Coronary Territory Research Articles

P857 Diagnostic and prognostic value of 2D Strain in Non ST elevation myocardial infarction patients

Abstract Background Following an acute coronary syndrome, ischemic myocardial dysfunction has several degrees of severity and different outcomes from a total or partial recovery to an irreversible injury. In this study led in non-ST elevation myocardial infarction (NSTEMI) patients without otherwise previous non-ischemic cardiomyopathy (NICM), we investigated the correlation between 2D global longitudinal strain (GLS) and angiographic prognostic factors. The ability of territorial longitudinal strain (TLS), defined as the sum of segmental strain in a coronary territory,to identify culprit artery occlusion was also assessed. Methods 82 consecutive NSTEMI patients were prospectively screened for inclusion; 70 of them without NICM were enrolled. Severe coronary artery disease (CAD) was defined as three-vessel disease or a left main disease. Group 1 and 2 were defined by the presence or not of severe CAD. Statics ‘analyses was performed with IBM SPSS Statistics (version 22). Results mean age of patients was 60, 2 ±10 years. 37 patients had diabetes mellitus (53%), 31 had hypertension (44%), 21 had dyslipidemia (30%) and 5 had renal insufficiency (7%). Severe CAD was present in 24 patients (34%). The first ultrasound exam showed that mean EF was 49 ± 11, mean WMSI was 1.43 ± 0.4 and mean GLS was -14.9 ± 4. GLS was higher in group 1 (-12.82 ± 0.95 vs -16.04 ± 0.42; p < 0.001); LVEF and WMSI in group 1 and 2 were (43.3 ± 13.5% Vs 52.7 ± 7.9%; p < 0.001) and (1.64 ± 0.1 Vs 1.32 ± 0.04; p < 0.001) respectively. Correlations were found between LVEF and GLS (p = 0.004), and between WMSI and GLS (p = 0.002) . TLS was able to discriminate between coronary stenosis of LAD, LCX or RCA and to predict the occlusion of the culprit vessel: 7 patients had acute coronary occlusion (10%). TLS was -7.4 ± 5.1 in patients with coronary occlusion and -14.1 ± 6 in the absence of coronary occlusion (p < 0.001). A cut off of -9.5 was able to detect this occlusion with a specificity of 82% and a sensitivity of 85%. The second ultrasound exam, performed after a median of 10 ± 3.1 months, showed a statistically significant improvement of EF (53 ± 10, p =0.02), WMSI (1.35 ± 0.39, p= 0.01) as well as GLS (-17.1 ± 4.2, p =0.004). Patients who received only medical treatment (n = 11) had the lowest variation of EF (47% to 48 %; p = 0.7), WMSI (1.62 to 1.59; p = 0.69) and GLS (14.2 to 15.2; p = 0.2) with no statistical correlation between the two exams. While patients who had PCI or bypass revascularization, had the best outcome with improvement of EF (49% to 53%; p = 0.002), WMSI (1.4 to 1.32;p = 0.01) and GLS (15 to 17.4;p = 0.004). Conclusion GLS is a strong diagnostic and prognostic ultra sound parameter for NSTEMI patients correlated to CAD severity. Strain is a reliable parameter during follow up.TLS can be used to localize the culprit coronary artery and especially to predict its occlusion during the acute phase of NSTEMI which can lead to a different therapeutic strategy.

P1787 Pharmacologic stress test: still an important prognostic factor? a follow-up study

Abstract Introduction Dobutamine stress echocardiography (DSE) is an established exam for evaluation of extent and severity of coronary artery disease. Purpose To analyse the results and complications of DSE and identify prognostic predictors in patients (P) who underwent DSE for myocardial ischemia detection. Methods 220P who underwent consecutive DSE from 2013 to 2017. P with significant valvular disease were excluded. Clinical data, echocardiographic parameters and data from follow up (FU) regarding all-cause mortality and MACEs were analysed. Mean age 64.8 ± 12.0 years(Y), 143 men (65%). Results 88P (40%) had positive, 102 had negative and 30 had inconclusive DSE; complications rate of 15%. Prevalence of hypertension, diabetes mellitus (DM), dyslipidemia, prior MI, percutaneous coronary interventionc (PCI), coronary arterial bypass graft (CABG) and HF was 82.7%, 42.3%, 67.7%, 35.9%, 31.8%, 10.9% and 9.5%, respectively. Mean left ventricular endsystolic (LVSD) and enddiastolic dimensions were 33.7 ± 8.9 and 52.8 ± 7.1 mm. Mean resting wall motion score index (rWMSI) and peak (pWMSI) were 1.16 ± 0.28 and 1.24 ± 0.34. Mean resting GLS (rGLS) and peak GLS (pGLS) were -16.3 ± 4.3 and -16.6 ± 4.3. Mean no. of ischemic segments was 1.7 ± 2.4 and 16.8% had ischemia >3 segments. There was ischemia in left anterior descending (LAD) coronary in 53P and in circumflex and right coronary territories in 18 and 68P. 22.6% had more than one ischemic territory. 43P (49.4%) underwent intervention, 38 with PCI and 5 with CABG. During a mean FU of 38.8 ± 16.8 months, 47 MACEs were observed, including 32 deaths (14.5%). Positive DSE (p = 0.012), no. of ischemic segments (p = 0.019), ischemia in the LAD (p = 0.003), rGLS (p = 0.038) and pGLS (p = 0.038) were related to the occurrence of MACEs. In Cox regression analysis, age (p = 0.005), DM (p = 0.005), HF (p = 0.006), prior CABG (p = 0.015), LVSD (p = 0.026), rWMSI (p = 0.029), pWMSI (p = 0.013) and pGLS (p = 0.038) were associated with increased all-cause mortality. Kaplan–Meier survival analysis showed that survival was significantly worse for ischemia > 3 segments (log rank 0.005), ischemia of more than one territory (log rank 0.025) and pWMSI >1.5 (log rank < 0.0005). With multivariate Cox regression analysis, age >65Y (HR 4.22, p = 0.004), DM (HR 2.49,p = 0.038) and pWMSI > 1.5 (HR 9.73,p = 0.007) were independently associated with all-cause mortality. Conclusion In patients who underwent DSE there were some baseline and DSE-related independent predictors of long-term prognosis: age, DM and peak WMSI. Abstract P1787 Figure. Kaplan–Meier curves

A026 Use and Safety of Pressure Wire Studies During Coronary Angiography in New Zealand - A National Analysis – ANZACS QI - 39

To compare baseline characteristics in patients who undergo a pressure wire study (PWS). Also to describe the characteristics of patients with haemodynamically significant (FFR < 0.8) lesions and their treatment disposition. We used the “All New Zealand Acute Coronary Syndrome Quality Improvement” program (ANZACS-QI) web-based system. This data set includes all patients undergoing a diagnostic coronary angiogram (DCA) between the dates 01/09/14 – 01/09/17. During this period 46281 procedures were done. 28258 were diagnostic coronary angiograms (DCA) and 18025 underwent PCI. In total 1901 patients had 2201 PWS performed. 677 patients went on to have PCI. PWS was done in 4.6% of all patients having a coronary angiogram. Patients that had a PWS were more commonly men (71%) of European descendent (76%). The most common indication for a PWS was an acute coronary syndrome (ACS). 35% of these had a PCI. The left anterior descending artery was the most common territory for PWS. Only 60% of patients with an FFR < 0.8 proceeded to PCI. 429 FFR results were borderline positive (FFR 0.75-0.79). 34% did not have PCI. 572 FFR results were borderline negative (FFR 0.8-0.85). 16% had PCI. Performing a PWS did not increase in-hospital MACE. This is one of the largest real world analysis of PWS use. It shows which patients and coronary territories are likely to have a PWS and characteristics which lead to positive results and PCI. It shows that PWS are safe without an increase of in-hospital MACE.

The accuracy of distribution of non-ST elevation electrocardiographic changes in localising the culprit vessel in non-ST elevation myocardial infarction.

IntroductionST-segment elevation distribution on electrocardiogram (ECG) in patients presenting with ST-elevation myocardial infarction (STEMI) accurately localises the culprit vessel. However, the utility of the ECG changes in localising the coronary culprit territory in the setting of non-ST segment elevation myocardial infarction (NSTEMI) is not well established.Material and methodsThis study included patients presenting with NSTEMI, who had dynamic non-ST elevation ischaemic changes in one or more ECG leads and underwent percutaneous coronary intervention (PCI) in a single vessel between October 2011 and November 2017 in a single university hospital institution. The accuracy, sensitivity, and specificity of the distribution of ECG changes in localising the culprit vessel were calculated.ResultsThere was a total of 82 patients included in this study, who received PCI to the left anterior descending (LAD), right coronary artery (RCA), and left circumflex (LCX), in 43.9%, 24.4%, and 31.7%, respectively; 51% were male. In this cohort, sensitivity of ECG in localising single-culprit-vessel NSTEMI was 41.5%. The overall accuracy of ECG changes was 50.0%, 72.0%, and 70.0% in LAD, RCA, and LCX distribution, respectively. The sensitivity and specificity were 72.2% and 32.6% in LAD distribution, 20% and 88.7% in RCA distribution, and 15.4% and 82.1% in LCX distributions, respectively.ConclusionsIschaemic non-ST elevation ECG changes had modest accuracy in localising the culprit vessel in patients with PCI-treated NSTEMI. These changes were more sensitive in LAD distribution and more specific in RCA and LCX distributions.

Prevalence and clinical significance of cardiovascular magnetic resonance adenosine stress-induced myocardial perfusion defect in hypertrophic cardiomyopathy

BackgroundHypertrophic cardiomyopathy (HCM) is thought to be associated with microvascular dysfunction. Adenosine stress-perfusion cardiovascular magnetic resonance imaging (CMR) is a sensitive method for assessing microvascular perfusion abnormalities. We evaluated the prevalence and clinical characteristics of HCM patients with adenosine-induced perfusion defects on CMR.MethodsAmong 189 consecutive patients with HCM who underwent adenosine-stress perfusion CMR, 115 patients who had clinical, echocardiography, 24-h Holter monitoring and treadmill exercise test data were analyzed. We calculated myocardial perfusion ratio index from the intensity-over-time curve to quantify perfusion defects. The presence and extent of the stress-induced perfusion defect were compared with clinical characteristics, presence and extent of late gadolinium enhancement (LGE), left ventricular (LV) mass index and volume, presence of non-sustained ventricular tachycardia (NSVT) and results of treadmill exercise test.ResultsThe mean age of enrolled patients was 51.8 ± 11.3 years. Most patients were asymptomatic except 25 subjects presented with New York Heart Association Class II dyspnea and 16 patients with atypical non-exertional chest discomfort. LGE was present in 103 (89.6%) subjects. Adenosine stress-induced perfusion defects were present in 48 (42%) subjects. None of the perfusion defects corresponded with a single or multiple coronary artery territories, showing a multiple patchy pattern in 24 (50.0%), a concentric subendocardial pattern in 20 subjects (41.7%), and as a single blot-like defect in the remaining 4 (8.3%). A perfusion defect was associated with NSVT, LV apical aneurysm, higher LV mass index, and higher LGE volume on univariate analysis. Multivariate analysis revealed female gender (P = 0.008), presence of apical aneurysm and NSVT (P = 0.036 and 0.047, respectively), and LV mass index (P = 0.022) to be independently associated with adenosine stress-induced perfusion defects.ConclusionsIn patients with HCM, adenosine-stress perfusion defects on CMR are present in more than 40% of subjects. This perfusion defect is associated with NSVT, higher LV mass index, and apical aneurysms. The prognostic value of this finding needs further elucidation.

P258 Giant coronary arteriovenous fistula with significant left-to-right shunt in symptomatic patient - a multimodal diagnostic approach and successful surgical treatment

Abstract Funding Acknowledgements none OnBehalf none Coronary arteriovenous fistula (CAF) is a rare usually congenital defect that occurs in 0.1-0.2% of patients undergoing coronary angiography. A left-to-right shunt exists in more than 90% cases. In approximately 20% of patients CAF is accompanied with coronary artery aneurysm (CAA). We describe a case of 65-years-old woman with history of murmur from childhood, who presents with symptoms of slowly worsening dyspnea on exertion and strong pericardial pain. A suspicion for CAF was made from echocardiography and finally confirmed by other diagnostic modalities (coronary angiography and computed tomography with 3D reconstructions). We have diagnosed a complex case of a giant CAA involving left main and a periphery of left circumflex artery, accompanied with CAF terminating in the right atrium, responsible for a significant left-to-right shunt and coronary steal phenomenon. Patient was successfully treated by surgical ligation of the distal part of CAF in the right atrium. There were no signs of an acute myocardial ischemia on beating heart (ECG, perioperative echocardiography) when CAF was temporary occluded by tourniquet and so definitive surgical ligation of CAF was performed back on cardiopulmonary bypass. The postoperative course was uneventful without complications and the patient was discharged 6 days after surgery. One year after surgery patient is doing well with no complaints. Control echocardiography showed a regression of left and right ventricle volume overload. Coronary angiography showed normal perfusion in the left coronary artery territory, and no more visible collaterals flow right coronary artery. Abstract P258 Figure. complex coronary artery aneurysm

P796 Feasibility of exercise stress echocardiography and its correlation with angiographically significant coronary disease

Abstract Background European Society of Cardiology (ESC) guidelines on the management of stable coronary artery disease (CAD) advocate stress echocardiography (SE) as a first line assessment for functionally significant ischaemia. Pharmacological stressors such as dobutamine are typically utilised in most UK centres in view of practical benefits when compared with treadmill testing. However, exercise provides the best physiological mimic and enables additional data on haemodynamics and electrocardiogram (ECG) changes to be obtained. Purpose To assess the feasibility and safety of exercise stress echocardiography (ESE), and the correlation of positive testing with significant coronary disease and major adverse cardiovascular events. Methods A retrospective, single-centre analysis of 500 consecutive patients undergoing ESE for investigation of stable CAD. Cases were excluded when a pharmacological stressor was utilised, or in contexts where ESE was performed for other clinical indications. ESE reports were interrogated for patient demographics, co-morbidities, achievement of target heart rate (HR), procedural sequelae, image quality and findings. Electronic records were reviewed after 24 months to assess results of invasive angiography, when performed, and long-term outcomes including myocardial infarction (MI) and cardiovascular mortality. Concordance between ischaemic territory on ESE and coronary lesions on angiography was also collated. Results 95% (475/500) of patients were suitable for inclusion. Of these, 83% (394/475) achieved target HR. Sequelae arose in 0.02% (9/475), with the most frequent being ectopy (4 cases). Image quality was adequate in 98% (465/475), with the requirement for contrast agent in the remainder. There were no significant differences in burden of cardiovascular risk factors between the positive and negative ESE groups. 13% (63/475) were positive for inducible ischaemia in one or more myocardial segments. Of these, 71% (45/65) underwent angiography, with 48% (31/65) requiring stenting or bypass surgery. Ischaemic territory on ESE correlated with angiographic lesions in 65% (29/45) of cases. ESE underestimated extent of significant CAD in only 7% (3/45). In the subcohort positive for ESE, 3% (2/63) suffered a MI and cardiovascular mortality was 1.5% (1/63). Conclusions ESE is a safe, non-invasive modality for functional testing that reaches diagnostic threshold in the vast majority of cases. It has reasonable concordance in localising ischaemic coronary territory to enable targeted revascularisation.

P251 Fragmented QRS in prediction of ischemic heart disease diagnosed by stress cardiovascular magnetic resonance imaging

Abstract Funding Acknowledgements None Background Fragmented QRS complex (fQRS) on 12-lead EKG is not uncommon in general population. Previous studies found an association between fQRS and myocardial scar, heart failure, and increased cardiac mortality. However, data in adults without history of coronary artery disease is limited. We aimed to evaluate whether there is an association between fQRS and ischemic heart disease (IHD) diagnosed by stress cardiac MRI. Method We retrospectively reviewed data from 604 patients who underwent stress cardiac MRI, in which 50 patients were excluded due to known history of coronary artery disease or incomplete stress test. A positive result was defined as stress-induced perfusion defect in at least 2 contiguous myocardial segments corresponding to epicardial coronary territory, or a presence of ischemic scar. The 12-lead EKG done on the same day with MRI, prior to stress testing, were analyzed. Fragmented QRS was defined as the presence of additional R wave (R’), notching in the nadir of R or S wave, or the presence of more than one R’ in any EKG leads. Both cardiac MRI and EKG were analyzed by two independent observers. Result Final analysis included 554 patients, 39% were male, with a mean age of 67.8 ± 11.1 years. There was positive stress cardiac MRI in 219 patients (39.5%). Older age, diabetes mellitus, and hypertension were more frequent in the positive group (p &amp;lt;0.05). fQRS was identified in 300 patients (54.2%). Baseline characteristic did not differ significantly between patients with and without fQRS. There is an association between fQRS and IHD, OR 1.605 (95% CI 1.136-2.269), p = 0.007. Using linear regression, the number of leads with presence of fQRS showed an association with IHD (OR 1.204, p = 0.005). After adjustment for age, diabetes, hypertension, renal function, and left ventricular ejection fraction, the strong association between fQRS and IHD persisted, OR 1.709 (95% CI 1.182-2.470), p = 0.004. Conclusion In patients without known history of coronary artery disease, fragmented QRS is independently associated with ischemic heart disease diagnosed by stress cardiac MRI. Multiple regression analysis OR 95% CI p-value Age (years) 1.013 0.992 - 1.035 0.234 Diabetes mellitus 1.532 1.032 - 2.274 0.034 Hypertension 1.194 0.737 - 1.935 0.471 GFR (ml/min/1.73m&amp;sup2;) 0.999 0.987 - 1.011 0.904 LV ejection fraction (%) 0.972 0.950 - 0.994 0.014 fragmented QRS 1.709 1.182 - 2.470 0.004

Myocardial infarction with non-obstructive coronary arteries: A comprehensive review and future research directions.

Acute coronary syndromes constitute a variety of myocardial injury presentations that include a subset of patients presenting with myocardial infarction with non-obstructive coronary arteries (MINOCA). This acute coronary syndrome differs from type 1 myocardial infarction (MI) regarding patient characteristics, presentation, physiopathology, management, treatment, and prognosis. Two-thirds of MINOCA subjects present ST-segment elevation; MINOCA patients are younger, are more often female and tend to have fewer cardiovascular risk factors. Moreover, MINOCA is a working diagnosis, and defining the aetiologic mechanism is relevant because it affects patient care and prognosis. In the absence of relevant coronary artery disease, myocardial ischaemia might be triggered by an acute event in epicardial coronary arteries, coronary microcirculation, or both. Epicardial causes of MINOCA include coronary plaque disruption, coronary dissection, and coronary spasm. Microvascular MINOCA mechanisms involve microvascular coronary spasm, takotsubo syndrome (TTS), myocarditis, and coronary thromboembolism. Coronary angiography with non-significant coronary stenosis and left ventriculography are first-line tests in the differential study of MINOCA patients. The diagnostic arsenal includes invasive and non-invasive techniques. Medical history and echocardiography can help indicate vasospasm or thrombosis, if one finite coronary territory is affected, or specify TTS if apical ballooning is present. Intravascular ultrasound, optical coherence tomography, and provocative testing are encouraged. Cardiac magnetic resonance is a cornerstone in myocarditis diagnosis. MINOCA is not a benign diagnosis, and its polymorphic forms differ in prognosis. MINOCA care varies across centres, and future multi-centre clinical trials with standardized criteria may have a positive impact on defining optimal cardiovascular care for MINOCA patients.

The results of simultaneous revascularization operations of the carotid and coronary territory in patients with multifocal atherosclerosis

Objective : To determine the effectiveness of simultaneous surgical interventions for revascularization of the carotid and coronary basins. Materials and methods : The effectiveness of the surgical intervention was assessed in 34 patients (31 male patients, 3 female patients, average age 61.8 ± 1.52 years) who underwent simultaneous carotid endarterectomy and coronary artery bypass grafting. The indications for surgical treatment for carotid arteries disease were determined by a neurosurgeon, and for coronary artery bypass grafting — by a cardiac surgeon. Results : Postoperative complications were observed in 55.9 % of patients. In 3 (8.8 %) patients, an acute ischemic stroke with a neurological deficit developed on the first day after the operation. One patient (2.9 %) presented with both an acute myocardial infarction in the postoperative period and an acute heart failure. Perioperative rhythm disturbances in the form of atrial fibrillation were observed in 6 (17.6 %) cases. Postoperative mortality was 2.9 %. During the first year after surgery, an improvement in the quality of life was observed in 31 (93.9 %) patients in the form of an improvement in the functional state of angina pectoris, a reduction of the heart failure symptoms, or a complete regression of cardiac symptoms. Two (6.06 %) patients needed for repeated myocardial revascularization. Within 3 years of follow-up, no patient developed an ischemic stroke. The patients who developed cerebral event immediately after surgery had a stable neurological status. The commutative survival rate (percentage of patients who survived within the indicated period) of patients for 1 year of observation was 100 %, for 3 years — 96 %. A significant drop in survival function was observed in the fourth year of observation up to 75 % due to the development of repeated acute myocardial infarction. Conclusions: The simultaneous revascularization of the carotid and coronary territory in the form of a carotid endarterectomy and aortocoronary bypass surgery is an effective modern method for preventing the development of stroke and acute myocardial infarction, improving the neurological and general somatic status, quality of life of patients with combined atherosclerotic lesions of the carotid and coronary arteries.

The Value of Regional 2D Longitudinal Strain Analysis during Dobutamine Stress Echocardiography in Detecting the Culprit Coronary Territory

Aim: To evaluate the diagnostic value of analyzing the regional longitudinal strain by 2D speckle tracking modality during dobutamine stress echocardiography (DSE) in detecting the culprit disease in either coronary circulation. Methodology: Prospectively 101 symptomatic patients at intermediate pretest probability for CAD were studied within one month by DSE, followed by coronary angiography. The 3 standard apical views were acquired both at rest and peak stress at an average frame rate of 70/sec. The following indices: longitudinal peak systolic strain (LS), longitudinal peak systolic strain rate (LSRs), and longitudinal early diastolic strain rate (LSRd) were obtained from each segment of the 17 segment model. Regional strain was calculated as the mean of strain parameters of all 10 segments representing the anterior coronary circulation and of the 7 segments representing the posterior coronary circulation separately. Coronary stenosis ≥ 50% was considered significant. Results: 52 patients had normal or mild CAD , the 49 patients with significant CAD were classified into ACC group n-21, and PCC group n=22. Those with mixed territory disease (n=17) were excluded from final analysis. At rest, LS &amp; LSRs were significantly lower in PCC than ACC group (-19.462.6 vs -21.762.5, p: 0.007 and -1.2360.17 vs -1.4960.33, p: 0.015 respectively). At peak stress, all strain parameters were significantly different between the two groups regardless of the involved territory. In Receiver Operator Characteristics analysis, peak stress LS in either ACC and PCC territories showed the largest area under the curve: 0.9 (p&lt;0.001) and 0.88 (p&lt;0.001) respectively. The mean LS at cutoff value of -21% &amp; -20% had 90.5% sensitivity and 88.5% specificity for detecting significant ACC disease, and 81.8% sensitivity and 79% specificity for detecting significant PCC disease respectively Conclusion: Baseline regional strain analysis has the potential to detect significant CAD in PCC territory. At peak stress the longitudinal systolic strain can detect significant disease in either coronary territory with high sensitivity and specificity.

A Single Coronary Artery with an Absent Right Coronary and a Superdominant Left Circumflex Giving off a Branch Supplying the Right Coronary Artery Territory

An absent right coronary artery (RCA) with single left coronary artery (LCA) originating from left aortic sinus with a superdominant left circumflex (LCX) and giving off an RCA branch is one of the rarest coronary artery anomalies. It occurs with an incidence of less than 0.1%. Usually, patients are asymptomatic and abnormality is found incidentally on cardiac catheterisation or CT angiography. We present a case report of an unusual coronary anomaly in a patient who presented with anterior myocardial infarction. Patient was subjected to coronary angiography, which revealed absent RCA originating from distal LCX artery, supplying the base of heart and RCA territory. He underwent primary percutaneous intervention (PCI) with stenting to the left anterior descending (LAD) artery. This type of anomaly, in which single LCA from which dominant LCX continues as RCA, is important to diagnose and manage if diseased, as stenosis of the dominant LCX artery in such cases can jeopardise a large portion of myocardium, which can lead to increased morbidity and mortality, if left untreated.

Patency When Grafted to Coronary Stenosis More Than 50% in LIMA-RA-Y Grafts

Recent coronary surgery practice is to graft arterial conduits to more severely stenosed coronary targets than in the past. We aimed to investigate postoperative arterial graft patency with native coronary stenosis at the time of surgery, using the left internal mammary artery and radial artery (RA) as a composite Y graft (LIMA-RA-Y). In the study timeframe, it was routine clinical practice to graft coronary arteries with >50% stenosis. Of 464 patients previously reported 1996-1999, 346 who underwent LIMA-RA-Y at the Royal Melbourne Hospital, 76 had postoperative angiograms at the same institution. Each anastomosis was considered separately. For arterial grafts a "string sign" was analysed as being occluded. Predictor of patency was performed with a generalised linear mixed model (GLMM). Seventy-six (76) patients had postoperative angiograms at 5.8±5.4 years (range 0.23-19.4; interquartile range 1.7-10.0) years postoperative; with age at operation 62.5±10.7 years and 3.4±0.8 grafts per patient, 82% were male. Of 256 anastomoses, 230 were to coronary targets >50% stenosis. Overall patency was 84.0% (214/256). For coronary stenosis >50%, patency was 88% (201/230) and varied by coronary territory left anterior descending (LAD) 94% (87/93), circumflex 90% (71/79) and right coronary artery (RCA) 74% (43/58). Interaction for coronary territory was significant (p=0.022). Higher preoperative coronary stenosis predicted higher patency; with odds ratio for improved patency of 1.83 (95% CI 1.51, 2.22), p<0.001 for each 10% increase in stenosis. Late patency of composite arterial grafts is acceptable when grafted to coronary arteries of greater than 50% stenosis.

Left ventricular wall findings in non-electrocardiography-gated contrast-enhanced computed tomography after extracorporeal cardiopulmonary resuscitation

BackgroundFew studies have reported left ventricular wall findings in contrast-enhanced computed tomography (CE-CT) after extracorporeal cardiopulmonary resuscitation (ECPR). This study examined left ventricular wall CE-CT findings after ECPR and evaluated the association between these findings and the results of coronary angiography and prognosis.MethodsWe evaluated out-of-hospital cardiac arrest patients who were treated with ECPR and subsequently underwent both non-electrocardiography-gated CE-CT and coronary angiography at our center between January 2011 and April 2018. Left ventricular wall CE-CT findings were classified as follows: (1) homogeneously enhanced (HE; the left ventricular wall was homogeneously enhanced), (2) segmental defect (SD; the left ventricular wall was not segmentally enhanced according to the coronary artery territory), (3) total defect (TD; the entire left ventricular wall was not enhanced), and (4) others. Successful weaning from extracorporeal membrane oxygenation, survival to hospital discharge, and predictive ability of significant stenosis on coronary angiography were compared among patients with HE, SD, and TD patterns.ResultsA total of 74 patients (median age, 59 years) were eligible, 50 (68%) of whom had initial shockable rhythm. Twenty-three (31%) patients survived to hospital discharge. HE, SD, TD, and other patterns were observed in 19, 33, 11, and 11 patients, respectively. The rates of successful weaning from extracorporeal membrane oxygenation (84% vs. 39% vs. 9%, p < 0.01) and survival to hospital discharge (47% vs. 27% vs. 0%, p = 0.02) were significantly different among patients with HE, SD, and TD patterns. In post hoc analysis, patients with HE patterns had a significantly higher success rate of weaning from extracorporeal membrane oxygenation than those with SD and TD patterns. SD predicted significant stenosis with a sensitivity of 74% and specificity of 94%.ConclusionsHomogenously enhanced left ventricular wall might be a predictor of good left ventricular function recovery. In contrast, total enhancement defect in the entire left ventricular wall was associated with poor outcomes. Contrast defect matching the coronary artery territory could predict significant coronary artery stenosis with good specificity. The left ventricular wall findings in non-electrocardiography-gated CE-CT after ECPR might be useful for diagnosis and prognostic prediction.

The no-touch saphenous vein is an excellent alternative conduit to the radial artery 8 years after coronary artery bypass grafting: A randomized trial

BackgroundIn 2004, a prospective randomized trial demonstrated that after 3 years, saphenous veins (SVs) harvested with a no touch (NT) technique had a greater patency than radial grafts for coronary bypass surgery. Here we report the 8-year follow-up data of this trial. MethodsThe trial included 108 patients undergoing coronary artery bypass grafting (CABG). Each patient was assigned to receive 1 NT SV and 1 radial artery (RA) graft to either the left or right coronary territory to complement the left internal thoracic artery (LITA). Sequential grafting was common, so overall graft patency as well as the patency of each anastomosis were assessed. ResultsAngiography was performed in 84 patients (78%) at mean of 97 months postoperatively. Graft patency were high and similar for both NT and RA: 86% for NT versus 79% for RA (P = .22). The patency of coronary anastomoses was significantly higher with the NT SV grafts (91% vs 81%; P = .046). The NT grafts also had excellent patency in coronary arteries with <90% stenosis (93% patency) and in coronary arteries of small diameter (87% patency) or with mild calcification (88% patency). Patency for the LITA was 92%. ConclusionsNT SV grafts have excellent patency similar to that of RA grafts after 8 years. In addition, NT SV grafts can be used in situations that are not ideal for RA grafts.

Genetically elevated levels of metals and subclinical atherosclerosis in an adult population from Spain

TPS 636: Metals and health 2, Johan Friso Foyer, Floor 1, August 28, 2019, 3:00 PM - 4:30 PM Background/Aim: While the evidence supporting a causal association of metals with clinical cardiovascular disease is substantial, fewer studies have evaluated subclinical atherosclerosis. We tested the association of non-essential metals with subclinical atherosclerosis by using genetic polymorphisms in candidate genes as a proxy of unconfounded metal exposure. Methods: Urine Antimonium (Sb), Barium (Ba), Cadmium (Cd), Chromium (Cr), Titanium (Ti), Tungsten (W), Uranium (U) and Vanadium (V), and urine Arsenic (As) speciation, were measured by ICPMS and HPLC-ICPMS, respectively, in 1815 workers from a car assembly factory in Figueruelas (Spain) participating in the Aragon Workers’ Health Study. Atherosclerosis presence (yes/no) was measured in carotid and femoral arteries with ultrasounds, and in coronary arteries with NMR. For statistically significant metals in traditional logistic models, we evaluated the association of genetically controlled biomarker levels with atherosclerosis presence using 2-stage least squares Mendelian Randomization methods. Results: The geometric mean of Sb, sum of inorganic As (∑iAs), Ba, Cd, Cr, Ti, W, U and V was 0.22, 8.1, 1.88, 0.43, 1.06, 213.05, 0.23, 0.03, and 0.5 μg/g, respectively. In multi-adjusted models (including arsenobetaine adjustment for ∑iAs), the odds ratio (95% CI) for atherosclerosis presence in any of the evaluated vascular territories were, 1.21 (1.00-1.46) for ∑iAs, 1.60 (1.17-2.19) for Cd and 1.26 (1.05-1.52) for Ti. These associations were driven by ∑iAs and Cd in carotid, Cd and Ti in femoral and Ti in coronary territories. For ∑iAs the associations of genetically-elevated concentrations (3 ∑iAs-associated SNPs) were statistically significant and directionally consistent compared to the observational associations. For Cd the corresponding associations (2 Cd-associated SNPs) were only consistent in femoral atherosclerosis models. Conclusions: Replication of findings is needed. Our results, however, support a role of As and Cd as cardiovascular risk factors. Reinforced exposure reduction interventions may decrease cardiovascular disease.

P3358Cardiovascular risk, aortic valve microcalcification and vascular microcalcification: is there a link?

Abstract 18F-sodium fluoride (18F-NaF) has been used to evaluate aortic stenosis. It is know that its uptake is related with microcalcification. The purpose of this study is to assess the relationship between 18F-NaF uptake by the aortic valve and by the main arterial vessels and cardiovascular risk. Twenty-five hypertensive patients without known cardiovascular disease or aortic stenosis underwent PET-CT with 18F-NaF. Cardiovascular risk was assessed through the ASCVD risk calculator. The patients had a mean age of 64.0±8.6 years and 56% were males. The mean ASCVD risk was of 28.8±19.0 (IQR: 10–48.5). The uptake of 18F-NaF assessed through the corrected uptake per lesion (CUL = max SUV – mean blood-pool SUV) was of 0.49±0.14 (IQR: 0.44–0.57) and the mean uptake in the aortic, coronary and carotid territories was of 0.66±0.21 (IQR: 0.53 - 0.76).The patients were classified according to the ASCVD: Group A: patients with a risk above the 50thpercentile of the ASCVD risk distribution (50thpercentile=25), 12 patients) and Group B: patients with a risk under or equal to the 50thpercentile of the ASCVD risk distribution, 13 patients. The uptake of 18F-NaF in the aortic valve (AoV)and in the main vascular territories (VT) were evaluated in both groups: A vs B: AoV CUL = 0.57±0.09 vs 0. 42±0.14, p=0.005; VT= 0.78±0.16 vs 0.54±0.20, p=0.003. We also evaluate the relation between AoV uptake and VT uptake and they were significantly related (r=0.69, p=0.0001). In conclusion on this study microcalcification of the aortic valve and in the main vessels, evaluated through 18F-NaF uptake, were related between them and with cardiovascular risk reinforcing the importance of cardiovascular risk prevention in aortic valve degeneration and vascular atherosclerosis.

GIANT CELL MYOCARDITIS: A RARE AND LETHAL DIAGNOSIS

SESSION TITLE: Monday Abstract Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Giant cell myocarditis (GCM) is a rare, rapidly progressive, and frequently fatal myocardial disease in otherwise healthy young and middle-aged adults. It is attributed to a T lymphocyte-mediated inflammation of the myocardium. Here, we present the case of an acute onset of exertional dyspnea that rapidly progressed to cardiogenic shock requiring a left ventricular assist device (LVAD), due to newly-developed giant cell myocarditis. CASE PRESENTATION: A 21-year-old male with a past medical history of asthma presented with 3 weeks of exertional dyspnea. He was in his usual state of health, when he developed flu-like symptoms 1 month ago. On resolution, he had a cough with clear sputum that persisted. The patient also reported orthopnea, paroxysmal nocturnal dyspnea, and increased dyspnea on exertion with decreased exercise tolerance. On admission, his proBNP was 11,200 and troponin-T was 0.360. EKG showed ST abnormalities in the anteroseptal leads. Transthoracic echocardiogram (TTE) showed a left ventricular ejection fraction (LVEF) of 35 % with a severely hypokinetic anterior wall. Initially, viral myocarditis was suspected, however it was ruled out after infectious workup was negative. ESR was 51 and CRP was 3.01. Cardiac MRI showed scaring in all 3 coronary artery territories and moderate global hypokinesis of the right ventricle, as well as moderate pericardial effusion and bilateral pleural effusions. The patient continued to deteriorate and developed cardiogenic shock, at which point a LVAD was placed. Endomyocardial biopsy of the right ventricle showed myocyte necrosis, multinucleated giant cells, and prominent interstitial mixed inflammatory infiltrate with lymphocytes and eosinophils consistent with giant cell myocarditis. The patient was started on immunosuppressive therapy and follow up TTE in 6 months showed an LVEF of 61% with complete resolution of symptoms. Given full cardiac recovery, it was decided that the LVAD would be explanted. DISCUSSION: GCM is a rare disease with high morbidity and mortality. The most common manifestations are heart failure, ventricular arrhythmias, and atrioventricular block, but it can also present as an acute myocardial infarction or even sudden cardiac death. Diagnosis rests on myocardial biopsy and cardiac MRI, which often shows hyper-enhancement sparing of the sub-endocardium not matching any coronary artery distribution. The definitive treatment of GCM is a heart transplant. However, in patients with early diagnosis, immunosuppressive therapy has been shown to arrest the disease in 66% of patients - resulting in clinical remission sufficient enough for survival without the need for a heart transplant. CONCLUSIONS: GCM is an extremely rare and lethal disease. However, as demonstrated in this case, early diagnosis and initiation of immunosuppressive therapy can change the course of the disease and avoid the need for a heart transplant. Reference #1: Cooper LT, Berry GJ, Shabetai R. Idiopathic giant-cell myocarditis–natural history and treatment. Multicenter Giant Cell Myocarditis Study Group Investigators.N Engl J Med. 1997; 336:1860–1866. Reference #2: Riina Kandolin-Jukka Lehtonen-Kaisa Salmenkivi-Anne Räisänen-Sokolowski-Jyri Lommi-Markku Kupari.Diagnosis, Treatment, and Outcome of Giant-Cell Myocarditis in the Era of Combined Immunosuppression. Circulation: Heart Failure - 2013 DISCLOSURES: No relevant relationships by Xuming Dai, source=Web Response No relevant relationships by Sharmila Sarkar, source=Web Response

P4590Temporal trends of the characteristics, management, and clinical outcomes of patients with acute coronary syndrome and multi-vessel disease - the ACSIS registry

Abstract Introduction Multi-vessel coronary artery disease (MVD) is common among patients with acute coronary syndrome (ACS) and is associated with worse outcomes compared with single-vessel disease. Multiple studies focused particularly on patients with ACS and MVD and their results were incorporated into guidelines' recommendations. Objectives To examine temporal trends in clinical characteristics, treatment and outcomes of patients presenting with ACS and MVD. Methods Time- dependent analysis of patients enrolled in the biennial ACS Israeli Surveys (ACSIS) between 2000 and 2016 according to three time periods: early (2004–2006; n=2,111), mid (2008–2010; n=2,049), and late (2013–2016; n=2,010). MVD was defined as &gt;50% stenosis in ≥2 separate major coronary territories at the index ACS. Clinical outcomes were 30-day MACE (death, unstable angina, myocardial infarction, stroke, stent thrombosis, urgent revascularization) and 30-days and 1-year mortality. Results Overall 6,170/15,000 patients (41.1%) had MVD (age 64.5±12.1, males 80%). Patients admitted in the later periods were older with a higher prevalence of cardiovascular risk factors and their treatment (i.e. statins, and hypoglycemic drugs) prior to admission. The rate of CABG has decreased and of MV percutaneous coronary intervention and guideline recommended medical treatment has increased with time. At 30 days, the rates of mortality, MACE and re-infarction have decreased (Figure). A trend of reduction in 1-year mortality was observed with time, yet it did not reach statistical significance (early=9.3%, mid=7.8%, late=7.7%, P=0.13). A multivariate adjusted analysis demonstrated that the mid and late periods were associated with significantly reduced risk for 30-day MACE (OR=0.65 [0.54–0.77] and 0.54 [0.45–0.65], respectively). Figure 1. Temporal trends in 30-day outcomes of patients with ACS and MVD Conclusions During the last decade, the burden of cardiovascular risk factors among ACS patients with MVD has increased, more extensive invasive and medical treatments were provided and significant improvements in 30-day outcomes were observed. Acknowledgement/Funding None

P4583Effect of permanent right internal mammary artery occlusion on right coronary artery collateral function. a randomized controlled trial

Abstract Background Extracardiac coronary artery supply via the pericardiophrenic branch of the internal mammary arteries (IMA) has been well documented anatomically. Recently, a proof-of-concept study has found functional relevance of these anastomoses in patients with coronary artery disease (CAD) during a brief right coronary artery (RCA) occlusion. Purpose The aim of the present randomized controlled, single-blind trial was to investigate the effect of permanent right IMA (RIMA) occlusion on RCA collateral flow index (CFI) and on the occurrence of angina pectoris. We hypothesized that the change in RCA CFI from baseline to follow-up examination is higher in the group of patients with than without permanent RIMA occlusion. Methods One hundred patients with CAD were randomly allocated (1:1) to permanent RIMA device occlusion at baseline or to no RIMA occlusion (sham control group). The primary study endpoint was CFI change in the RCA from baseline to the 6-week follow-up examination. CFI is the ratio between mean coronary occlusive and aortic pressure both subtracted by central venous pressure as obtained during a 1-minute proximal RCA balloon occlusion. RCA CFI was measured at baseline before RIMA occlusion or the sham procedure and at the follow-up invasive exam. At the end of the same occlusion, occurrence of angina pectoris was assessed. Percutaneous coronary intervention (PCI) of the RCA was deferred until after follow-up RCA CFI measurement. Results There were 51 patients in the RIMA occlusion (verum) group and 49 patients in the sham control group. PCI in the left coronary territory was performed at baseline for clinical reasons in 27 patients of the verum group and in 25 patients of the sham control group. There were no differences in clinical characteristics at baseline between the groups (age 68±12 years, 88 men). RCA CFI change during the 6 weeks of follow-up was equal to +0.028±0.077 in the verum group and −0.026±0.079 in the sham control group (p=0.0017). Angina pectoris during CFI measurement had disappeared at follow-up exam in 30% of the verum group and in 2% of the sham control group (p=0.0013). Conclusions Right coronary collateral function is augmented 6 weeks after permanent RIMA occlusion when compared to sham treatment. This manifests as less frequent angina pectoris during myocardial ischemia among patients with RIMA occlusion. Acknowledgement/Funding This study was supported by a grant from the Swiss National Science Foundation for Research (grant #32003B_163256/1 to CS).