Left Main Artery Disease Research Articles

Measurement of D-dimer after the off-pump coronary artery bypass grafting in the patients with non-ST-segment elevation myocardial infarction

Objective To study the variation of D-dimer after the off-pump coronary artery bypass grafting(OPCAB), and to evaluate its value for the assessment of postoperative cardiovascular ischemia events. Methods This is a retrospective cohort study. 203 patients with non-ST-segment elevation myocardial infarction(NSTEMI) were random selected from the Tianjin medical university general hospital from 2010 to 2012, including 151 males and 52 females with a mean age of (66.9±8.4) years. The level of D-dimer was analysed by using the Biomerieux VIDAS fluor-euzymelinked immunoassay Analyzer assay. Receiver operating characteristic curve(ROC) was used to evaluate the sensitivity and specificity, the relevance between D-dimer and clinical pathological factors was analysed by χ2 test, the effect on prognosis was evaluated by using cox regression analysis model. Results Compared the group with stable disease, the level of D-dimer was increased remarkable in the group with poor recovery on the 14th day after surgery, (U=75.09, P<0.01). The optimum cut-off point with D-dimer(the 14th day after surgery) for the diagnosis of ischemic events within the 31th-90th day after surgery was 2 590μg/L, the area under ROC curve was 0.867(95% confidence interval:0.791-0.943). The logistic analysis showed that the D-dimer was influenced by the sex, age, left ventricular ejection fraction, left main coronary artery disease, the number of vascular with bypass grafts, using internal mammary artery, hypertension and other factors, OR value was 0.495(95% CI：0.327-0.694), 0.527(95% CI：0.370-0.812), 0.564(95% CI：0.419-0.638), 0.331(95% CI：0.278-0.426), 0.592(95% CI：0.440-0.785), 2.093(95% CI：1.533-2.856), 0.580(95% CI：0.451-0.709) respectively(P<0.01). The Cox analysis showed that the level of D-dimer on the 14th day after surgery was not the independent assessment parameter for long-term prognosis. Conclusion The serum D-dimer was influenced by multiple pathological factors after the OPCAB, the level of serum D-dimer(on the 14th day after surgery) could be used as effective estimate parameter for the adverse events within the 31th-90th after OPCAB. （Chin J Lab Med，2014,37：222-226） Key words: Myocardial infarction; Coronary artery bypass, off-pump; D-dimer

Interaction of Chronic Total Occlusion and Chronic Kidney Disease in Patients Undergoing Primary Percutaneous Coronary Intervention for Acute ST-Elevation Myocardial Infarction

Chronic total occlusion (CTO) in a non-infarct-related artery and chronic kidney failure (CKD) are associated with worse outcomes after primary percutaneous coronary intervention (PCI). The aim of this study was to investigate the interaction of CTO and CKD in patients who underwent primary PCI for acute ST-segment elevation myocardial infarction (STEMI). Patients with STEMIs with or without CKD, defined as an estimated glomerular filtration rate <60 ml/min/1.73 m(2), were categorized into those with single-vessel disease and those with multivessel disease with or without CTO. The primary outcomes were the incidence of 30-day and 1-year mortality. Among 1,873 consecutive patients with STEMIs included between 2006 and 2011, 336 (18%) had CKD. The prevalence of CTO in a non-infarct-related artery was 13% in patients with CKD compared with 7% in those without CKD (p= 0.0003). There was a significant interaction between CKD and CTO on 30-day mortality (p= 0.018) and 1-year mortality (p= 0.013). Independent predictors of late mortality in patients with CKD were previous myocardial infarction (hazard ratio [HR] 1.71, 95% confidence interval [CI] 1.01 to 2.79), age >75 years (HR 1.86, 95% CI 1.19 to 2.95), a left ventricular ejection fraction after primary PCI <40% (HR 2.20, 95% CI 1.36 to 3.63), left main culprit artery (HR 4.46, 95% CI 1.64 to 10.25), and shock (HR 7.44, 95% CI 4.56 to 12.31), but multivessel disease with CTO was not a predictor. In contrast, multivessel disease with CTO was an independent predictor of mortality in patients without CKD (HR 3.30, 95% CI 1.70 to 6.17). In conclusion, in patients with STEMIs who underwent primary PCI, with preexisting CKD, the prevalence of CTO in a non-infarct-related artery was twice as great. In these patients, the clinical impact of CTO seems to be overshadowed by the presence of CKD.

74-year-old man with left main and carotid artery disease - how life can change plans.

An unexpected incident or rapid deterioration of a patient's condition may require optimal adaptation of the treatment to the current state of the patient. We present a case of a 74-year-old man with significant left main coronary artery stenosis and tight stenoses of both carotid arteries. The case was initially qualified for bypass grafting with accompanying carotid artery endarterectomy, but an unexpected accident changed our way of treatment. Three days after angiography the patient suffered an ischemic stroke. We held a multidisciplinary meeting of the “Neuro-Vascular-Heart Team” and decided to treat the patient percutaneously.

Clinical Usefulness of Exercise-Induced ST-Segment Depression Occurring or Increasing during the Recovery Phase

Background Despite the current availability of diagnostic image tests with excellent diagnostic and prognostic accuracy, exercise stress testing (EST) remains as the procedure most commonly used for the evaluation, diagnosis and risk stratification of patients with coronary artery disease (CAD). Objectives 1) To investigate the clinical usefulness of significant exercise-induced ST-segment depression (ST-d) occurring or increasing during the recovery phase of exercise stress test and to compare it with significant ST-segment depression presenting during the active phase of exercise; 2) to evaluate the clinical data and the information provided by EST and coronary angiography. Material and Methods Clinical and EST data from 147 patients with positive stress test were analyzed. All patients had significant ST-segment depression and were divided into three groups: GI, 94 patients with ST-d during exercise; GII, 29 patients with ST-d only during the recovery phase; and GIII, 24 patients with borderline ST-d during exercise which became significant during the recovery phase. The results of the EST were correlated with the coronary angiography findings in each group. Results A diagnosis of significant CAD was made in 78 patients in GI (82.9%), in 22 in GII (75.8%) and in 21 in GIII (87.5%) (p = 0.52). Patients in GIII were older, with high prevalence of dyslipemia, history of previous infarction and three-vessel and/or left main coronary artery disease. GII presented the higher number of asymptomatic patients with one-vessel disease and high prevalence of CAD. Conclusions There were no statistical differences in the percentage of patients with significant CAD among the groups. Patients in GIII had high prevalence of significant and severe CAD. A proper evaluation of ST-d occurring or becoming significant during the recovery phase provided additional clinical information to the results of the EST.

Percutaneous Coronary Intervention in Left Main Coronary Artery Disease - A Case Report

Not available DOI: http://dx.doi.org/10.3329/uhj.v8i1.11669 University Heart Journal Vol. 8, No. 1, January 2012

Effect of percutaneous coronary artery interventional therapy on unprotected left main coronary artery disease

Objective To observe the effect of percutaneous coronary intervention(PCI) treatment on unprotected left main coronary artery(ULMCA) lesion.Methods 40 patients with ULMCA lesions treated with PCI were followed up for 6 to 20 months,adverse cardiovascular events (MACE) occurrence were observed.Results All patients treated by immediate PCI success rate was 100.0％.There were no serious complications.There were no serious adverse cardiovascular events during hospitalization.Patients were followed up 6 ～ 20 (7 ± 2) months,4 weeks after operation,acute myocardial infarction in 1 case,CAG confirmed circumflex artery open subacute stent thrombosis,re-PCI cure; postoperative mobilization of 28 patients took CAG in 6 ～ 12 months,including the opening circumflex artery stent restenosis in 3 cases,one distal left anterior descending branch of the trunk opening and then stenosis,2 cases of restenosis in patients with angina symptoms,3 patients re-line PCI,no need to CABG patients.No deaths during followup.The overall incidence of cardiovascular adverse events rate was 12.5％ (5/40),restenosis rate was 10.0％ (4/40).Conclusion The choice of ULMCA lesions after PCI was safe and feasible,with good short and long term prognosis. Key words: Coronary disease; Angioplasty,transluminal, percutaneous coronary

Determinants of variations in coronary revascularization practices

The ratio of percutaneous coronary interventions to coronary artery bypass graft surgeries (PCI:CABG ratio) varies considerably across hospitals. We conducted a comprehensive study to identify clinical and nonclinical factors associated with variations in the ratio across 17 cardiac centres in the province of Ontario. In this retrospective cohort study, we selected a population-based sample of 8972 patients who underwent an index cardiac catheterization between April 2006 and March 2007 at any of 17 hospitals that perform invasive cardiac procedures in the province. We classified the hospitals into four groups by PCI:CABG ratio (low [< 2.0], low-medium [2.0-2.7], medium-high [2.8-3.2] and high [> 3.2]). We explored the relative contribution of patient, physician and hospital factors to variations in the likelihood of patients receiving PCI or CABG surgery within 90 days after the index catheterization. The mean PCI:CABG ratio was 2.7 overall. We observed a threefold variation in the ratios across the four hospital ratio groups, from a mean of 1.6 in the lowest ratio group to a mean of 4.6 in the highest ratio group. Patients with single-vessel disease usually received PCI (88.4%-99.0%) and those with left main artery disease usually underwent CABG (80.8%-94.2%), regardless of the hospital's procedure ratio. Variation in the management of patients with non-emergent multivessel disease accounted for most of the variation in the ratios across hospitals. The mode of revascularization largely reflected the recommendation of the physician performing the diagnostic catheterization and was also influenced by the revascularization "culture" at the treating hospital. The physician performing the diagnostic catheterization and the treating hospital were strong independent predictors of the mode of revascularization. Opportunities exist to improve transparency and consistency around the decision-making process for coronary revascularization, most notably among patients with non-emergent multivessel disease.

ST-segment depression during vasodilator stress is of minor clinical importance in women with normal myocardial perfusion imaging and low or intermediate risk of coronary artery disease

The prognostic value of electrocardiographic (ECG) ST-segment depression during vasodilator stress testing in patients with normal myocardial perfusion scintigraphy (MPS) is based on retrospective studies with controversial results. Moreover, the true incidence of obstructive coronary artery disease (CAD) in these patients is unknown. During a 33-month period, all consecutive patients referred for MPS were prospectively evaluated for interpretable ST-segment depression ≥ 1 mm during vasodilator stress testing. Of 1,687 patients with normal MPS and without known CAD, 109 (100 women) aged 65.2 ± 9.2 years demonstrated ST-segment shifts and formed the ECG-positive group. The pretest probability of CAD was low in 56%, intermediate in 39% and high in 5%. They were advised to proceed to coronary angiography. An equal number of patients with normal MPS and no ECG abnormalities matched for CAD predisposing factors comprised the control group. Follow-up of both groups was accomplished through a telephone interview. Fifty-two patients from the ECG-positive group (48%) consented to coronary angiography. Six (11.5%) had obstructive CAD (≥50% lumen stenosis), one with left main artery disease, while three required revascularization. Follow-up was complete in 99 ECG-positive patients for a period of 20.6 ± 8.9 months. One hard event (non-fatal myocardial infarction) and one soft event (revascularization) were observed. No event was recorded in the control group. In patients with low-intermediate risk of CAD, "ischaemic" ECG changes during vasodilator stress combined with normal MPS are encountered mostly in women and are associated with a low prevalence of significant CAD and a low cardiac event rate.

Outcomes of Drug-Eluting Stents for Protected Left Main Coronary Artery Disease (from the Multicenter, United States DEScover Registry)

Percutaneous coronary intervention (PCI) for protected left main coronary artery (PLM) disease is complex because of patient and lesion factors; however, limited data exist on the outcomes of drug-eluting stent (DES) use for this indication. DEScover is a prospective observational study that enrolled consecutive patients with PCI in 2005. In-hospital and 1-year statuses were analyzed for 6,172 patients treated with DES according to LM and coronary artery bypass grafting (CABG) statuses (PLM, n = 93; previous CABG native vessel non-LM, n = 722; no previous CABG, n = 5,357). Cumulative event rates were calculated by the Kaplan-Meier method. Cox proportional hazards regression was used for multivariable analysis of adverse events. Baseline clinical, angiographic, and procedural variables differed significantly among groups, with patients with previous CABG, PLM, and non-LM having higher risk characteristics. In patients with previous CABG, after adjustment with CABG non-LM as a reference group, there were no significant differences in 1-year risk of any adverse event except a trend toward a greater risk of myocardial infarction (MI) in patients with PLM (adjusted hazard ratio 2.4, confidence interval 0.95 to 6.2, p = 0.06). However, patients after CABG (PLM and non-LM) compared to patients without previous CABG had a similar adjusted risk of death, MI, and stent thrombosis; an increased risk of target lesion revascularization (adjusted hazard ratio 1.79, confidence interval 1.2 to 2.6, p = 0.003), target vessel revascularization and death/MI/target vessel revascularization; and a lower risk of CABG (adjusted hazard ratio 0.25, confidence interval 0.09 to 0.67, p = 0.006). In conclusion, status after CABG rather than PLM location increases the risk of repeat revascularization with PCI in DES-treated patients.

TCT-46: EuroSCORE Predicts Long-term Cardiovascular Events After Percutaneous Coronary Intervention in Patients with Left Main or Multivessel Coronary Artery Disease

TCT-46: EuroSCORE Predicts Long-term Cardiovascular Events After Percutaneous Coronary Intervention in Patients with Left Main or Multivessel Coronary Artery Disease

Severe coronary artery disease Is there a place for percutaneous coronary intervention?

Management of severe coronary artery disease (CAD), defined as multivessel disease with or without significant left main artery disease remains a topic for considerable discussion. Although coronary artery bypass graft (CABG) surgery has been the mainstay of treatment, the steady pace of improvement in percutaneous coronary intervention (PCI) continues to beg the question as to whether PCI can perform as well as CABG for these patients. This short review is intended to place the recently published SYNTAX (Synergy between PCI with Taxus and Cardiac Surgery) trial in perspective, considering the previous major clinical trials in this field and to further consider whether PCI can be used appropriately in the management of patients with advanced CAD. The major clinical trials comparing PCI to CABG published prior to SYNTAX are briefly reviewed in chronologic order. The SYNTAX trial is reviewed in more depth and the implications of its results for contemporary clinical management are discussed. PCI has been applied to more advanced forms of CAD as percutaneous technology has evolved from balloon angioplasty to bare metal stents to drug eluting stents. Long-term survival has remained comparable between PCI and CABG patients despite the more advanced nature of disease treated in more recent trials, recognizing that a significant number of patients are excluded from randomization because equivalent revascularization is not achievable percutaneously. Repeat revascularization is more frequently required in PCI patients than in CABG patients. PCI has a role to play, although CABG remains the mainstay of therapy for patients with advanced CAD.

Revascularization of Unprotected Left Main Lesions in Octogenarians

Surgery is the standard treatment for left main coronary artery disease (LMCAD), but surgical risk increases with age. To explore the relative

Long-term Clinical Results for Randomised Comparison of Paclitaxel-eluting versus Bare-metal Stents in Unprotected Left Main Coronary Artery Disease

Long-term Clinical Results for Randomised Comparison of Paclitaxel-eluting versus Bare-metal Stents in Unprotected Left Main Coronary Artery Disease To optimise percutaneous coronary intervention (PCI) strategy for unprotected left main (ULMCA) disease we performed a randomised study: IVUS-guided bare metal stent (BMS) versus paclitaxel-eluting stent (PES) implantation after lesion pre-treatment with cutting balloon (CB) for unprotected LM lesions. The purpose of this randomized study was to evaluate six-month and three-year clinical results. Several recent publications have demonstrated good short- and midterm outcomes in patients with left main artery disease after stent implantation. However, data on long-term comparison of BMS and PES for LM lesions are limited. Patients with left main coronary artery disease enrolled at Latvian Centre of Cardiology were randomly assigned to either BMS (n = 50) or PES implantation (n = 53). All interventions were IVUS-guided and CB pre-treatment before stenting was performed in all patients. All patients were scheduled for six-month and three-year follow-up. The primary endpoint was major adverse cardiac events (MACE) defined as death, Q wave myocardial infarction or target lesion revascularisation (TLR). Baseline clinical and procedural characteristics were comparable in both groups. At six months, the MACE-free survival rate was 70% in BMS and 87% in PES patients (P &lt; 0.05). At three years, MACE occurred in 18 patients (36.0%) in the BMS and seven patients (13.2%) in the PES group (P &lt; 0.05). The current study demonstrates the benefit of IVUS guided paclitaxel-eluting stent implantation after cutting balloon pre-treatment in left main coronary artery disease over bare metal stent implantation at six months and three years.

Clinical Application of Cardiac Hybrid Imaging in Coronary Artery Disease

Constant technological developments in coronary artery disease have contributed to the assessment of both the presence of coronary stenosis and its hemodynamic consequences. Hence, noninvasive imaging helps guide therapeutic decisions by providing complementary information on coronary morphology and on myocardial perfusion and metabolism. This can he done using single photon emission computed tomography (SPECT) or positron emission tomography (PET) and multidetector CT (MDCT). Advances in image-processing software and the advent of SPECT/CT and PET/CT have paved the way for the combination of image datasets from different modalities, giving rise to hybrid imaging. Three dimensional cardiac hybrid imaging helped to confirm hemodynamic significance in many lesions, add new lesions such as left main coronay artery disease, exclude equivocal defects, correct the corresponding arteries to their allocated defects and identify culprit segment. Cardiac hybrid imaging avoids the mental integration of functional and morphologic images and facilitates a comprehensive interpretation of coronaty lesions and their pathophysiologic adequacy by three dimensional display of fused images, and allows the best evaluation of myocardial territories and the coronary-artery branches that serve each territory. This integration of functional and morphological information were feasible to intuitively convincing and might facilitate development of a comprehensive non-invasive assessment of coronary artery disease.

Free Anterolateral Thigh Flap Coverage for Post-sternotomy Mediastinitis: Report of a Case

Post-sternotomy mediastinitis is a rare and very troublesome complication of cardiac surgery. A 49-year-old male patient with critical left main coronary artery disease underwent urgent coronary artery bypass grafting surgery by means of median sternotomy. Unfortunately, the patient developed mediastinitis and a spacious defect was left after adequate debridement. Reconstructive plastic surgery with free anterolateral thigh flap coverage was used for treating this problem. We believe that it is the first application of such an anterolateral thigh free flap for treating an extensive tissue defect caused by a deep sternal wound infection after cardiac surgery.

Interventional therapy of coronary artery disease in China: retrospective and perspective

Interventional therapy of coronary artery disease in China: retrospective and perspective

Increased Major Bleeding Complications Related to Triple Antithrombotic Therapy Usage in Patients With Atrial Fibrillation Undergoing Percutaneous Coronary Artery Stenting

The optimal antithrombotic therapy strategy for atrial fibrillation (AF) patients who undergo percutaneous coronary intervention with stent implantation (PCI-S) is unknown. We assessed the safety of antithrombotic therapy strategies in AF patients with indication for oral anticoagulation (OAC) undergoing PCI-S. We studied consecutive AF patients with indication for OAC who underwent PCI-S. We compared patients that received triple antithrombotic therapy (TT) [aspirin, clopidogrel, and coumadin] against other regimes (non-TT) after PCI-S. The primary end point was defined as the occurrence of major bleeding complications that were termed as early major bleeding (EMB) [< or = 48 h] or late major bleeding (LMB) [> 48 h]. Clinical follow-up was performed, and complications were recorded. We studied 104 patients (mean age +/- SD, 72 +/- 8 years; 70% men); TT was used in 51 patients (49%). TT was associated with a higher incidence of LMB (21.6% vs non-TT, 3.8%; p = 0.006) but not of EMB (5.8% vs non-TT, 11.3%; p = 0.33). In multivariate analyses, glycoprotein (GP) IIb/IIIa inhibitor use (hazard ratio [HR], 13.5; 95% confidence interval [CI], 1.7 to 108.3; p = 0.014) and PCI-S of three vessels or left main artery disease (HR, 7.9; 95% CI, 1.6 to 39.2; p = 0.01) were independent predictors for EMB. TT use (HR, 7.1; 95% CI, 1.5 to 32.4; p = 0.012), the occurrence of EMB (HR, 6.7; 95% CI, 1.8 to 25.3; p = 0.005), and baseline anemia (HR, 3.8; 95% CI, 1.2 to 12.5; p = 0.027) were independent predictors for LMB. No differences in major cardiovascular events were observed in patients treated with TT vs non-TT (25.5% vs 21.0%; p = 0.53). A high rate of major bleeding is observed in AF patients with indication for OAC undergoing PCI-S who receive TT. GP IIb/IIIa inhibitor use and multivessel/left main artery disease during PCI-S were independent predictors for EMB, while TT use, occurrence of EMB, and baseline anemia were independent predictors for LMB.

Stenting for Left Main Coronary Artery Disease

Patients with significant left main coronary artery disease have traditionally been treated with coronary artery bypass grafting, but recent advances

Can CT Evaluate Left-Main Stent Patency?

Several studies have reported outcomes after drug-eluting stenting to treat left-main coronary artery disease (e.g., Journal Watch Cardiology Jul 19 2006). Routine coronary angiography is recommended at 2 to 6 months after this procedure. Now, researchers in the Netherlands have compared angiography with multislice computed tomography (MSCT) to detect in-stent restenosis (ISR) after left-main …

Percutaneous Intervention for Severe Aortic Stenosis and Left Main Artery Disease in a Morbidly Obese Patient

Obesity increases significantly the rate of postsurgical complications and mortality in patients undergoing major surgery. We present the case of a morbidly obese 65-year-old female with severe aortic stenosis and left main coronary artery disease who underwent successful aortic valvuloplasty and angioplasty, with placement of a stent in the left main coronary artery. After undergoing bariatric surgery and losing 30% of her body weight, the patient was accepted for cardiac surgery to replace the aortic valve and to bypass the left anterior descending coronary artery using the mammary artery. There were no surgical complications.