Critical Coronary Artery Disease Research Articles

MITRACLIP TREATMENT FOR CARDIOGENIC SHOCK DUE TO ACUTE MITRAL REGURGITATION IN A PATIENT WITH POSTINFARCTION PAPILLARY MUSCLE RUPTURE

Abstract A 85–year–old woman presented to ED with worsening dyspnea for 24 hours; no other related symptom. Her medical history included hypertension, dyslipidemia, type 2 DM and surgical coronary revascularization 13 years before for multiple critical coronary artery disease (LIMA to LAD and sequential SVG to PDA and OM branch). The ECG promptly revealed a subacute infero–lateral STEMI. Transthoracic echocardiography (TTE) showed inferior and postero–lateral wall akinesia with severely reduced left ventricle ejection fraction (LVEF), mildly reduced right ventricle systolic function and severe mitral regurgitation (MR) due to posterior papillary muscle (PM) rupture (Fig.1). Clinical scenario was complicated by pulmonary edema and cardiogenic shock treated with diuretics and sodium nitroprusside infusion, non–invasive ventilation and IABP insertion. Urgent coronary angiography revealed a thrombotic occlusion of the venous graft for OM branch. Surgical correction was excluded due to hemodynamic instability. Graft occlusion was treated with manual thromboaspiration, balloon dilatations and abciximab infusion. After an initial stabilization, transesophageal echocardiography (TEE) was performed confirming severe MR resulting from rupture of one head of a bifid posterior PM (red arrows, Fig.1) and prolapse of the anterior leaflet combined with restrictive systolic movement of the posterior leaflet due to wall motion abnormalities. 3 days later a transcatheter mitral valve edge–to–edge repair (MTEER) was performed using a MitraClip device (1 XTR clip and 1 NTR clip, Fig.2). TEE with 3D and TrueVue vision confirmed the correct placement of clips (Fig.3), a mild–to–moderate residual MR, absence of significant transmitral gradient and a mildly reduced LVEF. No clinical events were reported during recovery; patient was discharged after 2 weeks. Conclusion MTEER is an established therapy for reducing degenerative and functional MR. Little data is available on its use in the setting of PM rupture. This rare complication of AMI carries a mortality rate of 80% during the first week without surgical correction but more than half of patients are excluded because of prohibitive operative risk. TEER may be an alternative for these patients. In this case report we described the utility of MTEER in the setting of cardiogenic shock secondary to acute ischemic MR with papillary muscle partial rupture. This procedure can be useful with acceptable safety and procedural success.

Risk analysis of the association between different hemoglobin glycation index and poor prognosis in critical patients with coronary heart disease-A study based on the MIMIC-IV database

BackgroundThe hemoglobin glycation index (HGI) is the difference between the observed and predicted values of glycosylated hemoglobin (HbA1c), which is closely associated with a variety of poor prognoses. However, there are still no studies on the correlation between HGI and poor prognosis in patients with critical coronary artery disease. The purpose of this study was to analyze the correlation between HGI and all-cause mortality in patients with critical coronary artery disease using the MIMIC-IV database.MethodsThe HGI was calculated by constructing a linear regression equation between HbA1c and fasting plasma glucose (FPG). A Kaplan‒Meier survival analysis model was constructed based on the HGI quartiles to clarify the differences in all-cause mortality rates between groups, and the log-rank test was used to assess the differences between groups. The hazard ratio (HR) of HGI as a risk factor for outcome events was assessed using the Cox proportional risk model and restricted cubic spline (RCS), with the Q2 group serving as the reference group.ResultsA total of 5260 patients were included in this study. The 30-day mortality rate of the patients was 4.94% and the mortality rate within 365 days was 13.12%. A low HGI was significantly associated with 30-day mortality (HR, 1.96; 95% CI, (1.38, 2.78); P < 0.001) and 365-day mortality (HR, 1.48; 95% CI, (1.19, 1.85); P < 0.001) in patients with critical coronary artery disease in the completely adjusted Cox proportional risk model. In addition, high levels of HGI were associated with 365-day mortality (HR, 1.31; 95% CI, (1.02, 1.69); P < 0.05). RCS analysis revealed a U-shaped relationship between HGI and outcome events. According to the stratified analysis, the interaction test revealed that the correlation between HGI and outcome events remained stable.ConclusionThere was a significant correlation between HGI and all-cause mortality in patients with critical coronary artery disease, particularly in those with low HGI. HGI can be used as a potential indicator for assessing the short- and long-term risk of mortality in such patients.

Coronary artery disease in atrial fibrillation ablation: impact on arrhythmic outcomes.

Catheter ablation (CA) is an established treatment for atrial fibrillation (AF). A computed tomography (CT) may be performed before ablation to evaluate the anatomy of pulmonary veins. The aim of this study is to investigate the prevalence of patients with coronary artery disease (CAD) detected by cardiac CT scan pre-ablation and to evaluate the impact of CAD and revascularization on outcomes after AF ablation. All consecutive patients with AF diagnosis, hospitalized at Universitair Ziekenhuis Brussel, Belgium, between 2015 and 2019, were prospectively screened for enrolment in the study. Inclusion criteria were (i) AF diagnosis, (ii) first procedure of AF ablation with cryoballoon CA, and (iii) contrast CT scan performed pre-ablation. A total of 576 consecutive patients were prospectively included and analysed in this study. At CT scan, 122 patients (21.2%) were diagnosed with CAD, of whom 41 patients (7.1%) with critical CAD. At survival analysis, critical CAD at CT scan was a predictor of atrial tachyarrhythmia (AT) recurrence during the follow-up, only in Cox univariate analysis [hazard ratio (HR) = 1.79] but was not an independent predictor in Cox multivariate analysis. At Cox multivariate analysis, independent predictors of AT recurrence were as follows: persistent AF (HR = 2.93) and left atrium volume index (HR = 1.04). In patients undergoing CT scan before AF ablation, critical CAD was diagnosed in 7.1% of patients. Coronary artery disease and revascularization were not independent predictors of recurrence; thus, in this patient population, AF ablation should not be denied and can be performed together with CAD treatment.

Clinical case of successful treatment of a patient with anaplastic thyroid cancer in combination with ischemic heart disease and critical multivessel coronary artery disease

The article presents a clinical case of a patient with locally advanced anaplastic thyroid cancer and concomitant cardiovascular pathology. Anaplastic thyroid cancer is a very rare and highly aggressive disease requiring long-term multistage treatment, often using cardiotoxic drugs. Combination of this pathology with ischemic heart disease affecting coronary arteries is a complex clinical problem requiring timely evaluation of cardiac risk at every stage. Treatment of this patient cohort is possible only by a multidisciplinary team of specialists.

Pattern of coronary artery occlusion in patients undergoing coronary angiography at Birat Medical College Teaching Hospital

Introduction: Coronary artery disease (CAD), is the leading cause of death globally. Among different diagnostic and treatment procedures, coronary angiography is considered the gold standard. Birat Medical College Teaching Hospital (BMCTH) is also providing cardiovascular services to people from eastern Nepal and from the neighboring country India. We aim to analyze the pattern of coronary artery occlusion in patients undergoing coronary angiography. Method: A hospital based observational cross-sectional study was conducted at BMCTH from 10 Sep 2022 to 10 Jan 2023. A total of 220 patients were enrolled by consecutive sampling techniques. Ethical approval was obtained from the Institutional Review Committee of BMCTH. Data was collected on baseline characteristics, risk factors, clinical presentation and degree of coronary artery occlusion. Collected data was entered in Microsoft Excel and analyzed by Statistical Package for Social Sciences version 23. Frequency, mean, percentage were calculated. Result: Nearly half (49.1%) patients had significant, 6(2.7%) had intermittent CAD and 14(6.4%) had non critical CAD. Three patients (1.4%) had left main coronary artery disease. Left anterior descending artery 66(30%) was the most commonly involved. Single vessel disease was present in most patients 49(22.27%). Double vessel disease 15(46.8%) and triple vessel disease was more common 14(51.8%) in above 65 y of age. Conclusion: The coronary angiography revealed presence of significant coronary artery disease and multiple vessel involvement with increasing age.

The Relationship between Visceral Adiposity Form of Non-Alcoholic Fatty Liver Disease and Increased Epicardial Adipose Tissue Mass with Coronary Artery Disease

Abstract Background Cardiovascular disease is the largest cause of death in the world, and coronary artery disease (CAD) makes up the greatest proportion of those deaths that may enable more sensitive measures for risk stratification, or offer novel therapeutic targets for the prevention and treatment of coronary vascular disease. Aim of the Work to determine the association between visceral adiposity form of non-alcoholic fatty liver and increased Epicardial adipose tissue mass with coronary artery disease severity. Patients and Methods This study was conducted on fifty patients presented with signs and symptoms of coronary artery disease who were coming for elective coronary angiography at cardiovascular outpatient clinic in the internal medicine hospital, Ain Shams University from March 2018 to October 2018. Results In two patients with severe steatosis (Grade 3) the average thickness of long and short axes was detected 9.600 ± 0.141 mm. Average of 12 patients with no steatosis, Epicardial fat thickness was 6.323 ± 0.754 mm. In our study, Non critical coronary artery disease (below the 50% stenosis) was detected in eight patients (16 %). While critical coronary artery disease (Above the 50% stenosis) was detected in forty two patients (84%). According to the severity of coronary artery disease, in patients who do not have significant stenosis, EAT mean thickness was found 5.600± 0.400 mm measured. In patients with severe stenosis coronary artery disease, this value was measured as 7.857 ± 0.707 mm. In our study, Hypertension, diabetes mellitus and dyslipidemia (represented by LDL-c) were found to have statistically significant relations and correlation with EAT, but it was found that there was no statistically significant relationship between NAFLD fibrosis scoring system and FIB-4 with CAD. In this study, it was found a statistically significant relationship between the severity of NAFLD and CAD and a similar relationship between EAT and CAD. Conclusion Epicardial fat deposition is part of the same metabolic disorders associated with the development of fatty liver in individuals with insulin resistance and metabolic syndrome. High EAT may represent a marker of the severity of visceral adiposity as well as an independent predictor of cardiovascular and coronaries diseases risk.

P313 AN UNUSUAL CASE OF SEVERE LEFT VENTRICULAR DYSFUNCTION: MILANESE ‘BREAKING BAD‘

Abstract A 39–year–old Filipino man was admitted for dyspnea and lower limb edema for about a month, in combination with stable cardiac enzymes movement (TnT 128&amp;gt;78&amp;gt;115 ng/dl), fluctuating unspecific inflammatory profile and hepatic impairment. Trans–thoracic echocardiography confirmed heart failure (HF) in a setting of eccentric left ventricular hypertrophy, diffuse hypokinesia and severe global functionreduction. Despite the absence of typical chest pain, the presence of cardiovascular (CV) risk factors (DMT2, smoking, dyslipidemia), previous alcoholism and the finding of widespread ventricular repolarization ECG changes seemed to suggest an ischemic or multifactorialorigin of the HF. After the finding of a critical trivascular coronary artery disease on coronarography and a pulmonary nodule on chest CT, the cardiac magnetic resonance (CMR) confirmed the diagnosis of severe dilated HF with evidence of a diffuse wall signal hyperintensity in STIR sequences and a intramyocardial and subepicardial patchy LGE pattern of non–ischemic meaning. The possible ischemic etiology was thus overlaid with an inflammatory disease, leading to assume sarcoidosis or myocarditis be the cause of HF. The main screening tests (ACE and immunologic–infectious profile) were negative a a PET/CT scan confirmed a diffuse cardiac inflammation with no focal hypercaptant lesions. Therefore, sarcoidosis was ruled out, and an endomyocardial biopsy (BEM) was performed, and resulted, however, inconclusive. Following, an unexpected finding revealed through a more scrupulous anamnesis: a long–time abuse of a methamphetamine (MDMA) prevalent in the Filipino community called Shaboo. This type of MDMA is accompanied by multiple CV system impacts, including MDMA–associated cardiomyopathy (MACM), a clinical picture compatible with the findings obtained by CMR and BEM performed. After discussion in Heart Team and therapeutic optimization, the patient was candidate for coronary artery bypass. Thus, with the correct diagnostic definition and treatment of HF triggers, an improvement in clinical and left ventricularfunction was marked (EF 45%). Monitoring will allow evaluation of the evolution of the changes found at CMR and will document eventually reversibility of MACM after protracted abstention from MDMA abuse.

P327 A STRANGE CASE OF ACUTE CORONARY SYNDROME

Abstract We report a case of a 46–years–old man hypertensive, diabetic with dyslipidemia with a previous hospitalization for NSTEMI. The Coronary angiography highlighted right coronary artery vasospasm. Echocardiogram reported good left ventricular function with left ventricular hypertrophy. ECG showed Sinus Rhythm with HR 60 bpm, PR 110 msec and right bundle branch block (Figure 1). He was discharged in dual antiplatelet therapy and with Diltiazem and nitrates. Later the patients reported several events of worsening angina and required the ER access: his therapy was integrated with ranolazine. After that he was bring to our attention for a relapse of NSTEMI. ECG: Sinus Rhythm with HR 55 bpm, PR 110 msec and right bundle branch block. Echocardiogram showed LV with severe wall thickening (ventricular septum/posterior wall 17/14 mm), LVEF 55% in the absence of segmental kinetic alterations, no intraventricular and/or outflow obstruction. There was a first degree diastolic disfunction, and there was mild reduction in both systolic and diastolic velocities on TDI. The right ventricle was not dilated, with thickened free wall, and normal systolic function [figure 2]. A repeated coronary angiography excluded a critical coronary artery disease, but it reveals again evidence of right coronary artery vasospasm. Diltiazem was replaced with nifedipine.A careful anamnesis revealed a history of tinnitus, with right receptive hypoacusia as a result of vestibular neuritis. Blood tests revealed proteinuria with 1800 mg/24 h with glycated Hb 5.8%. Based on the clinical history and the ECG and echocardiographic findings screening for Fabry disease was performed: the results showed abnormal levels of alpha–galactosidase A and plasma lyso–Gb3. Further investigations included cardiac MRI, which confirmed interventricular septal hypertrophy but no late gadolinium enhancement, and ophthalmologic examination, which revealed cornea verticillata in the left eye. Electromyography showed signs of peripheral neuropathy, and renal biopsy was consistent with Fabry disease. Genetic analysis revealed a mutation in exon 1 of the GLA gene (c.62 T&amp;gt;G) that results in the amino acid substitution p.L21R, which has been previously described in patients with Fabry disease. The final diagnosis was Fabry disease with cardiac, renal, and peripheral neuropathic involvement. Enzyme replacement therapy was started with regression of angina episodes.

Myocardial strain analysis by 4D-speckle tracking echocardiography for prediction of coronary artery disease severity in patients with stable angina pectoris

ObjectiveWe sought to evaluate the myocardial strain by four-dimensional speckle-tracking echocardiography (4D-STE) in patients with stable angina pectoris (SAP) to determine the severity of coronary artery disease (CAD) based on the Gensini score. MethodsThe present study comprised of 150 patients with SAP. Patients with history of SAP, normal left ventricular ejection fraction, and without regional wall motion abnormalities (RWMA) were scheduled for elective coronary angiography. Based on Gensini score, there were two groups: non-critical stenosis group [Gensini score (0–19), n = 117] and critical stenosis group [Gensini score ≥20, n = 33]. Correlation between Gensini score and 4D-STE strain parameters were investigated. ResultsOut of 150 patients, critical stenosis group had significantly depressed values of all 4D-STE strain parameters than non-critical stenosis group (p < 0.001), except global radial strain (GRS) parameter. Significant positive correlation was found between Gensini score and 4D global longitudinal strain (GLS), global circumferential strain (GCS), global area strain (GAS) with Spearman's correlation coefficient (ρ) as 0.626, 0.548, and 0.631, respectively (p < 0.001), whereas significant negative correlation was found between Gensini score and GRS (ρ = −0.433, p < 0.001). A 4D GLS value of ≥ −17 had 84.9% sensitivity and 97.4% specificity, GAS ≥ −31 (90.9% sensitivity, 78.6% specificity), GCS ≥ −17 (69.7% sensitivity, 92.3% specificity), and GRS <47 (sensitivity 72.7%, specificity 76.1%) to detect critical CAD described by Gensini score ≥20. ConclusionThe 4D-STE can aid in the assessment of severe CAD stenosis with good sensitivity and specificity in the patients with SAP without RWMA on traditional echocardiography.

Correlation of Left Ventricular Global Longitudinal Strain and Angiographically Derived SYNTAX Score in Patients of Stable Angina Pectoris

Background: The present study aimed to assess the relationship between global longitudinal strain (GLS) by two-dimensional (2D) speckle tracking echocardiography (STE) and SYNTAX score (SS) in patients with stable angina pectoris and normal baseline left ventricular (LV) function. Methods: Fifty patients aged ≥18 years presented with stable angina pectoris with LV ejection fraction ≥60.0% posted for elective coronary angiography were included in the study. All the patients underwent 2D echocardiography, 2D STE, and coronary angiography. GLS and SSs were calculated. The primary objective was to find the correlation between GLS and SS in assessing the severity of coronary artery disease (CAD), whereas the secondary objectives were to find the sensitivity and specificity of GLS to predict critical CAD. Results: A significant negative correlation (−0.862, P = 0.001) was observed between GLS and SSs. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of GLS score 16 were 100.0%, 64.0%, 73.5%, 100.0%, and 82.0, respectively, in predicting higher SS (≥22). The mean GLS values were significantly higher in noncritical CAD (16.4 ± 1.1) as compared to critical CAD (12.4 ± 1.3). Conclusions: GLS is a useful noninvasive tool to detect the severity of CAD.

647 COMPLEX PERCUTANEOUS CORONARY INTERVENTION IN HIGHT BLEEDING AND THROMBOTIC RISK PATIENT: WHICH ANTITHROMBOTIC THERAPY?

Abstract Background Antiplatelet therapy is required in patients with atherosclerotic coronary artery disease (CAD) undergoing percutaneous coronary intervention (PCI) with drug-eluting stents (DES). Current European and American guidelines recommend 6 months of DAPT in CCS and 12 months after ACS. However, a shorter duration of DAPT may be considered in high bleeding risk (HBR) patients, and a longer duration in those at higher thrombotic risk (HTR). To minimize the risk of thrombotic and bleeding events of an individual patient and therefore improve the overall outcomes of PCI, risk stratification is essential. In particular, bleeding and thrombotic characteristics must be weighed on a case-by-case basis to tailor antiplatelet therapy strategies and decisions over a patient's individual risk profile. We describe an illustrative case of complex PCI in patient with ACS in which defining the appropriate duration of DAPT is a clinical challenge. Clinical case A 68-year-old man with ACS-NSTEMI and anemia was hospitalized in intensive care unit. His medical history was notable for hypertension, dyslipidemia, diabetes mellitus, diabetic retinopathy, chronic kidney disease (CKD) and paroxysmal atrial fibrillation. A transthoracic echocardiogram showed left ventricular ejection fraction of 30% with diffuse hypokinesia, without relevant valvular disease. He was conducted to the cath-lab for a diagnostic coronary angiogram which showed a three-vessel critical CAD. After Heart Team evaluation coronary artery bypass surgery (CABG) was indicated. However, during the hospitalization in intensive care unit there was a worsening of clinical conditions with cognitive impairment due to mesencephalic stroke leading to a new Heart Team assessment that indicated PCI after stabilization of clinical scenario. After two weeks patient was conducted to the cath-lab to undergoing an IVUS guided PCI. PCI of the right coronary artery was performed with implantation of 1 DES (3.0/30 mm) on the middle segment and 1 DES (4.0/15 mm) on the ostial segment. PCI of the left main bifurcation was performed with implantation of 2 DES (4.0/28 mm) with culotte technique. Patients have both HBR and HTR, therefore, after procedure, the new trade off model score introduced by the Academic Research Consoritum (ARC) was applied. Based on his risk factor, the predicted 1-y risk of BARC type 3 to 5 bleeding (51.41%) was greater than the predicted 1-y risk of myocardial infarction or stroke (25.00%). Based on this result we decided to prescribe Triple antithrombotic therapy for 1 week, dual antithrombotic therapy for 12 months and after only oral anticoagulation. Conclusion In the context of patient with several risk factor undergoing complex PCI the stratification of bleeding and thrombotic individual risk is mandatory to define the appropriate duration of DAPT. The new trade-off model score is an important useful tool to identify patients who might benefit from individualized DAPT durations depending on the balance between HBR and HTR characteristics.

Mid-term results of open transaortic implantation of the «MedLab-CT» prosthesis: prospective clinical study

Aim. To evaluate the mid-term clinical and hemodynamic results of open transaortic implantation of the balloon-expandable prosthesis MedLab-CT in patients with high surgical risk.&#x0D; Material and methods. The study included 41 patients (mean age 65.711.7 years) who underwent open implantation of the MedLab-CT (MedInzh, Russia) aortic valve (AV) prosthesis under cardiopulmonary bypass and cardioplegia, belonging to the cohort of high surgical risk according to the data EuroSCORE II scale, with critical symptomatic aortic stenosis, high functional class according to the classification of the New York Heart Association (NYHA). All studied patients had clinical indications for transcatheter AV replacement, however, given the concomitant surgical pathology of the heart (critical multivessel coronary artery disease unsuitable for endovascular treatment and/or damage to other valves), as well as the morphological features of the aortic root (low location coronary artery ostia relative to the annulus fibrosus of the AV, large calcifications of the coronary cusps according to computed tomography, with a high risk of ostium occlusion), they were denied a minimally invasive procedure. The incidence of adverse clinical events and hemodynamic parameters of the AV prosthesis in the medium-term period were assessed.&#x0D; Results. The average follow-up period was 13.1 months, the maximum was 3 years. Mortality 2.4% (n=1), there were no cases of stroke. The average gradient in the long-term period on AK MedLab-CT is 8.53.1 mm Hg. Paravalvular regurgitation above grade 2 and transvalvular regurgitation were not detected. Thus, no cases of dysfunction of the aortic prosthesis were noted.&#x0D; Conclusion. In the medium term, satisfactory clinical and hemodynamic results of open implantation of the MedLab-CT balloon-expandable prosthesis were obtained in high surgical risk patients.

Evaluating the Safety of Transcarotid Artery Revascularization under Local Anesthesia Prior to Coronary Artery Bypass Grafting Surgery

Controversy exists regarding the timing of intervention for patients with critical coronary artery disease awaiting coronary artery bypass and severe carotid artery stenosis. Transcarotid artery revascularization (TCAR) is a minimally invasive revascularization alternative through direct transcervical carotid access that minimizes the chance of arch manipulation and consequent antegrade embolic stroke rate. While the TCAR procedure can be performed under local anesthesia (monitored anesthesia care, MAC) vs general anesthesia, the hemodynamic benefits of local anesthesia in patients with severe CAD are significant. Patients receiving staged TCAR-CABG have high-risk cardiovascular disease and require accurate perioperative neurological and hemodynamic evaluation that can be safely provided with local anesthesia. In this retrospective single-center study, 14 patients were systematically identified to have undergone staged TCAR prior to CABG surgery from December 2018 to October 2021. All patients underwent TCAR with local anesthesia and minimal sedation. Relevant patient demographics, medical and surgical history, preoperative covariates, and type of anesthesia administered were obtained from patients' charts. Carotid artery disease was confirmed by either carotid duplex imaging or computed tomography angiography (CTA) of the head/neck. Staged TCAR-CABG interventions were performed on 14 patients (64% male; mean age 65.0 years). No major adverse cardiac events were reported including transient ischemic attack (TIA), stroke, myocardial infarction, or TCAR-related death in the interval between their TCAR and CABG as well as in a 12-month follow-up period. One patient required to return to the operating room (OR) for evacuation of a neck hematoma. This study demonstrated high success rate of TCAR under local anesthesia prior to CABG (100%) with no incidence of perioperative stroke, myocardial infarction (MI), or death at 1-month, 6-month, and 12-month follow-up intervals. The authors support the use of staged TCAR-CABG with local anesthesia as a safe and promising treatment option for patients with high-grade cardiac disease, high risk of stroke, or multiple comorbidities that preclude a CEA.

Predicting the Severity of Coronary Artery Disease: Can the Leukocyte Glucose Index be Used?

To investigate the usability of leuko-glycemic index (LGI) at chronic coronary syndromes (CCS) class 1 for determining the extent and severity of coronary artery disease (CAD). An observational study. Department of Cardiology, University of Pamukkale University Hospital, Turkey, between September 2021 and January 2022. One hundred and thirty-four patients, whose myocardial perfusion scintigraphy (MPS) was requested due to CCS class 1, and on whom a coronary angiogram (CAG) was performed due to evidence of ischemia, were analysed. Blood samples were taken from the patients during their hospitalisation before CAG. LGI was calculated as mg/dl.mm3 by multiplying both values and dividing by a thousand. The patients were analysed in two groups according to the critical stenosis and non-critical stenosis detected in the coronary arteries. The LGI was recorded as 480 mg/dl.mm3 (407-603) vs. 572 mg/dl.mm3 (433-877), p=0.006, and the Gensini score (6 (3-10) vs 40 (23-60), p<0.001) was significantly higher in the critical CAD group. A significant relationship has detected the increase in LGI and the extensity and severity of CAD (Unadjusted; OR (95% CI); 1.003 (1.001 - 1.004) p=0.002, adjusted; OR (95% CI); 1.002 (1.001 - 1.004) p=0.004). A high LGI was a predictor of CAD severity among CCS class 1 patients and was found to correlate with the Gensini score. The use of this simple and inexpensive index, together with other non-invasive tests before CAG, may provide some knowledge about the severity of CAD. Coronary artery disease, Leukocyte glucose index, Myocardial perfusion scintigraphy.

Chronic kidney disease is a key predictive factor for potential myocardial ischaemia and poor prognosis in asymptomatic patients with diabetes mellitus

Some asymptomatic patients with diabetes mellitus (DM) have critical coronary artery disease (CAD), although the guidelines do not recommend aggressive screening for CAD in asymptomatic patients. Chronic kidney disease (CKD) is among the serious co-morbidities of severe systemic atherosclerosis. Thus, CKD may be associated with potential myocardial ischaemia. Therefore, the present study aimed to determine the impact of CKD on the incidence of silent myocardial ischaemia (SMI) and the long-term outcomes in asymptomatic patients with DM. This study investigated 461 consecutive patients with DM. All patients who were asymptomatic and self-sufficient in daily life underwent the ergometer exercise (ERG) test. Coronary angiography was performed if the stress test was positive, or if the patient did not achieve 90% of the target heart rate. The primary end point included major adverse cardiac and cerebrovascular events (MACCE) including death, non-fatal myocardial infarction and stroke. The median follow-up duration after study enrolment was 35 months for the entire cohort of 461 patients. Eighty-one patients were diagnosed with SMI. The estimated glomerular filtration rate was significantly lower in the SMI group (70.5 ± 23.8 vs. 81.8 ± 30.0 mL/min/1.73 m2, P < 0.001). SMI occurred more frequently in patients with advanced CKD [27/103, (26.2%) in stages 3–5], whereas only 5/68 (7.3%) patients without CKD, 13/81 (16.0%) patients with stage 1 CKD and 36/209, (17.2%) in stage 2, had SMI. The Kaplan–Meier curves revealed that, patients with SMI had poor clinical outcomes (log-rank: P = 0.016). The incidence of MACCE (log-rank: P = 0.009) was higher in patients with severe CKD > stage 3a in the SMI subgroup. Urinary albumin (mg/gCr) was associated with MACCE in the SMI subgroup [HR 3.37, 95%CI (1.170–9.521), P = 0.025] after adjusting for age, sex, and conventional risk factors. SMI was more prevalent in patients with CKD and the incidence was proportional to the CKD stage in asymptomatic patients with DM. Those Patients with CKD and SMI exhibited poor clinical outcomes. CKD may be a key factor for the identification and management of SMI in asymptomatic patients with DM in routine clinical practice.Trial Registration: UMIN000038340.

Peripheral extracorporeal membrane oxygenation support expands the application of robot-assisted coronary artery bypass.

Robot-assisted coronary artery bypass (RCAB) is typically not offered to higher risk patients with reduced cardiopulmonary function, critical coronary artery disease, and challenging chest wall anatomy. In this study, we report the novel use of nonemergency intraoperative peripheral extracorporeal membrane oxygenation as partial cardiopulmonary support during RCAB for patients who were considered high-risk candidates for conventional CAB and at the same time not eligible for RCAB without cardiopulmonary support. Forty-five high risk patients (mean age, 68years; Society of Thoracic Surgeons score, 6.27%; ejection fraction, 45%) underwent RCAB with nonemergency peripheral extracorporeal membrane oxygenation support for the following indications: inability to tolerate single-lung ventilation (n=17; 38%), low ejection fraction <35% (n=17; 38%), inadequate exposure of internal thoracic artery (n=24; 53%), critical coronary artery disease (n=16; 36%), and hemodynamic instability after anesthesia induction (n=3; 7%). Following robotic internal thoracic artery takedown, all patients had beating heart minimally invasive direct CAB through a 2-inch minithoracotomy. Up to 30days, there were no strokes (0%), myocardial infarctions (0%), or access vessel complications (0%). One noncardiac related mortality (2.2%) was related to hemodialysis access issues in a patient with preexisting end-stage renal disease. One redo-CAB (2.2%) patient required sternotomy to locate the target vessel. Thirty-four (75.6%) patients were extubated within 6hours of surgery. Our results examine the feasibility of using peripheral extracorporeal membrane oxygenation during RCAB for high-risk patients who otherwise had limited options. The use of peripheral extracorporeal membrane oxygenation in RCAB can potentially expand the surgical treatment options in high-risk coronary artery disease patients.

The RIFLE Classification: A Stratification Scheme for Patients of Acute Renal Failure after Coronary Artery Bypass Surgery

Background: Acute renal failure is linked to an increased risk of death and morbidity after cardiac surgery. Because there are no standard criteria for acute renal damage, there is a wide variation in the reports that have been published. The Acute Dialysis Quality Initiative Workgroup has developed new RIFLE criteria for acute renal dysfunction. The goal of current study was to appraise whether this definition of postoperative renal dysfunction after coronary artery bypass surgery (CABG) was accurate. Methods: Fifty patients with critical coronary artery disease &amp; undergoing CABG were enrolled in the study. Out of 50 patients, 25 patients had CABG with cardiopulmonary bypass (CPB) and remaining 25 underwent off pump CABG (OPCAB). Patients were distributed into various groups (based on the severity of renal impairment) using the RIFLE classification: Risk, Injury, Failure, Loss, End-stage kidney disease) depending on either serum creatinine level/ estimated glomerular filtration rate (eGFR) or urine output. The variation with 30 days-mortality, ICU stay and renal replacement therapy after CABG were identified. Results: After CABG, 10% of patients experienced renal impairment, as per definitions of RIFLE classification. In this study, there is no significant difference in ARF (RIFLE classification-normal and risk) with or without use of CPB. However, incidence of RIFLE- injury and failure is higher in CPB group than no CPB group. The postoperative proportions of death and renal failure necessitating renal replacement therapy (RRT) were 2% (number of patients, 1 of 50) and 2% (1 of 50), respectively in RIFLE-failure. For the whole study cohort, the median duration of postoperative ICU stay was 4.0 days, with interquartile ranges of 3.0 to 7.0 days. All the patients of Rifle classification-injury and failure had prolonged ICU stay (5 or more days). Conclusions: The RIFLE criteria are a useful tool for determining renal impairment after CABG. Increased renal replacement treatment, longer ICU stays, and a higher death rate are all linked to the severity of RIFLE classification. Cardiovasc j 2022; 14(2): 150-156

Val109Asp polymorphism in Intelectin 1 gene is associated with coronary artery disease severity in women.

Intelectin-1 is an anti-inflammatory adipokine encoded by the Intelectin 1 (ITLN1) gene. Genetic variations in the ITLN1 gene affect the risk of coronary artery disease (CAD) and related CAD risk factors. In this study, we aimed to investigate whether the ITLN1 gene Val109Asp polymorphism has an effect on the severity of CAD and serum lipid levels in both men and women. A total of 493 subjects who underwent coronary angiography (43.5% women, mean age 63.1±9.5 years) were grouped as individuals with critical CAD (≥70% stenosis, n=202), non-critical CAD (31%-69% stenosis, n=90), and non-CAD (control group) (1%-30% stenosis, n=201). Genotyping was performed using LightSNiP assay in Real-Time PCR. The frequency of the Val allele was significantly different among all the patients with critical CAD (n=41) and non-CAD control (n=51) groups in women (p=0.033) but not in men (n=77 and n=38). Women with the Val allele had a 1.69-fold increased risk for critical CAD (p=0.033). In addition, the presence of Val allele was associated with higher coronary stenosis after adjustment for several confounders only in women with critical CAD (p=0.025). Furthermore, carriers of the Val allele exhibited an increased low-density lipoprotein cholesterol (LDL-C) in men with critical CAD than in those with non-CAD (p<0.05). These results suggest that the Val allele of the ITLN1 Val109Asp polymorphism is associated with critical CAD and high LDL-C levels in our study population. Further studies are required to elucidate the effect of Val109Asp polymorphism on CAD pathogenesis.

Simultaneous Operation on Pump Coronary Bypass Grafting and Left Hemicolectomy in Patient with Reduced Ejection Fraction

This is written so as to report the case of a 75-year-old male with a diagnosis of sigmoid adenocarcinoma accompanied by critical coronary artery disease and angina, which was subject to simultaneous surgical treatment. Was performed first an on – pump coronary artery revascularization and then a left colectomy. Our case suggests that performing an on-pump bypass in patient also with reduced ejection fraction procedure prior to cancer surgery can be a safe surgical in appropriately selected cases.

Mega Coronary Arteries with Obstructive Coronary Artery Disease in Hypertrophic Obstructive Cardiomyopathy: A Case Report and Literature Review

We report a rare case of hypertrophic obstructive cardiomyopathy (HOCM) presenting with mega coronary arteries with obstructive coronary artery disease. Interestingly, the patient had large septals, large diagonals, large obtuse marginal with a large left atrial branch, and a large conus almost mimicking a duplicate right coronary artery. Because of massive left ventricular hypertrophy, to overcome the supply-demand mismatch, coronary arteries may become large or with more arborization in hypertrophic cardiomyopathy but the same is rarely encountered in routine clinical practice. Our case is a rare illustration of the simultaneous presence of mega coronary arteries and critical obstructive coronary artery disease in HOCM in a young male of 38 years of age.