LAD Lesions Research Articles

Comparison of Immediate and Long-term Outcomes of Stent vs. Grafts in Proximal LAD Lesions Complicated by TVD

Background: The management of triple-vessel disease (TVD) with proximal left anterior descending (PLAD) artery involvement remains a critical challenge in cardiology. Current guidelines advocate for both stent placement and graft surgery, yet evidence supporting the optimal approach is conflicting. Objective This study aims to compare the immediate and long-term outcomes of stent placement versus graft surgery in patients with TVD and PLAD involvement, focusing on all-cause mortality, myocardial infarction (MI), stroke, and major adverse cardiovascular and cerebrovascular events (MACCE). Methods: Conducted at Lady Reading Hospital, Peshawar, from January 2021 to December 2021, this research utilized data from the BEST and SYNTAX randomized controlled trials. The study included patients with at least one lesion causing ≥50% diameter stenosis in the PLAD. Primary outcomes included all-cause death, MI, stroke, and MACCE. Secondary outcomes encompassed cardiac death and all-cause revascularization. Statistical analyses were performed using IBM SPSS Statistics software, version 25, with significance set at a two-sided p-value of less than 0.05. Kaplan-Meier estimates and Cox proportional hazards models were applied for survival analysis, stratified by SYNTAX score. Results: The study encompassed 200 patients (110 in the stent group and 90 in the graft group). Graft surgery was associated with a significantly lower incidence of the combined endpoint of all-cause mortality, MI, and stroke (p < 0.05), as well as reduced rates of MACCE, cardiac death, and all-cause revascularization compared to stent placement. In patients with low SYNTAX scores (≤22), graft surgery was linked with a reduced rate of MI. For those with intermediate to high SYNTAX scores (≥22), graft surgery showed superiority in reducing all-cause death, cardiac death, MI, all-cause revascularization, and MACCE. Conclusion: Graft surgery is superior to stent placement in reducing the incidence of critical adverse events in patients with TVD and PLAD involvement over a five-year follow-up period. These findings underscore the importance of personalized, evidence-based decision-making in the management of complex coronary artery disease.

History of cerebrovascular events is associated with a higher risk of significant left anterior descending artery stenosis

Abstract Funding Acknowledgements Type of funding sources: None. Background Acute coronary syndrome (ACS) remains a frequent cause of hospital admission, with its prognosis depending on many factors, one being the location of the culprit lesion. It is established that anterior myocardial infarction, caused mostly by left anterior descending artery occlusion is associated with a worse prognosis and higher morbimortality. Therefore, identifying patients at a higher risk of significant LAD lesions could potentially impact outcomes. Purpose We aim to identify if having personal history of cerebrovascular events could be related to more severe LAD stenosis. Methods We retrospectively analysed a population of 988 patients (L) admitted with ACS and divided them into two groups: those who had significant stenosis of the left anterior descending artery (LAD) documented in coronary angiography, defined as a stenosis above 50% (L1), and those who had no significant stenosis of the LAD (L2), which included those with no stenosis or stenosis under 50%. We then compared the prevalence of previous cerebrovascular events, defined as stroke or TIA, between both groups. Age, sex, personal history of smoking, hypertension, dyslipidaemia and diabetes mellitus were also documented. Results L1 was comprised of 553 patients (56,0% of the population). When comparing between groups, results show that L1 had a significantly higher prevalence of previously documented stroke or TIA (1,4% vs 0,2%, p=0,026; odds ratio: 7,628, 95% CI [0,922; 63,120]) than L2. Regarding age, sex and history of hypertension, dyslipidaemia and diabetes, there were no relevant differences and no impact on the severity of the LAD stenosis. Conclusions Patients with ACS and previous history of cerebrovascular events have a sevenfold-increased risk of having significant LAD stenosis on coronary angiography. This could potentially impact pre-procedure risk stratification and timing of percutaneous intervention.

Propensity-matched analysis of long-term clinical results after ostial circumflex revascularisation

BackgroundPercutaneous coronary intervention (PCI) of the ostium of the left circumflex artery (LCx) is technically challenging. The aim of this study was to compare long-term clinical outcomes of ostial PCI...

Strain Rate Changes during Stress Echocardiography Are the Most Accurate Predictors of Significant Coronary Artery Disease in Patients with Previously Treated Acute Coronary Syndrome.

Dobutamine stress echocardiography (DSE) is a well-established non-invasive investigation for the detection of ischemic myocardial dysfunction. The aim of this study was to evaluate the accuracy of myocardial deformation parameters measured by speckle tracking echocardiography (STE) in predicting culprit coronary artery lesions in patients with prior revascularization and acute coronary syndrome (ACS). We prospectively studied 33 patients with ischemic heart disease, a history of at least one episode of ACS and prior revascularization. All patients underwent a complete stress Doppler echocardiographic examination, including the myocardial deformation parameters of peak systolic strain (PSS), peak systolic strain rate (SR) and wall motion score index (WMSI). The regional PSS and SR were analyzed for different culprit lesions. The mean age of patients was 59 ± 11 years and 72.7% were males. At peak dobutamine stress, the change in regional PSS and SR in territories supplied by the LAD showed smaller increases compared to those in patients without culprit LAD lesions (p < 0.05 for all). Likewise, the regional parameters of myocardial deformation were reduced in patients with culprit LCx lesions compared to those with non-culprit LCx lesions and in patients with culprit RCA legions compared to those with non-culprit RCA lesions (p < 0.05 for all). In the multivariate analysis, the △ regional PSS (1.134 (CI = 1.059-3.315, p = 0.02)) and the △ regional SR (1.566 (CI = 1.191-9.013, p = 0.001)) for LAD territories predicted the presence of LAD lesions. Similarly, in a multivariable analysis, the △ regional PSS and the △SR predicted LCx culprit lesions and RCA culprit lesions (p < 0.05 for all). In an ROC analysis, the PSS and SR had higher accuracies compared to the regional WMSI in predicting culprit lesions. A △ regional SR of -0.24 for the LAD territories was 88% sensitive and 76% specific (AUC = 0.75; p < 0.001), a △ regional PSS of -1.20 was 78% sensitive and 71% specific (AUC = 0.76, p < 0.001) and a △ WMSI of -0.35 was 67% sensitive and 68% specific (AUC = 0.68, p = 0.02) in predicting LAD culprit lesions. Similarly, the △ SR for LCx and RCA territories had higher accuracies in predicting LCx and RCA culprit lesions. The myocardial deformation parameters, particularly the change in regional strain rate, are the most powerful predictors of culprit lesions. These findings strengthen the role of myocardial deformation in increasing the accuracy of DSE analyses in patients with prior cardiac events and revascularization.

The Comparative Assessment of Wellens' Syndrome With Proximal Left Anterior Descending Artery (LAD) Stenosis Versus Right Coronary Artery (RCA) or Circumflex Coronary Artery Stenosis and Its Prevalence: A Systematic Review.

Wellens'syndrome is well-known for its critical stenosis of the proximal left anterior descending artery (LAD) with characteristic electrocardiographic findings of biphasic or deeply inverted T waves in V2-V6 under specific diagnostic criteria. Although the syndrome is known as a high-grade LAD lesion, its sequence of events can also be seen with the right coronary artery (RCA) and the left circumflex artery (LCX). This systemic review attempts to expand on these findings while analyzing the prevalence of Wellens' syndrome with the RCA and/or the circumflex artery. This study also comparatively indicated that Wellens'syndrome is seen in RCA and circumflex arterystenoses when present; the indication of the same medical management is warranted for effective treatment and survival. We extracted and analyzed 24 case reports each with an atypical presentation of acute coronary syndrome (ACS) and specific Wellens'syndrome pattern of electrocardiogram (ECG) presentation with critical stenosis in the LAD, RCA, and left circumflex artery.The risk of bias assessment was undertaken using internal risk analysis by utilizing medical libraries and certain search phrases to find research articles with the involvement of the LAD as opposed to the RCA and LCX in Wellens' syndrome. Based on the number of respective primary research articles found, a bias calculation was done on the reported respective coronary artery involvement. The finding of our systemic review confirms that Wellens'syndrome is a precordial lead disease with T wave abnormalities that presentwithcritical stenosis of not only the LAD but also the RCA and circumflex artery. The result of our systemic review affirmed that although most Wellens'syndrome cases reported involve the stenosis of the LAD, the critical occlusion of the RCA and/or the circumflex artery was found with Wellens'syndrome pattern of ECG presentation, meaning that the sequence of events is not limited to the proximal LAD.

Inferior and precordial ST-segment elevation myocardial infarction due to large wrap-around left anterior descending artery occlusion

Left anterior descending artery (LAD) occlusion normally develops into precordial ST-segment elevation; however, we describe a case of a 50-year-old man with inferior and precordial ST-segment elevation myocardial infarction that resulted from proximal occlusion of the wrap-around LAD perfusing the anterior and inferior wall. We performed early and prompt reperfusion and were able to save the patient without any complications. A wrap-around LAD perfuses a large myocardial area; therefore, this type of coronary occlusion causes severe myocardial damage and has a poor prognosis. The rates of new-onset heart failure and heart failure rehospitalization are also high. Simultaneous inferior and precordial ST-segment elevations on electrocardiography suggest acute myocardial infarction with a wrap-around LAD lesion, which requires prompt revascularization. More careful medications for heart failure and follow-up should be also required even after discharge in such case.

ECG patterns suggestive of high-risk coronary anatomy in non-ST-segment elevation acute coronary syndrome - an analysis of real-world patients.

Electrocardiographic (ECG) patterns suggestive of high-risk coronary anatomy are indications for an urgent invasive approach in non-ST-segment elevation acute coronary syndrome (NSTE-ACS). To estimate the frequency of the observed phenomenon and assess the clinical characteristics of NSTE-ACS subjects associated with Wellens syndrome, the de Winter sign, or ST-segment depressions by ≥ 1 mm in ≥ 6 classic ECG leads with simultaneous ST-segment elevation in aVR and/or V1. Out of 207 pre-screened subjects diagnosed with NSTE-ACS, 64 patients (26 women and 38 men) with complete medical records (including admission ECG and coronary angiography during the index hospitalization), and significant culprit stenosis or occlusion of the left main coronary artery (LMCA) or the proximal/middle segment of the left anterior descending artery (LAD) entered the final analysis. Clinical characteristics of patients exhibiting any of the high-risk ECG patterns was compared to their counterparts with significant lesions in LMCA or proximal/middle LAD without any of the high-risk ECG patterns. Among 64 patients with significant culprit lesions in LMCA or LAD, 19 (29.69%) exhibited one of the high-risk ECG patterns: Wellens syndrome (n = 10), the de Winter sign (n = 0), or multiple ST-segment depressions (n = 9). Clinical characteristics were comparable in 19 NSTE-ACS patients with the high-risk ECG patterns and their 45 counterparts. Because ECG patterns suggestive of high-risk coronary anatomy are relatively frequent in patients with NSTE-ACS and culprit lesions in LMCA or LAD, their early recognition is of clinical importance.

Impact of target vessel on the procedural techniques and outcomes of chronic total occlusion percutaneous coronary intervention.

There is limited information on the impact of the target vessel on the procedural techniques and outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI). We analyzed the baseline clinical and angiographic characteristics and procedural outcomes of 11,580 CTO PCIs performed between 2012 and 2022 at 44 centers. The most common CTO target vessel was the right coronary artery (RCA) (53.1%) followed by the left anterior descending artery (LAD) (26.0%) and the left circumflex artery (LCX) (19.8%). RCA CTOs were longer and more complex, with a higher Japanese CTO score compared with LAD or LCX CTOs. Technical success was higher among LAD (88.8%) lesions when compared with RCA (85.7%) or LCX (85.8%) lesions (P less than .001). The incidence of major adverse cardiovascular events (MACE) was overall 1.9% (n = 220) and was similar among target vessels (P=.916). There was a tendency toward more frequent utilization of the retrograde approach for more proximal occlusions in all 3 target vessels. When compared with all other RCA lesions combined, distal RCA lesions had higher technical success (87.7% vs 85.3%; P=.048). Technical success was similar between various locations of LAD CTOs (P=.704). First/second/third obtuse marginal branch had lower technical success when compared with all other LCX lesion locations (82.7% vs 86.8%; P=.014). There was no association between MACE and CTO location in all 3 target vessels. LAD CTO PCIs had higher technical and procedural success rates among target vessels. The incidence of MACE was similar among target vessels and among various locations within the target vessel.

Angiographic Characteristics of Young Yemeni Patients Undergoing Diagnostic Coronary Angiography: Data from A Major Cardiac Center In Yemen

Background: Coronary artery disease (CAD) accounts for the greatest proportion of CVDs and is one of the most common causes of death in the developed countries. It is one of the main etiologies of disease burden in developing countries. There is increase in the number of patients with coronary artery disease in Yemen. The number of patients undergoing elective diagnostic coronary angiography is increasing among different age groups. This study was aimed to identify and compare the prevalence of the risk factors, clinical presentation, management, and angiographic characteristics of CAD between young patients (age ≤ 40 years) and older patients (age ≥ 40 years) presented with ischemic heart disease (IHD). Methods: A total of 555 patients were were enrolled between January 2013 and June 2013. Patient admitted in ward as one-day admission and discharged 6 hours after the procedure. Demographic data, clinical findings, and details of electrocardiographic and echocardiographic findings were recorded. The traditional cardiovascular risk factors (smoking, hypertension, Khat chewing, family history and diabetes mellitus, dyslipidemia) were noted. The patient included were patients with sable angina, post myocardial infarction and pre-operative coronary angiography before valve replacement. Results: The older group accounts for 90.3% while younger group accounts for 9.7% of the patients. The majority of patients in both groups were male (81.5% in the young and 74.5% in the older group). Most of the patients in the study were diagnosed as post MI angina. High incidence of diabetes and hypertension among the older group in comparison to the younger group (24.4% diabetes and 43.1% hypertensive Vs. 11.1% diabetes and 29.6% hypertensive). 50% of the younger group were smokers in comparison to 23.8% in older group with statistically significant difference (p=0.0001). Family history of IHD was higher in the younger age group (24.1%) than that in the older age group (16%) (p = 0.129). Dyslipidemia was not common risk factor among both groups. The percentage of Khat chewing did not differ between the two groups (70.4% and 62.5% in younger and older group respectively). Significant left main disease was more than double in younger group (3.7%) when compared older group (1.9%). About one-third (31.5%) of patients of younger group had significant LAD lesion while small number of older patients had significant LAD lesion (1.6%) (p = 0.037). The involvement of right coronary artery (RCA) was significantly higher in older group than in younger group (27.7% and 7.5% respectively; with p = 0.001). Although the incidence of left circumflex artery (LCX) disease was higher in older group (28.8% and 16.7% respectively) it did not reach statistical significance. The left anterior descending artery (LAD) was commonly involved vessel in the young group (31.5%) in comparison to older group (1.6%) while left circumflex artery and right coronary artery was common in in the older group. Conclusion: Coronary angiography is a useful diagnostic and therapeutic tool for CAD. Smoking, male gender as well as family history of cardiovascular diseases showed high prevalence in the in younger patients ≤ 40 years, while hypertension and diabetes were common in the older patients. Khat chewing was highly prevalent among both groups.

Plaque rupture after coronary CT angiography.

A 61-year-old man presented to the emergency room with intermittent chest pain. Electrocardiography (ECG) showed no significant ST-T changes. Transthoracic echocardiography revealed regional left ventricular (LV) asynergy in the anterior septum, with an elevated cardiac troponin I level (68.1 pg/mL). Although urgent hospitalization and coronary angiography were recommended for the treatment of a suspected non-ST-segment elevation myocardial infarction, the patient refused as his symptoms had resolved. However, the patient agreed to undergo urgent coronary computed tomography angiography (CCTA). CCTA revealed severe stenosis with high-risk plaque features in the proximal left anterior descending artery (LAD) (Panel A−D).1 After the CCTA, he developed sudden-onset, severe chest pain in the emergency room. An additional ECG showed significant ST-segment elevation in the V2-V5 leads. The patient agreed to undergo urgent coronary angiography. Emergency coronary angiography revealed a lesion in the proximal LAD with complete occlusion (Panel E). Intravascular ultrasonography revealed an intraluminal thrombus secondary to plaque rupture (Panel F). The maximum cardiac enzyme levels were CK (467 IU/L), CK-MB (35 IU/L), and troponin I (8461 pg/mL). The patient had an improvement in LV asynergy at follow-up one-month post-discharge.

MANAGEMENT OF MAJOR AIRWAY HAEMORRHAGE WITH VENOVENOUS EXTRACORPOREAL MEMBRANE OXYGENATION IN A HEART TRANSPLANT RECIPIENT

<h3>Objective</h3> To report the successful use of venovenous extracorporeal membrane oxygenation in a heart transplant recipient with a catastrophic airway haemorrhage. <h3>Design and methods</h3> Review of hospital records and imaging. <h3>Results</h3> A 56 year-old man with a past medical history of asthma, bronchiectasis and immunoglobulin A deficiency presented with end-stage ischaemic cardiomyopathy and recurrent pulmonary oedema. He was assessed for and underwent a heart transplant. The donor graft was well matched, but a small soft left anterior descending coronary artery plaque was noted at retrieval. In the first 24 hours post-transplant, he had a falling cardiac index followed by dysrhythmias. He was placed on veno-arterial extracorporeal membrane oxygenation (VA ECMO) and underwent PCI to the LAD lesion and started on aspirin and prasugrel. 48 hours later, his oxygenation requirements increased, his chest x-ray showed infiltrates and differential hypoxia (Harlequin Syndrome) was diagnosed. VAV ECMO was established. Overnight following VAV ECMO, fresh blood and clots were suctioned from the endotracheal tube, with falling tidal volumes to the point he was effectively unventilated. A CT scan showed extensive bronchial casts. A rigid bronchoscopy removed the clot. No specific bleeding point was identified, but general ooze from both bronchi was observed. Antiplatelet agents and systemic heparin were stopped, whilst distal limb perfusion catheter heparin was continued. Serial bronchoscopies were performed daily, removing small quantities of clot and applying topical therapies to various bleeding points in the right upper lobe. Tidal volumes remained under 100ml. Disseminated intravascular coagulation was diagnosed and product replacement guided by laboratory results and thromboelastography was undertaken. With improving cardiac function, arterial decannulation was achieved, leaving the patient on VV ECMO. This was continued for a further week with repeated flexible bronchoscopy and clot retrieval. Bleeding resolved after several days with conservative therapy, avoiding surgical or interventional radiological procedures. Improvements in tidal volumes were observed and eventually VV ECMO was successfully weaned. Aspirin was restarted as single antiplatelet therapy. He subsequently made a good recovery. <h3>Discussion</h3> VV ECMO is well established as a treatment in respiratory failure and pulmonary haemorrhage. However, use of VAV and VV ECMO for a major airway bleed in a heart transplant patient has not, to our knowledge, been previously described. The risks of running circuits without anticoagulation in patients totally dependent on them are high and managing this risk, alongside the new stent in a crucial coronary artery, were challenging. This case highlights the importance of balancing thrombosis and bleeding risk, especially in the context of new coronary stents, and has prompted consideration whether short-acting agents such as tirofiban may have a role in these especially high-risk cases.

Abstract 14701: Angiographic and Prognostic Difference of Acute Myocardial Infarction Patients With and Without Out of Hospital Cardiac Arrest Stratified by Killip Classification

Backgrounds: Although the mortality rates for AMI have declined, the mortality rate for AMI with out-of-hospital cardiac arrest (OHCA) remains high. It has been supposed that CTO (chronic total occlusion) in non-infarct related artery is associated with OHCA patients. However, the detailed angiographic and prognostic comparison between OHCA patients and non-OHCA patients stratified by Killip classification has not been well evaluated. Methods: Among 5662 AMI patients (5420 non-OHCA patients and 242 OHCA patient) who underwent emergency coronary angiography between 2013 and 2020 were enrolled from Mie ACS registry. Difference of culprit lesion and non-infarct related CTO lesion were analyzed between with and without OHCA. They were further stratified using Killip classification. Results: In-hospital mortality for AMI patients with OHCA was 31.4%, significantly higher than the 5.5% for AMI patients with non-OHCA (p&lt;0.001), and mortality rates tended to be increased with increasing Killip class in each group(P&lt;0.001). AMI patients with OHCA also had a significantly higher frequency of culprit artery with LMT and LAD and a higher frequency of CTO lesion in non-infarct related artery compared to the AMI patients with non-OHCA.(See Table) Multivariate analysis revealed that LAD CTO in non-infarct related artery(Odds ratio 2.3) culprit artery of LMT and LAD (Odds ratio 3.2 and 1.6), lower BMI(Odds ratio 0.96), younger age(Odds ratio 0.98) and male gender (Odds ratio 1.7)was significantly associated with OHCA(P&lt;0.05, respectively). However, non-LAD CTO lesion in non-infarct related artery was not associated with OHCA Conclusions: Patients with OHCA had a higher incidence of culprit artery with LMT and LAD, and non-infarct-related LAD CTO lesion, suggesting that extensive myocardial ischemia with LAD lesion was strongly associated with OHCA.

Abstract 12981: Non-Conventional Causes of ST-Elevation Myocardial Infarction: Essential Thrombocytosis

Case: A 61-year-old female with no significant past medical history, except hospitalization for COVID-19 pneumonia complicated by myocarditis ten months prior, presented to the emergency department with worsening chest pain over the last two weeks. The admission electrocardiogram (ECG) was without ischemic changes. The initial impression was that the patient's symptoms were attributed to her prior myocarditis. However, a repeat ECG obtained six hours later, due to worsening chest pain, demonstrated ST-segment elevations in leads V2, I and AVL. Emergent coronary angiography was performed, showing a 90% occlusion of the proximal LAD, which was managed with a drug-eluting stent. Admission platelet count was significantly elevated at 1,049,000mm 3 , which resulted in a hematology consultation. Her further work up included a positive JAK2-V617F mutation and negative BCR-ABL1 translocation, which confirmed the diagnosis of essential thrombocythemia. During the prior hospitalization for her COVID pneumonia, she underwent invasive coronary angiogram for suspected myocardial infarction in the setting of elevated troponin, which showed a mild, non-obstructive lesion in the proximal LAD. She underwent a cardiac MRI that demonstrated both sub-epicardial and mid-wall late gadolinium enhancement consistent with myocarditis. Discussion: Essential thrombocythemia is a clonal myeloproliferative disease caused by a pathological expansion of megakaryocytes, which results in excess platelet production. Essential thrombocythemia leads to a hematologic hyper-viscosity and subsequent increased risk of vasomotor, thrombotic and hemorrhagic manifestations. Myocardial infarction as the primary clinical presentation of essential thrombocythemia is rare but an important risk factor that should be considered in patients presenting with acute coronary syndromes and elevated platelet counts, both with and without traditional cardiovascular risk factors.

Abstract 13857: Reduction of Infarct Size in Anterior ST Segment Elevation Myocardial Infarction (STEMI) With LAD Occlusion and LV Unloading Using a Micro-Axial Pump for 30 Minutes Before PCI: A Per Protocol Analysis of the STEMI DTU Pilot Study

BACKGROUND: The STEMI-DTU pilot trial was the first exploratory study to identify that LV unloading and delaying reperfusion is safe and feasible in anterior STEMI without cardiogenic shock. We now report new findings in patients who met all protocol inclusion and exclusion criteria (per protocol cohort). Methods: In a multicenter, prospective, randomized safety and feasibility trial, we assigned 50 patients with anterior STEMI to LV unloading by using the Impella CP followed by immediate reperfusion (U-IR) versus delayed reperfusion after 30 minutes of unloading (U-DR). Cardiac magnetic resonance (CMR) imaging assessed infarct size normalized to the area at risk (IS/AAR) 3-5 days after PCI. Patients without CMR at 3-5 days (n=10; 5/arm), without PCI of a culprit LAD lesion (n=2; 1/arm) and without STEMI (n=5; 4 in U-IR, 1 in U-DR) were not per protocol and thus excluded from this analysis. Results: A total of 33 patients met all inclusion and exclusion criteria (U-IR n=15; U-DR n=18) with respective door-to-balloon times of 75±26 and 89±23 minutes (p=.10) and mean unload-to-balloon times of 10±5 and 34±3 (p&lt;0.01). In the total cohort, IS/AAR was significantly associated with microvascular obstruction (MVO), 30-day IS normalized to total LV mass, 90 day LVEF, and 90dday LV end systolic volume with or without a delay to reperfusion (Table, R&gt;0.5, p&lt;0.005 for all). Despite longer symptom to balloon times in the U-DR arm (174±59 vs 228±78, p&lt;0.01), IS/AAR was lower in the U-DR arm (62±16 vs 48±16, p=0.04) and remained significantly lower irrespective of the magnitude of precordial STE. MVO was significantly lower in the U-DR arm among patients with the highest precordial STE (Figure). Conclusion: A per protocol analysis of the STEMI-DTU Pilot trial identified a significant reduction in infarct size among patients with unloading and delayed reperfusion irrespective of precordial STE magnitude. These findings are currently under investigation in the STEMI-DTU Pivotal trial.

Abstract 12718: ST Segment Elevation Myocardial Infarction Case With a Novel Therapy

History: A 78-year-old man presented with anterior ST-segment elevation. Coronary angiography demonstrated an occluded left anterior descending coronary artery (LAD Figure 1A) with stenosis of the left circumflex (Cx) coronary artery. Procedure: The LAD was crossed with a workhorse wire (Figure 1B). Predilation restored the flow in the LAD and two diagonal branches (Figure 1C). After assessing the lesion with intravascular imaging (Figure 1D), two drug-eluting stents (DES) were deployed with provisional technique (Figure 1E). The diagonal was rewired and dilated with a 2.0 mm balloon (Figure 1F). A 3.5x20 mm DES was deployed covering the proximal LAD lesion (Figure 1G). The Cx ostium appeared pinched, but the diastolic pressure ratio was 0.95, hence no PCI was performed. Given the large MI size, we administered super saturated oxygen (SSO2). A 5F FR5 catheter was inserted into the LM ostium and SSO2 was administered for 1 hour. An excellent final angiographic result was achieved with TIMI 3 flow and well-expanded stents (Figure 1H). Peak creatinine kinase was 5840 U/l. Magnetic resonance imaging on the next day showed small thrombi, prominent microvascular obstruction in the mid LAD territory, and transmural infarction (Figure 1I). Left ventricular ejection fraction of 39% with normal left ventricular volume. The patient was discharged 3 days later on dual antiplatelet therapy and warfarin and referred to cardiac rehabilitation. Conclusion: “Time is muscle”, hence immediate revascularization is essential. Large anterior STEMIs may benefit from SSO2.

TREATMENT OF ASTHMA MIGHT HAVE DELAYED END-ORGAN DAMAGE IN THE PATIENT WITH LYMPHOCYTIC HYPEREOSINOPHILIC SYNDROME

<h3>Introduction</h3> Hypereosinophilic syndrome (HES) is characterized by an absolute eosinophil count (AEC) > 1,500 and organ damage or dysfunction attributable to tissue eosinophilia. <h3>Case Description</h3> This 71-year-old patient with a 12-year history of asthma was treated with inhaled and variable daily doses of oral corticosteroids for four years. Without the risk factors for cardiovascular disease, he suddenly developed stroke symptoms. His brain MRI revealed multiple scattered patchy foci of acute cortical matter ischemia, and he was diagnosed with an acute cerebrovascular accident. He also had elevated troponin and underwent cardiac catheterization with stent placement to a proximal LAD and mid-LAD lesion. Four months later, he came for an allergy evaluation because of "elevated white cells" and "food allergy." However, he had an increased AEC of 3,800 and clinically irrelevant IgE to the tolerated foods. His medical record revealed that over the last four years, his AEC fluctuated between 374 and 8,730. Therefore, we initiated an evaluation for suspected HES, eosinophilic granulomatosis with polyangiitis, and, less likely, parasitoses. Molecular studies revealed a clonal population of lymphocytes with T-cell receptor gene γ and β rearrangement consistent with a diagnosis of lymphoid variant HES. Other laboratory findings are in figure 1. <h3>Discussion</h3> A common occurrence of eosinophilia in the patients with asthma might lower the index of suspicion of HES. However, this patient's very high AEC should have prompted an investigation earlier. His HES presented as multifocal ischemic brain and cardiac infarcts. This presentation was likely delayed by treating the patient's asthma with systemic corticosteroids.

Correlation of FFR measured after DES implantation with clinical parameters and long-term clinical outcome

Abstract Introduction The role of fractional flow reserve (FFR) measured directly after drug eluting stent (DES) implantation (post-PCI FFR) is not clear in predicting major adverse cardiac events (MACE), and it is not known which clinical parameters affect post-PCI FFR. Aim We aimed to clarify the relationship between post-PCI FFR and clinical parameters, post-PCI FFR and long-term MACE and determine the best post-PCI FFR cut-off in MACE prediction. Method Patients who underwent post-PCI (DES) FFR measurement at our center between March 2009 and January 2021 were included. We examined the relationship between post-PCI FFR and gender, age, hypertension, diabetes mellitus, hyperlipidemia, indication (acute (ACS) vs. chronic coronary syndrome (CCS)), stent diameter, in-stent restenosis vs de novo lesion category, proximal vs. non-proximal lesion location, LAD (vs. non-LAD) location, and pre-PCI FFR. We sought to determine the correlation between post-PCI FFR and target vessel-related MACE (cardiovascular death (CVD), non-fatal myocardial infarction (MI), recurrent revascularization (TVR)). Optimal cut-off was determined by ROC curves. Results Post-PCI FFR measurement was performed in 500 coronary arteries of 434 patients. LAD location (0.86 vs. non-LAD 0.91, p&amp;lt;0.001), male gender (0.87 vs. 0.89, p=0.001), younger age (p=0.0215), smaller stent diameter (p=0.0028) and lower pre-PCI FFR (p=0.0006) proved to be independent predictors of lower post-PCI FFR, no other parameter showed a significant correlation with post-PCI FFR. During a median follow-up of 37 months, 24 CVD, 15 MI and 47 TVR occurred. Follow-up was complete in 96.2% of patients. There was a significant inverse correlation between post-PCI FFR and MACE (p&amp;lt;0.001). Diabetes mellitus (p=0.0024) and in-stent restenosis (0.0356) were also independent predictors of MACE. The best post-PCI FFR cut-off for the total patient population, LAD and non-LAD lesions were 0.83 (p&amp;lt;0.0001), 0.83 (p&amp;lt;0.0001), and 0.88 (p=0.0091), respectively. Conclusion LAD location, male gender, younger age, smaller stent diameter and lower pre-PCI FFR value result in lower post-PCI FFR. There is no significant difference between post-PCI FFR measured in ACS vs. CCS. FFR measured after PCI, diabetes mellitus and in-stent restenosis are significant predictors of MACE-free long-term survival. The best post-PCI FFR cut-off to predict MACE was 0.83 for the whole patient population and for LAD and 0.88 for non-LAD lesions. Funding Acknowledgement Type of funding sources: None.

The diagnostic value of left-anterior-descending artery velocity assessed by transthoracic Doppler echocardiography for microvascular dysfunction in stenotic left-anterior-descending artery

Abstract Background Index of microcirculatory resistance (IMR) has been used as a clinical measure of microvascular function. Transthoracic Doppler echocardiography (TDE) can provide information on the functional status of coronary artery circulation. This study aims to assess the diagnostic value of left-anterior-descending artery (LAD) flow velocity by TDE for microvascular dysfunction. Methods Consecutive patients who were scheduled for elective percutaneous coronary intervention (PCI) for LAD lesions were prospectively enrolled in the single tertiary-care center between April 2020 and July 2021. Pre-PCI LAD diastolic peak velocity (DPV) by TDE at rest and hyperemia were measured. By invasive coronary angiography, quantitative coronary angiography and invasive wire-based physiological indices including fractional flow reserve (FFR) and index of microcirculatory resistance (IMR) were measured. Results A total of 104 patients were studied. Median FFR and IMR values were 0.70 (0.60–0.74) and 20.68 (14.92–31.69), respectively. No significant relationship was observed between FFR and IMR. The prevalence of microvascular dysfunction defined as IMR≥25 was 39.4%. Basal DPV was 25 (20–33) cm/sec, and hyperemic DPV was 51 (41–67) cm/sec. In lesions with IMR≥25, reference diameter (RD) was significantly greater [2.63 (2.22–3.19) mm vs 2.39 (2.09–2.66) mm, p=0.019], basal DPV was lower [26 (18–29) cm/sec vs 29 (22–37) cm/sec, p=0.022)] and hyperemic DPV was lower [49 (19–54) cm/sec vs 56 (42–70) cm/sec, p=0.023] compared to lesions with IMR&amp;lt;25. ROC analysis showed basal DPV and RD are significant predictors of IMR≥25 [basal DPV: AUC 0.633 (0.525–0.742), best cutoff 29cm/sec RD: AUC 0.636 (0.523–0.750), best cutoff 2.84mm]. Multivariable logistic regression analysis showed basal DPV&amp;lt;29cm/sec and RD&amp;gt;2.84mm are independent predictors for IMR≥25 [Odds ratio: 3.08 (1.22–7.78), p=0.017; odds ratio 4.40 (1.55–12.50), p=0.005]. Conclusion Basal DPV by non-invasive pre-PCI TDE and reference diameter can predict lesions with coexisting microvascular dysfunction in LAD territory with functionally significant lesions without the need of vasodilator-induced hyperemia and a wire-based invasive physiological measurement. Funding Acknowledgement Type of funding sources: None.

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

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

Coronary artery lesion distribution in patients with chronic kidney disease undergoing percutaneous coronary intervention

Purpose To determine the location of coronary atherosclerosis distribution observed in patients with chronic kidney disease (CKD). Methods A cross-sectional study was conducted using the database of cardiovascular medicine data from Saitama Sekishinkai Hospital to clarify the association between renal function and angiographic characteristics of coronary atherosclerosis. In total, 3268 patients who underwent percutaneous coronary intervention were included. Propensity score matching revised the total to 1772. The association of renal function with the location and/or distribution of coronary atherosclerosis lesions was then examined. Results Overall, coronary lesion was observed in the left anterior descending coronary artery (LAD) in 56% patients, whereas 28% and 22% were in the right coronary artery (RCA) and left circumflex coronary artery (LCX), respectively. LAD was most affected and observed in 57% patients with stage 1 CKD. RCA was second-most affected, at 26% CKD stage 1, but it increased to 31%, 38%, and 59% in CKD 3, 4, and 5, respectively. In CKD 5 patients, the RCA was the most affected artery (59%), with 41% LAD lesions. Logistic regression analysis after propensity score matching showed that the odds ratios for an RCA lesion was 3.658 in CKD 5 (p = .025) compared with CKD 1 after adjusting for traditional risk factors. Conclusion The prevalence of RCA lesions, but not LAD or LCX lesions, increased with increasing CKD stage. The pathophysiology of coronary atherosclerosis may differ by lesion location. Deterioration of renal function may affect progression of atherosclerosis more in the RCA than in the LAD or LCX.