LAD Artery Research Articles

Prevalence, characteristics and significance of anomalous coronary arteries in adults undergoing cardiac CT scans

Abstract Background/introduction The widespread use of CT coronary angiogram (CTCA) for the evaluation of patients with suspected coronary artery disease has resulted in increased identification of anomalous coronary arteries. These are often incidental findings and their prevalence and significance remains unknown. Purpose To identify the prevalence, characteristics and significance of anomalous coronary arteries in patient undergoing cardiac CT for suspected coronary artery disease. Methods This is a retrospective analysis of all cardiac CT scans (n= 5727 CTCAs) performed at two tertiary centres in the UK from 2015 to 2022. For the purpose of this study, we excluded separate LAD and circumflex artery coronary origins given it is clinical non-significance. Results Eighty three patients (1.45%) were identified as having anomalous coronary arteries. The average age of patients with anomalous coronary arteries was 57 years (range 18 - 86 years) and 36% were female. The most common coronary anomaly was the left circumflex artery arising from the right side (49 patients, 59%) and all had a retroaortic course. This was followed by an anomalous right coronary artery arising from the left side (29 patients, 35%) with 93% of them taking an interarterial course whilst 7% had a subpulmonic course. We also identified an anomalous left main stem (14 patients, 17%) arising from the right side (5 retroaortic, 5 subpulmonic, 2 prepulmonic, 1 anterior and 1 interarterial course). Four patients (5%) had an anomalous LAD arising from the right (2 prepulmonic, 1 subpulmonic and 1 anterior course). Four patients had other coronary anomalies (left circumflex artery arising from right pulmonary artery, OM arising from left ventricle, congenital atresia of left main stem and an ALCAPA). Majority of the patients with an anomalous coronary artery taking an interarterial course underwent a stress test. During a mean follow-up period of 4 years, four patients (5%) underwent cardiac surgery for treatment of anomalous coronary artery (ALCAPA, left main stem atresia and two anomalous right with interarterial course), seven patients underwent cardiac surgery for other reasons (significant atherosclerotic coronary artery disease and/or valve disease), five patients underwent PCI for treatment of atherosclerotic coronary artery disease and two patients died for reasons unrelated to their coronary anomaly. Conclusion This study of a large and unselected cohort of CTCA patients demonstrates an overall prevalence of coronary artery anomalies (as defined above) of 1.45%. We also report the prevalence and characteristics of different coronary anomalies and their outcomes. In the majority of patients, coronary artery anomalies are incidental findings and can be managed conservatively.

Locally increased dysferlin expression improves left-ventricular function by stabilizing membrane nanodomains of cardiomyocytes in the myocardial infarction border zone

Abstract Introduction Dysferlin, a transmembrane protein with multiple Ca2+-binding C2-domains, is expressed in the sarcolemma and vesicle membranes of striated muscle cells. Upon Ca2+ entry, Dysferlin is thought to mediate vesicle fusion and membrane repair events in order to rapidly seal sarcolemmal lesions. Dysferlin mutations are associated with progressive muscular dystrophies and dilated cardiomyopathy. However, the precise role of Dysferlin in protection of membrane nanodomains in ventricular myocytes (VMs) after myocardial infarction (MI) remains elusive. Purpose We hypothesized that Dysferlin is crucial to prevent VMs from loss-of-function and cell death by stabilizing membrane nanodomains like the transverse-axial tubule (TAT) system and the intercalated disc (ICD) cell-cell contact sites post-MI. Methods and Results 1 week post-MI induced by LAD artery ligation, investigator-blinded echocardiography revealed increased infarct sizes and decreased left-ventricular (LV) ejection fraction of Dysferlin-knockout (KO) vs. WT mice (mean±SEM: 21±2 vs. 28±2%, n=20/30 mice, P<0.05). Immunoblotting of WT LV tissue lysates showed an upregulated Dysferlin expression to 148% compared to sham-operated controls. Importantly, immunohistology identified a maximal Dysferlin expression of 230% in the MI border zone that faces a high ischemic and mechanical stress. Hence, we used data-independent mass spectrometry (DIA-MS) to analyse the proteomic profile of the infarction zone, border zone and remote zone from WT vs. KO hearts 1 week post-MI (each n = 5 mice). Overall, we reproducibly quantified 4360 proteins across all LV samples, identifying local genotype-specific proteotypes post-MI. In WT vs. KO samples, DIA-MS revealed 725 differentially abundant proteins in the zone pairwise comparison, highlighting a vital role of Dysferlin for LV remodelling post-MI. In addition, superresolution stimulated emission depletion (STED) microscopy was applied to study the subcellular localization and function of Dysferlin in the MI border zone. Here, we observed VMs with disrupted TAT endomembrane networks and significantly extended ICD regions. Interestingly, STED imaging revealed Dysferlin clusters that highly decorated residual TAT structures and interdigitated ICD membrane folds in the MI border zone. DIA-MS analysis of anti-Dysferlin co-imunoprecipitation experiments from WT vs. KO LV tissues characterized the cardiac interactome of Dysferlin, confirming interactions with proteins of the TAT system and the gap junction hemichannel Connexin-43. Conclusions Our data demonstrate Dysferlin as an endogenous membrane repair protein necessary to stabilize sarcolemmal nanodomains in the MI border zone. Dysferlin not only prevents from loss of TAT structures, but also compensates for increased mechanical stress at the ICDs. Hence, Dysferlin emerges as a novel therapeutic target to control membrane integrity in VMs to prevent from loss-of-function and cell death post-MI.

A personalized, 3D printed, polymeric elastic support device for the prevention of post-MI cardiac remodeling

Abstract Introduction Myocardial remodeling and dilatation following myocardial infarction (MI) initiates a vicious cycle leading to heart failure (HF). The anatomy and pathophysiology of every patient is unique. We have developed a 3D printed, biopolymer based personalized Elastic Support Device, that is 3D printed based on patient’s imaging, aiming to restore cardiac physiology. This study aimed to assess the device on rat MI model. Materials and Methods MI was induced in 24 Sprague Dawley rats by permanently ligating the mid LAD artery via midline sternotomy cut. Twelve animals underwent immediate implantation of the elastic support device that was pre-printed from animal specific 3D echocardiography. The animals were followed up with echocardiography at days -2, 7, 14, 28. The animals were sacrificed at day 28, cardiac tissue and plasma were taken for further histological and biochemical analysis. Results and discussion Mortality was similar at both groups (5 vs 4 in the device and control groups respectively). Ejection fraction reduced in both groups from a baseline of 61.9±8.9% to 47.5±12.7%. Left Ventricular End Diastolic Diameter increased from baseline to day 28 in the control (7.0±0.56mm vs 7.7±1mm) but not the device group (6.87±0.2mm vs 6.93±1.1mm, p<0.05). Parameters of diastolic function such as E/E’ were similar in both groups throughout the follow-up. Mason’s Trichrome stained cardiac sections revealed improved infarct size at the device group (7.4±1.9% vs. 10.6±2.8%) and lower overall cardiac fibrosis. Conclusion In this preliminary small animal model study, the capability to 3D print and implant an imaging based, personalized, 3D printed elastic support device. The cardiac diastolic function was not impaired, and no safety issues were noticed. Furthermore, cardiac dilatation was prevented, and infarct size was reduced.Trial design and results

A DIFFERENT VIEW OF MINOCA; A RARE CASE OF CORONARY CAMERAL FISTULA

Abstract Coronary cameral fistula (CCF) is defined as an abnormal connection between the coronary artery and the heart chambers. Although rare, most are asymptomatic, usually arising from the right coronary artery and terminating in the right ventricle or right atrium. Often detected incidentally, CCFs may present with symptoms of heart failure or rarely with anginal symptoms. Introduction A coronary cameral fistula is defined as an abnormal connection between the coronary artery and the heart chambers. CCFs are found in less than 1% of the population.[1] The most common coronary artery fistula is that arising from the right coronary artery and spilling into the right ventricle.[2] In particular, CCFs arising from all three epicardial coronary arteries are rare but can be clinically significant. These cases may present with acute coronary syndrome causing steal syndrome. Since there is usually no underlying obstructive lesion, these cases may be diagnosed as myocardial infarction without obstructive coronary arteries (MINOCA)[3] Case; A 51 years old male patient was admitted to the emergency room with a complaint of stabbing chest pain for the last one week. In his anamnesis, he described that the chest pain increased with exertion and radiated to the back. It was learned that he had no known disease and coronary history, was a 20 pack/year smoker, had no family history and was not taking any medication regularly. Vital signs in the emergency room revealed a blood pressure of 120/80 mmHg, pulse rate of 85 per minute and normal saturation. Electrocardiography (ECG) showed sinus rhythm V 1-6 with T negativity 85/min. (Figure 1) Echocardiography revealed no wall motion defect and no major valve pathology. Laboratory findings showed renal function tests within normal range, C-reactive protein within normal range, hemoglobulin level 17.6 gr/dl, HS Troponin-T level 12.9 ng/l (upper limit 14 ng/l). At 3 hours, the control HS Troponin-T level was 69.2 ng/l and the patient was hospitalized in the coronary intensive care unit with a prediagnosis of acute coronary syndrome. Coronary angiography was performed during follow-up. Angiography showed dilatation in the main coronary artery (LMCA), ectasia in the left anterior descending artery (LAD) and circumflex artery (CX), and diffuse tortuosity in the coronaries. CCF formed by the LAD, CX and right coronary artery (RCA) together and spilled into the left ventricle. Opaque filling was observed in the left ventricle. (Figure 2) Although the patient had a low body mass index, dilatation of the coronary arteries was thought to be the effect of steal syndrome caused by multiple fistulas. The patient was admitted to the coronary intensive care unit with medical follow-up. The patient's medical treatment was adjusted as acetylsalicylic acid (ASA) 100 mg pill 1*1, metaprolol 50 mg pill 1*1 and rosuvastatin 20 mg pill 1*1 due to an LDL cholesterol level of 149 mg/dl. In the patient who currently had no signs of heart failure, medical treatment was decided primarily in terms of CCF. The patient was discharged with the recommendation of outpatient follow-up. Discussion and Conclusion; CCFs are rare coronary anomalies.[1] When we look at the etiology, the most common cause of CCFs is abnormal embryogenesis.[4] While the diagnosis can be made at any age, the diagnosis is usually made in early childhood when a heart murmur occurs in an asymptomatic child or in a child with symptoms of heart failure. However, cases of CCF diagnosed at an advanced age with anginal complaints and signs of acute heart failure are seen in the literature. [5]Treatment depends on the anatomical features of the fistula and, of course, the patient's symptoms. While small fistulas may close spontaneously with age, large fistulas may require closure.It may cause anginal symptoms by causing heart failure symptoms and steal syndrome. [6]When we look at the literature, we can see that patients with CCF also present with acute coronary syndrome. [2, 4, 5,] As in the case reported by Alsancak Y et al., CCFs originating from all three coronary arteries cause steal syndrome and are often diagnosed with a prediagnosis of acute coronary syndrome.[7] The absence of an occlusive lesion after angiography in these patients with high troponin levels suggests atherosclerosis at the microvascular level and the diagnosis of MINOCA. [3]Angiography performed with suspicion of stenosis in the coronary arteries and finding a CHF instead of a stenosis may be considered lucky in these patients. The size of the fistula and the possibility that it may lead to heart failure in the follow-up will be the other side of the unlucky coin.

Exclusion of a left main pseudo aneurysm complicating SCAD by two overlapping DES - a case report.

SCAD is now recognized as an important cause of ACS in women, and its treatment is generally based on conservative therapy leading to complete cure. However, complete cure is not systematic, and data are lacking to identify patients at risk of malignant progression and to define the best therapeutic strategy.A 36-year-old woman with STEMI on SCAD extending from the LM to the middle LAD and circumflex artery, evolving under medical treatment to a large LM pseudo aneurysm. After CT evaluation and IVUS measurement, the patient underwent pseudo aneurysm exclusion by implantation of two overlapping DES on his collar. The choice of conservative treatment in the initial phase, given the extension of SCAD to all left coronary arteries, and the management of this voluminous LM pseudo aneurysm by implantation of two overlapping DES rather than by a covered stent or coil embolization, can be discussed here.

Risk factors for unsuccessful restoration of coronary flow reserve after coronary bypass surgery

Objectives: Coronary flow reserve (CFR) is a strong predictor of cardiovascular events and prognosis in patients with coronary artery disease. This study aimed to evaluate preoperative factors associated with the unsuccessful restoration of CFR after coronary artery bypass grafting (CABG). Methods: Included in this study were the 65 patients who presented with functionally significant left anterior descending artery (LAD) lesions confirmed by both fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR), and who underwent successful CABG at our hospital within the study period. After CABG, graft patency was confirmed by coronary computed tomography angiography, and CFR in the LAD artery was measured by echocardiography. We defined postoperative CFR <2.5 as impaired CFR, and CFR ≥2.5 as preserved CFR. Results: Of the 65 patients, 14 patients (22%) showed impaired CFR, while 51 patients had preserved CFR. Patients with impaired CFR had significantly higher HbA1c (6.7% vs. 6.0%, P < 0.01), greater use of insulin (43% vs. 4%, P < 0.01), longer lesion length (33 mm vs. 25 mm, P = 0.044), and lower iFR (0.69 vs 0.81, P = 0.01) than those with preserved CFR, although both groups had comparable FFR (0.65 vs 0.64, P = 0.46). In receiver operating characteristic curve analysis, iFR had a significantly larger area under the curve than FFR in terms of the prediction of impaired CFR (0.74 vs 0.42, P = 0.01). Conclusions: Poorly-controlled preoperative diabetes, greater reliance on insulin, longer lesion length and lower iFR were associated with postoperative impaired CFR, suggesting the involvement of microvascular dysfunction.

Abstract Tu048: Viscoelastic remodeling of the left ventricular myocardium in myocardial infarction

Introduction. Myocardial infarction (MI) leads to cardiac myocyte death and the formation of a fibrotic scar in the left ventricular myocardium (LV). LV free wall (LVFW) remodeling in MI is known to significantly alter the biomechanical response of the LV and, in turn, LV function. While changes in the elastic behavior of the LVFW in MI have been reported, changes in the viscoelastic behavior of the LVFW remain understudied. Our objective in this study was to determine the changes in the stress relaxation behavior of the LVFW in MI. Methods. MI was induced in rats via the ligation of the LAD artery, and hearts were harvested for three groups: sham, 2-week (2wk), and 4wk post-MI (n=3 for each group). Prior to sacrifice, echocardiography was performed to estimate ejection fraction (EF). LVFW specimens were harvested and subjected to viscoelastic stress relaxation tests. The specimens were stretched to 15% along the circumferential and longitudinal directions and allowed to relax. The stress was normalized against the peak (initial) stress for each specimen for proper comparison across the groups. Results. The EF at 2wk and 4wk specimens was reduced compared to the sham specimens (Fig. 1A). The 4wk post-MI specimens showed slower stress relaxation compared to that in the sham and 2wk specimens in both directions (Figs. 1B, C). Considering a 2-minute stress relaxation span, the normalized stress in the 4wk specimens was significantly higher than the sham specimens in both directions (Fig. 1D). Conclusions. Our results suggest that the viscoelastic relaxation rate of the LVFW diminishes at late MI timepoints. A larger and more mature scar in the LVFW is expected to contribute to slower relaxation at late MI. Future studies can determine the effect of LVFW viscoelastic remodeling on LV diastolic dysfunction and impaired relaxation in MI.

Angiographic evaluation of coronary artery disease in diabetic patients with and without end-stage kidney disease.

The objective of the present investigation was to compare the coronary angiography results in diabetic patients with and without end-stage kidney disease (ESKD). We included prolonged diabetic patients with ESKD (93 patients) and without ESKD (control group, 126 patients). Angiography of the coronary arteries was performed on all patients. Our results revealed that the ESKD patients tended to have a higher degree of coronary artery stenosis in all parts of LAD (p = 0.001, 0.024, and 0.005), proximal and distal RCA (p = 0.013, and 0.008), and proximal and distal LCX artery (p = 0.001, 0.008) than non-ESKD patients. Furthermore, we found that the ESKD group had higher significant coronary artery stenosis in the LAD artery (60.5% vs. 39.5%, p < 0.001), RCA (60.3% vs. 39.7%, p < 0.001), LCX artery (79.5% vs. 20.5%, p < 0.001), and LMCA (84.6% vs 15.4%, p = 0.002) compared to control group. There was a greater prevalence of multiple vessels coronary artery disease (≥ two) among ESKD patients (29%), compared with the non-ESKD group (16.8%, p < 0.001). Significant coronary artery stenosis was meaningfully higher in asymptomatic diabetic ESKD patients on hemodialysis than non-ESKD diabetic patients. Coronary angiography may be beneficial in diabetic patients with ESKD regardless of whether they have ischemic symptoms with low complication rate through radial access.

This video shows our setting for minimally invasive off-pump coronary artery bypass grafting procedures, which includes preparing the skeletonized LITA with a heparine-papaverine solution and sewing of the left internal thoracic artery to LAD artery.

This video shows our setting for minimally invasive off-pump coronary artery bypass grafting procedures, which includes preparing the skeletonized LITA with a heparine-papaverine solution and sewing of the left internal thoracic artery to LAD artery.

Transient formation of collaterals contributes to the restoration of the arterial tree during cardiac regeneration in neonatal mice

Revascularization of ischemic myocardium following cardiac damage is an important step in cardiac regeneration. However, the mechanism of arteriogenesis has not been well described during cardiac regeneration. Here we investigated coronary artery remodeling and collateral growth during cardiac regeneration. Neonatal MI was induced by ligature of the left descending artery (LAD) in postnatal day (P) 1 or P7 pups from the Cx40-GFP mouse line and the arterial tree was reconstructed in 3D from images of cleared hearts collected at 1, 2, 4, 7 and 14 days after infarction. We show a rapid remodeling of the left coronary arterial tree induced by neonatal MI and the formation of numerous collateral arteries, which are transient in regenerating hearts after MI at P1 and persistent in non-regenerating hearts after MI at P7. This difference is accompanied by restoration of a perfused or a non-perfused LAD following MI at P1 or P7 respectively. Interestingly, collaterals ameliorate cardiac perfusion and drive LAD repair, and lineage tracing analysis demonstrates that the restoration of the LAD occurs by remodeling of pre-existing arterial cells independently of whether they originate in large arteries or arterioles. These results demonstrate that the restoration of the LAD artery during cardiac regeneration occurs by pruning as the rapidly forming collaterals that support perfusion of the disconnected lower LAD subsequently disappear on restoration of a unique LAD. These results highlight a rapid phase of arterial remodeling that plays an important role in vascular repair during cardiac regeneration.

S-Nitroso Human Serum Albumin Enhances Left Ventricle Hemodynamic Performance and Reduces Myocardial Damage after Local Ischemia-Reperfusion Injury.

Endothelial nitric oxide (NO) production is crucial in maintaining vascular homeostasis. However, in the context of ischemia-reperfusion (I/R) injury, uncoupled endothelial nitric oxide synthase (eNOS) can exacerbate reactive oxygen species (ROS) generation. Supplementation with S-nitroso human serum albumin (S-NO-HSA) offers a potential solution by mitigating eNOS uncoupling, thereby enhancing NO bioavailability. In a study conducted at the University of Verona, male rats underwent thoracotomy followed by 30 min left anterior descendant coronary (LAD) occlusion and subsequent reperfusion. Hemodynamic parameters were meticulously assessed using a conductance catheter inserted via the carotid artery. The rats were stratified into two main groups based on reperfusion duration and the timing of drug infusion, with the effects of S-NO-HSA evaluated after 2 or 24 h. Remarkably, intravenous administration of S-NO-HSA, initiated before or during ischemia, exhibited notable benefits. It significantly improved left ventricular function, safeguarded energetic substrates such as phosphocreatine and ATP, and sustained glutathione levels akin to basal conditions, indicative of diminished oxidative stress. The data from this study strongly suggest a protective role for S-NO-HSA in mitigating I/R injury induced by LAD artery occlusion, a phenomenon observed at both 2 and 24 h post-reperfusion. These findings underscore the promising therapeutic potential of NO supplementation in alleviating myocardial damage subsequent to ischemic insult.

Prognostic significance of non-ischemic computational pressure-flow dynamics derived fractional flow reserve in stable coronary artery disease patients in LAD versus non-LAD artery lesions

Prognostic significance of non-ischemic computational pressure-flow dynamics derived fractional flow reserve in stable coronary artery disease patients in LAD versus non-LAD artery lesions

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 &lt;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&lt; 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.

Correlation of Non-Invasive Transthoracic Doppler Echocardiography with Invasive Doppler Wire-Derived Coronary Flow Reserve and Their Impact on Infarct Size in Patients with ST-Segment Elevation Myocardial Infarction Treated with Primary Percutaneous Coronary Intervention.

Background: Coronary microvascular dysfunction is associated with adverse prognosis after ST-segment elevation myocardial infarction (STEMI). We aimed to compare the invasive, Doppler wire-based coronary flow reserve (CFR) with the non-invasive transthoracic Doppler echocardiography (TTDE)-derived CFR, and their ability to predict infarct size. Methods: We included 36 patients with invasive Doppler wire assessment on days 3-7 after STEMI treated with primary percutaneous coronary intervention (PCI), of which TTDE-derived CFR was measured in 47 vessels (29 patients) within 6 h of the invasive Doppler. Infarct size was assessed by cardiac magnetic resonance at a median of 8 months. Results: The correlation between invasive and non-invasive CFR was modest in the overall cohort (rho 0.400, p = 0.005). It improved when only measurements in the LAD artery were considered (rho 0.554, p = 0.002), with no significant correlation in the RCA artery (rho -0.190, p = 0.435). Both invasive (AUC 0.888) and non-invasive (AUC 0.868) CFR, measured in the recanalized culprit artery, showed a good ability to predict infarct sizes ≥18% of the left ventricular mass, with the optimal cut off values of 1.85 and 1.80, respectively. Conclusions: In patients with STEMI, TTDE- and Doppler wire-derived CFR exhibit significant correlation, when measured in the LAD artery, and both have a similarly strong association with the final infarct size.

ELECTROCARDIOGRAPHY PATTERNS IN PATIENTS WITH PROXIMAL LEFT ANTERIOR DESCENDING CORONARY ARTERY STENOSIS

Background: Stenosis of proximal left anterior descending coronary artery presents with diverse electrocardiographic patterns. This study aimed to determine different types of ECG changes and their frequency in patients with proximal left anterior descending coronary artery stenosis. Methods: This descriptive cross-sectional study was conducted at the Department of Cardiology, College of Medical Sciences, Bharatpur from Ist June 2023 to 30 October 2023. Patients who underwent coronary angiography and had proximal left coronary artery stenosis were included in the study. Total 80 such patients were evaluated. Electrocardiographic changes in these patients was noted. Proximal left anterior descending coronary artery stenosis was independent variable and ECG changes were dependent variables. The ECG changes were ST elevations in leads I, aVL and precordial leads V1-V6, ST elevations in V1-V6, De Winter’s T-wave pattern, acute LBBB and Wellen’s Syndrome. Frequency of varying electrocardiographic changes in proximal left anterior descending coronary artery stenosis was evaluated. Results: Electrocardiographic analysis of proximal left anterior descending artery revealed diverse patterns. 37.5% (n=25) had ST elevations in leads I, aVL and V1-V6. 25% (n=20) had ST elevations in V1-V6. De Winter’s T-wave pattern was seen in 16.25% (n=13) patients. Left bundle branch block was present in 15% (n=12). A Wellen’s Syndrome was present in 12.5% (n=10). Conclusions: Proximal LAD artery stenosis reveals significant diversity in ECG patterns.

Hemodynamics in left coronary artery with ramus intermedius: A patient-specific computational study

Clinical studies based on coronary computed tomography angiography (CCTA) images suggest that the presence of ramus intermedius (RI) in the left coronary artery (LCA) may aggravate the atherosclerotic depositions in the furcation region. In this study, computational fluid dynamics simulations are performed in patient-specific coronary models consisting of bifurcating LCA and two models having trifurcating LCA. Three-dimensional patient-specific coronary models are constructed from CCTA images obtained from North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences, Shillong, India. Results indicate that the flow redistribution happens in the left coronary branch due to the presence of RI and the flow to left anterior descending artery (LAD) is reduced significantly. Recirculation and flow separation regions are observed in the proximal parts of the LAD and left circumflex artery for trifurcation geometries. The qualitative and quantitative analysis of wall shear stress-based descriptors suggests that the presence of the intermediate branch may affect the atherosusceptibility of the proximal region of LAD. The study indicates that the presence of RI may act as a contributing factor for plaque development and progression in the furcation region and proximal parts of LAD.

Wellens Syndrome: prevalence, risk factors and coronary angiographic variation. A cross-sectional study.

Wellens syndrome complicates acute coronary syndrome and, if unmanaged, can lead to immanent myocardial infarction. This study aimed towards determining the prevalence of Wellens syndrome among acute coronary syndrome patients while focusing on both types and identifying the associated risk factors, then exploring the variation in affected coronary arteries within patients fulfilling Wellens syndrome criteria. Implementing a descriptive cross sectional hospital based observational study design, at Ahmed Gasim Teaching Hospital for Cardiac Surgery and Renal Transplantation in Khartoum North, Sudan, the study was conducted following using a non probability convenience sampling of patients fitting the inclusion criteria. Data was collected using closed ended structured questionnaires. Ethical clearance was obtained from relevant authorities. Statistical analysis was done using descriptive and comparative data analysis with the aid of the SPSS software, and STROBE guidelines were followed. A total of 120 patients were included, 70 males and 50 females, majority in their fifth decade. 14 patients had no documented risk factors. 42.5% had STEMI, 34.2% had NSTEMI and 23.3% had unstable angina. Patients fulfilling Wellens syndrome criteria were 18 (15%), 55.6% of them were type A and 44.4% were type B. Most frequently encountered risk factor among Wellens syndrome patients was Diabetes (50%). Out of 16 Wellens syndrome patients who underwent coronary angiography, 50% had mid LAD involvement, most were type A; 25% had proximal LAD involvement and 25% had normal coronary angiography. There was some association between Wellens syndrome and NSTEMI, but no significant association with any specific risk factor. Wellens syndrome complicates 15% of acute coronary syndrome patients with a 55.6% possibility of becoming type A, it can present even without a specific predisposing risk factor and coronary angiographic variation other than the proximal part of the LAD artery may occur, including multiple vessels involvement. This is a descriptive cross sectional study conducted at Ahmed Gasim Teaching Hospital in Sudan, to determine the prevalence and risk factors of Wellens syndrome. Data was collected using questionnaires and analyzed with the SPSS software. Out of 120 patients, 14 patients had no documented risk factors. 34.2% had NSTEMI and 23.3% had unstable angina. Patients fulfilling Wellens syndrome criteria were 18 (15%). The commonest risk factor among Wellens syndrome patients was Diabetes (50%). 50% of Wellens syndrome patients had mid LAD involvement. The study concluded that Wellens syndrome is not rare, it can present without specific risk factor and coronary angiographic variation other than the proximal LAD artery can occur.

Cardiac segments dosimetric benefit from deep inspiration breath hold technique for left-sided breast cancer radiotherapy.

The objective was to compare dosimetry in left-sided breast cancer (LSBC) patients receiving deep inspiration breath hold (DIBH) radiotherapy (RT) with free-breathing (FB) treatment plans. Voluntary DIBH with a spirometer-based video-assisted system and CT-simulation were performed under FB and DIBH conditions on 40 LSBC patients, segmented according Duane's atlas. IMRT plans kept the same dosimetric goals on FB and DIBH conditions. Target, lungs and heart volumes were measured. Planning target volume (PTV) dose distribution, organs at risk (OARs) dose/volume parameters, including cardiac substructures, were calculated. Lungs and left-lung volumes increased in DIBH conditions (ΔV = 1637.8 ml ± 555.3 and 783.5 ml ± 286.4, respectively). Heart volume slightly decreased in apnea (p = 0.04), but target volumes, CTV and PTV were similar in FB or DIBH plans. PTV dose coverage was similar irrespective of respiratory conditions (median D50% = 41.1 Gy vs 41.0 Gy, p = 0.665; V95% = 96.9% vs. 97%). Mean dose for the whole heart (MHD), left ventricle (LV), and LV segments were significantly reduced in DIBH plans. V20 values for heart subvolumes were significantly different only for those that received considerable doses (apical and anterior). DIBH plans provided significantly smaller doses (Dmax, D2%, and V20) to the LAD artery. Important dosimetric improvements can be achieved with DIBH technique for LSBC patients, reducing the dose to the LAD artery and heart, particularly to the segments closer to the chest wall. Apical/anterior LV segments, should be considered as separate organ at risk in breast RT.

Type IV dual left anterior descending artery circulation: A rare coronary artery anomaly

Dual left anterior descending artery (LAD) is a rare coronary anomaly with varied presentation. We present the case of a 63-year-old male with complaints of exertional angina whose coronary angiogram and computerized tomography coronary angiogram showed type 4 dual LAD arteries, a rare variant of dual LAD.

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