Left Anterior Descending Artery Lesion Research Articles

Coronary Extramural Haematoma Caused by Perforation during Left Main Coronary Artery Intervention

A year-old male patient with a background of quintuple coronary artery by-pass graft surgery 16 years ago presented to our department with symptoms consistent with unstable angina pectoris. Previous angiography performed in 2001 revealed occluded saphenous vein grafts to the left anterior descending (LAD), right coronary, obtuse The presence of pericardial effusion was immediately ruled out by echocardiography and because of absence of myocardial contrast staining heparin was not reversed. Subsequent intravascular ultrasound (IVUS) examination revealed a minimal lumen area of ≥11.00 mm2 throughout the stented segment despite stent underexpansion at marginal and first diagonal (DA) arteries, and patent left internal mammary artery (LIMA) graft to a second DA. At the same session he underwent percutaneous coronary intervention with bare metal stent implantation for significant mid to distal LAD artery disease. Since then, the patient was stable with Canadian angina class I. During this admission, his echocardiogram revealed an ejection fraction of 40%, akinesia of the inferior wall which was known to be predominantly infarcted and hypokinesia of the basal and mid anterior septum. Coronary angiography (Fig. 1) showed subocclusive calcified and angulated distal left main coronary artery (LMCA) disease, significant ostial LAD artery disease, collateralised occlusion of the distal LAD, left circumflex (LCx) and right coronary arteries, tight proximal disease of a first DA and patent LIMA graft to a second DA. Given these findings we proceeded with stent angioplasty to the LMCA-ostial LAD artery lesion. After a series of predilations with semicompliant balloons, a 4.0 mm × 24 mm drug-eluting stent was the LMCA opposite to the LCx artery ostium and at the LAD artery ostium. Cross-sections of IVUS at the site of perforation revealed an echo-dim pattern suggesting an extramural haematoma and local stent underexpansion with a compression effect by the haematoma whereas the site of blood entry into the adventitia was identified at the distal margin of the haematoma adjacent to a fibrocalcific plaque (Fig. 2). Given the adequate minimal lumen area further stent postdilation was not performed to avoid the risk of frank coronary perforation. The patient was maintained on dual antiplatelet therapy and discharged home after a two-day uneventful hospital course. He remained stable eight months post stenting with Canadian angina class I and no evidence of a cardiovascular event. Extramural haematoma that is accumulation of blood outside the arterial wall in the adventitia tissue is a rare complication of percutaneous coronary intervention and is thought to develop secondary to adventitial dissection implanted from the ostium of the LMCA across the stenosis into the LAD artery at 8 atms. Control angiography after [1–3]. It presents with an echo-dim pattern due to the dilution of the red blood cells and dissemination throughout

Prognostic significance of papillary muscle infarction detected by late gadolinium-enhanced MRI in acute reperfused ST-segment elevation myocardial infarction

Background The frequency and prognostic significance of papillary muscle infarction (PapMI) have not been investigated in a large multicenter study of patients with acute reperfused ST-elevation myocardial infarction (STEMI) because papillary muscle necrosis is difficult to visualize premortem. Noninvasive investigation by late gadoliniumenhanced magnetic resonance imaging (LGE-MRI) enables the detection of PapMI with high tissue contrast and spatial resolution. Aim of the study was to assess the exact frequency and clinical characteristics of PapMI using LGE-MRI in patients with STEMI. Methods We enrolled 795 STEMI patients reperfused by primary percutaneous coronary intervention (<12 h after symptom onset) in this CMR study at 8 centers. The CMR was completed within one week after infarction using a standardized CMR protocol. Central core lab-masked analyses for the presence of PapMI were performed. The primary clinical end point of the study was the occurrence of major adverse cardiovascular events (MACE) defined as death, reinfarction, and congestive heart failure within 12 months after infarction. Results PapMIs were detected in 12% of our patients. The posterior papillary muscle was involved more frequently than the anterior papillary muscle (68% versus 16%; P<0.001), whereas in 18% both PapMIs (anterior and posterior) were infarcted. PapMI was encountered more frequently in patients with right coronar ya rtery and left circumflex lesions compared with left anterior descending artery lesion (50%, 39% and 11%, P<0.001). The presence of PapMI was associated with larger infarcts (p=0.01), less myocardial salvage (p<0.001), and impaired left ventricular function (P=0.001). By multiple logistic regression analysis, PapMI was identified as an independent predictor of the presence of MACE (p<0.001). Conclusions

Left and Codominant Coronary Artery Circulations Are Associated With Higher In-Hospital Mortality Among Patients Undergoing Percutaneous Coronary Intervention for Acute Coronary Syndromes

Left or codominant coronary arterial circulation may represent less well-balanced myocardial perfusion and thus confer worse prognosis in acute coronary syndrome, especially for culprit lesions arising from the left coronary artery. We related left and codominance, relative to right dominance, with in-hospital mortality in 207 926 percutaneous coronary interventions (PCI) for acute coronary syndromes from July 1, 2009 through June 30, 2010 in the National Cardiovascular Data Registry Cath Percutaneous Coronary Intervention (CathPCI) Registry database version 4. Generalized estimating equations and logistic regression analyses were used in unadjusted and multivariable adjusted models. Models were adjusted using the validated National Cardiovascular Data Registry mortality risk model. We performed subgroup analyses and formally tested for effect modification by the epicardial coronary artery containing the culprit lesion. Left coronary dominance was associated with higher in-hospital mortality in unadjusted (odds ratio=1.29, 95% confidence interval [CI], 1.17-1.42) and adjusted models (1.19, 95% CI, 1.06-1.34). Codominance was associated with worsened mortality only in adjusted models (odds ratio=1.16, 95% CI, 1.01-1.34). Addition of coronary dominance to the National Cardiovascular Data Registry risk model did not materially change model discrimination or calibration. The odds of death for left versus right dominance among those with left circumflex or left main culprit lesions was 1.25 (95% CI, 1.02-1.53), for right coronary artery lesions was 1.19 (95% CI, 0.83-1.71), and for left anterior descending artery lesions was 1.09 (95% CI, 0.93-1.28). There was no statistical evidence for effect modification by culprit lesion vessel (P=0.8). Left and codominance are associated with modestly increased post-percutaneous coronary intervention in-hospital mortality in patients with acute coronary syndrome. Confirmation of these findings with angiographic core laboratory verification of coronary dominance and longer term follow-up will be desirable.

PCI TO CHRONIC TOTAL OCCLUSION, LIAQUAT NATIONAL HOSPITAL EXPERINCE

BACKGROUND PCI of chronic total occlusion represents 10%- 20% of all angioplasty procedures and poses a management dilemma for the interventional cardiologist. Percutaneous coronary interventions in chronic total occlusions have been associated with lower success rate. We therefore studied percutaneous interventions in chronic total occlusions done during year 2004 at Liaquat National Hospital Karachi. METHODS All patients with chronic total occlusion undergoing percutaneous coronary interventions were included during year 2004. Data was analyzed using SPSS 10. Version. RESULTS 57 patients with chronic total occlusions underwent PCI out of them 31.58% are female and 68.42%are male. There was no periprocedural or in hospital complications. 49.1% patients had multivessel disease. 33.33% left anterior descending artery lesion, 29.82% right coronary lesion, 24.56% circumflex lesion and 12.28% obtuse marginal lesion. Predilation was done in all cases using various size balloons. Various wires were used and in most cases more than one wire were used. Cypher, Taxus and driver stents were used for stenting. 75.4% are successful while 24.6% were unsuccessful. CONCLUSION Revascularization success rate for CTO in our study was 75.4%that was comparable to other data worldwide. The most common reason for procedural failure included the inability to cross the occlusion with guidewire (57.14%), failure to cross the occlusion with a balloon (28.57%) and failure to dilate the stenosis (12.28%).

Reciprocal ST segment changes in acute inferior myocardial infarction: Clinical, hemodynamic and angiographic implications

To investigate the clinical significance of reciprocal ST segment depression on the presenting electrocardiogram in patients with acute inferior myocardial infarction. Design and setting: A prospective, randomized, controlled single center study done in the critical care department, Cairo university Hospital. Forty consecutive patients with acute inferior myocardial infarction were enrolled in this study divided into two groups, 20 patients with reciprocal ST depression (group 1) and 20 patients without such depression (group 2). Interventions: All patients were investigated with serial ECG, cardiac biomarkers, echocardiography and coronary angiography. There was no significant difference in the proportion of coronary disease risk factors in patients in group 1, versus those in group 2. Patients in group 1 had significant higher degree ST elevation (in inf. Leads) than patients in group 2, higher levels of peak total CPK and CKMB was also seen. In addition patients in group 1 developed complication more frequently than those in group 2. Although no statistically significant difference between the two groups was seen as regard the ejection fraction sought by echocardiography, it did show a higher incidence of mitral regurge in group 1 [14 (70%)] versus 6 (30%) in group 2 with P value of 0.01. In group 1 left anterior descending artery lesions was significantly more frequent than in group 2 with P value < 0.001, also multivessel disease was significantly more frequent in group 1. The significance of reciprocal ST depression on the electrocardiogram during the course of inferior MI remains uncertain, opinion is divided as to whether it is a benign electrical phenomenon or a sign of a greater myocardial necrosis and more frequent left coronary artery disease, from our study we support the latter opinion. This simple ECG finding may be used to differentiate high risk patients for a more aggressive approach.

AS-134: Impact of Left Anterior Descending Artery Lesion versus Non-Left Anterior Descending Artery Lesion on 1-Year Clinical Outcomes in Patients with Acute Myocardial Infarction Undergoing Percutaneous Coronary Intervention

AS-134: Impact of Left Anterior Descending Artery Lesion versus Non-Left Anterior Descending Artery Lesion on 1-Year Clinical Outcomes in Patients with Acute Myocardial Infarction Undergoing Percutaneous Coronary Intervention

Atrial Fibrillation

Case Presentation —A 68-year-old white man presents to the cardiology office complaining of mild fatigue. A new and first finding is an irregular pulse. Atrial fibrillation is confirmed on 12-lead ECG. He has no additional symptoms. Four months earlier, he had a drug-eluting stent placed for a discrete proximal left anterior descending artery lesion. Past history includes hypertension, hyperlipidemia, and non–insulin-dependent diabetes mellitus. The first step is to establish that the patient is hemodynamically stable and whether he needs inpatient evaluation for an associated condition. The patient has a normal blood pressure (125/80 mm Hg) and a well-controlled irregular heart rate (72 bpm) on atenolol 50 mg daily. There are no interval ECG changes apart from the atrial fibrillation suggestive of an acute process. On examination, he has a short 1/6 systolic murmur at the apex without radiation. He has no evidence of heart failure. Neurological examination is normal. Medications include atenolol 50 mg daily, lisinopril 5 mg daily, metformin, atorvastatin 20 mg daily, aspirin 325 mg daily, and clopidogrel 75 mg daily. Immediate hospitalization is not needed. Management goals are to rule out reversible causes of atrial fibrillation, maintain the heart rate at rest and with exercise in the physiological range, consider conversion to sinus rhythm, and determine which stroke prevention measures are needed. Reversible causes of atrial fibrillation are conveniently separated into cardiac and noncardiac causes. Noncardiac causes (electrolyte imbalance, thyrotoxicosis, fever from any cause [particularly pneumonia], pharmacological and recreational drug use, and alcohol use) were ruled out by history and physical and simple blood tests (thyroid function tests, serum electrolytes, and urine and serum toxicology). The cardiac causes of atrial fibrillation include any mechanism resulting in structural and functional changes to the heart. Transthoracic echocardiogram revealed moderate left ventricular hypertrophy but normal left ventricular systolic function, no …

An integer based risk score for predicting 30-day major adverse cardiac or cerebrovascular events after percutaneous coronary intervention with drug-eluting stents: results from a?large prospective multicentre registry, the STENT Group

Previous risk models predicting in-hospital major adverse cardiac or cerebrovascular events (MACCE) after percutaneous coronary interventions (PCI) may underestimate actual short-term post-procedure complications due to the trend toward early discharge of patients. Using a subset (N=10,679) from the STENT Group registry, a logistic regression model was developed to predict 30-day MACCE which includes death, myocardial infarction, target vessel revascularisation and stroke. An integer-based risk score was created from the model and validated in another subset (N=3,099). In the study subset, there was significant difference between in-hospital and 30-day MACCE N=443 (2.0%) vs. 131 (4.2), p<0.01, respectively. A final risk model included nine variables; absence of pre-procedural statin (odds ratio=1.3, 95% confidence interval=1.0-1.5), haemoglobin level (0.9/1 gm increase, 0.8-0.9), cardiogenic shock (4.4, 3.1-6.3), acute congestive heart failure (1.6, 1.2-2.3), left main disease (2.2, 1.3-3.7), left anterior descending artery lesion (1.3, 1.0-1.5), ostial lesion (1.6, 1.2-2.1), coronary thrombosis (2.0, 1.4-2.9) and ACC/AHA type C lesion (1.3, 1.1-1.6). The c-statistics of the final model were 0.653 and 0.692 in the study and validation subset, respectively. In this large real world registry of DES, in-hospital MACCE did not represent short-term post-procedure prognosis. The risk model consisting of nine variables predicted 30-day MACCE with modest discriminatory value.

Anomalous Left Main Coronary Artery From Right Coronary Cusp

Anomalous origin of the left main coronary artery is a rare clinical entity that can present with symptoms across the clinical gamut, from asymptomatic to chest pain and possibly even sudden death. The clinical syndrome varies depending on the course of the aberrant left main. The anterior course where the artery runs between the aorta and the pulmonary artery can lead to compression of the left main, resulting in ischemia and possibly sudden death. In this article, the authors describe a case of a left main arising from the right coronary cusp that took a posterior course. There was a high-grade, proximal left anterior descending artery lesion that was treated with percutaneous intervention after defining the course of the aberrant left main.

A Case of a Zotarolimus-Eluting Stent Fracture in the Left Anterior Descending Artery in a Patient Undergoing Hemodialysis

Although stent fracture after implantation of a drug-eluting stent (DES) is a rare complication, it has been suggested to be a cause of restenosis. To date, most DES fractures have been associated with sirolimus-eluting stents. We describe here a case of a zotarolimus-eluting stent fracture after 8 months of stent placement in a calcified left anterior descending artery lesion in a patient undergoing hemodialysis.

Outcomes of stenting with overlapping drug-eluting stents versus overlapping drug-eluting and bare-metal stents for the treatment of diffuse coronary lesions

we investigated the outcomes of stenting with overlapping drug-eluting stents (DES) versus overlapping stenting with a combination of drug-eluting and bare metal stents (BMS) in very long coronary lesions (≥ 25 mm). fifty-two patients treated with either overlapping DES-DES (n = 22) or DES-BMS (n = 30) were selected from a registry of 588 patients with very long coronary lesions. Patients with acute myocardial infarction (MI) within the preceding 48 hours were excluded. The DES-DES combination was more frequently used for longer lesions compared with the DES-BMS group (47.95 ± 9.25 vs 39.98 ± 9.15 mm, p = 0.003). Left anterior descending artery lesions were also more frequently treated with the DES-DES combination (95.5 vs 66.7%, p = 0.02). In four patients in the DES-BMS group, overlapping stents were used for the coverage of dissections. Peri-procedural non-Q-wave MI occurred in one patient in the DES-BMS group. On follow up, only one case of non-fatal MI occurred in a patient with overlapping DES-DES. overlapping a BMS in the proximal part of a long DES instead of exclusive deployment of two or more overlapped DES seems to be a safe and feasible therapeutic strategy in our practice.

Prevalence and Clinical Significance of Papillary Muscle Infarction Detected by Late Gadolinium-Enhanced Magnetic Resonance Imaging in Patients With ST-Segment Elevation Myocardial Infarction

The frequency of papillary muscle infarction (PapMI) without rupture has not been fully investigated in vivo. Furthermore, the relationship between papillary muscle dysfunction and mitral regurgitation (MR) has been controversial in patients with ST-segment elevation myocardial infarction. Therefore, the aim of this study was to assess the frequency and clinical characteristics of PapMI without rupture using late gadolinium-enhanced magnetic resonance imaging (MRI) in patients with ST-segment elevation myocardial infarction. One hundred eighteen ST-segment elevation myocardial infarction patients with primary percutaneous coronary intervention underwent cardiac MRI twice 9±4 days and 8±1 months (n=104) after myocardial infarction. MR was categorized by echocardiography. Of these patients, 40% were found to have late gadolinium enhancement of papillary muscle, in which the posterior papillary muscle was involved more frequently than the anterior papillary muscle (77% versus 26%; P<0.001). PapMI was encountered more frequently in patients with left circumflex and right coronary artery lesions compared with left anterior descending artery lesion (78%, 48%, and 13%; P<0.001). By multiple logistic regression analysis, only coaptation height was identified as an independent predictor of the presence of MR. The second cardiac magnetic resonance imaging showed that the infarct size had a positive correlation with left ventricular end-diastolic volume (r=0.41, P<0.001) and that PapMI was not associated with left ventricular remodeling (P=0.31). Deterioration of MR was not observed in patients with PapMI. PapMI is more frequent than previously thought yet appears to have significant clinical latency. The size of the myocardial infarction, but not the presence of PapMI, seems to affect left ventricular remodeling, and PapMI is not obligatorily associated with MR.

Combined Off-Pump Transapical Transcatheter Aortic Valve Implantation and Minimally Invasive Direct Coronary Artery Bypass

Transcatheter aortic valve implantation has been shown to be an effective treatment for severe aortic stenosis in high-risk surgical patients. Many of these patients have significant coexisting coronary artery disease. We report the first case of combined off-pump transapical aortic valve implantation and minimally invasive direct coronary artery bypass via a left mini-thoracotomy in an 82-year-old man with significant comorbidities. This combined procedure is technically feasible and can be performed safely in selected patients with aortic stenosis and left anterior descending artery lesion that is not suitable for percutaneous intervention.

Rotational atherectomy of a complex, highly calcified left anterior descending artery lesion

Abstract Rotational atherectomy (RA) is an advanced coronary debulking technique, often used in cases, where traditional percutaneous coronary intervention (PCI) methods (e.g. balloon predilatation, use of cutting balloons, direct stenting etc.) are inadequate. We report a case of a male patient, who previously underwent PCI of the right coronary artery (RCA) and was free of chest pain for several weeks, but his clinical symptoms have developed again. Angiography showed a “de novo”, highly calcified left anterior descending (LAD) lesion that, after high-pressure balloon inflation, failed to dilate, thus the intervention was suspended. RA was scheduled for the patient within one month. As a complication of the previous LAD dilatation attempt, a chronic dissection of the target lesion occurred. Problems arose during the direct wiring attempt of the main vessel and the true lumen was only found via plaque modification, after accessing a small septal branch. Accessing the true lumen was only possible by using a conventional cross-wire. This was exchanged to a RA wire, with the help of an over-the-wire (OTW) balloon catheter. RA and debulking of the target lesion was performed. An everolimus-eluting stent (BioMatrix, Biosensors Europe, Morges, Switzerland) was implanted, with excellent results. The patient is free of clinical symptoms since the intervention, which took place 14 months ago.

Very Late Bare Metal Stent Thrombosis Presenting with Acute Myocardial Infarction: 14 Years after Coronary Stenting

Fourteen years previously, a 67-year-old man underwent percutaneous coronary intervention (PCI) for proximal left anterior descending artery lesion with a bare metal stent (BMS) for acute myocardial infarction (AMI) and attained an excellent result. Ticlopidine (200 mg) was administered for one month and 100 mg of aspirin was daily has been continued. One year after PCI, coronary angiography showed no restenosis. However, 14 years after PCI, he suffered from AMI due to stent thrombosis. Intracoronary aspiration thrombectomy and implantation of a drug-eluting stent were successful. This report demonstrates evidence of a very late case of stent thrombosis with the use of BMS.

Iodinated Contrast Opacification Gradients in Normal Coronary Arteries Imaged With Prospectively ECG-Gated Single Heart Beat 320-Detector Row Computed Tomography

To define and evaluate coronary contrast opacification gradients using prospectively ECG-gated single heart beat 320-detector row coronary angiography (CTA). Thirty-six patients with normal coronary arteries determined by 320 x 0.5-mm detector row coronary CTA were retrospectively evaluated with customized image postprocessing software to measure Hounsfield Units at 1-mm intervals orthogonal to the artery center line. Linear regression determined correlation between mean Hounsfield Units and distance from the coronary ostium (regression slope defined as the distance gradient G(d)), lumen cross-sectional area (G(a)), and lumen short-axis diameter (G(s)). For each gradient, differences between the 3 coronary arteries were analyzed with ANOVA. Linear regression determined correlations between measured gradients, heart rate, body mass index, and cardiac phase. To determine feasibility in lesions, all 3 gradients were evaluated in 22 consecutive patients with left anterior descending artery lesions > or =50% stenosis. For all 3 coronary arteries in all patients, the gradients G(a) and G(s) were significantly different from zero (P<0.0001), highly linear (Pearson r values, 0.77 to 0.84), and had no significant difference between the left anterior descending, left circumflex, and right coronary arteries (P>0.503). The distance gradient G(d) demonstrated nonlinearities in a small number of vessels and was significantly smaller in the right coronary artery when compared with the left coronary system (P<0.001). Gradient variations between cardiac phases, heart rates, body mass index, and readers were low. Gradients in patients with lesions were significantly different (P<0.021) than in patients considered normal by CTA. Measurement of contrast opacification gradients from temporally uniform coronary CTA demonstrates feasibility and reproducibility in patients with normal coronary arteries. For all patients, the gradients defined with respect to the coronary lumen cross-sectional area and short-axis diameters are highly linear, not significantly influenced by the coronary artery (left anterior descending artery versus left circumflex versus right coronary artery), and have only small variation with respect to patient parameters. Preliminary evaluation of gradients across coronary artery lesions is promising but requires additional study.

Long-Term Safety and Efficacy With Paclitaxel-Eluting Stents: 5-Year Final Results of the TAXUS IV Clinical Trial (TAXUS IV-SR: Treatment of De Novo Coronary Disease Using a Single Paclitaxel-Eluting Stent)

The pivotal TAXUS IV (TAXUS IV-SR: Treatment of De Novo Coronary Disease Using a Single Paclitaxel-Eluting Stent) trial evaluated the long-term safety and effectiveness of the paclitaxel-eluting stent (PES) compared with an otherwise identical bare-metal stent (BMS) in a relatively uncomplicated population of patients with a single de novo lesion in a native coronary vessel, treated between March and July 2002. Long-term follow-up is required to determine whether the early safety and efficacy of drug-eluting stents are maintained. The primary end point of this prospective, randomized, double-blind trial was 9-month ischemia-driven target vessel revascularization (TVR) for PES versus the BMS control. Follow-up was complete in 1,230 (95.1%) of 1,294 randomized evaluable patients at 5 years. Compared with BMS, PES significantly reduced TVR at 9 months (12.1% vs. 4.7%; p < 0.0001); this benefit was maintained through 5 years (27.4% vs. 16.9%; p < 0.0001), given comparable TVR rates for BMS and PES between years 1 and 5 (4.1%/year vs. 3.3%/year; respectively, p = 0.16). Similar patterns were observed for composite major adverse cardiac events (MACE) (32.8% BMS vs. 24.0% PES, p = 0.0001 at 5 years). Stent thrombosis was comparable for PES and BMS at 9 months (0.8% BMS vs. 0.8% PES; p = 0.98) and at 5 years (2.1% BMS vs. 2.2% PES, p = 0.87). The overall revascularization benefits of PES were consistent across multiple subgroups, including sex, diabetes, left anterior descending artery lesion location, reference vessel diameter, lesion length, and multiple stents. These 5-year results demonstrate the long-term safety and sustained efficacy of PES compared with BMS in patients with noncomplex lesions. (TAXUS IV-SR: Treatment of De Novo Coronary Disease Using a Single Paclitaxel-Eluting Stent; NCT00292474).

Twenty-Five-Year Outcome of Pediatric Coronary Artery Bypass Surgery for Kawasaki Disease

The long-term outcome of pediatric coronary artery bypass for patients with severe inflammatory coronary sequelae secondary to Kawasaki disease is unknown. One hundred fourteen children and adolescents ranging in age from 1 to 19 (median, 10) years at operation were followed up for as long as 25 years with a median of 19 years. The number of distal anastomoses was 1.7+/-0.8 per patient, and the internal thoracic artery was used in all but 3, most frequently for left anterior descending artery lesions. Saphenous vein grafts were used in 24 patients, mostly for non-left anterior descending artery lesions. Patients underwent multiple angiograms to evaluate their coronary and graft status. There was no operative or hospital mortality. Both 20- and 25-year survival rates were 95% (95% confidence interval [CI], 88 to 98). Five deaths occurred, all cardiac in origin. Cardiac event-free rates at 20 and 25 years were 67% and 60% (95% CI, 46 to 72), respectively. Percutaneous coronary intervention and reoperation were the most common events. Overall, the 20-year graft patency rate was 87% (95% CI, 78 to 93) for internal thoracic artery grafts (n=154) and 44% (95% CI, 26 to 61) for saphenous vein grafts (n=30) (P<0.001), and the rate for non-left anterior descending artery lesions was also significantly better for arterial grafts (87% [95% CI, 73 to 94]; n=59) than for saphenous vein grafts (42% [95% CI, 23 to 60]; n=27) (P=0.002). Eighty-eight patients (77%) remain on medications, but all 109 survivors are presently symptom free in their daily activities. Although the 25-year survival was excellent after pediatric coronary bypass for Kawasaki disease, the event-free rate declined progressively. This reality mandated continued follow-up. Reinterventions successfully managed most cardiac events. An internal thoracic artery graft was the most favorable for children.

Long‐Term Clinical Efficacy of Cutting Balloon Angioplasty Followed by Bare Metal Stent Implantation for Treating Ostial Left Anterior Descending Artery Lesions

Drug-eluting stents (DES) are superior to bare metal stents (BMS) for treating ostial left anterior descending artery (LAD) lesions, but DES is not suitable for all patients in real life practice. We hypothesize that cutting balloon angioplasty (CBA) followed by BMS (CBA + BMS) for treating ostial LAD lesions is an alternative strategy. In our study, 101 consecutive patients (51 with DES and 50 with CBA + BMS) with ostial LAD stenting were included for retrospective investigation between November 2003 and May 2005. The target vessel diameter was > or =3.0 mm. We compared the DES group with the CBA + BMS group, the rates of restenosis (10.3% versus 17.9%, p = 0.386), target lesion revascularization (TLR) (5.88% versus 10%, p = 0.487) and major adverse cardiac events (MACE) (7.84% versus 12%, p = 0.525) were similar at 6-8 months angiographic follow-up, but there were higher bleeding events in the DES group (p = 0.033). During a 2-year clinical follow-up, no myocardial infarction occurred in the 2 groups, the rates of TLR (7.84% versus 10%, p = 0.741) and MACE (9.8% versus 12%, p = 0.723) were also similar. The MACE-free survival rate was 90.2% versus 88 % (p = 0.723). The CBA + BMS combination has a good long-term clinical effect in the treatment of ostial LAD lesions; it might be an alternative strategy for patients with contraindication for DES implantation, or patients who cannot endure long-term dual antiplatelet medication, or in elderly patients.

Impact of Myocardial Bridge on Clinical Outcome After Coronary Stent Placement

Most intravascular ultrasound (IVUS)-identifiable myocardial bridges (MBs) were not appreciated angiographically, especially when they occurred adjacent to fixed proximal obstructive disease. The impact of MB stent placement on clinical outcome was determined in 317 consecutive patients with obstructive left anterior descending coronary artery lesions undergoing coronary stent placement. In these patients, IVUS identified 70 MBs, defined as a segment of coronary artery with both systolic compression and perivascular echolucent muscle. IVUS showed that the stent extended into the MB segment beyond the obstructive lesion in 24 patients (34%; MB stent group), although significant plaque was not observed within any MB segment. In the remaining 46 patients, the left anterior descending artery stent was implanted in only the obstructive lesion, avoiding the distal MB segment (non-MB stent group). Minimum stent area was significantly smaller in the MB stent group than non-MB stent group (4.8 +/- 1.1 vs 5.8 +/- 1.8 mm(2); p = 0.02). Rates of target-lesion revascularization, target-vessel revascularization, and composite end point (death/myocardial infarction/target-lesion revascularization/target-vessel revascularization, evaluated at a mean follow-up of 358 +/- 252 days) were more common in patients with versus without MB stent placement. Specifically, target-lesion revascularization rates were 24% versus 3%, respectively (log-rank p = 0.003). In-stent restenosis occurred within the stented MB segment in 3 of 5 MB stent group patients who required target-lesion revascularization (60%). In conclusion, inadvertent MB stent placement in left anterior descending artery lesions occurred commonly and may have been associated with an increased incidence of late events.