LAD Vessel Research Articles

Predictors of outcomes after PCI with incomplete revascularization: Impact of CTO and LAD vessel.

Incomplete revascularization (ICR) after percutaneous coronary intervention (PCI) is associated with mortality and morbidity. We sought to investigate whether ICR in the left anterior descending artery (LAD) is worse than ICR of the right coronary artery (RCA) or left circumflex artery (LCX); and whether ICR in patients with a chronic total occlusion (CTO) is worse than in those without. In the RIVER-PCI trial, 2651 patients with ICR after PCI were randomly assigned to ranolazine or placebo. Angiograms were assessed at an independent core laboratory in 2501 patients (94.3%). The primary endpoint was the composite of ischemia-driven revascularization or hospitalization. A total of 1664 patients (66.5%) had ICR involving the LAD, whereas 837 (33.5%) had ICR limited to the RCA or LCX. At median follow-up of 643 days, the primary endpoint occurred in 26.9% versus 26.5% of patients (adjusted HR [aHR]: 1.03, 95% confidence interval [CI]: 0.88-1.21). A nonrecanalized CTO was present in 854 patients (34.1%) with ICR after PCI. The primary endpoint occurred in 28.6% versus 25.9% of ICR patients with versus without a CTO (aHR: 1.10, 95%CI: 0.94-1.29). However, patients with a CTO had higher rates of ischemia-driven hospitalization without revascularization (aHR: 1.27, 95%CI: 1.04-1.56), heart failure hospitalization (aHR: 2.69, 95%CI: 1.61-4.59) and myocardial infarction (aHR: 1.46, 95%CI: 1.11-1.92) compared with those without. The 2-year prognosis was similar in post-PCI patients with ICR whether the LAD was versus was not involved. ICR patients with a CTO had more frequent hospitalizations for ischemia and myocardial infarctions compared with those without.

Wellens\u2019 syndrome: incidence, characteristics, and long-term clinical outcomes

BackgroundFew studies with large sample sizes are available regarding patients with Wellens’ syndrome. Therefore, we sought to assess the current incidence, risk factors, clinical presentation and long-term outcomes of this population.MethodsAmong a total of 3528 patients with ACS who underwent angioplasty from 2017 to 2019 in our centre, 2127 NSTE-ACS patients with culprit LAD vessels were enrolled in this study. According to electrocardiographic criteria, the patients were divided into a Wellens’ group (n = 200) and non-Wellens’ group (n = 1927). The primary endpoint was cardiac death; the secondary endpoint was MACCE, a composite of all-cause death, cardiac death, recurrent myocardial infarction, target lesion revascularization, heart failure and stroke.ResultsThe incidence of Wellens’ syndrome was 5.7% (200 of 3528) of all ACS patients. Wellens’ syndrome more often manifested as NSTEMI (69% vs. 17.5%, P < 0.001). The percentages of preexisting coronary heart disease (39.6% vs. 23%) and previous PCI (19.5% vs. 9%) were significantly higher in the non-Wellens’ group than in the Wellens’ group (all P < 0.001). More importantly, the proportion of early PCI was higher in the Wellens’ group (68% vs. 59.3%, P = 0.017). At a median follow-up of 24 months, Wellens’ syndrome was not associated with an increased risk of MACCE (P = 0.05) or cardiac death (P = 0.188).ConclusionsThe presence of Wellens’ syndrome is not definitively associated with adverse prognosis in patients with NSTE-ACS. Age ≥ 65 years, diabetes, NSTEMI, eGFR < 60 ml/min and left main disease are associated with the incidence of cardiac death. Early recognition and aggressive intervention are critical, as they may help to attenuate adverse outcomes.

Detection of myocardial bridge by optical coherence tomography.

Myocardial bridge (MB) is less commonly documented by angiography than autopsy. Optical coherence tomography (OCT) may be useful to detect angiographically undetectable MB. To investigate OCT characteristics of MB, 86 LAD vessels were imaged by OCT. MB was defined as presence of intermediate optical intensity, "fine" layer surrounding coronary artery by OCT. Frequency and characteristics of the angio-detectable and angio-undetectable but OCT-detectable MB were investigated. In a subset of patients with angio-detectable MB, cyclic changes in coronary arterial dimensions were analyzed. OCT detected MB in 44 of 86 (51%). Arc of the MB was significantly larger (334.8 ± 58.5° vs. 268.4 ± 92.1°, P = 0.008) and length was significantly longer (22.6 ± 11.7 mm vs. 14.5 ± 8.1 mm, P = 0.014) in angio-detectable MB than OCT-detectable but angio-undetectable MB. Both vessel (6.8 ± 1.5 to 5.3 ± 1.0 mm2, P = 0.035) and lumen area (4.4 ± 1.5 to 3.1 ± 0.7 mm2, P = 0.040) decreased significantly from diastole to systole. Adventitial (0.08 ± 0.03 to 0.08 ± 0.02 mm, P = 0.828) and intima+plaque thickness (0.12 ± 0.05 to 0.10 ± 0.03 mm, P = 0.398) did not change significantly during cardiac cycle. On the other hand, medial thickness increased significantly from diastole to systole (0.08 ± 0.03 to 0.12 ± 0.03 mm, P = 0.022). In conclusion, MB is frequently detected as intermediate intensity, fine layer by OCT. During systole, vessel and lumen size decrease with increased medial thickness. Therefore, we should be careful for OCT interpretation of the coronary arteries with MB.

P966Clinical impact of target vessel on long term cardiac survival in patients with chronic total occlusion treated by percutaneous coronary intervention

Abstract Background Chronic total occlusions (CTOs) occur in 15–35% of patients with significant coronary artery disease who undergo coronary angiography. The rationale of percutaneous CTO revascularization is the improvement in survival and in quality of life, mainly reducing angina symptoms and increasing LVEF. The clinical impact of target vessel has been investigated in previous studies, with controversial results. Purpose The aim of this study, based on a large scale single-center registry, is to determine the impact of different target vessel successful CTO percutaneous coronary intervention (PCI) on long-term survival in a “real world” population. Methods All consecutive patients who attempted a CTO-PCI from 2004 to 2015 in our Hospital department were included in a CTO-PCI Registry. CTO was defined as a coronary obstruction with TIMI flow grade 0 with an estimated duration of &gt;3 months. Patients with multiple CTO were excluded. Long-term mortality was assessed by Kaplan-Meier and Cox multivariable analysis. Results A total of 1235 patients attempted PCI for CTO; patients were stratified into two main groups according to the CTO carrying vessel: LAD-CTO (n=360) and not-LAD CTO (n=875). Cardiac survival rate at 5 years was lower in LAD-CTO patients compared with not-LAD CTO patients (85±3% vs. 90±2%; p=0.001), but when a successful CTO-PCI was achieved, there was no statistical difference between the two groups (89±3% vs. 93±1%; p=0.095). On the other side, a failure of the CTO PCI in LAD vessel was associated with a worse outcome (67±8% vs. 85±4%; p=0.001). Completeness of revascularization carried a significant survival benefit independently from the target vessel CTO (LAD CTO group 94±2% vs. not-LAD CTO group 95±1%; p=0.256), but an incomplete revascularization was associated with a worse outcome in LAD-CTO patients (67±6% vs. 81±4%; p&lt;0.001). By multivariable Cox analysis, age &gt;75 years, diabetes, left ventricular ejection fraction &lt;40%, complete revascularization and LAD-CTO were independently related to death. Conclusions In a “real world” population, LAD-CTOs were associated with a lower cardiac survival rate when compared to other vessel CTOs; however, this survival gap was no longer significant when a successful CTO PCI was performed. The survival benefit was even greater when a complete coronary revascularization was achieved.

TCTAP C-163 Case Report Simply Describes Lesion Is Not Simple Procedure LAD Vessel Perforating Complication During Wiring in Primary Angioplasty

TCTAP C-163 Case Report Simply Describes Lesion Is Not Simple Procedure LAD Vessel Perforating Complication During Wiring in Primary Angioplasty

Three coronary arteries arising from the right coronary cusp with a malignant sub-pulmonary course of the left anterior descending artery

We describe a case of a 45-year-old man presenting with acute myocardial infarction investigated by computed tomography coronary angiography. Interestingly all three coronary arteries arose from the right coronary cusp. The left anterior descending artery (LAD) subtended an acute angle from the aortic root, associated with significant kinking and stenosis at the ostium, before passing anteriorly, taking a sub-pulmonic course and descending in the anterior interventricular groove. The distal vessel was small with an atrophic appearance. The circumflex artery followed a retro-aortic route, before trifurcating to supply the lateral and posterior walls of the left ventricle. The right coronary artery was normal. Given his unstable presentation and the potentially lethal course of the LAD, he was referred for grafting of the LAD vessel which successfully ameliorated his symptoms and has thus far prevented recurrent myocardial infarction.<Learning objective: Computed tomography coronary angiography is becoming increasingly accessible to physicians for the investigation of patients with suspected coronary disease and the planning of surgery. As such, coronary anomalies are likely to be encountered more frequently, and it is important to appreciate their clinical significance.>

The Survival of an Old Lady with ALCAPA

The coronary artery system is composed of two major systems, the left and right coronary artery system. Both left and right coronary arteries originate from the aortic left and right coronary cusp respectively. The left anterior descending artery (LAD), the main vessel of the left coronary artery system, is considered to be the most important of the coronary artery system. The LAD supplies the left ventricular anterior wall that plays the main role in the left ventricular pumping function. The right coronary artery system is also considered to be the second most important system that mainly supplies the left ventricular inferior wall. The balance of myocardium blood supply demands an adequate coronary artery blood supply from both systems. If the blood supply to some portion of the myocardium is entirely blocked or the energy demand is much higher than the supply, severe myocardium injury or sudden cardiac death may occur. Total blocking of the left main coronary artery (LMA) and proximal LAD vessel is the main cause of death. How does aperson survive with a total absence of arterial blood supply from the left coronary artery system?

Coronary Artery Wall Thickness of the Left Anterior Descending Artery Using High Resolution Transthoracic Echocardiography – Normal Range of Values

Recently it has been demonstrated that high resolution transthoracic echocardiography (HRTTE) is able to detect differences in the wall thickness of the left anterior descending coronary artery (LAD) between patients with coronary artery disease (CAD) and normal volunteers. We sought to validate this technique, develop a normal range of values and demonstrate the test-retest variability of each measurement. Two hundred forty-two volunteer participants had a HRTTE study to measure their LAD wall thickness, luminal, and external diameters. Thirty of these subjects had these measurements taken on 3 separate occasions by 2 different echosonographers. All subjects were free of clinical CAD, hypertension, hyperlipidemia, and diabetes mellitus. The average anterior wall thickness was 1.1 ± 0.2 mm; posterior wall thickness was 1.1 ± 0.2 mm, luminal diameter 2.2 ± 0.6 mm, and external elastic membrane (EEM) diameter 4.5 ± 0.9 mm. The bias of the measurements within the same operator for LAD wall thickness, luminal diameter, and EEM was 0.042, -0.06, and -0.077 mm, respectively. The bias of the measurements between 2 different operators for LAD wall thickness, luminal diameter, and EEM was 0.082, -0.077, and -0.027 mm, respectively. In conclusion, HRTTE measurement of the LAD vessel is reproducible within and between operators in normal volunteers. This technique therefore warrants further study as a potential screening modality for subclinical coronary atherosclerosis.

202 Coronary artery wall thickness of the left anterior descending artery using high resolution transthoracic echocardiography an intra and inter operator variability

Results: 1 .Compared with the control group, the MAC group had a higher prevalence ,31 coronary artery disease (88.28% Vs 65.12%,P = 0.0003),and a higher prevalence el left main coronary disease(15.63% Vs 4.65%,P = 0.007)and triple vessel disease(55.47% Vs 32.56%,P = 0.001).2.On multivariate analysis, MAC(P=0.008)was the independent predictors el coronary artery disease, and the predicting value el MAC were higher than hyperlipidaemia(P=0.02), chesl pain(P=0.0G)and age (P=0.04). 3. The positive predictive value el MAC lot find- ing coronary arlery disease was 88.28%. Conclusions: In patients aged=65years, There is a significant association be- tween the presence el MAC and coronary artery disease. MAC may be an im- portant marker for coronary artery disease. Coronary arteriongraphy should be underwent to the patients with MAC diagnosed by translhoracic echocardiography as a common. Of the risk laclors studied, hyperlension(P<0.05)and diabetes mellilus(P<0.001)were significantly associ- ated with MAC. Hyperlension(P<0.01),diabetes mellitus(P<0.05)and a smok- ing hislory(P<0.05)were significantly more prevalent in patients with AVC than those wilhoul AVC. Hyperlension was significantly more frequent in palienls wilh AVAC(P<0.05).2. There was a progressive increase in age(P<0.001), prevalence of hypertension(P<0.00t)and diabetes(P<0.05) with an increasing number el silos with calcium deposits. 3. Compared with patients with no calcium deposits, those with calcium deposils had a significantly higher positive prevalence el coro- nary arteriongraphy(P<0.0t), and lhere was a progressive increase in positive prevalence el coronary arteriongraphy(P< 0.001).4. Multiple logistic analyses iden- tified the multiple calcium deposits(P<0.01 ), age(P<0.05), male gender(P<0.001 ), diabetes mellitus(P<0.001 ), and hypercholesterolemia(P<0.05)as significant pre- dictors lor the positive prevalence el coronary arteriongraphy. )he multiple calcium deposils(P<0.001)and diabetes mellilus(P<0.001)were significant pre- dictors in lemale patients. In patients aged =55 years, the multiple calcium deposits(P<0.05), diabetes mellitus(P<0.05), smoking history(P<0.05)and male gender(P<0.05)were stalislically significant predictors el the posilive prevalence of coronary arteriongraphy. Conclusions: There is a significanl association between the presence el calcium deposits and coronary artery disease. The presence el multiple calcium deposits is an independent predictor el coronary arlery disease. these measurements. Thirty volunteers with- out a hislory el cardiac disease underwent a HRTTE assessment el their LAD by two dillerenl operators on three separate occasions. Resulls: The correlations lor inlra-operator variability were r= 0.86 (p<0.001), r=0.86 (p<0.001), r=0.81 (p<0.001) and r=0.85 (p<0.001) lot anterior and pos- terior wall thickness and luminal and e~ternal diameters respectively. The correla- lions lot inter-operator variability were r=0.68 (p<0.001), r=0.82. (p<0.001), r=0.76 (p<0.001) and r=0.70 (p<0.001) for anterior and posterior wall thickness and lumi- nal and external diameters respectively. Conclusion: HRTTE measurement el the LAD vessel is reproducible within and between operators in normal volunteers. This technique lherelore warrants lurlher sludy as a potential screening medalily lot subclinical coronary atherosclerosis.

Real-time patency control with thermal coronary angiography in 1401 coronary artery bypass grafting patients.

Intraoperative coronary angiography has always been favoured by cardiac surgeons. Thermal coronary angiography (TCA) is a useful method for intraoperative control of graft patency. It detects heat differences between tissues, provides easy-to-interpret angiographic images and even measures the flow of the grafts quantitatively. Between January 2000 and January 2002, TCA has been used in scheduled coronary bypass operations. Upon completion of each distal anastomosis, the perfusion of the distal arterial tree from the graft was evaluated with a thermal camera. TCA was applied to 1401 patients, mean age 60.97+/-9.61 years, who underwent simple coronary artery bypass grafting (CABG) procedures. A total of 4105 thermal images were obtained including 2161 venous, 1355 single internal thoracic artery (ITA), 56 bilateral ITA and 477 radial artery grafts. Image quality was not sufficient in 34 grafts (1.57%) due to either deep intramyocardial vessels or excessive epicardial fat tissue. Technical failures in three ITA anastomoses were detected and revised before the cross-clamp was removed. Flow-restricting lesions distal to the anastomosis on the left anterior descending artery (LAD) in nine patients were managed with a secondary distal bypass graft (five patients) or plaque splitting and anastomotic revision (four patients). Endarterectomy was combined in seven patients since the graft flow and the distal visualization was not satisfactory, although the anastomoses were performed on a good lumen. Angiographically undetected diagonal arteries were revascularized in 11 patients with totally occluded LAD vessels. Thermal imaging provides decisive coronary angiographies, and detects the perfusion area and flow of the implanted graft. It allows real-time detection of technical failures, reveals unexpected occluding plaques or any kind of flow-restricting lesions, and gives the chance of refinement of the anastomosis during the arrest period. We believe that the thermal imaging technique is a safe, noninvasive and feasible method to document the quality of the myocardial revascularization intraoperatively.

792-2.Is the Anti-Restenosis Effect of Stent (vs PTCA) Greater in LAD Vessels? A Subgroup Analysis of the STent REStenosis Study

In the multicenter randomized STent REStenosis Study (STRESS), stent (S) implantation has shown to reduce restenosis (RES) by 26% compared with PTCA. To determine the impact of Svs PTCA in reducing RES in various vessel locations, we analyzed the data from STRESS in LAD and non-LAD vessels. LAD PTCA N = 98 LAD S N = 96 Non-LAD PTCA N = 104 Non-LAD S N = 109 Final % stenosis 34 ± 15 17 ± 11 † 35 ± 14 20 ± 12 † Acute gain (mm) 1.14 ± 0.47 1.62 ± 0.43 † 1.32 ± 0.49 1.81 ± 0.47 † Late Loss (mm) 0.52 ± 0.55 0.78 ± 0.57 * 0.34 ± 0.57 0.73 ± 0.57 † Net gain (mm) 0.59 ± 0.55 0.88 ± 0.62 * 1.03 ± 0.61 1.06 ± 0.61 RES (&gt;50% stenosIs) 52.6 32.9 * 29.9 29.5 * . p ≤ 0.01 † . p ≤ 0.0001 compared S with PTCA In both LAD and non-LAD vessels, S (compared with PTCA) achieved a greater acute ga in and resulted in a lower final % stenosis. Late loss was also greater in S than PTCA group and similar for LAD and non-LAD vessels. However, in PTCA pts, late loss was much lower in non-LAD vessels (vs LAD). Thus, the overall net gain and RES in non-LAD vessels were similar for S.and PTCA, whereas the net gain was greater after S in LAD vessels and resulted in much lower RES compared with PTCA. Similarly, the difference in eventfree survival (freedom from death, MI, CABG, or repeat PTCA) between S and PTCA was greater in LAD (77% vs 66%, P = 0.06) than non-LAD vessels (78% vs 72%, NS). STRESS substudy analysis indicates 1) S provides uniformly greater improvement of angiographic results in all lesion locations compared with PTCA, 2) much greater anti-restenosis and clinical benefits in S pts within the LAD vessels, and 3) more aggressive post-S dilatation strategies (to further reduce final % stenosis) are recommended for non-LAD vessels to achieve greater differential anti-restenosis benefit for S.

Effects of Nafazatrom and Indomethacin on Experimental Myocardial Ischemia in the Anesthetized Dog

The anti-ischemic effects of nafazatrom (10 mg/kg intraduodenally) have been studied in a canine model of myocardial infarction. Nafazatrom was given 30 min before and 2 h after occlusion of the left anterior descending coronary artery (LAD). Effects were compared with those after intravenous indomethacin (10 mg/kg) treatment. Infarct size was measured at 6 h of coronary occlusion by postmortem tetrazolium staining. Myocardial ischemia was reduced after nafazatrom administration, whether related to total left ventricle (18 +/- 3.3 vs. 30.7 +/- 4.8%; p less than 0.05) or to the LAD vessel area at risk for infarction (51.4 +/- 4.0 vs. 82.5 +/- 4.5%; p less than 0.01). Salvage with nafazatrom occurred in the subepicardial and endomural tissues without lateral protection. Indomethacin had no effects on infarction. The LAD occlusion-induced hemodynamic consequences were reduced at 15 min by nafazatrom and remained unchanged by indomethacin. During the following experimental course, no differences were noted between the groups. At 6 h, blood flow in the nonoccluded circumflex artery increased by 12.6 +/- 3.2 ml/min (p less than 0.05) following nafazatrom treatment. Thus, nafazatrom reduced ischemia by a mechanism unrelated to changes in hemodynamics. Most likely, this was due to 5-lipoxygenase inhibition. This may shift arachidonic acid metabolism to cyclooxygenase products and prevent release of deleterious lipoxygenase products by neutrophils during ischemic injury.

Effects of nafazatrom and indomethacin on experimental myocardial ischemia in the anesthetized dog

The anti-ischemic effects of nafazatrom (10 mg/kg intraduodenally) have been studied in a canine model of myocardial infarction. Nafazatrom was given 30 min before and 2 h after occlusion of the left anterior descending coronary artery (LAD). Effects were compared with those after intravenous indomethacin (10 mg/kg) treatment. Infarct size was measured at 6 h of coronary occlusion by postmortem tetrazolium staining. Myocardial ischemia was reduced after nafazatrom administration, whether related to total left ventricle (18 +/- 3.3 vs. 30.7 +/- 4.8%; p less than 0.05) or to the LAD vessel area at risk for infarction (51.4 +/- 4.0 vs. 82.5 +/- 4.5%; p less than 0.01). Salvage with nafazatrom occurred in the subepicardial and endomural tissues without lateral protection. Indomethacin had no effects on infarction. The LAD occlusion-induced hemodynamic consequences were reduced at 15 min by nafazatrom and remained unchanged by indomethacin. During the following experimental course, no differences were noted between the groups. At 6 h, blood flow in the nonoccluded circumflex artery increased by 12.6 +/- 3.2 ml/min (p less than 0.05) following nafazatrom treatment. Thus, nafazatrom reduced ischemia by a mechanism unrelated to changes in hemodynamics. Most likely, this was due to 5-lipoxygenase inhibition. This may shift arachidonic acid metabolism to cyclooxygenase products and prevent release of deleterious lipoxygenase products by neutrophils during ischemic injury.