Left Anterior Descending Research Articles

Aeromedical Fitness Considerations in Myocardial Bridging: A Case Study and Literature Review

Aims: Management of cardiac disease in aeromedical expertise can be challenging for asymptomatic crew members, especially during the first aeromedical examination, myocardial bridging is a good example. Presentation of Case: A 24-year-old student pilot candidate shows repolarization disorders at the ECG in the aeromedical examination, the exploration allowed the discovery of a myocardial bridge on The Coronary computed tomographic angiography (CCTA) of the left anterior descending (LAD) coronary artery responsible for tight stenosis. Discussion: The prevalence of MB varies according to the method of investigation, ranging from 2% in coronary angiography and 19% in coronary computed tomography to 42% in autopsy.The prevalence among active civilian aircrew (pilots and cabin crew) monitored at CEMPN is 0.4%, all revealed by electrocardiogram abnormalities. MB are usually small and of no clinical significance, the myocardial bridge proximal segment has been associated with atherosclerosis. Symptomatic patients with myocardial bridges as their only cardiac abnormality may present with myocardial ischemia, acute coronary syndromes, coronary spasm, syncope or even sudden death. The initial therapeutic strategy in the treatment of MB is medical management. Revascularization is indicated by PCI or surgery, including coronary artery bypass grafting (CABG) or myotomy in the case of symptoms recalcitrant to maximal medical treatment. The aviation environment may expose aircrew to additional physiological stressors, including hypobaria, hypoxia and sustained acceleration (+Gz). Such exposure may present a risk if associated with cardiovascular abnormalities, potentially leading to incapacity to fly due to symptoms or complications of the myocardial bridge. Conclusion: The myocardial bridge is an anatomical variant rather than a congenital anomaly with varied symptomatology (ECG abnormality, stable or unstable angina or sudden death), the aeromedical decision is made on a case-by-case basis, and makes a challenge diagnostic, particularly for asymptomatic crews.

Analysis of influential factors of stent-related adverse events after percutaneous coronary intervention more than twice: a single-center retrospective study.

We aimed to assess the factors affecting patient outcomes in multiple stent placements over a 10-year period. The single-center study included 1,200 patients who had multiple stents implanted at least twice or more. Participants were divided into the adverse outcomes as endpoints (n = 204 [17%]) and control groups. Univariate and multivariate analyses of stent-related adverse events risk during 10 years and logistic regression analysis of the adverse outcomes risk factors were performed. Univariate analysis revealed the impact of acute coronary syndrome (ACS), diabetes mellitus, hypertriglyceridemia, cumulative lesions in the left anterior descending (LAD) and left circumflex (LCX) arteries, number of stents in the LAD, LCX, and right coronary artery (RCA), presence of multiple coronary artery lesions, total number of stents used, and intervals between the first and second and between the fourth and fifth implantations. For secondary stent implantation, significant factors in univariate analysis included the number of LAD and LCX lesions, stents in LAD, LCX, and RCA, extent of coronary lesions, ACS, hypertension, diabetes, and total stent count. Many factors affect the outcomes in this patient group over time. Reducing the need for frequent percutaneous coronary intervention and considering the number of stents implanted are essential to improving outcomes.

Sequential Grafting of the Left Internal Thoracic Artery to the Left Anterior Descending Artery and Graft Failure.

There is concern that left internal thoracic artery (LITA) to diagonal to left anterior descending artery (LAD) grafts may be more susceptible to failure compared to single LITA-LAD grafts. Pooled individual patient data from eight clinical trials with systematic graft imaging were analyzed to assess the incidence of sequential LITA-Diagonal-LAD vs. single LITA-LAD grafts. Mixed-effects multivariable logistic regression, adjusting for patient characteristics and clustering within trials, was used. Of 3969 patients with LITA-LAD grafts, 283 (7.1%) patients received sequential LITA-Diagonal-LAD grafts. Patients with sequential LITA-Diagonal-LAD grafts were older (66 vs. 65 y, p=0.009) and more often male (88% vs. 83%, p=0.03). Overall, graft failure occurred in 9.3% of patients with LITA-LAD grafts, with more graft failure occurring in single (9.5%) than in sequential LITA-Diagonal-LAD grafts (6.4%, p=0.08) at a median (25th-75th percentile) time to imaging of 1.0 (1.0-1.1) years. After multivariable adjustment, sequential LITA-Diagonal-LAD grafting was not associated with graft failure (adjusted odds ratio: 1.22, 95% confidence interval: 0.68-2.18, p=0.55). There was no difference in mortality (2.8% vs. 5.3%, p=0.06), myocardial infarction (1.4% vs. 1.6%, p=0.90), revascularization (4.5% vs. 7.3%, p=0.08), or stroke (1.7% vs. 1.2%, p=0.40) between groups. In selected patients, LITA-Diagonal-LAD grafting was not associated with higher risk of graft failure or adverse clinical events at one year.

Abstract 4138792: A Case of Right Coronary Artery Chronic Total Occlusion in a Transplanted Heart: To Stent or Not to Stent?

Background: Cardiac Allograft Vasculopathy (CAV) is commonly seen in transplanted hearts. Due to the absence of innervation, many transplanted patients have no symptoms despite extensive disease. This poses a challenge in deciding when to perform coronary interventions. We present a case of significant CAV on surveillance angiogram that posed a challenge in management. Case: A 67-year-old female presented for her fifth surveillance coronary angiography nine and a half years after her heart transplant. The angiogram revealed ostial right coronary artery (RCA) chronic total occlusion (CTO) with left-to-right collaterals as well as diffuse irregularities in the left anterior descending (LAD) and left circumflex arteries. The patient was asymptomatic and two years prior to that, her angiogram revealed no significant disease. Biopsies for the past nine years showed no evidence of allograft rejection. She was subsequently referred for coronary intervention. Due to concern of CTO being a sign of rapidly progressing CAV, it was decided to undergo revascularization of the RCA. Antegrade approach was performed with guidance from contralateral injections. Three overlapping drug-eluting stents were deployed proximally-distally using intravascular ultrasound guidance. Surveillance angiography nine months later showed patent RCA stents with no significant disease otherwise. Eighteen months later, angiography demonstrated CTO of the mid LAD and patent RCA stents with mild in-stent restenosis in the most distal RCA stent. The patient remained asymptomatic. Discussion: CAV develops in fifty percent of transplanted hearts within 10 years and requires close surveillance. In this case, revascularization of the RCA CTO resulted in maintaining graft function for at least two additional years as the development of LAD CTO may have resulted in graft failure had the RCA CTO not been intervened upon. CTO revascularization in CAV has the potential to prolong graft viability and delay the need for re-transplantation. Further studies related to CTO revascularization, especially in asymptomatic transplanted patients, are needed to understand the impact on morbidity and mortality in this patient population.

Abstract 4112620: Cardiomyocyte-specific Increases in Forkhead Box M1 (FoxM1) Expression May Promote Cardiomyocyte Proliferation and Improve Recovery from Myocardial Injury in Mice and Pigs

Background: The cardiomyocytes (CMs) can not regenerate after myocardial infarction (MI) in adult mammals. FoxM1 is essential for cell proliferation. Targeted deletion of the Foxm1 in mice leads to serious cardiac proliferation defects and embryo death. The primary aim of this study was to demonstrate that the Specific Modified mRNA Translation System (SMRTs) can specifically overexpress FoxM1 in CMs and observe the benefits of overexpressing FoxM1 on myocardial repair in mice and pigs with myocardial injury. Methods: The FoxM1-CM SMRTs is composed of two modRNA constructs: one encoding L7Ae regulates the specific expression of FoxM1 on the other coding chain in CMs and inhibits its expression in non-cardiomyocytes through he CM-specific microRNAs miR-1 and miR-208 on L7Ae coding chain. Myocardial-specific expression of FoxM1-CM SMRTs and its proliferation-promoting effect were detected in hiPSC-CM (human-induced pluripotent stem cell-derived cardiomyocyte), mouse and pig models (days 3 after FoxM1-CM SMRTs treatment). In vivo experiments were conducted in both mouse and pigs with LAD (left anterior descending) ligation. The effects of FoxM1-CM SMRTs on cardiac function, MI size and hypertrophy in mice and pig models were detected after 4 weeks of FoxM1-CM SMRTs treatment. Results: FoxM1 was abundantly expressed in postmitotic CMs after transfection with the FoxM1-CM SMRTs, accompanied by activation of cell-cycle and proliferation markers (Ki67, PH3 and Aurora B kinase) and an increase in cell number. When the GFP-CM SMRTs was injected into mouse hearts with MI, GFP was only expressed in CMs, but not in non-CMs. Compared with the MI group, FoxM1-CM SMRTs significantly increased CM proliferation (days 3 after treatment administration in mice and pigs), improved left-ventricular ejection fractions (days 10 and 28 in both species) and hypertrophy, and reduced MI size (days 28 in both species). Conclusion: Intramyocardial injections of the FoxM1-CM SMRTs promoted CM proliferation, reduced MI size, and improved cardiac function in small and large mammals with acute myocardial infarction.

Obscure Rare Cause of Recurrent Angina in Post CABG Patient: Coronary-Subclavian Steal Syndrome

Coronary subclavian steal syndrome (CSSS) is a rare and unrecognized complication of coronary bypass grafting surgery when a left internal mammary artery (LIMA) graft is utilized for left anterior descending (LAD) artery revascularization without knowing left subclavian artery status. We describe a case of a 67-year-old male, with a known history of triple vessel coronary artery disease (CAD) managed with CABGx3 in March 2003. The patient presented after 16 years with complaints of recurrent angina for the past 15 years which aggravates on exertion, especially of left hand. Recurrent hospitalizations and repeated Coronary angiograms (CAG) as well as CT Coronary angiography failed to diagnose the cause of angina. Subclavian angiography and subsequent methodical clinical examination during the present admission revealed left subclavian origin stenosis which was successfully revascularized by deployment of a stent resulting in convincing relief in the patient’s angina.

The role of COX2 deficiency attenuates cardiac damage in acute myocardial infarction

Cardiac cell damage frequently occurs as a consequence of acute myocardial infarction (AMI), a critical complication of coronary atherosclerotic heart disease. There is an escalating recognition of the association between COX2 and myocardial damage induced by ischemia. The objective of this study is to investigate the inhibitory effect of the COX2 on cardiomyocyte damage in the context of AMI. To create an AMI model, mice with the genetic background of wild-type C57BL6/J (WT) and COX2-/- mice were utilized. The left anterior descending (LAD) coronary artery in their hearts was obstructed, and subsequent assessment of hemodynamic parameters and heart function was conducted. Notably, increased levels of COX2 were observed in AMI mice. Through correlational analysis between COX2 expression and cardiac function following AMI, it was revealed that COX2 knockout mice had smaller infarct sizes, better cardiac performance, and suppressed levels of reactive oxygen species (ROS) compared to WT mice. Additionally, we discovered that COX2 knockout mice exhibited significantly higher mRNA levels of smooth muscle actin, collagen I, and collagen III than normal mice with AMI. Conversely, the levels of superoxide dismutase (SOD), malondialdehyde (MDA) were higher but iron content was decreased in COX2 knockout mice compared to normal mice with AMI.In summary, our research demonstrates that the downregulation of COX2 enhances cardiac tissue recovery in the context of AMI.

The Impact of Different Revascularization Strategies Implemented in Acute Myocardial Infarction on the Recovery of Left Ventricular Functional and Deformational Parameters

Background: Despite well-established therapeutic techniques, such as direct revascularization through percutaneous coronary intervention (PCI), acute myocardial infarction (AMI) remains a leading cause of mortality and morbidity. Objectives: To determine if two-dimensional speckle tracking echocardiography (STE) deformation parameters and the early recovery of left ventricular (LV) functions are affected by the timing of PCI in AMI. Methods: A total of 200 cases with newly-onset acute myocardial infarction (AMI) who had a baseline left ventricular ejection fraction (LVEF) higher than 40% and received effective therapy with percutaneous coronary intervention (PCI) were included in this investigation. cases were categorized as either ST-elevation myocardial infarction (STEMI) or non-ST-elevation myocardial infarction (NSTEMI). cases were grouped into four groups according to the time between presentation and PCI. Using standard echocardiography and two-dimensional (2D) ST-elevation STE, individuals were re-evaluated three months later to find out if remodeling had taken place or if the LV function had returned. Results: Of the 200 AMI patients, including 140 males (70%), improvement in global longitudinal strain (GLS) and harmed longitudinal strain (HLS) were better in STEMI and NSTEMI patients received urgent revascularization with PCI (groups I and III) versus patients with pharmacoinvasive strategy or routine invasive strategy (Groups II and IV) (P < 0.05) while there was an insignificant difference between group I and III (P = 0.79). Of the 200 patients, 47 patients (23.5%) presented signs of LV remodeling at 3 months follow up. Age, smoking history, hypertension, dyslipidemia, Killip class, peak creatine phosphokinase - MB level, baseline left ventricular end diastolic volume (LVEDV), HLS, and harmed longitudinal strain rate (HLSR) were all factors that were found to be significantly associated with left ventricular remodeling (P<0.05) in the univariate logistic regression analysis. The following factors were identified as independent predictors of left ventricular remodeling in multivariate logistic regression analysis: damaged left ventricular ejection fraction (EF) and end-systolic volume, peak troponin I, Killip class, culprit left anterior descending (LAD), 2 and 3-vessel coronary artery disease (CAD), and wall motion score index (WMSI). Conclusion: Earlier PCI in AMI helps earlier improvement in myocardial strain parameters. HLS and HLSR are excellent predictors for LV remodeling and may do better than global parameters.

Overcoming Challenges in Kabul, Afghanistan: Successful Management of Mid-Portion Left Anterior Descending Artery Ellis Class 3 Coronary Artery Perforation, Complicated by Cardiac Tamponade and Concurrent Cardiac Arrest

Overcoming Challenges in Kabul, Afghanistan: Successful Management of Mid-Portion Left Anterior Descending Artery Ellis Class 3 Coronary Artery Perforation, Complicated by Cardiac Tamponade and Concurrent Cardiac Arrest

An In Vivo Model of Estrogen Supplementation Concerning the Expression of Ca2+-Dependent Exchangers and Mortality, Vitality and Survival After Myocardial Infarction in Ovariectomized Rats

Background: Ischemic-reperfusion damage of cardiomyocytes due to myocardial infarction (MI) often leads to the death of an individual. Premenopausal women have been observed to have a significantly lower risk of cardiovascular disease (CVD) than men of the same age. In menopausal women, this trend is significantly reversed, and the risk of CVD increases up to 10-fold. Estrogens affect the development and function of the heart muscle, and as they decrease, the risk and poor prognosis of CVD increase. This study is focused on the effects of estrogen supplementation on morbidity, vitality, and NCX1 expression after MI on a model system. Methods: In this study, female Sprague Dawley rats (n = 58), which were divided into three experimental groups (NN—control group, non-supplemented; OVX-N—ovariectomized, non-supplemented; OVX-S—ovariectomized, supplemented), received left thoracotomy in the fourth intercostal space. The left anterior descendent coronary artery was ligated 2 mm from its origin with an 8.0 suture. An immunohistological analysis as well as an RT-PCR analysis of NCX1 expression were performed. Results: A higher survival rate was recorded in the OVX-N group (86%) in comparison with the OVX-S group (53%) (p < 0.05). In addition, higher NCX1 expression 7 days/14 days after MI in the OVX-S group in comparison with the NN and OVX-N (p < 0.001 and p < 0.05) groups was recorded. Seven days after MI, a significantly higher expression (p < 0.005) of mRNA NCX1 in the OVX-N group was also recorded in comparison with the NN group. Conclusions: This study provides a comprehensive description of the effect of estrogen supplementation on NCX1 expression and overall vitality in ovariectomized rats that survived MI.

Anomalous origin of right coronary artery from left anterior descending coronary artery presenting with syncope – a case report

Introduction and importance: Non-dominant right coronary artery (RCA) is supposed to be benign as it does not result in large myocardial infarction. Still, in this case, non-dominant RCA from left anterior descending (LAD) artery not only produces ischemia but also results in incessant ventricular tachycardia, which is a life-threatening arrhythmia because of compromised blood flow. However, RCA is free of atherosclerotic plaque, which is the main cause of ischemia/infarction and subsequent arrhythmia. Case presentation: A 21-year-old male was admitted to the emergency cardiology ward of the National Institute of Cardiology following an episode of syncope. The patient reported a sudden loss of consciousness without preceding symptoms. Clinical discussion: The present case highlights the importance of a comprehensive evaluation and diagnosis in the management of syncope in young patients. The case presented here revealed a rare finding of a single coronary artery with a left main origin and an anomalous RCA emerging from the LAD artery. This is a very unusual presentation, with less than 50 occurrences recorded in the medical literature. This abnormality is classified as a single coronary artery anomaly (CAA), which means that the coronary arteries arise from a single coronary ostium within the aorta. Conclusion: In conclusion, CAA is an uncommon cause of SCA that can easily be overlooked without a systematic approach. In this report, we discuss the case of a patient who was discovered to have an anomalous RCA that branched off from the LAD artery.

Coronary Angiographic Features of de Winter Syndrome: More Than Just Occlusion of the Left Anterior Descending Artery.

The de Winter electrocardiogram (ECG) pattern is a rare presentation of ST-segment elevation myocardial infarction (STEMI) equivalent. The clinical profile of de Winter syndrome remains to be clarified. Medical records of 1865 consecutive patients with acute myocardial infarction admitted from November 2018 to July 2023 were screened. Twelve patients (0.6%) with de Winter syndrome were included. STEMI patients whose culprit vessel was the left anterior descending artery (LAD) but without de Winter ECG pattern were selected as controls after 1:2 matching for age and sex. The de Winter syndrome patients were all male, aged 49.0 (46.3-52.5) years. The culprit lesion was the proximal LAD in seven patients (58.3%), the middle LAD in three (25%), the left main coronary artery in one (8.3%), and the ramus intermedius artery in the other. All of their culprit lesions had TIMI Thrombus Grade < 4, Cohen-Rentrop Score ≤ 2, and residual stenosis ≥ 80% after pretreatment with thrombus aspiration or balloon predilatation. Intracoronary imaging data were available in four patients, showing severe atherosclerotic stenosis. Compared with STEMI, de Winter syndrome had a higher prevalence of prior recurrent angina (75.0% vs. 37.5%, p = 0.034), better coronary collateralization (Cohen-Rentrop Score: 1 vs. 0, p = 0.001), lower thrombus burden (TIMI grade: 1 vs. 2, p = 0.005) but more severe atherosclerotic stenosis in the culprit lesions (90% vs. 60%, p < 0.001). The culprit lesions of de Winter syndrome have a low thrombus burden, severe atherosclerotic stenosis, and poor collateral circulation protection.

The risk factors for in-stent restenosis following drug-eluting stent implantation in end-stage renal disease patients receiving renal replacement therapy

Abstract Background Chronic renal disease is a recognized risk factor for in-stent restenosis (ISR) following percutaneous coronary intervention (PCI) with a drug-eluting stent (DES). However, the specific risk of ISR among individuals with end-stage renal disease (ESRD) remains unclear or insufficiently studied. Purpose It is imperative to identify the risk factors associated with ISR among patients with ESRD and coronary artery disease following the implantation of DES. This identification is crucial for generating evidence-based strategies aimed at preventing ISR. Methods ESRD patients undergoing renal replacement therapy with concomitant coronary artery disease who underwent PCI with their initial DES implantation at our hospital between January 2013 and December 2022 were included in the study cohort. Clinical data, laboratory test results, and PCI specifics were compared between patients with and without ISR. Univariate and multivariate analyses utilizing Cox proportional hazard regression were employed to identify independent risk factors for DES-ISR. Results Among the 321 patients with ESRD who underwent PCI with DES implantation, totaling 874.5 patient-years of follow-up, 53 cases of ISR occurred during this period, yielding an incidence rate of 6.1 per 100 patient-years. Several baseline characteristics, angiographic findings, and procedural details were found to elevate the risk of ISR significantly. These included underlying diabetes mellitus, peripheral artery disease (PAD), high serum parathyroid hormone levels, LDL-C levels, acute coronary syndrome as the clinical presentation, the presence of triple vessel disease, duration of dual antiplatelet therapy less than 1 year, target lesion involving the left main (LM) or left anterior descending (LAD) artery, target vessel size less than 3 mm, ostial lesion, bifurcation lesion, number of stents implanted equal to or more than 3, and stent size less than 3 mm. In the multivariate Cox proportional hazard model, bifurcation lesion (HR 14.70, 95% CI 4.66-46.38), PCI of LM or LAD (HR 5.29, 95% CI 1.14-24.60), target vessel size less than 3 mm (HR 4.10, 95% CI 1.77-9.50), PAD (HR 3.92, 95% CI 1.52-10.08), and ostial lesion (HR 2.92, 95% CI 1.16-7.38) were identified as independent risk factors for ISR (all p-values &amp;lt; 0.05). Conclusions Among ESRD patients with coronary artery disease, bifurcation lesion, PCI involving the LM or LAD, target vessel size less than 3 mm, PAD, and ostial lesion are identified as independent risk factors for ISR. These findings hold significance in enhancing risk stratification and decision-making concerning treatment planning for this population.Univariate analysis risk factors for ISR

Prognostic significance of coexistent coronary artery disease in patients undergoing transcatheter aortic valve implantation for aortic stenosis

Abstract Background The optimal management of coronary artery disease (CAD) in patients undergoing transcatheter aortic valve implantation (TAVI) for aortic stenosis (AS) is uncertain. As TAVI expands into lower risk cohorts with longer life expectancies there is increasing need to determine the prognostic significance of coexistent CAD and identify which lesions may benefit from revascularisation. Purpose To evaluate the prognostic significance of coexistent CAD in patients with AS undergoing TAVI stratified according to myocardial territories at risk. Methods Using a retrospective, single-centre, observational registry, patients undergoing TAVI for severe AS between 2015 and 2020 were included. CAD was angiographically determined using computed tomography or invasive coronary angiography. CAD was stratified into 1) low-risk: &amp;lt;70% stenosis in all major epicardial coronary arteries or &amp;lt;50% in the left main (LM); 2) intermediate-risk: ≥70% stenosis in one or two arteries, except the proximal left anterior descending (LAD) and LM; 3) high-risk: ≥70% stenosis in the proximal LAD, ≥70% stenosis in 3 arteries or LM stenosis ≥50%. Patients with previous CABG were categorised as high-risk if: ≥70% stenosis of 3 coronary grafts or graft supplying a proximally stenosed LAD; and intermediate-risk if: ≥70% stenosis of 1 or 2 non-LAD grafts. Baseline characteristics and procedural outcomes were compared between the 3 cohorts, with the impact of CAD on outcomes evaluated after adjustment for demographics and comorbidities. Results 1805 patients were included; median age 84 (79-88), 51% male sex, median logistic Euroscore 13 (8-21). 1281 (71%), 384 (21%) and 140 (8%) patients were characterised as low-, intermediate- and high-risk coronary anatomy respectively. High risk patients were older than the other groups, however, did not have the highest prevalence of comorbidities (Table 1). Other than pacemaker implantation (9% vs 12% vs 6%, p=0.04), there were no differences in procedural complications or in-hospital mortality between groups (Table 1). At a median follow-up of 3.5 (2.3-4.8) years, 920 patients (51%) died, 292 (16%) had hospitalisation for heart failure (HHF) and 565 patients (31%) had a major adverse coronary event (MACE); defined as either myocardial infarction, HHF or cardiovascular death. Coronary anatomical stratification was associated with MACE (Log rank p&amp;lt;0.001) (Figure 1). After multivariate adjustment, high-risk anatomy was associated with all-cause mortality (hazard ratio (HR): 1.34, 95% confidence interval (CI): 1.06-1.68, p=0.013), HHF (HR: 1.49, 95% CI: 1.01-2.21, p=0.046) and MACE (HR: 1.68, 95% CI: 1.27-2.21, p&amp;lt;0.001). Conclusions Whilst the presence of CAD does not impact TAVI procedural safety, untreated high-risk coronary anatomy is associated with future adverse events and may warrant intensive medical therapy and/or revascularisation.

Incremental role of Cardio-Ankle Vascular Index in predicting ischemic threshold in patients with suspected coronary artery disease

Abstract Background The Cardio-Ankle Vascular Index (CAVI) quantifies arterial stiffness and has emerged as a potential biomarker for cardiovascular disease and its associated risk factors. This study explores the prognostic utility of CAVI in predicting myocardial ischemia in patients with suspected coronary artery disease (CAD). Additionally, it examines the relationship between global longitudinal strain (GLS) and the wall motion score index (WMSI) during both rest and stress echocardiography. Methods We conducted a retrospective analysis of patients with suspected CAD who underwent CAVI measurement and stress echocardiography within a three-month window. Coronary angiography was utilized to evaluate anatomical stenosis (&amp;gt;50%). We used multivariate analysis to identify predictors of the ischemic threshold. Results In our cohort of 127 patients (average age 61.4 ± 9.1, 78% male), the prevalence of hypertension, dyslipidemia, and diabetes was 76%, 68% and 47% of patients, respectively. Prior coronary intervention and a history of myocardial infarction were showed significant prevalence at 33% and 9%, respectively. CAD distribution included absence in 15%, left main (LM) disease in 8%, proximal left anterior descending (LAD) artery disease in 38%, mid-to-distal LAD disease in 50%, left circumflex artery disease in 46%, and right coronary artery disease in 57%. A robust correlation between GLS and WMSI was observed both at rest and during peak stress (r=0.68 and r=0.57, p&amp;lt;0.001, respectively). High CAVI (≥8.5), resting GLS in the LAD(&amp;lt;-15.5%), and peak GLS during stress (&amp;lt;-15.3%) emerged as significant ischemic threshold predictors in multivariate analysis (AUC = 0.82, p&amp;lt;0.0001). Conclusion The correlation between WMSI and GLS provides valuable insights into cardiac mechanics. These findings underscore the clinical relevance of incorporating CAVI, GLS, and WMSI into routine assessments for patients with suspected CAD to enhance prognostic stratification.ROC for final predictive model

Residual ischemia location after STEMI by CMR and association with non-culprit coronary artery disease

Abstract Background Many ST-segment elevation myocardial infarction (STEMI) patients present with non-culprit coronary artery disease. In cases with incomplete revascularization, stress cardiac magnetic resonance (sCMR) could help detect and locate residual ischemia. Purpose We aim to evaluate the usefulness of sCMR to detect and locate residual ischemia in STEMI patients after discharge and correlate the findings with angiographical non-culprit coronary lesions, if any. Methods Reperfused, stable STEMI patients submitted to undergo sCMR within the first year after STEMI were included in the cohort. Index coronary angiography was revised, culprit and non-culprit coronary artery disease were registered, and significant stenoses were defined as ≥50% by visual assessment. Residual ischemia on sCMR (by first-pass vasodilator stress perfusion) was analysed and categorized as either absent or present in anterior, lateral, and inferior territories. Unrevascularized non-culprit coronary lesions were correlated with territories with residual ischemia on sCMR and lesions in subsequent coronary angiography. A p-value &amp;lt;0.05 was considered statistically significant. Results The study group was made up of 234 patients who underwent sCMR within the first year after STEMI (mean age 58.95±11.85 years, 78.2% male, 48.7% anterior infarction). Residual ischemia by sCMR was noted in 63 (26.9%) patients. In the 95 patients (40.6%) who underwent complete revascularization during index admission, residual ischemia by sCMR was seldom detected (n=14, 14.7%) and distributed on anterior (n=8), lateral (n=3) and inferior (n=4) territories. More than half of the cohort (n=139, 59.4%) depicted unrevascularized non-culprit coronary lesions, and residual ischemia was detected in 49 (35.3%) patients. Non-culprit lesions on left anterior descendent artery (n=62) associated with ischemia in 38.7% of cases (n=24), most commonly in the anterior territory (n=17, 70.8%). Similar findings were noted for lesions on circumflex artery (n=66), which depicted residual ischemia in 34.8% (n=23) of cases and most frequently in the lateral territory (n=13, 56.5%); and lesions in right coronary artery (n=45), which depicted residual ischemia in 42.2% (n=19) of cases, most commonly in the inferior territory (n=13, 68.4%). Significant coronary stenosis was found in most patients who underwent subsequent coronary angiography after residual ischemia detection (41 out of 47, 87.2%). Conclusions One third of STEMI patients with incomplete revascularization and non-culprit coronary artery disease depict residual ischemia on sCMR, the location of which generally correlates with index coronary anatomy and significant stenosis in subsequent coronary angiography. Residual ischemia is infrequent in patients with complete revascularization, but not inexistent. sCMR should be considered in selected STEMI patients according to coronary anatomy and/or symptoms to guide therapy.Stress CMR and ischemia location

Complete vs culprit-lesion-only myocardial revascularization in patients with out-of-hospital cardiac arrest: insights from the multicentric "Lombardia CARe" registry

Abstract Background Out-of-hospital Cardiac Arrest (OHCA) is a potentially devastating complication of patients with Myocardial Infarction (MI). Multivessel Disease (MVD) is a frequent occurrence in this setting, being present in nearly half patients undergoing Coronary Angiography (CAG). We previously reported that, in case of MI complicated by OHCA and evidence of MVD, a complete myocardial revascularization, as compared to culprit-lesion-only revascularization, was associated with an improved 1-year survival and favorable neurological outcomes. We aimed to validate and confirm these results on a multicentric scale with a larger patient cohort. Methods This is a multicentric, prospective, observational study. We considered all the consecutive patients with OHCA and MI enrolled in the Lombardia CARe Registry from January 1st 2015 to December 31st 2022 who underwent CAG in 6 centers in Northen Italy. Results A total of 623 patients were included; of these, 403 underwent CAG. Median age was 64 years, and about 80% had no previous history of ischemic heart disease. Median ejection fraction (EF) at presentation was 40%. MVD was present in 186 (46.1%) patients and was subsequently treated with either complete (32.3%) or incomplete (67.7%) coronary revascularization. Left anterior descendent (LAD) artery was the culprit lesion in almost 1/3 of patients. The 1-year survival rate was 78.3% in the complete revascularization group and 42.9% in the culprit-lesion-only revascularization group (p-value &amp;lt; 0.001). After correction for factors that were predictors on univariate analysis, complete revascularization strategy was independently associated with a reduced risk of death [HR: 0.27 (95% CI: 0.01 to 0.739; p = 0.01] and death or unfavorable neurological outcome [HR: 0.23 (95% CI: 0.08 to 0.67); p = 0.007]. Conclusions Complete revascularization strategy was confirmed to be associated with an improvement of 1-year survival and with a good neurological outcome in patients resuscitated from OHCA. These results highlight the independent impact on survival of a complete coronary intervention strategy in patients with OHCA plus MVD.

The utility of angiography-derived fractional flow reserve in predicting graft occlusions prior to bypass surgery

Abstract Background Occurrence of graft occlusion following coronary artery bypass graft (CABG) surgery has been linked to the presence of native coronary artery competitive flow (1). Despite its routine use in guiding revascularization, coronary angiography lacks sensitivity for assessing coronary stenosis significance. Data regarding the use of pressure-derived fractional flow reserve (FFR) to assess the hemodynamic significance of coronary stenoses prior to CABG are inconclusive (2) and the penetration of FFR in clinical routine is limited for various reasons (3). Different systems have been developed to predict FFR based on coronary angiographic images, eliminating pressure wires or hyperemic agents (4). Preliminary data demonstrated a high concordance between off-site angiography-derived FFR and pressure wire–based FFR (5-7). However, the use of this technique prior to CABG is not well studied. Purpose This study aims to correlate pre-CABG angiography-derived FFR with graft occlusion. Secondary endpoint is the correlation between the presence of at least one occluded bypass graft and overall mortality. Methods Retrospective study of patients undergoing CABG in whom a follow-up angiogram has been performed. Angiography-based FFR was calculated with a dedicated software (vFFR, CAAS 8.2 Workstation, Pie Medical Imaging), obtaining each major native coronary vessel before CABG. Post-CABG angiograms were conducted at least 6 weeks post-surgery to exclude graft-failures due to technical factors and thrombosis. Results From 2005 and 2014, 204 patients underwent pre-CABG angiography, with post-CABG angiograms at a median of 3.85 years [IQR 1.33-8.80] post-surgery. In total, 125 patients had to be excluded due to inadequate angiogram quality for vFFR assessment (outdated imaging system, improper vessel angles, vessel overlap, insufficient contrast). Consequently, 79 patients were suitable for pre-CABG vFFR analysis, including 132 grafted vessels (93 arterial and 39 saphenous grafts). The median patient age was 68 years [IQR 58-72] and mean time for clinical follow-up was 9.9±3.6 years. Vessels analyzed using vFFR were left anterior descending (LAD) (n=60, 45.5%), left circumflex (LCX) (n=39, 29.5%), ramus intermedius (RIM) (n=8, 6.1%) and right coronary artery (RCA) (n=25, 18.9%). Mean pre-CABG vFFR was 0.59±0.15. To predict graft occlusion, a vFFR cut-off value of 0.745 with an area under the curve (AUC) of 0.847 (95%CI 0.752–0.942) had a specificity of 0.722 and a sensitivity of 0.902 (Figure A). There was no difference in overall-mortality when comparing patients with at least one occluded bypass graft to those without (57.1% vs. 57.9%, p=0.949, Figure B). Conclusions vFFR can be used as a noninvasive tool to predict graft patency in patients undergoing CABG with acceptable sensitivity and specificity. Bypass graft occlusion did not correlate with overall-survival in this cohort.

How to predict myocardial injury in patients with large ischaemic burden identified during stress echocardiography?

Abstract Background/Introduction Stress echocardiography (SE) is well established diagnostic tool in coronary artery disease (CAD) with broadly agreed consensus for the indications and protocols. There is, however, no clear non-invasive SE parameter in identifying high risk features in patients with large burden of inducible regional wall motion abnormalities (RWMA) that would require prompt treatment or urgent admission. Purpose To identify high risk features during SE associated with myocardial injury following a positive SE with large amount of RWMA. Methods All consecutive patients referred for SE from June 2019 to November 2022 to diagnose coronary artery disease were assessed for inducible RWMAs using a hybrid protocol (low dose Dobutamine and exercise on supine bike with 3 min increments of workload of 25W). Those with ≥4/17 segments of inducible RWMAs underwent measurement of Troponin level 1 hour after the test termination. Somatometric characteristics, risks factors, symptoms, haemodynamic pre- and during SE and results of subsequent coronary angiography were recorded. Results 631 patients were referred for assessment of CAD. 87 patients had ≥4/17 inducible RWMAs out of 152 patients with positive SE. 61/87 who had Troponin measurements were included in the analysis. Mean age was 65 ± 13 yo, 61% were male. There was high prevalence of known CAD (77%) and cardiovascular risks factors as hypertension (59%) and hyperlipidaemia (61%). The median exercise time was 9 minutes, 46% developed chest pain (CP), 49% - ECG changes, 39% - left ventricular (LV) dilatation and 74% - reduction in LVEF. Troponin was positive in 25/61 patients. Invasive coronary angiography confirmed clinical CAD in 51/61 patients. 5 patients had either normal angiogram or non-obstructive CAD, 5 patients were awaiting diagnostic test. The severity of CAD appears to be associated with magnitude of Troponin release (1 vessel disease - 16.5 ng/L, 2 vessels disease - 39.9 ng/L, 3 vessels disease – 58.2 ng/L). All patients (6/61) with higher troponin values (&amp;gt;90ng/L) had multivessel disease involving the left anterior descending (LAD) artery. Interestingly, 2/5 patients without CAD had elevated Troponin suggesting possible ongoing myopathic process. The only non-invasive SE parameters that were significantly related to troponin increase were recovery time (P=0.001) and exercise time (P&amp;lt;0.05) whereas symptoms, BP response and LVEF reduction showed a trend which did not achieve significance. Conclusions In patient with positive SE with large burden of inducible RWMAs prolonged recovery time and low threshold for ischaemia appear to be the most reliable characteristic to identify patients with potential myocardial injury and should be used as a triaging tool for admission or early invasive assessment.

Predictive ability and prognostic correlation of global longitudinal strain in patients with negative dipyridamole stress echocardiography by wall motion criteria

Abstract Background Dipyridamole stress echocardiography (DSE) is an established technique to detect coronary artery disease (CAD) and for risk stratification. Speckle Tracking Echocardiography (STE), as an objective and quantitative evaluation of ventricular function, may add incremental value to conventional stress echo analysis. Purpose To assess the prognostic value of rest (Rest-GLS) and peak (Peak-GLS) stress global longitudinal strain (GLS) in patients with suspected CAD and negative DSE according to wall motion index (WMI) criteria. Methods We retrospectively enrolled patients who underwent DSE at our centre for suspected CAD, with normal WMI. Strain Reserve was calculated as Rest GLS – Peak-GLS (Delta-GLS). We also collected data regarding other conventional parameters such as coronary flow reserve (CFR) of left anterior descending (LAD), left ventricle contractile reserve (LVCR), delta left ventricular ejection fraction (Delta-LVEF), heart rate response (HRR). Our primary endpoint was a composite of all-cause death and coronary revascularization. Receiver operating characteristic (ROC) curves were used to compare the predictive ability of the parameters. Adjusted logistic regression analyses were used to assess associations, also modelled as a restricted cubic spline. Results A total of 355 patients were included in the analysis (median age 68.2, IQR 58.2-75.2, 38.0% female). At follow-up, 58 patients met the primary endpoint. Figure 1 shows the ROC curves of different DSE parameters. Delta-GLS and Peak-GLS showed high predictive ability of composite endpoint events (area under the curve [AUC] 0.87, 95% Confidence Interval [CI] 0.82-0.92, AUC, 0.85, 95% CI 0.79-0.91, respectively), which was significantly higher compared with other DSE parameters, included Basal-GLS (P for difference for all &amp;lt; 0.001). After adjustments for age, previous CAD, sex, and diabetes, reducing values of Rest-GLS, Peak-GLS and Delta-GLS were significantly associated with higher odds of experiencing composite endpoint events (Basal-GLS, odds ratio [OR] 1.13, 95% CI 1.04-1.24; Peak-GLS, OR 1.45, 95% CI 1.32-1.63; Delta-GLS, OR 1.73, 95% CI 1.50-2.04). Plotting the results of the logistic regression analysis on a restricted cubic spline, reducing values of Peak-GLS and Delta-GLS showed a linear increase for the risk of adverse events, while Rest-GLS showed a plateau for lower values. Conclusion The use of GLS parameters in DSE can help to better stratify the risk for the patients since they are associated with adverse cardiovascular events.Figure 1Figure 2