgery team. Since 2018 the patient has had gradually worsening complaints despite of the therapy adjusted for chronic heart failure. Q-waves were depicted on the 12-lead ECG in aVL and V1-V6 leads. Echocardiography showed dilated left ventricle (LV), LV hypertrophy, diffuse hypokinesia, decreased LV systolic function and diastolic dysfunction. At our clinic, we performed cardiac magnetic resonance imaging (CMR) which showed moderately reduced LV ejection fraction, diffuse LV hypokinesia, increased LV volume, septal LV hypertrophy. We visualized the retrograde flow on the LMCA, the shunt volume at the anomalous artery was 1,27 L/min. The CMR also showed irreversible damage of the subendocardial region of the myocardium via late gadolinium enhancement in the area supplied by the LMCA. Since we planned to reevaluate the surgical possibilities, the collateral network with tortuous and dilated left and right coronary arteries were visualized by coronary CT angiography. The surgical team at our institute decided to perform myocardial revascularization and restoration of dual coronary artery supply. Discussion ALCAPA is usually diagnosed in infancy however, in about 10-15% of cases the disease is only recognized in adulthood. The long-term morphological and functional characteristics of the syndrome may include reversible/irreversible ischemic damage, systolic and diastolic dysfunction, mitral regurgitation, significant collateral circulation, left-to-right shunt, dilated coronary arteries. Surgical myocardial revascularization and restoration of dual coronary artery supply is recommended even in adult patients. Abstract P1338 Figure. CTA reconstruction and LGE CMR

873 Rapid Recruitment of Coronary Collaterals During ST Elevation Myocardial Infarction (STEMI): A Meta-Analysis of Over 14,000 Patients

873 Rapid Recruitment of Coronary Collaterals During ST Elevation Myocardial Infarction (STEMI): A Meta-Analysis of Over 14,000 Patients

Are Well-Developed Coronary Collaterals Functionally Sufficient for Chronic Total Occlusion Ischemic Territory Perfusion?

Are Well-Developed Coronary Collaterals Functionally Sufficient for Chronic Total Occlusion Ischemic Territory Perfusion?

Angiographically visible coronary artery collateral circulation improves prognosis in patients presenting with acute ST segment-elevation myocardial infarction.

Coronary collaterals are often seen supplying retrograde flow to an acutely occluded arterial territory. Whether this early collateralization offers prognostic benefit is not well established. We analyzed data from all patients presenting to our regional cardiac unit with acute ST-elevation myocardial infarction requiring immediate angiography (years 1999-2017). Data on all patients is entered prospectively into a bespoke tailored database prior to knowledge of patient outcome. Only patients with TIMI 0 or 1 flow in the infarct-related vessel were included in the analysis. In-hospital and long-term outcome were assessed according to the presence or absence of angiographically visible collateral flow prior to treatment of the occluded vessel. Two thousand five hundred and forty-two patients were included in the analysis. 76% of these (n = 1944) had TIMI 0/1 flow at angiography. Angiographically-visible collateralization was seen in 17% (n = 322) and was more commonly observed in the right coronary artery (64%) than in the left anterior descending (25%) or Cx (6%). Cardiogenic shock (10.8%) and use of an intra-aortic balloon pump (5.4%) were more frequent in patients without coronary collateralisation (p = .04 and p = .02, respectively). The presence of collaterals improved long term survival (95% CI 11.4-18.7 months; p < .01). One-sixth of patients with STEMI have angiographically visible collaterals to the infarcted territory. Patients without collaterals are more likely to present in cardiogenic shock. The presence of angiographically visible collaterals at the time of STEMI is associated with an improved long-term survival.

Functional Mediastinal Paraganglioma Irrigated by Coronary Artery Collaterals Associated With Bilateral Renal Artery Fibro-Dysplasia in a Hypertensive Patient

We present a symptomatic functional anterior mediastinal paraganglioma (PGL) in a 56-year-old woman. The patient was known to have renovascular resistant hypertension caused by fibromuscular dysplasia diagnosed several years ago. The diagnosis of PGL was confirmed by 123I-metaiodobenzylguanidine scintigraphy, 18F-FDOPA positron emission tomography/computed tomography and a thoracic tomographic scan which revealed an anterior mediastinal tumor. Complete tumor resection was done through a sternotomy and extracorporeal circulation with cardiac arrest. The histological examination of the operative specimen was characteristic of PGL. J Med Cases. 2019;10(10):296-301 doi: https://doi.org/10.14740/jmc3379

Coronary wave intensity patterns in stable coronary artery disease: influence of stenosis severity and collateral circulation

ObjectiveWave intensity analysis is a method that allows separating pulse waves into components generated proximally and in the periphery of arterial trees, as well as characterising them as accelerating or...

P969Predictors of survival after bifurcation stenting (practical insights from COSIBRIA registry)

Abstract Background There is no much information about survival after coronary bifurcation stenting. We explored specifically predictors of death in all-comers registry database. Methods The COSIBRIA registry (COronary SIde Branch Residual IschemiA and COllateralization Assessment Study, Identifier: NCT01268228) collected all coronary bifurcation patients treated with intracoronary ECG (icECG) guidance or angiographically guided PCI. It was designed to explore relation between periprocedural ischemia assessed by means of icECG and post-procedural myonecrosis (troponin rise). Patients with STEMI, distal left main, cardiogenic shock or hemodynamic instability or BVS implantations were excluded. Unipolar icECGs were recorded before, during and after stent placement and at the end of procedure in side branch (SB) and main branch (MB). The coronary wire was placed in all distal vessels with diameter &gt;1.5mm, to “map” the distal zones of ischemia. Provisional T-stenting, with proximal balloon optimization (POT) after stent implantation was default strategy. SB was stented in case of non-normalization of icECG ST-segment elevation after kissing-balloon dilatation or flow compromise and severe dissection (&gt;type C) associated with symptoms. All patients were treated with 3rd and higher generation drug-eluting stents. Results 731 patients were included in the analysis recruited from 01.08.2014 to 31.12.208 – 321 (44%) icECG guided. The mean age of patients was 67±10 years, 68% males, 38% smokers, 94% dyslipidemic, 41% diabetics, 26% had previous MI, 47% previous PCI, previous CABG 3%, renal failure 32%, cerebrovascular and peripheral artery disease – 15% and 10%. At median follow-up of 28 months (IQR 18–45 months), 110 patients died (15%): icECG-guided vs. angio guided (18.1% (58/321) vs. 12.7% (52/410), p=0.043, log-rank p=0.045). Side branches were stented in 27%. On univariate analysis significantly associated with mortality were: age, sex, COPD, renal failure, total cholesterol, atrial fibrillation, cerebrovascular disease, ejection fraction (EF), mitral regurgitation &gt;1st degree, SB stenting, kissing balloon inflation, stent length, lesion location (LAD), SYNTAX score. On Cox-regression analysis an independent predictors of survival were: age (HR=1.033, CI: 1.011–1.055, p&lt;0.001), male sex (HR=1.733, CI: 1.056–2.845, p=0.030), COPD (HR=0.586, CI: 0.349–0.985, p=0.044), EF (HR=0.972, CI: 0.953–0.992, p=0.006), MR&gt;1 (HR=1.617, CI: 1.224–2.136, p=0.001), SB stenting (for non-stent implantation HR=0.497, CI: 0.300–0.824, p=0.007). Conclusions Even with modern treatment of coronary bifurcations the demographic factors and parameters of left ventricular function governs the patient survival. The only technical factor associated with survival was implantation of stent in SB, associated with worse survival. Intracoronary ECG guided PCI was not independently associated with survival.