Left Main Stem Stenosis Research Articles

Combined Computed Coronary Tomography Angiography and Transcatheter Aortic Valve Implantation (TAVI) Planning Computed Tomography Reliably Detects Relevant Coronary Artery Disease Pre-TAVI.

Background: Before surgical or transcatheter aortic valve implantation (TAVI), coronary status evaluation is required. The role of combined computed coronary tomography angiography (cCTA) and TAVI planning CT in this context is not yet well elucidated. This study assessed whether relevant proximal coronary disease requiring coronary revascularization can be safely detected by combined cCTA and TAVI planning CT, including CT-derived fractional flow reserve (FFR) calculation in patients with severe aortic stenosis. Methods: This study analyzed patients with successful cCTA combined with TAVI planning CT using a 128-slice dual-source scanner. The detection via cCTA of relevant left main stem stenosis (>50%) or proximal coronary artery stenosis (>70%) was compared to invasive coronary angiography (ICA). Results: This study comprised 101 consecutive TAVI patients with a median age of 83 [77-86] years, a median STS score of 3.7 [2.4-6.1] and 54% of whom had known coronary artery disease. Of 15 patients with relevant coronary stenoses, 14 (93.3%) were detected with cCTA, while false positive results were found in 25 patients. Only in patients with previous percutaneous coronary stent implantation (PCI) were false positive rates (11/29) increased. In the subgroup without previous PCI, an improved classification performance of 87.5%, being mainly due to 11.1% false positive classifications, led to a negative predictive value of 98.5%. Conclusions: Combined cCTA and CT-FFR with TAVI planning CT via state-of-the-art scanners and protocols as a one-stop shop can replace routine ICA in patients prior to TAVI due to its safe detection of relevant coronary artery stenosis, although diagnostic performance of cCTA is only reduced in patients with coronary stents.

Outcome of Left Anterior Descending Coronary Artery Ostial Lesions Treated with Drug-Eluting Stents

Patients with severe Left Main Stem (LMS) stenosis have very high risk of major cardiovascular events because of the extent of myocardium suffering ischemia. Coronary artery disease of left main stem is not very common but key cause of characteristic coronary artery disease. Such stenosis is usually treated with CABG which is the gold standard treatment. Objective: To determine the outcome of left anterior descending coronary artery ostial lesions stenting with drug-eluting stents. Methods: The descriptive case series was conducted at a teaching hospital in Lahore, from 01-08-2019 to 29-07-2020. After informed consent 113 patients were included in study; both genders and diagnosed cases of LAD ostial disease, keeping in view inclusion and exclusion criteria. Then patients were admitted in cardiology wards after recording demographic data. Next day, the patients underwent angioplasty under local anesthesia. After procedural success patients were followed-up there for 3 days to assess if there was repeat myocardial infarction or mortality within hospital stay. All information obtained was recorded on a standard performa. Quantitative and qualitative data were analyzed and outcome of the procedure was recorded. Results: In our study 104(92.04%) patients were male and 9(7.96%) patients were females. The Drug-Eluting Stents (DES) procedural success was found in 93.81% patients, post stenting MI observed in 6.4% patients and the mortality occurred in 2.7% patients. Conclusions: The left anterior descending coronary artery ostial lesions stenting with DES is effective and feasible procedure with good outcome.

Complete revascularization is associated with higher mortality in patients with ST-elevation myocardial infarction, multi-vessel disease and shock defined by hyperlactataemia: results from the Harefield Shock Registry incorporating explainable machine learning.

Revascularization strategy for patients with ST-elevation myocardial infarction (STEMI) and multi-vessel disease varies according to the patient's cardiogenic shock status, but assessing shock acutely can be difficult. This article examines the link between cardiogenic shock defined solely by a lactate of ≥2 mmol/L and mortality from complete vs. culprit-only revascularization in this cohort. Patients presenting with STEMI, multi-vessel disease without severe left main stem stenosis and a lactate ≥2 mmol/L between 2011 and 2021 were included. The primary endpoint was mortality at 30 days by revascularization strategy for shocked patients. Secondary endpoints were mortality at 1 year and over a median follow-up of 30 months. Four hundred and eight patients presented in shock. Mortality in the shock cohort was 27.5% at 30 days. Complete revascularization (CR) was associated with higher mortality at 30 days [odds ratio (OR) 2.1 (1.02-4.2), P = 0.043], 1 year [OR 2.4 (1.2-4.9), P = 0.01], and over 30 months follow-up [hazard ratio (HR) 2.2 (1.4-3.4), P < 0.001] compared with culprit lesion-only percutaneous coronary intervention (CLOP). Mortality was again higher in the CR group after propensity matching (P = 0.018) and inverse probability treatment weighting [HR 2.0 (1.3-3.0), P = 0.001]. Furthermore, explainable machine learning demonstrated that CR was behind only blood gas parameters and creatinine levels in importance for predicting 30-day mortality. In patients presenting with STEMI and multi-vessel disease in shock defined solely by a lactate of ≥2 mmol/L, CR is associated with higher mortality than CLOP.

Frequency and Pattern of Left Main Stem Stenosis in Patients Undergoing Coronary Angiography.

Background: To find out the frequency and pattern of left main stem (LMS) stenosis among patients who had coronary angiography in a tertiary care hospital.&#x0D; Methodology: The cross-sectional observational study was carried out for the duration of six months. Total number of 123 patients referred for coronary angiography to the department of cardiac catheterization (Cath Lab). All patients underwent coronary angiography, diagnosis of LMS stenosis was made. Pattern of LMS (ostial or distal) and vessel involvement was also observed.&#x0D; Results: Mean age of patients was 51.12±10.44 years. There were 81 (65.85%) males and 42 (34.15%) female patients. There were 39 (31.71%) obese, 50 (40.65%) patients were diabetics, hypertension was found in 83 (67.48%) patients, and 46 (37.40%) were smokers. LMS disease was found in 15 (12.20%) patients. Ostial LMS was found in 05 (4.07%) and distal LMS in 10 (8.13%) patients.&#x0D; Conclusion: There is a high prevalence of left main disease. Majority of patients with LMS have distal lesions.

Management of patients with left main stem stenosis in Iceland 2010–2020: PCI or CABG?

Abstract Introduction Coronary artery bypass surgery (CABG) has been standard treatment for patients with left main coronary artery disease (LMCAD) but percutaneous coronary intervention (PCI) is a good alternative in selected patients. Our purpose was to evaluate the prevalence of LMCAD in Iceland, the impact of background factors on treatment choices, and treatment changes in recent years with respect to current guidelines. Methods This retrospective, population-based study analyzed data from the SCAAR-SWEDEHEART database. Patients with significant LMCAD on coronary angiography in Iceland 2010–2020, without previous history of CABG or contraindication for surgery were enrolled. Survival analysis was estimated with Kaplan-Meier and COX regression analysis for investigating the association between survival time and predictor variables. Findings Of 702 patients with LMCAD, 195 were treated with PCI, 460 with CABG and 47 with medical treatment only. The widest age range was in the PCI group and the mean age was highest in the medical therapy only group (p&amp;lt;0.001). Patients with LMCAD and either three vessel disease or heart valve disease were most often treated with CABG (76.1% and 84.4%, p&amp;lt;0.001).The majority of patients with LMCAD only were treated with PCI, as were patients with STEMI or cardiogenic shock (67.1% and 70.0%, p&amp;lt;0.001). The proportion of patients treated with PCI increased from 19.8% in 2010–2015 to 42.7% in 2016–2020. There was no significant difference in survival between PCI and CABG (p=0.41). Conclusions In patients with LMCAD the main factors that affect treatment choice are age, anatomical complexity and acuteness. Treatment choice appears to be in keeping with current guidelines. There is no significant difference in long term survival between PCI and CABG groups but the groups are different. There has been a significant increase in patients treated with PCI in recent years. Funding Acknowledgement Type of funding sources: None.

THIRD-TRIMESTER PREGNANCY COMPLICATED BY NON-SMALL CELL LUNG CANCER INITIALLY PRESENTING WITH CENTRAL AIRWAY OBSTRUCTION AND STENOSIS

THIRD-TRIMESTER PREGNANCY COMPLICATED BY NON-SMALL CELL LUNG CANCER INITIALLY PRESENTING WITH CENTRAL AIRWAY OBSTRUCTION AND STENOSIS

An unusual culprit lesion in acute coronary syndrome: In stent-restenosis of a subclavian artery stent

A 73-year old man with past medical history of coronary artery bypass grafting in 2012 and subclavian artery stenting in 2021 was scheduled for an ophthalmologic minor surgery requiring conscious sedation. During the surgery, he developed hemodynamic instability and shortness of breath requiring the conversion to general anesthesia with mechanical ventilation. An electrocardiogram was immediately realized revealing deep negative T waves in all the precordial leads. Elevated troponin level confirmed the diagnosis of non-ST elevation myocardial infarction. Urgent coronary artery angiography revealed a known left coronary system with a chronic Left Anterior Descending (LAD) artery occlusion, a chronic occlusion of the distal circumflex artery and a severe stenosis of left main stem. The right coronary artery presented a significant and calcified stenosis on its mid part. The two venous grafts on the obtuse marginal and the posterolateral artery were both patent. The left subclavian artery could not be crossed to selectively film the left internal mammary artery and an angiogram revealed a tight stenosis in the previous stented segment, limiting the blood flow in the left internal mammary artery. Careful review of the in-stent restenosis suggested neointimal hyperplasia and stent fracture, as detected by stentboost imaging.

The European bifurcation club Left Main Coronary Stent study: a randomized comparison of stepwise provisional vs. systematic dual stenting strategies (EBC MAIN).

Patients with non-left-main coronary bifurcation lesions are usually best treated with a stepwise provisional approach. However, patients with true left main stem bifurcation lesions have been shown in one dedicated randomized study to benefit from systematic dual stent implantation. Four hundred and sixty-seven patients with true left main stem bifurcation lesions requiring intervention were recruited to the EBC MAIN study in 11 European countries. Patients were aged 71 ± 10 years; 77% were male. Patients were randomly allocated to a stepwise layered provisional strategy (n = 230) or a systematic dual stent approach (n = 237). The primary endpoint (a composite of death, myocardial infarction, and target lesion revascularization at 12 months) occurred in 14.7% of the stepwise provisional group vs. 17.7% of the systematic dual stent group (hazard ratio 0.8, 95% confidence interval 0.5-1.3; P = 0.34). Secondary endpoints were death (3.0% vs. 4.2%, P = 0.48), myocardial infarction (10.0% vs. 10.1%, P = 0.91), target lesion revascularization (6.1% vs. 9.3%, P = 0.16), and stent thrombosis (1.7% vs. 1.3%, P = 0.90), respectively. Procedure time, X-ray dose and consumables favoured the stepwise provisional approach. Symptomatic improvement was excellent and equal in each group. Among patients with true bifurcation left main stem stenosis requiring intervention, fewer major adverse cardiac events occurred with a stepwise layered provisional approach than with planned dual stenting, although the difference was not statistically significant. The stepwise provisional strategy should remain the default for distal left main stem bifurcation intervention. http://clinicaltrials.gov NCT02497014.

Computed tomography coronary angiogram in left main stem disease: how does it fare against invasive coronary angiography?

Abstract Funding Acknowledgements Type of funding sources: None. Background Computed Tomography Coronary Angiography (CTCA) is increasingly being used to detect and exclude the presence of coronary artery stenosis. Published studies to date comparing CTCA to invasive coronary angiography (ICA) have focused on epicardial vessels other than the left main stem (LMS) (1 - 4). Despite the diagnostic accuracy of CTCA specifically for LMS disease being unknown, it has been used in a recent multi-centre trial (5). Purpose To evaluate the diagnostic performance of CTCA compared with ICA for the detection and visual grading of native Left Main Stem lesions. Methods Retrospective study of patients who underwent CTCA and ICA within 12 months as part of a Quality Improvement project, with no prior coronary intervention. CTCA LMS lesions were graded by consensus of 3 independent blinded reviewers using the Coronary Artery Disease - Reporting and Data System (CAD-RADS) (none, minimal, mild, moderate and severe) and ICAs were similarly evaluated by consensus of 2 independent, blinded reviewers. Moderate and severe LMS lesions were considered clinically significant. Results A total of 53 subjects underwent both CTCA and ICA (70% male, mean age: 62). 66% of LMS lesions were found to be significant on ICA. Compared to ICA, CT angiography has a sensitivity of 83% and a specificity of 89% for detecting a significant LMS stenosis of 50% or more, with a positive predictive value of and a negative predictive value of 94% and 73% respectively. CTCA for detecting a significant LMS stenosis has a AUC of 0.88. In stenosis grading, CTCA correlated with ICA at the same CAD-RADS level in 53% of cases, with over-estimation in 19% and under-estimation in 28% of cases. Conclusion In this retrospective single centre study of patients with native coronary vessels, CTCA is shown to be accurate in identifying significant LMS lesions detected on ICA. However, at a level of stenosis grading, there is significant inter-modality discrepancy with CTCA associated with over- and under-estimation of LMS lesion severities compared with ICA. Diagnostic Performance of CTCA vs ICA Significant LMS lesion ICA positive ICA negative CTCA positive 29 2 CTCA negative 6 16 Diagnostic Performance of CTCA vs ICA in significant LMS lesions Abstract Figure. Significant LMS lesions:CTCA performance

Rescue aortic balloon valvuloplasty during procedural cardiac arrest while treating critical left main stem stenosis: a case report.

BackgroundBest timing for coronary revascularization in patients with severe aortic stenosis (AS) who was a candidate for transcatheter aortic valve implantation (TAVI) is still matter of debate.Case summaryWe here report the case of an 87-year-old man with severe AS presenting with non-ST-segment elevation myocardial infarction. Coronary angiography revealed a highly complex and calcific left main stem (LMS) lesion. Rotablation-assisted percutaneous coronary intervention (PCI) was attempted but was complicated by post-stenting rapidly evolving haemodynamic impairment. A rescue ‘pacing-free’ balloon aortic valvuloplasty (BAV) was performed to rescue the patients, allowing prompt restoration of cardiac output and coronary perfusion.DiscussionAccording to guidelines and preliminary evidence, decision should be performed case by case and based on the degree of severity and complexity of either AS or coronary disease. The strategy of treating coronary lesions first may limit the risk of potential ischaemic complications during TAVI. However, the downside of it is the risk of hemodynamic crash with potential catastrophic evolution in case of PCI complications in presence of severe AS. A ‘bailout BAV’ can be considered as a salvage-strategy in case of complex and complicated LMS-PCI in the context of severe AS and advanced status of haemodynamic impairment. This approach must be seen as very last resort, while appropriate pre-procedural planning is still highly recommended in order to prevent potentially fatal procedural complications in this fragile clinical setting.

Low-Volume Cardioplegia and Myocardial Protection in Coronary Artery Bypass Graft Surgery.

We studied myocardial protection during coronary artery bypass graft surgery using low-volume cardioplegia (Cardioplexol) and minimal extracorporeal circulation (MECC) for different types of coronary artery diseases. In total, 426 consecutive patients were included and divided into four groups: those with left main stem stenosis (n = 45), those with three-vessel disease (n = 200), those with both (n = 141), and those with neither (n = 40). The peak postoperative myocardial markers and 30-day mortality were analyzed. Both myocardial markers and 30-day mortality were significantly elevated in patients with isolated main stem stenosis. We conclude that the use of low-volume cardioplegia and MECC is safe. However, patients with underlying isolated left main stem stenosis might be less protected.

The prognostic significance of incomplete revascularization and untreated coronary anatomy following percutaneous coronary intervention: An analysis of 6,755 patients with multivessel disease.

More than half of the patients undergoing percutaneous coronary intervention (PCI) have multivessel disease. Whether complete revascularization impacts long-term mortality or whether selected patients or those with specific coronary anatomy benefit from complete revascularization is unclear. A total of 14,452 patients underwent PCI between 2004 and 2015 at Harefield Hospital, UK. Of these, 7,076 patients had multivessel disease. We excluded 321 patients with left main-stem stenosis ≥50%, with 6,755 patients included in the analysis (936 patients had complete revascularization). The unadjusted 3-year mortality rates were lower with complete revascularization (10.8% vs 13.1%, P = 0.047). However, multivariable-adjusted analyses indicated that complete revascularization was not independently associated with mortality (HR = 1.01, 95% CI: 0.78-1.31, P = 0.939). These findings were unchanged when addressing measured confounding using propensity-matched analyses (HR = 1.16, 95% CI: 0.81-1.65, P = 0.417) and inverse probability treatment weighted analyses (HR = 1.01, 95% CI: 0.77-1.33, P = 0.950); and unmeasured confounding using instrumental variable analyses (Δ = 0.9%, 95% CI: -2.5%, 4.3%, P = 0.958). There was no association with mortality and untreated LAD disease (HR = 0.92, 95% CI: 0.72-1.17, P = 0.482) and LCx disease (HR = 0.90, 95% CI: 0.74-1.10, P = 0.999). However, untreated proximal LAD disease (HR = 1.23, 95% CI: 1.06-1.51, P = 0.045) and RCA disease (HR = 1.36, 95% CI: 1.08-1.65, P = 0.007) was associated with increased mortality, particularly in patients with ST-elevation acute coronary syndrome (STEACS). In this study of unselected patients undergoing PCI, complete revascularization did not confer a mortality benefit. However, the presence of untreated proximal LAD and RCA disease was prognostic in patients with STEACS. Thus, complete revascularization may be considered in select patient groups with anatomical subsets of coronary disease.

EXCEL and NOBLE: stents or surgery for left main stem stenosis?

EXCEL and NOBLE: stents or surgery for left main stem stenosis?

Relative survival and excess mortality following primary percutaneous coronary intervention for ST-elevation myocardial infarction.

High survival rates are commonly reported following primary percutaneous coronary intervention for ST-elevation myocardial infarction, with most contemporary studies reporting overall survival. The aim of this study was to describe survival following primary percutaneous coronary intervention for ST-elevation myocardial infarction corrected for non-cardiovascular deaths by reporting relative survival and investigate clinically significant factors associated with poor long-term outcomes. Using the prospective UK Percutaneous Coronary Intervention registry, primary percutaneous coronary intervention cases ( n=88,188; 2005-2013) were matched to mortality data for the UK populace. Crude five-year relative survival was 87.1% for the patients undergoing primary percutaneous coronary intervention and 94.7% for patients <55 years. Increasing age was associated with excess mortality up to four years following primary percutaneous coronary intervention (56-65 years: excess mortality rate ratio 1.61, 95% confidence interval 1.46-1.79; 66-75 years: 2.49, 2.26-2.75; >75 years: 4.69, 4.27-5.16). After four years, there was no excess mortality for ages 56-65 years (excess mortality rate ratio 1.27, 0.95-1.70), but persisting excess mortality for older groups (66-75 years: excess mortality rate ratio 1.72, 1.30-2.27; >75 years: 1.66, 1.15-2.41). Excess mortality was associated with cardiogenic shock (excess mortality rate ratio 6.10, 5.72-6.50), renal failure (2.52, 2.27-2.81), left main stem stenosis (1.67, 1.54-1.81), diabetes (1.58, 1.47-1.69), previous myocardial infarction (1.52, 1.40-1.65) and female sex (1.33, 1.26-1.41); whereas stent deployment (0.46, 0.42-0.50) especially drug eluting stents (0.27, 0.45-0.55), radial access (0.70, 0.63-0.71) and previous percutaneous coronary intervention (0.67, 0.60-0.75) were protective. Following primary percutaneous coronary intervention for ST-elevation myocardial infarction, long-term cardiovascular survival is excellent. Failure to account for non-cardiovascular death may result in an underestimation of the efficacy of primary percutaneous coronary intervention.

Glycosylated haemoglobin and coronary atherosclerosis in non-diabetic patients: is it a prognostic factor?

Background: Some studies aimed to evaluate the relationship between HbA1c and coronary artery disease (CAD). However, it is well known that long-term glycometabolic disorders put the heart at risk for CAD. Considering the inconsistencies between previous studies, this study aimed to investigate the relationship between HbA1c and coronary artery atherosclerosis.Methods: A cross-sectional study was conducted on 411 non-diabetic patients who underwent their first coronary angiography between November 2013 and December 2014 in Baqiyatallah Hospital. Blood samples were taken before angiography. Coronary angiograms were reported and reviewed by two cardiologists according to the Gensini score. They were not aware about the patients’ HbA1c level. Severity of CAD was determined through ascertaining the prevalence of multi-vessel disease, extent of CAD (single-, two- or three-vessel disease or left main stem stenosis (>50%)). Data analysis was performed by using SPSS software.Results: A total of 411 patients (252 men and 159 women) were evaluated. Angiography was normal in 67 patients (16.3%), 30.7% had single-vessel disease (SVD), and 29.1%, 20.7% and 3.2% had two-, three- and multivessel disease, respectively. Based on the ROC curve, the HbA1c was able to differentiate between patients with and without coronary atherosclerosis (p < .001, cut-off point = 5.45). The cut-off points for differentiation of severe CAD and patients with 75–100% stenosis of coronary artery were 5.55 (p < .001) and 5.65 (p < .001), respectively.Conclusions: The present study demonstrated that HbA1c might be an independent diagnostic factor in non-diabetic patients with severe coronary atherosclerosis.

Gender differences in coronary angiography, subsequent interventions, and outcomes among patients with acute coronary syndromes

The objective was to investigate whether gender disparities are found in referrals of patients with acute coronary syndromes to percutaneous coronary interventions (PCIs) or coronary artery bypass grafting (CABG) and, furthermore, to study gender differences in complications and mortality. All consecutive coronary angiographies (CAs) and PCIs performed in Sweden and Iceland are prospectively registered in the Swedish Coronary Angiography and Angioplasty Registry. For the present analysis, data of patients with acute coronary syndromes, enrolled in 2007-2011, were used to analyze gender differences in revascularization, in-hospital complications, and 30-day mortality. A total of 106,881 CAs were performed during the study period. In patients with significant coronary artery disease, the adjusted odds ratio (OR) for women to undergo PCI compared with men was 0.95 (95% CI 0.92-0.99) and 0.81 (0.76-0.87) for referrals to CABG. In patients with 1-vessel disease, women were less likely to undergo PCI than men, but women with 2- or 3-vessel or left main stem disease were more likely to undergo PCI. All in-hospital complications after CA followed by PCI were more frequent among women (adjusted OR 1.58 [1.47-1.70]). There was no gender difference in adjusted 30-day mortality after PCI (1.02 [0.92-1.12]) and after CABG (0.97 [0.72-1.31]). After CA showing 1-vessel disease, women as compared with men were less likely to undergo PCI. In the group with 2- or 3-vessel disease or left main stem stenosis, women were more likely to undergo PCI but less likely to undergo CABG. However, there was no gender difference in 30-day mortality.

Angina in Patients with Non-obstructive Coronary Angiograms: Six-years Follow-up

&lt;p&gt;&lt;span style="font-family: Calibri;"&gt;&lt;strong&gt;Background and Aim: &lt;/strong&gt;About one third of patients undergoing coronary angiography for angina have non-obstructive coronary artery disease (CAD). Until recent years the prognosis has been thought to be favourable and no treatment were recommended. More recently, an increased risk of cardiovascular (CV) events has been documented in these patients compared with a general population. We aimed to evaluate the long term persistence of angina and the occurrence of major CV events in patients with stable angina and non-obstructive CAD.&lt;/span&gt;&lt;/p&gt;&lt;p&gt;&lt;span style="font-family: Calibri;"&gt;&lt;strong&gt;Methods: &lt;/strong&gt;We retrospectively evaluated all patients with effort angina referred to the cardiac catheterization laboratory of the Cardiovascular Unit, University of Catania, Sicily, between 1&lt;sup&gt;st&lt;/sup&gt; July 2008 and 31&lt;sup&gt;st&lt;/sup&gt; December 2009, because of a clinical suspicion of myocardial ischemia, without obstructive CAD, defined as &amp;lt;50% stenosis of left main stem or &amp;lt;70% in any epicardial coronary artery.&lt;/span&gt;&lt;/p&gt;&lt;p&gt;&lt;span style="font-family: Calibri;"&gt;&lt;strong&gt;Results: &lt;/strong&gt;Among 2574 patients (2025 men and 549 women) referred for diagnostic coronary angiography, 151 (5.8%) had non-obstructive coronary angiograms. Six-years follow-up was available in 127 patients (63 men and 64 women). Persistence of angina was reported in 20.4%. Four patients (3.1%) had acute myocardial infarction and two (1.6%) had stroke.&lt;/span&gt;&lt;/p&gt;&lt;p&gt;&lt;span style="font-family: Calibri;"&gt;&lt;strong&gt;Conclusion: &lt;/strong&gt;During a six-years follow-up, persistence of angina and occurrence of acute major CV events were found in a significant proportion of patients with stable angina and non-obstructive coronary angiograms.&lt;/span&gt;&lt;/p&gt;

Carotid artery screening at the time of coronary artery bypass - Does it influence neurological outcomes?

ObjectivePatients undergoing coronary artery bypass graft (CABG) are recommended to undergo carotid duplex study in presence of risk factors. Aim of the study was to quantify the relationship between risk factors and presence of carotid disease and examine if screening influenced outcomes. MethodsOver a four year period in a single institution, 4364 consecutive patients presenting for primary isolated CABG were enrolled to undergo carotid duplex scanning. Patients were grouped as no significant carotid artery stenosis (<50%), moderate stenosis (50%–70%) and severe stenosis (>70%). Sub group analysis of patients with severe carotid stenosis was performed. Sensitivity of risk factors thought to be associated with carotid disease was also assessed. ResultsOf the 4364 patients, 406 patients (9.3%) had moderate or severe carotid artery stenosis. 32 (7.88%) had bilateral disease. Age>65, hypertension, left main stem stenosis, peripheral vascular disease, and previous neurological injury were all associated with carotid artery disease (p<0. 01). Diabetes (p=0.06) and smoking (p=0.79) were not significant risk factors.In patients with moderate carotid artery stenosis there was no difference in the incidence of major 4 (0.98%) vs.18 (0.45%) p=0.14 or minor 8 (1.9%) vs. 56 (1.41%); p=0.38 neurological outcomes. However, severe carotid stenosis was associated with an increase in all-cause mortality but no increase in neurological events. ConclusionsIn the presence of risk factors carotid screening identifies at risk population. Severe carotid stenosis was associated with increased all-cause mortality. However, moderate stenosis did not influence neurological outcomes or mortality in patients undergoing coronary artery bypass grafting.

Value of ST- Segment Depression with T-Wave Inversion in Lateral Leads I, aVL, V4-V6 in Diagnosing the Left Main or Left Main Equivalent Coronary Artery Disease

Background: Critical stenosis in the proximal part of the left anterior descending, severe 3 vessel disease and left main stem stenosis have all been recognized as clinical conditions complicated by a high incidence of large infarction, pump failure, arrhythmias and sudden death in patients with acute coronary syndrome (ACS). As many effective treatment modes are available currently, early recognition of those circumstances is crucial for appropriate management.Methods: this observational study was carried out at the Department of Cardiology, National Institute of Cardiovascular Disease (NICVD), Dhaka. Patients (30 patients) with NSTEACS having ST-segment depression with T-wave inversion maximally in leads I,avL,V4-V6 were considered as cases (Group I) and those (30 patients) with ST-segment depression without T-wave inversion in lateral leads were controls (Group II). Coronary angiogram (CAG) was done during in-hospital stay.Results: In present study, it was evident that among group I patients, 43.3% had stenotic lesion in left main artery (LM) and 26.67% in LM equivalent coronary artery (LME CA), whereas had no stenotic lesion in LM and 3.33% had LME CA lesion in group II patients. Low cost, widely available ECG criteria is supposed to be useful predictor of left main or left main equivalent coronary artery obstruction (Sensitivity=95%, Specificity= 76%, Positive predictive value= 70.0% and Negative predictive value= 97.0%) and high ST–segment changes score (&gt;18 mm (100%) &amp;/or ³10mm (80%) was an additive predictor of LM or LMECA lesion.Conclusion: Maximum ST- segment depression with T-wave inversion in the lateral leads I, aVL, V4-V6 on admission ECG can predict the critical LM or LMECA obstruction in patients with NSTEACS. It can help to provide prompt and appropriate management earlier to reduce the mortality &amp; morbidity.Cardiovasc. j. 2017; 9(2): 135-141

Pattern of left main stenosis at a tertiary cardiac center of Nepal

Background and Aims: Left main stem stenosis is defined as a lesion occupying more than 50% of the lumen diameter. Various studies have shown that left main stem stenosis occurs in 4%-6% of all the patients undergoing coronary angiography. We aim to find out the pattern of Left main stem disease in cardiology department of a tertiary cardiac center of Nepal.Methods: This was a retrospective study and was conducted from the properly maintained record of 2 years (August 2011 to July 2013) from cardiaccatheterization labs of Shahid Gangalal National Heart Centre, Bansbari, Kathmandu, Nepal.Results: During the study period 3290 coronary angiogram were done. Among them 102 (3.1%) patients had left main stem stenosis of more than 50%. Mean age of the patients with left main stem stenosis was 60.6±10.1yrs. Most of (73.5%) of patients with left main stem stenosis were of age more than 55 years. Most (80.3%) of them were male. Ostial left main stem stenosis was present in 32 (31.3%) patients whereas distal left main stem stenosis was present in 70 (68.6%) patients. In patients with Left main stem stenosis, single vessel disease was present in 12 (11.7%), double vessel disease in 33(32.3%) and triple vessel disease in 49 (48.0%) patients, whereas 8 (7.8%) patients with non-critical coronary artery disease.Conclusion: Left main stem disease is not an uncommon angiographic finding and is often associated with multivessel coronary artery disease. It commonly occurs in distal part of vessel and the patients were older males.Nepalese Heart Journal 2017; 14(1): 29-30