LAD Artery Research Articles

Coronary Angiography and Intravascular Ultrasound in an Ex-Vivo Perfused Heart Using the Organ Care System (OCS)

Purpose To describe technical aspects of angiography and intravascular ultrasound (IVUS) in ex-vivo perfused hearts using the Organ Care System (OCS, TransMedics, Andover, MA USA). Methods During ex-vivo perfusion of a pig heart a moderate stenosis of the mid left anterior descending coronary artery (LAD) was created in order to test the sensitivity of angiography and IVUS. The operating table was removed and the OCS was lifted by 45 cm to achieve an AP position of the heart within the X-ray system. As tilted or rotated projections are limited by radiopaque materials within the OCS, the heart had to be rotated to facilitate different views. Results The standard heart position in the OCS revealed good visualization of the right coronary artery(RCA) using a 5 Fr. JR catheter (Fig 1). Using a JL catheter the left coronary artery(LCA) ostium could be intubated easily, however, visualization was suboptimal. Therefore the heart was rotated 90°-clockwise, which led to good LAD and suboptimal circumflex artery(RCx) visualization. 135°-anticlockwise-rotation(-45° from standard position) led to good LAD and RCx projection(Fig 2). The LAD stenosis could be visualized in the angiography and confirmed by IVUS. Conclusion Coronary angiogram of hearts during ex-vivo perfusion is feasible. As the OCS allows only AP fluoroscopy, the heart needs to be rotated to achieve sufficient views for coronary diagnostics. IVUS can be implemented to extend the diagnostic value.

Association of coronary artery Doppler-echocardiography diastolic-systolic velocity ratio at rest with obstructive coronary artery stenosis on the left main or left anterior descending coronary artery

BackgroundWe assessed whether the non-invasive measure of peak diastolic-systolic velocity ratio (rDSVR) at rest on the left anterior descending artery (LAD) using Doppler transthoracic echocardiography is associated with obstructive coronary artery disease (CAD) on the LAD and left main (LM) arteries. We compared rDSVR diagnostic accuracy with stress wall motion (WM) and coronary flow reserve (CFR-LAD), in a group of subjects who underwent contrast stress-echocardiography (cSE) and coronary angiography within 3 months. Methods286 patients selected with a clinical indication to cSE, in which CFR-LAD was measured during the test who also underwent coronary angiography within 3 months were selected and diagnostic performance compared. ResultsDemographics and clinical variables were univariate predictors of LAD or LM >50% stenosis, but rDSVR < 1.7 outperformed other variables (OR 11.18, 95% CI 5.82–21.49, p < 0.001), comprising cSE variables such as reversible WM abnormalities (OR 1.53, 95% CI 0.94–2.49, p = 0.087) or CFR-LAD < 2 (OR 2.88, 95% CI 21.74–4.77, p < 0.001). The addition of rDSVR to multivariate logistic regression models (clinical or clinical + cSE variables) led to a marked increase in C-index (0.82, 95%CI 0.78–0.87) with significant improvement compared to all prior models (p < 0.001). ConclusionsOur data suggest a strict association of reduced rDSVR with >50% coronary artery stenosis on the LM/LAD, superior to other standard clinical or cSE related indexes, such as WM assessment or CFR-LAD, and builds incrementally to them and clinical variables in multivariable logistic models for the prediction of CAD on LM and LAD coronaries.

Personalised deposition maps for micro- and nanoparticles targeting an atherosclerotic plaque: attributions to the receptor-mediated adsorption on the inflamed endothelial cells.

Endothelial inflammation as a prominent precursor to atherosclerosis elicits a distinct pathological surface expression of particular vascular proteins. To exhibit a site-specific behaviour, micro- and nanoparticles, as carriers of therapeutics or imaging agents, can distinguish and use these proteins as targeted docking sites. Here, a computational patient-specific model capturing the exclusive luminal qualities has been developed to study the transport and adsorption of particles decorated with proper antibodies over an atherosclerotic plaque located in the LAD artery of the patient. Particles, in nano- and micron sizes, have been decorated with Sialyl Lewisx (sLex), P-selectin aptamer (PSA), and ICAM-1 antibody (abICAM) to target the three of the most well-known endothelial adhesion proteins that display pathological expressions on the plaque surface, namely E-selectin, ICAM-1, and P-selectin. We learned that in the receptor-mediated adhesive dynamics in pathological contexts, parameters such as specific diffusivity of ligand-receptor pairs and the affinity constant play crucial roles in the final amount and homogeneity of surface density of adsorbed particles (SDA). In spite of ascending nature of SDAs with the increase in particle size, our model specified that the alteration in results due to increase in particle diameter can be insignificant depending upon the special parameters associated with the type of ligand-receptor bonds. Also, the combination of 95.1% sLex and 4.9% PSA ligands for dual-targeting 800-nm particles was introduced as the optimal decorating arrangement for which the surface of plaque experiences a significant SDA along with a homogeneously improved deposition pattern. Finally, the key results of this work were compared with the results of similar experiments in a pulsatile flow chamber and a relevant in vivo test.

Influence of Local Myocardial Infarction on Endothelial Function, Neointimal Progression, and Inflammation in Target and Non-Target Vascular Territories in a Porcine Model of Acute Myocardial Infarction.

BackgroundPatients with acute myocardial infarction (AMI) have worse clinical outcomes than those with stable coronary artery disease despite revascularization. Non-culprit lesions of AMI also involve more adverse cardiovascular events. This study aimed to investigate the influence of AMI on endothelial function, neointimal progression, and inflammation in target and non-target vessels.MethodsIn castrated male pigs, AMI was induced by balloon occlusion and reperfusion into the left anterior descending artery (LAD). Everolimus-eluting stents (EES) were implanted in the LAD and left circumflex (LCX) artery 2 days after AMI induction. In the control group, EES were implanted in the LAD and LCX in a similar fashion without AMI induction. Endothelial function was assessed using acetylcholine infusion before enrollment, after the AMI or sham operation, and at 1 month follow-up. A histological examination was conducted 1 month after stenting.ResultsA total of 10 pigs implanted with 20 EES in the LAD and LCX were included. Significant paradoxical vasoconstriction was assessed after acetylcholine challenge in the AMI group compared with the control group. In the histologic analysis, the AMI group showed a larger neointimal area and larger area of stenosis than the control group after EES implantation. Peri-strut inflammation and fibrin formation were significant in the AMI group without differences in injury score. The non-target vessel of the AMI also showed similar findings to the target vessel compared with the control group.ConclusionIn the pig model, AMI events induced endothelial dysfunction, inflammation, and neointimal progression in the target and non-target vessels.

Iatrogenic giant left anterior descending coronary artery pseudoaneurysm with contained perforation following percutaneous coronary intervention

Giant iatrogenic coronary pseudoaneurysms are very rare. Left untreated, they may cause serious adverse outcome. We present a case of a male patient with recurrent NSTEMIs and coronary interventions who developed a large LAD artery pseudoaneurysm with contained rupture. He underwent excision of the large proximal LAD pseudoaneurysm, excision of the previous LAD stent, ligation of proximal LAD, and coronary artery bypass grafting with LIMA-LAD graft. He subsequently recovered and was stable on follow up. In conclusion, an aggressive surgical strategy, though difficult, is likely the best means of management for lasting benefit.

Perioperative myocardial infarction in a case of mitral valve replacement: Rare complication of a common procedure

A 56-year-old female underwent mitral valve replacement for severe symptomatic rheumatic mitral stenosis. There was perioperative myocardial infarction as evidenced by the regional echocardiogram (ECG) and echocardiographic changes (left anterior descending [LAD] territory) and hemodynamic instability. The patient was immediately taken up for coronary angiogram to find complete occlusion of mid-segment of the LAD artery. Thrombus aspiration and intracoronary nitrates were given to restore thrombolysis in myocardial infarction (TIMI) III flow in the vessel. The patient was discharged after 10 days without any other complications. On follow-up ECG, the regional wall motion abnormality persisted. Repeat coronary angiogram done for the same revealed no lesions in coronary vessels with TIMI III flow.

Impact of SYNTAX Score on In-hospital Outcome after Primary Percutaneous Coronary Intervention

Background: Limited contemporary data exist regarding the impact of SYNTAX score on in-hospital outcomes undergoing primary percutaneous coronary intervention(PCI) in acute STEMI patients.&#x0D; Objectives: To evaluate the significance of the SYNTAX score for predicting in- hospital outcome after primary PCI in patient with acute STEMI.&#x0D; Methods: This cohort study was conducted in the department of cardiology, National Institute of Cardiovascular Diseases, Dhaka, Bangladesh from September, 2015 to September, 2016. 42 patients with acute STEMI who underwent primary PCI were considered for the study. But 2 patients were excluded from the study due to failure of primary PCI. The patients were divided into two groups: Group I (low SYNTAX score d”22) and Group II (high Syntax score &gt; 22). The Syntax score of all patients were calculated from an initial coronary angiogram before primary PCI. In-hospital outcome was observed in between two groups.&#x0D; Results: Among traditional cardiovascular risk factors diabetes was significantly more prevalent in the Group II than Group I ( 82.4% vs 34.8%, p  0.003). Angiographic profile revealed maximum (69.6% vs 17.6%) culprit lesion in LAD artery in Group I and maximum culprit lesion (64.7% vs 21.7%) in RCA in Group II, these were the statistically significant between Group I and Group II (P&lt;0.05). The high SYNTAX score group had lower TIMI 3 (76.47% vs 91.3%, p  0.03) compared to the low SYNTAX score group. But there were no significant difference in complications as arrhythmia (2.5% vs 0%), cardiogenic shock (2.5% vs 0%), heart failure (5% vs 2.5%) and mortality (5%vs 0%) between high and low SYNTAX score. Multivariate logistic regression analysis revealed SYNTAX score (OR = 5.95, p  0.001) was an independent predictor of in-hospital outcome in patients under going primary PCI. Performance test of SYNTEX score in the setting of Primary PCI outcome showed positive predictive value 83%.&#x0D; Conclusions: SYNTAX score was an independent variable that can predict in-hospital outcomes of patients with acute STEMI undergoing primary PCI.&#x0D; Bangladesh Heart Journal 2018; 33(2) : 121-125

Reduction of Heart Dose Using Voluntary Deep Inspiration Breath- Holding Technique in Left Breast Cancer Patients Treated by Hypofractionated Radiation Therapy

This study aims at proving that voluntary Deep Inspiration Breath- Holding (vDIBH) technique lowers radiation exposure to the heart and Left Anterior Descending Artery (LAD) without compromising coverage of left breast or chest wall. Irradiation of a substantial volume of the heart to a sufficiently high dose can damage virtually any component of the heart which can cause significant morbidity or mortality. Sixty-six women with left sided breast cancer requiring post-operative radiotherapy and fulfilling inclusion criteria were accrued from radiotherapy department at a single institution from November 2015 to December 2016. Inclusion criteria comprised patients with non-metastatic left breast cancer who are candidates for post-operative radiotherapy and can hold their breaths for longer than 20 seconds. Informed consent was obtained from all patients who were then coached on proper method of breath holding. 2 sets of CT simulations were done during free breathing and DIBH techniques. The average time for which the patients were asked to hold their breath was between 18 and 23 seconds. Both CT image data serials were then transferred to the treatment planning system where target volume and organs at risk (left lung, heart, and contralateral breast) were delineated according to RTOG protocols. LAD arteries were contoured according to the University of Michigan cardiac atlas. 3D-conformal planning using hypofractionated dose of 40Gy/15 fractions was done in all cases. Dose-Volume Histograms were used to compare between both techniques regarding doses to critical organs at risk (mean heart dose, V10-heart, V20-heart, V25-heart, LAD artery, contralateral breast, and lungs), and planning target volume (PTV). Acceptance was based on RTOG 1005 and University of Michigan protocols. Using vDIBH technique, all patients had lower heart and LAD artery doses. In the free breathing serials, mean heart doses ranged from 99 cGy to 613 cGy with the average being 330 cGy. Based on RTOG 1005 protocol, 3 patients had an unacceptable mean heart dose of more than 500 cGy, while 14 patients had a less than ideal mean heart dose between 400 and 500 cGy. Utilizing vDIBH technique, mean heart doses ranged from 74 cGy to 407 cGy with the average being 210 cGy. This represents a statistically significant difference (p-value <0.001). Patients who received internal mammary nodal irradiation, with wide tangential fields, showed statistically significant lower doses regarding heart and LAD artery between both techniques (p-value <0.05). vDIBH technique was associated with lower radiation dose to the heart, LAD artery and ipsilateral lung without compromising coverage of the breast or chest wall.

CRYPTIC CHEST PAIN: WELLEN’S SYNDROME DUE TO MYOCARDIAL BRIDGING

SESSION TITLE: Cardiovascular Disease 2 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Chest pain of cardiac origin is commonly ischemic in etiology. However, the phenomenon of myocardial bridging as a cause of chest pain has come to attention recently. Herein, an epicardial coronary artery develops a transient myocardial course. During systole, a portion of the vessel is mechanically compressed and results in ischemia. This has been attributed to as a rare cause of angina. Here we present our experience with a patient who was diagnosed with the same. CASE PRESENTATION: A 51 year old man with no past medical history, presented to the emergency room with pressure like chest pain of two days duration. He had multiple episodes of pain and each lasted for around 20 minutes. It was associated with palpitations, and exacerbated by physical exertion. He was a former smoker and reportedly quit smoking 20 years back. His blood pressure was 153/95 mmHg; temperature 98.1F; heart rate 73/min regular; respiratory rate 18/min. ECG showed Type 1 Wellen's biphasic pattern in V2, V3. Three sets of cardiac troponins were normal. Wellens pattern on ECG is highly specific (89%) for critical left anterior descending artery (LAD) stenosis. [1] [2]. Therefore, the patient was sent for emergent cardiac catheterization. Coronary angiography revealed normal left main, left circumflex and right coronary artery. However, LAD artery showed moderate myocardial bridging. DISCUSSION: In myocardial bridging, a coronary artery that normally runs on the epicardium, develops a transient intra-myocardial course. This section of the artery gets compressed during ventricular systole. Generally asymptomatic, bridging sometimes results in angina, arrhythmias myocardial ischemia. Most myocardial bridging has been found to occur in the middle portion of the LAD artery. However, on autopsy right coronary and left circumflex arteries have shown bridging at comparable rates. [3]. Proximal portion of the bridged segment is prone to accelerated atherosclerosis.Hypertrophic obstructive cardiomyopathy (HOCM) has shown increased association with myocardial bridging. Treatment is with beta blockers and non-dihydropyridine calcium channel blockers. Therapeutic benefit results from decreased chronotropy and inotropy. In cases refractory to medical management, surgical myotomy, coronary artery stenting or coronary artery bypass grafting (CABG) can be pursued. Our patient was started on aspirin, amlodipine, metoprolol, and rosuvastatin. His hospital course was uneventful and he was discharged on pharmacological therapy. CONCLUSIONS: Myocardial Bridging is being recognized increasingly as a cause of refractory angina. However, it is still not widely included as a differential diagnosis. Since the treatment is fairly specific, we wish to underscore the importance of recognizing myocardial bridging as an atypical cause of chest pain. Reference #1: C. de Zwaan, F.W. Bar, H.J. Wellens. Characteristic electrocardiographic pattern indicating a critical stenosis high in left anterior descending coronary artery in patients admitted because of impending myocardial infarction. Am Heart J, 103 (1982), pp. 730-736. Reference #2: C. de Zwaan, F.W. Bar, J.H. Janssen, et al. Angiographic and clinical characteristics of patients with unstable angina showing an ECG pattern indicating critical narrowing of the proximal LAD coronary artery. . Am Heart J, 117 (1989), pp. 657-665. Reference #3: Polacek P, Kralove H. Relation of myocardial bridges and loops on the coronary arteries to coronary occlusions. Am Heart J. 1961;61:44-52 DISCLOSURES: No relevant relationships by Paurush Ambesh, source=Web Response No relevant relationships by Stephan Kamholz, source=Web Response No relevant relationships by Dikshya Sharma, source=Web Response No relevant relationships by Ankur Sinha, source=Web Response

Abstract 210: Coronary Artery Luminal Diameter, False Positive Stress Myocardial Perfusion Imaging and Body Mass Index: Is There an Association?

Background: Single Photon Emission Computerized Tomography Myocardial Perfusion Imaging (MPI) stress test is a widely used test to evaluate patients with suspected CAD with relatively higher false positive rate. There is a paucity of data on the association of false positive MPI, coronary artery diameter particularly focusing on left anterior descending artery (LAD) and body mass index (BMI). Methods: An institutional review board approved, retrospective study included female patients with abnormal MPI stress tests showing reversible ischemia in the anterior walls but without any disease in LAD arteries as assessed by coronary angiography within 3 months of the stress tests. Two qualified physicians reviewed the cine-angiograms and LAD diameter was categorized into two groups 3 mm and 3 mm. Categorical and continuous variables were analyzed using chi -square test and analysis of variance test respectively with a p value for significance as &lt; 0.05. Results: A total of 251 female patients who had both false positive MPI stress test and normal coronary angiograms were analyzed. The mean (±SD) age, BMI and left ventricular ejection fraction (LVEF) was 59.9±12.3 years, 34.1±9.5 kg/m 2 and 59.4±7.2 % respectively. There was 76% of the patients had LAD diameter of ≥3 mm and 24% had &lt; 3 mm. There was no statistically significant difference in mean age, BMI and LVEF between the two groups of the vessel sizes. The mean age was 60.5±12.5 vs 58.1±11.7 years (p = 0.20) and mean BMI was 33.5±9.3 vs 35.7±10.2 kg/m2 (p = 0.12) in ≥3 mm vs &lt; 3 mm vessels. There was no statistically significant association noted between BMI categories and vessel diameters. When BMI was categorized as &lt; 24.9, 25-29.9, 30-39.9 and &gt; 40, there was 17.6% vs 15.5 %; 22.5% vs 17.2%; 36.4% vs 39.7% and 23.5% vs 27.6% patients had ≥ 3 vs &lt; 3 mm vessels respectively (Chi-square p value = 0.77). Conclusion: There is no association between the luminal diameter of LAD and false positive MPI. Additionally, vessel diameter does not depend upon BMI. Further studies are needed to assess these observations.

Abstract 235: Revascularization Patterns of Systolic Heart Failure in a Large Urban County Hospital

Background: Coronary angiography is frequently performed after the initial diagnosis of heart failure to determine etiology and revascularization strategy. Current body of evidence suggests that surgical revascularization conveys a mortality benefit as compared to medical therapy alone, and the role of percutaneous coronary intervention (PCI) is not yet established. The aim of this study is to describe revascularization patterns among patients presenting with systolic heart failure who underwent diagnostic angiography at a large urban county hospital. Methods: We evaluated patients presenting to the emergency department with symptomatic heart failure with reduced ejection fraction (HFrEF) without acute coronary syndrome (n=150; average left ventricular ejection fraction of 25%) who underwent coronary angiography between January 2011 and January 2015. We defined surgical coronary artery disease (CAD) as: 1) three-vessel disease, 2) two-vessel disease including the proximal LAD artery, or 3) two-vessel disease including the left main coronary artery. Primary outcomes included intervention (PCI, CABG, or medical therapy [MT] alone) as well as referral for CABG. Results: Of patients presenting with HFrEF who underwent diagnostic angiography, 80% (n=120) of patients had obstructive CAD with 36% (n=43) of those patients having surgical CAD. Of those with surgical CAD, 74% (n=32) underwent PCI, 18% (n=8) underwent CABG and 7% (n=3) received MT alone. Of patients with 1-vessel CAD, or 2-vessel CAD without involvement of the proximal LAD artery or left main coronary artery, 81% (n=63) underwent PCI while 19% (n=14) received MT alone. Conclusion: Patients presenting with symptomatic HFrEF referred for cardiac catheterization have a high prevalence of obstructive CAD. Most patients with evidence of either surgical or non-surgical CAD during coronary angiography underwent revascularization, with PCI being the dominant revascularization method.

In vivo predictors of plaque erosion in patients with ST-segment elevation myocardial infarction: a clinical, angiographical, and intravascular optical coherence tomography study.

Plaque erosion is a significant substrate of acute coronary thrombosis. This study sought to determine in vivo predictors of plaque erosion in patients with ST-segment elevation myocardial infarction (STEMI). A prospective series of 822 STEMI patients underwent pre-intervention optical coherence tomography. Using established diagnostic criteria, 209 had plaque erosion (25.4%) and 564 had plaque rupture (68.6%). Plaque erosion was more frequent in women <50 years when compared with those ≥50 years of age (P = 0.009). There was a similar, but less striking, trend in men (P = 0.011). Patients with plaque erosion were more frequently current smokers but had fewer other coronary risk factors (dyslipidaemia, hypertension, chronic kidney disease, and diabetes mellitus) than those with plaque rupture. There was a preponderance of plaque erosion in the left anterior descending artery (LAD; 61.2%), whereas plaque rupture was more equally distributed in both the LAD (47.0%) and right coronary artery (43.3%). Despite the similar spatial distribution of erosions and ruptures over the lengths of the coronary arteries, plaque erosion occurred more frequently near a bifurcation (P < 0.001). In the multivariable analysis, age <50 years, current smoking, absence of other coronary risk factors, lack of multi-vessel disease, reduced lesion severity, larger vessel size, and nearby bifurcation were significantly associated with plaque erosion. Nearby bifurcation and current smoking were especially notable in men, while age <50 years was most predictive in women. Plaque erosion was a predictable clinical entity distinct from plaque rupture in STEMI patients, and gender-specific role of risk factors in plaque erosion should be considered.

Cardioprotective effect of resistance training and Crataegus oxyacantha extract on ischemia reperfusion–induced oxidative stress in diabetic rats

Discovering an effective approach to limit infarction size after ischemia-reperfusion has a clinical importance in diabetics. We investigated the anti-myocardial ischemia-reperfusion injury effect of resistance training and Crataegus oxyacantha extract on diabetic rats. To this end, 50 male Wistar rats were randomly divided into 5 groups: the sedentary control (SC), sedentary diabetic (SD), resistance trained diabetic (RD), diabetic plus C. oxyacantha extract treatment (CD) and resistance trained diabetic plus C. oxyacantha extract treatment (RCD) groups. Animals in trained groups were subjected to progressive resistance training program with the use of a ladder (5 days/week, for 10 weeks). C. oxyacantha extract rats were treated with 100 mg/kg body weight of the extract using a gavage every day for 10 weeks. After treatments, rats were subjected to ischemia via LAD artery ligation for 30 min followed by 90 min reperfusion. The heart was collected following the ischemia-reperfusion and analyzed for oxidative stress and ischemia-reperfusion injury. Compared to the SC group, LDH, CK-MB and infarction size in the SD group were significantly higher, whereas injury indices in the RCD group were significantly lower than those in the SD group. GPx and MPO levels after reperfusion increased and decreased, respectively in response to training and C. oxyacantha. These findings suggest that 10 weeks resistance training and C. oxyacantha can synergistically decrease ischemia-reperfusion injury, and this mechanism may be related to a reduction in oxidative stress which is normally associated with ischemia-reperfusion.

Anomalili Koroner Olgularda Kateter Şekillendirmenin Anjiyografifik Görüntüleme Başarısındaki Rolü

In this article, we present a case that suggesting some coronaries were not recognized in coronary angiography. On 2.6% of coronary angiograms anomalous origin of coronary arteries is encountered. In 0.58% of the cases left anterior descending artery (LAD) is arises from a separate ostium. Absence of LMCA can be discerned directly on coronary angiograms obtained using selective visualization of CX or LAD because in most of the cases of LAD and circumflex artery (CX) arise from separate ostia. A 54-year-old-female patient underwent coronary angiography through right radial route. In previous angiography performed at another center, The intermediate coronary (IM) artery was supposed to be the LAD and that was applied stent to the artery. We had watched the patient's previous angiography and we recorded various images considering that there may be another vessel in the new coronary angiography. Aortography was performed because the LAD area was empty in the left cranial view. When aortography is carefully examined, a weak image appears from a separate ostium, thought to belong to LAD. That could not be visualized using standard catheters. Using a 5F left Judkins catheter reshaped using a hot air gun LAD could be visualized selectively, and symptoms of the patient could be explained clinically. In patients who are undergoing coronary angiography where standard catheters can not be selectively engaged, in case of need, reshaping the catheter in the catheterization laboratory can be a practical, applicable method for the disclosure of occult coronaries.

A Cure of Coronary Artery Disease by Removing Atheromatous Plaques from Coronary Arteries in a Diabetic Patient

Objective: A cure for coronary artery disease is desperately needed as more people die of this disease. The coronary disease can be cured by removal of all atheromatous plaques by pharmacological intervention. This pharmacological treatment can also prevent acute myocardial infarction, unstable angina, chronic stable angina, CABG, PTCA and cardiac death. Case presentation: The patient is 75 years old, who had CABG and PTCA and suffered from daily chest pain which was relieved with nitroglycerin. Also had pain in both upper arms and both forearm several hours a day and this arm pain did not respond to nitroglycerin. She suffered with coughing wheezing and shortness of breath. No treatment helped her. Chest X-Ray showed cardiomegaly. EKG showed right bundle branch block. The coronary angiogram of 2013 showed advanced obstructive disease involving LAD and left circumflex artery with disease of the grafts. The right coronary artery was completely blocked with partially blocked graft. The patient was given standard treatment of coronary artery disease and for other conditions she suffered. The medications given for the removal of atheroma from coronary arteries were Carvedilol, Metformin, statin and Evolocumab. The patient was symptom free in 3 months. A repeat coronary angiogram in 2018 showed that LAD, left circumflex and right coronary arteries and their branches had no disease and no obstructive lesion. The graft to right to the right coronary artery was open and other grafts remained unchanged. Conclusions: 1) The atherosclerotic coronary artery disease can be cured. 2) Primary and secondary prevention of coronary artery disease can be achieved. 3) Intractable angina can be cured. 4) Stroke and TIA can be prevented. 5) Totally occluded coronary arteries can be opened.

Congenital Extra-Cardiac Vascular Anomalies as Detected on Multislice Computed Tomography Angiography

Background: Accurate evaluation of extra cardiac and intra cardiac anomalies in congenital heart diseases (CHD) is vital for diagnosis and treatment. Trans-thoracic echocardiography (TTE) is the classical choice for children suspected to have CHD because TTE is safe, readily available and its capacity to perform Doppler flow studies therefore can measure hemodynamic parameters. Plus its ability to evaluate intra cardiac abnormalities like atrial septal defect and ventricular septal defect. Therefore, owing to its lower spatial resolution and limited acoustic window; it is not precise in evaluation of extra cardiac abnormalities. Aim of the Work: to evaluate the advantage of recent advances of ECG gated MDCT in diagnosis of congenital heart disease in pediatrics and assessment of associated extra cardiac abnormalities within the great vessels in comparison with echocardiography findings. Patients and Methods: The current study was carried out on 36 patients in Radio-diagnosis Department, Faculty of medicine, Ain Shams University and specialized private radiology centers. The patients were referred from pediatric hospital, cardiology clinic with their echocardiographic reports to radio-diagnosis department, cardiac imaging unit with a view to execute ECG- gated multi-slice CT of the heart & extra-cardiac great vessels. Results: In this study aortic anomalies represent the most common extra-cardiac anomalies accounting for 36.5% of our cases while comprising: Supravalvular aortic stenosis; 4.3%, Aortic CoA; 26.1%, arch anomalies with vascular rings; 52.2% and finally anomalous coronary arteries; 17.4%. By Using MDCT we were able to delineate eight cases of right aortic arch (RAA).Two of them with aberrant left subclavian artery (ALSCA) adding to two cases of left aortic arch with an aberrant right subclavian artery (ARSCA). On the other hand ,TTE failed to identify 6 cases of RAA with a sensitivity 75%, specificity 100%, NPV 96.61% and one case of ALSCA with a sensitivity 50.0%, specificity 100%, NPV 98.41% .Regarding coronary anomalies , Cardiac CTA succeeded in characterization of origin and course of all coronary abnormalities encountered in our study encompassing 4 cases specifically anomalous LAD from right coronary sinus running a prepulmonic course anterior to RVOT , RCA from LAD and single coronary artery adding to LCX- RV coronary fistula. While TTE failed to depict two cases of the coronary anomalies with a sensitivity of 50%, specificity 100%, PPV 100% and NPV 96.83%. Conclusion: CTA can provide the confident detection and exclusion of extra- cardiac vascular abnormalities with superb anatomical description which was feasible with a sensitivity 98.41%, specificity 99.76%, PPV 96.88% and NPV 99.88%.

Is There a Role for Diagonal Coronary Artery Stenting in Patients Undergoing Robotic Coronary Artery Bypass Graft Surgery?

BackgroundThe efficacy of diagonal coronary artery stenting in patients undergoing robotic left internal thoracic artery-to-left anterior descending (LITA-to-LAD) anastomosis is not well defined. The objective of this study was to assess graft and stent patency in a single-stage hybrid revascularization with LITA-to-LAD anastomosis and PCI to a diagonal coronary artery.MethodsFrom 2004 to 2014, a total of 25 patients consented to robotic-assisted LITA harvesting and a small left anterior thoracotomy for off-pump coronary artery bypass anastomosis onto the LAD along with concomitant PCI to the diagonal coronary artery. PCI to the diagonal coronary artery was performed in the same fluoroscopy-equipped hybrid operating room.ResultsPatients were on average 66 ± 11 years with 32% female. Pre-operative characteristics of these patients included 8% with a grade 3 or 4 left ventricle, 16% with a recent MI, and 92% with CCS III/IV symptoms. There were no death, one patient required an intra-aortic balloon pump, and one patient required re-operation for bleeding. The average ICU stay was 1.1 ± 0.53 days, and the average hospital stay was 4.6 ± 2.4 days. Fitzgibbon Grade A LITA-to-LAD patency at 6-month follow-up was 100%. As well, at 6-month follow-up the DES to the diagonal coronary artery had a patency rate of 96%.ConclusionsSingle-stage hybrid revascularization strategy for bifurcating lesions of the LAD and diagonal coronary arteries with LITA-to-LAD anastomosis and PCI to a diagonal coronary artery appears to have acceptable clinical results with excellent 6-month angiographic patency results.

Abnormal coronary vasoreactivity in transient left ventricular apical ballooning (tako-tsubo) syndrome.

The exact etiology and pathophysiologic mechanisms of tako-tsubo syndrome (TTS) remain controversial. To further evaluate the abnormal coronary vasoreactivity and its possible anatomical substrate in TTS. We studied 47 patients (46 women; age 67±12years) who underwent diagnostic cardiac catheterization and evaluation of coronary vasoreactivity by sequential acetylcholine (Ach), nitroglycerine and adenosine testing with angiographic and intracoronary pressure-Doppler flow monitoring. Coronary artery wall morphology was also evaluated by intravascular ultrasound (IVUS) imaging in 45 vessels of 43 patients. Abnormal coronary vasoconstriction to Ach stimulation was elicited in 40 patients (85%) involving the LAD artery and its branches in 39 (83%). Abnormal microvascular function was seen in 39 (83%) patients. Overall, hyperemic microvascular resistance index (HMR) was higher and Doppler coronary flow velocity reserve (CFVR) was lower in the LAD artery territory as compared to the reference territories (2.64±1.23 vs 2.05±0.56; p=0.008 and 1.95±0.7 vs 2.3±0.6; p=0.018, respectively). IVUS revealed no plaque rupture, dissection or thrombosis but occult plaque formation and myocardial bridging were found as a possible anatomical substrate of endothelial dysfunction in 67% and 48.8% patients respectively. A global failure of coronary vasomotor function was demonstrated in most TTS patients. These findings implicate abnormal vasoconstrictive response to the activation of the sympathetic system as a potential mechanism involved in the pathogenesis of myocardial stunning in TTS. Competency in medical knowledge: Abnormal coronary vasoconstriction secondary to endothelial dysfunction may actively contribute to the clinical manifestation of acute coronary syndromes in patients with non-obstructive coronary disease. Translational outlook 1: TTS patients reveal a global failure of vasomotor function with both vasoconstrictive response to acetylcholine and increased hyperemic microvascular resistances in the territory of myocardial stunning. They may also show occult coronary atherosclerosis and myocardial bridging as the anatomic substrates of endothelial dysfunction. Translational outlook 2: The cardiac phenotype of TTS includes a high prevalence of coronary vasomotor disturbances. These findings implicate abnormal vasoconstrictive response to the activation of the sympathetic system as a potential mechanism involved in the pathogenesis of TTS in post-menopausal women. Thus, a systematic evaluation of coronary vasoreactivity could better characterize the syndrome.

IMPACT OF SMOKING STATUS ON SHORT TERM CLINICAL OUTCOMES OF DRUG ELUTING STENTS IN PATIENTS WITH STABLE CORONARY ARTERY DISEASE

Objective: To evaluate the impact of smoking status on short-term clinicaloutcomes of Drug Eluting Stents (DES) in patients with stable coronary arterydisease. Methodology: This cross sectional study was carried out at the Department ofCardiology, Lady Reading Hospital Peshawar from April 2011 to July 2012. Itincluded all patients with stable coronary disease undergoing DES implantation.Smoking status was assessed on the basis of information obtained from hospitalmedical records at the time of first medical examination and rechecked bytelephone interview. All patients were classified as non-smokers and smokers.Clinical outcomes (Myocardial infarction [MI], unstable angina [UA], and positiveETT) at three months stratified by smoking status were measured in patients whoreceived DES for coronary artery lesions. All patients were followed andreassessed after 3 months from the index procedure. Exercise Tolerance Test(ETT) was performed on every patient and recorded on proforma. Data analysiswas done using SPSS version 16. Result: A total of 376 patients were enrolled in this study. The mean age was57±9.313 years. Males were 271(72.1%). Among 376 patients who werefollowed up, 70 of them were smokers (18.6%) at the index procedure, 306patients (81.4%) were non-smokers. The frequency of dyslipidemia and diabetesmellitus was higher in smokers as compared to non-smokers. Mean stent lengthin smokers was 27.824±6.23mm as compared to 26.592±4.73mm in nonsmokers.Mean stent diameter was 2.91±0.347mm in smoker group while itwas 3.01±0.141mm in non-smoker group. Most of the patients in both groupsunderwent DES implantation to LAD and LCx arteries. There were significantlyhigher rates of myocardial infarction (7.1% vs 2%, p<0.036),unstable angina(22.9% vs 3.3%, p<0.001) and positive ETT (30% vs 5.2%, p<0.001) in thesmoker group as compared to non-smoker group. Conclusion: This study provides evidence that smokers treated with DESexperience higher rates of myocardial infarction, unstable angina and positiveETT at three months as compared to non-smokers, particularly in the setting ofstable coronary artery disease. Key Words: Smokers, Coronary artery disease, Drug eluting stent

Postmastectomy Radiation Therapy Technique and Cardiopulmonary Sparing: A Dosimetric Comparative Analysis Between Photons and Protons With and Without Deep Inspiration Breath Hold

Post-mastectomy radiation therapy (PMRT) can be challenging in patients with left-sided disease due to significant risk of cardiopulmonary toxicity. Prior dosimetric studies have suggested greater cardiopulmonary sparing with protons over tangential photons for left-sided PMRT. However, modern techniques, such as deep inspiration breath hold (DIBH), can help spare the heart. This analysis compares photon and proton delivery with and without DIBH. Ten women with left breast cancer referred for PMRT on a prospective clinical trial underwent free breathing (FB) and DIBH CT simulation. Target volumes and cardiopulmonary organs-at-risk were delineated with assistance of the RTOG atlas by a single physician. Structures were contoured on the FB scan and transferred to the DIBH scan using MimVista deformable registration and modified. A partially wide tangent (PWTF) during DIBH (photon-BH), passively scattered proton during FB (scatter-FB), pencil-beam scanning (PBS) proton during FB (PBS-FB), and PBS proton during DIBH (PBS-BH) plan was completed for each patient. Each plan was designed to achieve 95% prescription dose coverage of 95% of all target volumes while maximally sparing the heart and lung. ANOVA or Kruskal-Wallis test was used to measure a difference in target volume coverage, chest wall homogeneity index (HI), and cardiopulmonary avoidance among the four plans. For each metric with a significant interaction (P < 0.05), pairwise t-test and Wilcoxon test with Bonferroni correction was used to compare individual plans. All techniques resulted in similar target coverage, though protons improved chest wall HI and cardiopulmonary sparing (omnibus P < 0.0001 for each metric). Heart/lung metrics for photon-BH, scatter-FB, PBS-FB, and PBS-BH, respectively, were as follows: mean heart dose (2.09, 0.39, 0.98, 0.71 Gy(RBE)), mean left ventricle dose (3.72, 0.08, 0.19, 0.21 Gy(RBE)), V20 left ventricle (2.73, 0.03, 0, 0%), maximum LAD artery dose (46.14, 8.28, 4.58, 4.63 Gy(RBE)), mean lung dose (13.30, 5.74, 7.63, 7.49 Gy(RBE)), V20 lung (26.04, 12.04, 15.18, 14.43 %). Pairwise testing confirmed an improvement in each metric with all proton plans compared to photon-BH; however, there were no differences in HI or cardiopulmonary sparing between passively scattered and PBS protons, regardless of addition of DIBH. For left-sided PMRT, passively scattered or PBS protons with or without DIBH improves homogeneity and cardiopulmonary sparing without compromise in target coverage compared to PWTF photons with DIBH. Furthermore, the addition of DIBH to proton therapy did not provide a significant dosimetric benefit.