Extensive Coronary Artery Disease Research Articles

Complete revascularization in coronary artery bypass grafting with coronary artery endarterectomy: updated findings from Vietnam

We examined the technique and early outcomes of coronary artery bypass graft surgery (CABG) with endarterectomy. In 2023, the single-center database identified 24 severe coronary disease patients undergoing CABG with coronary artery endarterectomy. The patients were in a selected cohort with a minimum of three grafts for the three main vessels. Patients’ mean age was 63.8 years. The mean number of grafts was 4.3. A coronary endarterectomy (CE) was performed on the right coronary artery in 45.8% of patients, the left anterior descending artery in 29.1%, the circumflex artery in 16.6%, and the diagonal artery in 29.1%. Aortic cross-clamp took 147.2 minutes, perfusion 180.9 minutes, mechanical ventilation 18.9 hours, and intensive care unit stay 4.8 days. Our in-hospital mortality rate was 8.3% with no technical complications. To achieve complete revascularization in patients with extensive coronary artery disease, CE should be considered an acceptable adjunct to CABG.

Artificial intelligence–enhanced electrocardiography analysis as a promising tool for predicting obstructive coronary artery disease in patients with stable angina

Abstract Aims The clinical feasibility of artificial intelligence (AI)-based electrocardiography (ECG) analysis for predicting obstructive coronary artery disease (CAD) has not been sufficiently validated in patients with stable angina, especially in large sample sizes. Methods and results A deep learning framework for the quantitative ECG (QCG) analysis was trained and internally tested to derive the risk scores (0–100) for obstructive CAD (QCGObstCAD) and extensive CAD (QCGExtCAD) using 50 756 ECG images from 21 866 patients who underwent coronary artery evaluation for chest pain (invasive coronary or computed tomography angiography). External validation was performed in 4517 patients with stable angina who underwent coronary imaging to identify obstructive CAD. The QCGObstCAD and QCGExtCAD scores were significantly increased in the presence of obstructive and extensive CAD (all P < 0.001) and with increasing degrees of stenosis and disease burden, respectively (all Ptrend < 0.001). In the internal and external tests, QCGObstCAD exhibited a good predictive ability for obstructive CAD [area under the curve (AUC), 0.781 and 0.731, respectively] and severe obstructive CAD (AUC, 0.780 and 0.786, respectively), and QCGExtCAD exhibited a good predictive ability for extensive CAD (AUC, 0.689 and 0.784). In the external test, the QCGObstCAD and QCGExtCAD scores demonstrated independent and incremental predictive values for obstructive and extensive CAD, respectively, over that with conventional clinical risk factors. The QCG scores demonstrated significant associations with lesion characteristics, such as the fractional flow reserve, coronary calcification score, and total plaque volume. Conclusion The AI-based QCG analysis for predicting obstructive CAD in patients with stable angina, including those with severe stenosis and multivessel disease, is feasible.

Coronary Revascularisation in Heart Failure with Reduced Ejection Fraction

The role of myocardial revascularisation in patients suffering from ischaemic cardiomyopathy with extensive coronary artery disease and heart failure with reduced ejection fraction (HFrEF) remains controversial. Percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) are considered revascularisation procedures. Evidence prior to the latest medical treatment advances only suggests a long-term benefit of CABG over pharmacological therapy in this population. When angina-related symptoms dominate patients’ lives despite optimal medical treatment, PCI can be considered if the patient is ineligible for CABG after carefully weighing up the perioperative risk. Viability and/or ischaemia detection to guide revascularisation have been unable to accurately predict treatment effects of CABG or PCI. Optimal heart failure treatment should be initiated in all patients presenting with ischaemic cardiomyopathy and HFrEF as the first and most important measure to improve long-term prognosis.

Hypertension, microvascular obstruction and infarct size in patients with STEMI undergoing PCI: Pooled analysis from 7 cardiac magnetic resonance imaging studies

Mortality after ST-segment elevation myocardial infarction (STEMI) is increased in patients with hypertension. The mechanisms underlying this association are uncertain. We sought to investigate whether patients with STEMI and prior hypertension have greater microvascular obstruction (MVO) and infarct size (IS) compared with those without hypertension. We pooled individual patient data from 7 randomized trials of patients with STEMI undergoing primary percutaneous coronary intervention (PCI) in whom cardiac magnetic resonance imaging was performed within 1 month after reperfusion. The associations between hypertension and MVO, IS, and mortality were assessed in multivariable adjusted models. Among 2174 patients (61.3 ± 12.6 years, 76% male), 1196 (55.0%) had hypertension. Patients with hypertension were older, more frequently diabetic and had more extensive coronary artery disease than those without hypertension. MVO and IS measured as percent LV mass were not significantly different in patients with and without hypertension (adjusted differences 0.1, 95% CI -0.3 to 0.6, P = .61 and -0.2, 95% CI -1.5 to 1.2, P = .80, respectively). Hypertension was associated with a higher unadjusted risk of 1-year death (hazard ratio [HR] 2.28, 95% CI 1.44-3.60, P < .001), but was not independently associated with higher mortality after multivariable adjustment (adjusted HR 1.04, 95% CI 0.60-1.79, P = .90). In this large-scale individual patient data pooled analysis, hypertension was not associated with larger IS or MVO after primary PCI for STEMI.

Sex Differences in Revascularization, Treatment Goals, and Outcomes of Patients With Chronic Coronary Disease: Insights From the ISCHEMIA Trial.

Women with chronic coronary disease are generally older than men and have more comorbidities but less atherosclerosis. We explored sex differences in revascularization, guideline-directed medical therapy, and outcomes among patients with chronic coronary disease with ischemia on stress testing, with and without invasive management. The ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) trial randomized patients with moderate or severe ischemia to invasive management with angiography, revascularization, and guideline-directed medical therapy, or initial conservative management with guideline-directed medical therapy alone. We evaluated the primary outcome (cardiovascular death, myocardial infarction, or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest) and other end points, by sex, in 1168 (22.6%) women and 4011 (77.4%) men. Invasive group catheterization rates were similar, with less revascularization among women (73.4% of invasive-assigned women revascularized versus 81.2% of invasive-assigned men; P<0.001). Women had less coronary artery disease: multivessel in 60.0% of invasive-assigned women and 74.8% of invasive-assigned men, and no ≥50% stenosis in 12.3% versus 4.5% (P<0.001). In the conservative group, 4-year catheterization rates were 26.3% of women versus 25.6% of men (P=0.72). Guideline-directed medical therapy use was lower among women with fewer risk factor goals attained. There were no sex differences in the primary outcome (adjusted hazard ratio [HR] for women versus men, 0.93 [95% CI, 0.77-1.13]; P=0.47) or the major secondary outcome of cardiovascular death/myocardial infarction (adjusted HR, 0.93 [95% CI, 0.76-1.14]; P=0.49), with no significant sex-by-treatment-group interactions. Women had less extensive coronary artery disease and, therefore, lower revascularization rates in the invasive group. Despite lower risk factor goal attainment, women with chronic coronary disease experienced similar risk-adjusted outcomes to men in the ISCHEMIA trial. URL: http://wwwclinicaltrials.gov. Unique identifier: NCT01471522.

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.

Neutrophil-to-albumin ratio: a promising tool for CAD assessment in non-ST elevation AMI.

In the context of coronary artery disease (CAD) pathogenesis, inflammation has emerged as a critical player. This study investigates the potential of the Neutrophil-to-Albumin Ratio (NAR) as a novel biomarker for assessing CAD severity and extension in patients suffering from acute myocardial infarction (AMI) without ST-segment elevation. We conducted a comprehensive analysis of consecutive patient records (n = 211) from a single center, focusing on individuals diagnosed with non-ST elevation AMI. To gauge CAD severity, we employed Syntax Scores (SS) and examined their correlation with NAR, C-reactive protein-albumin ratio (CRPALB), and the systemic immune inflammation index (SII). Statistical analyses were conducted to establish associations and predictive capabilities. Our analysis revealed a significant correlation between NAR and Syntax Scores (r: .416, p<0.01). Notably, patients with intermediate-high SS exhibited significantly elevated NAR values compared to those in the low SS group [20.86+5.38 vs. 16.41+6.30 (p<0.001)]. Furthermore, NAR outperformed CRPALB, SII, and Neutrophil Percent-to-Albumin Ratio (NPAR) in discriminating CAD severity, as demonstrated by the Receiver Operating Characteristic (ROC) curve analysis (NAR AUC: 0.736; CRPALB AUC: 0.673; SII AUC: 0.660; NPAR AUC: 0.717). This study underscores the potential of NAR as a robust predictor of CAD severity and extension in non-ST elevation AMI patients. While previous markers, such as CRPALB and SII, are advantageous, NAR's superior predictive capabilities are a valuable addition to the clinician's toolkit, offering enhanced risk assessment for this specific patient subgroup.

Comparing the long-term outcomes in chronic coronary syndrome patients with prior ST-segment and non-ST-segment elevation myocardial infarction: findings from the TIGRIS registry

ObjectivesCompared with ST-segment elevation myocardial infarction (STEMI) patients, non-STEMI (NSTEMI) patients have more comorbidities and extensive coronary artery disease. Contemporary comparative data on the long-term prognosis of stable post-myocardial infarction...

Atrial fibrillation diagnosed at different phases of myocardial infarction are all associated with excess risk

Abstract Background Atrial fibrillation (AF) in patients with myocardial infarction (MI) is associated with higher mortality and cardiovascular complications such as hospitalisation due to heart failure and ischaemic stroke. It is unknown whether the association with poor outcomes is general or specific for AF diagnosed before, at or during follow-up after an MI. Purpose The aim of this study was to investigate the occurrence of AF, and its clinical correlates at different stages in patients with acute MI. In addition, we also explored whether any association between AF and mortality, incident heart failure or stroke differed for AF diagnosed at these stages. Methods Patients attending cardiac rehabilitation after MI in Sweden 2006-2020 were identified in the Swedish registry for cardiac disease SWEDEHEART. The patients were divided into groups with sinus rhythm at hospitalisation and follow-up (reference group), AF at MI hospitalisation including prior and new-onset AF during MI hospitalisation, and late-onset AF diagnosed at cardiac rehabilitation follow-up visits during the first year post-MI. All patients were followed until 2020-12-31 and the groups were compared regarding overall mortality, hospitalisation due to heart failure, and stroke using log-rank test and Cox-regression adjusted for age in cubic splines and sex. Results Overall 104,325 patients (26% female) between 18-80 years old were investigated. 4731 patients presented with AF at admission for MI (4.5%) and 2,119 (2%) had a persistent AF at discharge. Out of these, 139 had new-onset AF at MI. STEMI was more common in patients with new onset AF compared to those with a history of AF before MI (40.3% vs 31.7%, p=0.013). During the one-year follow-up period after index MI 448 patients had a new-onset AF which was associated with older age, NSTEMI, reduced ejection fraction and more extensive coronary artery disease at the index MI. The association between AF diagnosed at the different phases of MI with outcomes are illustrated in figure 1. During a median follow-up of 7.0 years, patients with AF at MI had a higher mortality (33.3% vs 14.2%, p&amp;lt;0.001), more hospitalisations due to heart failure (25.6% vs 6.7%, p&amp;lt;0.001) and stroke (8.0% vs 3.9%, p&amp;lt;0.001) compared to patients with SR. Patients with new-onset AF at MI had a similar risk for these outcomes compared to patients with a history of AF at MI. Patients with late-onset AF during the one-year follow-up period after index MI also had higher mortality (28.3% vs 12.2%, p&amp;lt;0.001) and more hospitalisations for heart failure (21.9% vs 5.6%, p&amp;lt;0.001) but not stroke (4.2% vs 3.9%, ns) compared to patients that remained in SR. Conclusion In patients attending cardiac rehabilitation after MI, chronic AF, new-onset AF at MI and late-onset AF were associated with increased risk for mortality, heart failure hospitalisations and stroke. Hence, AF should be considered a severe risk factor in patients with MI irrespective of time of occurrence.AF at MI

Mid-term outcomes in aortic stenosis patients treated with contemporary balloon expandable and self-expanding valves; does valve size have an impact on outcome?

Abstract Background No data currently exists comparing the performance of the contemporary iterations of balloon-expandable (BE) Edwards SAPIEN 3/Ultra and the self-expanding (SE) Medtronic Evolut PRO/R34 valves. In addition, no direct head to head comparisons of the aforementioned devices have been performed in patients with small annuli with the exception of small registries. Purpose Aim of the study was the head-to-head comparison of these transcatheter heart valves (THV) with emphasis on patients with small aortic annulus. Methods In this retrospective registry, peri-procedural outcomes and mid-term all-cause mortality were analyzed. Results 1673 patients (917 SE vs. 756 BE) were followed-up for a median of 15 months. Baseline demographics were similar apart from worse left ventricle systolic function amongst SE patients and more extensive coronary artery disease amongst BE patients. 194 patients died (11.6%) during follow-up. SE and BE groups showed similar survival at one (92.6 vs. 90.6%) and three-years (80.3% vs. 85.2%), plog-rank=0.136. Compared to the BE group, patients treated with SE device had lower peak (16.3±8mmHg SE vs. 21.9±8mmHg BE, p=0.001) and mean (8.8±5mmHg SE vs. 11.5±5mmHg BE, p=0.001) gradients at discharge. Conversely, the BE group demonstrated lower rates of at least moderate paravalvular regurgitation (PVR) post-operatively (5.6% vs. 0.7% for SE and BE valves respectively, p&amp;lt;0.001). In patients treated with small THV (≤26 for SE and ≤23mm for BE; N=284 for SE and N=260 for BE) survival was higher amongst patients treated with SE valves at both 1 (96.7% SE vs. 92.1% BE) and 3-years (91.8% SE vs. 82.2% BE), plog-rank=0.042. Conclusions Real-world comparison of the latest generation SE and BE devices demonstrated similar survival up to 3 years follow-up. Among patients with small aortic annulus, those treated with SE valves seem to demonstrate improved survival rates.36months survival rates

A simple coronary CT angiography-based jeopardy score for the identification of extensive coronary artery disease: Validation against invasive coronary angiography

PurposeThe invasive British Cardiovascular Intervention Society Jeopardy Score (iBCIS-JS) is a simple angiographic scoring system, enabling quantification of the extent of jeopardized myocardium related to clinically significant coronary artery disease (CAD). The purpose of this study was to develop and validate the coronary CT angiography-based BCIS-JS (CT-BCIS-JS) against the iBCIS-JS in patients with suspected or stable CAD. Materials and methodsPatients who underwent coronary CT angiography followed by invasive coronary angiography, within 90 days were retrospectively included. CT-BCIS-JS and iBCIS-JS were calculated, with a score ≥ 6 indicating extensive CAD. Correlation between the CT-BCIS-JS and iBCIS-JS was searched for using Spearman's coefficient, and agreement with weighted Kappa (κ) analyses. ResultsA total of 122 patients were included. There were 102 men and 20 women with a median age of 62 years (Q1, Q3: 54, 68; age range: 19–83 years). No differences in median CT-BCIS-JS (4; Q1, Q3: 0, 8) and median iBCIS-JS (4; Q1, Q3: 0, 8) were found (P = 0.18). Extensive CAD was identified in 53 (43.4%) and 52 (42.6%) patients using CT-BCIS-JS and iBCIS-JS, respectively (P = 0.88). CT-based and iBCIS-JS showed excellent correlation (r = 0.98; P < 0.001) and almost perfect agreement (κ = 0.93; 95% confidence interval: 0.90–0.97). Agreement for identification of an iBCIS-JS ≥ 6 was almost perfect (κ = 0.94; 95 % confidence interval: 0.87–0.99). ConclusionThe CT-BCIS-JS represents a feasible, and accurate method for quantification of CAD, with capabilities not different from those of iBCIS-JS. It enables simple, non-invasive identification of patients with anatomically extensive CAD.

Viability and Outcomes With Revascularization or Medical Therapy in Ischemic Ventricular Dysfunction

In the Revascularization for Ischemic Ventricular Dysfunction (REVIVED-BCIS2) trial, percutaneous coronary intervention (PCI) did not improve outcomes for patients with ischemic left ventricular dysfunction. Whether myocardial viability testing had prognostic utility for these patients or identified a subpopulation who may benefit from PCI remained unclear. To determine the effect of the extent of viable and nonviable myocardium on the effectiveness of PCI, prognosis, and improvement in left ventricular function. Prospective open-label randomized clinical trial recruiting between August 28, 2013, and March 19, 2020, with a median follow-up of 3.4 years (IQR, 2.3-5.0 years). A total of 40 secondary and tertiary care centers in the United Kingdom were included. Of 700 randomly assigned patients, 610 with left ventricular ejection fraction less than or equal to 35%, extensive coronary artery disease, and evidence of viability in at least 4 myocardial segments that were dysfunctional at rest and who underwent blinded core laboratory viability characterization were included. Data analysis was conducted from March 31, 2022, to May 1, 2023. Percutaneous coronary intervention in addition to optimal medical therapy. Blinded core laboratory analysis was performed of cardiac magnetic resonance imaging scans and dobutamine stress echocardiograms to quantify the extent of viable and nonviable myocardium, expressed as an absolute percentage of left ventricular mass. The primary outcome of this subgroup analysis was the composite of all-cause death or hospitalization for heart failure. Secondary outcomes were all-cause death, cardiovascular death, hospitalization for heart failure, and improved left ventricular function at 6 months. The mean (SD) age of the participants was 69.3 (9.0) years. In the PCI group, 258 (87%) were male, and in the optimal medical therapy group, 277 (88%) were male. The primary outcome occurred in 107 of 295 participants assigned to PCI and 114 of 315 participants assigned to optimal medical therapy alone. There was no interaction between the extent of viable or nonviable myocardium and the effect of PCI on the primary or any secondary outcome. Across the study population, the extent of viable myocardium was not associated with the primary outcome (hazard ratio per 10% increase, 0.98; 95% CI, 0.93-1.04) or any secondary outcome. The extent of nonviable myocardium was associated with the primary outcome (hazard ratio, 1.07; 95% CI, 1.00-1.15), all-cause death, cardiovascular death, and improvement in left ventricular function. This study found that viability testing does not identify patients with ischemic cardiomyopathy who benefit from PCI. The extent of nonviable myocardium, but not the extent of viable myocardium, is associated with event-free survival and likelihood of improvement of left ventricular function. ClinicalTrials.gov Identifier: NCT01920048.

TCT-357 Immediate Complete Revascularization in Patients Presenting With Acute Coronary Syndrome and Extensive Coronary Artery Disease: Insights From the BIOVASC Trial

TCT-357 Immediate Complete Revascularization in Patients Presenting With Acute Coronary Syndrome and Extensive Coronary Artery Disease: Insights From the BIOVASC Trial

Treatment with SGLT2 Inhibitors in Patients with Diabetes Mellitus and Extensive Coronary Artery Disease: Mortality and Cardiovascular Outcomes.

Sodium-glucose type2 cotransporter inhibitors (SGLT2-I) have shown solid benefits in reducing cardiovascular mortality and admissions for heart failure in patients with type2 diabetes mellitus (T2DM) and cardiovascular disease. However, no specific studies exist in patients with high-risk coronary artery disease (CAD). Single-center, retrospective, observational study including patients with T2DM and a new diagnosis of extensive CAD (defined as left main disease or three main coronary vessel disease). Patients were recruited from 2015 until 2020, with a follow-up of at least 12months. The primary outcome was to compare all-cause mortality in patients treated with or without SGLT2-I at discharge and adjusted by inverse probability of treatment weighting (IPTW) propensity score. A total of 420 patients were included: 104 (24.7%) were treated with SGLT2-I and 316 (75.3%) were not (non-SGLT2-I group). The presentation was acute coronary syndrome in 44.3%. The mean age was 71.2 ± 10.5years. The mean left ventricular ejection fraction was 51.5 ± 12.5%, and the mean estimated glomerular filtration rate was 73.9 ± 22ml/min. After a mean follow-up of 3 ± 1.6years, all-cause mortality was 16.4%, and cardiovascular mortality was 9.5%. After IPTW, the risk of all-cause death was lower in the SGLT2-I group with a hazard ratio of 0.32 (95% confidence interval 0.12-0.81), p = 0.016. With regard to secondary outcomes, patients in the SGLT2-I group were associated with less renal function deterioration but an increase in unplanned revascularizations. In patients with T2DM and extensive CAD, treatment with SGLT2-I after discharge was associated with a reduced risk of all-cause death.

Off Pump CABG Improves Postoperative Incidence of Coagulopathy Compared with CABG on Pump

Abstract Background Coronary artery bypass grafting remains the standard treatment for patients with extensive coronary artery disease. Coronary surgery without use of cardiopulmonary bypass avoids the deleterious systemic inflammatory effects of the extracorporeal circuit. However there is an ongoing debate surrounding the clinical outcomes after on-pump versus off-pump coronary artery bypass (ONCAB versus OPCAB) grafting surgery. Aim of the Work To compare the incidence of postoperative coagulopathy transfusion of blood product therapy, (Packed RBCs, FFP and platelet concentrate) bleeding (amount of blood in chest tube drains) and reexploration, that occur in adults off pump CABG surgery in comparison to on pump CABG. Patients and Methods We enrolled sixty consecutive adult patients scheduled for isolated CABG surgery (with a median sternotomy) with or without cardiopulmonary bypass pump. The patients are allocated in two groups where thirty patients in each group (group A – On pump – ONCAB- conventional surgery) and (group B – Off pump – OPCAB – beating heart) after obtaining their written informed consent. Results The clinical outcome measure was the incidence of bleeding in group B less than group A. In our study there was highly significant increase in the amount of blood in drains, transfusion requirements and need for re-exploration within twenty four hours after surgery in group A than group B. Conclusion We concluded that off pump cardiac surgery is better than on pump procedure in decreasing risk of bleeding, post-operative transfusion requirements and risk of re-exploration.

Impact of Diabetes Duration and Control on the Extent and Severity of Coronary Artery Disease in Egyptian Patients: Evaluation by Coronary CT Angiography

Abstract Background Diabetes mellitus (DM) has reached epidemic proportions worldwide and approximately 40% of diabetics die due to ischemic heart disease, 15% from other forms of heart disease, principally congestive heart failure, and about 10% from stroke. The role of DM in CAD progression is now universally accepted. Aim of the Work To explore the association between diabetes duration and control on the extent of coronary artery disease (CAD) using coronary computed tomography angiography (CCTA). Patients and Methods This study is a cross sectional observational study that included 100 diabetic patients who were eligible for CT coronary angiography. They were evaluated in the diabetic outpatient clinic of the internal affairs ministry Hospitals for symptoms suggestive of CAD or for preoperative cardiovascular system risk stratification. CT coronary angiography was performed in all patients, and CACS was calculated using Agatston score. CCTA was analyzed for the site and severity of stenosis. For each patient, the number of diseased vessels was calculated through the assignment of one, two, and three or left main (LM) coronary artery vessels. Results The prevalence of atherosclerotic coronary artery disease among diabetics in the studied population was 78%, moderate to severe degree of obstructive lesions was found in 81% of them as detected by CTCA. Coronary calcification was found in 65% of diabetic patients. Coronary calcium score showed a significant positive correlation with age (p-value =0.002), HB1c level and the Triglycerides, cholesterol and LDL levels. The severity of atherosclerotic coronary artery disease was significantly associated with dyslipidemia. On the other hand, the extent of coronary affection was associated with the duration of diabetes. Among the studied subjects, the LAD was the most frequently affected artery (60% of patients). Low risk diabetics (zero calcium and no atherosclerotic plaques) had a mean duration of DM &amp;lt; 10 years with controlled lipid profile. Conclusion Based on the results of the current study, we can draw several conclusions. Diabetic patients are at risk for significant CAD with or without calcium burden. Extensive significant CAD is associated with long standing diabetes. Uncontrolled diabetes mellitus and the presence of dyslipidemia augment the process of atherosclerosis and the severity of the disease. Younger patients with controlled diabetes and lipid profile have a more favorable coronary anatomy profile and a favorable outcome. The LAD is the artery of predilection in diabetics. Abbreviations ASCVD: Atherosclerotic cardiovascular disease; BP: Blood pressure; CABG: Coronary artery bypass graft; CAD: Coronary artery disease; CCTA: Coronary computed tomography angiography; CVD: Cardiovascular disease; DM: Diabetes mellitus; HDL-c: High density lipoprotein cholesterol; HS: Highly significant; IQR: Inter-quartile range; LAD: Left anterior descending; LCX: Left circumflex; LDL-c: Low density lipoprotein cholesterol; LM: Left main; MDCT: Multidetector coronary CT angiography; MSCT: Multi-slice computed tomography; NS: Non significant; PCI: Percutaneous coronary intervention; RCA: Right coronary artery; S: Significant; TC: Total cholesterol; TG: Triglycerides

Roadmap towards an institutional Impella programme for high-risk coronary interventions.

Coronary artery disease (CAD) and its complications remain the main cause of morbidity and mortality worldwide. Patients with extensive CAD and multiple comorbidities who require complex, high-risk percutaneous coronary intervention (HR-PCI) are at risk of haemodynamic instability and may require short-term mechanical circulatory support (MCS) during the procedure to maintain sufficient perfusion and prevent ischaemia. Impella is a microaxial continuous blood flow pump used for percutaneous support of the left ventricle in patients undergoing HR-PCI. Data from randomized controlled trials and registries suggested an advantage for Impella devices in patients undergoing HR-PCI, compared with other types of MCS. As a thorough understanding of the benefits and drawbacks of the Impella technology is crucial for patient outcomes, we provide a technological overview of Impella and share our experiences gathered during the implementation of institutional Impella programmes in Poland as a roadmap of selection and periprocedural care for patients treated with Impella in the setting of HR-PCI. We propose 10 steps for implementation of an institutional Impella programme for HR-PCI, including (i) dedicated staff training; (ii) standard operating procedure and troubleshooting algorithms prior to the first intervention; (iii) patient selection by the multidisciplinary Heart Team; (iv) patient preparation using multimodality imaging; (v) procedure planning in terms of large-bore access, equipment, and complete revascularization; (vi) starting with HR-PCI support; (vii) starting with femoral artery access in a patient without extensive peripheral artery disease; (viii) multidisciplinary care after the procedure; (ix) haemodynamic and laboratory monitoring to ensure immediate diagnosis of access-site complications, bleeding, haemolysis, acute kidney injury, and infections; and (x) careful revision of every HR-PCI case with the team.

Impact of Impella protected-percutaneous coronary intervention on left ventricle function recovery of patients with extensive coronary disease and poor left ventricular function

BackgroundThe use of Impella support is increasingly adopted to “protect” patients with severe coronary artery disease (CAD) and left ventricle (LV) dysfunction undergoing percutaneous coronary intervention (PCI). AimsTo evaluate the impact of Impella-protected (Abiomed, Danvers, Massachusetts, USA) PCIs on myocardial function recovery. MethodsPatients with significant LV dysfunction undergoing multi-vessel PCIs with pre-intervention Impella implantation were evaluated by echocardiography before PCI and at median follow up of 6 months: global and segmental LV contractile function were assessed by LV ejection fraction (LVEF) and wall motion score index (WMSI), respectively. Extent of revascularization was graded using the British Cardiovascular Intervention Society Jeopardy score (BCIS-JS). Study endpoints were LVEF and WMSI improvement, and its correlation with revascularization. ResultsA total of 48 high surgical risk (mean EuroSCORE II 8) patients with median LVEF value of 30%, extensive wall motion abnormalities (median WMSI 2.16), and severe multi-vessel CAD (mean SYNTAX score 35) were included. PCIs brought a significant reduction of ischemic myocardium burden with BCIS-JS decrease from mean value of 12 to 4 (p < 0.001). At follow-up, WMSI reduced from 2.2 to 2.0 (p = 0.004) and LVEF increased from 30% to 35% (p = 0.016). WMSI improvement was proportional to the baseline impairment (R − 0.50, p < 0.001), and confined to revascularized segments (from 2.1 to 1.9, p < 0.001). ConclusionsIn patients with extensive CAD and severe LV dysfunction, multi-vessel Impella-protected PCI was associated to an appreciable contractile recovery, mainly determined by regional wall motion improvement in revascularized segments.

Transient ischaemic dilation ratio thresholds in patients with zero coronary calcium score undergoing exercise or dipyridamole stress SPECT myocardial perfusion imaging using a cadmium-zinc-telluride camera

Abstract Aims Transient ischaemic dilation (TID) is a marker of underlying extensive coronary artery disease (CAD) during myocardial perfusion imaging (MPI). The cut-off for a normal TID ratio (TIDr) value is often derived from a cohort of individuals with no apparent CAD. Varying criteria have been used to define the absence of CAD. We aim to derive TIDr cut-offs using patients with normal MPI and coronary artery calcium (CAC) score of zero, and compare the TIDr obtained from different software packages. Methods and results We studied 232 patients with zero CAC and normal MPI undergoing exercise or dipyridamole stress using either a 1- or 2-day protocol. All patients were scanned in the supine position with a cadmium-zinc-telluride camera. TIDr was automatically generated using quantitative perfusion SPECT (QPS) software initially, and subsequently using Myometrix for comparison. The TIDr cut-offs calculated using the mean + 2 standard deviation were 1.29 and 1.24 for the 1- and 2-day protocol groups, respectively. In patients undergoing a 2-day protocol, dipyridamole stress resulted in significantly higher mean TIDr when compared to exercise stress (1.07 ± 0.13 vs. 1.01 ± 0.12, P = 0.035). Myometrix-derived TIDr were also significantly lower compared to QPS-derived values for most protocols except for 2-day exercise stress. Conclusion This study is the first to derive TIDr threshold values using a normal population defined by zero CAC and normal MPI. TIDr was found to vary depending on stress modality, protocol as well as the software used.

Patient-specific computational simulation of coronary artery bypass grafting.

Coronary artery bypass graft surgery (CABG) is an intervention in patients with extensive obstructive coronary artery disease diagnosed with invasive coronary angiography. Here we present and test a novel application of non-invasive computational assessment of coronary hemodynamics before and after bypass grafting. We tested the computational CABG platform in n = 2 post-CABG patients. The computationally calculated fractional flow reserve showed high agreement with the angiography-based fractional flow reserve. Furthermore, we performed multiscale computational fluid dynamics simulations of pre- and post-CABG under simulated resting and hyperemic conditions in n = 2 patient-specific anatomies 3D reconstructed from coronary computed tomography angiography. We computationally created different degrees of stenosis in the left anterior descending artery, and we showed that increasing severity of native artery stenosis resulted in augmented flow through the graft and improvement of resting and hyperemic flow in the distal part of the grafted native artery. We presented a comprehensive patient-specific computational platform that can simulate the hemodynamic conditions before and after CABG and faithfully reproduce the hemodynamic effects of bypass grafting on the native coronary artery flow. Further clinical studies are warranted to validate this preliminary data.