LAD Disease Research Articles

Abstract 4138424: Ring of Power: Unraveling a Rare Diagnosis in a Young Male with Palpitations

Case Description: A 36-year-old male presented for an outpatient treadmill ECG stress test for further evaluation of palpitations exacerbated by exercise. He had no ischemic ECG changes, but developed a sustained episode of polymorphic VT at 13 minutes (Figure 1a). The test was stopped and the VT self-terminated after 43 seconds. The patient was admitted for further workup. Lab workup was unremarkable; baseline ECG demonstrated no ST-T wave changes and displayed normal QT and QRS duration. TTE showed mild biventricular dysfunction. Coronary CT angiogram showed type 3 subtype of Vieussens’ arterial ring (VAR), with an absent left main and super-dominant RCA supplying both LAD and LCx. FFR-CT showed non-hemodynamically significant stenosis in the mid-distal LAD (Figure 1b). Left heart catheterization confirmed presence of VAR and mild diffuse disease in a small-caliber mid-distal LAD (Figures 1c&d). No malignant course or dynamic coronary compression was present. Cardiac MRI revealed normal biventricular function and the absence of late gadolinium enhancement. An exercise stress test, now with myocardial perfusion, was performed and was entirely normal without evidence of myocardial ischemia. Genetic testing for catecholaminergic polymorphic VT was negative. After a multidisciplinary discussion, it was decided not to pursue CABG in the absence of demonstrable ischemia at peak exercise. He underwent an ICD placement for secondary prevention and was discharged on beta blockers. Discussion: Three distinct subtypes of VAR have been described, with type 3 being the rarest. The coronary anomaly was first described by Raymond de Vieussens in 1706, and represents an embryologic remnant of the conotruncal circle. It may be diagnosed incidentally in asymptomatic patients or present with angina especially if underlying CAD, aneurysms or fistulae are present. We report the first case of exercise-induced polymorphic VT in a type 3 VAR patient, theorizing that intermittent myocardial ischemia at peak exercise may induce VT in these patients. Surgical revascularization may be considered if myocardial ischemia is demonstrated on stress testing, although its benefit in patients without such evidence of ischemia is unknown.

Comprehensive Risk Assessment of LAD Disease Progression in CCTA: The CLAP Score Study

Background: a wider left main bifurcation angle (LMBA) has been linked to severe plaque development in the proximal left anterior descending artery (LAD). This study aimed to identify predictors of severe proximal LAD stenosis and major adverse cardiovascular events (MACE) using coronary computed tomography angiography (CCTA). Methods: from an initial cohort of 650 consecutive patients, we analyzed 499 patients who met the inclusion criteria after exclusions. Plaque morphology and characteristics were assessed by CCTA, and MACE occurrences were recorded at follow-up. A predictive score for LAD disease progression (CLAP score) was developed and validated. Results: severe proximal LAD stenosis was detected in 32% (160/499) of patients by CCTA. MACE occurred in 12.5% of patients at follow-up. Significant predictors of MACE were LMBA > 80° (HR: 4.47; 95% CI: 3.80–6.70; p < 0.001), diabetes (HR: 2.94; 95% CI: 1.54–4.63; p = 0.031), chronic kidney disease (HR: 1.71; 95% CI: 1.31–6.72; p = 0.041), high-risk plaques (HR: 2.30; 95% CI: 1.45–3.64; p < 0.01), obstructive CAD (HR: 2.50; 95% CI: 1.50 to 4.10, p = 0.01), and calcium score (CAC) (HR: 1.05; 95% CI: 1.02–1.08, p = 0.004). The CLAP score demonstrated good discriminatory power in both the development (AUC 0.91; 95% CI: 0.86–0.96) and validation cohorts (AUC 0.85; 95% CI: 0.79–0.91); Conclusions: LMBA > 80°, diabetes, chronic kidney disease, obstructive CAD, CAC score >180 and high-risk plaques were significant predictors of MACE in CCTA patients. The CLAP score effectively predicted LAD disease progression, aiding in risk stratification and optimization of intervention strategies for suspected coronary artery disease.

Clinical and Angiographic Pattern of Coronary Artery Disease in a Urban Sri Lankan Population

Clinical and Angiographic Pattern of Coronary Artery Disease In A Urban Sri Lankan Population. Introduction: Coronary artery disease (CAD) is a leading cause of mortality worldwide. Objectives: This study was conducted to describe the clinical and angiographic pattern of CAD in a urban Sri Lankan population. Methods: We studied consecutive patients of all ages who underwent coronary angiogram done by a single operator in a leading private hospital, Colombo. This study was a retrospective descriptive study conducted among the total number of 352 patients who underwent angiogram from May 2013 to December 2016. Results: The population with CAD is predominantly male and old (≥41 years). Non-Acute Coronary Syndrome (ACS) is the most common clinical presentation. Triple Vessel Disease (TVD) is most prevalent 136 (38.6%) with the multiplicity of synergistic risk factors. In Single Vessel Disease (SVD), the distribution of disease in LAD, RCA and LCX are 44%, 15% and 8% respectively. Higher rate of ectasia is found in RCA. Diabetes Mellitus (DM) is present in 49% of our patients, which is the second common risk factor next to dyslipidemia (DL) 55% and is significantly associated with TVD. Conclusion: ST-Elevation Myocardial Infarction (STEMI) is the commonest ACS type in the study group. TVD is more common in old age group whereas SVD is the common pattern in younger population. LAD is the predominantly and severely affected artery among both ACS and non – ACS groups. DL is the commonest risk factor. DM is commonly associated with TVD, which is related to multiple risk factors.

Left anterior descending coronary T-wave inversion pattern (Wellens’ syndrome) associated with myopericarditis and a normal left coronary artery

Background: Wellens’ syndrome is characterised by a history of chest pain with an abnormal electrocardiogram (EKG), demonstrating biphasic or deeply inverted T waves in leads V2–3 (may extend to involve all precordial and lateral limb leads – the type B Wellens’ pattern). A Wellens’ EKG pattern is considered highly specific for critical stenosis involving the ostial/proximal left anterior descending artery (LAD). However, there are no reported cases of an association of a Wellens’ EKG pattern with myopericarditis. Here, we present such a rare case. Case description: A thirty-one-year-old female with known essential hypertension and psoriatic arthritis presented with a constant, central chest pain radiating to the shoulders and back. The patient’s physical examination was unremarkable at presentation other than elevated blood pressure at 170/68 mmHg. An EKG at presentation demonstrated deep symmetric T-wave inversions in anterolateral leads with elevated high-sensitivity troponin, and an elevated erythrocyte sedimentation rate. The patient was referred to the cardiac catheterisation laboratory for concerns of a Wellens’ EKG pattern; however, invasive angiography demonstrated only obtuse marginal branch disease – no LAD disease was noted. Cardiac magnetic resonance (CMR) imaging confirmed the diagnosis of myopericarditis and absence of myocardial infarction. The patient was medically managed and discharged home in a stable condition. Conclusion: In literature and established clinical practice, the Wellens’ EKG pattern is considered highly concerning for critical ostial/proximal LAD stenosis. However, we now propose that myopericarditis may be considered in a differential diagnosis for this EKG pattern.

Reviewing Successful Dual LAD Disease Intervention: A Radiological Diagnostic Approach and Literature Overview

Reviewing Successful Dual LAD Disease Intervention: A Radiological Diagnostic Approach and Literature Overview

Abstract 3118: An Unusual Case Of Severe Multivessel Atherosclerotic Coronary Artery Disease In A Very Young Patient

Introduction: Premature coronary artery disease (CAD) is defined as CAD prior to the age of 55 for men and 65 for women, while CAD in young is defined as age <45 years. In the last decade, incidence of global premature CAD has increased by 25 %. Case presentation: A 20-year-old female with medical history of dyslipidemia, hypertension, type 1 diabetes mellitus and family history of premature coronary artery disease presented to the emergency room with chief complaint of chest pain and shortness of breath. EKG revealed sinus tachycardia and poor R-wave progression on anterior precordial leads. Serum troponin trend was unremarkable. Echocardiogram revealed severely reduced left ventricular (LV) ejection fraction of 20-25% with global LV hypokinesis, trace mitral and tricuspid regurgitation. Given new onset cardiomyopathy and family history of premature CAD, CT heart with coronary calcium scoring was performed which was concerning for severe LAD disease. Surprisingly, coronary angiogram revealed severe atherosclerotic disease in LAD, left circumflex and right coronary artery territories. Patient was started on guideline directed medical therapy for cardiomyopathy and has been referred to tertiary center for surgical revascularization. Discussion: To our best knowledge only one case has been reported before in the literature when a 21-year-old male patient had multivessel CAD requiring surgical revascularization. However, we report a case, which will be the youngest ever to have severe multivessel CAD needing surgical revascularization in the future. Cole et al, in a study of 800 young patients with CAD at long term follow up of 15 years, showed an overall mortality rate of 30 %, with 83% mortality rate in patients with EF< 30%, thus carrying a poor long-term prognosis.(2) Hence, an early initiation of treatment, including both medical therapy and revascularization should strongly be considered in these young patient population. Conclusion: With the increasing prevalence of premature CAD and associated risk factors, age alone should not be taken as a reliable indicator for risk stratifying patients. Emphasizing awareness among young adults with high risk of CAD that primary prevention and early lifestyle modification are of paramount importance.

Optimal Percutaneous Treatment Approach to Unprotected Ostial Left Anterior Descending Artery Disease: A Meta-Analysis and Systematic Review

The optimal management strategy for significant unprotected ostial left anterior descending artery (LAD) disease remains undefined. Merits of the two most common percutaneous approaches are considered in this quantitative synthesis. A meta-analysis was performed to compare ostial stenting (OS) and crossover stenting (CS) in the treatment of unprotected ostial LAD stenosis. The primary outcome is the disparity in target lesion revascularisation (TLR). The Mantel-Haenszel method was employed with random effect model, chosen a priori to account for heterogeneity among the included studies. Seven studies comprising 1,181 patients were included in the analyses. Of these, 482 (40.8%) patients underwent CS. Overall, there was a statistically significant trend in favour of CS (odds ratio 0.51, 95% confidence interval 0.30-0.86, p=0.01) with respect to the rate of TLR at follow-up. This remained true when TLR involving the left circumflex artery (LCx) was considered, even when there was a greater need for unintended intervention to the LCx during the index procedure (odds ratio 6.68, 95% confidence interval: 1.69-26.49, p=0.007). Final kissing balloon inflation may reduce the need for acute LCx intervention. Imaging guidance appeared to improve clinical outcomes irrespective of approach chosen. In the percutaneous management of unprotected ostial LAD disease, CS into the left main coronary artery (LMCA) appeared to reduce future TLR. Integration of intracoronary imaging was pivotal to procedural success. The higher incidence of unintended LCx intervention in the CS arm may be mitigated by routine final kissing balloon inflation, although the long-term implication of this remains unclear. In the absence of randomised trials, clinicians' discretion remains critical.

Hybrid robotic-assisted coronary revascularization and transcatheter aortic valve replacement: a single-center experience.

The efficacy of hybrid robotic-assisted coronary artery bypass grafting (CABG) and transcatheter aortic valve replacement (TAVR) for coronary and aortic valve disease is poorly reported. Herein, we report our experience with this hybrid approach. Between January 2018 and June 2022, 10 (7 male, 3 female) patients with a mean age of 81 years underwent the hybrid procedure. Coronary revascularization was performed prior to TAVR with robotic-assisted left internal mammary artery-to-left anterior descending (LAD) bypass grafting for left main or proximal LAD lesions with or without multivessel disease with or without hybrid percutaneous coronary intervention (PCI). Five patients had left main disease, and 5 had proximal LAD disease with or without multivessel disease. All patients tolerated the robotic-assisted CABG procedure well; 9 patients were extubated in the operating room and all patients were ambulatory on postoperative day 1. Five patients underwent hybrid PCI for non-LAD lesions. TAVR was subsequently performed at intervals ranging from 3 days to 5 months after CABG. One patient with end-stage renal disease on hemodialysis required hospitalization for heart failure during the interval period. The 1-year mortality rate was 0%, and 3 patients died during late follow-up (24-43 months). This innovative, less invasive approach demonstrates the potential for early recovery in appropriately selected patients with complex coronary and aortic valve disease with promising mid-term outcomes.

Coronary artery bypass grafting versus percutaneous coronary intervention in single-vessel left anterior descending artery disease: mid-term propensity matching study.

Coronary artery bypass grafting (CABG) has been considered to be the proven therapeutic choice for coronary artery disease. However, percutaneous coronary intervention (PCI) with drug-eluting stents is increasingly used for extensive coronary artery disease with contradictory results. The aim of this study is to compare immediate- and mid-term results of CABG where skeletonized internal mammary artery (IMA) was used as in situ graft versus PCI with serolimus drug eluted stents (SES) in single-vessel left anterior descending artery (LAD) disease. In 2014-2022, 938 patients treated for isolated LAD revascularization were included in this study. Among them, there were 346 patients with CABG-IMA and 592 patients with SES-PCI. CABG-IMA patients (n = 266) were compared with SES-PCI patients (n = 266) in propensity score-matched method.Primary outcome measures were identified as all-cause mortality at 30days and 3years after surgery, while secondary outcome measures were length of hospital stay and the incidence of postoperative major adverse cardiovascular and cerebrovascular events (MACCE). Increased incidence for post procedural MACCE after PCI was recorded (CABG = 1.2% vs. PCI = 5.3%; p < 0.05). There was no difference in immediate-term (30days: CABG = 1.2% vs. PCI = 1.5%; p = ns) and mid-term (3years: CABG = 3.7% vs. PCI = 4.5%; p = ns) mortality between the groups. Patient after SES-PCI had shorter length of hospital stay (CABG = 7.7days vs. PCI = 3.8days; p < 0.05). The results of the study indicated that CABG-IMA performed at the time of myocardial revascularization in single-vessel LAD disease is better than SES-PCI. Our conclusion is independent of traditionally accepted risk factors incorporated in the Logistic EuroSCORE II (European System for Cardiac Operative Risk Evaluation) and SYNTAX score II (Synergy Between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery Score II) and is exclusively method related.

Differences in left anterior descending coronary artery disease in participants without standard modifiable cardiovascular risk factors: the Multi-Ethnic Study of Atherosclerosis (MESA)

Abstract Background/Introduction The development of coronary artery disease (CAD) and myocardial infarction (MI) in the absence of standard modifiable cardiovascular risk factors (SMuRFs) has been highlighted as an unmet clinical need, accounting for between 10-27% of ST elevation MI and associated with higher 30-day mortality. One potential contributor to the early mortality is the higher observed rates of LAD territory culprit lesions in SMuRFless patients compared to those with at least one SMuRF. Purpose To characterise the differential proportion of LAD disease in an asymptomatic population with no prior cardiovascular disease (CVD) history, comparing individuals with CAD despite no SMuRFs to those with at least one SMuRF in the Multi-Ethnic Study of Atherosclerosis (MESA). Methods A MESA sub-cohort with a baseline coronary artery calcium score (CACS) &amp;gt;0 Agatston units (AU) was prepared. SMuRF status was assigned by self-report, treatment, or biomarkers for hypertension, hypercholesterolaemia, diabetes, and smoking. Proportion of disease in the left main, LAD, circumflex, and right coronary arteries were calculated by the vessel CACS divided by the total CACS. Standard descriptive statistics were used to characterise baseline differences. Group comparisons were completed with Wilcoxon rank sum for continuous measures and Chi-square for categorical. Results A CAC positive cohort of 3,417 participants was prepared from participants with SMuRF and CT imaging data, 14.3% of whom were considered SMuRFless. Total CACS was lower in SMuRFless participants compared to those with ≥1 SMuRF (58 AU vs. 102 AU, p&amp;lt;0.0001). However, proportion of calcium burden in the LAD was significantly higher in SMuRFless participants with CAD (74.2% vs. 56.8%, p&amp;lt;0.0001). When considering clinically significant CACS strata, proportion of LAD calcium burden was not significantly different between SMuRFless vs. ≥1 SMuRF participants with a total CACS of 1-99 AU (93.7% vs. 80.0%). However, statistically significant differences in LAD calcium proportion were observed between SMuRFless vs. ≥1 SMuRF participants with a total CACS 100-400 AU (69.5% vs. 57.8%) and CACS&amp;gt;400AU (45.2% vs. 40.5%). This difference remained significant during multivariate modelling, including consideration of absolute CACS. Conclusion Of patients with evidence of CAD (CACS&amp;gt;0) in the MESA cohort, SMuRFless status was associated with a higher proportion of LAD disease compared to participants with ≥1 SMuRF. This adds to previous observations in STEMI cohorts suggesting a heightened susceptibility to atherosclerosis development in the LAD territory against a lower traditional risk burden, and highlights the need for consideration of distinct biology and clinical significance in future studies.Fig. 1Fig. 2

Impact of symptom-to-reperfusion-time on transmural infarct extent and left ventricular strain in patients with ST-segment elevation myocardial infarction: a 3D view on the wavefront phenomenon.

We examined the association between the symptom-to-reperfusion-time and cardiovascular magnetic resonance (CMR)-derived global strain parameters and transmural infarct extent in ST-segment elevation myocardial infarction (STEMI) patients. The study included 108 STEMI patients who underwent successful primary percutaneous coronary intervention (PPCI). Patients were categorized according to the median symptom-to-reperfusion-time: shorter (<160 min, n = 54) and longer times (>160 min, n = 54). CMR was performed 2-7 days after PPCI and at 1 month. CMR cine imaging was performed for functional assessment and late gadolinium enhancement to evaluate transmural infarct extent. Myocardial feature-tracking was used for strain analysis. Groups were comparable in relation to incidence of LAD disease and pre- and post-PPCI thrombolysis in myocardial infarction (TIMI) flow grades. The mean transmural extent score at follow-up was lower in patients with shorter reperfusion time (P < 0.01). Both baseline and follow-up maximum transmural extent scores were smaller in patients with shorter reperfusion time (P = 0.03 for both). Patients with shorter reperfusion time had more favourable global left ventricular (LV) circumferential strain (baseline, P = 0.049; follow-up, P = 0.01) and radial strain (baseline, P = 0.047; follow-up, P < 0.01), whilst LV longitudinal strain appeared comparable for both baseline and follow-up (P > 0.05 for both). In multi-variable regression analysis including all three strain directions, baseline LV circumferential strain was independently associated with the mean transmural extent score at follow-up (β=1.89, P < 0.001). In STEMI patients, time-to-reperfusion was significantly associated with smaller transmural extent of infarction and better LV circumferential and radial strain. Moreover, infarct transmurality and residual LV circumferential strain are closely linked.

D-26 | Outcomes of Stenting vs Robotic Bypass Surgery in Isolated Single Vessel LAD Disease

D-26 | Outcomes of Stenting vs Robotic Bypass Surgery in Isolated Single Vessel LAD Disease

Prioritization of invasive coronary angiogram for deserving patients with chronic coronary syndrome (CCS) using an Angiogram Eligibility Scoring (AES) system - A Clinical Audit

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Many patients with CCS are usually referred for invasive treatment early on first come first serve basis. Proper clinical assessment of the severity of symptoms and optimization of the medical therapy lack before referral for invasive therapy due to increased workload and less man power. Patients with non-limiting symptoms are noticed to receive invasive therapy over medical therapy more. Recent ISCHAEMIA trial showed that invasive therapy is not associated with reduction in adverse ischaemic events compared to optimal medical therapy in CCS. Therefore, We implemented a scoring system to identify high risk CCS patients to receive invasive therapy Methods Angiogram eligibility scoring (AES) is given to patients according to age, gender, atherosclerotic risk factors, symptom profile, stress test findings and the history of myocardial infarction. Similar numbers of patients who underwent invasive angiography through first come first serve basis group and AES group over three consecutive months are compared. Patients in the AES group were called for invasive angiogram according to score in descending order. Each group of patients were analyzed for cardiometabolic risk factors, anginal symptoms, ejection fraction, angiography findings and revascularization plan. Results Patients came for invasive angiogram through AES had significant risk factors such as diabetes and dyslipidaemia (P&amp;lt;0.01). Limiting symptoms (Class 3-4 angina) and strongly positive stress test (P&amp;lt;0.01) are significantly high in AES group than first come first serve group. Ejection fraction is normal range in AES group (P&amp;lt;0.01). No significant difference found in the significant LMCA (&amp;gt;50%) plaque disease, severe (&amp;gt;70%) LAD and proximal LAD disease frequency, complexity in coronary artery disease and revascularization strategies between two groups (P&amp;gt;0.01). Conclusion AES system facilitated us to prioritize patients with limiting symptoms, strongly positive stress test and multiple atherosclerotic risk factors who would benefit from early invasive angiogram and revascularization over other patients with non-limiting symptoms and without non-invasive investigation before invasive angiography.

405 A NATURAL HISTORY OF VERY LONG-TERM BIORESORBABLE ATHEROSCLEROTIC RESTORATION THERAPY

Abstract A 49-year-old man was referred to our cath-lab in 2015 after the detection of inducible ischaemia in the infero-lateral wall on single-photon emission CT performed due to a worsening stable angina. His cardiovascular risk factors accounted for family history of ischemic disease, high blood pressure and dyslipidaemia. The echocardiography highlighted a mildly reduced left ventricular function with infero-lateral wall hypokinesia. Coronary angiography revealed a chronic total occlusion (CTO) of the left circumflex artery (LCX) and a long diffuse severe disease of the right coronary artery (RCA). The left anterior descending artery (LAD) showed a diffuse atherosclerotic involvement without critical stenoses. Percutaneous coronary intervention (PCI) was performed after Heart Team discussion with implantation of two 3.5×28mm and 3.5×23mm Absorb bioresorbable vascular scaffold (BVS) on the RCA. Moreover, the LCX CTO was successfully treated by anterograde approach with implantation of a 3.0×28 mm Absorb BVS. Intravascular ultrasound confirmed the optimal result of both the interventions, while confirmed the long diffuse calcific involvement of the LAD with a thick cap calcific fibroatheroma at the virtual histology. The patient was discharged on dual antiplatelet therapy for twelve months. After five uneventful years, he was readmitted to our department for recurrence of worsening stable angina. At the coronary angiography a significant progression of the proximal LAD disease was noted. The lesion was judged hemodynamic relevant with pressure derived indices (instantaneous wave-free ratio 0.86; fractional flow reserve 0.70). The IVUS and optical coherence tomography (OCT) analysis confirmed the significant progression of the disease with a long, diffuse, sub-occlusive thick cap fibroatheroma stenosis (minimal lumen area 1.9 mm2; plaque burden 91%). The OCT analysis showed the complete resorption of the devices previously implanted to the RCA and the LCX, with optimal long-term results and positive remodelling in the LCX. Therefore, an OCT-guided PCI with marker-to-marker implantation of two 3.5×25 and 3×20 mm magnesium-based Magmaris BVS was performed. In 2022, the patient underwent an elective coronary angiography that demonstrated a complete resorption of both the Magmaris with an optimal OCT result. Conversely, the positive remodelled segment resulting from complete resorption of the poly-L-lactic-based BVS in the mid-LCX was shown to be progressed to a critical sub-occlusive fibroatheroma. A further OCT-guided PCI with deployment one 3.5×20mm Magmaris BVS was performed. Six months later, patient was asymptomatic with a good performance status. To the best of our knowledge, the present is the first case of multivessel repetitive imaging-based percutaneous revascularizations with the use of two different BVS technologies and a total of six devices implanted, with very long-term intracoronary imaging result. Through the paired intravascular imaging analysis, this case sought to provide insightful findings on vulnerable plaque atherosclerotic progression and on BVS biologic restoration therapy, a process that appears particularly appealing in young patients with advanced CAD, namely multivessel involvement and diffuse disease that still poses limitations to PCI.

CASE REPORT OF SPONTANEOUS CORONARY ARTERY DISSECTION IN A PATIENT POSITIVE FOR COVID-19

CASE REPORT OF SPONTANEOUS CORONARY ARTERY DISSECTION IN A PATIENT POSITIVE FOR COVID-19

Long Term Results of LAD reconstruction with LIMA Patch in Patients with multiple significant LAD disease

Long Term Results of LAD reconstruction with LIMA Patch in Patients with multiple significant LAD disease

S2264 A Case of Progressive Untreated Eosinophilic Gastrointestinal Disorder Complicated by Eosinophilic Myocarditis

Introduction: Eosinophilic gastrointestinal diseases (EGID) are immune-mediated conditions characterized by GI dysfunction and histological evidence of eosinophilic infiltration. While usually confined to the GI tract, severe inflammation can involve multiple organ systems, typically under the umbrella term of hypereosinophilic syndrome (HES). Patients can present with cardiac involvement such as eosinophilic myocarditis which results in an uncommon, but potentially lethal complication. We present a case of a patient with prior history of eosinophilic esophagitis (EoE) subsequently presenting with diffuse EGID complicated by eosinophilic myocarditis. Case Description/Methods: A 63-year-old female with a history of EoE and breast cancer post mastectomy presented with acute epigastric and chest pain. The patient had biopsy-proven EoE which was managed with PPI in the past. On physical examination, she had diffuse abdominal tenderness. Labs were remarkable for peripheral eosinophilia peaking at 57%. Initial high sensitivity troponin I was 300 ng/L without EKG changes, and ultimately peaked at 7821 ng/L. CT of the abdomen and pelvis showed thickening of the stomach, duodenum, and jejunum. Left heart catheterization revealed LAD disease without obstructive disease. EGD demonstrated severe inflammation, erythema, and eosinophilic infiltration in the gastric body, antrum, and throughout the duodenum. High dose steroids were initiated with subsequent improvement in symptoms, serum troponin, and complete resolution of peripheral eosinophilia. Patient followed up as an outpatient, where cardiac MRI confirmed eosinophilic myocarditis, and she was started on Mepolizumab for maintenance therapy and prevention of relapse. Discussion: EGID are increasingly prevalent disorders that can result in significant morbidity and mortality without prompt diagnosis. This patient had a history of EoE and developed diffuse GI involvement and subsequent eosinophilic myocarditis. Her presentation as atypical chest pain suggestive of NSTEMI resulted in delay of initiation of steroids until after heart catheterization. Our case suggests that without glucocorticoid suppression, eosinophilia can cause widespread tissue infiltration and damage. The majority of these patients have chronic disease that require long term maintenance therapy. Mepolizumab has been demonstrated to be an effective agent for hypereosinophilic disorders. When managing EGID, it is pertinent to recognize early involvement of systemic eosinophilic infiltration.Figure 1.: EGD.

LIMA to LAD grafting returns patient survival to age-matched population: 20-year outcomes of MIDCAB surgery.

OBJECTIVESPrevious studies have demonstrated the safety and excellent short-term and mid-term survival after minimally invasive direct coronary artery bypass (MIDCAB). We reviewed the long-term outcomes up to 20 years, including overall survival and freedom from reintervention.METHODSConsecutive patients who underwent MIDCAB between February 1997 and August 2020 were identified. Demographic details, operative information and long-term outcomes were obtained. The Australian National Death Index database was accessed to obtain long-term mortality data.RESULTSA total of 271 patients underwent an MIDCAB procedure during the study period. There were no intraoperative deaths and only one 30-day mortality (0.4%). The mean length of follow-up was 9.82 ± 8.08 years. Overall survival at 5-, 10-, 15- and 20-year survival was 91.9%, 84.7%, 71.3% and 56.5%, respectively. Patients with single-vessel disease [left anterior descending artery (LAD) only] had significantly better survival compared to patients with multivessel disease (P = 0.0035). During long-term follow-up, there were no patients who required repeat revascularization of the LAD territory. Sixty-nine patients died with the cause of death in 15 patients (21.7%) being attributable to ischaemic heart disease. An analysis comparing the isolated LAD disease MIDCAB cohort survival with the expected survival among an age/gender/year matched sample of the Australian reference population, using the standardized mortality ratio, demonstrated that the rate of survival returned to that of the reference population (standardized mortality ratio = 0.94).CONCLUSIONSMIDCAB is a safe and effective revascularization strategy which can be successfully performed in a carefully selected patient population with low morbidity and excellent long-term results. The survival of MIDCAB patients returns to that of their age/gender/year-matched counterparts within the normal population and hence should be offered as an alternative to coronary stenting when counselling patients with ischaemic heart disease.

Comparison of post-procedural rise of cardiac biomarkers after implantation of an everolimus-eluting bioresorbable vascular scaffold versus everolimus-eluting metallic stent in patients with long/diffuse LAD disease

Objectives This study sought to evaluate the incidence and the mechanism of post-procedural cardiac biomarker (CB) rise following device implantation. Background A fully bioresorbable Absorb scaffold, compared with everolimus-eluting metallic stents (EES), might be associated with a higher incidence of periprocedural myocardial injury. Methods Prospective nonrandomized comparative study enrolled 52 patients with stable myocardial ischemia with diffuse/ long LAD lesion for either an everolimus-eluting bioresorbable vascular (BVS) scaffold (22 patients) or an EES (30 patients), 3 types of CB (creatine kinase (CK), creatine kinase-myocardial band (CK-MB), and troponin) were obtained before and after procedure. Per protocol, periprocedural myocardial infarction (PMI) was defined as CK rise &gt;2 the upper limit of normal with CK-MB rise. Results Incidence of side branch occlusion (SBO) and any anatomic complications assessed by angiography was similar between the 2 treatment arms (SBO: Absorb: 4.5% vs. Xience: 6.7%, p=1; One PMI with acute instent thrombosis occurred in EES group. Dissection occurred in only 1 patient in BVS arm after stent implantation; this event was not associated with elevated cardiac biomarkers. One patient had PMI in BVS arm with no angiographic complications to explain it.

Feasibility and Safety of Drug-Coated Balloon-Only Angioplasty for De Novo Ostial Lesions of the Left Anterior Descending Artery: Two-Center Retrospective Study.

IntroductionThere is limited evidence regarding the effectiveness of drug-coated balloon (DCB) angioplasty in the percutaneous treatment of complex de novo ostial coronary lesions. This study primarily aimed to explore the feasibility and safety of this innovative approach for ostial lesions in the left anterior descending artery (LAD).MethodsPatients treated with paclitaxel DCB or second-generation drug-eluting stents (DES) were retrospectively enrolled from two large centers. The primary endpoints were major adverse cardiovascular events (MACE), including cardiovascular death, target lesion revascularization (TLR), target vessel revascularization, and recurrent myocardial infarction related to target artery occlusion. Cox regression analysis was used to identify risk factors for MACE, and propensity score matching was performed to minimize selection bias.ResultsA total of 388 patients were included; among them, 52 were treated with paclitaxel DCB, and 336 with DES for ostial LAD lesions. Using propensity score matching, 49 patients were treated with DCB-only and 49 with the DES strategy. The average follow-up time was 12 months; subsequently, a non-significant decrease in MACE rate was observed in the DCB-only angioplasty treatment group (MACE: 6 vs. 6%, p = 1.0; TLR: 2 vs. 4%, p = 0.56). Cox regression analysis indicated that DCB-only angioplasty was not an independent risk factor for adverse events after adjusting for confounding risk factors (hazard ratio: 1.713, p = 0.43).ConclusionThe use of the DCB-only approach is an innovative and optional strategy in the treatment of isolated ostial LAD disease. A further randomized trial is of necessity to confirm the feasibility and safety of drug-coated balloon-only angioplasty for LAD de novo ostial lesions.