Left Coronary Artery Involvement Research Articles

Application of intravascular physiology methods in clinical practice: two-year data from the Russian registry

Aim. To analyze the use in clinical practice of intravascular coronary assessment methods based on two-year data from the Russian Registry on the Use of Intravascular Imaging and Physiology.Material and methods. Since 2021, the Russian Registry on the Use of Intravascular Imaging and Physiology has included data from 7967 studies in 3932 patients, of which 3086 (38,7%) were studies of intravascular physiology. In 2021, 13 branches from 9 cities participated in the registry, in 2022 — 20 branches from 11 cities. For chronic coronary artery disease, 2484 (80,5%) studies were performed, for acute coronary syndrome (ACS) — 598 (19,4%).Results. In 2022, the registry included 1,9 times more intravascular functional studies compared to 2021. The contribution of different clinics was uneven — 75,7% of studies were performed in three departments. The use of non-hyperemic indexes prevailed over hyperemic ones (58%), and in ACS they were used three times more often. All coronary arteries were examined, most often the anterior descending artery. As a primary diagnosis, 1968 (63,8%) studies were performed, while for the purpose of dynamic control — 122 (3,9%), at the surgical stage — 996 (32,3%). In 85,5% (n=2638) of observations, the functional assessment of stenosis hemodynamic significance directly influenced the treatment tactics.Conclusion. The registry data indicate the significant role of functional methods among intravascular diagnostic options in the practice of domestic clinics participating in the registry. The registry demonstrated their use as a primary diagnosis 2 times more often than for coronary artery stenting. Some indications for the active use of intravascular physiology methods (in acute coronary syndrome, left coronary artery involvement) are currently controversial and require further research.

Factors affecting the availability of hybrid cerebral and myocardial revascularization

Aim. To analyze factors affecting the availability of hybrid cerebral and myocardial revascularization by synchronous percutaneous coronary intervention (PCI) and carotid endarterectomy (CEA).Material and methods. This retrospective study included 263 patients with coronary and internal carotid artery involvement undergoing PCI and CEA during the period from 2011 to 2017.Results. The study revealed the following factors increasing the availability of revascularization: hybrid cerebral and myocardial revascularization, successful PCI using drug-eluting stents, postPCI TIMI flow grade 3, and radial access for PCI. The following factors reduced the availability: polyvascular disease >50% in three beds, prior PCI, left ventricular ejection fraction <50%, left coronary artery involvement, living without a family, staged revascularization, CEA before PCI, unsuccessful/complicated PCI with post-PCI TIMI flow grades of 0-1, residual SYNTAX score >9, emergency hospitalization and multiple emergency PCI of the coronary arteries in the long-term follow-up period.Conclusion. Comprehensive analysis of clinical, demographic, anatomical, angiographic, and perioperative factors made it possible to identify predictors that affect the availability of hybrid revascularization.

Editorial Comment: What really matters in aortic dissection?

Aortic dissection affects between 5 and 30 people per million population per year, while the incidence of acute myocardial infarction exceeds 4400 per million per year [1]. More than 70% of dissection patients are hypertensive before the event and 30% have pre-existing aneurysmal dilatation of the ascending aorta [2]. Many are misdiagnosed on initial evaluation, and around 30% are discovered at autopsy [3]. It can be difficult to differentiate between dissection and myocardial infarction on clinical history or initial findings and this delays surgical repair. Seventy percent of dissection patients have electrocardiographic changes and around 25% manifest troponin elevation [4]. For those with troponin elevation, 14% have ST segment elevation, 14% ST depression and 36% T-wave inversion. Though dissection commonly involves the coronary ostia, an additional mechanism for troponin release is haemodynamic stress through acute aortic regurgitation. Those with troponin elevation have a four times elevated risk of early death [3]. Information from the International Registry of Acute Aortic Dissection (IRAD) shows that 15% of patients suffer acute myocardial ischaemia through coronary malperfusion and 3% present with myocardial infarction [1]. As for primary myocardial infarction, these patients are likely to experience myocardial stunning with cardiogenic shock or prehospital cardiac arrest. The overall number with combined dissection plus acute myocardial infarction is probably underestimated, because they die before reaching the hospital. While no one disputes the value of protocol-driven antiplatelet therapy or thrombolysis for myocardial infarction, this has become a frequent and unnecessary risk factor in aortic dissection surgery. Inhibition of coagulation promotes bleeding during surgical repair and, intuitively, it facilities the propagation of dissection by preventing thrombosis in the false lumen [5]. It provides the surgeon with a further taxing problem in an already difficult condition. Some prefer to postpone surgery until the coagulation profile is improved. So far, there is little evidence to support or refute this approach, but an interim death may raise concerns. During aortic root repair, it is common to find periostial dissection around the right coronary ostium, because the primary tear begins in the convexity with propagation of the false lumen proximally and distally. Periostial dissection is found less frequently in the left coronary sinus. Autopsy findings show the dissection to extend down the coronary artery through the outer one-third of the media in a circumferential or spiral passage. Haematoma within the vessel wall alters the tolerance of the coronary endothelium to shear stress, which may result in a secondary intimal tear. Narrowing of the true lumen by the false lumen or flap may interrupt flow. The process is similar to that of spontaneous coronary dissection, so lessons may be learnt from the treatment of that disorder [6]. Selective coronary angiography may worsen ischaemia if contrast injection increases pressure in the false lumen or the guide wire tears the delicate dissected membranes [7]. If extensive mural thrombus is present with no luminal flap, stenting may simply displace haematoma proximal or distal to the stent. Long segments of stent may be needed to completely exclude the false lumen. In spontaneous coronary dissection, intravascular ultrasound is recommended to guide stent deployment, but if the lumen remains adequate, conservative management is advisable [7]. Coronary bypass surgery is an option, but because of branch occlusion by dissection, this may not revascularize the ischaemic territory. Surgical revascularization is also rarely achieved soon enough to abort the infarction process. In this issue, Imoto et al .[ 8] retrospectively review 516 acute Type A dissection patients, 15% of whom had coronary artery involvement documented variously by direct intraoperative inspection, coronary angiography or echocardiographic detection of wall motion abnormality. Of those with coronary dissection, 64% had myocardial ischaemia. The right coronary was most frequently affected, with the left coronary involved in only 32 (6%) of the 516 patients. Left coronary artery involvement was associated with widespread anterolateral ischaemia, ST segment elevation, extensive hypokinesia and low cardiac output state. While the overall mortality for coronary dissection patients was 24%, it was 7.4% in those without ischaemia vs 33% for those with. Relative mortalities were 15% for right coronary involvement, 47% for left main dissection and 100% when both coronaries were involved. Specific risk factors for mortality were myocardial ischaemia, left main coronary involvement and preoperative cardiac arrest. Patients with widespread anterolateral ischaemia, low cardiac output state and preoperative cardiopulmonary resuscitation had universally poor outcome. This led the authors to suggest that preoperative stenting of the left main stem is advisable before surgical repair when left coronary involvement is suspected. This occurred in only 7 (1.35% of all)

ECG after near-drowning mimicking acute coronary syndrome with left main coronary artery involvement.

We present the case of a 74-year-old man with diabetes and hypertension who had to be rescued owing to a near-drowning syndrome at sea. When he was rescued, he complained of dyspnea and chest pain. An electrocardiogram (ECG) suggested acute coronary syndrome (ACS) affecting the left main coronary artery. Therefore, he was referred to our hospital for urgent coronary angiography. Arriving at our hospital, the patient was asymptomatic, but his blood pressure and saturation were normal. The ECG (Figure 1) showed normalization of previous anomalies. Besides, an echocardiogram showed nothing abnormal, and a blood sample was normal and served as a cardiac marker. Angiogram showed normal coronary arteries. After the procedure, the patient remained asymptomatic without an increase of cardiac enzymes, and he was discharged from the hospital after three days. Figure 1 First ECG, with the patient complaining of chest pain and dyspnea, showing ST depression in inferior and left precordial leads and elevation in V1 and VR (A). Second ECG, during the transfer to the hospital, showing minimal changes in ST segment (B). ... The initial response to immersion is apnea and aspiration of water, provoking a syndrome of respiratory failure and changes in serum electrolytes. This is frequently associated with hypothermia, which can lead to cardiac damages, mainly, conduction disturbance and ventricular arrhythmia.[1] A study[2] showed that the appearance of ECG changes in dogs subjected to experimental aspiration of fresh or sea water provoked bradycardia, tall T waves and ventricular fibrillation or ventricular asystole as the cause of death. Another study found[3] ECG changes in 37 patients who suffered from a near-drowning syndrome at the Dead Sea in addition to important changes in electrolyte levels, namely, hypercalcemia and hypermagnesemia. The most common findings were sinus tachycardia, prolongation of PR interval, widening of QRS complex and inversion of T waves. Nearly 35% of the 37 patients presented with ST segment depression. Besides, cases of Tako-Tsubo cardiomyopathy and corresponding ECG changes after near-drowning have also been reported.[4] Our case illustrates the importance of differential diagnosis in cases of near-drowning, since the associated symptoms can easily be mistaken with those of ACS. ECG changes could be confusing, leading to the mismanagement of the patient. In our case, clinical evolution and coronary angiogram of the patient were conducive to the correct diagnosis and treatment of the condition. In conclusion, the ECG findings of patients suffering from near-drowning may be similar to those of the patients affected by ACS with left coronary artery involvement. Hence, the patients should be managed with caution and a differential diagnosis should be made. An accurate medical history and additional examinations such as coronary angiogram are also necessary so as to make a final diagnosis and choose an appropriate treatment.

The value of angiography in the follow-up of coronary involvement in mucocutaneous lymph node syndrome (Kawasaki disease)

From September 1976 to August 1988, 205 patients with mucocutaneous lymph node syndrome (Kawasaki disease) were evaluated; 29 were suspected of having coronary artery abnormalities because of either abnormalities on echocardiography (n = 21), congestive heart failure (n = 3), prolonged fever (n = 3) or cardiac arrest (n = 2). All 29 underwent cardiac catheterization and 22 were found to have coronary artery abnormalities. An additional 4 patients were diagnosed solely by autopsy; therefore, 26 patients (12%) in this series had coronary artery abnormalities.The clearance of contrast medium from the coronary arteries after aortography was significantly prolonged in patients with coronary artery aneurysms as compared with that in a control group (p < 0.001). All patients exhibited delayed clearance of contrast medium on the initial aortogram as compared with that on follow-up studies (p < 0.01). Of the 22 patients with angiographically documented coronary artery abnormalities, 19 had right and 20 had left coronary artery involvement; the majority had diffuse involvement of both vessels.In 15 patients who underwent follow-up catheterization 6 months to 7 years after initial study, complete resolution was observed in only 37% of affected coronary artery segments. In four patients, three of whom were asymptomatic, severely stenotic or occluded coronary artery segments were found on late catheterization. Coronary artery bypass surgery was performed in two of these patients. Echocardiography did not detect any of these stenoses. Although echocardiography is important for initial diagnosis and serial evaluation, angiography is essential to fully define the nature and extent of coronary artery lesions, particularly if stenosis is present.