Intracoronary Administration Of Nitroglycerin Research Articles

Successful recognition and management of life-threatening multivessel coronary artery vasospasm after conventional coronary artery bypass grafting.

Background: The occurrence of native coronary artery vasospasm after coronary artery bypass grafting (CABG) is a rare phenomenon with potentially catastrophic outcomes. The absence of a clear understanding of contributing factors and an undetermined occurrence rate underscores the importance of coronary angiography as the primary diagnostic tool for this condition. Case Presentation: We present the case of a 70-year-old Asian male with a 14-year history of diabetes mellitus, seven years of Giant Cell Arteritis (GCA), and Ischemic Heart Disease (IHD). The patient experienced severe native coronary artery vasospasm following conventional CABG, prompting intervention through coronary angiography. Management & Results: The patient underwent coronary angiography, revealing multivessel coronary artery vasospasm. Intracoronary administration of nitroglycerin and diltiazem was initiated promptly. The swift identification and treatment of vasospasm were instrumental in preventing severe myocardial injury. Conclusion: Coronary artery vasospasm post-CABG poses a significant threat, emphasizing the need for early identification and intervention. The successful management presented in this case underscores the importance of timely recognition and the administration of vasodilators in mitigating potential myocardial damage. This report contributes to the growing understanding of this rare but critical complication, highlighting the necessity for vigilance in post-CABG patient care.

PO-04-005 LEFT CIRCUMFLEX ARTERY VASOSPASM DURING PULSED FIELD ABLATION AT THE MITRAL ISTHMUS: CHARACTERIZATION OF TIME-TO-RESOLUTION

While pulsed field ablation (PFA) has emerged as a novel energy modality for ablation of atrial arrhythmias and is accompanied by a theoretically safer profile given its tissue selectivity and sparing of collateral structures, a recent study has highlighted the occurrence of subtotal coronary vasospasm during atrial fibrillation (AF) ablation on the cavo-tricuspid isthmus with PFA. While these observations were subclinical, there is at least one case report of left circumflex (LCx) coronary artery vasospasm during PFA at the mitral isthmus (MI) during AF ablation. To evaluate the natural history time-to-resolution of coronary vasospasm of the LCx artery during PFA at the MI. In a prospective, consecutively enrolled cohort of patients receiving AF ablation under deep sedation, diagnostic coronary angiography was performed via right femoral arterial access before, during, and after ablation on the MI with a multi-spline PFA catheter (Farawave, Boston Scientific Inc). LCx spasm was identified, characterized by severity, and monitored for progression and time-to-resolution. A total of 19 patients underwent PFA on the lateral MI with successful bidirectional block. Notably, 7 patients (37%) developed LCx vasospasm during ablation, of which 3 cases were mild (<50% decrease in luminal diameter), 2 were moderate (50 to 90% decrease), and 2 were severe (>90% decrease). All of the mild and moderate spasm occurrences self-resolved, with mild spasm taking on average 5.7 minutes to be relieved, and moderate spasm requiring 5 minutes. Relief of severe spasm required an average of 15 minutes, with both necessitating administration of intracoronary or intravenous nitroglycerin. Electrocardiographic ST changes were only present in one case of severe spasm (which resolved with relief of spasm), and there were no hemodynamic changes during spasm. As PFA becomes an alternative to radiofrequency and cryothermal ablation, it behooves operators to be vigilant for vasospastic effects on adjacent coronary vessels during ablation. Further investigation with larger populations is required to more fully elucidate the injurious potential of PFA-induced coronary vasospasm. This study is one of the first to elaborate on the features of LCx vasospasm during PFA on the MI.Tabled 1Patient CharacteristicsAge, mean±SD, y65.6±10.1Male, n (%)14 (74)Body mass index, mean±SD30.3±4.9Medical HistoryType of atrial fibrillationParoxysmal, n (%)4 (21)Persistent, n (%)15 (79)Duration of atrial fibrillation, mean±SD, months48.2±66.4CHA2DS2-VASc Score, mean±SD2.1±1.4Hypertension, n (%)13 (68)Diabetes, n (%)4 (21)Dyslipidemia, n (%)11 (58)Sleep apnea, n (%)1 (5)Prior stroke or transient ischemic attack, n (%)2 (11)Coronary artery disease, (%)4 (21)Congestive heart failure, n (%)1 (5)Left ventricular ejection fraction, mean±SD, %62.3±3.4Left atrium dimension, mean±SD, mm45.8±9.2MedicationsWarfarin, n (%)12 (63)Non-Warfarin oral anticoagulant, n (%)7 (37)Antiarrhythmic drugs, n (%)Class I7 (37)Class II11 (58)Class III5 (26)Class IV0 (0) Open table in a new tab

Abstract 11578: A Case of Spontaneous Coronary Artery Dissection Masking as Acute Myopericarditis

Introduction: Chest pain is a common reason for emergency room visits. Acute coronary syndrome (ACS) remains a high mortality etiology of chest pain. Spontaneous coronary artery dissection (SCAD) is a rare cause of ACS in the general population, but a relatively common cause of ACS in young women. Case: Patient is a 29-year-old female with history of anxiety and fibroids that presented with chest pain. She described the chest pain as sharp, substernal, non-radiating that lasted for 10 minutes after eating dinner. The pain improved with leaning forward and resolved when lying on her stomach. She had a second episode of chest pain after 2 hours with similar characteristics which lasted 10 minutes. She was 4 months post-partum. She reported having a sore throat 4 days prior to the presentation. Troponin peaked at 0.173. ECG showed diffuse ST-elevation and PR depression in V3-V6 I II III aVF. TTE showed LVEF 65% and no wall motion abnormalities. CTA coronary showed 50-60% narrowing of mid LAD. Cardiac MR showed mild hypokinesis of mid-anteroseptal wall with associated subendocardial to midmyocardial delayed enhancement with focal elevations in myocardial native T1 and T2, and LVEF 53%. Coronary catheterization showed 50-60% stenosis in the mid-LAD distal to the first diagonal artery, there was no improvement in the stenosis after administration of intra-coronary nitroglycerin, there were no septals noted to arise from this area, consistent with diagnosis of SCAD (figure 1). Diagnosis: On initial evaluation, the etiology of her chest pain appeared to be myopericarditis. However, using CTA coronary, cardiac MR and coronary catheterization findings, the pain was more consistent with type 1 NSTEMI in the setting of SCAD. Patient was started on IV heparin, metoprolol tartrate, and aspirin. Conclusions: SCAD is a life-threating and often missed etiology of ACS. It requires a high index of suspicion and should be in the differential diagnosis in young women presenting with chest pain.

Air pollution and coronary vasomotor disorders in patients with myocardial ischemia and non-obstructive coronary arteries

Abstract Background Coronary vasomotor abnormalities are an important cause of myocardial ischemia in patients with non-obstructive coronary artery disease (NOCAD). However, the role of air pollution in determining vasomotor disorders has never been investigated. Purpose In this study, we evaluated the association between long-term exposure to particulate matter (PM) PM2.5 and PM10 and coronary vasomotor disorders in NOCAD patients. Methods Patients with myocardial ischemia and NOCAD undergoing intracoronary provocative test with acetylcholine (ACh) were prospectively enrolled. The test was considered positive for epicardial coronary spasm in the presence of focal or diffuse epicardial coronary diameter reduction ≥90% in comparison with the relaxed state following intracoronary nitroglycerin administration given to relieve the spasm, associated with the reproduction of the patient's symptoms and ischaemic ECG shifts. Both patients with chronic myocardial ischemia (INOCA) and myocardial infarction with non-obstructive coronary arteries (MINOCA) were enrolled. Based on each case's home address, exposure to PM2.5 and PM10 was assessed. Only patients with &amp;gt;2 years of available data on air pollution exposure prior to coronary angiography were included. Results We enrolled 287 patients (median age 62.0 years [52.0–70.0], 149 [51.9%] males): 161 (56.1%) INOCA and 126 (43.9%) MINOCA. One hundred seventy-six patients (61.3%) had positive provocative test. Exposure to PM2.5 (Figure 1) and PM10 was higher in patients with a positive provocative test (p&amp;lt;0.001). PM2.5 and PM10 were independent predictors of a positive coronary provocative test after adjustment for confounders. Interestingly, among patients with a positive provocative test, PM2.5 and PM10 were both independent predictors of MINOCA (p&amp;lt;0.001 and p=0.001, respectively; Figure 2) as clinical presentation, while only PM2.5 was independently associated with the occurrence of epicardial spasm as opposed to microvascular spasm (p&amp;lt;0.001). Conclusions We provide novel insights into the missing link between air pollution and ischemic heart disease. In particular, higher exposure to air pollution in patients with myocardial ischemia and NOCAD is associated with coronary vasomotor abnormalities, and PM2.5 is an independent risk factor for the occurrence of epicardial spasm and for MINOCA as clinical presentation. Funding Acknowledgement Type of funding sources: None.

Intracoronary injection of nitroglycerine can prevent unnecessary percutaneous coronary intervention

BackgroundDespite the recommendation of the current guidelines, intracoronary administration of nitroglycerine during coronary angiography is often neglected. We investigated the effect of intra-coronary nitroglycerin on the relief of coronary artery stenosis in the candidates for percutaneous coronary intervention (PCI).MethodsWe included patients with angina pectoris or myocardial infarction who were candidates for PCI. In the coronary angiography, the culprit vessel involved was evaluated, and bolus nitroglycerin at a dose of 25–200 mcg was injected into the affected coronary artery. A significant change in the percentage of coronary artery stenosis was considered a positive response, and these patients were then compared with patients who did not have a substantial change in the percentage of stenosis at the same time. Univariate analysis and then multivariate logistic regression analysis was performed to determine the predictors of response to intracoronary nitroglycerin.ResultsAmong 360 patients, 27 (7.5%) responded to nitroglycerine, and 333 (92.5%) were non-responsive. The mean age of patients was 60.2 ± 11.6 years, ranging from 23 to 93 years, and 265 (73.6%) were men. The study groups were not significantly different in the baseline demographic characteristics. The presence of multivessel disease (Odds ratio (OR) = 16.26, 95% confidence interval (CI):2.07–127.6; P = 0.008) and stenosis in the left circumflex artery (OR = 3.62, 95% CI: 1.03–12.70; P = 0.044) were the independent predictors for nonresponse to nitroglycerine, leading to PCI.ConclusionIn some cases, especially those without multivessel diseases, intracoronary nitroglycerine administration can efficiently relieve coronary stenosis and prevent unnecessary PCI.

Severe Coronary Artery Vasospasm after Mitral Valve Replacement in a Diabetic Patient with Previous Stent Implantation: A Case Report.

Postoperative coronary vasospasm is a well-known cause of angina that may lead to myocardial infarction if not treated promptly. We report a case of a 70-year-old female with severe mitral regurgitation submitted to mitral valve replacement, and a history of diabetes mellitus type II, stroke, idiopathic thrombocytopenic purpura on steroid therapy, and previous percutaneous coronary intervention (PCI) for severe obstruction of the circumflex coronary artery, 4 months prior to surgery. Immediately after intensive care unit admission, the patient developed pulseless electrical activity which required extracorporeal membrane oxygenation for hemodynamic support. The coronary angiography showed diffuse occlusive coronary artery vasospasm, ameliorated after intra-coronary administration of nitroglycerin. The following postoperative evolution was marked by cardiogenic shock and multiple organ dysfunction syndrome. Subsequent echocardiographic findings showed an increase in left ventricular function with an EF of 40%, and extracorporeal membrane oxygenation (ECMO) support was weaned after seven days. However, after a few hours, the patient progressively deteriorated, with cardiac arrest and no response to resuscitation maneuvers. Hemodynamic instability following the surgical procedure in a patient with previous PCI associated with an autoimmune disease and diabetes mellitus should raise the suspicion of a coronary artery vasospasm.

Acetylcholine Rechallenge: A First Step Toward Tailored Treatment in Patients With Coronary Artery Spasm.

The present study aimed to assess the feasibility and clinical value of acetylcholine (ACh) rechallenge for the detection of coexisting epicardial and microvascular spasm and to determine the efficacy of nitroglycerin in these spasm endotypes. The coexistence of epicardial and microvascular spasm is difficult to identify; thus, its frequency is unknown. Nitroglycerin treatment is equally recommended for both epicardial and microvascular coronary spasm despite contradictory data. In this multicenter study, 95 patients with coronary spasm were included to undergo ACh rechallenge, which consisted of repeated ACh provocation 3minutes after intracoronary nitroglycerin administration using the same dose that previously induced spasm. In total, 95 patients (age 61 ± 12 years, 69% female) were included. Fifty-five patients (58%) had microvascular spasm, and 40 patients (42%) had epicardial spasm during initial ACh provocation. In 48% of patients with epicardial spasm, ACh rechallenge revealed coexisting nitroglycerin-persistent microvascular spasm. Nitroglycerin administration before ACh rechallenge prevented reinducibility of epicardial spasm in all patients with focal spasm and in 80% of patients with diffuse spasm. Microvascular spasm was prevented in only 20% by prior nitroglycerin administration but was attenuated in another 49% of patients. This study demonstrates a high frequency of epicardial spasm with coexisting nitroglycerin-persistent microvascular spasm. Intracoronary nitroglycerin was very effective in preventing reinducibility of epicardial spasm, whereas it prevented microvascular spasm in only 20% of patients. ACh rechallenge is a novel method that facilitates the detection of coexisting spasm endotypes and may pave the way towards tailored treatment of vasospastic angina.

546 Antegrade in-stent CTO recanalization

Abstract Methods and results A 64-year-old man with prior PCI and stent of proximal LAD due to an anterior ST-elevation myocardial infarction (STEMI) presented with exertional angina (CCS III), despite optimal medical therapy (OMT). The echocardiogram showed a dilatated left ventricle with anterior and apical akinesia and a severely reduced left ventricle ejection fraction. Coronarography was performed and a chronic total occlusion was found at the proximal edge of the stent previously implanted in the proximal LAD, with a thin tapered entry (J-CTO score 1). Moderate angiographic disease was present in the circumflex (LCX) and in the right coronary artery (RCA). Interventional collaterals were absent. Dobutamine stress echocardiogram was performed to unmask myocardial viability. Indeed, during intravenous Dobutamine administration, we registered an increase in the left ventricle function, whereas only apex remained still akinetic. Accordingly, the patient underwent LAD CTO PCI using a 7 Fr EBU 4.0 guiding catheter, via right femoral artery access. The RCA ostium was engaged with a 6 Fr Judkins right 4.0 guiding catheter, via right radial artery access. Antegrade wire escalation technique was attempted. Due to scarce support, a 7 Fr Guidion guiding catheter extension and a Corsair microcatheter were placed in the proximal LAD. Antegrade crossing was very difficult due to intrastent high plaque burden. The occlusion was crossed with an Asahi Conquest Pro 9 guidewire. Subsequently, an Asahi Gaia third guidewire was advanced through the intrastent segment and then in the distal part of LAD. The advance of microcatheter was challenging but successfully achieved taking advantage of the low profile, high torqueability and trackability of the Asahi Corsair Pro microcatheter. Microcatheter tip injection confirmed the correct position in the vessel’s true lumen. An Asahi Grand Slam guidewire was placed in the distal LAD to provide extra support for delivery of interventional devices. The lesion was pre-dilated with progressively larger balloon, starting from a 1.1 mm diameter semi-compliant over-the-wire balloon (OTW). Two stents were implanted with a minimal overlap at the distal edge of the proximal stent (Resolute Onyx 3.0 × 38 mm and 2.5 × 24 mm). The result was improved with stents high-pressure post-dilatation and with selective intracoronary adenosine and nitroglycerin administration with final Thrombolysis in Myocardial Infarction (TIMI) grade 3 flow. The total amount of contrast media used was 210 ml. The total procedure time was with 125 min with 45 min of fluoroscopy. No complications occurred. Conclusions CTO PCI still represents one of the most challenging subsets of coronary interventions despite the improvement in technology and techniques. Although data regarding percutaneous PCI CTO are still inconsistent, successful CTO recanalization has been associated with relief of angina and ischemia-related dyspnoea (Werner at al., 2018). In stable patients CTO PCI has been associated with a lower risk of death, stroke, and coronary artery bypass grafting and less recurrent angina pectoris in some registry studies (Christakopoulos et al., 2015). Additionally, CTO PCI increased left ventricle function in a subgroup of patients with LAD CTO (Henriques et al., 2016). Conversely, randomized multicentre failed to demonstrate a superiority of CTO PCI medical to OMT in terms of major adverse cardiac events (MACE) and all-cause mortality.

B-AB19-04 DIAGNOSIS OF CORONARY VASOSPASM-INDUCED VENTRICULAR FIBRILLATION DURING PERICARDIAL MAPPING

After excluding cardiac genetic and structural abnormalities, idiopathic VF is estimated to account for ∼5% of cases of sudden cardiac death. In these cases, it may be difficult to identify an etiology for VF. We present a case of idiopathic polymorphic VT/VF (pVT/VF) with the diagnosis made in the EP lab. N/A A 47-year-old man had a witnessed cardiac arrest and was found to be in VF. A work-up including coronary angiography was unrevealing; MRI was largely normal, though suggestive of an inferolateral area of subepicardial scar. A subcutaneous ICD (SICD) was placed. He presented to us with recurrent pVT/VF on sotalol resulting in multiple ICD shocks, some of which failed to immediately defibrillate. At EP study, stimulation did not induce sustained ventricular arrhythmias. Standard pericardial access was obtained to permit epi/endo mapping to identify arrhythmogenic substrate. But immediately upon onset of pericardial mapping, ST segment elevation occurred, and the patient developed non-sustained pVT (Figure). Immediate coronary angiography revealed diffuse coronary spasm, most strikingly in the proximal LAD. With administration of intracoronary nitroglycerin, the LAD spasm and pVT/VF resolved; ST segment abnormalities resolved within minutes. DFT testing revealed a normal functioning SICD. He was discharged on long-acting nifedipine and nitrates for coronary vasospasm. Severe coronary vasospasm may cause idiopathic polymorphic VT/VF. Medical therapy with calcium-channel blockers and oral nitrates are the first-line therapy as ICD therapies alone may be ineffective in the setting of on-going spasm and ischemia.

CASE OF CORONARY ARTERY SPASM WITH FATAL OUTCOME IN THE EARLY PERIOD AFTER PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY OF THE RIGHT CORONARY ARTERY WITH IMPLANTATION OF BARE METAL STENTS

The paper presents a clinical case of coronary artery spasm after implantation of bare metal stents. The 60-year-old man was admitted to the hospital with the progression of the coronary heart disease and high angina pectoris functional class for coronary angiography. The patient had the main predisposing factor for the development of coronary artery spasm, which is 20-year smoking history. Based on the results of the coronary angiography, the decision was made to conduct endovascular treatment. The patient was discharged on the 2 nd day after angioplasty with implantation of two stents in the right coronary artery. On the evening of discharge, the man developed a severe pain attack in the epigastric region and turned to the hospital. The electrocardiogram revealed ST-segment elevation in leads II, III, aVF, T-waves were negative in leads I, aVL and V3-6. Repeat coronary angiography showed the stent implantation sites were passable, there was a pronounced diffuse coronary artery spasm, which could not be eliminated by intracoronary administration of nitroglycerin. Coronary artery spasm induced by coronary angioplasty with stent placement is a rare complication that can develop at different time intervals after endovascular intervention. Based on the presented clinical case, it appears likely that even after bare metal stents implantation, the development of endovascular dysfunction leading to coronary spasm is possible.

Coronary Artery Vasospasm: A Under-recognized Phenomenon in Orthotopic Heart Transplant

Introduction Cardiac allograft vasculopathy (CAV) is known as the primary cause of death in the first year after orthotopic heart transplant (OHT). Coronary artery spasm (CAS) in OHT is a rare and under-recognized phenomenon in patients undergoing surveillance. The mechanism of coronary vasospasm in OHT remain largely unknown. The presentation can vary from an incidental finding to severe episodes of symptomatic ventricular arrhythmias, high-degree atrioventricular block, syncope, cardiac arrest, or even myocardial infarction in cases of prolonged ischemia. Case Presentation 65 yo female with history of chronic kidney disease, diabetes mellitus type 2, hypertension, hyperlipidemia, and orthotopic heart transplantation with CMV mismatch in 2016 secondary to apical hypertrophic cardiomyopathy. Prior coronary angiography (CA) done at our institution had shown no evidence of vasculopathy. During one of her follow-up visits in the Clinic, she complained of increasing dyspnea on exertion, prompting urgent referral for CA, as per our surveillance protocols. Prior to the procedure, echocardiography was performed which revealed normal graft function and no valvular abnormalities. She underwent CA which showed a proximal significant diffuse luminal narrowing of the right coronary artery (RCA) (Image 1) and normal left coronary artery anatomy (Image 2). We proceed to repeat CA with intracoronary administration of nitroglycerin (ICN) and measurement of fractional flow reserve (FFR) of RCA (Image 3, 4). Angiography revealed near resolution of the RCA lesion, ultimately suggesting that transient vasospasm had been responsible for the previous angiographic appearance (Image 1). Summary CAS can present in patients with or without vasculopathy. It can produce luminal narrowing and can be difficult to distinguish angiographically from CAV. Misdiagnosis of this entity has led to the incorrect diagnosis of CAV and subsequent unnecessary stenting. ICN use can improve angiographic visualization, and prevent the adverse effects of coronary spasm. In conclusion, CAS is a rare and potential complication post OHT. It is a difficult entity to prognosticate due to scarcity of clinical evidence, as prevalence ranges from 4.9% to 12.1%. Some authors hypothesize that CAS in OHT carries a poor prognosis as it is often an early manifestation of CAV. However, this remains largely hypothetical and further studies are needed to better understand this disease.

Catheter-induced Multiple Non-proximal Coronary Spasm in a Patient Presenting with Myocardial Infarction

Interventional cardiologists encounter a wide range of lesions that cannot be angiographically distinguished from fixed atherosclerotic obstructive disease. In this case report, we document vasospasm at multiple sites in the coronary territory in a patient presenting with acute coronary syndrome. A 61-year-old woman was referred to our hospital with typical chest pain lasting approximately 1 h. After performing the left coronary artery angiography, a severe tubular stenosis was detected in circumflex (Cx) artery. Diffuse spasm was observed in the right coronary artery (RCA) and it resolved after intracoronary administration of nitroglycerin. After performing left system angiography again, severe stenosis in Cx artery was also completely resolved. Our finding is of clinical importance in that it is more likely to simulate a constant coronary stenosis than would have spasm occurred proximally. The clinical importance of our report is that a catheter-induced vasospasm (CIV) may simulate fixed coronary stenosis, not always osteally and in some instances at multiple sites. Awareness of this phenomenon and liberal use of nitroglycerin in any patient with discrete luminal narrowing, even when an ostial “lesion” is not present, can help to avoid misinterpreting CIV as an atherosclerotic lesion.

Does Coronary Microvascular Spasm Exist? Objective Evidence from Intracoronary Doppler Flow Measurements During Acetylcholine Testing

A 43-year-old woman with recurrent atypical angina underwent invasive coronary angiography including intracoronary Doppler blood flow assessment and coronary spasm provocation testing. While obstructive epicardial disease could be ruled-out angiographically, the patient experienced reproduction of her angina symptoms after intracoronary administration of acetylcholine (100 µg) during spasm provocation testing. Simultaneously, the ECG showed new-onset ST-segment depression in the absence of epicardial spasm. In addition, coronary flow velocity was significantly reduced after acetylcholine compared to the baseline condition. Following intracoronary administration of nitroglycerine (200 µg), the patient’s symptoms as well as the ECG changes and coronary flow reduction were reversed. Considering the ongoing challenges in appropriate evaluation of the pathophysiological mechanisms of coronary microvascular dysfunction, simultaneous intracoronary Doppler flow measurement during spasm testing – as shown in this case – may provide objective evidence for microvascular spasm in addition to the standardized diagnostic criteria, especially if they are ambiguous.

Unrecognized coronary vasospasm in patients referred for percutaneous coronary intervention: Intracoronary nitroglycerin, the forgotten stepchild of cardiovascular guidelines.

The goal of this study was to demonstrate the importance of intracoronary nitroglycerin (IC NTG) administration during diagnostic coronary angiography and prior to percutaneous coronary intervention (PCI). PCI has been a mainstay treatment for patients with symptomatic coronary artery disease. While current guidelines emphasize the importance of periprocedural antithrombotic medications, they fail to mention the use of nitroglycerin prior to PCI. Retrospective chart and angiographic review was performed to identify patients referred for PCI who had significant angiographic stenoses that resolved after administration of IC NTG. The study group consisted of 6 patients (3 men, 3 women) with mean age 52 ± 4years (range 46-57 years). All had anginal symptoms and significant (>70%) stenosis on diagnostic coronary angiography. None had documented ST segment elevation. The median interval between diagnostic and staged PCI procedures was 3 days. IC NTG was not administered to any of the patients at the time of diagnostic coronary angiography. In each case, repeat coronary angiography following administration of IC NTG (155 ± 46 mcg) before planned PCI demonstrated resolution of the target stenosis. PCI was deferred and all patients were successfully managed medically. Coronary artery spasm is an under-recognized cause of chest pain in patients with significant angiographic lesions. Coronary spasm should be suspected especially in younger patients (less than 60 years old) with apparent single vessel disease. IC NTG should be routinely administered during diagnostic angiography and before PCI to avert unnecessary coronary interventions. © 2017 Wiley Periodicals, Inc.

Abstract 525: Cases with Uncommon Anti-phospholipid Antibody Syndrome Developed Multifocal Vascular Disorders Such as Ischemic Enteritis, Portal Vein Thrombosis, Ischemic Heart Disease and Cerebral Infarction

Purpose: We report cases with uncommon anti-phosholipid antibody syndrome developed ischemic enteritis, portal vein thrombosis, ischemic heart disease and cerebral infarction. The difficulty in diagnosing and treatment procedures for multifocal vascular disorders is discussed. Patients and Methods: Patient 1, 76-year-old man, with acute abdomen. Patient 2, 54-year-old man, with intractable esophageal varices. Clinical manifestation was superior mesenteric artery (SMA) thrombosis in the patient 1 and portal vein thrombosis in the patient 2. Serial CT scans were examined on 64 or 80 multidetector-row CT (Toshiba), with bolus injection of contrast media for CT angiography (CTA). Abdominal angiography with endovascular intervention and coronary angiography were performed on Allura Xper FD-20 and FD-10 (Philips). Results: Emergency CTA of patient 1 showed decreased contrast enhancement of SMA and SMV but enhancement of intestinal walls were well preserved. Although the patient’s symptom got better, follow-up CT revealed the growth of SMA thrombosis. The aspiration and the dissolution of SMA thrombosis were performed through the SMA catheter for five days resulted in complete recanalization.Then he felt chest oppression and 75% stenosis of RCA segment 4, followed by complete spastic occlusion on Acetylcholine loading on the coronary angiography, which recovered perfectly with intra-coronary nitroglycerin administration. He discharged our hospital with health, while he had cerebellar infarction with right cerebellar artery occlusion. On patient 2, to resolve portal hypertension, balloon-occluded retrograde transvenous obliteration was scheduled, however, due to numerous collaterals prevented the effective venous obliteration and splenic arterial embolization was selected alternatively. Discussion and Conclusions: The progressive SMA thrombosis with coronary disease and subsequent cerebellar occlusion seen in patient 1, and the portal vein thrombosis in patient 2 without chronic hepatitis nor cirrhosis were unusual. To discover underlining uncommon anti-phosholipid antibody syndrome is important to prevent serious vascular diseases in sequence.

Pulse waveform analysis in the optic nerve head circulation reflects systemic vascular resistance obtained via a Swan-Ganz catheter.

To determine whether a pulse waveform analysis in the optic nerve head (ONH) circulation as determined by laser speckle flowgraphy (LSFG) can provide systemic hemodynamic values - the systemic vascular resistance (SVR) in particular - similar to those obtained by using a Swan-Ganz catheter, which is an invasive method. Sixteen consecutive subjects were examined. Hemodynamic monitoring was obtained from right heart catheterization with a Swan-Ganz catheter and coronary angiography without an intracoronary nitroglycerin administration. Direct blood pressure was measured with a trans-radial approach. Single regression analyses were used to determine the relationship between the blowout score and blowout time, which are the items of the pulse waveform analysis in the ONH, by using LSFG and the hemodynamic parameters. The blowout time was significantly and negatively correlated with the SVR (r = -0.52, p = 0.04), the ocular perfusion pressure with the mean arterial blood pressure of the radial artery (r = -0.52, p = 0.04) and the radial artery pulse pressure (r = -0.52, p = 0.04).The pulmonary capillary wedge pressure (r = -0.44, p = 0.09) and the mean arterial blood pressure of the radial artery (r = -0.44, p = 0.09) tended to be correlated with the blowout time, but did not reach significance. The blowout score was significantly and negatively correlated with the radial artery blood pressure (r = -0.51, p = 0.046). A pulse waveform analysis in the ONH by LSFG may be one of the useful methods for understanding the SVR.

Abstract 199: Vasospastic Angina In A School Child Long After Kawasaki Disease

Though it has been already reported that the endothelial function was impaired in patients with a history of Kawasaki disease (KD) and coronary artery aneurysms, vasospastic angina has been rarely reported, especially in school child. A 13-year-old school child referred to us because of repeated chest pain on exercise and reverse redistribution in myocardial perfusion scan. His past history included KD at 2 years of age that was complicated by resistance to initial immunoglobulin treatment and he was left with coronary aneurysms; left main trunk (LMT) of 6.1mm, left anterior descending artery (LAD) of 6.0mm, and right coronary artery (RCA) of 6.0mm. He received oral warfarin treatment in addition to aspirin for 2 years and since then aspirin alone. Coronary angiogram at 7 years old showed LMT aneurysm of 6.1mm starting from orifice extending to bifurcation and regression of RCA aneurysm. He joined baseball club since 8 years old and has been doing well without any symptoms. In this summer, he started complain chest pain after 10 minutes of running 2-3 times a week that lasts for about 30 minutes. Though exercise stress test using treadmill did not show any abnormal electrocardiographic finding, stress myocardial perfusion scan using Thallous chloride-201Tl showed an area of reverse redistribution in the LAD territory. Baseline coronary angiogram at this time showed basically the same finding as that in the last study, intact RCA without stenosis and LMT aneurysm without any stenosis. However, provocative study using intra-coronary administration of 100 ug of acetylcholine, showed diffuse coronary artery spasm in all LCA branches and he indeed complained the same chest pain as that felt in exercise. In addition, intra-coronary administration of nitroglycerine completely reversed coronary spasm and chest pain. Conclusion: Vasospastic angina with chest pain can occurred in the school child with coronary artery aneurysms without coronary stenosis long after KD.

ST Elevation Myocardial Infarction due to Cocaine Induced Coronary Vasospasm

A 59-year-old man with medication-treated hypertension, noninsulin dependent diabetes mellitus and a current tobacco user, presented with substernal pressure-like chest pain of one hour duration, prior to arrival to the emergency room. Electrocardiography on arrival (Figure 1A) showed anterior ST segment elevations with subsequent anterior T-wave inversions. Initial troponin concentration was 72.58 ng/mL (reference range: 0.01-0.04 ng/mL). He underwent emergent coronary angiography, which revealed 50% mid-left anterior descending (LAD) artery stenosis with severe vasospasm involving the entire LAD segment with TIMI 1 flow down the artery (Figure 1B). Intra-coronary nitroglycerin administration resolved the vasospasm and TIMI 3 flow was restored (Figure 1C). Subsequent echocardiography showed a depressed left ventricular ejection fraction to 40% with wall motion abnormalities consistent with a LAD territory infarct. Urine toxicology screen showed evidence of cocaine and the patient eventually admitted to using cocaine prior to the onset of the chest pain. He was eventually discharged after being medicated with calcium channel blockers and nitrates. He was also started on carvedilol, aspirin, atorvastatin, lisinopril and spironolactone for management of his ischemic cardiomyopathy and concomitant atherosclerosis. Prior evidence suggests the safety of non-selective beta-blockade in the setting of cocaine use which was demonstrated in our case [1-4]. The patient was counseled extensively about abstinence from illegal drugs. Figure 1: (A) Echocardiography on arrival; (B) Emergent coronary angiography; (C) Restored vasospasm and TIMI 3 flow

A Rare Cause of Chest Pain and Ventricular Fibrillation

Aman in his late 50s presented with sudden-onset chest pain followedbyashockfromhis implantablecardioverter-defibrillator (ICD). His history included a cardiac arrest secondary to ventricular fibrillation resulting in ICD implantation 1yearprior, chronicobstructivepulmonarydisease,hypertension,andactivetobaccoandalcoholabuse. Therewas no history of hyperlipidemia or family history of coronary arterydisease.His initial symptomwasparesthesia in the righthand, whichprogresseduphisarmandwasfollowedbychest tightnessand dyspnea.Notably,hehad6similarpresentations intheprecedingyear, butmyocardial infarction hadbeen ruled out by serial electrocardiograms (ECGs) and cardiac biomarker results on all occasions. On arrival to the hospital, his blood pressure was 109/77 mmHg, heart ratewas 66 beats/min, and blood oxygen saturation was97%while breathing roomair. Hewas admitted to thehospital and received3 additional shocks fromhis ICD in the emergencydepartment. EachshockwasprecededbychestpainandECGchanges that resolved after administration of sublingual nitroglycerin. One of theseECGs is shown inFigure 1,whichprompted immediatecoronary angiography. Questions: What is the etiology of his chest pain? Why did his ICD fire? Patient Course Coronary angiography showed no obstructive coronary artery disease, with only a 30% stenosis in his circumflex coronary artery. Initial views showed diffuse vasospasm of both the right and left coronary arteries, which resolved with administration of intracoronary nitroglycerin (Figure 2). Tests for serum creatine kinase and troponin T had negative results. His lipid panel results were notable for total cholesterol of 127 mg/dL and low-density lipoprotein cholesterol of 67 mg/dL (to convert to millimoles per liter, multiply by 0.0259). Interrogation of the ICD revealed 4 episodes of ventricular fibrillation with appropriate treatment (Figure 3), each preceded by chest pain. He received a diagnosis of coronary vasospasm leading to ventricular fibrillation and was treated with a statin, antiplatelet therapy, long-acting nitrate, and amlodipine besylate (dihydropyridine class of calcium channel blockers). He continued to have recurrent episodes of chest pain and ST-segment elevation while receiving amlodipine, so he was switched to verapamil hydrochloride (phenylalkylamine class of calcium channel blockers), after which he had no recurrence of chest pain or ST-segment elevation on ECG. He was exhorted to cease tobacco and alcohol use and discharged home.

(458) - Safety of Intravascular Ultrasound in Nearly 900 Cases

Purpose: Coronary intravascular ultrasound (IVUS) can detect evidence of cardiac allograft vasculopathy with much higher sensitivity than coronary angiography in transplant recipients. However, in randomized trials fewer than a third of patients usually undergo this procedure due to renal dysfunction or perceived risk of the intervention. At a single large transplant center, IVUS has been available since 2006. With increasing familiarity, the application of this technique has grown and now includes patients with significant renal dysfunction. The procedural and renal safety of IVUS is described below. Methods: 892 consecutive IVUS examinations were performed for 354 adult heart transplant recipients from 2006-2013. Cardiac biopsy was performed immediately prior to coronary angiography and IVUS in 65 % of the cases. The Boston Scientific Atlantis Pro SR catheter was utilized in all cases after therapeutic anticoagulation and administration of intracoronary nitroglycerin. Results: The table details the utilization of contrast and the baseline renal function of patients undergoing IVUS examinations. Analysis of baseline serum creatinine across the year categories demonstrated a trend to reduced renal function at the time of IVUS exam (p= 0.06), but a highly significant reduction in contrast dose over time (p< 0.0001). Regardless of time period, there was no significant change in serum creatinine or GFR following IVUS examination. The 90 % quantile and maximum serum creatinines are tabulated below. Even patients with significant renal impairment (creatinine over 1.9 mg/dl) underwent IVUS successfully. There were no complications such as pericardial tamponade, nor any new-onset renal replacement therapy.Conclusion: IVUS can be safely performed in cardiac transplant recipients with a low dose of contrast, at the time of myocardial biopsy, and without significant risk of contrast-induced nephropathy.